NICU Individual Compliance MetricsMonica Larsen RN

GBMC NICU

Objectives

• Name 3 reasons why the implementation of a compliance metric program supports staff engagement in NICU safety

• Discuss how this compliance metric program can be a segway into larger quality initiatives

• Describe how a compliance metric program promotes staff to staff communication and support

• Identify skills the staff nurse learns from participation in this program

• Name the outcome measurements of this NICU program

About GBMC’s NICU

• 30 Bed Level 3 NICU• Opened in 1965• Prior culture of manager having a directive

style• New Manager Oct. 2011 with transactional

style

NICU Goal Status Jul Aug Sep OctCentral Line Associated Blood Stream Infection

(CLABSI)ZERO   1 0 0 0

Hand Hygiene 0.90   84% 93% 90%  

Proper ID Band Placement100%

     86.0% 100.0%

Daily Teach-Back 75%       80.0% 22.0%

Discharge Education Completed before discharge

date80%

 

 66%

 

20.0% 33.0%

Care Plans Individualized 80% 

 72% 85.0% 80.0% 

Overall Initiation Breast Feeding Rate

75%

 

72% 

 

 70% 65.0%

Exclusive breast feeding for premature infants with weight

1250 and less

90%

 

52% 33.0% NA 0.0%

2012 GBMC NICU Compliance Metrics

GBMC NICU Individual Safety Commitments for FY2013

Compliance Metrics

Name Commitment Jan Feb Mar Evaluate April May June Evaluate July Aug Summary CHRISTIE GREER

Every week, I will monitor that the right breastmilk is in the right bin in the refrigerator.

NICOLE PETtERSON

Twice weekly, I will monitor that breastmilk in each infants bin is dated within appropriate time frame.

JULIE BRIDGEMAN

Twice weekly, I will monitor that all intubated babies have inline suction catheters in place.

LORI MURPHY

Twice weekly, I will monitor patients on phototherapy to make sure eyes and genitals are properly shielded.

KATIE STUMPF

Every week, I will monitor that infant baths are being completed every three days

HOLLIE KROUT

Weekly, I will monitor that the discharge criteria are documented on the checklist in Meditech.

KIM WHITE Weekly, I will monitor that the discharge criteria are documented on the checklist in Meditech.

ELLEN DRAKE

Twice weekly, I will monitor infants on bubble cpap for clear eyes and no drainage.

JACKIE RYAN

Twice weekly, I will monitor infants who are on fortifiers for skin integrity of the peri-anal area.

JOSEPH HENRY

Weekly, I will monitor the Tissue Bank database for completion.

LISA RUTLEDGE

Weekly, I will monitor labeling of suction canisters and tubing for date and time within 24hrs.

Sample of an Audit Tool

Visibility

Measurable NICU Practice Outcome

GBMC NICU Individual Safety Commitments for FY2014

Compliance Metrics

Name Commitment Nov Dec. Jan Evaluate Feb March April Evaluate May June Summary CRISTIE GREER

Every week, I will monitor that claves on IV lines are changed per policy

NICOLE PETERSON

Twice weekly, I will monitor that breastmilk in each infants bin is dated within appropriate time frame.

JULIE BRIDGEMAN

Twice weekly, I will monitor that all intubated babies have inline suction catheters in place.

LORI MURPHY

Twice weekly, I will monitor patients on phototherapy to make sure eyes and genitals are properly shielded.

KATIE STUMPF

Every week, I will monitor that infant baths are being completed every three days

HOLLIE KROUT

Weekly, I will monitor that the discharge criteria are documented on the checklist in Meditech.

KIM WHITE Weekly, I will monitor that the discharge criteria are documented on the checklist in Meditech.

ELLEN DRAKE

Twice weekly, I will monitor infants on bubble cpap for clear eyes and no drainage.

JACKIE RYAN Twice weekly, I will monitor infants who are on fortifiers for skin integrity of the peri-anal area.

JOSEPH HENRY

Weekly, I will monitor labeling of suction canisters and tubing for

Performance Improvement Outcome

2015 --- 100% Staff Involvement

What our nursing staff learned….

Peer to Peer Communication Increased

Working Together

Metric and Audit Tool Development and Support

A Sample Compliance Metric

“Once a week, I will monitor that the infant’s heart rate lower limits, are set on the monitor, appropriate for the infant’s

gestational age.”

Measurement and Analysis of Data

Increased Staff Nurse Satisfaction and Engagement

In 2014, the Press Ganey safety survey results indicated NICU staff engagement improved significantly.

GBMC NICU Staff Nurses on Safety

95% I know the proper channels to direct questions regarding patient safety in this work setting.

Engaged Staff