Glossary
EP - Exemplary Professional Practice

EP32EO. Culture of Safety - Describe and Demonstrate that Nursing Sensitive Indicator Data Aggregated at the Organizational Level Outperform the Mean of the National Database Used. Provide Analysis and Evaluation of Data Related to Patient Falls, Nosocomial Pressure Ulcer Prevalence and/or Incidence, and Two (2) of the Following:

  • Blood Stream Infections,
  • Urinary Tract Infections,
  • Ventilator-Associated Pneumonia,
  • Restraint Use,
  • Pediatric IV Infiltrations
  • Other Specialty-Specific Nationally Benchmarked Indicators (Use only for Units for which the above do not Apply).

Findings:

Missing from the graphed data:

  • Benchmark cohort group for each indicator
  • Identification of the specific VAP database used

The majority of data for two indicators (CLABSI and VAP outperformed the benchmark means the majority of the time

  • The majority of falls and HAPU data did not show outperformance of the benchmarks

Resolution:

  • The Benchmark cohort group for each indicator was provided
  • VAP database identified
  • The original data for all indicators was presented for the first quarter of 2010 through the fourth quarter of 2011. This submission include data analyzed and displayed using the second quarter of 2011 through the first quarter of 2013

Percent of Surveyed Patients with Hospital Acquired Pressure Ulcers 2011 – 2012

Analysis and evaluation of Data

The Nursing Quality Indicators (NDNQI) database displayed at the unit level reveals that seven out of seven patient care units outperformed the NDNQI Teaching Hospitals Mean comparative for the percent of surveyed patients with hospital acquired pressure Ulcers (HAPU).

CCCU- Consolidated Cardiac Care Unit

CCCU- Consolidated Cardiac Care Unit

The Consolidated Cardiac Care Unit (CCCU) outperformed the NDNQI, Teaching Hospital Mean for HAPU in seven of eight quarters.

ICU Medical/Surgical

ICU Medical/Surgical

The Medical Surgical Intensive care unit outperformed the NDNQI, Teaching Hospital Mean for HAPU in eight of eight quarters.

Critical Care Step Down

Critical Care Step Down

The Critical Care Step Down unit outperformed the NDNQI, Teaching Hospital Mean for HAPU in seven of eight quarters. *The pressure ulcer prevalence study was unable to be completed during the fourth quarter of 2011 because the unit was transitioning into another physical location. Therefore the patients were unavailable for examination

6E Telemetry

6E Telemetry

The 6E telemetry unit outperformed the NDNQI, Teaching Hospital Mean for HAPU in eight of eight quarters.

6W Surgical

ICU Medical/Surgical

The 6W Medical Surgical Unit outperformed the NDNQI, Teaching Hospital Mean for HAPU in six of eight quarters.

7E Medical Surgical

ICU Medical/Surgical

The 7E medical surgical units outperformed the NDNQI, Teaching Hospital Mean for HAPU in five of eight quarters.

7W Medical Surgical

ICU Medical/Surgical

The 7W medical surgical units outperformed the NDNQI, Teaching Hospital Mean for HAPU in Six of eight quarters

Total Patient Falls per 1000 Patient Days 2011-2012

Analysis and evaluation of Data

The Nursing Quality Indicators (NDNQI) database displayed at the unit level reveals that four out of seven patient care units outperformed the Teaching Hospital comparative mean for total patient falls per 1000 patient days.

CCCU- Consolidated Cardiac Care Unit

ICU Medical/Surgical

The Consolidated Cardiac Care Unit (CCCU) outperformed the NDNQI, Teaching Hospital Mean for falls in three of eight quarters.

ICU – Medical Surgical

ICU Medical/Surgical

The Medical Surgical Critical Care Unit (ICU) outperformed the NDNQI, Teaching Hospital Mean for falls in six of eight quarters.

CSD – Critical Care Step Down

CSD – Critical Care Step Down

The Critical Care Step Down Unit (CSD) outperformed the NDNQI, Teaching Hospital Mean for falls in five of eight quarters.

6E Telemetry

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The 6E telemetry unit outperformed the NDNQI, Teaching Hospital Mean for falls in six of eight quarters.

6W Surgical

EP32EO_Image17

The 6W Medical Surgical Unit outperformed the NDNQI, Teaching Hospital Mean for falls in six of eight quarters.

7E Medical Surgical

EP32EO_Image12

The 7E Medical Surgical Unit outperformed the NDNQI, Teaching Hospital Mean for falls in one of eight quarters.

7W Medical Surgical

EP32EO_Image13

The 7W Medical Surgical Unit outperformed the NDNQI, Teaching Hospital Mean for falls in three of eight quarters.

Additional Fall Prevention Measures Implemented in 2013

JCMC’s nursing leaders have strategized ways to further evaluate, hardwire established processes, and implement new evidence based interventions to prevent falls. Claudia Garzon-Rivera MSN, RN, CNL, the newly promoted Director of Clinical Excellence is now overseeing the falls prevention department. Under the leadership of Mrs. Garzon-Rivera, Peggy Petrucelli Wound Care Manager is currently focusing on doing enhanced assessments of all falls during real time with the nursing staff after a fall event. A post fall huddle event form was developed for data collection (Reference EP32EO-A). In addition, a focus group was held with Nursing Staff, Physicians, PT/OT, Patient Care Technicians (PCT) and pharmacists to identify the further barriers and facilitators to falls prevention at JCMC (Reference EP32EO-B). As a result of the post fall assessment and focus group findings an action plan was devised for implementation (Reference EP32EO-C). As a result of the 2013 action plan, the following has been accomplished

  • A nursing task force has been established to review data relevant to falls including the post fall huddle assessments, hourly rounding compliance, and appropriate usage of white boards
  • Random audits of nursing fall Assessments have been implemented to identify and address educational needs identified by nursing staff (Reference EP32EO-D)
  • Hourly rounding audits have been implemented by nursing leaders to ensure appropriate hourly rounding by nursing staff (Reference EP3EO-E)
  • Reinforced and enhanced the use of Safety Briefings for prevention of falls and other adverse events (Reference EP32EO-F)
  • Bed Alarms are in the process of being purchased for immediate educational role out and implementation on the units.
EP32EO_Image14

Central Line Associated Blood Stream Infections per 1000 Central Line Days 2011-2012

Analysis and evaluation of Data

The Nursing Quality Indicators (NDNQI) database displayed at the unit level reveals that two out of two patient care units outperformed the Teaching Hospital mean comparative for central line associated blood stream infection (CLABSI) per 1000 central line days. This data is reported through NDNQI for the critical care units only.

CCCU- Consolidated Cardiac Care Unit

EP32EO_Image15

The Consolidated Cardiac Care Unit (CCCU) outperformed the NDNQI, Teaching Hospital Mean for CLABSI in seven of eight quarters.

ICU- Medical/ Surgical

ICU- Medical/ Surgical

The Medical Surgical Intensive Care Unit (ICU) outperformed the NDNQI, Teaching Hospital Mean for CLABSI in seven of eight quarters.

Ventilator Associated Pneumonia per 1000 Ventilator Days

Analysis and evaluation of Data

The Nursing Quality Indicators (NDNQI) database displayed at the unit level reveals that two out of two patient care units outperformed the Teaching Hospital mean comparative for ventilator associated pneumonia (VAP) per 1000 ventilator days. This data is reported through NDNQI for the critical care units only.

CCCU- Consolidated Cardiac Care Unit

The Consolidated Cardiac Care Unit (CCCU) outperformed the NDNQI, Teaching Hospital Mean for VAP in eight of eight quarters.

CCCU- Consolidated Cardiac Care Unit

ICU- Medical/ Surgical

ICU- Medical/ Surgical

The Medical Surgical Intensive Care Unit (ICU) outperformed the NDNQI, Teaching Hospital Mean for VAP in eight of eight quarters.