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Quality Improvement Initiatives
Continuous Improvement has been a way of doing business at NMC for years. It started out as a management development topic and has become how we go about daily life. As a community hospital, we must always search out better ways to do things in order to remain a viable, vital organization. We are constantly looking to improve patient care, enhance patient satisfaction, increase employee safety, operate with greater efficiency, and achieve better outcomes. The uniform format of the Act 53 report card calls for descriptions of three new quality improvement projects. We are pleased to provide overviews of these efforts: pre-op waiting time reduction, preventing infection: "the CLEAN" initiative, and STEMI heart attack collaboration.
Project Name: Pre-Op Waiting Time Reduction
Situation Description:
The Surgical Services Department (includes: Ambulatory, Central Sterile, Office, Outpatient, Operating Rooms, and the PACU (Post Anesthesia Care Unit)) aimed to address patient surgical throughput by increasing efficiency, minimizing work practices, and increasing patient/nursing/surgeon satisfaction through process improvement projects. One aspect of this effort was to reduce pre-op visit times to less than one hour.
Project Goals & Measures:
In 2007, NMC’s Surgical Services Department aimed to maintain pre-op visit times to a maximum of one hour from the time the patient arrives until departure by developing a one-stop service that meets the standards required for pre-op services. Reasons cited for the pre-op visit lasting more than one hour included: no anesthetist available, no nurse available, patient needing to relocate out of the Surgical Services department for lab testing, and waiting for an available EKG tech.
Intervention Description:
The intervention began by heightening awareness within the department of the one hour or less goal for pre-op visits. To improve on the availability of a nurse for these visits, a nurse is now being scheduled for the sole purpose of pre-op visits. In addition, a medical assistant position was created to provide in-department EKG’s and phlebotomy services.
As of June 1st, 2008, Surgical Services has designated Tuesday through Thursday, 8:30 a.m. to 3:00 p.m. for pre-op visits. Friday mornings has been designated for telephone pre-op calls, and Fri afternoons for patients added to the schedule at the last minute requiring a pre-op. Surgical Services is also working collaboratively with Physical Therapy, so that patients needing a PT visit will have their appointment on Tuesday when PT is available.
Evaluation & Results:
Between December, 2007 and April, 2008, the changes they have made have resulted in a reduction in wait time from over 60 minutes to near 40 minutes for pre-op appointments.
Contact Information:
Cheri Losito, Surgical Services Nurse Manager
Northwestern Medical Center
PO Box 1370, St. Albans, VT 05478
524-1073 * 524-1251 (fax) * closito@nmcinc.org
Project name: Preventing Infection – “the CLEAN initiative”
Situation Description:
NMC’s surgical site infection rate is less than the national average (typically below 1%, with a national average of approximately 2.5%), an achievement NMC is very proud of and our staff works very hard to maintain. Part of that emphasis recently has been an improvement effort targeted at hand hygiene throughout the organization.
At a May 2006 meeting of the Infection Control Practitioners from Vermont’s hospitals discussed a collaborative multi-faceted emphasis on hand hygiene with the Vermont Program for Quality Health Care. This effort ultimately included a review of policies, staff self-assessments, a review of employee and patient survey data, observations (by VPQHC) of actual practices, and ultimately, improvement efforts based on the findings.
Project Goals & Measures:
Data from the VPQHC snapshot observations found NMC units at 31%, 65%, and 100% compliance – compared to a national average of 40%. Data from the self-assessments and the patient satisfaction report provided additional support for an improvement effort. The hope was a well-planned intervention would allow NMC to achieve the goal of significantly increasing observed compliance with hand hygiene initially to well beyond -- possibly doubling -- the national rate of 40%, on its way to 100% compliance.
Intervention Description:
The review of the policies showed NMC had strong policies in place – the need for additional staff training and increased awareness was then selected for attention. “CLEAN” (NMC’s hand hygiene improvement program was implemented. It’s components are; 1. Cultivate an atmosphere where it’s encouraged to remind one another about hand hygiene, 2. Learn the specifics about the appropriate times and ways to perform hand hygiene, 3. Exhibit what was learned, 4. Assess the need for additional dispensers of hand hygiene products, 5. eNumerate hand hygiene compliance through direct observation and monitoring volume of hand hygiene products used.) Signage was developed and now rotates through the patient care areas and staff areas to maintain fresh awareness of the importance of proper hand hygiene and the steps in that process. A segment on hand hygiene was introduced into the yearly staff Inservice program, featuring the musical performance of an adapted Beatles’ hit “You Better Wash Your Hands.” Presentations were made at department meetings to clarify the policy and work through the logistical challenges presented on busy patient care units. (“From doing observations and watching the staff interact with patients, it is remarkable how many times people have to wash their hands to comply with proper hand hygiene,” says Pam Bonsall, NMC’s Infection Control Practitioner.) In addition, the topic was reinforced through material in the hospital newsletter (including a hand hygiene quiz), installation of additional hand sanitizer stations throughout the hospital, and through discussions with the physicians on the Medical Staff.
Evaluation & Results:
While our singing of “You Better Wash Your Hands” won’t win anyone a spot on “American Idol”, it has had its desired effect of raising awareness and compliance around hand hygiene. Observations were held for three consecutive months in 2007 on the four nursing units (the three originally observed as well as NMC’s fourth to fully cover the inpatient services). Average rates of compliance had jumped to 77%, 89%, 92%, and 100% -- nearly all double the national average of 40% and moving strongly towards NMC’s ultimate goal of 100%. A noticeable change in patient satisfaction scores relating to this topic was also documented. Our work on this project is ongoing, with continued efforts relating to staff awareness and education.
Contact Information:
Pam Bonsall, Infection Control Practitioner
Northwestern Medical Center
133 Fairfield Street, St. Albans, VT 05478
524-8481 * 524-1250 (fax) * pbonsall@nmcinc.org
Project Name: STEMI Heart Attack Collaboration Project
Situation Description:
Living in rural Vermont doesn’t have to mean feeling isolated and without access to high tech health care services. In times of medical crisis, the ability of a community hospital to get patients the care they need can be critical. NMC has worked closely and collaboratively with Fletcher Allen Health Care in Burlington to ensure that patients in northwestern Vermont have appropriate access to care. In 2007, the hospitals began work together to reduce “door to balloon time” for patients with a particular type of heart attack.
Project Goals & Measures:
“ST Elevated Myocardial Infarctions” (STEMI) are among the most dangerous of heart attacks, given their sudden onset and deadly implications. For these patients especially, time is of the essence. NMC’s Emergency Department has worked with Fletcher Allen’s Cardiology to implement a specialized STEMI Protocol – which calls for patients experiencing that type of heart attack in northwestern Vermont to be assessed, diagnosed, and stabilized at NMC, transferred to Burlington, and into the FAHC Cardiac Catheterization Lab within 90 minutes, which is the national standard for hospitals with a Cardiac Cath lab of their own.
Intervention Description:
Beginning in the fall of 2006, work began behind the scenes to set the stage for implementation of the STEMI protocol at NMC. Dr. Prospero Gogo, a Fletcher Allen Cardiologist with Courtesy (consulting) privileges at NMC and part-time office hours on the NMC campus, began conversations about STEMI with Dr. Marc Kutler of NMC’s Emergency Department.
Collaboration takes effort from all parties involved, including Fletcher Allen, NMC, and the area ambulance squads:
- Early on, Fletcher Allen’s Cardiology department made a commitment and put into practice immediately taking calls from NMC’s Emergency Department to reduce call-back time for these time sensitive patients.
- Working together, a STEMI documentation tool was created that included all of the protocol information onto one sheet of paper that follows through the entire process. This includes demographics, nursing documentation, physician orders, and transfer documentation.
- Individuals presenting to the Emergency Department with a potential STEMI diagnosis are never removed from the ambulance stretcher to save valuable time in the process prior to transporting the patient to FAHC’s Cardiac Catheterization Lab.
Evaluation & Results:
In 2007, NMC’s average time from arrival at NMC’s Emergency Department to an open artery at Fletcher Allen was just 88 minutes—including drive time to travel 27 miles between facilities along I-89—according to data collected by Harold L. Dauerman, MD, Director of Cardiovascular Catheterization Laboratories, Professor of Medicine University of Vermont/Fletcher Allen. Dr. Dauerman and Dr. Marc Kutler review every STEMI case that occurs to review the process and the timeframes to be able to address any issues that may have arisen.
This amazing collaborative approach is a prime example of both organizations’ unquestioned commitment to saving lives. When every minute makes a difference, this effort is truly a life saver in northwestern Vermont.
Contact Information:
Molly Grismore, Emergency Department Nurse Manager
Northwestern Medical Center
PO Box 1370, St. Albans, VT 05478
524-4307 * 524-1053 (fax) * mgrismore@nmcinc.org
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