Quality and Patient Safety Annual Report 2017 Quality & Safety Annual Report 2017 | Page 27

Ambulatory and Inpatient FY2017 • Quality and Performance Improvement Project Database: – November 2016 CMS mock survey • A-0273 QAPI indicators for all services, monitoring of QAPI in all areas, department-specific QAPI indicators, and QAPI projects specified in writing – CMS compliance – Promotes synergy and accountability – Reduces redundancy – Eliminates silos Inpatient FY2017 • Vascular Access Team: The CVAT team replaced the previous PICC line nurse team. The nurse-led group evaluates patients with difficult access for the appropriate peripheral device. • Pediatric codes: This group was brought together to evaluate the organization’s response to pediatric codes (vs. neonatal) away from the bedside (not in WIC). A review of appropriate resources such as certified personnel, mediation, and equipment was included. • Antibiotics while under the care of surgical services: Standardization of the processes for continuation of regularly scheduled antibiotics within the perioperative timeframe for in-house patients following antibiotic protocol. • Travel tracker: Electronic trigger from EMR to help identify appropriate oxygen support during patient travel to procedures. • O2 cylinder collection: A team formed to decrease the number of O2 cylinders left and stored in undesignated locations • Foam usage in the pneumatic tube system: Blood transported through the pneumatic tube system without the correct foam can result in delays in care due to the blood having to settle after travel. This team aims to make sure foam is available throughout the units and that education is provided to discourage using other items for transport (towels, etc). • ICU patient ownership: Developing a standard ownership (attending assignment & service) for patients while in the ICU • Telemetry system evaluation: Contracted ECRI to conduct a house- wide assessment of the telemetry system and offer recommendations for vendors to replace the system • FMEA lab specimens: Failure Mode Effects Assessment conducted on lab processes for specimen processing, assignment, and posting results • Dietary consults with tube feed order: Addition of an automatic dietary consult when a tube feed order is placed by a physician. The tube feed order is now a PowerPlan item and requires additional information from the physician. • Sentinel event fall team: Multidisciplinary team formed to develop the criteria for falls with injury that should be designated as sentinel events • Interdisciplinary skin team: A team formed to decrease the occurrence of pressure ulcers • Pain/opioid administration: Ongoing improvements in opioid administration processes • Patient safety rounds: – On a monthly basis, quality and patient safety coordinators visit various ambulatory clinics across UAB Medicine to conduct “patient safety rounds”. During these rounds, coordinators ask frontline staff if they have any patient safety concerns. – This is recognized as an excellent way to connect frontline staff with the Quality and Patient Safety Department – not only as a way to educate staff about safety concerns from the viewpoint of the caregivers, but also to demonstrate the organization’s commitment to creating a culture of safety. – The overall goals of patient safety rounds are to: • Ensure a systematic process is in place for identifying, prioritizing, and implementing solutions to patient safety opportunities; • Provide opportunities for identifying, reporting, and resolving issues contributing to near misses and adverse events; • Foster transparency and just culture by encouraging staff to discuss events; and • Focus on patient safety-related topics through an informal process. Staff working in the area are encouraged to participate in the discussion, and all comments are strictly confidential. Discussions are documented only for purposes of identifying issues and are focused on the system or area, not on the individual, so neither names nor identifiers are documented. www.uabmedicine.org 25