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.
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