In a large healthcare system, there are advantages to leveraging standardized sedation committees, a standardized sedation audit tool and convening all facility sedation committees to report to a system committee. To ensure consistent practices across the system, the System Safe...

UMass Memorial Health System Suicide Steering Committee identified three focused areas for continuous improvement for patients at risk for suicide: incomplete evidence-based suicide risk assessments, inadequate documentation of observation levels, and gaps in environmental checklist documentation. The team implemented enhancements...

Research indicates medical errors as the third leading cause of deaths, with national estimates suggesting that 14-56% of inpatient deaths are preventable. To address this issue, the mortality review process was designed to be the driving force in identifying opportunities...

We will discuss how a virtual nursing team can support an organization’s efforts to enhance patient safety and reduce risk in the face of patient surges, work stoppages, and staff turnover. Demonstrate how we used clinician engagement and measures of...

St. Louis Children’s Hospital is a member of Solutions for Patient Safety (SPS), a network of pediatric hospitals working together to eliminate serious harm. SPS identified that a safety coach program is a crucial component of the culture of safety....

Deployed system redesign lean principles and Change Management strategies to move key stakeholders from buy-in to ownership were used effectively to roll-out best practice management of C-diff in acute care and nursing home community living centers (NHCLC). Reduction in C-diff...

We developed a quality metric board, ‘Healthy Planet’, in the electronic health record system to observe HEDIS measure performance in the offices. Based on the data, we set yearly goals on our Balanced Score Card to strategically identify barriers and...

For prescribing teratogenic medications to women Veterans, although both the national pharmacy Teratogenic Medication warning and national guidance regarding teratogenic clinical reminders were implemented, process was not optimal as most medications were prescribed in the specialty setting and processes implemented...

Kaiser Permanente Northen California has been on a journey to build a robust succession and competency program over the last two years. Currently developing Role Profiles for each role in this structure which are mapped to the NAHQ competency framework...