90-Day Action Plan

(October 1-Dec 31, 2009)

Group: Partners in Improving Quality and Measuring for Excellence Date: October 22, 2009

Category / IPCC Goals / 90-Day Action Steps / Team Members / Result/Measure of Success
Daily Goals / Achieve 100% compliance with daily goals communication sheet / 1)Identify outcomes measure (e.g., avoidable delays, communication with sub-specialty teams, follow-through of goals)
2)Determine best way to educate and encourage RTs and CMs compliance
3)Refine process & form for completion with new rounds structure
4)Pilot involvement of one new sub-specialty team / Leader: Lesta
Jonathan Seigel
Heather
Jane
Sara
Lupe /
  • Clearly defined measure and data collection process
  • RT and CM compliance improved
  • No copies are being used (originals kept at door)
  • Revised daily goals sheet

Partnering with Families /
  • Establish a family member as part of PIQME
  • Achieve 100% compliance with daily communication of goals with families and patients able to participate
  • Increase family/patient awareness of PRRS from 40% to 85%
/ 1)Coordinate with Rapid Response Committee to improve family education
2)Complete information-gathering projects: survey/interview of PICU families, lit review and FCC organization study
3)Plan for focus group / Leader: Jonathan Slagle
Doreen
Roger
Hadley
Ken /
  • Improved family awareness rates
  • Feedback data from families
  • Recommendations on FCC structure for PICU
  • Focus group scheduled

Standardizing Rounds /
  • Reduce average ICU length of stay by 10%
  • Improve efficiency (time) of bedside ICU rounds by 30%
  • Improve satisfaction of staff participating on rounds
/ 1)Fully implement new rounds structure
2)Mean length of rounds to hold steady (or reduce by 10-20%)
3)Determine outcome measure
4)Refine data collection process (use second ½ of resident rotation period)
5)Video new structure to help with education and implementation / Leader: Tina
Benny
Jonathan Seigel
Lesta
Lindsay
Jane
Chris, RT /
  • Clearly defined measure and data collection process
  • Rounds structure implemented and mean length reduced
  • Training video developed

Infection Rates: CLABSI, VAP, UTI /
  • Decrease VAP rate per 1000 ventilator-days by an additional 25%
  • Decrease CLABSI rate per 1000 central line-days by additional 25%
  • Decrease catheter-associated urinary tract infections per 1000 catheter-days by 10%
/ 1)Continuehand hygiene audits
2)If rates increase, develop reaction plan such as root cause analysis
3)Include report out from Six Sigma UTI team at PIQME meetings / Brad (VAP)
Roger (CLABSI, UTI)
Tina Adams (as needed) /
  • Rates continue to decrease for VAP & CLABSI
  • Rates showing improvement for UTI

Program Management / Develop a coordinated approach for implementing a system-wide model to improve the quality and safety of care for critically ill pediatric patients at the NC Children's Hospital / 1)Define LOS measure for peds cardiac patients and establish baseline
2)Develop and distribute quarterly report (internal communication)
3)Meet with Karen to discuss internal and external communication
4)Submit IRB determination form for approval
5)Identify strategies for obtaining continued support for IPCC
Note: Operational definition for communication of daily goals with patients & families to be developed next quarter / Tina, Erin, Ashley /
  • Clearly defined measure and data collection process
  • Quarterly report distributed
  • Communication plan implemented
  • IRB approval received
  • Plan for sustainability efforts