Improvement Charter[1]

Team Name: / 1A Medical/Oncology
Team Members: / Colleen Snelgrove, Jassy Moores, Amy Purton, Dr. Kevin Miller, Rose Niemi, Jane Horiguchi, Nicole Potter, Dawna Maria Perry, Cori Watson, Hilary McIver, Cathy Covino
Team Sponsor: / Cathy Covino, Senior Director Quality & Risk Management
WHAT ARE WE TRYING TO ACCOMPLISH? / Purpose
Decrease hospital associated infections
Scope & Boundaries
1A admitted patients
Improvement Objectives
By November, 2012;
1.Improve hand hygiene compliance to 80%
2.Once achieved, maintain 80% hand hygiene compliance
3.Decrease hospital associated VRE colonization and infection to 0/1000 patient days
4.Once achieved, maintain hospital associated VRE colonization and infection rate at 0/1000 patient days
HOW WILL WE KNOW A CHANGE IS AN IMPROVEMENT? / Measures
1.Complete at a minimum, 25 hand hygiene compliance audits every month
2.Compile VRE rate data every month
3.Perform admission swab testing for VRE on all 1A admitted patients who meet the IP&C criteria for swabbing / Current Performance
50.6%
0/1000 patient days
Currently not measured / Goals
80%
0/1000 patient days
100%
WHAT CHANGES CAN WE MAKE THAT WILL RESULT IN IMPROVEMENT? / Change Concepts and Ideas to Test – Generated with the Unit Team
1.Swab appropriate patients on admission for VRE
2.BP cuff dedicated to patient
3. Cleaning of wheelchairs and other equipment after patient use by health care provider (i.e. OT, PT, Nursing etc.)
4. Hooks outside doors for hanging of visitor belongings, lab coats, stethoscopes etc.
5.Cleaning wipes in med rooms
6.Providing approved compatible hand lotion to staff to assist with maintenance of skin integrity and increase compliance with hand hygiene
7.More availability of cleaning wipes in hallways
8.Look at feasibility of signage for the use of personal protective equipment in picture form for families and visitors unable to read or understand English
HOW WILL WE MANAGE THE IMPROVEMENT PROJECT? / What are some strategies your team will use to engage others at the unit-level and involve them in the project?
1.TRIZ
2.1-2-4-all
3. Map of unit identifying rooms where hospital associated VRE/MRSA/Cdiff infection and or colonization has occurred.
4.Ethnography
Principles for Working Together
1.30 min meeting every 2 weeks
2.1-3 hours every week
3.“Not about me but with me”
4.Mutual respect
5.Open communication
6.Commitment from all team members
7.Each team member to spend about 1-3 hours/week on testing and implementing change
Roles & Responsibilities
Lead: Colleen Snelgrove
Communication: Nurse Educator
Documentation: Dawna Maria Perry
Monthly Reports: All with sponsor approval
Testing Cycles and Strategies: All
Participation on Conference Calls: Rotated amongst team members
Review Schedule
1.30 minute meeting every 2 weeks to discuss PDSAs
2.Submission of monthly report
3.Submission of monthly hand hygiene compliance
4.Submission of monthly IP&C rates
Key Dates
December 14 submit baseline data
December 30 submit first monthly report
By February 29 try 2 PDSA cycles
By February 29 try different liberating structures

Author: Dawna Maria Perry, Colleen Snelgrove, Cori Watson

Date: December 14, 2011

[1] Sandham, D. et. al. Canadian Collaborative to Improve Patient Care and Safety in the ICU. Manuscript, Edmonton 2007 and Improvement Associates Ltd. (www.improvementassociates.com)