Continuous Improvement has been a way of doing business at NMC for years. It started out as a management development topic and has become how we go about daily life. As a community hospital, we must always search out better ways to do things in order to remain a viable, vital organization. We are constantly looking to improve patient care, enhance patient satisfaction, increase employee safety, operate with greater efficiency, and achieve better outcomes. The uniform format of the Act 53 report card calls for descriptions of three new quality improvement projects. We are pleased to provide overviews of these efforts: Quiet Culture Program at NMC, Preventing Infection: "the CLEAN" initiative, and STEMI Heart Attack Collaboration.
Project Name: Quiet Culture Program at NMC
Situation/Description:
The quietness of the hospital environment is one of the indicators of patient satisfaction that is assessed and reported to CMS and publically on national websites. This is one of the most difficult indicators to influence because of numerous variables that might impact a patient’s ability to sleep at night in a hospital setting. At NMC we recognize that restfulness, sleep and the quietness of the hospital environment (especially at night) directly impacts our patient’s ability to heal.
As we continually assess our HCAHPS scores for patient satisfaction we noted that we had opportunity for improvement in this area. As a result, in September 2010, we put together a PI “Quiet Culture Team” to brainstorm solutions. Our Aim Statement was developed and frames our objective to: “reduce noise and disruptions within NMC to create a more restful environment in order to promote a culture of quiet to enhance healing and the patient’s hospital experience”. In the fall of 2011, we asked our Service Improvement Team to take the program to the next level, by incorporating new initiatives. These include a ‘turn down service’ (launching July 2012) and updated signage to assist with visual cues to our noise reduction efforts.
Project Goals/Measures
Our goals:
- Increasing our HCAHPS score to 97% for the cumulative score of “Usually” and “Always” for Question #9: During this hospital stay, how often was the area around your room quiet at night? The baseline measure for the time frame of 12/08 to 12/09 is 93%.
- Decreasing our HCAHPS score to ≤3% for the cumulative score of “Sometimes” and “Never” for Question #9: During this hospital stay, how often was the area around your room quiet at night? The baseline for the time frame of 12/08 to 12/09 is 7%.
- Moving the “Usually” respondents up to “Always” for Question #9 and resulting in an “Always” score of 70%. The baseline for the time frame of 12/08 to 12/09 is 63%.
- Decrease the noise level by 5 decibels (dB) which can be perceived as a clearly noticeable change.
We will measure our success by:
- Monitoring HCAHPS Question #9:
- During this hospital stay, how often was the area around your room quiet at night?
- A.M SBAR rounding questions:
- How did you sleep last night?
- Was there something specific that disrupted your sleep/rest?
- Target decibel level at _55_db on evg/night shift; Target decibel level at _45__db on day shift
Intervention Description
In October 2010, we rolled out a new program which was developed by our staff team: “Quiet Because We Care”. It includes visual imagery and education sound bytes for staff to remind them to keep their work environments quiet. We launched the program with a photo contest to promote and embrace soothing and restful images. The winner of the contest had their photos turned into large posters that are displayed around the hospital. We are continually seeking feedback about how to reduce noise hospital wide and make a difference for our patient’s experience, including ongoing maintenance from fixing ‘squeeky wheels’ to putting rubber stoppers on door jams. As previously mentioned, we are adding new initiatives which we hope will continue to promote our Quiet Culture efforts at the hospital.
Evaluation and Results:
Our team is continually monitoring our patient satisfaction and HCAHPS scores for improvement. We have demonstrated some slight increase in score over the past 3 months, but recognize we will need more data to determine overall improvements related to the program. We are planning to formally reassess our noise levels by June 2011 and compare new results with our baseline scores.
Over the next year, our team will continue to monitor our noise levels and our patient satisfaction scores for improvement and continue to strategize new ideas for change.
Contact Information:
Lisa Clark
Hospitality Manager
Northwestern Medical Center
133 Fairfield Street, St. Albans, VT 05478
(802) 524-8832 * lbclark@nmcinc.org
Project name: Preventing Infection – "the CLEAN initiative"
Situation/Description:
NMC's surgical site infection rate is less than the national average (typically below 1%, with a national average of approximately 2.6% - see more by following this link), an achievement NMC is very proud of and our staff works very hard to maintain. Part of that emphasis has been an improvement effort targeted at hand hygiene throughout the organization.
At a May 2006 joint meeting of the Infection Control Practitioners from Vermont's hospitals and members of the Vermont Program for Quality Health Care, a collaborative multi-faceted emphasis on hand hygiene was discussed. This effort included a review of policies, staff self-assessments, a review of employee and patient survey data, direct observation of practices, and ultimately, improvement efforts based on the findings.
Project Goals/Measures
Data from the initial observations for hand hygiene compliance, done by VPQHC, found NMC units at 31%, 65%, and 100% compliance – compared to a national average of 40%. Data from the self-assessments and the patient satisfaction report provided additional support for an improvement effort. The hope was a well-planned intervention would allow NMC to achieve the goal of significantly increasing observed compliance with hand hygiene initially to well beyond -- possibly doubling -- the national rate of 40%, on its way to 100% compliance.
Intervention Description
The review of the policies showed NMC had strong policies in place – the need for additional staff training and increased awareness was then selected for attention. "CLEAN" (NMC's hand hygiene improvement program) was implemented. It's components are; 1. Cultivate an atmosphere where it's encouraged to remind one another about hand hygiene, 2. Learn the specifics about the appropriate times and ways to perform hand hygiene, 3. Exhibit what was learned, 4. Assess the need for additional dispensers of hand hygiene products, 5. eNumerate hand hygiene compliance through direct observation and monitoring volume of hand hygiene products used. Signage was developed and now rotates through the patient care areas and staff areas to maintain fresh awareness of the importance of proper hand hygiene and the steps in that process. A segment on the importance of hand hygiene was introduced into the yearly staff Inservice program. Presentations were made at department meetings to clarify the policy and work through the logistical challenges presented on busy patient care units. In addition, the topic was reinforced through material in the hospital newsletter (including a hand hygiene quiz), installation of additional hand sanitizer stations throughout the hospital, and through discussions with the physicians on the Medical Staff.
Evaluation and Results:
In 2009 the overall Hand Hygiene compliance rate was 92.3% up from 88.5% in 2008 and 65% in 2006! That is a 27.3% increase in over 3 years! In 2011 we have held our gains, and our continued goal for 2012 is to reach 95% compliance consistently.
In addition to these dramatic improvements, is an overall increase in the use of hand sanitizers across the organization. Over the past 3 years, we have seen a dramatic increase in the consistent use of hand sanitizer across the organization; approximately an 80% increase over previous years! This is a demonstrated measure of improved overall hand hygiene compliance hospital wide. As we know, many infections can be prevented by simply washing our hands. Given our current low infection rate and excellent compliance with hand hygiene principles demonstrates our commitment to patient safety at NMC!
Contact Information:
Pam Bonsall
Infection Control Practitioner
Northwestern Medical Center
133 Fairfield Street, St. Albans, VT 05478
(802) 524-8481 * (802) 524-1250 fax * pbonsall@nmcinc.org
Project Name: STEMI Heart Attack Collaboration Project
Situation/Description:
Living in rural Vermont doesn't have to mean feeling isolated and without access to high tech health care services. In times of medical crisis, the ability of a community hospital to get patients the care they need can be critical. NMC has worked closely and collaboratively with Fletcher Allen Health Care in Burlington to ensure that patients in northwestern Vermont have appropriate access to care. In 2007, the hospitals began work together to reduce "door to balloon time" for patients with a particular type of heart attack.
Project Goals/Measures
"ST Elevated Myocardial Infarctions" (STEMI) are among the most dangerous of heart attacks, given their sudden onset and deadly implications. For these patients especially, time is of the essence. NMC's Emergency Department has worked with Fletcher Allen's Cardiology to implement a specialized STEMI Protocol – which calls for patients experiencing that type of heart attack in northwestern Vermont to be assessed, diagnosed, and stabilized at NMC, transferred to Burlington, and into the FAHC Cardiac Catheterization Lab within 90 minutes, which is the national standard for hospitals with a Cardiac Cath lab of their own.
Intervention Description
Beginning in the fall of 2006, work began behind the scenes to set the stage for implementation of the STEMI protocol at NMC. Dr. Prospero Gogo, a Fletcher Allen Cardiologist with Courtesy (consulting) privileges at NMC and part-time office hours on the NMC campus, began conversations about STEMI with Dr. Marc Kutler of NMC's Emergency Department.
Collaboration takes effort from all parties involved, including Fletcher Allen, NMC, and the area ambulance squads:
- Early on, Fletcher Allen's Cardiology department made a commitment and put into practice immediately taking calls from NMC's Emergency Department to reduce call-back time for these time sensitive patients.
- Working together, a STEMI documentation tool was created that included all of the protocol information onto one sheet of paper that follows through the entire process. This includes demographics, nursing documentation, physician orders, and transfer documentation.
- Individuals presenting to the Emergency Department with a potential STEMI diagnosis are never removed from the ambulance stretcher to save valuable time in the process prior to transporting the patient to FAHC's Cardiac Catheterization Lab.
Evaluation and Results:
In 2007, NMC's average time from arrival at NMC's Emergency Department to an open artery at Fletcher Allen was just 88 minutes—including drive time to travel 27 miles between facilities along I-89—according to data collected by Harold L. Dauerman, MD, Director of Cardiovascular Catheterization Laboratories, Professor of Medicine University of Vermont/Fletcher Allen. Dr. Dauerman and Dr. Marc Kutler review every STEMI case that occurs to review the process and the timeframes to be able to address any issues that may have arisen.
Four years later in 2011, we continue to drive improvements in cardiac care forward! This past year 23 patients met all criteria for our STEMI protocols for treatment. Our average transfer time was 25 minutes, down 8 minutes from last year, and our overall average “Door to FAHC time” was 82 minutes, down from 85 minutes in 2009!), including a 30 minute drive from St. Albans to Burlington. When every minute counts in the treatment of heart attacks, NMC is leading the way. Saving patients and reducing harm!
This amazing collaborative approach is a prime example of both organizations' unquestioned commitment to saving lives. When every minute makes a difference, this effort is truly a life saver in northwestern Vermont.
Contact Information:
JoAnn Manahan, RN, Emergency Department Nurse Manager
Northwestern Medical Center
133 Fairfield Street, St. Albans, VT 05478
(802) 524-1208 * (802) 524-1250 fax * jmanahan@nmcinc.org
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