The Antianxiety Medications Some Practical Questions

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Emergency Services FY 07
Strategic Value Dashboard Performance
Indicators and Action Plans Supporting Our
Strategic Plan
S a f e t y ? Q u a l i t y
? S e r v i c e ?
R e l a t i o n s h I p s ? P e
r f o r m a n c e
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Our Mission, Vision and Values

• Our Mission
• We will make a difference.
• Our Vision
• We will become the leading medical center in our
  region.
• Our Cardinal Value
• We honor the dignity and worth of each person.
• Our Strategic Values
• ? Safety ? Quality ? Service ? Relationships ?
  Performance ?

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Emergency Department FY 07
Safety ? Quality
? Service ?
Relationships ?
Performance
AP Action Plan ?
Explanation/Calculation BM
Benchmark
M Magnet Indicator
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Emergency Department FY 07
Safety ? Quality
? Service ?
Relationships ?
Performance
AP Action Plan ?
Explanation/Calculation BM
Benchmark
M Magnet Indicator
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Emergency Department FY 07
Safety ? Quality
? Service ?
Relationships ?
Performance
AP Action Plan ?
Explanation/Calculation BM
Benchmark
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Best Quartile and Comparative Data
Explanation

• Recordable Injuries
• Departmental data is total number of employee
  recordable injuries. The comparative data is
  OSHAs national rate. OSHA does not provide rates
  that are specific to a hospital department so our
  data has no department-specific comparison.

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What is our Action Plan Unscheduled Returns to
the ED admitted - Updated 6/07

• What is our Plan?
• Continue to review if pt admitted for the same
  or different diagnosis
• Data collected monthly per Tracy
• How will we Do it?
• Cases to monthly ED DR mtg as needed
• Who will Do it?
• Medical Director/ Asst Medical Director

• How will we Check to document improvement?
• Monthly Data collection
• Compare data to MHA
• How will we Act to sustain improvement?

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What is our Action Plan Left Before completion
of treatment - Updated 6/07

• What is our Plan?
• Encourage RN to notify physician that patient
  is leaving prior to leaving in an attempt to
  decrease LBE
• Treatment Triage 2 PM to 230 AM
• Increase Bedside Registration
• Activate Code ED Purple
• How will we Do it?
• RN education to notify the ED DR that pt is
  leaving so ED DR may attempt to decrease pt
  leaving
• Hire additional mid-level providers to work the
  Treatment Triage 2 PM schedule
• ED Charge RN attends daily 180 Patient Flow
  meeting
• Who will Do it?
• Physician Nursing staff

• How will we Check to document improvement?
• LBE rate
• TAT
• How will we Act to sustain improvement?

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Total Recordable Incident Rate Explanation and
Calculation

• Recordable Injuries
• TRIR All injuries requiring treatment beyond
  First Aid and sharps injuries
• This is the number of recordable injuries per 100
  FTEs
• Total number of department recordable injuries
• X 200,000
• Department total hours worked

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What is our Action PlanCommunity Acquired
Pneumonia Updated 6/07

• What is our Plan?
• A weekly report run by Becky Hall and given to
  Dr. Angelos.
• How will we Do it?
• Education of staff
• Constant review
• Who will Do it?
• Dr. Angelos by one-on-one review with
  physicians and with Angie Hodge if there is a
  delay in the nurse administration time.

• How will we Check to document improvement?
• Case review.
• How will we Act to sustain improvement?
• We have also tried to educate staff that the
  clock does begin at WUCC for any pneumonia
  patients who are transferred and even encourage
  that Wheelersburg could start the antibiotic, if
  possible.

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Best Quartile and Comparative Data
Explanation

• Door to EKG Within 10 Minutes for Myocardial
  Infarction (MI)
• Data is submitted to the CRUSADE National Quality
  Improvement Initiative.
• CRUSADE is designed to increase the practice of
  evidenced-based medicine for patients with
  diagnosed acute coronary syndromes (ACS).
• CRUSADE uses as its gold standard the ACS
  clinical practice guidelines developed by the
  American College of Cardiology (ACC) and the
  American Heart Association (AHA).
• Best practice guidelines are 10 minutes for
  patient arrival to EKG obtained.

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Door to EKG Within 10 Minutes Explanation
and Calculation

• Number of MI patients who
• had an EKG performed within
• 10 minutes of arrival to ED
• X
  100
• Number of MI patients

Higher is Better
Why is this important?
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What is our Action PlanDoor-to-EKG Time Within
10 Minutes - Updated 6/07

• What is our Plan?
• Educate the ERTechs about current data.
• Purchase a third EKG machine in follow up to
  the Chest Pain accreditation of visit
• To obtain an EKG within 10 minutes of arrival
  for patients exhibiting cardio distress.
• How will we Do it?
• Schedule EKG training for the Techs on the new
  equipment October 2006.
• Identify additional staff that can provide
  EKGs such as 2 to 3 key RN staff on all 4 ED
  rotations. Cross-train them with EKGs with the
  ERTech staff and then have their competency
  completed with the laboratory staff.
• By locating one of the new EKG machines to
  triage 3.
• Who will Do it?
• ED Nurse Managers, Asst. Nurse Managers and
  Clinical Coordinators.
• RNs and ERTechs trained to do this testing.

• How will we Check to document improvement?
• Monthly data from Crusade and the PI Department
  about door-to-EKG time within 10 minutes for
  MI.
• Chart reviews.
• How will we Act to sustain improvement?
• Discuss whether or not after training 8 to 10
  ER nurses should we eventually train all ED RN
  staff to complete EKGs.
• Also discussed teams. Triage teams with 2 RNs
  and a Tech, or teams in the zone, 2 RNs and a
  Tech, that could help each other do EKGs vs.
  just the Stat Lab
• staff.
• Continued monitoring the results and a training
  program for qualified staff.

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What is our Action PlanDoor-to-Doctor Time
Main Campus Updated 6/07

• What is our Plan?
• Consider mid-level provider at triage for 60
  days
• Treatment Triage Team (Mid-level RN) 2 PM to
  230 AM
• Rapid cycle test was positive
• How will we Do it?
• Work with EPMG to hire or schedule a mid-level
  provider for triage.
• Need to hire several mid-level providers
• Who will Do it?
• EPMG mid-level provider and nursing staff.

• How will we Check to document improvement?
• Monitor door-to-discharge and door-to-doctor
  times for this 60 days.
• How will we Act to sustain improvement?
• Based on the turnaround time data, we will
  decide whether this needs to continue as a
  regular part of our physician provider staffing.

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What is our Action Plan Throughput Time (Main)
- Updated 6/07

• What is our Plan?
• Continue Bedside Registration
• Call in RN/ DR help as needed
• Hire RN staff to cover the databases/ hall
  patients
• Code ED Purple
• Attend 180 mtg daily
• How will we Do it?
• Increase RN staffing
• Increase DR staffing if extended waits
• Who will Do it?
• DON/NM/ANM
• Medical Director

• How will we Check to document improvement?
• Monitor daily monthly data
• Conference call with Advisory Board
• Collect TAT from Ohio Health ED group
• How will we Act to sustain improvement?

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What is our Action PlanActual vs. Budgeted FTEs
Main and South Campus Updated 6/07

• What is our Plan?
• Met with Nurse Managers and follow up Asst.
  Nurse Managers. Orientation and training with
  the Nurse Managers regarding financial data and
  OrMed.
• How will we Do it?
• Monitor our staffing, our schedules, our census
  and our use of overtime. Pay particular
  attention to orientation and training hours.
• Who will Do it?
• Director of Nursing, Nurse Managers and Asst.
  Nurse Managers.

• How will we Check to document improvement?
• Monthly financial reports
• How will we Act to sustain improvement?
• Monthly agenda item, looking at our financial
  operation expenses and FTEs.

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What is our Action PlanStaffing vs. Actual FTEs
at WUCC Updated 10/06

• What is our Plan?
• Met with Nurse Manager. Orientation and
  training with the Nurse Manager regarding
  financial data and OrMed.
• How will we Do it?
• Monitor our staffing, our schedules, our
  census and our use of overtime. Pay particular
  attention to orientation and training hours.
• Who will Do it?
• Director of Nursing and Nurse Manager

• How will we Check to document improvement?
• Monthly financial reports.
• How will we Act to sustain improvement?
• Monthly agenda item, looking at our financial
  operation expenses and FTEs.

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What is our Action Plan ED
Updated 6/07

• What is our Plan?
• Improve and Maintain the 90th percentile rank or
  greater in Emergency Services
• How will we Do it?
• Meeting with Emergency physicians to discuss
  physician-related questions
• interview candidates for vacant part-time ED
  Patient Representative on evening and night
  shift
• ED to develop comment cards to give to patients.
  same prototype as used at the HCC that thanked
  the patient for choosing SOMC and list the
  staff on duty each day
• Continue to run weekly Press, Ganey reports and
  to share them with the key leaders in medicine,
  nursing, registration, lab, x-ray and nursing
  staff in general
• Monitor lower scoring areas such as Physicians
  and Test Treatments and to hone in on key
  words and key questions
• Who will Do it?
• Medical Director, Assistant Medical Director,
  Director of Nursing, nurse Manager, Assistant
  Nurse Manager and all staff and related
  departments

• How will we Check to document improvement?
• Monitor monthly results
• How will we Act to sustain improvement?
• Continue with action plans

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What is our Action Plan ED
Updated 10/22/06

• What is our Plan?
• Increase ED patient satisfaction
• How will we Do it?
• Review customer comments for trends
• Run weekly PG reports share with key
  stakeholders staff
• Meet with ED Medical Director since ED
  Physician score is lowest scoring area
• Re-assess ED physician staffing
• Meet with ED DR group at monthly meeting/review
  key works in ED DR questions
• Use key words in patient interaction
• Who will Do it?
• ED Medical Director ED Asst. Medical Director
  DON/NM/ANMs
• All Staff

• How will we Check to document improvement?
• Monitor weekly and monthly PG results
• How will we Act to sustain improvement?
• Patient Centered Care principles
• Celebrate Service gains
• Weekly PG reports

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What is our Action Plan ED
Updated 12/06

• What is our Plan?
• Improve and maintain the 90th percentile rank,
  or greater, for patient satisfaction in
  Emergency Services.
• How will we Do it?
• Medical Director and Director of Nursing
  reviewing actual surveys and survey comments.
• Looked at day/evening vs. night scores days
  99, evenings 58 and nights 47.
• Replace vacant hours on nights for ED Pt Rep.
• Continue to run weekly Press, Ganey reports and
  share with key leaders in medicine, nursing,
  registration, lab, x-ray and nursing staff.
• Focus on key words in the survey.
• Educate staff on the hospitalwide Service
  Action Plan.

• Who will Do it?
• Medical Director, Asst. Medical Director,
  Director of Nursing, Nurse Manager, Asst. Nurse
  Managers and all staff in related depts.
• How will we Check to document improvement?
• Monitor monthly Press, Ganey results.
• How will we Act to sustain improvement?
• Communicate results, celebrate results and
  continue with Action Plans

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What is our Action Plan Overall Employee
Satisfaction Updated 6/07

• What is our Plan?
• Qtrly staff meeting away from dept
• Brainstorm issues with staff
• Open door policy
• Improve communication
• Rounding
• How will we Do it?
• DON/NM/ANM mo mtg reinstated
• Rounding on staff
• ANM expectations (mtg with DON/NM/ANM)
• Benefit mtg for staff per HR
• Explain ED staffing plans
• Who will Do it?
• ED DON/NM/ANM
• HR to present benefit mtg

• How will we Check to document improvement?
• Repeat EOS 10/07
• How will we Act to sustain improvement?

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What is our Action Plan PRC Medical Staff
Satisfaction with ED Services Updated 6/07

• What is our Plan?
• DON Rounding with EPMG providers
• ED Physician Nsg leadership to hold focus group
  with Medical Staff
• How will we Do it?
• Focus group lunch/dinner mtg with Family Practice
  one month, Internal Medicine second month
• Who will Do it?
• Dr Angelos/ Cheatham
• Jason Ross/ Mary Kate

• How will we Check to document improvement?
• PRC scores
• How will we Act to sustain improvement?

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Best Quartile and Comparative Data
Explanation

• Unscheduled Returns to ED Admitted
• - Data is submitted to the Maryland Hospital
  Association (M.H.A.) quality indicator
  project. The project wide data is
  aggregated by overall mean rate and best
  quartile (top 25 percent). The best quartile
  is what we use for our targets for both
  indicators. Currently 138 facilities participate
  in this indicator set.

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Best Quartile and Comparative Data
Explanation

• Patients Who Leave the ED Before completion of
  Treatment
• - Data is submitted to the Maryland Hospital
  Association (M.H.A.) quality indicator
  project. The project wide data is aggregated
  by overall mean rate and best quartile (top 25
  percent). The best quartile is what we use
  for our targets for both indicators. Currently
  214 facilities participate in this indicator
  set.

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Initial Antibiotic Timing for C.A.P. lt 4 Hours
Explanation and Calculation

• Community acquired pneumonia (C.A.P.) patients
  who receive their first dose of antibiotics
  within 4 hours after arrival at the hospital.
• Data includes inpatients 18 years old or older.
• Number of C.A.P. inpatients whose initial
  antibiotic dose is administered within 4 hours
  from hospital arrival
• X 100
• Number of inpatients 18 years of age and older

• Exclusions
• Patients received in transfer from another or
  another E.D.
• Patients who have no Working Diagnosis of
  Pneumonia at the time of admission
• Patients receiving Comfort Measures Only
• Patients less than 18 years of age
• Patients whose initial antibiotic was
  administered more than 36 hours from the time of
  arrival
• Patients who have received antibiotics within 24
  hours prior to hospital arrival

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Retention Rate Explanation and Calculation

• Retention Rate 100 Terminations Turnover Rate
• Terminations Turnover Rate
  Terminations for period
• (Period is rolling 12-months)
  Active employees at beginning of the period
  
  
  Note This number is available on the monthly
  report provided to departments from Treasury
  Services

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Expenses vs. Budget Explanation and Calculation

• 100 unless Increased volume exceeds budget
  volume

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What is our Action Plan Solucient Indicators
Updated 6/07

• What is our Plan?
• DON/NM meet monthly with Fin. Rep to understand
  financial indicators
• Monitor dept volumes with Solucient data for
  trends etc
• How will we Do it?
• Review Soucient criteria to make sure data is
  accurate
• Search for like compare group
• Conference call with like hospitals if
  available
• Who will Do it?
• DON/ NM/ Financial Rep

• How will we Check to document improvement?
• Quarterly results
• How will we Act to sustain improvement?

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What is our Action Plan Expenses to Budget -
Updated 6/07

• What is our Plan?
• Monitor volume, staffing expenses
• As volume has increased admitted patients
  held in the ED, additional resources have been
  added to manage the work flow
• How will we Do it?
• Do not expect to change this indicator this
  year
• Who will Do it?

• How will we Check to document improvement?
• Make the case for additional FTEs in the
  coming year
• Monitor volume, staffing expenses
• How will we Act to sustain improvement?

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What is our Action Plan Percent of Patients EKG
within 10 minutes for MI Updated 6/07

• What is our Plan?
• Contact PI for definition parameters and
  educate staff on MI vs. STEMI
• Facilitate Physician exam of atypical chest
  pain presentations
• Utilize exam table in place in triage cubicle 2
• How will we Do it?
• Schedule additional EKG training for RNs in
  July- Sept
• Utilize triage protocols and bedside
  registration when appropriate
• Who will Do it?
• ED managers, Assistant Nurse managers and
  Clinical coordinator and RN staff

• How will we Check to document improvement?
• Monthly Crusade data and PI department data
• Chart reviews
• How will we Act to sustain improvement?
• Train ED charge nurses to perform 12 lead EKG
• Implement teams in zones as staffing permits

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What is our Action Plan Door to EKG within 10
minutes for NSTEMI Updated 6/07

• What is our Plan?
• Staff education of definition of NSTEMI
• Facilitate clinician exams of atypical
  presentation patients that triage protocols do
  not address
• Discuss with Becky Hall the defining parameters
  of NSTEMI
• How will we Do it?
• Schedule EKG training for charge RNs in July
  to Sept 07
• Set up meeting with Becky Hall to better define
  parameters and educate staff
• Who will Do it?
• ED nurse manager, Ed assistant nurse manager,
  clinical coordinator, DON emergency services

• How will we Check to document improvement?
• Monthly Crusade data
• Chart review
• How will we Act to sustain improvement?
• Train all Charge nurses to do EKGs
• Implement teams in zones

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What is our Action Plan Overtime in the Main ED
Updated 2/07

• What is our Plan?
• Convert 1.0 FTE 12 hour employees to 0.9 FTE
• Post any new 12 hour positions to 0.9 FTE
• Identify high overtime employees and reasons
• Identify 8/80 positions and convert to over 40
• Identify float employees who may be on overtime
  in their own department
• How will we Do it?
• Monitor API and Daily Census staffing grid
• Monitor hourly census trends and staff
  accordingly utilizing low census when
  appropriate
• Who will Do it?
• Ed nurse manager and assistant nurse managers

• How will we Check to document improvement?
• Overtime report
• API
• Fte/budget report
• How will we Act to sustain improvement?
• Keep all new positions over 40 and 0.9 FTE
• Monitor API bi-weekly

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What is our Action Plan Home Care instructions
Updated 6/07

• What is our Plan?
• Educate staff on scripting during discharge
  instructions to include homecare
• Educate staff on current data and make aware of
  specific questions to pinpoint
• How will we Do it?
• Promote scripting to staff via, in servicing,
  and weekly talking points during pre-shift
  briefing
• Discharge phone calls
• Who will Do it?
• ED nurse manager, Assistant nurse managers,
  clinical coordinator, Staff RN

• How will we Check to document improvement?
• Press Ganey survey returns
• Follow up call anecdotal data
• How will we Act to sustain improvement?
• Monitor anecdotal comments
• Hold staff accountable for scripting behaviors

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What is our Action Plan Overall Nursing Care
Updated 6/07

• What is our Plan?
• Contact data specialist to pinpoint survey
  questions that address this indicator
• Educate staff after data information is
  received on appropriate scripts to use
• How will we Do it?
• Pre-shift briefing weekly talking points
• Consider adding scripting to yearly competency
• Who will Do it?
• Ed nurse managers, ED staff, clinical
  coordinator, ED assistant nurse managers

• How will we Check to document improvement?
• Press,Ganey Survey
• Follow-up calls
• How will we Act to sustain improvement?
• Hold individuals accountable for nursing care
  standards by peers and ED leadership
• Maintain yearly competency on scripting

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What is our Action Plan How Well Your Pain was
Controlled Updated 6/07

• What is our Plan?
• Enact specific scripting behavior standards
  that relate to pain control
• ED leadership will participate on Pain control
  PI team
• Educate staff on pain control techniques
• How will we Do it?
• Pre-shift briefing
• Yearly competency
• Who will Do it?
• ED Assistant nurse managers, ED nurse manager,
  ED Staff, ED clinical coordinator

• How will we Check to document improvement?
• Press, Ganey Results
• Chart reviews
• How will we Act to sustain improvement?
• Hold individuals accountable for scripting
  behaviors
• Chart reviews to measure individual performance

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Our Accomplishments FY 07

• Safety
• SOMC became a tobacco free, smoke free campus on
  12/7/06
• Commercial toaster installed in the Emergency
  Department
• Please note all glass removed from framed
  documents in patients rooms in the Main Campus ED
  Apr 07
• Safety Ergonomic assessment completed May 07
• Staff education by Kim Hughes - June 07

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Our Accomplishments FY 07

• Quality
• Sign off on ED building plans
• Purchase 3rd EKG machine (f/u Chest Pain
  accreditation Visit) Staff education 9-10-06
• ENA Poster presentation by KL AH AIC
  Emergency Services Model for the Future, 9/06
• LBE report created to help with documentation
  incomplete Empower files
• ED Venoscope Transilluminator purchased
• EMPG site visit Aug 06
• Will implement an electronic data base for AIC
  patients Jan 07
• Proposal for CPOE from SOMC IS to Empower 12/06
• ESI Triage Education 12/06 Attendance 68
  implementation by 1/1/07
• 4 staff completed TNCC 12/06
• New metal linen supply cart purchased for Main
  Campus ED, January 07
• 4 staff RN educators have completed TNCC provider
  course - 12/06
• 4 staff RN educators have completed TNCC
  instructor course 2/07
• Plan to have first department TNCC course Fall
  2007, after additional requirements are completed
• Data collection for how many minutes RN and Techs
  are out of the ER Dept. working for transporter

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Our Accomplishments FY 07

• Quality
• ESI Triage went live Mar 07
• ENA presentation per MKDS Drug Dependency
  Lessons for leaders Feb 07
• Code ED Purple Jan 07
• Empower upgrade 1.6 with Physician Order Entry
  (Lab Medical Imaging) Apr 07
• Treatment Triage Project Feb, 9 shifts, with
  mid-level 2pm, to 230am March 6 shifts with
  mid-level 2pm to 230am
• 4 staff completed 12 hour PALS class
• 1 staff member competed Basic Arrhythmia
• C-Port pharmacy box in the Pyxis in acute Care
  room 2 Apr 07
• Radiolucent electrodes in the C-port box to
  decrease time to the Cath Lab May 07

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Our Accomplishments FY 07

• Service
• Meeting with Cea Elliott Cohen, 8/15/06, in
  preparation for the National Customer Celebration
  October 06
• Patient Centered Care Poster July 06 275
  attended
• PG 2nd quarter Apr-Jun 06 HCC tokens 87, Jan
  Mar 07 HCC tokens 73,
• ED Jul Sept tokens 108, Oct Dec 06 tokens
  122, Q107 110,
• ED callbacks Jul 2, Aug 1, Dec 278, Feb 07
  27, Mar 07 143, Apr 07 755, May
  07 911, June 07 - 117
• HCC callbacks Jul-204, Aug 156, Sept 143, Oct
  322, Nov 448, Dec 161, Jan 07 364,
  Feb 07 523, Mar 07 238, Apr 07 474, May 07
  - 463
• ED staff bought Christmas gifts for Hospice
  patients and families
• Sky lights added to patient rooms at ED, HCC and
  WUCC
• PG 3rd quarter tokens awarded to HCC staff 66
• Shoot cardiac commercials Feb -07

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Our Accomplishments FY 07

• Relationships
• ED Squad room printer installed Jul-06
• Make a Difference Fair, ED
• ED Policy and Procedure Manual reviewed 9/06,
  by Medical Director/DON/CNO
• HCC held 3 retreats with attendance of 39 9/06
• Going Away party for Dr. Wagenaar, Sept-06
• EOS feedback sessions held January 3 and January
  10,07. There were 8 sessions held involving all
  shifts with 77 staff in attendance
• EOS Feedback Sessions held January 3 and January
  10, 07
• Eight sessions held involving all shifts with 77
  staff in attendance
• HCC staff celebrated Employee Opinion Scores of
  99 on 3/10/07 at the Life Center with a party.
  Fifteen employees and their spouses attended plus
  one doctor and two mid-levels
• HCC Brought cookies to celebrate a Press, Ganey
  95th percentile rank in Feb. Lucky to have you
  on our team
• ED Main Campus celebrated Press, Gandy 95th
  percentile rank with a cookie/cupcake/punch
  reception for the staff.
• ED was represented at the South Webster Health
  Fair Apr 07
• Celebrate patient ending 7 years as AIC infusion
  patient May 07

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Our Accomplishments FY 07

• Relationships
• Department of Defense Names Healthcare Center and
  Southern Ohio Medical Center for Patriot award,
  related to our employee Kim Bradley, LPN May 07
• Department retreat held May 2007, 95 staff
  representing ED, HCC,WUCC and EEG attended

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Our Accomplishments FY 07

• Performance
• 3.00 Co-pay signs posted ED/HCC
• HCC Expense to Budget Jul-06
• ED overtime Jul 1600, Aug 1659
• HCC overtime Jul 99, Aug 166
• Nurse Manager meeting with Bob/coding plan
  staff meetings with Bob to maximize revenue with
  improved documentation
• Will extend mid-level hours beginning at 10am on
  Mondays and Tuesday, effective Dec 06
• Revised charge sheet for Nursing Documentation to
  increase revenue capture, especially 23 hour
  observations Dec 06
• T24 Zone and TT (Treatment Triage) data collected
  in the ED log. Mar 07

43
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