1. Eliminate VAP Coaching Call February 7, 2013

2. Objectives Share Daily Rounding Data Collection Process Methods Introduce Process Mapping Highlight Next Steps 2

3. Group Discussion When PEEP and Fi02 are measured – Who documents it? – Where is it documented? For other process measures, e.g., HOB => 30 degrees, use of oral care, etc. – Who documents it? – Where is it documented? Who enters the data into the Patient Safety and Quality portal? How do you manage coverage of these activities on off-shifts, weekends, holidays and vacations? How do you know if your process is working? Who is responsible for training the data collectors? 3

4. Process Mapping

5. Process Map Process maps (also known as process diagrams or flowcharts) allow teams to – Visualize a process – Identify the actual flow or sequence of events in a process – Identify problem areas and unnecessary steps – Come to agreement on the steps of the process – Examine which activities may impact the process performance – Compare and contrast actual versus ideal flow to identify improvement opportunities and maximize efficiency 5

6. Creating a Process Map 1.Determine the boundaries of the process – Clearly define where the process starts (input) and ends (final output) 2.Determine the steps in the process – Brainstorm a list of all major activities, inputs, outputs, transfers, handovers and decisions from the beginning of the process to the end 6

7. Creating a Process Map 3.Sequence the steps – Arrange the steps in the order they are carried out. – Sequence what is, not what should be. – Don’t draw in the arrows yet. – HAVE FUN! Consider using Post-It® Notes so you can move steps 7

8. Creating a Process Map 4.Draw the process map – Label each step in a way that is understandable to everyone. – Document who carries out the step. – Add arrows to show the direction of the flow of each step in the process. 8

9. Creating a Process Map 5.Test the process map – Validate the map. – Follow the people who carry out the process and adjust the map as needed to reflect the current process. 9

10. Creating a Process Map 6.Finalize the process map – Is this process being run the way it should be? – Are people following the process as charted? – Are there obvious complexities or redundancies that can be reduced or eliminated? – How different is the current process from an ideal one? – Draw an ideal Flowchart. Compare the two (current versus ideal) to identify discrepancies and opportunities for improvements. 10

11. Considerations Minimize the potential for staff burnout by distributing responsibilities among many. Identify which steps can be carried out by non-clinical staff and delegate accordingly. Think about how can you tweak the environment (i.e., the systems) to better support the process and minimize the likelihood for “cutting corners.” How will you know if your process is working as designed? 11

12. Take our Pit Stop challenge! Create a map or flowchart documenting your current processes for daily rounding data collection – weekdays and weekends. 12

13. You will be judged on: 1. Submitting by March 8 to kwicker@mhaonline.org or fax 410-379-8239kwicker@mhaonline.org 2. Level of detail in the process map/flowchart - Include what, how, and who - Hand-drawn maps accepted! 3. Identification of opportunities for improvement/problem areas - e.g., unnecessary steps, bottlenecks, lack of coverage, etc. 4. Description for how the process will be modified to overcome problem areas 13

14. Next Steps 1.Daily Rounding Data Collection – Continue to collect. – Submit data to Patient Safety and Quality portal https://armstrongresearch.hopkinsmedicine.org/Default.aspx https://armstrongresearch.hopkinsmedicine.org/Default.aspx 2.VAE Collection – Continue to collect. – Submit January data into NHSN when module becomes available (expected mid February) 3.Participate in Quarterly Interview 4.Accessing the Social Networking Site – Instructions available at: http://www.mhaonline.org/File%20Library/Quality/Eliminate%20Ventilator- Associated%20Pneumonia/Connecting-to-the-Social-Networking-Site.pdf http://www.mhaonline.org/File%20Library/Quality/Eliminate%20Ventilator- Associated%20Pneumonia/Connecting-to-the-Social-Networking-Site.pdf 5.Hospital Survey on Patient Safety Culture (HSOPS) – Prepare to conduct survey. – If conducted in the last 12 months, results can be uploaded to the Patient Safety and Quality portal 14

15. Next Webinar February 14 Content Call at 2:00 PM Audio: 800-779-9891 Pass code: 4757941 Web link: https://connect.johnshopkins.edu/cuspevap/ https://connect.johnshopkins.edu/cuspevap/

16. Questions? Maryland Participants – Karol G. Wicker, MHS – Phone 410-540-5056 – kwicker@mhaonline.org kwicker@mhaonline.org Pennsylvania Participants – Mary Catanzaro, RN BSMT CIC – Phone 717-756-3958 – mcatanzaro@haponline.org mcatanzaro@haponline.org 16