1. NICU Individual Compliance Metrics Monica Larsen RN GBMC NICU

2. Objectives Name 3 reasons why the implementation of a compliance metric program supports staff engagement in NICU safety Discuss how this compliance metric program can be a segway into larger quality initiatives Describe how a compliance metric program promotes staff to staff communication and support Identify skills the staff nurse learns from participation in this program Name the outcome measurements of this NICU program

3. About GBMC’s NICU 30 Bed Level 3 NICU Opened in 1965 Prior culture of manager having a directive style New Manager Oct. 2011 with transactional style

4. NICUGoalStatusJulAugSepOct Central Line Associated Blood Stream Infection (CLABSI) ZERO 1000 Hand Hygiene 0.90 84%93%90% Proper ID Band Placement 100% 86.0%100.0% Daily Teach-Back 75% 80.0%22.0% Discharge Education Completed before discharge date 80% 66% 20.0%33.0% Care Plans Individualized80% 72%85.0%80.0% Overall Initiation Breast Feeding Rate 75% 72% 70%65.0% Exclusive breast feeding for premature infants with weight 1250 and less 90% 52%33.0%NA0.0% 2012 GBMC NICU Compliance Metrics

6. Sample of an Audit Tool

7. Visibility

8. Measurable NICU Practice Outcome

10. Performance Improvement Outcome

11. 2015 --- 100% Staff Involvement

12. What our nursing staff learned….

13. Peer to Peer Communication Increased

14. Working Together

15. Metric and Audit Tool Development and Support

16. A Sample Compliance Metric “Once a week, I will monitor that the infant’s heart rate lower limits, are set on the monitor, appropriate for the infant’s gestational age.”

17. Measurement and Analysis of Data

18. Increased Staff Nurse Satisfaction and Engagement In 2014, the Press Ganey safety survey results indicated NICU staff engagement improved significantly.

19. GBMC NICU Staff Nurses on Safety 95% I know the proper channels to direct questions regarding patient safety in this work setting.

20. Engaged Staff