Norton Sound Health CorporationProviding quality health services and promoting wellness within our people and environment.

Norton Sound Health Corporation Welcome to the Norton Sound Health Corporation (NSHC), a Tribally owned and

operated, independent, not-for-profit health care organization. NSHC operates the Norton Sound Regional Hospital in Nome and clinics in the 15 villages within the 44,000 square miles that comprise the Bering Strait region. Roughly the size of the state of Ohio –

BIGGER than 16 US states

NSHC was established in 1970 to meet the health care needs of the Bering Strait region’s Inupiaq, Siberian Yupik and Yup’ik people. Its mission is to provide quality health services and promote wellness within our people and environment.

Our Core Values Integrity

Cultural sensitivity and respect for traditional values

Always learning and improving

Compassion

Teamwork

Pride

New hospital facility opened in Spring 2013

Introduced a new nursing staffing model with Nursing dedicated by unit rather than shared.

Rooms were larger and more spread apart

Rooms no longer all visible from a centralized nursing area

Increased falls with injury

18 bed Critical Access Facility

2 beds dedicated Mother/Baby

4 telemetry rooms (1 neg pressure)

Average census increases from 5 to 9 (2016-2018)

The jumper

• Implemented Post Fall Huddle

• Pat Quigley Visit

The helpful family

• Family Training• Bedside Rounding

Moving forward Other changes made toward Zero Falls with Harm:

- More patient observers

- Using lower beds/mats on floor when appropriate

- Training regarding cultural housing/sleeping patterns as well as elder care.

- in local custom it is not unusual for elders to crawl around their homes as vision and mobility decrease

- in local homes beds are very often a mattress on the floor that may be shared my multiple family members

-Training in traditional schedules and adjusting systems to match the patient rather than vis versa.

Quality ImprovementTeam

AQUUTAQ- “We cannot control the changes, but we can control the rudder”

Includes Appointed board representatives –

June Walunga (Gambell)

Mary D. Charles (White Mountain)

Matilda Hardy (Shaktoolik)

Liz Johnson (Solomon)

Al Salhin (Nome Eskimo Community)

HRSA Director – Angie Gorn (President/CEO)

HRSA Clinical Director – Dr. Gary Kulka (not pictured)

Quality Improvement/Risk Management – Megan Mackiernan, PA-C

Representatives from all units

Meets monthly

Any Questions?

Bartlett Regional Hospital

• Bartlett is a municipally owned hospital with 57 inpatient beds and 16 residential substance-abuse treatment facility beds. Approximately 55,000 people reside in our services area, with most communities inaccessible by road.

• Accredited by The Joint Commission

Insert a picture or two of your hospital & community

Sarah Hargrave, Senior Director of Quality

Your Team

• Deb Koelsch, Clinical Nurse Reviewer

• Mary Crann, Risk Manager

• Carmi Clark, Data Systems Analyst

• Charlee Gribbon, Infection Preventionist

• Ismalia Sickoria, Employee Health Nurse

• Gail Moorehead, Director of Staff Development (not pictured)

Also shown:

• Lynn Van Vector, ASHNA Director of Quality and Performance Improvement

• “Sterile Meryl,” BRH UV Light

The Chosen Measure:

◦ Why did you choose this measure? ◦ Area of opportunity◦ Progress has been sustained◦ 2 CAUTI in 2015, 1 in 2017

Scanning electron micrograph of S. aureus bacteria on the luminal surface of an indwelling catheter with interwoven complex matrix of extracellular polymeric substances known as a biofilm . Photograph from CDC Public Health Image Library: http://phil.cdc.gov/phil/details.asp

3.9

7.5

4.4

0

1.3

3.3

0

1.06

00

1

2

3

4

5

6

7

8

2010 2011 2012 2013 2014 2015 2016 2017 2018

BRH Catheter Associated Urinary Tract Infection

National Rate

Improvement Efforts

Standardization Accountability

Visual Management

Problem-Solving

Escalation Integration

3. Prompting catheter removal

1

4

3

2

1. Preventing unnecessary and improper placement

2. Maintaining awareness and proper care of catheters

4. Preventing catheter replacement

Meddings J, Saint S. (2011). Disrupting the life cycle of the urinary catheter. Clinical Infectious Diseases.52(11):1291–1293.

Mate, K.S., Rakover, J. (2019). The Answer to Culture Change: Everyday management tactics. NEJM Catalyst, online. Available at: https://catalyst.nejm.org/high-performance-management-system/

It takes a TeamWho was involved in the improvement efforts

associated with this measure?

◦ ICP

◦ Quality Director

◦ Nursing Unit Directors

◦ Staff Development Dept

◦ Products and Forms Committee (now electronic)

◦ Surgeons

How was their work organized? Tracked? Facilitated?

◦ RCA of issues surrounding increase in cases

◦ Action plan tracked and monitored

◦ ICP Determination

◦ Surprise hot button

How did you share Data?

◦ Internally:

◦ Externally:

(QBS data)

0

My Takeaways◦Determination and strategy pay

off◦Use, share evidence◦ Standardization, use of existing

workflows◦ Accountability

◦Culture eats strategy for lunch… and sometimes that really helps!

Jefferson HealthcareBrandie Manuel, MBA, CPHQ

Chief Quality Officer

◦ Located in Port Townsend, Washington

◦ Accredited by DNV◦ 25-Bed Critical Access Hospital◦ Family Birth Center◦ 24/7 Emergency Services:

12,400+ visits/year◦ Lab and Imaging Services◦ Rehab Therapy◦ Nuclear Medicine◦ Primary Care with Integrated

Behavioral Health◦ Population Health ◦ Home Health and Hospice

◦ TeleStroke◦ Palliative Care◦ Specialty Services:

◦ Anticoagulation◦ Orthopedics◦ General Surgery◦ Cardiology◦ Dermatology◦ Women’s Health◦ Oncology◦ Urology◦ Sleep Medicine◦ Dental ◦ Express Clinic

PATIENT SAFETY & QUALITY

TEAMLeft to Right:

Tracie Harris, MD, FACP, Laura Showers, Infection

Preventionist, Brandie Manuel, CQO, Joe

Mattern, MD, Gin Rourke, Christine Curtis

Not Pictured: Cindy Hansen, Data Analyst,

Rebecca Strona, RN

The Chosen Project: c. diff-erently

Antimicrobial Stewardship Team

2015

Great News! Days of Therapy Decreased

2016

Wait – what?! C. Diff cases increased

2016

A deep dive: understanding our data

2017

c. Diff Task Force Created

2017

Engage, implement, coach, test, study: Wash, Rinse, Repeat…

2018

Results! Reduction of reportable c.diff events

2019

Improvement EffortsCore

ConceptsTeamwork

Data-Driven

Culture of Safety: Open Communication

Identification of Root Causes

Factors Identified

Equipment: Epic!

Systems: Training, Education, Policy

Human Factors: Communication

Good Intentions

Strategies Tested

Change to Epic algorithm

Staff and Provider Training and Education

Created a hard stop in lab (based on specimen)

with feedback loop

Changed Testing Algorithm

Seek first to understand…

• Learn: What is the story behind the numbers?

• Ask/Observe: What is current practice?

• Ask: What is expectedpractice? (Policy Review)

• Study: What is BESTpractice?

• Engage: Share information with key stakeholders

• Identify: Concrete next steps, goals, and timelines

It Takes a TeamWho was involved in the improvement efforts associated with this measure?

Team Members Role

Laura Showers, Infection Preventionist

Team Lead; Content Expert

Brandie Manuel, CQO Executive Sponsor

Tracie Harris, MD, Chief of Medicine

Physician Champion

Magdy Kandil, Lab Supervisor

Content Expert

Cindy Fox, Inpatient Nursing Director

Nursing Champion

How was their work organized? ◦ Meeting Frequency: Monthly◦ Reporting To: Antimicrobial Stewardship Team◦ Goal: Eliminate Hospital Acquired C.Diff◦ Metrics:

◦ C.Diff◦ Appropriateness of lab orders◦ Education and Training attendance

◦ Organization of Work:◦ Deference to Expertise/Engagement◦ Data collection and reporting◦ Teamwork and Motivational Task Design◦ Feedback: Case Study

◦ Project Management: Standard tool for tracking action items

How did you share Data? ◦ Internal Reporting:

◦ Dashboard

◦ Board Reports

◦ Email

◦ Visibility Boards

◦ Newsletters

◦ Safety Huddles and Team Meetings

◦ External Reporting:

◦ Benchmarking (WRHC)

◦ NHSN

◦ WSHA

Lessons Learned &

Key Takeaways

GOALS: FIND A SHARED PURPOSE EARLY

PHYSICIAN LEADERSHIP IS KEY

LISTEN WITH CURIOSITY

TOOLS DESIGNED TO MAKE US SAFER DON’T ALWAYS MAKE US MORE SAFE

SALY IS A DUMB RULE

QUALITY IS NOT (NECESSARILY) THE EXPERT AT THE TABLE

CELEBRATE!

How do we know Quality Efforts are being embedded within our organizations?

Embedding Quality Throughout the Organization◦ Quality – top down and ground up◦ Connect staff and providers at all levels with quality data◦ …which means allowing them to define quality. Sort of.

◦ People: Hire slow and fire fast ◦ Leadership: Development, Training, and Engagement◦ Internal Audits: Through the Eyes of a Surveyor◦ Staff: Find the pebbles in their shoe and help eliminate them◦ Patients: Bring patients to the table – Really!◦ Providers: set expectations, and be willing to incentivize◦ Contract Review and Community Partnerships

What has happened to validate your success?◦ Culture Change and Increased Team Engagement

◦ Internal Audit Process: Success!◦ Continuous survey readiness

◦ Patient and Family Advisory Council

◦ Shift in community discussion

◦ Improved compliance with best practice

◦ Improved patient experience

◦ Improved outcomes

◦ February 2019 Release: CMS 5-Star Rating

How do you know quality has been integrated?

Going well Needs Improvement

Beyond the walls

Front-line Involvement

Back to Basics

Leadership Participation

Results

Safety Huddle

How Do You Know?

Integration of Quality:

◦ We ask (and sometimes we don’t)

◦ When improvements are made with (and not for) our patients and bedside staff

◦ The flywheel starts to turn

◦ When your data team (almost) can’t keep up with the demands

◦ Improved outcomes!

Failure to Integrate:

◦ Tasks are not completed

◦ Staff haven’t heard about the project/initiative

◦ The dial doesn’t move

◦ Changes don’t stick

◦ Failure to report issues

◦ Quality owns it all

How does organizational Structure affect your quality efforts?

Organizational Structure – Communication Flow

Dept. Priorities

Performance Improvement Committee

Hospital Board

Board

Strategic Plan

Projects

“Sharp end” of care

Organizational Structure & Communication Flow

What role does organizational structure have on quality efforts?

◦ Quality reports to the CEO

◦ Board presence on key committees

◦ Staff and Patient presence on key committees

◦ How does flow of communication between departments have an affect your quality management?◦ Leverage different communication styles

◦ Face to face is best

◦ COLA: Communicate out loud always

◦ Pictures can be worth 1,000 words

CEO

CFO CMO CNO CQO

Data Analysts Clinical Informatics

Infection Prevention Accreditation Education Performance

Improvement

CHRO CAMGO

Hospital Commissioners

Operations

Final thoughts◦ Situational Awareness is the key to the kingdom◦ Find the pebbles in the shoes of the staff and providers◦ Also – don't trip on the boulders

◦ Correlation doesn't always mean causation◦ Resist the temptation to solve 'problems'...seek to understand them

◦ OVER Communicate. Then communicate more.◦ Create a burning platform◦ Look at issues differently – and make them personal

◦ Quality might not be at the table when quality improvement takes place (and that's okay!)

Final thoughts… start and end with the whyAnd, we will celebrate. Starting with pizza and ending with champagne. We will celebrate ourselves because the patients whose lives we save cannot join us, because their names can never be known. Our contribution will be what did not happen to them. And, though they are unknown, we will know that mothers and fathers are at graduations and weddings they would have missed, and that grandchildren will know grandparents they might never have known, and holidays will be taken and work completed and books read and symphonies heard and gardens tended that, without our work, would have been only beds of weeds.-Donald Berwick, December, 2004