UNCH 2016-2017 Nursing Annual Report - 13

THE CAUTI BUNDLE

HOW TO SPREAD
SUCCESS,
SUCCESSFULLY

INITIATIVE REDUCED
THE INPATIENT
15%, AS COMPARED
TO THE FISCAL
YEAR IN 2015.

·

·
·
·
·

·
·
·

·

·
·

Include credible messenger from pilot during spread
Reduce amount of non-project related visual boards
in unit prior to start

Educate clinical portion first; then share lean tools
(A3/MDI) (i.e. don't roll everything out
simultaneously). Consider 'Open House' format
when appropriate
Respect for people first: don't treat mistakes
punitively



No

N/A Spread

Yes

Quality Council rep should roll new projects out to
service line during service line meetings (weekly
meetings) and then the NM/CNIV from each unit
cascades information to individual unit
Project Leads coordinate NQC to discuss project
barriers and solicit ideas for improvement
Include Flex Team rep

Pilot Unit evaluates for
spread using
Spreadability Scorecard
Spreadable?

NQC rep walk-thru SL units in to assist with MDI and
answering questions
Clinical team members study/observe what high
performing units are doing and take practices back
to their areas
Determine amount of time it will take to collect and
analyze project data - consider reducing number of
metrics when needed.

Service line

Pilot Unit pilots
innovation

Successful?

Collect final project insights (Box 9) via focus group

Present at SL leadership
meeting

or
New Knowledge to Practice Algorithm

Single SL

Yes

Process Owner presents
to SL director (using
template PPT)

No

N/A Spread

Glossary:
A3 - The lean tool used to charter, create, and
manage the outcomes of the project
Child A3 - The A3 used by Target Area leadership
which contains project information specific to each
Target Area (each Target Area has own A3)
EBP - Evidence-based practice
Executive Sponsor - The person responsible for
sponsoring the innovation intending to be spread
IHI Scorecard - Institute for Healthcare
Improvement's tool for determining if a project
should be spread
NQC - Nursing Quality Council
NQC Criteria - Organizational goal alignment
Parent A3 - The A3 used by the PL and Exec
Sponsor; contains information for global project
Pilot Unit - Unit where innovation either
originates or is initially tested
PL - Project Lead (*this person may be a quality
coach, project manager, or other expert in
managing quality improvement projects).
Responsible for managing the spread of the
innovation and ensuring regular communication
with Target Areas
Process Owner - The person responsible for the
success of the project in the affected area(s)
RCA - Root cause analysis/gap analysis (A3=box 4)
SL - Service line
Target Area - Areas selected by the Exec Sponsor
where the innovation will roll-out (once Pilot Unit
completes testing)
Target Area Leadership - Likely the nurse
manager or CNIV for area. Responsible for ensuring
roll-out of previously tested innovation in area and
communicating outcomes to PL
Template PPT - The Power Point that is to be used
for presenting the innovation to others

Process Owner
presents to
2016-2017 FISCALMult.
YEAR
NURSING
ANNUAL
REPORT | 13
SL

SL director determines
applicability (*and identifies
Sponsor & PL)

NQC (use NQC Scoring Tool)

NQC ranks presentations

ACCOMPLISHMENTS

·
·

Utilize Kaizen Coaches (MDI, data, rollout)

START: Nursing
Executive-Driven
Initiative

START: Unit-Driven Initiative

STAFF AWARDS

·

Adapted from IHI's A Framework for Spread V.7 Please send revisions to owner: Erica Wolak
← OR→

Best Practice Considerations:
Resources to consider: NPPD, Infection Prevention,
Patient representative
Complete SIPOC to identify stakeholders (reach out
early)

STAFF PROFILES

Spread of Innovations Algorithm - UNCH Nursing -

MOVING FORWARD

Spreading successful quality improvement
processes effectively is essential for
achieving system wide improvement goals
while reducing duplication of efforts. In order
to create a sustainable structure for spread,
Erica Wolak, MHA, BSN, NE-BC, coached a
team through the development of a Model for
Spread for UNC Hospitals Division of Nursing.
To test the model, the team partnered with
the CAUTI Steering Committee and together
reduced the inpatient CAUTI rate by 13% and
decreased catheter utilization by nearly 5%,
as compared to Fiscal Year 15, exceeding
project goals. Due to the initial success, this
model will now be used for future spread
initiatives throughout the Division of Nursing.

MAGNET STORIES

INFECTION RATE BY

LETTER

"



Table of Contents for the Digital Edition of UNCH 2016-2017 Nursing Annual Report

http://digital.unchealthcare.org/2021/
http://digital.unchealthcare.org/2020/
http://digital.unchealthcare.org/2019
http://digital.unchealthcare.org/2018
http://digital.unchealthcare.org/2017
http://digital.unchealthcare.org/2015
http://digital.unchealthcare.org/2014
https://www.nxtbook.com/nxtbooks/uncnursing/annualreport2013
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