90 Day Leadership Action Plan



90-Day Action Plan

(October 1-Dec 31, 2009)

Group: Partners in Improving Quality and Measuring for Excellence Date: October 22, 2009

|Category |IPCC Goals |90-Day Action Steps |Team Members |Result/Measure of Success |

| | | | | |

|Daily Goals |Achieve 100% compliance with daily goals |Identify outcomes measure (e.g., avoidable delays, |Leader: Lesta |Clearly defined measure and data collection process |

| |communication sheet |communication with sub-specialty teams, follow-through of |Jonathan Seigel |RT and CM compliance improved |

| | |goals) |Heather |No copies are being used (originals kept at door) |

| | |Determine best way to educate and encourage RTs and CMs |Jane |Revised daily goals sheet |

| | |compliance |Sara | |

| | |Refine process & form for completion with new rounds |Lupe | |

| | |structure | | |

| | |Pilot involvement of one new sub-specialty team | | |

| | |Coordinate with Rapid Response Committee to improve family|Leader: Jonathan Slagle |Improved family awareness rates |

|Partnering with |Establish a family member as part of PIQME |education |Doreen |Feedback data from families |

|Families |Achieve 100% compliance with daily |Complete information-gathering projects: survey/interview |Roger |Recommendations on FCC structure for PICU |

| |communication of goals with families and |of PICU families, lit review and FCC organization study |Hadley |Focus group scheduled |

| |patients able to participate |Plan for focus group |Ken | |

| |Increase family/patient awareness of PRRS | | | |

| |from 40% to 85% | | | |

| |Reduce average ICU length of stay by 10% |Fully implement new rounds structure |Leader: Tina |Clearly defined measure and data collection process |

|Standardizing Rounds |Improve efficiency (time) of bedside ICU |Mean length of rounds to hold steady (or reduce by 10-20%)|Benny |Rounds structure implemented and mean length reduced |

| |rounds by 30% |Determine outcome measure |Jonathan Seigel |Training video developed |

| |Improve satisfaction of staff participating |Refine data collection process (use second ½ of resident |Lesta | |

| |on rounds |rotation period) |Lindsay | |

| | |Video new structure to help with education and |Jane | |

| | |implementation |Chris, RT | |

|Infection Rates: |Decrease VAP rate per 1000 ventilator-days by|Continue hand hygiene audits |Brad (VAP) |Rates continue to decrease for VAP & CLABSI |

|CLABSI, VAP, UTI |an additional 25% |If rates increase, develop reaction plan such as root |Roger (CLABSI, UTI) |Rates showing improvement for UTI |

| |Decrease CLABSI rate per 1000 central |cause analysis |Tina Adams (as needed) | |

| |line-days by additional 25% |Include report out from Six Sigma UTI team at PIQME | | |

| |Decrease catheter-associated urinary tract |meetings | | |

| |infections per 1000 catheter-days by 10% | | | |

|Program Management |Develop a coordinated approach for |Define LOS measure for peds cardiac patients and establish|Tina, Erin, Ashley |Clearly defined measure and data collection process |

| |implementing a system-wide model to improve |baseline | |Quarterly report distributed |

| |the quality and safety of care for critically|Develop and distribute quarterly report (internal | |Communication plan implemented |

| |ill pediatric patients at the NC Children's |communication) | |IRB approval received |

| |Hospital |Meet with Karen to discuss internal and external | |Plan for sustainability efforts |

| | |communication | | |

| | |Submit IRB determination form for approval | | |

| | |Identify strategies for obtaining continued support for | | |

| | |IPCC | | |

| | | | | |

| | |Note: Operational definition for communication of daily | | |

| | |goals with patients & families to be developed next | | |

| | |quarter | | |

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