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[pic] Sustainability Action Plan [pic]

Below is a sample of a continuous action plan template created by Baiba Zarins, Project Manager, Best Practice Guidelines, University Health Network, Toronto, Ontario. The plan depicts the identified sustainability indicators utilized within a large acute care hospital to monitor the sustainability of simultaneous BPG integrations.

Each row identifies a particular indicator established as a unique measure, as applicable within multiple levels of the organization. Within each column are identified measures used to ascertain multiple points of sustainability monitoring within each BPG. This tool is useful for internal monitoring, revision and evaluation of BPG status, particularly with respect to the introduction of future guidelines. A long-term consideration of this table includes comparison of interrelated BPG benchmarks when strategizing efficiency and outcome effectiveness over time.

University Health Network is a designated RNAO Best Practice Spotlight Organization and is actively involved in the development, pilot testing, implementation and evaluation of numerous RNAO BPGs.

|BPG topic |Pain |Fall safety and restraints |Pressure ulcers |Vascular access |PCC |

| |Patient Resource Network |Clinical Educator packages: |Wound Care Resource Nurses|Vendor education sessions |Corporate PCC integration team |

|Implementati|(4-8hr. sessions) | |(4-8hr. sessions) | | |

|on and | |Power point | |Clinical educators |UHN PCC Toolkit for Managers (2003) |

|Evaluation |VAS signage | |Product chart on intranet | | |

| | |Staff pocket cards |site |PICC insertion Midline insertion |PCC integrated within all HR, clinical |

| |“No Pain” signage & lapel | | |by trained staff |and research process |

| |buttons |Documentation samples |Vendor sponsored unit | | |

| | | |in-services |Hospital orientation |Role description |

| |Pain awareness education to |Hospital orientation | |Presentation | |

| |transportation and volunteer |presentation |Hospital orientation | |Interview |

| |services | |presentation |PMH Clinical Vascular Nurse |Consent |

| | | | |Resource |Clinical doc |

| |Equianalgesia chart | |APN Clinical Resources | | |

| | | | |Corporate Clinical Resource |Patient, staff, family Education |

| |Quarterly site based Lunch & | |Heel Boots implementation | | |

| |Learns | |(summer 2005) |CVAD care and maintenance review |PCC clinical rounds |

| |(vendor sponsored) | | |for oncology patients (2010) | |

| | | | | |Staff Education: Lunch/Learn, calendar,|

| |Interdisciplinary Pain Rounds | | | |3 day comp, |

| |(monthly) | |UHN Mattresses Replacement| |Customized |

| | | |project | | |

| |Hospital orientation | |(spring 2006) | |High Impact Strategy: PCC Acceleration |

| |presentation | | | |Initiative |

| | | |UHN Stretcher surface | |2007 |

| | | |replacement project | | |

| | | |(Spring, 2010) | | |

| |Pain management strategies | | | | |

| |within unit goals & objectives | |ICU (TWH Site) therapeutic| | |

| | | |surface replacement | | |

| |APN | |project (Spring 2010) | | |

| |Clinical Resources | | | | |

| | | |Digital Signage content | | |

|Integration |Numeric Rating Scale (NRS) |Morse Fall Risk Assessment |Braden Pressure Ulcer Risk|Vascular Access Flow sheet |PCC extended and accelerated course via|

|Tool |within UHN standardized | |Assessment | |HR |

| |documentation tools: |Patient Care Record | |Vascular Device Clinical | |

| | | |Patient Care Record |decision-making chart |Site/program/unit initiatives and |

| |VS record |UHN Incident Report |Tick box | |quality teams |

| |Neuro record | | |Proposal for infusion therapy | |

| |PCA | | |nurses for TGH and TWH sites |Unit/team charters, goals and |

| |PCEA | | | |objectives |

| |Epidural | | | | |

| |ICU/ACU flow sheets | | | |UHN Balanced Scorecard indicator |

| | | | | | |

| | | | | |Embedded within: |

| | | | | |Job Postings |

| | | | | | |

| | | | | |Interview questions |

| | | | | | |

| | | | | |Performance Evaluation |

| | | | | |System |

| | | | | | |

| | | | | |Employee Opinion Survey |

| | | | | |(annual) |

| | | | | | |

| | | | | |PCC Competencies and Standards |

| | | | | |Checklist |

| | | | | | |

| | | | | |Code of Conduct |

| | | | | | |

| | | | | |Workplace Ethics |

|Clinical | | | | |PCARE clinical model |

|standards |VAS and pain management plan |Risk Assessment and |VAC dressing criteria |Vascular Access Device | |

|(link with | |prevention plan |Skin Assessment and risk |decision-making algorithm |UHN PCC Standards |

|e-doc) | | |prevention plan | | |

| | | | | |PCC Doc. Guidelines |

| |3 modules: | | | | |

|e-learning |Case Studies |1.Morse Fall Scale |Braden Scale |1. Assessment for device |1 module |

|strategy |1. Assessment |2. Use of restraints at UHN |Skin breakdown |2. Maintenance |1. focus charting |

| |2. Post-op | | |Troubleshooting | |

| |3. Acute on chronic pain | | |Infusion Pumps |e-Learning Module Fall 2010 |

| | | | |central line infections |Collaboration York U-UHN Academy |

|Medical |Not legislated within scope of |May 2005-restraint |January 2005 |Feb 2003- |Not applicable |

|directive |practice |application |Treatment for Stage 1 & 2 |Heparin lock | |

| | | |ulcers | | |

| | | | |TVKO conversion to saline lock | |

| | | | | | |

| | | | | | |

| | | | | | |

| |(2003-2010) |May, 2005 |Sept 2005 |February 2003 |PCC Visiting Policy |

|Clinical |Pain Management |Fall prevention linked with |(updated to include |(update pending) |2009 |

|Policy | |revised restraints |current changes with |Vascular access: initiation, | |

| |PCEA |minimization policy |supplies & dressing |maintenance, troubleshooting |Care Provider Preference |

| |PCA | |options) |Occlusion intervention |2009 PCC |

| |(2009) | |Heel boot policy pending | | |

| | | |VAC dressing | | |

| | | |criteria/policy pending | | |

| |Extensive and multilingual on |Fall Safety in hospital | |Implanted Central Vascular devices|Digital signage |

|Patient |internal & external websites | |Caring for your skin | | |

|Education | |Fall Safety in the home | |PICC catheter |PCC Intranet |

|Network |Pain Management |brochure |Incontinence products | | |

|Materials |Procedural Pain | | |Intravenous Therapy-All you need |UHN Annual report |

| |Adjunct therapy |Restraints utilization |Nutrition and Wound |to know about your central venous |UHN Nursing report |

| |Alternative therapy |information sheet |Healing |catheter |Allied health Report |

| | | | | | |

| | |Falls Prevention Program |Pressure Ulcer Prevention |Intravenous Therapy |(posted for public) |

| |Internal |(referral service) | | | |

| |Patient-Education TV episode | | |Medication Fact Sheets |PCC-what it means to me |

| |(2010) |Protecting yourself from |Infection Prevention | | |

| | |Falls | |Needle Safety at home |PCC-UHN video series |

| | | | | | |

| | | | |Vascular Access for Haemodialysis |Health Literacy for patients and their |

| | | | | |families |

| | | | |Infection Prevention and control | |

| | | | | |PCC-Working Together |

| | | | | | |

| | | | | |PCC info kiosks (PMH) |

| | | | | | |

| | | | | |PEN Library at each hospital site |

| |Chart Audits-June 2005 |Clinical Audit |Annual P & I |Creation of datasets and building |UHN Balanced Scorecard |

|Evaluation | |November 1 2005 |Data collection in |EPR around required outcomes to | |

| |Patient Satisfaction surveys |and Nov. 2006 |November |ensure future quality data. |Picker tool/patient satisfaction scores|

| | | | | | |

| |Nurse satisfaction surveys |Report directly to UHN |Report directly to UHN |Balanced Scorecard-Central Line |EOS |

| |(telehealth Northern network |QCC-Risk Management |QCC-Risk Management |Infection | |

| |system) | | | |UHN Balanced Scorecard |

| | |UHN Performance Indicator |UHN Performance Indicator |Task force on CLI (Safer | |

| |Pocket Pain Assessment Cards | | |Healthcare Now!) |Patient Relation Complaints |

| |(February 2006) | | | | |

| | | | | |Patient narratives |

| |PRN focus group November 2005 |UHN out-patient fall safety |P & I tool |UHN performance measurement data: |Patient focus group |

| | |clinic through Senior’s |validation-UHN/SMH/Sunny- |infection/complication rate | |

| |Staff knowledge & attitudes |Wellness Clinic (TWH) |brook collection tool | |Accreditation standard |

| |survey | |study |Continual review of published | |

|Research and | |Annual in-patient clinical | |research. |Best of Nursing Research Study (2009) |

|Quality |UHN patient satisfaction data |audits: November |UHN performance | | |

|Assurance | | |measurement data |NBPRU collaboration-Validation of |Patient Virtual focus group |

| | |UHN incident report tracking | |Phlebitis and Infiltration Scale | |

| | |data with quarterly reports | |(2010) |HBT PCC 80/20 |

| | |to UHN QCC | | | |

| | | | |PICC insertion at point-of care |High Impact Strategy: PCC Acceleration |

| | | | |(CVICU-pilot project) |Initiative |

| | | | | | |

| | | | |Infusion pump utilization review |Nursing Research Challenge Studies |

| | | | |and future needs (Smart pumps) | |

| | | | | | |

| | | | |Collaboration with CVA-GTA chapter| |

| | | | |meetings (UHN. president) | |

| | | | | | |

| | | | |Safety Engineered Device Review | |

| | | | |and New Product Trial (2010) | |

| |Corporate Priority |Liaison with DDD group RE: |New mattress |On-going new product |Imbedded in work of all BPG integration|

|Comments | |safety measures and policies |trials/evaluation/purchase|trials/evaluations | |

| |Funding-Krembil Neurosciences | |project-need done by March|Safe needles |Patient Safety |

| |for focus group study | |31, 2006 |Pumps | |

| | |ACPF 2009: | |Intravenous tubing |Patient Diversity |

| |Publication 2009 (Oral PCA) | |Link with Pain | | |

| | | | |Link with Pain |Wireless Internet Access |

| |ACPF: | |Publication 2007 | | |

| |2004, 2008 | | |Publication 2009 |Public Computer stations in waiting |

| | | | | |areas |

| | | | |Global spread teleconference: | |

| | | | |dissemination of BPG |Communication discs for |

| | | | |teleconferencing. |surgical/procedure families (TWH) |

| | | | |(2009) |ACPF: 2004 |

| |Corporate and Nursing Intranet |Merge with Falls = UHN |Skin and Wound care BPG |UHN Vascular Access home page |Corporate and Nursing sites |

|UHN Website |site |Confusion Management and Fall|home page on intranet | | |

| | |Prevention committee | |UHN Digital Signage info (new VAD | |

| |UH Digital Signage info (2010) | | |Dressings) April 2010 | |

|UHN Contact | | | | | |

|Liaison |Corporate Pain APN | |UHN Skin and Wound Care |Corporate Vascular Access |Corporate PCC Implementation Team |

| | |Contact Information |Leadership Team |Coordinator | |

| |Contact Information | | | |Contact Information |

| | | |Contact Information |Contact Information | |

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