Engaging the Nurse, Physician, Patient/Family, CUSP- Learn From Defects

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Engaging The Nurse, Physician, Patient/Family; CUSP – Learn from Defects

Jenny Tuttle, RN, MSNEd, CNRN
Clinical Nurse Leader
Neuro/Medical/Surgical ICU
Tucson Medical Center
Tucson, Arizona

Christin Ko, MD, MBA, SFHM, FACP
Assistant Professor
Feinberg School of Medicine
Northwestern University
Chicago, IL

Images: Photos of the 2 presenters.

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Sue Collier, MSN, RN, FABC
Clinical Content Development Lead
Health Research & Education Trust
American Hospital Association

Emily Pasola MSN, RN, CNL
Clinical Nurse Leader
Surgical Intensive Care Unit
Saint Joseph Mercy Hospital
Ann Arbor, Michigan

Images: Photos of the 2 presenters.

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Learning Objectives

  • Define nurse, physician, and patient and family engagement.
  • Describe the benefits and examples of engaging key team members as partners in reducing CAUTI in the ICU
  • Identify the key elements of the CUSP: Learning From Defects process and how it can be used to improve performance
  • Identify the scope, and challenges and solutions around physician engagement

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Case Study

  • 08/02/12 – Ms. C is a 66 y.o. who is in the OR for an exploratory lap. An indwelling urinary catheter was inserted in OR. Ms. C was transferred to ICU post-op. Nurse OR gave report to Nurse ICU.
  • 08/03/12 – Ms. C is stable. The  indwelling urinary catheter is still in place. Ms. C’s son has been with her since surgery, but he has not been included in any rounds with the nurses or physicians, because they occur outside of visiting hours. Daily rounds and morning huddle did not include assessment of the indwelling catheter.

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Case Study

  • 08/04/12 – Ms. C is febrile (38.9°C) and complains of diffuse abdominal pain. WBC has increased to 19,000. She has cloudy, foul-smelling urine and urinalysis shows 2+ protein, + nitrite, 2+ leukocyte esterase, WBC – 15/mm3 of unspun urine and 3+ bacteria. Urine culture was 10,000 CFU/ml E. coli. The abdominal pain seems localized to the surgical area.
  • 8/04/12 – Ms. C is diagnosed with a CAUTI by the attending physician. The physician ordered a course of antibiotics. During morning huddle the infection preventionist reviewed the prevalence of urinary catheter use. Several staff indicated that a higher prevalence of UTI in the ICU is not unusual. When Ms. C’s son was at the bedside during visiting hours, he stated he was angry and concerned that his mother has an infection.

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How Might Nurse, Physician, and Patient/Family Engagement Impact This Scenario?

Consider these three elements as we discuss engagement of each role (nurse, physician, patient/family):

  • Concerns/fears: What might be some unique issues or concerns each role has relative to UC?
  • Skills/Knowledge (e.g. communication skills, information/education): What do they need to know to adopt new practices and to be confident it’s the right thing?
  • System support (policies, protocols, check lists, teamwork): What can the system do to promote evidence-based practice and a culture of safety?

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Reducing CAUTIs: Nurse Engagement in the ICU

Jenny Tuttle, RN, MSNEd, CNRN
Clinical Nurse Leader
Neuro/Medical/Surgical ICU
Tucson Medical Center
Tucson, Arizona

Image: Photo of the Tucson Medical Center sign.

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Laying the Groundwork

  • Education to staff:
    • Who = Case Studies, Current unit data
    • What = Making clear goals, protocols and expectations
    • Where = Unit specific? Department?
    • When = Rounding, every shift
    • Why = Provide the stats, harm, cost

Image: Poster which says "Fright Fact: An estimated 13,000 deaths annually are attributed to urinary tract infections. #ERASECAUTI".

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Providing the Tools to Succeed

  • Review of current supplies
  • Listen and identify opportunities to make workflow easier:
    • Extra techs?
  • Give staff an opportunity to be apart of the decision making.
  • It may cost more in supplies but every CAUTI avoided is worth it
  • Reminders – flyers, t-shirts, slogan, computer based assessments

Image: Poster which is titled: "Don't Be Naughty! Prevent CAUTI!".

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Making Staff Accountable

  • Are they following your hospital based guidelines?
    • Auditing/survey – asking open questions
    • Nursing based - Urinary insertion/removal protocol
  • Providing current data:
    • Bulletin board
    • Unit newsletter

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Acknowledge the Success

  • Rewards:
    • Even small rewards stand out
    • “High five”
  • Sunflower” (North Shore University Hospital, NY)

Images: Photos of four health professionals who were acknowledged for their success. On the right side of the slide is a smiley face with two hands in a "thumbs up" position with the words "Great Job!" above it.

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Attaining Physician Engagement: From the Medical Executive to the Individual Physician

Christin H. Ko, MD, MBA

Image: Photo of two men shaking hands - one in a formal suit, and the other wearing a lab coat.

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Agenda

  • Definition of Physician Engagement
  • Scope of Physician Engagement
  • Challenges around Physician Engagement
  • Solutions: General and Specific
  • Putting It All Together: Scenario-Solution Summary

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Definition of Physician Engagement

  • An intentional and deliberate process
  • To bring physicians and other stakeholders together
  • To address problems and continuously improve care and the patient experience

Image: Photo of a hospital staff meeting.

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What it Looks and Feels Like

  • Invest their Time
  • Curious
  • Enthusiastic
  • Contribute
  • Influence Others

Adapted from J. Silversin

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Why Does It Matter?

Evidence Links Physician Engagement to:

  • Better Outcomes
  • Greater Impact on Quality and Safety
  1. Dickinson H et al. Engaging Doctors in Leadership: Review of the literature. University of Birmingham 2008
  2. Reinertsen et al. Engaging Physicians in a Shared  Quality Agenda. IHI Innovation Series White Paper. Cambridge, MA IHI 2007
  3. Ham C et al. Engaging Doctors in Leadership: What Can We Learn from International Experience and Research Evidence? University of Birmingham 2008

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Scope of Physician Engagement

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Scope of Physician Engagement

Image: This is a diagram which shows the relationship between physician stakeholders including medical executives, physician champions, and individual physicians. The different types of stakeholders are broken down into even more descriptions.

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Challenges Around Physician Engagement

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Challenges Surrounding Physician Engagement

  • Institutional Culture:
    • Different Incentives and Goals from Physicians
    • May See Physicians as Barriers
  • Physician Culture:
    • Trained to be Autonomous and Independent
    • Medico-legal Concerns
  • Physician Worklife:
    • Limited Time
    • Attend at Several Hospitals
    • Not Hospital Employees
    • Not Aware of Projects
    • Lack of QI Skills

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Solutions: General

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Solutions: 3 General Approaches

Image: Circle with 3 rings in it. The inner ring has text pointing to it that says "CUSP Model: 4E's", the middle ring is "IHI Approach: 6 Elements", and the outer ring is "6 Drivers".

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10 Hospitals Study: 6 Drivers

Image: Diagram showing the 6 drivers leading to strong physician engagement. The drivers are: Relalignment of Financial Incentives, Data and Enablers, Academic Promotion, Physician Compact, Appropriate Compensation, and Engaged Leadership.

Taitz, JM et al. BMJ Qual Saf 2012

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IHI Approach: 6 Elements

Image: Diagram showing the 6 elements of engaging physicians in quality and safety, which are: Discover a Common Purpose, Reframe Values and Beliefs, Segment the Engagement Plan, Use Engaging Improvement Methods, Show Courage, and Adopt an Engaging Style. In the center of the diagram it says "Engaging Physicians in Quality and Safety".

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Discover A Common Purpose

Image: Venn diagram with a stethoscope in one oval, and a hospital symbol in the other. In the intersection is the text:

  • Good Patient Outcomes
  • Improved Efficiency
  • Excellent Reputation
  • Greater Cause

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Reframe Values and Beliefs

View Physicians as Partners

Image: Photo of hands shaking - one in a doctor white coat, the other in a suit.

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Segment the Engagement Plan

  • Early Adopters
  • Hospitalists
  • Infectious Disease
  • Nephrologist
  • Surgeons
  • Urologists

Pareto Principle

Image: Diagram showing that 20% effort leads to 80% better results.

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Use Engaging Improvement Methods

  • Use Data for feedback: rapid cycle
  • Use Data to generate awareness, not to inflame
  • Show Evidence-Based Guidelines as needed

Image: Line graph showing theoretical results in implementing a CAUTI reduction program.

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Show Courage

Image: Photo of a penguin holding a pair of cymbals on top of a sleeping polar bear.

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Adopt an Engaging Style

  • Involve Physicians from the Beginning
  • Build Trust
  • Communicate Often
  • Value Their Time

Image: Photo of a group of smiling health professionals.

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CUSP Model: Engage Physicians Using the 4 E’s

Engage (Adaptive): How does this make the world a better place?

Educate (Technical): What do we need to know?

Execute (Adaptive): What do we need to do? What can we do with our resources and culture?

Evaluate (Technical): Hogw do we know we improved safety?

Adapted from: Pronovost PJ, Berenholtz SM, Goeschel CA, et al. Creating high reliability in health care organizations Health Serv Res 2006;41(4, pt 2):1599-1617.

Image: Three gears interacting. They are labeled: Medical Executive, Physician Champion, and Individual Physician.

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Solutions: Specific

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Physician Stakeholders

Image: This is a diagram explaining the scope of physican engagment. It describes the different types of physican stakeholders, including the medical executive, physician champion and individual physicians.

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Medical Executives & Medical Executive Committee

  • Consider Cultural Assessment
  • Present Data on CAUTI: Initially and Regularly"
    • Prevalence
    • Morbidity
    • Mortality
  • Present the Business Case for CAUTI Prevention:
    • CAUTI Cost Calculator
    • LOS Reduction
    • CMS Non-reimbursement Policy for HAI

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Physician Champion: Choosing One

  • Respected Clinician
  • Courageous and Sociable
  • Good Communication Skills
  • Motivated – Internal Engine
  • Consider Hospitalists, Infectious Disease, Urologist, Nephrologist, Geriatrician, Hospital Epidemiologist

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Physician Champion: Roles and Responsibilities

  • Communicate to other physicians
  • Education of medical staff about the appropriate indications for urinary catheter use
  • Assist with development of processes
  • Assists with implementation of technical and adaptive components
  • Assist with physician barrier removal
  • Urologist, infectious disease specialist, hospitalist, quality/patient safety officer or any physician interested in improving safety and quality

Fakih, Mohamad. Building a Team and Process to Reduce CAUTI Risk. On the CUSP: Stop CAUTI Cohort 5 Onboarding Call #1; 2012. http://www.onthecuspstophai.org

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Physician Champion: Equipping and Supporting

  • Provide Materials and Resources
  • Provide Leadership Support
  • Connect with Early Adopters and Supporters
  • Have a  Communication Plan
  • Consider Incentives/Recognition/Reward

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Sample Script

  • “I understand you feel that way, Bob. The evidence isn’t perfect. But it never is, is it?
  • And the leading minds - the CDC, AHRQ and the IDSA - have all recommended we make this change.
  • I don’t think we’re going to reinvent science here at this hospital and I think we should adopt these changes.
  • Sure, there might be risk in making the change but we’ve seen the evidence of the harm that’s occurring with our current approach.
  • What is the risk to our patients of not making the changes?”

Adapted from IHI

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Individual Physicians: General Physicians and Specialists

  • Make it As Easy as Possible
  • Involve Early in Decisions: Design and Plans
  • Physician Champion Presentation at Staff Meetings
  • Provide Data and Feedback
  • Appeal to Professional Pride
  • Engage Medical Leadership support, eg Chief of Staff
  • Use Scripts to Engage
  • Frame it:  “WIIFM”
  • One on One Education
  • Listen Carefully
  • Ask: “What will it take for you to Participate or Commit”
  • Rewards/Recognition

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Individual Physicians: Surgeons

A Chief of Staff and a Surgeon: “ Surgeons are very tribal… so what you need to do if you have something you think is a best practice at your hospital… you need to get….either the Chair of Surgery or some reasonable surgeon…If you come in and you’re an internist… into a group of surgeons…the first thing we’re going to do is say ‘Look, you’re not one of us’…the way to get buy-in from surgeons is you got to have a surgeon on your team”.

Saint et al. Joint Comm Journal Qual Safety 2009

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What NOT to do……

  • Use Inflammatory Language: Message Carefully
  • Adopt “One Size Fits All” Mentality
  • Use Only Educational Material/Meetings
  • Give Up

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Putting It All Together: Scenario – Solution Summary

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Engagement Level Problem Scenario Solution
Medical Executive Committee Leadership Does Not see CAUTI as a Priority. Part I
  • Consider Cultural Assessment
Medical Executive Committee Leadership Does Not see CAUTI as a Priority. Part II
  • Prepare and present a good business case
  • Remind about the CMS nonpayment rule
  • Give monthly CAUTI/catheter prevalence data
  • Consider a Physician Compact/Written Engagement Plan
Physician Champion Choosing a Physician Champion
  • Choose courageous and social communicators
  • Consider Hospitalists, ID, urologist, nephrologist
Physician Champion Equipping a Physician Champion
  • Support from Leadership
  • Provide Evidence based Resources and Data/outcomes
  • Connect with Early Adopters
  • Craft a Communication plan
Individual Physicians: Non-Surgeons Lack of Buy-In to New Practice
  • Make it As Easy as Possible to do the right thing
  • Involve Early in Decisions: Design and Plans
  • Physician Champion Presentation at Staff Meetings
  • Provide Data and Feedback
  • Engage Medical Leadership support, eg Chief of Staff
  • Use Scripts to Engage
  • Frame it: "WIIFM"
  • One on One Education
  • Listen Carefully
  • Ask: "What will it take for you to Participate or Commit"
  • Rewards/Recognition
Individual Physicians: Non-Surgeons Resistance to Early Indwelling Urinary Catheter Removal
  • All of the above plus:
  • Engage medical leadership support ie Chief of Surgery
  • Participate in SCIP initiative
  • Engage a surgeon or urologist as a champion/team member
  • Leverage organizational policies
  • Consider Posting Data on Individual Physicians: only if culturally correct

Adapted from Catheterout.org

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Patient and Family Engagement

Sue Collier, RN, MSN, FABC
Clinical Content Development Lead
Health Research & Education Trust
American Hospital Association

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Patient and Family Engagement (PFE)

Consider these three elements as we discuss engagement of the patient and their family:

  • Concerns/fears: What are their unique concerns or issues?
  • Skills/Knowledge: What do they need to know to be part of the team?
  • System support: What can the system do to promote PFE?

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PFE Defined

Definition of patient and family engagement.

"Patient and family engagment is defined as patients, families and their representatives, and health professionals working in active partnership at various levels across the health care system - direct care, organizational design and governance, and policy making, to improve health and health care."
Carman et al., 2013, Health Affairs

Images: 3 photos of patients and families engaging with health professionals.

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Image: Top of a journal article titled: "Evidence Boost: A Review of Research Highlighting How Patient Engagement Contributes to Improved Care". The author is G. Ross Baker, Ph.D. August 2014

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Creating the Environment for PFE

  • Mutual respect for skills and knowledge
  • Honest, clear, two-way communication
  • Understanding and empathy by being accessible and responsive
  • Mutually agreed upon goals through joint planning and evaluation
  • Shared planning and decision-making (doing things with patients-families, not for or to them)

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Examples of PFE Practices

  • Including patient/family in rounds
  • Supporting family presence
  • Including patient/family in CAUTI prevention education
  • Sharing patient stories in quality team meetings
  • Developing Patient-family advisor roles and councils
  • Encouraging Patient Advisors to serve on safety and quality performance improvement teams

Images: 3 photos of patients and families engaging with health professionals.

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SSCM and AACN PFE Initiatives

SCCM

  • Project Dispatch (Disseminating Patient-Centered Outcomes Research to Healthcare Professionals)
  • THRIVE project (effects of ICU)
  • ACCCM Statement on EOL Care in ICU
  • Podcasts (Family Presence, Family-centered rounds, Integrating communication bundles)

AACN

  • Scope & Standards for Acute & Critical Care Nursing Practice
  • Practice Alert: Family Presence During Resuscitation and Invasive Procedures
  • Clinical Practice Guidelines for Support of the Family in ICU

Images: Screen shots of publications from Society of Critical Care Medicine (SCCM) and American Association of Critical Care Nurses (AACN).

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Your Organization's PFE Practices

  • How does your organization demonstrate the principles and practices of patient and family engagement in infection prevention, especially CAUTI prevention?
  • What is your organization’s long-term plan to advance patient- and family-centered care across all areas of patient safety, especially CAUTI prevention?
  • Who is guiding your unit’s or organization’s efforts in this area?

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Selected Resources For Engaging Patients and Families as Partners in Safety

AHRQ CUSP Toolkit, Patient Family Engagement. Retrieved from http://www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/modules/patfamilyengagement/index.html.

Association for Professional in infection Control and Epidemiology. Patient safety resources for consumers. Retrieved from http://www.apic.org/For-Consumers/Patient-safety-resources.

Institute for Patient and Family Centered Care. Retrieved from http://www.ipfcc.org/advance/topics.html.

Centers for Disease Control and Prevention. FAQs about Catheter-Associated Urinary Tract Infection. Retrieved from http://www.cdc.gov/HAI/ca_uti/uti.html

Carman KL, Dardess P, Maurer ME, Workman T, Ganachari D, Pathak-Sen E. A Roadmap for Patient and Family Engagement in Healthcare Practice and Research. September 2014. www.patientfamilyengagement.org and  http://patientfamilyengagement.org/#sthash.ACZ81zY8.dpuf

Reinertsen JL, Bisognano M, Pugh MD. Seven Leadership Leverage Points for Organization-Level Improvement in Health Care (Second Edition). Cambridge, Massachusetts: Institute for Healthcare Improvement; 2008. Available on www.ihi.org

Guide to Patient and Family Engagement in Hospital Quality and Safety, Rockville, MD; Agency for Healthcare Research and Quality; May 2013, AHRQ Publication No. 13-0033. http://www.ahrq.gov/professionals/systems/hospital/engagingfamilies/index.html

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Learn From a Defect

Emily Pasola MSN, RN, CNL
Clinical Nurse Leader
Surgical Intensive Care Unit
Saint Joseph Mercy Hospital
Ann Arbor, Michigan

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Finding the Defects

  • Staff feedback:
    • Shift huddles, staff meetings
  • Event reporting:
    • Root Cause Analysis, hospital reporting system
  • Quality and safety measures:
    • Monthly data reports
    • Recurring gaps
  • Staff Safety Assessment survey

Anything that you do not want to happen again….

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Learn From a Defect

Supporting a culture of safety

  • Easy to use:
    • Efficient
  • Continuity
  • Non-punitive:
    • “What” went wrong, not “Who” went wrong
  • Ownership:
    • Engages frontline staff
    • Collaborative, multidisciplinary
  • Communication:
    • Structured method
    • Key words at Key times
  • Improve Quality

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Images: 2 safety posters on learning from defects created by the Saint Joseph Mercy Health System.

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Examples

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Image: Sample incident report.

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Image: Sample communication plan.

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Image: Sample Post Fall Huddle report.

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Image: Sample Post Fall Huddle report continued.

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Next Steps:

  • Assess your ICU’s level of engagement of nurses, physicians and patients/families:
    • Are there opportunities for improvement?
    • What are the barriers you are facing with regards to engagement?
    • Utilize the learning from defects tool
  • Review the concepts and tools referenced here today to help bolster your ICU’s level of physician/nurse/patient and family engagement

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Thank you!

Questions

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Funding

Prepared by the Health Research & Educational Trust of the American Hospital Association with contract funding provided by the Agency for Healthcare Research and Quality through the contract, “National Implementation of Comprehensive Unit-based Safety Program (CUSP) to Reduce Catheter-Associated Urinary Tract Infection (CAUTI), project number HHSA290201000025I/HHSA29032001T, Task Order #1.”

Return to CAUTI Toolkit Implementation Page

Page last reviewed December 2017
Page originally created December 2015
Internet Citation: Engaging the Nurse, Physician, Patient/Family, CUSP- Learn From Defects. Content last reviewed December 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/engaging-nurse-physician-patient-slides.html