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NICU Individual Compliance MetricsMonica Larsen RN
GBMC NICU
Objectives
• Name 3 reasons why the implementation of a compliance metric program supports staff engagement in NICU safety
• Discuss how this compliance metric program can be a segway into larger quality initiatives
• Describe how a compliance metric program promotes staff to staff communication and support
• Identify skills the staff nurse learns from participation in this program
• Name the outcome measurements of this NICU program
About GBMC’s NICU
• 30 Bed Level 3 NICU• Opened in 1965• Prior culture of manager having a directive
style• New Manager Oct. 2011 with transactional
style
NICU Goal Status Jul Aug Sep OctCentral Line Associated Blood Stream Infection
(CLABSI)ZERO 1 0 0 0
Hand Hygiene 0.90 84% 93% 90%
Proper ID Band Placement100%
86.0% 100.0%
Daily Teach-Back 75% 80.0% 22.0%
Discharge Education Completed before discharge
date80%
66%
20.0% 33.0%
Care Plans Individualized 80%
72% 85.0% 80.0%
Overall Initiation Breast Feeding Rate
75%
72%
70% 65.0%
Exclusive breast feeding for premature infants with weight
1250 and less
90%
52% 33.0% NA 0.0%
2012 GBMC NICU Compliance Metrics
GBMC NICU Individual Safety Commitments for FY2013
Compliance Metrics
Name Commitment Jan Feb Mar Evaluate April May June Evaluate July Aug Summary CHRISTIE GREER
Every week, I will monitor that the right breastmilk is in the right bin in the refrigerator.
NICOLE PETtERSON
Twice weekly, I will monitor that breastmilk in each infants bin is dated within appropriate time frame.
JULIE BRIDGEMAN
Twice weekly, I will monitor that all intubated babies have inline suction catheters in place.
LORI MURPHY
Twice weekly, I will monitor patients on phototherapy to make sure eyes and genitals are properly shielded.
KATIE STUMPF
Every week, I will monitor that infant baths are being completed every three days
HOLLIE KROUT
Weekly, I will monitor that the discharge criteria are documented on the checklist in Meditech.
KIM WHITE Weekly, I will monitor that the discharge criteria are documented on the checklist in Meditech.
ELLEN DRAKE
Twice weekly, I will monitor infants on bubble cpap for clear eyes and no drainage.
JACKIE RYAN
Twice weekly, I will monitor infants who are on fortifiers for skin integrity of the peri-anal area.
JOSEPH HENRY
Weekly, I will monitor the Tissue Bank database for completion.
LISA RUTLEDGE
Weekly, I will monitor labeling of suction canisters and tubing for date and time within 24hrs.
Sample of an Audit Tool
Visibility
Measurable NICU Practice Outcome
GBMC NICU Individual Safety Commitments for FY2014
Compliance Metrics
Name Commitment Nov Dec. Jan Evaluate Feb March April Evaluate May June Summary CRISTIE GREER
Every week, I will monitor that claves on IV lines are changed per policy
NICOLE PETERSON
Twice weekly, I will monitor that breastmilk in each infants bin is dated within appropriate time frame.
JULIE BRIDGEMAN
Twice weekly, I will monitor that all intubated babies have inline suction catheters in place.
LORI MURPHY
Twice weekly, I will monitor patients on phototherapy to make sure eyes and genitals are properly shielded.
KATIE STUMPF
Every week, I will monitor that infant baths are being completed every three days
HOLLIE KROUT
Weekly, I will monitor that the discharge criteria are documented on the checklist in Meditech.
KIM WHITE Weekly, I will monitor that the discharge criteria are documented on the checklist in Meditech.
ELLEN DRAKE
Twice weekly, I will monitor infants on bubble cpap for clear eyes and no drainage.
JACKIE RYAN Twice weekly, I will monitor infants who are on fortifiers for skin integrity of the peri-anal area.
JOSEPH HENRY
Weekly, I will monitor labeling of suction canisters and tubing for
Performance Improvement Outcome
2015 --- 100% Staff Involvement
What our nursing staff learned….
Peer to Peer Communication Increased
Working Together
Metric and Audit Tool Development and Support
A Sample Compliance Metric
“Once a week, I will monitor that the infant’s heart rate lower limits, are set on the monitor, appropriate for the infant’s
gestational age.”
Measurement and Analysis of Data
Increased Staff Nurse Satisfaction and Engagement
In 2014, the Press Ganey safety survey results indicated NICU staff engagement improved significantly.
GBMC NICU Staff Nurses on Safety
95% I know the proper channels to direct questions regarding patient safety in this work setting.
Engaged Staff