Perianesthesia Quality and Patient Safety Council

We improve lives. In big ways through learning, healing and discovery.

In small, personal ways through human connection. But in all ways, we improve lives.

Performance Excellence in each Global Path to Success Measure will drive the Mission, Vision and Values of UCHealth.
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Purpose: May Meeting Facilitator: Raelyn Nicholson Sponsor: Michelle Ballou and Carolyn Dietrich
Date: 5/28/2014 Scribe: Arlette Kokeny Timekeeper: Raelyn Nicholson
Out Today: Location: Blue PACU Time: 0900 - 1000

Topic Discussion Recommendations/ Actions Follow-up
GPS
Component
Magnet
Component
Catch-A-Bug
May Initiative: Callie Dewbre submitted research article regarding the
spread of bacteria via lanyards and badges. Staff who read article and
completed questions received CE.
June Initiative: Hand Hygiene
Per a request by John Harney, perioperative services needs to think of
ways to improve hand hygiene. For the month of June, the council
will focus on methods to improve rates.
Council members identified that a barrier to proper hand hygiene is
awkwardly placed foamers. If some were moved to more convenient
locations, rates may improve.

May Initiative: Encourage staff to
wipe down badges with cavi wipes
every shift.
June Initiative: When council
members see staff/family/other
employees not use proper hand
hygiene, they will use the handheld
foamer and say, We are trying to
improve our hand hygiene in the
PACU and I noticed that you didnt
foam. May I offer you some? The
council may implement a reward
system in the future.
Raelyn will speak with Michelle and
Carolyn about the feasibility of
moving foamers.

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May Audits
Medication scanning
PreOp: 96.97% (target 93%)
PACU: 97.8% (target 93%)
Patient scanning
PreOp: (target 98%)
PACU: (target 98%)
Hand Hygiene
PreOp: (target 95%)
PACU: (target 95%)
Lab specimen labeling PreOp: (target 100%)
Critical lab documentation PACU: 100% (target 100%)
Medication labeling PACU: 100% (target 95%)
To prevent scanning errors when
PACU meds are discontinued, RNs
need to contact the anesthesiologist
to reinstates the PACU orders.

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7
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Perianesthesia Quality and Patient Safety Council
We improve lives. In big ways through learning, healing and discovery.
In small, personal ways through human connection. But in all ways, we improve lives.

Performance Excellence in each Global Path to Success Measure will drive the Mission, Vision and Values of UCHealth.
Page 2 of 2
Topic Discussion Recommendations/ Actions Follow-up
GPS
Component
Magnet
Component
Ambu Bag on
Transport
Nurses and CNAs are occasionally forgetting to take an ambu bag.
Council indicated that any change takes time for staff to adjust. The
sign next to the transport monitors is helpful.
The council recognized their role in
reminding staff to take ambu bags
and model this new standard.
Raelyn will speak with CNAs to
remind them of taking ambu bags.

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Joint Commission
Preparation
Management would like the council to help periop prepare for
upcoming JCAHO visit. This may include assisting in a mock visit,
helping Nicole Babu with trackers, and working on the outcomes
board.

Council will readdress JCAHO needs
in June meeting. Raelyn will
communicate with management to
fine tune details. She will also email
JCAHO PowerPoint (made by Kyla,
Carolyn, and Raelyn) so that council
can educate themselves on JCAHO
requirements.


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UCHealth Global Path to Success
1. Quality and Patient
Experience
2. Engaged Workforce 3. Growth 4. Clinical & Non-Clinical
Integration
5. Deliver Superior Value 6. Academic Enterprise 7. Mission, Vision and
Brand Awareness
Ensure universal, distinctive
standard of quality and patient
experience.
Attract, retain and excite a
unified and engaged workforce.
Enhance reach and relevance
through growth.
Integrate clinically and non-
clinically across our system.
Deliver superior value to
remain an option for most
payor plans.
Maintain, enhance and
leverage the academic
enterprise.
Enhance messaging around
the mission, vision and
brand

Magnet Model Components
1. Transformational Leadership 2. Structural Empowerment 3. Exemplary Professional Practice 4. New Knowledge, Innovations & Improvements 5. Empirical Outcomes
Leadership that results in extraordinary
outcomes by empowering, influencing,
and motivating others.
Strategies used to support shared
leadership decision-making, life-long
learning and professional development.
Interprofessional collaboration to ensure
patient safety resulting in high-quality
outcomes.
Integration of evidence-based practice and research
into practice. New ways of achieving high-quality,
effective and efficient care through innovation.
Measurable outcomes related to the impact
of structure and process on patients, staff,
and the organization.