a3 signed august 2015
TRANSCRIPT
Gre
en B
elt
Can
did
ates
: B
ill (
Wil
liam
) O
live
r an
d M
ich
iele
(M
yra)
Sch
rieb
erG
reen
Bel
t tr
ain
ing:
Au
gust
201
3, F
ayet
tevi
lle
(Bil
l);
Jun
e 20
12, O
kla
hom
a C
ity
Pro
ject
Dat
es -
3/2
3/1
5 t
o 6
/30/1
5,
contin
ued w
ith f
ollo
w u
p in
July
2015
3.M
EA
SU
RE
:Id
entif
y op
erat
iona
l bar
riers
and
failu
re m
odel
s in
the
curr
ent p
roce
ss.
5.S
US
TAIN
: Sus
tain
abili
ty S
trate
gy
Cre
ate
a pr
oces
s co
ntro
l str
ateg
y- a
str
ateg
y fo
r in
surin
g lo
ng te
rm s
usta
inab
ility
and
spr
ead
adop
tion.
•
Gai
ned
buy
in fr
om p
rovi
ders
reg
ardi
ng s
tand
ardi
zed
hepa
rin p
roto
col.
•C
hang
ed M
CM
to r
efle
ct th
at h
epar
in w
ill o
nly
be in
fuse
d vi
a th
e w
eigh
t bas
ed p
roto
col.
•
Rev
ised
Hep
arin
Infu
sion
Nur
sing
Ser
vice
Mem
oran
dum
(11
8-15
), r
esci
nded
118
-15
as a
sta
nd-a
lone
pol
icy,
inco
rpor
ated
thos
eel
emen
ts in
to th
e M
CM
reg
ardi
ng M
anag
emen
t of A
ntic
oagu
latio
n T
hera
py (
11-1
16)
to s
trea
mlin
e in
form
atio
n fo
r pr
ovid
ers,
nurs
es, p
harm
acis
ts, a
nd o
ther
sta
ff.•
ED
hep
arin
pro
toco
l ord
ers
deve
lope
d.•
Inpa
tient
hep
arin
pro
toco
l ord
ers
revi
sed.
•R
evis
ed h
epar
in fl
ow s
heet
(H
epar
in In
fusi
on N
ote)
to e
nsur
e ap
prop
riate
and
com
plet
e do
cum
enta
tion.
•
Com
plet
ed e
duca
tion
rega
rdin
g ch
ange
s fo
r he
parin
infu
sion
s.•
Con
tinue
d m
onito
ring.
Tea
m m
embe
rs: B
ill O
liver
, Mic
hiel
e Sc
hrie
ber,
Dra
ke R
ip p
elm
eyer
, Lin
da H
arw
ell,
Shaw
na D
igby
, Kat
hryn
Poo
le, T
iffan
y T
odd,
Kin
dra
Dia
l, W
endy
Kri
ng, R
onda
McC
iain
, Jen
nife
r C
ole,
Pat
rick
Sco
tt, K
im A
dam
s, K
athl
een
Wilc
ox, A
lice
Car
pent
er, K
ris
Dic
kson
, M/c
ha;/
Mey
er. T
his
cert
ifhj
s th
at B
ill O
Iive
,rnd
,.VIc
hiel
e Sc
hrie
ber
acti
vely
par
tici
pate
d in
the
abov
e pr
ojec
t and
com
plet
ed th
is A
3 R
epor
t on
our
own.
Pro
ject
Nam
e: H
epar
in In
fusi
on
Imp
rove
men
t T
eam
1.T
EA
M/A
IM: D
efin
e th
e P
robl
emV
HS
O is
not
in c
ompl
ete
com
plia
nce
with
Joi
nt C
omm
issi
on S
tand
ard
NP
SG
05.
01.0
3 [P
2 re
gard
ing
"use
app
rove
d pr
otoc
ols
for
the
initi
atio
n an
d m
aint
enan
ce o
f ant
icoa
gula
tion
ther
apy"
to r
educ
e th
e lik
elih
ood
of p
atie
nt h
arm
from
ant
icoa
gula
tion
ther
apy.
AIM
: Im
prov
e pa
tient
saf
ety
rela
ted
to in
trav
enou
s he
parin
adm
inis
trat
ion
by c
reat
ing/
usin
g a
stan
dard
ized
pro
toco
l and
docu
men
tatio
n as
evi
denc
e by
impr
oved
doc
umen
tatio
n re
quire
men
t aud
it re
sults
(90
%)
by 6
/1/2
015.
Sub
-Al M
s:
•D
evel
op o
utpa
tient
hep
arin
pro
toco
l by
6/1/
15.
•D
evel
op e
mer
genc
y de
part
men
t spe
cific
hep
arin
flow
she
et b
y 6/
1/15
.•
Pre
-infu
sion
wei
ght w
ill b
e ob
tain
ed a
nd d
ocum
ente
d (1
00%
).•
Intr
aven
ous
hepa
rin a
dmin
istr
atio
n w
ill b
e or
dere
d on
ly v
ia th
e st
anda
rdiz
ed w
eigh
t bas
ed p
roto
col (
100%
).•
Hep
arin
flow
she
et w
ill b
e th
e on
ly a
ccep
tabl
e fo
rm o
f doc
umen
tatio
n an
d w
ill b
e us
ed to
doc
umen
t hep
arin
adm
inis
trat
ion/
mai
nten
ance
(10
0%).
•S
econ
d nu
rse
verif
icat
ion
will
be
docu
men
ted
usin
g th
e he
parin
flow
she
et (
100%
).
2.M
AP
: Eva
luat
e C
urre
nt S
tate
e-
O_ 2
,,,n
nu5d
f!
,ait r-*t
t 'r
Gm
t
= tt : :uT
,-
tr,
4;
Ord
ered
ICU
/SD
U
Ord
ered
ED
Wei
ght O
btai
ned
Ver
ifica
tion
Ver
ifica
tion
ED
Use
d to
Doc
umen
tIC
U/S
DU
4.CH
ANG
E:Im
prov
e S
yste
ms
Cre
ate
a fu
ture
sta
te p
roce
ss b
y ap
plyi
ng L
ean
tech
niqu
es to
elim
inat
e op
erat
iona
l bar
riers
and
failu
re
Hep
arin
Pro
toco
lH
epar
in P
roto
col
Pre
-The
rapy
2nd
Nur
se2n
d N
urse
Hep
arin
Flo
wsh
eet
-4-
FY
14 Q
2
-4-F
Y14 Q
3
-=
FY14
Q4
FY15
Qi
120
100 80 60 40 20 0
mod
es.
• H
epari
n P
roto
col O
rdere
d r
cu/s
ou
• H
epar
in P
roto
col O
rder
ed E
D
Pre
-The
rapy
Wei
ght O
btai
ned
•2nd N
urs
e V
eri
ficatio
n IC
U/S
DU
•2nd N
urs
e V
eri
ficatio
n E
D
• H
epari
n F
low
sheet U
sed to D
ocu
ment
FY
14 0
2 F
Y14 Q
3 F
Y14 0
4 F
Y15 0
1 F
Y15Q
2 A
pr-
15 M
ay-
15 J
un-1
5
P4ü
•
(Exe
cuti
ve S
pons
or S
iana
ture
)th
z//$
(Dat
e)