a3 signed august 2015

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)