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CAUTI Does the hospital avoid unnecessary urinary catheters? Are indwelling urinary catheters discontinued as soon as indications expire? Is the necessity of catheter continuation for all patients with a urinary catheter reviewed

on a frequent basis? Is aseptic technique maintained throughout the life of the catheter including insertion

and daily care and maintenance? Does the hospital conduct a standardized review for each occurrence (mini-RCA)?

CLABSI Has the hospital adopted guidelines for catheter insertion? Are there processes in place to remove catheters as soon as possible? Does the hospital have standardized policies or processes that ensure appropriate care

and maintenance of central line catheters? Are proper supplies/kits and equipment standardized and available for easy accessibility? In making changes to the hospital’s CLABSI approach, has there been adaptive changes? Has the hospital adopted guidelines for catheter insertion? Does the hospital conduct a standardized review for each occurrence (mini-RCA)?

CALHEN Hospital ChecklistPrimary Drivers for Reducing Harm

FALLS Does the hospital use a valid and reliable Falls Risk Assessment? Does the hospital conduct Falls Risk RE-Assessments at standard intervals? Does the hospital conduct Environmental Inventories? Are there interventions for all patients regardless of assessed risk? Are there individualized interventions for High Risk patients? Does the hospital conduct a standardized review for each occurrence (mini-RCA)?

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SSI Has the hospital adopted a Surgical Safety Checklist? Does the hospital have an Antimicrobial Prophylaxis protocol? Does the hospital have a preadmission skin cleansing protocol? Is there a standardized procedure for normothermia in the operating room? Does the hospital have a perioperative glucose control procedure or process? Does the hospital conduct a standardized review for each occurrence (mini-RCA)?

ADE Is there awareness, readiness & education on the ADE risks posed by high risk medication? Has the hospital integrated pharmacy standardized care processes throughout the facility? Are Pharmacists included in patient level Decision Support? Are processes in place to prevent failure? Are there processes in place for the identification and mitigation of failure of practices

including education real time? Has the hospital implemented smart use of technology? Does the facility involve patient and family in the administration and education of

pharmaceuticals? Does the hospital conduct a standardized review for each occurrence (mini-RCA)?

HAPU Does the hospital conduct standardized Skin/Risk Assessment & Reassessments? Are there standardized processes to manage moisture? Does the hospital optimize hydration and nutrition? Are there standardized processes to minimize pressure? Do improvement efforts include multidisciplinary approach to HAPU prevention? Does the hospital conduct a standardized review for each occurrence (mini-RCA)?

VAP (all questions allow for patient variation in standard practices based on patient condition)

Are all ventilated patient’s Head of the Bed raised between 30-45°? Are all ventilated patient’s placed on Peptic ulcer disease (PUD) prophylaxis? Does the hospital have standardized processes that include prophylaxis for

Venous Thromboembolism (VTE)? Does the hospital have standardized processes that include spontaneous

Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT)? Do all ventilated patients receive standard Oral Care? Does the hospital conduct a standardized review for each occurrence (mini-RCA)?

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OB EED Has the hospital reduced demand for early elective deliveries

(prior to 39 weeks gestation)? Has the hospital reduced availability for early elective deliveries

(prior to 39 weeks gestation)? Does the hospital conduct a standardized review for each occurrence (mini-RCA)?

VTE Does the hospital perform effective VTE risk assessments? Has the hospital developed best practices for prophylaxis? Are there standardized care processes? Is there decision support for dosing and monitoring? Does the hospital involve the patient and family in VTE assessment and treatment? Does the hospital conduct a standardized review for each occurrence (mini-RCA)?

READMISSIONS Does the hospital identify patients at high-risk for readmission? Does the hospital confirm self-management skills? Does the hospital coordinate care across the continuum? Does the hospital ensure adequate follow-up and community resources? Does the hospital conduct a standardized review for each occurrence (mini-RCA)?

For more information, please refer to HRET’s change packagehttps://s3.amazonaws.com/CAUTI_Manuals_and_Toolkits/CAUTI+Implementation+Guide/CAUTI+Implementation+Guide+-+November+2012.doc

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CALHEN Hospital ChecklistSecondary for Reducing Harm

CAUTI: Catheter Associated Urinary Tract InfectionsPrimary Drivers Secondary Drivers Avoid unnecessary urinary catheters Identify conditions or situations that do not require a urinary catheter

Require the purpose for a urinary catheter when ordered by the physician or practitioner

Remove urinary catheters as soon as possible

Include daily review of catheter necessity into daily rounds, with prompt removal if catheter is no longer indicated

State the catheter day (e.g., “catheter day 6”) during daily rounds as a reminder of how long the catheter has been in place

Adopt a standard post-operative removal by the nurse unless certain conditions exist (24-48 hours post-operative)

Ensure appropriate care and maintenance

Ensure a standardized protocol for foley insertion, care and maintenance, and removal, including who can insert urinary catheters

Maintain a sterile, continuously closed drainage system

Keep catheter properly secured to prevent movement and uretheral traction

Keep the collection bag below the level of the bladder at all times

Maintain unobstructed urine flow

Empty the collection bag regularly using a separate collecting container for each patient and not allowing the draining spigot to touch the collecting container

Engage patients families and staff in the reduction of CAUTI

Include the patient and family in the care specifically in the avoidance of a urinary catheter

Provide patient education utilizing Teach Back and Ask Me 3 methodologies

Provide unit level information or feedback about patients that experience a catheter associated UTI to staff members (e.g., unit posted graphs or dashboards, staff meeting discussions, or daily huddle discussions)

For more information, please refer to HRET’s change packagehttps://s3.amazonaws.com/CLABSI_Elimination_Toolkit/CLABSI+Elimination+Toolkit+Manual.doc

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CLABSI: Catheter Associated Blood Stream InfectionsPrimary Drivers Secondary Drivers Adopt guidelines for catheter insertion Use an insertion checklist that includes all bundle elements for central

line insertions

Avoid the use of the femoral vein for central venous access in adult patients

Establish a process to assure correct insertion technique by all individuals inserting catheter and identify who inserts central lines

Empower nurses to stop insertion if element(s) of the bundle are not being executed

Remove catheters as soon as possible Include daily review of line necessity into daily rounds with prompt removal if catheter is no longer indicated

State the line day (e.g., “line day 6”) during daily rounds as a reminder of how long the line has been in place

Define an appropriate timeframe for regular review of necessity, such as weekly, when central lines are placed for long-term use (e.g., chemotherapy, extended antibiotic administration, etc.)

Ensure appropriate care and maintenance

Standardize dressing change policies

Adopt a process for access into the central line (e.g., scrub the hub process)

Availability of supplies and equipment Develop a process to assure proper equipment is available – central line insertion kit, central line dressing kits, administration sets, needleless systems

Keep equipment stocked in a cart for central line placement to avoid the difficulty of finding necessary equipment to institute maximal barrier precautions

Adaptive changes Adopt a senior leader as part of the improvement team

Engage frontline workers

Adopt team and communication skills

Engage Patients, Families, and Staff in the reduction of CLABSIs

When possible and as far in advance as possible, prepare the patient and family prior to insertion with what to expect information including appropriate line maintenance

Provide patient education utilizing Teach Back and Ask Me 3 methodologies

Provide unit level information or feedback about patients that experience a central line associated blood infection (CLABSI) to staff members (e.g., unit posted graphs or dashboards, staff meeting discussions, or daily huddle discussions)

For more information, please refer to HRET’s change packagehttp://hret-hen.org/images/phocadownload/falls_final_508.pdf

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FALLSPrimary Drivers Secondary Drivers Fall and Injury Risk Assessment Conduct a fall risk assessment upon admission using a validated

risk assessment

Assess patient’s fall risk by asking the patient and family what they do outside the hospital to prevent falls

High-injury risk patients include ABCS – Age > 85, Bone, C anticoagulation, coagulopathies, and Surgical patients

Fall Risk Reassessment Conduct ongoing reassessments including new and/or changed medications that increase fall risks

Perform hourly or bi-hourly rounds to assess and address patient needs for Ps: pain, position, potty, personal belongings and safe pathway

Environmental Interventions Create a safe environment for patients by eliminating hazards and injury hazards (e.g., sharp edges, clear hallways etc.)

Develop an equipment safety checklist to include bathroom and shower safety devices

Consider flooring and lighting and the setup of the patient rooms (e.g., clutter free, furniture placement based on the assessment of the patient’s strongest side when getting out of bed, and floor mats)

Institute fall prevention alerts in the electronic medical record (EMR)

Interventions for All Patients Use visual/audible cues, (e.g., colorful, easy to view alert wristbands, bedside risk signs, non-skid footwear)

Medication review – avoid unnecessary hypnotic/sedative medications

Use of beds that are lower/closer to the floor

Involve family and care givers in the care of the patient to prevent falls (e.g., sit with the patient during vulnerable times)

Intermittent but regular observation through hourly “rounding” by staff

Patient education – emphasizing the positive benefits of interventions (enhancing independence and quality of life) rather than the negative (e.g., risk of falls)

Achieve interdisciplinary participation and include all staff in the reduction of falls including nursing, medical staff, pharmacy, therapy staff, environmental services and engineering/maintenance

For more information, please refer to HRET’s change packagehttp://hret-hen.org/images/phocadownload/falls_final_508.pdf

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Primary Drivers Secondary Drivers Individualized Interventions for High Risk Patients

Increase the frequency of rounding

Enhance environmental changes (e.g., move closer to nursing station)

Assistive devices (e.g., walking aids, transfer bars, bedside commodes) located on exit side of bed

Engage Patients, Families and Staff in the Reduction of Falls

Provide verbal and written patient and family education related to falls reduction in their preferred language

Provide patient and family education utilizing Teach Back and Ask Me 3 methodology

Engage the patient and family in reducing falls

Include falls risk status or concerns during shift handoffs and patient transfers and document this communication

Provide unit level information or feedback about patients that experience a fall to staff members (e.g., unit posted graphs or dashboards, staff meeting discussions, or daily huddle discussion)

FALLS (continued)

For more information, please refer to HRET’s change packagehttp://www.hret-hen.org/images/downloads/508changepacks/ssi_change%20package_508.pdf

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SSI: Surgical Site InfectionsPrimary Drivers Secondary Drivers Adopt Surgical Safety Checklist Conduct three pauses with surgical team at critical points:

• Before induction of anesthesia• Before skin incision• Before patient leaves the operating room

Verbally confirm all items on the surgical checklist at each pause with appropriate surgical team members

Ensure the use of a standard tool so as not to rely on memory for items in the surgical checklist

Antimicrobial Prophylaxis Develop standardized order sets for each procedure that include antibiotic, timing, dose and discontinuation

Develop pharmacist and nurse-driven protocols that ensure correct antibiotic selection based on type of surgery and patient characteristics (e.g., age, weight)

Create a process to review all exceptions to protocols

Ensure that antibiotics are re-dosed appropriately in surgeries (longer than four hours)

Perioperative Skin Antisepsis Develop standardized practices for application of skin antiseptic agents

Educate perioperative personnel on the safe application of selective skin antiseptic agents

Preadmission Skin Cleansing Develop standardized order sets for preadmission skin cleansing

Develop a strategy for distribution of skin antiseptic agent to the patients

Educate patients as to how to apply the skin antiseptic agent prior to hospital admission

Normothermia in the Operating Room Develop standardized procedure for pre-warming for every surgical patient without a contraindication

Develop standardized procedure for active warming in the operating room that could include warming blankets under patients on the operating table

Perioperative Glucose Control Obtain glucometers for every anesthesia station

Develop a perioperative glycemic control team that includes surgeons, anesthesiologists, endocrinologists and nurses to ensure that responsibility and accountability is assigned for blood glucose monitoring and control

For more information, please refer to HRET’s change packagehttp://www.hret-hen.org/images/downloads/508changepacks/ssi_change%20package_508.pdf

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Primary Drivers Secondary Drivers Engage Patients, Families and staff in the Reduction of SSIs

Provide verbal and written patient and family education prior to surgery in their preferred language

Utilize standardized patient and family education when possible including checklists

Provide patient education utilizing Teach Back and Ask Me 3 methodologies

Provide unit level information or feedback about patients that experience a surgical site infection to staff members (e.g., unit posted graphs or dashboards, staff meeting discussions, or daily huddle discussions)

SSI (continued)

For more information, please refer to HRET’s change packagehttp://www.hret-hen.org/images/downloads/508changepacks/ade_changepackage_508.pdf

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ADE: Adverse Drug EventsPrimary Drivers Secondary Drivers Awareness, Readiness & Education Assess organizational capacity, readiness and willingness to implement

systems to prevent ADEs

Create awareness of high alert medications most likely to cause ADEs

Identify patients at high risk for ADEs

Standardize Care Processes Implement ISMP quarterly action agendas where appropriate

Develop standard order sets using safety principles

Allow nurses to administer rescue drugs based on protocol

Minimize interruptions during the process of medication distribution and administration

Standardize concentrations and minimize or eliminate multiple drug strengths where possible

Allow pharmacists to change anticoagulant doses based on lab values per protocol

Include a pharmacist in direct clinical activities (e.g., ICU rounds, ambulatory medication decision making)

Decision Support Include pharmacists on rounds

Monitor overlapping medications prescribed for a patient

Prevent Failure Minimize or eliminate nurse distraction during the medication administration process

Standardize concentrations and minimize dosing options where feasible

Timely lab results with effective systems to ensure review and action

Use non-pharmacological methods of pain and anxiety management where appropriate

Identification and Mitigation of Failure Analyze dispensing unit override patterns

Prompt real time learning from each failure

For more information, please refer to HRET’s change packagehttp://www.hret-hen.org/images/downloads/508changepacks/ade_changepackage_508.pdf

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Primary Drivers Secondary Drivers Smart Use of Technology Use “smart pumps” with up-to-date library or double check all IV infusions

for high alert medications

Understand errors that can occur from Patient Controlled Analgesic devices (PCAs)

Use bar coding

Use alerts wisely

Use data/information from alerts and overrides to redesign standards

Link order sets to recent lab values

Involve the Patient and Family Allow patient management of insulin where possible

Provide patient education at a literacy level understandable by all

Provide patient education at a literacy level that is understandable and in their preferred language

Utilize techniques like Teach Back and Ask Me 3 to ensure patient and family understanding of home management of medication and labs related to the management of pharmaceuticals at home

ADE (continued)

For more information, please refer to HRET’s change packagehttp://hret-hen.org/images/phocadownload/hapu_final_508.pdf

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HAPU: Hospital Acquired Pressure UlcersPrimary Drivers Secondary Drivers Conduct Skin/Risk Assessment & Reassessment

Use a head-to-toe skin and risk assessment as soon as possible, within 4 hours upon admission to the hospital

Utilize a validated standard tool for the skin and risk assessment

The risk and skin assessment should be age appropriate Pediatric versus adult

Skin Assessment and reassessment of risk daily or more frequently for high-risk patients

Engage a multidisciplinary team in the assessment and prevention of pressure ulcers (Medical Staff, licensed and unlicensed Nursing Staff, Nutritionists, Physical Therapy, Transporters etc.)

Conduct regular skin prevalence studies and share the findings with staff

Manage Moisture Keep the patient dry and moisturize the skin only if necessary

When necessary, use under-pads that wick moisture away from skin and provide a quick-drying surface

Set specific time frames to remind staff to reposition, offer toileting often, check PO fluids, reassess for wet skin, (i.e. P’s – Pain/Potty/Position/Pressure)

Keep supplies handy at the bedside in the event the patient is incontinent

Optimize Hydration and Nutrition Give patients preferences to encourage hydration and nutrition

Provide at risk patients with a different color water container so all staff and families will know to encourage hydration

Provide nutritional supplements if not contraindicated

Consult a registered dietician if the patient is at a high risk

Assess weight status, food and fluid intake, hydration status and laboratory data

Minimize Pressure Turn and reposition patients every two hours using visual or musical cues, bells and alarms at the nurses’ station

Use special beds, mattresses, pillows and blankets to redistribute the potential pressure areas

Use the NPUAP guidelines for alignment

Use lifting devices to prevent shearing or friction

Evaluate and investigate on a regular basis new products that are evidence-based to prevent or treat pressure ulcers

For more information, please refer to HRET’s change packagehttp://hret-hen.org/images/phocadownload/hapu_final_508.pdf

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Primary Drivers Secondary Drivers Engage Patients, Families, and staff in the reduction of Pressure Ulcers

Provide patient education utilizing Teach Back and Ask Me 3 methodologies

Include pressure ulcer findings or risk status or concerns during shift handoffs and patient transfers and document this communication

Provide unit level information or feedback about patients that acquire a hospital acquired pressure ulcer to staff members (e.g., unit posted graphs or dashboards, staff meeting discussions, or daily huddle discussions)

HAPU (continued)

For more information, please refer to HRET’s change packagehttp://hret-hen.org/images/phocadownload/vap_final_508.pdf

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VAP: Ventilator Acquired PneumoniaPrimary Drivers Secondary Drivers Standardize processes and care reminders

Institute a standardized protocol or bundle for the care of a ventilated patient

Include bundle reminders and checklists on a flow sheet or EMR checklist

Elevate Head of Bed raised between 30-45 degrees

Use visual cues so it is easy to identify when the bed is in the proper position, such as a line on the wall that can only be seen if the bed is below a 30-degree angle

Include the clues on order sets for initiation and weaning of mechanical ventilation, delivery of tube feedings, and provision of oral care

Create an environment where respiratory therapists work collaboratively with nursing to maintain head-of-the-bed elevation

Peptic ulcer disease (PUD) prophylaxis Evaluate the use of medications (H2 blockers are preferred over sucralfate). Proton pump inhibitors may be efficacious and an alternative to sucralfate or H2 antagonist

Include PUD on the ICU order admission set and ventilator order set

Incorporate review of PUD into daily multidisciplinary rounds

Engage pharmacy in daily multidisciplinary rounds to ensure ICU patients have some form of PUD and VTE prophylaxis

Venous Thromboembolism (VTE) prophylaxis

Initiate VTE prophylaxis on all mechanically ventilated patients unless contraindicated

Include VTE prophylaxis as part of your ICU order admission set and ventilator order set

Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT)

Develop protocols, order sets, and standard work for spontaneous awakening trials (SAT) and spontaneous breathing trial (SBT)

Perform daily assessments of readiness to wean and extubate

Create an environment where respiratory therapists work collaboratively with nursing to facilitate a daily “sedative interruption” in coordination to “weaning trials”

Implement a protocol to lighten sedation daily to assess for readiness to extubation. Include precautions to prevent self-extubation such as increased monitoring during the trial

For more information, please refer to HRET’s change packagehttp://hret-hen.org/images/phocadownload/vap_final_508.pdf

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Primary Drivers Secondary Drivers Oral Care Perform regular oral care with an antiseptic solution (e.g., chlorhexidine)

in accordance with the manufacturer’s product guidelines

Include daily oral care with chlorhexidine as part of your ICU order admission set and ventilator order set

Educate the RN staff about the rationale for supporting good oral hygiene and its potential benefit in reducing ventilator-associated pneumonia

Patient and Family Engagement Standard practice includes patient and family preparation for intubation (both conscious and unconscious)

Include the patient and family in daily care activities or expectations

Provide patient and family education in their preferred language

Provide unit level information or feedback about patients that experience a ventilator acquired pneumonia to staff members (e.g., unit posted graphs or dashboards, staff meeting discussions, or daily huddle discussions)

VAP (continued)

For more information, please refer to HRET’s change packagehttp://hret-hen.org/images/phocadownload/ChangePackages/perinatalharm_final_508.pdf

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OB EED: OB Early Elective DeliveriesPrimary Drivers Secondary Drivers Reduction in DEMAND for elective deliveries at prior to 39 weeks gestation

Raise awareness of risks of EED for physicians, nurses, and hospital staff

Raise the awareness of risks of EED for patients/families and the community

Reduction in AVAILABILITY of elective deliveries at prior to 39 weeks gestation

Create a hospital policy and procedure that guides scheduling and oversight for elective deliveries

Develop mechanisms to support the appropriate implementation and enforcement of policies and procedures

For more information, please refer to HRET’s change packagehttp://hret-hen.org/images/phocadownload/vte_final_508.pdf

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VTE: Venous ThromboembolismPrimary Drivers Secondary Drivers Effective risk assessment Adopt a VTE risk-assessment screening tool; simplify as much as possible

Assess every patient upon admission of his/her risk for VTE using the VTE risk assessment screening tool

Develop best practices for prophylaxis Review key resources and identify best practices

Adopt a standardized risk-stratified menu of choices for prophylaxis; simplify as much as possible

Standardize care processes Develop standard written order sets which link the risk assessment to the choice of prophylaxis

Identify contraindications and include them in order sets

Allow for ‘opt-out’ as clinically indicated

Institute hard stop alerts in the Electronic Medical Record (EMR)

Institute medication alerts within EMR

Decision support Use protocols for dosing and monitoring

Allow pharmacists to change anticoagulant doses based on lab values per protocol

Include a pharmacist in direct clinical activities (e.g., rounds, ambulatory medication decision making)

Engage the Patient, Family, and Staff in the Reduction of VTEs

Alert patients and families to early signs and symptoms of VTE

Give clearly written and well explained VTE discharge instructions to patients and families in their preferred language

Institute a standardized teaching tool for warfarin therapy

Utilize Teach Back and Ask Me 3 methodologies to ensure patients and families have thorough understanding of dosing and physician and lab follow-up appointments

Provide unit level information or feedback about patients that experience a venous thromboembolism to staff members (e.g., unit posted graphs or dashboards, staff meeting discussions, or daily huddle discussions)

For more information, please refer to HRET’s change packagehttp://hret-hen.org/images/phocadownload/presentations/readmission_chg_pkg_final_2013.pdf

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READMISSIONSPrimary Drivers Secondary Drivers Identify patients at high-risk for readmission

Use a risk of readmission assessment tool and validate it using your own data

Develop a method to stratify patients at higher risk of readmission

Adopt an enhanced admission assessment

Assess the patient’s engagement and assertiveness in managing their own care

Engage the patient and family early in the discharge process

Self-management skills Assign clear accountability for medication reconciliation

Educate patient regarding medication, need for medication, method of obtaining and taking medication once discharged

Utilize Teach Back and Ask Me 3 techniques to assess the patient and family’s understanding of their condition and discharge instructions

Educate patient on their condition, symptoms, and what to do if symptoms worsen

Provide clearly written medication instructions using health literacy concepts in their preferred language

Coordination of care across the continuum

Identify a person or role that is responsible for assuring discharge planning activities are executed (can be phased in with the highest risk populations targeted first)

Obtain accurate information about primary care physician at the time of admission and create a patient centered record

Include routine interdisciplinary rounding in standard daily processes

Ensure effective communication to non-hospital based care team members

Perform medication reconciliation at each transition of care

Send discharge summary to primary care physician with 48 hours of discharge

Call the patient within 24 to 48 hours after discharge

For more information, please refer to HRET’s change packagehttp://hret-hen.org/images/phocadownload/presentations/readmission_chg_pkg_final_2013.pdf

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Primary Drivers Secondary Drivers Adequate follow-up and community resources

Prior to leaving the hospital, determine what after-hospital resources and appointments are needed and ensure appropriate planning

Work with patient and care provider to identify and address any barriers to making and attending follow-up appointment(s) and other follow-up needs such as medications, special diet, etc.

Work with collaboratives and community organizations for a sustainable readmission solution. Some suggested programs are:• The Focus on Readmissions Reduction• Community-Based Care Transitions Program (CMS Partnership

for Patients)• Care Transitions Program (Eric Coleman)• Project RED (Brian Jack)• Transitional Care Model (Mary Naylor)• Project BOOST (Society of Hospital Medicine)• The PAVE Project (Health Care Improvement Foundation)

READMISSIONS (continued)