At Cache Valley Hospital, we experienced success in many metrics for a sustained period of time. However, when our performance unexplainably dropped significantly and efforts to change were not successful, we knew something needed to happen – and quickly.
At the time, our Professional Practice Council (PPC) existed but was definitely not effective. We needed help and knew things would not change unless we engaged our frontline nurses. Using our Division resources, we brought our frontline nurses together to develop a PPC charter, define the goals and to understand the outcome metrics that impact the care our patients receive.
One opportunity identified early on was a gap in our C-Diff screening practice. Patients were being screened upon admission in the ED and as a direct admit, however, the documentation was not complete. When the PPC took on this work, we identified the gap and the reason for the inconsistency and a solution was quickly put in place. Prior to the PPC work our documentation of the screening was at 40 percent compliance. The frontline staff worked with their clinical informatics to determine where documentation should occur consistently. A just-in-time training was developed and implemented with peer-to-peer coaching. After the new process was complete, compliance skyrocketed to 96 percent.
Important takeaways from the process development and implementation by the team include continued daily chart audits and peer-to-peer discussions. With these practice changes, our metrics have maintained compliance at 96 percent!
Great job to our frontline staff in identifying the gap, quickly finding a solution and implementing the practice change to make a difference!