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<br /> July/August 2013 Volume 10, Issue 4<br /> Community Hospital<br /> Gives Its Discharge<br /> Process a BOOST<br /> Patient Safety<br /> in the Middle East<br /> Six Sigma to Improve<br /> Perioperative Processes<br /> Radiation Exposure<br /> Monitoring<br /> <br /> <br /> 30<br /> 20<br /> CONTENTS<br /> July/August 2013 Volume 10, Issue 4<br /> Features<br /> 20 Community Hospital Gives Its Discharge Process a BOOST<br /> By Pam Cronrath, RN, MN; and Marisa Gillaspie Aziz, RN, MSN,<br /> ACNS-BC<br /> 30 From Blame to Fair and Just Culture:<br /> A Hospital in the Middle East Shifts Its Paradigm<br /> By Krishnan Sankaranarayanan MS, MBA, CPHQ;<br /> Steven A. Matarelli PhD, RN; Hasrat Parkar, MBBS, MRCGP; and<br /> Mamoon Abu Haltem MS, RN<br /> 36 Using Six Sigma to<a title="PSQH July/August 2013 page 1" href="http://viewer.zmags.com/publication/e9a4a3bc?page=1"> July/August 2013 </a> <a title="PSQH July/August 2013 page 2" href="http://viewer.zmags.com/publication/e9a4a3bc?page=2"> </a> <a title="PSQH July/August 2013 page 3" href="http://viewer.zmags.com/publication/e9a4a3bc?page=3"> </a> <a title="PSQH July/August 2013 page 4" href="http://viewer.zmags.com/publication/e9a4a3bc?page=4"> 30 20 CONTENTS July/August 2013 Volume 10, Is</a> <a title="PSQH July/August 2013 page 5" href="http://viewer.zmags.com/publication/e9a4a3bc?page=5"> </a> <a title="PSQH July/August 2013 page 6" href="http://viewer.zmags.com/publication/e9a4a3bc?page=6"> </a> <a title="PSQH July/August 2013 page 7" href="http://viewer.zmags.com/publication/e9a4a3bc?page=7"> </a> <a title="PSQH July/August 2013 page 8" href="http://viewer.zmags.com/publication/e9a4a3bc?page=8"> SPONSORING ORGANIZATIONS Amer</a> <a title="PSQH July/August 2013 page 9" href="http://viewer.zmags.com/publication/e9a4a3bc?page=9"> </a> <a title="PSQH July/August 2013 page 10" href="http://viewer.zmags.com/publication/e9a4a3bc?page=10"> NEWS ACR Task Force on Teleradiology Publishes </a> <a title="PSQH July/August 2013 page 11" href="http://viewer.zmags.com/publication/e9a4a3bc?page=11"> pletely erroneous diagnosis. Teleradi- ologist</a> <a title="PSQH July/August 2013 page 12" href="http://viewer.zmags.com/publication/e9a4a3bc?page=12"> NEWS Joint Commission and PCPI Recommend Strate</a> <a title="PSQH July/August 2013 page 13" href="http://viewer.zmags.com/publication/e9a4a3bc?page=13"> National Partnership Solicits Applications for Cl</a> <a title="PSQH July/August 2013 page 14" href="http://viewer.zmags.com/publication/e9a4a3bc?page=14"> RADIATION SAFETY Radiation Exposure Monitoring </a> <a title="PSQH July/August 2013 page 15" href="http://viewer.zmags.com/publication/e9a4a3bc?page=15"> patients to lower dose scanners, train- ing physi</a> <a title="PSQH July/August 2013 page 16" href="http://viewer.zmags.com/publication/e9a4a3bc?page=16"> CULTURE OF SAFETY How to Influence Accountabilit</a> <a title="PSQH July/August 2013 page 17" href="http://viewer.zmags.com/publication/e9a4a3bc?page=17"> unit/team will hold everyone else ac- countable. </a> <a title="PSQH July/August 2013 page 18" href="http://viewer.zmags.com/publication/e9a4a3bc?page=18"> INFECTION CONTROL Using Change Management Princ</a> <a title="PSQH July/August 2013 page 19" href="http://viewer.zmags.com/publication/e9a4a3bc?page=19"> discovery that technique variation was common wit</a> <a title="PSQH July/August 2013 page 20" href="http://viewer.zmags.com/publication/e9a4a3bc?page=20"> $600,000/year in CRBSI-related costs. H</a> <a title="PSQH July/August 2013 page 21" href="http://viewer.zmags.com/publication/e9a4a3bc?page=21"> </a> <a title="PSQH July/August 2013 page 22" href="http://viewer.zmags.com/publication/e9a4a3bc?page=22"> Community Hospital Gives Its Discharge Process a</a> <a title="PSQH July/August 2013 page 23" href="http://viewer.zmags.com/publication/e9a4a3bc?page=23"> T he nation’s healthcare system recognizes the ne</a> <a title="PSQH July/August 2013 page 24" href="http://viewer.zmags.com/publication/e9a4a3bc?page=24"> PROJECT BOOST SUPPORT FOR PROJECT BOOST IMPLEMEN</a> <a title="PSQH July/August 2013 page 25" href="http://viewer.zmags.com/publication/e9a4a3bc?page=25"> BOOST Executive Steering Committee members at St.</a> <a title="PSQH July/August 2013 page 26" href="http://viewer.zmags.com/publication/e9a4a3bc?page=26"> </a> <a title="PSQH July/August 2013 page 27" href="http://viewer.zmags.com/publication/e9a4a3bc?page=27"> </a> <a title="PSQH July/August 2013 page 28" href="http://viewer.zmags.com/publication/e9a4a3bc?page=28"> PROJECT BOOST </a> <a title="PSQH July/August 2013 page 29" href="http://viewer.zmags.com/publication/e9a4a3bc?page=29"> Another opportunity we identified for improved </a> <a title="PSQH July/August 2013 page 30" href="http://viewer.zmags.com/publication/e9a4a3bc?page=30"> PROJECT BOOST Discussions at staff meetings we</a> <a title="PSQH July/August 2013 page 31" href="http://viewer.zmags.com/publication/e9a4a3bc?page=31"> working both the BOOST unit and control unit thro</a> <a title="PSQH July/August 2013 page 32" href="http://viewer.zmags.com/publication/e9a4a3bc?page=32"> FROM BLAME TO FAIR AND JUST CULTURE: A Hospita</a> <a title="PSQH July/August 2013 page 33" href="http://viewer.zmags.com/publication/e9a4a3bc?page=33"> T he concept of a “culture of safety”</a> <a title="PSQH July/August 2013 page 34" href="http://viewer.zmags.com/publication/e9a4a3bc?page=34"> FAIR AND JUST CULTURE In the Middle East, s</a> <a title="PSQH July/August 2013 page 35" href="http://viewer.zmags.com/publication/e9a4a3bc?page=35"> Fair and Just Culture The hospital administrat</a> <a title="PSQH July/August 2013 page 36" href="http://viewer.zmags.com/publication/e9a4a3bc?page=36"> FAIR AND JUST CULTURE There is no substitute f</a> <a title="PSQH July/August 2013 page 37" href="http://viewer.zmags.com/publication/e9a4a3bc?page=37"> proactively identify and implement risk reduction</a> <a title="PSQH July/August 2013 page 38" href="http://viewer.zmags.com/publication/e9a4a3bc?page=38"> Using Six Sigma to Improve Patient Safety i</a> <a title="PSQH July/August 2013 page 39" href="http://viewer.zmags.com/publication/e9a4a3bc?page=39"> Figure 1. High Level Process Map </a> <a title="PSQH July/August 2013 page 40" href="http://viewer.zmags.com/publication/e9a4a3bc?page=40"> SIX SIGMA of the SCIP core measures, including:</a> <a title="PSQH July/August 2013 page 41" href="http://viewer.zmags.com/publication/e9a4a3bc?page=41"> actions. More specifically, each failure mode is a</a> <a title="PSQH July/August 2013 page 42" href="http://viewer.zmags.com/publication/e9a4a3bc?page=42"> SIX SIGMA Figure 4. Measure Phase Awareness Fl</a> <a title="PSQH July/August 2013 page 43" href="http://viewer.zmags.com/publication/e9a4a3bc?page=43"> The use of “coaster” pagers (similar to those use</a> <a title="PSQH July/August 2013 page 44" href="http://viewer.zmags.com/publication/e9a4a3bc?page=44"> HEALTH IT & QUALITY The Health Supply Chain By</a> <a title="PSQH July/August 2013 page 45" href="http://viewer.zmags.com/publication/e9a4a3bc?page=45"> ISMP Patient-Controlled Analgesia Fatal PCA adv</a> <a title="PSQH July/August 2013 page 46" href="http://viewer.zmags.com/publication/e9a4a3bc?page=46"> Table 1. Guidelines for PCA Monitoring Respirator</a> <a title="PSQH July/August 2013 page 47" href="http://viewer.zmags.com/publication/e9a4a3bc?page=47"> recognition of excessive sedation and interventio</a> <a title="PSQH July/August 2013 page 48" href="http://viewer.zmags.com/publication/e9a4a3bc?page=48"> NEWS Quality Conundrums Lynn Helmer, MD, MBA, CH</a> <a title="PSQH July/August 2013 page 49" href="http://viewer.zmags.com/publication/e9a4a3bc?page=49"> American Board of Quality Assurance and Utilizati</a> <a title="PSQH July/August 2013 page 50" href="http://viewer.zmags.com/publication/e9a4a3bc?page=50"> Patient Safety and Quality Healthcare (PSQH) welc</a> <a title="PSQH July/August 2013 page 51" href="http://viewer.zmags.com/publication/e9a4a3bc?page=51"> </a> <a title="PSQH July/August 2013 page 52" href="http://viewer.zmags.com/publication/e9a4a3bc?page=52"> </a> <a title="PSQH July/August 2013 page 53" href="http://viewer.zmags.com/publication/e9a4a3bc?page=53"> Central Venous Access: A New Approach Larry Mill</a> <a title="PSQH July/August 2013 page 54" href="http://viewer.zmags.com/publication/e9a4a3bc?page=54"> Central Venous Catheters: A New Approach 2 in</a> <a title="PSQH July/August 2013 page 55" href="http://viewer.zmags.com/publication/e9a4a3bc?page=55"> Central Venous Catheters: A New Approach 3 in</a> <a title="PSQH July/August 2013 page 56" href="http://viewer.zmags.com/publication/e9a4a3bc?page=56"> Central Venous Catheters: A New Approach 4 Mu</a> <a title="PSQH July/August 2013 page 57" href="http://viewer.zmags.com/publication/e9a4a3bc?page=57"> Central Venous Catheters: A New Approach 5 Ul</a> <a title="PSQH July/August 2013 page 58" href="http://viewer.zmags.com/publication/e9a4a3bc?page=58"> Central Venous Catheters: A New Approach 6 In</a> <a title="PSQH July/August 2013 page 59" href="http://viewer.zmags.com/publication/e9a4a3bc?page=59"> Central Venous Catheters: A New Approach 7 SU</a> <a title="PSQH July/August 2013 page 60" href="http://viewer.zmags.com/publication/e9a4a3bc?page=60"> Central Venous Catheters: A New Approach 8 44</a>