Green Belt Candidates: Bill (William) Oliver and Michiele (Myra) Schrieber Green Belt training: August 2013, Fayetteville (Bill); June 2012, Oklahoma City Project Dates - 3/23/15 to 6/30/15, continued with follow up in July 2015 3. MEASURE: Identify operational barriers and failure models in the current process. 5. SUSTAIN: Sustainability Strategy Create a process control strategy- a strategy for insuring long term susta inability and spread adoption. • Gained buy in from providers regarding standardized heparin protocol. • Changed MCM to reflect that heparin will only be infused via the weight based protocol. • Revised Heparin Infusion Nursing Service Memorandum (118-15), rescinded 118-15 as a stand-alone policy, incorporated those elements into the MCM regarding Management of Anticoagulation Therapy (11-116) to streamline information for providers, nurses, pharmacists, and other staff. • ED heparin protocol orders developed. • Inpatient heparin protocol orders revised. • Revised heparin flow sheet (Heparin Infusion Note) to ensure appropriate and complete documentation. • Completed education regarding changes for heparin infusions. • Continued monitoring. Team members: Bill Oliver, Michiele Schrieber, Drake Rip pelmeyer, Linda Harwell, Shawna Digby, Kathryn Poole, Tiffany Todd, Kin dra Dial, Wendy Kring, Ronda McCiain, Jennifer Cole, Patrick Scott, Kim Adams, Kathleen Wilcox, Alice Carpenter, Kris Dickson, M/cha;/Meyer. This certifhjs that Bill OIive,rnd,.VIchiele Schrieber actively participated in the above project and completed this A3 Report on our own. Project Name: Heparin Infusion Improvement Team 1. TEAM/AIM: Define the Problem VHSO is not in complete compliance with Joint Commission Standard NPSG 05.01.03 [P2 regarding "use approved protocols for the initiation and maintenance of anticoagulation therapy" to reduce the likelihood of patient harm from anticoagulation therapy. AIM: Improve patient safety related to intravenous heparin administration by creating/using a standardized protocol and documentation as evidence by improved documentation requirement audit results (90%) by 6/1/2015. Sub-Al Ms: • Develop outpatient heparin protocol by 6/1/15. • Develop emergency department specific heparin flow sheet by 6/1/15. • Pre-infusion weight will be obtained and documented (100%). • Intravenous heparin administration will be ordered only via the standardized weight based protocol (100%). • Heparin flow sheet will be the only acceptable form of documentation and will be used to document heparin administration/maintenance (100%). • Second nurse verification will be documented using the heparin flow sheet (100%). 2. MAP: Evaluate Current State e- O_ 2,,,nnu5d f! ,ait r-*t t 'rGm t = tt : :uT ,- tr, 4; Ordered ICU/SDU Ordered ED Weight Obtained Verification Verification ED Used to Document ICU/SDU 4. CHANGE: Improve Systems Create a future state process by applying Lean techniques to eliminate operational barriers and failure Heparin Protocol Heparin Protocol Pre-Therapy 2nd Nurse 2nd Nurse Heparin Flowsheet -4- FY14 Q2 -4-FY14 Q3 -= FY14 Q4 FY15 Qi 120 100 80 60 40 20 0 modes. • Heparin Protocol Ordered rcu/sou • Heparin Protocol Ordered ED Pre-Therapy Weight Obtained •2nd Nurse Verification ICU/SDU •2nd Nurse Verification ED • Heparin Flowsheet Used to Document FY14 02 FY14 Q3 FY14 04 FY15 01 FY15Q2 Apr-15 May-15 Jun-15 P 4ü • (Executive Sponsor Sianature) th z//$ (Date)