ࡱ> |~{ s.bjbjBrBr o  3&?77777$[[[P$4[acccccc$!d$J777$$$77a$a$$:Q,h3[j} M0R$$$$7t$$$ :   Sustainability Action Plan  Below is a sample of a continuous action plan template created by Baiba Zarins, Project Manager, Best Practice Guidelines, University Health Network, Toronto, Ontario. The plan depicts the identified sustainability indicators utilized within a large acute care hospital to monitor the sustainability of simultaneous BPG integrations. Each row identifies a particular indicator established as a unique measure, as applicable within multiple levels of the organization. Within each column are identified measures used to ascertain multiple points of sustainability monitoring within each BPG. This tool is useful for internal monitoring, revision and evaluation of BPG status, particularly with respect to the introduction of future guidelines. A long-term consideration of this table includes comparison of interrelated BPG benchmarks when strategizing efficiency and outcome effectiveness over time. University Health Network is a designated RNAO Best Practice Spotlight Organization and is actively involved in the development, pilot testing, implementation and evaluation of numerous RNAO BPGs. BPG topicPainFall safety and restraintsPressure ulcersVascular accessPCC Patient-centered Care AspectPicker tool tracking TWH Oral PCA research project-now spread to TGH siteUse of constant observers tracking via NRTPatient included wound care roundsDevice selection in collaboration with patient Patient taught to care for device in the community Process to fast track patients with hydration needs (subcutaneous infusions in the home/alternate level of care) Collaboration with Medical Imaging related to VA device insertion, care/maintenance. (2010UHN Charter 2003 Board retreat focus (2005) Public awareness and disclosure on internal and external website Virtual patient evaluation group Patient and family participation in implementation strategies (PCC Communication strategy) Implementation and Evaluation Patient Resource Network (4-8hr. sessions) VAS signage No Pain signage & lapel buttons Pain awareness education to transportation and volunteer services Equianalgesia chart Quarterly site based Lunch & Learns (vendor sponsored) Interdisciplinary Pain Rounds (monthly) Hospital orientation presentation Pain management strategies within unit goals & objectives APN Clinical ResourcesClinical Educator packages: Power point Staff pocket cards Documentation samples Hospital orientation presentationWound Care Resource Nurses (4-8hr. sessions) Product chart on intranet site Vendor sponsored unit in-services Hospital orientation presentation APN Clinical Resources Heel Boots implementation (summer 2005) UHN Mattresses Replacement project (spring 2006) UHN Stretcher surface replacement project (Spring, 2010) ICU (TWH Site) therapeutic surface replacement project (Spring 2010) Digital Signage contentVendor education sessions Clinical educators PICC insertion Midline insertion by trained staff Hospital orientation Presentation PMH Clinical Vascular Nurse Resource Corporate Clinical Resource CVAD care and maintenance review for oncology patients (2010)Corporate PCC integration team UHN PCC Toolkit for Managers (2003) PCC integrated within all HR, clinical and research process Role description Interview Consent Clinical doc Patient, staff, family Education PCC clinical rounds Staff Education: Lunch/Learn, calendar, 3 day comp, Customized High Impact Strategy: PCC Acceleration Initiative 2007 Integration ToolNumeric Rating Scale (NRS) within UHN standardized documentation tools: VS record Neuro record PCA PCEA Epidural ICU/ACU flow sheetsMorse Fall Risk Assessment Patient Care Record UHN Incident ReportBraden Pressure Ulcer Risk Assessment Patient Care Record Tick box Vascular Access Flow sheet Vascular Device Clinical decision-making chart Proposal for infusion therapy nurses for TGH and TWH sitesPCC extended and accelerated course via HR Site/program/unit initiatives and quality teams Unit/team charters, goals and objectives UHN Balanced Scorecard indicator Embedded within: Job Postings Interview questions Performance Evaluation System Employee Opinion Survey (annual) PCC Competencies and Standards Checklist Code of Conduct Workplace EthicsClinical standards (link with e-doc) VAS and pain management plan Risk Assessment and prevention plan VAC dressing criteria Skin Assessment and risk prevention plan  Vascular Access Device decision-making algorithm PCARE clinical model UHN PCC Standards PCC Doc. Guidelines e-learning strategy3 modules: Case Studies 1. Assessment 2. Post-op 3. Acute on chronic pain 1.Morse Fall Scale 2. Use of restraints at UHN Braden Scale Skin breakdown 1. Assessment for device 2. Maintenance Troubleshooting Infusion Pumps central line infections 1 module 1. focus charting e-Learning Module Fall 2010 Collaboration York U-UHN AcademyMedical directiveNot legislated within scope of practiceMay 2005-restraint applicationJanuary 2005 Treatment for Stage 1 & 2 ulcersFeb 2003- Heparin lock TVKO conversion to saline lock Not applicable Clinical Policy(2003-2010) Pain Management PCEA PCA (2009)May, 2005 Fall prevention linked with revised restraints minimization policySept 2005 (updated to include current changes with supplies & dressing options) Heel boot policy pending VAC dressing criteria/policy pending February 2003 (update pending) Vascular access: initiation, maintenance, troubleshooting Occlusion interventionPCC Visiting Policy 2009 Care Provider Preference 2009 PCC Patient Education Network MaterialsExtensive and multilingual on internal & external websites Pain Management Procedural Pain Adjunct therapy Alternative therapy Internal Patient-Education TV episode (2010)Fall Safety in hospital Fall Safety in the home brochure Restraints utilization information sheet Falls Prevention Program (referral service) Protecting yourself from Falls Caring for your skin Incontinence products Nutrition and Wound Healing Pressure Ulcer Prevention Infection Prevention Implanted Central Vascular devices PICC catheter Intravenous Therapy-All you need to know about your central venous catheter Intravenous Therapy Medication Fact Sheets Needle Safety at home Vascular Access for Haemodialysis Infection Prevention and controlDigital signage PCC Intranet UHN Annual report UHN Nursing report Allied health Report (posted for public) PCC-what it means to me PCC-UHN video series Health Literacy for patients and their families PCC-Working Together PCC info kiosks (PMH) PEN Library at each hospital site EvaluationChart Audits-June 2005 Patient Satisfaction surveys Nurse satisfaction surveys (telehealth Northern network system) Pocket Pain Assessment Cards (February 2006)Clinical Audit November 1 2005 and Nov. 2006 Report directly to UHN QCC-Risk Management UHN Performance IndicatorAnnual P & I Data collection in November Report directly to UHN QCC-Risk Management UHN Performance IndicatorCreation of datasets and building EPR around required outcomes to ensure future quality data. Balanced Scorecard-Central Line Infection Task force on CLI (Safer Healthcare Now!) UHN Balanced Scorecard Picker tool/patient satisfaction scores EOS UHN Balanced Scorecard Patient Relation Complaints Patient narratives Research and Quality Assurance PRN focus group November 2005 Staff knowledge & attitudes survey UHN patient satisfaction dataUHN out-patient fall safety clinic through Seniors Wellness Clinic (TWH) Annual in-patient clinical audits: November UHN incident report tracking data with quarterly reports to UHN QCCP & I tool validation-UHN/SMH/Sunny- brook collection tool study UHN performance measurement dataUHN performance measurement data: infection/complication rate Continual review of published research. NBPRU collaboration-Validation of Phlebitis and Infiltration Scale (2010) PICC insertion at point-of care (CVICU-pilot project) Infusion pump utilization review and future needs (Smart pumps) Collaboration with CVA-GTA chapter meetings (UHN. president) Safety Engineered Device Review and New Product Trial (2010)Patient focus group Accreditation standard Best of Nursing Research Study (2009) Patient Virtual focus group HBT PCC 80/20 High Impact Strategy: PCC Acceleration Initiative Nursing Research Challenge Studies CommentsCorporate Priority Funding-Krembil Neurosciences for focus group study Publication 2009 (Oral PCA) ACPF: 2004, 2008Liaison with DDD group RE: safety measures and policies ACPF 2009: New mattress trials/evaluation/purchase project-need done by March 31, 2006 Link with Pain Publication 2007On-going new product trials/evaluations Safe needles Pumps Intravenous tubing Link with Pain Publication 2009 Global spread teleconference: dissemination of BPG teleconferencing. (2009)Imbedded in work of all BPG integration Patient Safety Patient Diversity Wireless Internet Access Public Computer stations in waiting areas Communication discs for surgical/procedure families (TWH) ACPF: 2004 UHN WebsiteCorporate and Nursing Intranet site UH Digital Signage info (2010)Merge with Falls = UHN Confusion Management and Fall Prevention committeeSkin and Wound care BPG home page on intranetUHN Vascular Access home page UHN Digital Signage info (new VAD Dressings) April 2010Corporate and Nursing sitesUHN Contact Liaison Corporate Pain APN Contact Information Contact Information UHN Skin and Wound Care Leadership Team Contact Information Corporate Vascular Access Coordinator Contact Information Corporate PCC Implementation Team Contact Information     Implementation toolkit  PAGE 7  +1 ɵteUeIeIeI=eIeIeIeIh*O"CJOJQJaJhBSCJOJQJaJhO&hBS5CJOJQJaJhO&hBSCJOJQJaJhO&hBSCJOJQJaJ4jphYhYCJOJQJUaJmHnHsH u,hO&hBS5B* CJOJQJ^JaJph&hBS5B* CJOJQJ^JaJphDjhYhY5B* CJ OJQJU^JaJ mHnHphsH u%h^uhBSB* CJOJQJaJph n o k l m n o p q r s t u v $$Ifa$gdG$a$gdBS$a$gdBS$d1$9D@&H$a$gdBS   j k v z { 5 6 G J LMst幰{{{{{{mh^uhBS5CJ\aJhBSCJaJ h^uhBSh^uhBSCJaJhBSB*CJaJphh^uhBSB*CJaJphhBS5CJaJh^uhBS5CJaJh;9hBS6CJOJQJaJhx7hBS6CJOJQJaJhBSCJOJQJaJhO&hBSCJOJQJaJ* . 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