Our third meeting for 2014 hosted 121 attendees from 53 hospitals. Feel free to review the various presentations in detail at: http://www.hasc.org/southern-california-patient-safety-first-collaborative

Headline: Surgical Procedures are Safer in CA – Don’t Be Left Behind!
Verna Gibbs, MD, Director, No Thing Left Behind, Professor of Surgery UCSF, Staff Surgeon SFVAMC

A great many hospitals in California have accepted the challenge to eliminate retained surgical sponges and towels, and data demonstrate months and years with zero such events, particularly in the Dignity Health system. Nevertheless, these CDPH “Never Events” continue to be reported in California hospitals. A very simple protocol can protect your hospital from these “never events.” The protocol is simple, but implementation is not. This presentation reviewed helpful resources for our hospital teams.

Team Presentation: Sepsis Management
Fay Shinder, RN, BSN, Sepsis Program Coordinator, Long Beach Memorial Medical Center

Upon recognizing sepsis as a major contributor to the hospital’s overall mortality rate, a consistent process for consistent recognition, treatment, and care was created and implemented, including a multifaceted audit tool for ICU patients, a screening tool for ED, a treatment algorithm, and electronic order sets to expedite treatment.

Team Presentation: Glucose Control for Surgical Safety
Romic Eskandarian, Pharmacist, Glendale Adventist Medical Center

Hyperglycemia is a common and costly problem in hospitalized patients, inhibiting the healing process post operatively, as well as increasing the risk of infection and length of stay. The Pharmacy-driven Basal Bolus Insulin Protocol (BBIP) was reviewed. Results of this program indicate significant reduction in blood glucose levels and a reduction in length of stay for patients with diabetes by 0.393 days, computing to a reduction in costs of $90,000.

Team Presentation: Using Six Sigma and Lean Effectively in your QI Initiatives
Muder Alkrisat, Ph.D., MSN, RN, CSSBB, CSHA, HACP, Director of Clinical Process Improvement, Coastal Communities Hospital

Six Sigma performance in health care – only 1 defect in 600,000 - focuses on processes, and controlling variation. Using Six Sigma and Lean Thinking strategies, the health care team can understand the distribution of occurrences, identify common cause and special cause variation, and analyze variation to better design corrective actions. Six Sigma and Lean Thinking can help your hospital reduce untoward events such as falls and adverse events with statistical significance. Process and measurement tools were reviewed for application.

Reducing NTSV C-Sections: A Three Pronged Approach
Diana Ramos, MD, LA County Public Health

The primary C-section rate has increased by more than 20 percent since 1996. LA County’s three-pronged approach includes a provider survey to assess current thinking and preferences for communication avenues, understanding patient perspectives (31 percent believe a C-section is as safe as a vaginal delivery), and review of hospital capabilities to be optimally prepared for emergent C-sections. Targeted education to these three groups will follow, in partnership with other maternal/child patient safety organizations and efforts.

A Primer on Change Management- Key Concepts and Challenges
Marcey Uday-Riley, MSW, CPT and Pam Cunningham, Six Sigma Black Belt/Lean Instructor

This dynamic team presented a six-step model for driving change: Planning the Change, Communicate the Plan, Cultivate Commitment, Launch the Plan, Reinforce the Change, and Transition Forward. Using this framework, hospitals can navigate the muddy waters of important change strategies successfully. A workshop will be offered in the spring in which hospitals can opt to participate and learn the “how to” for the six change model steps.