HANYS PINNACLE AWARD FOR QUALITY AND PATIENT SAFETY One Empire Drive Rensselaer, NY 12144 PROFILES IN QUALITY hanys.org HealthcareAssociation AND PATIENT SAFETY hanyscomm © 2019 Healthcare Association 2019 of New York State QUALITY AFFORDABLE TIMELY Contact us for all your printing needs. 518.431.7920 hanysprintingservices.com We are pleased to share this annual compen- dium of nominations for HANYS’ Pinnacle Award for Quality and Patient Safety, which recognizes organizations that are playing a leading role in promoting improvements in healthcare delivery in New York state. The 115 nominee healthcare organizations from across the state are taking bold steps to improve patient care and outcomes. During this time of rapid change and uncertainty, their passion for innovation and ongoing improvement is critical to advancing the health of individuals and communities. HANYS thanks its members for their willing- ness to share their ideas, experiences and successes through their Pinnacle Award sub- missions. We encourage all members to take advantage of the information in this publi- cation as a means to inform and accelerate ongoing efforts to improve quality and patient safety. Sincerely, Bea Grause, RN, JD President © 2019 Healthcare Association of New York State, Inc. | HANYS’ PROFILES IN QUALITY AND PATIENT SAFETY 2019 | 1 TABLE OF CONTENTS 2019 Winners of HANYS Pinnacle Award for Quality and Patient Safety Post-acute/outpatient provider ..................................... 1 Hospital with less than 200 beds ................................... 2 Hospital with 200 to 500 beds..................................... 3 System or hospital with 500+ beds.................................4,5 Chapter one – Culture and leadership High five: Achieving continuous quality improvement Rochester Regional Health System ........................................7 Leadership rounds – CLIMBing to the top St. Charles Hospital, Port Jefferson........................................8 Implementing a daily management system and Gemba boards Long Island Jewish Medical Center, Queens..................................9 Patient safety Zero Harm: Aligning behavior and decision making Little Falls Hospital ..................................................11 ESTER: Enhancing safety through engagement and reporting Mount Sinai Beth Israel, New York .......................................12 Optimizing EMR alerts: Improving the safety of medication administration to enhance patient care Rochester Regional Health System .......................................13 Reducing the risk of medication errors using barcode technology Montefiore Nyack Hospital .............................................14 Resident physician-run patient safety council: Impact in achieving patient safety goals Richmond University Medical Center, Staten Island ...........................15 Huddle your way to high reliability: How 15 minutes per day can change your organization Adirondack Health, Saranac Lake ........................................16 Patient/family engagement as a strategy to enhance patient safety utilizing a multidisciplinary oral anticoagulant therapy program NYC Health + Hospitals/Queens, Jamaica ..................................17 © 2019 Healthcare Association of New York State, Inc. | HANYS’ PROFILES IN QUALITY AND PATIENT SAFETY 2019 | 3 Patient experience Innovating rounding White Plains Hospital ................................................19 Quantifying patient satisfaction with process metrics using a weighted bundle approach Northwell Health, Lake Success .........................................20 Achieving an organizational culture of excellence for the patient experience Community Memorial Hospital, Hamilton ..................................21 EVS collaboration for exceptional patient experiences White Plains Hospital ................................................22 Employee engagement and safety Building a culture of engagement — a precursor of high reliability Bassett Medical Center, Cooperstown .....................................24 Building a hospital team-based staff emotional support program Strong Memorial Hospital, Rochester .....................................25 Risk avoidance through safe patient mobility Catholic Health Services of Long Island, Rockville Centre .......................26 The trickle-down effect of employee engagement and psychological safety on harm prevention St. Joseph Hospital, Bethpage ..........................................27 Improving staff safety during care of patients with aggressive behavior NYC Health + Hospitals/Lincoln, Bronx ....................................28 Improving staff safety through safe patient handling Sunnyview Rehabilitation Hospital, Schenectady . 29 Six Sigma project: Nurse satisfaction Good Samaritan Hospital Medical Center, West Islip...........................30 Chapter two – Capacity and patient flow Optimizing hospital capacity through a discharge-before-noon initiative The Mount Sinai Hospital, New York City...................................32 Adult primary care continuity and access initiative NYC Health + Hospitals/Bellevue ........................................33 Serving the community through our front door St. Elizabeth Medical Center, Utica.......................................34 Peri-operative patient throughput improvement project New York Eye and Ear Infirmary of Mount Sinai, New York City ...................35 4 | HANYS’ PROFILES IN QUALITY AND PATIENT SAFETY 2019 | © 2019 Healthcare Association of New York State, Inc. Achieving predictive performance without a crystal ball Good Samaritan Hospital Medical Center, West Islip...........................36 Decreasing medicine length of stay to enhance patient flow NYC Health + Hospitals/Jacobi, Bronx.....................................37 Saving lives with ED throughput: In-person pull from the ED Kingsbrook Jewish Medical Center, Brooklyn ................................38 Chapter three – Healthcare-associated conditions Infections BROAD INFECTION CONTROL INTERVENTIONS Zero Harm: Our health system’s journey to eliminate hospital-acquired complications NYU Langone Health, New York City ......................................41 Our journey to ZERO: Reducing overall hospital-associated infections through a collaborative interdisciplinary approach Peconic Bay Medical Center, Riverhead....................................42 Starting with clean hands: Hand hygiene as a paradigm to align safety Mount Sinai Health System, New York City .................................43 Hand hygiene “CATCH” initiative Mount Sinai St. Luke’s, New York City.....................................44 CATHETER-ASSOCIATED URINARY TRACT INFECTIONS Catheter-associated urinary tract infection: The disappearing act Northern Westchester Hospital, Mount Kisco ................................46 Standardized system-wide initiative to reduce catheter-associated urinary tract infection by using best practices NYC Health + Hospitals ...............................................47 The Journey to “Zero” catheter-associated urinary tract infections Flushing Hospital Medical Center ........................................48 #NoMoreCAUTI: Reducing CAUTI by improving process reliability through frontline engagement NYU Winthrop Hospital, Mineola ........................................49 Getting to zero harm — Reduction of CAUTI Samaritan Hospital, Troy ..............................................50 CENTRAL LINE-ACQUIRED BLOOD STREAM INFECTIONS Vascular access stewardship: Enhancing patient safety and reducing cost one (less) line at a time NYU Langone Health, New York City ......................................52 Reducing central line-associated blood stream infections Albany Medical Center................................................53 © 2019 Healthcare Association of New York State, Inc. | HANYS’ PROFILES IN QUALITY AND PATIENT SAFETY 2019 | 5 It takes a village — Reducing CLABSI in an era of constrained resources SUNY Downstate Medical Center, Brooklyn .................................54 SURGICAL SITE INFECTIONS Improving outcomes of the cardiac patient through a multidisciplinary team approach in the peri-operative setting Mercy Hospital of Buffalo..............................................56 The basics make a difference John R. Oishei Children’s Hospital, Buffalo .................................57 Reducing immediate-use steam sterilization while increasing production St. Charles Hospital, Port Jefferson.......................................58 Point-of-use cleaning in the operating room Highland Hospital, Rochester ...........................................59 CLOSTRIDIUM DIFFICILE Improving hospital-acquired Clostridium difficile rates: An interdisciplinary approach to implementing best practice St. Luke’s Cornwall Hospital, Newburgh ...................................61 Clinical decision support strategies to reduce hospital-onset Clostridium difficile infections Jamaica Hospital Medical Center ........................................62 CDIFFerently: A bundled approach to sustained Clostridium difficile infection prevention Faxton St. Luke’s Healthcare – St. Luke’s Campus, Utica . 63 Technology utilization in the reduction of Clostridium difficile Peconic Bay Medical Center, Riverhead....................................64 Implementation of a clinical intervention and electronic decision support system to reduce healthcare-associated Clostridium difficile NewYork-Presbyterian/Queens, Flushing ...................................65 Success in decreasing