Exemplary Professional Practice

In October of 2024, the ICU HAPI prevention workgroup conducted impactful training sessions titled “HAPI Hour 2.0.” These sessions, which built on the success of the previous year’s “HAPI Hour,” were a focused quality improvement project to reduce HAPIs in the ICU.

The primary aim of this group is to demonstrate a reduction of stage 2+ HAPI in the ICU. In the ICU, previous barriers focused on obtaining appropriate nutrition for our critically ill patients. With the help of the ICU clinical nurse specialist, Amber Glukhenkiy MSN, APRN-CNS, ACCNS-AG, and CCRN, a focused literature review was completed to examine the correlations between adequate nutrition and pressure ulcer development.

Using the evidence as our guide, we structured our training to review (6) key areas: moisture management, nutrition, patient turning, wound consults, documentation, and appropriate surface. The group set a goal to provide this training to 70% of the staff and were able to meet their goal. The ICU has not had any reportable pressure injuries since July 2024, a testament to the effectiveness of the training. 

Pictured above: Sheila Kadel BSN, RN provides education to ICU peers Kevin Ho, BSN, RN, CCRN and Thien Tran , BSN, RN, CCRN 

RN’s and leaders worked together to launch Code BERT, a code that is called for any patient exhibiting behavior that staff feels has the potential to escalate, but does not appear to be an imminent threat to self and/or others.

Code BERT provides interdisciplinary behavioral health focused interventions on de-escalating behavior, with ongoing support for staff to maintain safety. With the support of hospital leadership and the dedication of front-line staff, Code BERT is now operational where patient care is performed. 

Pictured above: Shipti Parikh, BSN, RN rounding on units providing education to her nursing peers and staff. 

More than 700 South Sacramento Area physicians and employees recently attended the second annual Workplace Violence Prevention Fair, which featured resource tables, hands-on activities, law enforcement, flu shots, and tips for staying safe at work. 

The fair was held outside the Dan B. Moore Building on Oct. 18 and coordinated and sponsored by the multidisciplinary South Sacramento Workplace Violence Prevention Committee, which was launched in 2023 to enhance physician and employee safety and support our services area’s Culture of Safety. The executive leadership sponsors of the committee are Rachel Wyatt, DNP, MHA, RN, NEA-BC, Interim Chief Operating Officer, and Katie Hoganson, MSN, MBA, RN, NEA-BC, Interim Chief Nurse Executive. 

“Our 2nd Workplace Violence Prevention Fair was a great opportunity to share all the progress that our WPV Prevention Committee has worked on for the past year, with the launch of Code BERT, BVC, and expanding/educating on available support systems at South Sacramento,” said committee lead Nic Troxell, BSN, RN, Palliate Care RN II and CNA RN Quality Liaison. “I’m very thankful to South Sacramento Leadership, and especially our Safety Sue, for supporting all this work; highlighting our Fair’s theme: ‘Our Safety Matters.’” 

Sue Eisberg, Safety Operations Practice Leader and also a member of the WPV Prevention Committee, offered her gratitude to the dozens of teams and individuals who helped plan for and participated in the fair. 

“The planning and preparation that went into this event were evident, and I truly appreciate all the effort that went into making it a success,” Eisberg wrote in a thank you message. “Despite the challenging windy weather, you all handled the situation with remarkable professionalism and adaptability. I was truly impressed by how quickly you secured your items and ensured everything stayed in place. Your quick response and ability to maintain a positive attitude ensured that everyone visiting the fair had a great experience. 

“Each of you did an outstanding job at your booths — and with the roving cart — engaging coworkers and sharing vital information. Your collective efforts made a significant impact on everyone’s awareness of the fantastic work you all have been doing to keep our workplace safe and secure. I want to give a special shoutout to Nic Troxell for his awesome partnership in making our fair a success. We could not have done it without him! 

“Thank you once again for your teamwork, resilience, and dedication to workplace violence prevention. I’m proud to work alongside such a committed group of individuals.” 

The Leapfrog Group announced its latest round of Safety Grades in November 2024. For the second time this year, our medical center has earned an “A” for safety. This accomplishment is impressive, given less than 30% of the nation’s hospitals received an “A” rating in this reporting period. 

This achievement is a direct reflection of the tireless efforts of our entire team—our dedicated and highly skilled physicians, nurses, managers, and staff. Every day, you contribute to creating a safe, healing environment for our patients and their families. Whether through careful attention to infection prevention, innovative approaches to patient care, or unwavering commitment to our safety protocols, your work makes a difference and saves lives. 

Patient safety is not an easy feat—it requires constant vigilance, collaboration, and a shared commitment to the highest standards. Our “A” grade is a testament to the strength of our team and the culture of excellence we foster together. You have demonstrated that our patients’ well-being comes first, and for that, we are incredibly grateful. 

For more information and a complete list of the hospital safety grades, visit Leapfrog. 

Thank you for your exceptional work and dedication to upholding Kaiser Permanente’s reputation as a leader in safety and quality care. Let’s take a moment to celebrate this accomplishment, reflect on our achievements, and look forward to more successes in the future.

Pictured above left to right: Vanessa Tam, RN,  Michael Baldi, Katie Hoganson MSN, RN, MBA, NEA-BC, Carla Hodges, Brandon Pace, Charlene Johnson, MSN, RN, Bottom Row: Lulette Infante, MSN, RN, Danielle Lucas, BSN, RN, Huong Bui, BSN, RN, RNC-MNN, Jill Edgar, BSN, RN, RNC-OB, Jennifer Franco, BSN, RN, RNC-OB, Nguyet Berman, RN, Pik Kam, BSN, RN, RNC-OB  

While physicians and employees were enjoying the Season of Gratitude, our Safety, Quality & Regulatory Services and Patient Care Services teams were also busy celebrating their own “Tis the Season for Quality” campaign.

The campaign focuses on patient safety measures, including correct testing of C. difficile and preventing surgical site infections, central line bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), hospital-acquired pressure injuries (HAPI), and hospital-acquired pneumonia (HAP).

“Historically, our safety priority index (SPI) measures of harm increase in the fourth quarter of the year,” said Wilfren Esposo, RN, MSN, MBA, NP-C, CPHQ, Clinical Quality Director, SQRS Department. “The goal of the ‘Tis the Season for Quality’ campaign is to proactively keep staff focused on preventing harm by reinforcing bundle elements, especially those where compliance was a bit lower during the most hectic time of the year. The initiative also seeks to keep staff engaged by including prizes, snacks, and fun seasonal decorative themes. “

This marks the second year SQRS has held a year-end quality campaign and efforts this year have been led by Greg Woolf, RN, MS, CPHQ, Lead Quality Nurse Consultant, and the Quality Nurse Consultant Team in partnership with the Magnet Quality and Safety Council Chair and Co-chair. This year features a new celebrating the seasons theme and more direct involvement from frontline PCS staff in the planning and execution of the campaign.

The campaign features a decorated roving cart loaded with snacks and a large poster containing educational information. The cart is managed by frontline PCS staff who round on individual nursing units on all floors and talk with nurses about the different harm event bundles during their shifts. Staff who answer questions about the harm events are entered for a chance to win a prize that day. Staff in PCS, Perinatal/Mother-Baby, and Surgical Services can also take a quiz by scanning a QR code tailored to their specific care areas. Quiz questions are based on information provided during the campaign to check for understanding.

The unit with the most correct answers to the quiz will be awarded a party of their choosing, said Woolf. For those staff who do not get a chance to see the roving cart have the option to see the same information presented at a ‘Tis the Season for Quality’ table in the breezeway where they can engage with the Quality Nurse Consultants, spin a wheel to answer questions, and take the QR quiz on the topics presented.

“Staff have expressed appreciation for the opportunity to discuss specific questions about individual harm prevention bundles,” said Woolf. “They have also enjoyed the prize drawings and holiday themes making learning about quality measures more fun. The Quality Nurse Consultants and the chairs of the Magnet Safety and Quality Council have also had an opportunity to further strengthen their partnership, which will lead to improved consistency of messaging and create synergy for existing and future projects. The project has also allowed staff members to become experts in harm prevention bundles as they answer questions from their peers with the roving cart.”

Now in just its second year, the campaign is having an impact.

“Not only was there a heightened level of excitement as staff and leaders were asking when the drive would return this year, but we’ve seen an increase in participation and a heightened awareness of our hospital SPI trends,” said Esposo. “We’re confident that this will only grow as more and more teams engage in this annual effort. The SQRS team will evaluate both 4th quarter harm events and the staff’s understanding of the material based on quiz results and utilize this information to target ongoing performance improvement efforts into the new year.”

Picturedin main photo: Back Row: Edward Robinson, BSN, RN, CMSRN, NPDC, Harpreet Kooner, BSN, RN, CPHQ, Carminda Pantoja, BSN, RN, Lisa Rael, MSN, RN, RNC-OB, Jane Brinkerhoff, MSN, RN, Wilfren Esposo, RN, MSN, MBA, NP-C, CPHQ, Reid Hirsch, BSN, RN, CRRN, Lena Yaqubi, RN, Greg Woolf, RN, MS, CPHQ, Dr. Marelich, MD, Frank Kotowski, MBA, BSN, RN, CPHQ, Sherry Whitcomb, JD, MSN, RN, CPHQ, SCRN, Dr, Reza Sianati, MD, Chanae Joi Haylock, MSN, RN, PCCN, PMHNP-BC, Dr. Matthew Eldrich, MD, Middle: Pamela Jagur, BSN, RN, Bhupinder Kaur, BSN, RN, and Jamie Windsor, BSN, RN, RNC-OB. Bottom Row: John Kim, Dr. Jonathan Aron, Milanelle R. Guiao-Tranchina, BSN, RN, CMSRN, PCCN, Emily Morris, BSN, RN, Lulette Infante, MSN, RN.