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HAP Achievement Awards Winner Spotlight: UPMC Susquehanna

February 02, 2018

HAP Achievement AwardPennsylvania is home to some of the most cutting-edge hospitals in the country. This week, we’re sharing two award-winning programs developed by UPMC Susquehanna that improved maternity care and surgical instrument tracking.

The goal of the first program was to improve maternity care to encourage exclusive breastfeeding and better align postpartum practices with evidence-based standards.

A multidisciplinary team of physicians, nurses, lactation consultants, community members, and hospital leadership worked to complete Baby-Friendly USA’s 4D Pathway program. The team developed a policy that emphasized breastfeeding as the standard; engaged in significant staff training and patient education; and partnered with Women, Infants, and Children’s peer breastfeeding counselors to provide additional services for new mothers. The team also participated in the U.S. Centers for Disease Control and Prevention’s EMPower Breastfeeding initiative to reinvigorate the project.

Breastfeeding is a deeply personal venture that takes place during a time of rapid change in the mother’s life. UPMC Susquehanna undertook a challenging project that required ongoing training and collaboration across the entire care team.

The project’s impressive results benefit patients and the newest members of their families through:

  • Baby-Friendly USA’s Baby-Friendly hospital designation
  • Improved quality scores for key benchmarks, including labor and delivery care, postpartum care, family discharge care, as well as staff training, continuing education, and competency assessment
  • Improved Joint Commission Perinatal Core Measurement Quality Rates for initiation and breastfeeding exclusivity

UPMC Susquehanna’s second project focuses on operational improvements. Beyond the more obvious benefits, these improvements lead to greater staff satisfaction and cultivate stronger team engagement.

The goal of this program was to improve surgical instrument tracking through streamlining inventory, sterilization, and tagging systems. Tackling these changes require a shift in behaviors and cultural thinking, and they must be carefully and continually reassessed.

UPMC Susquehanna’s PeriOperative Service Department worked with staff members across departments to implement a surgical instrument tracking system. Staff worked to eliminate the use of paper log books and inventory sheets, create an accurate instrument pan labeling system, standardize instrument assembly, and improve reporting. A daily reporting system monitored results.

UPMC Susquehanna took a problem that may not be evident to everyone, found a solution, and realized results that are having a big impact on the organization, including:

  • Helping to achieve 100 percent compliance with Food and Drug Administration regulations for surgical instrument traceability well before the 2020 effective date
  • Decreasing instrument documentation time by 68 percent
  • Realizing a 25 percent improvement in set assembly productivity, reducing by half the time spent completing end-of-month tabulation
  • Achieving key benchmarks on or ahead of schedule, such as 100 percent elimination of paper log books and inventory sheets, 100 percent correct labeling of instrument pans, and 100 percent standardization of instrument assembly

Congratulations to UPMC Susquehanna for its work that led to earning two 2017 HAP Achievement Awards. Learn more about their effort as well as the other 11 award winning programs at HAP’s website.

Each year, HAP honors hospitals and health systems for their innovation, creativity, and commitment to patient care through its annual Achievement Awards program.

HAP members are encouraged to starting planning now for their 2018 Achievement Awards submission by identifying innovative patient-centered initiatives that improve health care quality and efficiency and the health of your communities. HAP will issue a call for entries during March, emailing it members and making it available online. Entries will be due in May, with winners announced in June.

Questions about the HAP Achievement Awards may be directed to HAP Member Services at (717) 561-5359.


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