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Standard Work



Chapter 0 : Templates and Tools

A3 Scientific Method Problem Solving Tool

Standard Work Template

Standard Work Template with 5 Components

Chapter 1 : Clinical Standard Work

Section : Assessment and Care Fundamentals

Vital Signs - Adult Acute Care - PCA, PCT & RN

Vital Signs - Patient Discharge Vital Signs & Focused RN Assessment

Section : Be Safe

Exposures - Gloves On, Goggles On - Safety in Pairs

Exposures - How to Enter HIV/HEP Exposure Order for BBF Exposure

Exposures - Team Member BBF Exposures in OPSC / Main OR

Isolation - Long Term Isolation Precautions in Ambulatory

Sharps - Engagement, Cleanup, and Disposal of Needle Safety Devices

Sharps - Hot Needles - Prevention of Injection Related Needle Sticks

Sharps - Needle Stick Prevention - Grey Vacutainer Needle on Blood Collection Set

Sharps - Nursing Work Surface / Keyboard Tray

Sharps - Opening Ampules Safely (Ampule Breakers)

Sharps - Preoperative Sharps Safety Checklist & Post Sharp Injury Actions (Main OR)

Violence - After Action Review (AAR) of Explosive Violence

Violence - Epic Flag for Situational Awareness and Violence

Violence - Explosive Violence Response & Recovery in Non-Inpatient Areas

Violence - Explosive Violence Response & Recovery on Inpatient Unit

Violence - IMPORTANT PHONE NUMBERS

Violence - Obtaining Private Security & Private Security Role Description

Violence - Performance Concern for Correction Officers/Law Enforcement

Violence - Restricted Access in Violent Event

Violence - SAVE Call Script

Violence - STOP Signage across Patient Doorway (Potential Impulsive Behavior Alert)

Violence - Threat Assessment

Section : CAUTI Prevention, Genitourinary and Renal Care

A3 Worksheet - Infection Investigation for CAUTI or CLABSI

Chlorhexidine (CHG) Bathing and Peri-Care

Dialysis - Adult Hemodialysis / Apheresis Catheter Blocking with Citrate

Foley Catheter Insertion

Foley Catheter Insertion with Substitute Insertion Kit

Intermittent Catheter Insertion with VaPro Plus Catheter

Ordering Peritoneal Dialysis Supplies

PrimaFit External Urine Management System for Females

Urinary Incontinence Pad Weighing

Urine Culture Specimen Collection with Indwelling Urinary Catheter Algorithm

Section : Children's Hospital

Admission | Admitting Oncology Patient from Outpatient to Inpatient with Active Infusion

Admission | Admitting Oncology Patient from Outpatient to Inpatient with Controlled Substance Infusion

Admission | Process for Periviable Birth

Antiseptic Choice for Venipuncture and Arterial Puncture in the Neonate

Breastmilk - Freezing Breastmilk

Breastmilk - Obtaining a DME Breast Pump with a Voucher Payment

Breastmilk - Procurement of a Breast Pump through ABC Healthcare

ECMO - Emergent Pediatric Cardiac ECMO (eCPR)

ECMO - Non-emergent ECMO Activation (Children’s Hospital)

ETT - NICU Stabilization of Endotracheal Tube with Neofit or Portex Stabilizers

Handover - NICU Handover of Care

Handover - PICU / NICU to OR Preoperative Handoff

Lab - Drying and Transit of Newborn Screening (NBS)

Meds - Administration of High Dose Methotrexate Infusions (Acute Care Pediatrics)

Neonate - Labeling Umbilical Venous and Arterial Catheters

NICU | Kangaroo Care for Ventilated Infant

NICU | Newborn Hearing Testing Process

NICU | Patient Death

Pediatric PICC 3M™ Tegaderm™ CHG Gluconate Dressing Change with SECUREMENT DEVICE

Pediatric Sepsis Evaluation

Phototherapy for Crigler-Najjar Patients

PICU | Double Pumping Vasoactive Infusion

PICU | Placement of Pediatric Non-Weighted Post-pyloric Tube

PICU | Pressure Ulcer Prevention in the Pediatric ICU

Sedation - Intranasal Versed for Minimal Sedation/Anxiolysis for Minor Procedures (Acute Care Pediatrics)

Subcutaneous Treprostinil (Remodulin) Infusion

Trach - Children’s Hospital Tracheostomy Inpatients

Zebra Band Printing

Section : CLABSI Prevention and IV Therapy Technique

A3 Worksheet - Infection Investigation for CAUTI or CLABSI

Central Line - Dressing Change with Betadine Cleanser

Central Line - Implanted Port Dressing Change

Central Line - Implanted Port Access

Central Line - Scrub the Hub and Cap the Hub

Central Line - Tegaderm Chlorhexidine Gluconate (CHG) Dressing Change

Central Line Insertion - LIP Standard Work

Central Line Insertion - RN Standard Work

Pediatric PICC - CHG Dressing Change with Stat-Lock Change

Section : Digestive Health

C. difficile Case Review

Fecal Incontinence Management Algorithm

Lactulose Administration and Hepatic Encephalopathy (HE) Algorithm

Stool Management System (SMS) Large Volume Medication Administration (>200 ml)

Taping, Securing, and Daily Care of Nasoenteric Tubes - and Bridling Criteria

Section : Documentation and Epic

*Epic - Find Other How-To Instructions in the Epic Learning Library

Epic - How to See and Use Banners and FYI Flags

Epic – How to Create Documentation-Only Behavior Note

Inpatient - Admission Documentation for Registered Nurses

Inpatient - Discharge Documentation for Registered Nurses

Inpatient - E-Faxing Inpatient Documentation to Health Information Services

Inpatient - Patient Transfer Documentation for Registered Nurses

Inpatient - Shift Documentation for Registered Nurses

Inpatient - Shift Handover for Registered Nurses

Nursing - Initiating, Documenting, and Resolving the Nursing Care Plan

Section : Emergencies, Resuscitation, and Mortality

Code - RT - Vent Boxes and Magill Forceps

Comfort Cart for Visitors of Patients at the End of Life

Defibrillator - Philips MRX Monitor Defibrillator - Check AC Power Light

Malignant Hyperthermia - Dantrolene Administration in Malignant Hyperthermia (MH)

Missing Patient - Missing Adult Patient with Compromised or Non-Compromised Status

Mortality Review Map - Real Time Root Cause Problem Solving

Mortality Reviews - Care Teams, UBLs, Clinical Department Quality Officer

Rapid Response - Initiating an Adult Code Response

Rapid Response - Pediatric Sepsis Evaluation

Transfer to Inpatient Hospice Unit

Section : Handover & Continuum of Care

Acuity - Use of Epic Acuity Score

Admission - New Admissions Standard Work for Bedside Nurses (Protective Isolation / Water Precautions)

Admission - Process for Periviable Birth

Admission - Room Setup Upon Patient Admission

Continuity - Pyxis Access for Visiting ICU RN Traveling to Procedure Areas

Discharge - Patient Discharge Vital Signs & Focused RN Assessment

Discharge - Patient Discharge Vital Signs for Women's & Children's Patients

Discharge - Room Breakdown Upon Patient Discharge

Discharge Planning for Outpatients Who Will Receive Sedation or Anesthesia

Handover - Continuous Infusion Transfer for the Interfacility Admission

Handover - Inpatient Shift Handover by RN

Handover - Medication Infusions between ICU RN & Anesthesia

Handover - NICU Handover of Care

Handover - Nursing Handover of Infusion Pump Interoperability

Handover - OR / INR to NNICU Post Anesthesia

Handover - Patients Going to SAS from Acute, IMU, and ED with PCA Pumps

Handover - PICU / NICU to OR Preoperative Handoff

Name - Changing Trauma Number Patient Identifiers to Real Name

Readmission - 30 Day Readmission Review Form

Transfer - Post-tPA Patient Transfers from the ED to NNICU

Transfer - To Inpatient Hospice Unit

Section : HAPU Prevention and Skin & Wound Care

Device - Continuous EEG (cEEG) Monitoring and Daily Work

Device - Initial Securement and Dressings of Percutaneous Tracheostomies

Device - Oxygen Saturation Monitoring Algorithm

Device - Pressure Injury Prevention in Orally Intubated Patients (ETT)

Device - Prevention of Tracheostomy-Related Pressure Injury

Device - Skin Checks and Skin Care Under Cervical Collars

Device - Taping, Securing, & Daily Care of Nasoenteric Tubes - and Bridling Criteria

Device - TCV ICU - Pressure Injury Prevention with TEDs, SCDs and ACE Bandages

Fecal Incontinence Management Algorithm

NPWT - Discharge Preparation & Troubleshooting for Patients with Inpatient Negative Pressure Wound Therapy

NPWT - Inpatient Negative Pressure Wound Therapy Application, Management & Troubleshooting

Positioning - Lateral Positioning in Procedure Areas

Positioning - Lateral Positioning in CT

Positioning - Lithotomy Positioning in Procedure Areas

Positioning - Prone Positioning in Procedure Areas

Positioning - Supine Positioning in Procedure Areas

Pressure Ulcer Prevention (Adult Acute Care)

Pressure Ulcer Prevention (TCV ICU High Risk)

Pressure Ulcer Prevention (Adult Intermediate & Critical Care)

Pressure Ulcer Prevention (*1 Page Summary* Adult Inpatient)

Pressure Ulcer Prevention (NICU)

Pressure Ulcer Prevention (PICU)

Pressure Ulcer Prevention - Patients Receiving Sedation/Anesthesia in Procedure Areas

Pressure Ulcer Prevention for Adult Inpatients with Braden Score of ≤18

Pressure Ulcer Prevention for All Adult Inpatients

Surface - TAPS Criteria and Standard Bed Linens with & without TAPS

Turning - Hemodynamic Instability Turning (Adult Critical Care)

Two Person Skin Assessment

Worksheet - HAPU Investigation Tool

Section : Heart & Vascular

Acute Severe Hypertension in Pregnant and Post-Partum Patients

Blood - Checking Blood Products

Blood - TRANSFUSION TIME-OUT

ECG Documentation in Intensive Care Unit

ECG Monitoring and Documentation in Acute or Intermediate Care Units

ECMO - Emergent Pediatric Cardiac ECMO (eCPR)

ECMO - Non-emergent ECMO Activation (Children’s Hospital)

ECMO - VV ECMO Cannula Documentation and Securement (TCVICU)

LVAD - Care of LVAD Patients in Interventional Radiology

Removal of Radial Hemostatic Band

TCV ICU - Daily Rounds

TCV ICU - Pressure Injury Prevention with TEDs, SCDs and ACE Bandages

TCV ICU - Pressure Injury Prevention in the High Risk Patient

TCV ICU - Temporary Pacing Wires

Section : Infection Prevention and Control

Ambulatory - Reading a PPD/Mantoux Tuberculin Skin Test in Ambulatory Settings

Exposures - Gloves On, Goggles On - Safety in Pairs

Exposures - How to Enter HIV/HEP Exposure Order for BBF Exposure

Exposures - Team Member BBF Exposures in OPSC / Main OR

Isolation - Long Term Isolation Precautions in Ambulatory

Norovirus Cluster

Section : Instrument Pre-Cleaning and Transport

1 : Instrument Findings A3: Train the Trainer Session

2 : Physician/APP Instrument Care and Handling

3 : Quick Reference SW - Pre-Clean & Transport Contaminated Instruments - With or Without a Pre-Clean Pack

4 : Detailed SW - Pre-Clean & Transport Contaminated Instruments - With or Without a Pre-Clean Pack

5 : Education - Pre-Clean & Transport Contaminated Instruments - With or Without a Pre-Clean Pack

6 : Leader Standard Work for Ensuring Instrument Pre-cleaning and Transport Compliance

8 : Supply Ordering Information

Code - RT - Vent Boxes and Magill Forceps

Directions to Sterile Processing Department (SPD)

Educational Video - Peel Packed Reusable Instruments and Spreader Cards

Section : Laboratory

Blood Culture - Adult Blood Culture Collection

Blood Culture - Pediatric Blood Culture Collection

Double Bagging Lab Specimen for Transport via Courier

Double Bagging Lab Specimen for Transport via Pneumatic Tube System

Drying and Transit of Newborn Screening (NBS)

Glucometer - Safely Downloading Patient Self-Testing Glucometer Data in Outpatient Clinic

Lab - Handling of Lab Specimens (Women's Services)

Lab - Placing Pathology Order in Epic (Women's Services)

Lab - Sending Specimens to Pathology (Women's Services)

Lab - Umbilical Cord Drug Screening Panel UCDSP (Women's Services)

Lab Sample Draw, Labeling, and Epic ‘Collection’, from Work List

Lab Sample Draw, Labeling, and Epic ‘Collection’, from “Orders Needing Specimen Collection”

POCT - Verifying Patient Identification with POCT in ED, ICUs, OR, Procedure Areas

Section : Medication Administration (Pain & Controlled Substances)

[RETIRED] Controlled Substance - Discrepancy Resolution of Controlled Substances Each Shift (Pyxis 4000)

[RETIRED] Controlled Substance - Daily Inventory of Controlled Substances (Pyxis 4000)

Controlled Substance (Ambulatory) - Collecting Chain of Custody Urine Specimens for Contract Med Screening

Controlled Substance (Ambulatory) - Placing Patient on Controlled Substance Contract

Controlled Substance (Ambulatory) - Processing Controlled Substance Refills and Pick Up with No Nurse Visit

Controlled Substance - CADD Pump Initiation, Wasting, and Transfer

Controlled Substance - Chain of Custody for Infusions

Controlled Substance - Daily Inventory of Controlled Substances (Pyxis ES)

Controlled Substance - Discrepancy Resolution of Controlled Substances Each Shift (Pyxis ES)

Controlled Substance - Diversion Management

Controlled Substance - Fentanyl Infusion via Purple Module (PCA Pump) - Adults

Controlled Substance - Handling IV and Oral Controlled Substances when Dispensed from Pharmacy

Controlled Substance - IV Bag Initiation, Wasting and Transfer - Large Volume Pump

Controlled Substance - Patients Going to SAS from Acute, IMU, and ED with PCA Pumps

Controlled Substance - PCA Syringe Initiation, Wasting and Transfer

Controlled Substance - Pyxis Injectable & Oral Controlled Substance Waste in OPSC PACU

Controlled Substance - Pyxis Injectable & Oral Controlled Substance Waste

Controlled Substance - Pyxis Injectable & Oral Controlled Substance Waste in PACU

Controlled Substance - Syringe Initiation, Wasting and Transfer (Syringe Infusion Pump)

Controlled Substance - Transdermal Patch Waste & Removal

Handover - Continuous Infusion Transfer for the Interfacility Admission

Handover - Medication Infusions between ICU RN & Anesthesia

Sedation - Intranasal Versed for Minimal Sedation/Anxiolysis for Minor Procedures (Acute Care Pediatrics)

Transdermal Patches in Perioperative and Procedural Areas

Section : Medication Administration (IV)

Acute Care Pediatrics - Administration of High Dose Methotrexate Infusions

Daily Check of Secondary Storage Locations for Infusion Fluids - Areas with Fluid Warmers

Daily Check of Secondary Storage Locations for Infusion Fluids

Handover - Continuous Infusion Transfer for the Interfacility Admission

Handover - Medication Infusions between ICU RN & Anesthesia

Handover - Nursing Handover of Infusion Pump Interoperability

Handover - Patients Going to SAS from Acute, IMU, and ED with PCA Pumps

High Risk Infusion Dual Sign-off Timeout: Shared Manual 5 Rights with Readback

Interoperability - Exchange of Alaris Pump Channel

Interoperability - Nursing Validation and Infusion Documentation

Interoperability - Promoting Basic Infusion to Guardrails Protected Infusion

Interoperability Workflows for Large Volume Pump & Syringe Pump

Labeling IV Infusion Tubing

Mannitol Administration

Pyxis Access for Visiting ICU RN Traveling to Procedure Areas

RN Checklists - Initiating and Adjusting Heparin Nomogram

Section : Medication Administration (non-IV)

Injection Technique

Nursing Work Surface / Keyboard Tray

Section : Musculoskeletal including Falls & Safe Mobility

Beds - Algorithm for Adult Inpatient Bed Type Selection, Traction, and Side Rail Use

Beds - Algorithm for Specialty Bed Ordering, Delivery, and Pick-Up

Beds - Ordering or Discontinuing Specialty Beds in Epic, and Reporting a Broken Specialty Bed

Blue Tube - Patient Repositioning and Lateral Transfer

C Collar - Skin Checks and Skin Care Under Cervical Collars

Falls - Screen Patient Tolerance for Standing Spine Films

Falls - Adult Inpatient Fall Prevention (Acute, ICU, and IMU areas) for HIGH Fall Risk Patients

Falls - Bedside Chair Alarm Panduit Installation

Falls - Chair Alarm Use

Falls - Fall Recovery Using Hover Jack

Falls - Initiation of Spinal Motion Restrictions for MET

Falls - Out of Bed Plan Completion

Sara Stedy - Bed to Chair/Commode/Toilet

Section : Neurosciences & Behavioral Health

C Collar - Skin Checks and Skin Care Under Cervical Collars

cEEG - Continuous EEG Monitoring and Daily Work

EVD - Attaching a Transducer to an External Ventricular Drain for ICP Monitoring

EVD - Cerebrospinal Fluid Drainage Using an External Ventricular Drain

EVD - Changing the Bag on an External Ventricular Drain

EVD - Dressing Change for an External Ventricular Drain

EVD - Monitoring Intracranial Pressure Using an External Ventricular Drain (Includes Zeroing)

EVD - RN Assist with External Ventricular Drain Placement

Lumbar Drain - Attaching a Transducer to a Lumbar Drain for Intraspinal Monitoring

Lumbar Drain - Cerebrospinal Fluid (CSF) Drainage Using a Lumbar Drain

Lumbar Drain - Changing the Bag on a Lumbar Drain

Lumbar Drain - Dressing Change for a Lumbar Drain

Lumbar Drain - Monitoring Intraspinal Pressure Using a Lumbar Drain (Includes Zeroing)

Lumbar Drain - RN Assist with Lumbar Drain Placement

Stroke - Nursing Bedside Swallow Screen for Stroke Patients

Stroke - Post-tPA Patient Transfers from the ED to NNICU

Stroke - Post-tPA/Post-Thrombectomy Assignments and Care

Stroke - Stroke Patient & Family Education

Suicide - Patient Suicide Precautions Companion Communication Tool – Inpatient NonBehavioral Units

Section : Nutrition

Standard Meal Tray Delivery for Patients on Fluid Restriction

Standard Volumes for Oral Intake Containers (Fluid Restriction Tool)

Section : Patient Experience, Visitors, Care Partners

Comfort Rounding

Leader Rounding

Quiet At Night, Inpatient Adult and Pediatric

Visitors - Hospital Staff Resources Regarding Visitors/Care Partners

Visitors - Visitor Restrictions

Visitors - Addressing the Needs of Visitors and Care Partners

Visitors - Obtaining and Maintaining a Comfort Cart for Visitors of Patients at the End of Life

Visitors - Orienting Visitors and Initiating Care Partners

Visitors - Visitors and Care Partners of Inpatients on Isolation

Section : Pneumatic Tubes

Double Bagging Lab Specimen for Transport via Pneumatic Tube System

Pneumatic Tube Station Instructions

Section : Respiratory

[RETIRED] Adult ICU Patient with Endotracheal Tubes

[RETIRED] Oral Care - Oral Care for Adult Ventilated Patients

ETT - NICU Stabilization of Endotracheal Tube with Neofit or Portex Stabilizers

ETT - Pressure Injury Prevention in Orally Intubated Patients

NO - Obtaining Nitric Oxide for Adult Patient in the Operating Theater

O2 - Oxygen Saturation Monitoring Algorithm

Pronation Therapy - Maintenance Positioning

Pronation Therapy - Proning the Critically Ill Patient

Trach - Children’s Hospital Tracheostomy Inpatients

Trach - Initial Securement and Dressings of Percutaneous Tracheostomies

Trach - Transporting Tracheostomy Patients with Oxygen

Vent - NICU Kangaroo Care for Ventilated Infant

Section : Women's Services

Ambulatory | Chorionic Villus Sampling

Ambulatory | Diagnostic Amniocentesis

Ambulatory | Fetal Blood Sampling

Ambulatory | Management of Birth Occurring in Clinic

Ambulatory | Nexplanon Insertion

Ambulatory/Inpatient | Point of Care Microscopy

Breastmilk - Freezing Breastmilk

Breastmilk - Obtaining a DME Breast Pump with a Voucher Payment

Breastmilk - Procurement of a Breast Pump through ABC Healthcare

Discharge - Patient Discharge Vital Signs for Women's & Children's Patients

IntraPartum - Active Management of the Third Stage of Labor (AMTSL)

IntraPartum - Epidural Placement Checklist

Intrapartum - Use of Birthing Stool During Labor

IntraPartum - Vaginal Delivery Checklist

IntraPartum : Vaginal Prep before Caesarian Section

Lab - Handling of Lab Specimens (Women's Services)

Lab - Placing Pathology Order in Epic (Women's Services)

Lab - Sending Specimens to Pathology (Women's Services)

Neonate - Admission Process for Periviable Birth

Neonate - Drying and Transit of Newborn Screening (NBS)

Neonate - Labeling Umbilical Venous and Arterial Catheters

PostPartum - Cleaning & Disinfecting Labor Tub with Jets

PostPartum : Prevention of Post-Anesthesia Falls

PostPartum : Transvaginal Use of Bakri Balloon for Uterine Tamponade

Pre & PostPartum - Acute Severe Hypertension in Pregnant and Post-Partum Patients

PrePartum - Diagnostic or Therapeutic Amniocentesis (Inpatient)

Triage/Antepartum | Caesarian Scheduling and Pre-op Preparation: ERAS-OB

TWP Lead RNs

Women’s and Newborn Patient Progression Board

Zebra Band Printing

Chapter 2 : Administrative Standard Work

Section : Area Huddles and Rounds

Section : Be Safe, Situation Room, and QPI

30-Day Readmission Review Form

A3 Worksheet - Infection Investigation for CAUTI or CLABSI

A3 Worksheet - Needle Sticks, Sharps Injuries and Splashes

Be Safe Event Management

Leaders - Daily Be Safe Leadership Huddle

Monthly Be Safe Huddle Rotation

Senior Leader Gemba

Service Line Analyst

Service Line Be Safe Coach

Situation Room Standard Work

Women's Services - Event Debriefing for Perishable Data

Worksheet - HAPU Investigation Tool

Section : Develop and Post Clinical Decision Tools

TCV ICU - Algorithm for Approving Standard Work

Section : Nursing

Nursing Shared Governance Meetings

Pressure Ulcer Prevalence - PUP Day Rounding

Section : Supply Chain & Value Management

Unit Supply & Supply Clerk Champions - Standard Work & Log Sheet

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