quality improvement in hospitals tools, tips,...
TRANSCRIPT
7/14/2014
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Quality Improvement in Hospitals
Tools, Tips, Teams
Quality Improvement Tools
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Resources
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https://synensis.box.com/ShellQuality
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1. Leadership Process and Accountability
2. Competent and Capable Workforce
3. Safe Environment for Patients
4. Clinical Care of Patients
5. Improvement of Quality and Safety
Framework
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International Essentials of Healthcare Quality
and Safety
Focus Area: Improvement of Quality and Safety
Criteria 1: There is an adverse event reporting system.
Criteria 2: Adverse events are analyzed.
Criteria 3: High-risk processes and high risk patients are monitored.
Criteria 4: Patient Satisfaction is monitored.
Criteria 5: Staff satisfaction is monitored.
Criteria 6: There is a complaint process.
Criteria 7: Clinical guideline and pathways are available and used.
Criteria 8: Staff understand how to improve processes.
Criteria 9: Clinical outcomes are monitored.
Criteria 10: Communicating quality and safety information to staff.
Joint Commission International
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Stuck
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Session Roadmap
10 Quality Improvement Tools
Adverse Event Reporting
Run Chart
Root Cause Analysis
Fishbone Diagram
Failure Mode Effects Analysis
Lean Process
Leadership Rounds
Debriefs
Checklists
Patient Satisfaction Surveys
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Session Roadmap
10 Quality Improvement Tools
Adverse Event Reporting
Run Chart
Root Cause Analysis
Fishbone Diagram
Failure Mode Effects Analysis
Lean Process
Leadership Rounds
Debriefs
Checklists
Patient Satisfaction Surveys
Event Reporting Process
Collect
Investigate
AnalyzeAction
Feedback
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Recording Reported Harm Events
Check sheets are used by staff to indicate how many times
(frequency) a particular incident occurred
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Date of Month
Day of Month
Patient Falls Medication Errors
Other Medication
Incidents
Report of 9-10 on the Pain
Scale
Incidence of Pneumonia Infections
1 Sun I I I I I I I 2 Mon I
3 Tue I I I I 4 We I I I I I
5 Thu I I
6 Fri I 7 Sat I I I I I I I I I I I
8 Sun I I I I I I I 9 Mon I
10 Tue I
Detailed Data Logs
Data logs are used to track more detailed information about
incidents.
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Patient Falls Log
Pt ID
Age Treated for
Date of Fall
Time of Fall
Location of Fall
Injury Yes/No
If Yes, What/ Where
Factors Contributing
to Fall
Was Patient
on Meds? Yes/No
1 45 Diabetes 1/1/10 7:30 am Pt Room No -- Fainted near bed Yes 2 34 Hypertension 1/7/10 4:40 pm Pt Room Yes Elbow
bruise Dizzy from
medications Yes
3 76 Stroke 1/7/10 6:13 pm Hallway No -- Unsteady gait Yes
4 51 Diabetes 1/11/10 7:42 am ER No -- Chair toppled No 3 76 Stroke 1/15/10 11:20 pm Bathroom Yes Hip
fracture Slipped near
toilet Yes
5 55 Heart attack 1/24/10 11:34 am Hallway Yes Head laceration
Floors slippery-just waxed
Yes
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Session Roadmap
10 Quality Improvement Tools
Adverse Event Reporting
Run Chart
Root Cause Analysis
Fishbone Diagram
Failure Mode Effects Analysis
Lean Process
Leadership Rounds
Debriefs
Checklists
Patient Satisfaction Surveys
Control Chart as Feedback Mechanism
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Upper Control Limit 0.004
Control Limit (Mean) 0.003
Lower Control Limit 0.001
0.0000
0.0005
0.0010
0.0015
0.0020
0.0025
0.0030
0.0035
0.0040
0.0045
0.0050
Jan 07 Feb 07 Mar 07 Apr 07 May 07 Jun 07 jul 07 Aug 07 Sep 07 Oct 07 Nov 07 Dec 07 Jan 08 Feb 08 Mar 08
Month and Year
Patient Fall Rate per Patient Days Control Chart
Pat
ien
t Fa
ll R
ate
Per
Pat
ien
t D
ay
Zone A
Zone A
Zone B
Zone C
Zone C
Zone B
(3-sigma)
(3-sigma)
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Session Roadmap
10 Quality Improvement Tools
Adverse Event Reporting
Run Chart
Root Cause Analysis
Fishbone Diagram
Failure Mode Effects Analysis
Lean Process
Leadership Rounds
Debriefs
Checklists
Patient Satisfaction Surveys
Root Cause Analysis
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Root Cause Analysis
A structured, reactive process for identifying the causal
or contributing factors underlying adverse events or
other critical incidents.
The process features interdisciplinary involvement of
those closest to and/or most knowledgeable about the
situation
RCA Goals
• Find out:–What happened?
–Why did it happen?
–What do you do to prevent it from happening again?
–How do we know we made a difference?
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Session Roadmap
10 Quality Improvement Tools
Adverse Event Reporting
Run Chart
Root Cause Analysis
Fishbone Diagram
Failure Mode Effects Analysis
Lean Process
Leadership Rounds
Debriefs
Checklists
Patient Satisfaction Surveys
Cause-and-Effect Exercise
Wrong
medication
dosage given to patient
People Protocols
Equipment Environment
Newly hired junior nurse
(2nd day)
Orientation training provided on medication
administration was not attended
Syringe used for injection was new product
Standard operating procedure on
medication administration was
not clear
The environment was congested and noisy, causing distractions
Medication administration form was
not easy to follow
Physician’s handwritten
prescription was hard to read
Patient room was next to the Group
Activity Room, which was being
used then
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Fishbone Exercise
At your table:
1. Share a story of harm to a patient that you
have observed or heard of.
2. Complete a Fishbone diagram based on the
story. Include Protocols, People, Equipment,
and Environment that led to the patient harm.
3. On person from the group will report out.
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Cause-and-Effect (Fishbone)
Harm to Patient
Protocols People
Equipment Environment
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Session Roadmap
10 Quality Improvement Tools
Adverse Event Reporting
Run Chart
Root Cause Analysis
Fishbone Diagram
Failure Mode Effects Analysis
Lean Process
Leadership Rounds
Debriefs
Checklists
Patient Satisfaction Surveys
Definitions of FMEA
Failure Modes and Effects Analysis (FMEA) is a
systematic, proactive method for evaluating a process to
identify where and how it might fail, and to assess the
relative impact of different failures in order to identify the
parts of the process that are most in need of change.
- Institute for Healthcare Improvement
Healthcare Failure Mode & Effect Analysis1. A prospective assessment that identifies and improves steps in a process, thereby reasonably ensuring a safe and clinically desirable outcome.2. A systematic approach to identify and prevent product and process problems before they occur.
- VA Health System, Center for Patient Safety
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Failure Modes Effects Analysis (FMEA)
FMEA Grid
Process Step
Potential Failure Mode
Potential Effect of Failure Se
veri
ty Potential Cause of Failure
Freq
uen
cy Current Controls in
Place Det
ecti
on
RP
N Recommended Action
Who and By When
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Pre-FMEA Environment
Design considerations: Location, grab bars, distance
traveled
Post-FMEA Environment
Image courtesy of HDR Architecture, INC
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Session Roadmap
10 Quality Improvement Tools
Adverse Event Reporting
Run Chart
Root Cause Analysis
Fishbone Diagram
Failure Mode Effects Analysis
Lean Process
Leadership Rounds
Debriefs
Checklists
Patient Satisfaction Surveys
5 S’s of Lean
SORT
Clear out rarely used
items by red tagging
STRAIGHTEN
Organize and label a place
for everything
SHINE
Clean it
STANDARDIZE
Create rules to sustain the first 3 S’s
SUSTAIN
Use regular management audits to stay
disciplined
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Lean and Systems Thinking
Lean Culture
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Clutter and Organization
What is Wrong with this Drawer?
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How is This an Improvement?
Session Roadmap
10 Quality Improvement Tools
Adverse Event Reporting
Run Chart
Root Cause Analysis
Fishbone Diagram
Failure Mode Effects Analysis
Lean Process
Leadership Rounds
Debriefs
Checklists
Patient Satisfaction Surveys
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Leadership Safety Rounds
Shared Mental Model?
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Session Roadmap
10 Quality Improvement Tools
Adverse Event Reporting
Run Chart
Root Cause Analysis
Fishbone Diagram
Failure Mode Effects Analysis
Lean Process
Leadership Rounds
Debriefs
Checklists
Patient Satisfaction Surveys
Debrief Checklist
TOPIC
Communication clear?
Roles and responsibilities understood?
Situation awarenessmaintained?
Workload distribution?
Did we ask for or offerassistance?
Were errors made or avoided?
What went well, what should change, what can improve?
• What went well?• What could we do
better?
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Facilitating Post Event Debriefs
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Debriefing
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Session Roadmap
10 Quality Improvement Tools
Adverse Event Reporting
Run Chart
Root Cause Analysis
Fishbone Diagram
Failure Mode Effects Analysis
Lean Process
Leadership Rounds
Debriefs
Checklists
Patient Satisfaction Surveys
Harm Reduction Rounding Checklist
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Briefing Checklist
TOPIC
Who is on core team?
All members understandand agree upon goals?
Roles and responsibilitiesunderstood?
Plan of care?
Staff availability?
Workload?
Available resources?
WHO Check List
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Session Roadmap
10 Quality Improvement Tools
Adverse Event Reporting
Run Chart
Root Cause Analysis
Fishbone Diagram
Failure Mode Effects Analysis
Lean Process
Leadership Rounds
Debriefs
Checklists
Patient Satisfaction Surveys
Patient Satisfaction Surveys
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Implementation Exercise
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Implementation Exercise
As a table (or individual):
1. Select one of the tools we have covered today
that you wish to implement in your clinic or
hospital.
2. Prepare a PDCA Plan for implementing this tool.
3. Volunteers with present their plan to the group.
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Source: Institute of Medicine (IOM)
Implementation
Act Plan
DoCheck
Design/Redesign Process
• What, Who, How
• When, Where
Evaluate Results
• Analyze data results
• Obtain lessons learned
• Brainstorm improvements
Take Next Steps to Improve
• Adopt
• Adjust
• Abandon
Implement Process
• Pilot process, if possible
• Collect data