IMPROVE: Quality, Safety

1
IMPROVE Quality, Safety and Performance
Improvement
2
What are we trying to do?

• Do the right thing the right way

• technically competent
• good communication
• shared decision making
• cultural sensitive

3
How do we do it?
4
Problem- Solving Model Performance Improvement I
identify the opportunity or problem M
measure definitions (goals) P problem
Analysis R remedy the cause (s)
intervention O operationalize the plan V
validate the effectiveness of your
intervention E evaluate if improvement is
sustained
5
Identify the problem or opportunity

• Dont try to solve world hunger
• Is it a problem, process or a system?
• Break down the project into manageable sizes

• Admission Process
• Documentation
• Discharge Planning
• EKG

6
Measure Definition (goals)

• How do you know you have gotten there unless you
  set a goal?
• Select performance indicator that tells you most
  about the process
• Quality vs research

• Improve documentation
• 0 occurrences resulting from IV insulin

7
Problem Analysis

• One of the most important steps
• May do additional data collection to determine
  root cause(s)
• Direct observation
• Focus groups
• GOYA

• EKG
• Lack of monitoring and feedback
• No return demonstration required

8
Remedy (Intervention)

• Most effective
• Forcing functions (poke yoke)
• Automation, computerization
• Protocols and preprinted orders
• Standardization of processes and equipment
• Checklists
• Rules and double-checking
• Education
• Information
• Least Effective

• Generally based on the root causes
• Automate
• Standardize
• Checklist
• Redundancy
• Always pair education with one of the above

9
Operationalize (implementation)

• Consider a challenge team
• Involve the owners of the process
• Consider the amount of change you are asking
  people to do
• Emotional factors
• Previous history of change

• Abbreviations
• Posters
• Reminder of the day
• Audits and feedback
• Paycheck stubs
• Reminders at the point of utilization
• Market, market, market

10
Validate your intervention

• This is the monitoring and tweaking that occurs
  throughout implementation

• Multiple cycles
• Expect the unexpected
• What was your measure?

11
Evaluate

• Must have ongoing monitoring to determine if
  change is needed or if your change has been
  effective

• Mislabeled specimens
• EKG
• Pt ID bands

12
Who has overall responsibility?
13
Quality Council

• Joan Herbert, Chair
• Stuart Smith
• John Heffner, MD
• Chris Malanuk
• Michael Irving
• Al Nesmith
• Tom Moore
• Dave Neff
• Phil Saul, MD
• Patrick Cawley, MD

• John Sanders
• Laurie Zone-Smith
• Rosemary Ellis
• Lisa Montgomery
• William Spring
• Marilyn Schaffner
• Jacob Robison, MD
• c. Betts Ellis
• Gautham Suresh, MD
• Carol Younker
• Dennis Frazier

14
What do they do?
15
Quality Council

• The oversite and coordination of performance
  assessment and improvement activities
• QC ensures that improvements are planned,
  designed, measured, analyzed, and sustained.

16
Quality Council

• Operationalizes PI activities that are consistent
  with the MUSC Medical Center Strategic Plan
• Receives reports and takes action on issues and
  initiatives that address pt rights, pt
  assessment, pt care, pt education, continuum of
  care, PI, leadership, EOC, HR, resource
  utilization, IM, and infection control

• UHC Safetynet
• McNair Training
• MRSA/VRE Efforts
• CMS AMI, CHF, CAP, SIP

17
Quality Council

• Allocates financial resources necessary to
  support organization-wide PI.
• Communicates PI assessment information and
  improvement activities to the MUSC Board of
  Trustees.

• MRSA/VRE
• July Board Report

18
Quality Council

• Identifies PI actions to be taken, assigns in
  writing responsibility for each action, and
  ensures accountability for follow through.
• Oversees analyses of sentinel events and ensures
  appropriate risk reduction strategies are
  implemented

• EKG
• FALLS
• Action Plan

19
How is this information communicated?
20
(No Transcript)
21
Who is directly responsible?

• Directors and Managers