Transcript KEEPING THE QI FIRE BURNING

PERFORMANCE
IMPROVEMENT
Performance Improvement Defined
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A continuous state of “being”
Driven by our mission and vision
That stimulates individuals and teams to look
at the way they deliver care & service
To identify the root causes of problems in
systems
And to innovate to make improvements
THE GOAL: A high-reliability
organization
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The right care for every patient, every time
Humans are not highly reliable, but systems
can be
It is the job of leadership to develop and
maintain systems that make it hard for staff
to make an error
It is also leadership’s job to hold staff
accountable for using the systems
Hardwiring Excellence
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Into the way we deliver care
Into the way we provide service
Into the way we develop our staff
Into the way we manage our finances
Into the way we grow our business
Defining our systems as “pillars”
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Growth: methodical approach, well-researched, key
stakeholders involved resulting in progress
Finance: planning, managing, charging and billing
resulting in a profit margin to sustain current and
future needs
People: well-trained, recognized, and rewarded staff
resulting in commitment and dedication
Service: consistently exceeding customer
expectations resulting in satisfaction
QUALITY (of course it has its own
slide!)
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Safe – do no harm
Effective – achieve the desired outcome
Timely – without delay
Efficient – without waste, without error
Patient-centered – individualized but not
discriminatory
RESULT: excellent care
But we give good care …
PROVE
IT!
Alright, we will!
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Performance scorecard – what gets
measured gets managed
BUT … not everything that can be measured
is worth managing, and everything that
should be managed can not always be easily
measured
Hospital-wide Performance
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Growth: market share, volume
Finance: revenue, expenses, productivity
People: evaluation timeliness
Service: customer satisfaction
Quality: patient safety and best practice
Organizational Quality
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National Patient Safety Goals:
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Medication safety (reconciliation, look/sound
alike, concentrations, labeling)
Health-care acquired infections (hand hygiene,
deaths are sentinel events)
Falls (reduction program)
Patient identification (2)
Communication among caregivers (order
readback, abbreviations, critical values, hand off)
Organizational Quality
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CMS Core Measures
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Surgical Infection Prevention: appropriate antibx given
w/in 1 hour of cut time, d/c’d w/in 24 hr of surgery end
Acute Myocardial Infarction: ASA at arrival & d/c, beta
blocker on arrival & d/c, 30 min door to drug time for
thrombolytic, lipid assessment
Heart Failure: LVF assessment, ace inhibitor for LVSD,
complete d/c inst (meds, f/u, wt, diet, activity, sx)
Pneumonia: appropriate antibx w/in 4 hr of arrival but after
BC, BC w/in 24 hr if obtained, O2 sat assess
All: smoking cc, pneumococcal & influenza immunization
Departmental Performance
“With great power comes great responsibility” Ben Parker
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Your very own scorecard!
Everyone gets to report on how they are
managing their productivity, expenses, staff
evaluations and customer service
You decide how you and your staff will
measure quality
You decide what processes need
improvement and how to improve them
“Stop a moment, cease your work, look
around you.”
Leo Tolstoy
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Quality is not about
data, graphs, and reports
These are just tools to
establish direction for
your work
If you don’t know where
you’re headed then
you’re never lost
Data Collection – Essential Elements
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Operational definition – describe in quantifiable
terms what you will measure & how to measure it
consistently (inclusion & exclusion criteria)
Know why you are collecting the data – what will you
do with it once you have it?
What stratification will be important to have?
Will you collect all data points or just a sampling?
How will you choose the sampling?
Data Pitfalls – Watch out!
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Misunderstanding about how to collect data
Inaccurate measuring instruments
Cheating/ fear
Poor choice of collection period
Poor sampling techniques
Lost data
Bias
Data Analysis – Run Charts
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Depicts data over time
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Data Analysis – Control Charts
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Shows trends over time
Uses statistically
determined upper and
lower limits to define a
range of acceptability
Goal is to gain
consistency in
operation
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East
lower limit
upper limit
mean
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Data Analysis - Histograms
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Frequency distribution
Presents data
organized in categories
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Data Analysis – Pareto Charts
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Tool to rank-order or
prioritize problems,
causes of a problem, or
categories of some
event or issue
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adm
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Data Analysis – Cause & Effect
Diagram (Fishbone)
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Tool used to identify the
multiple causes of any
result, outcome, or
problem
Data Analysis - Flowchart
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Create a picture of a
process
By outlining each essential
step it is possible to
streamline areas of
overlapping efforts &
eliminate unnecessary steps
Can also be used to
standardize a step-by-step
process
“If you want to achieve excellence, you can get there today.
As of this second, quit doing less than excellent work.”
Tom
Watson, IBM founder
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Let’s just find the people
who are doing less than
excellent work and tell
them to knock it off and
quit ruining it for the rest
of us!
I’m from the Government & I’m here
to help.
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Conditions of Participation
for Medicare and Medicaid
require hospitals to have a
hospital-wide QAPI program
that focuses on the outcomes
of their organization’s services
PPS hospital payments are
dependent on this – CAH
will soon be too
“Never mistake motion for action.”
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Ernest Hemingway
Quality Assessment
and Performance
Improvement are about
improving care and
service
It’s not about fulfilling a
duty to country, hospital,
or Quality Director
“Our plans miscarry because they have no aim. When you don’t know
what harbor you’re aiming for, no wind is the right wind.”
statesman 4 BC – AD65
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BHH has an organizationwide plan that gives general
direction and outlines the
process (FOCUSPDCA)
Departments build on this
framework and set specific
meaningful goals
Seneca, Roman philosopher and
“If I had six hours to chop down a tree, I’d spend the first
four sharpening the axe.”
Abraham Lincoln
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Quality Control is about
putting routine checks in
place to ensure that your
service will be safe and
effective
It should be documented and
is a task that is generally
easily shared among staff; we
all have an investment in
making day-to-day work
smoother
“The beginning is the most important
part of work.”
Plato
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Quality Assessment is meant
to determine where we are at
in relation to where we want to
be; we have to start
somewhere
It needs to be measurable and
there needs to be a
predetermined benchmark or
threshold
CAH PIN studies (stroke,
surgical care)
“The significant problems we face cannot be solved at the
same level of thinking we were at when we created them.”
Albert
Einstein
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Quality/ Performance
Improvement is about making
changes for the better
It requires setting specific
goals and making changes to
achieve those goals
It is measurable and needs
participation by everyone
involved
“Opportunity is missed by most people because it is dressed in overalls
and looks like work.”
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Thomas Edison
Failure Mode and Effects
Analysis (FMEA) is proactive risk
assessment
The object is to identify hazards
and put control measures into place
to prevent bad things from
happening
Root Cause Analysis (RCA) is
after the fact – something
undesirable has already happened,
but we can learn from it and prevent
it from happening again
“If you put off everything till you’re sure of it, you’ll get
nothing done.”
Norman Vincent Peale
Tips for a Successful
Year
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Keep after it – it benefits the
patients, the hospital, & you
personally
Involve your staff; they have
some great ideas and will be
more likely to buy in to goals
and action plans (assign data
collection too)
“To improve is to change, to succeed is to
change often.”
Winston Churchill
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Talk to your comrades in
other facilities; they can
give you a different
perspective
Use the process to help
you make things better
and recognize staff for a
job well done
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Generate a sense of
teamwork in your
department and with
other departments
Celebrate your success
(no matter how small);
reward yourself and your
staff
“Our life is frittered away by detail.
Simplify, simplify.”
Henry David Thoreau
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Don’t bite off more
than you can chew;
make your projects
worthwhile but not
overwhelming
Use the Quality
Director as a
resource for ideas,
data collection and
display, etc.
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Don’t reinvent the wheel;
research best practices;
you don’t have to make
stuff up
Align quality projects
with department
priorities; we’ve got
plenty to keep us busy,
we don’t need more
busywork
“Excellence is a habit, not an event.”
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Align your quality/
performance improvements
with the hospital strategic
plan and vision
Keep it in front of you; put it
on your calendar, your task
list, your office door, your
monthly staff meeting agenda,
your refrigerator, your
bathroom
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Aristotle
Be prepared when you report
to your administrative advisor
monthly
Attitude is everything; this
doesn’t have to be a
meaningless paper-pushing
process; YOU have the
power to make it meaningful to
you and your staff
“Celebrate, celebrate!! Dance to the
music!”
Three Dog Night
Find joy in your
work; if you
don’t, what’s
the point?