Transcript No Slide Title

Part 6: The Monitoring and Reporting Challenge
What is the most effective
method to provide EC
monitoring and reporting?
Healthcare Engineering Consultants
Monitoring Regulatory Compliance
How should regulatory
compliance be monitored?
Healthcare Engineering Consultants
Monitoring Regulatory Requirements
Regulatory Compliance Dashboard
Description
General Reqs
SC Meetings
Dashboard Rpt
Leadership Rpt
Evaluations
Policy Review
Safety Mgmt
Hospital Surv
Clinic Surv
Security Mgmt
Alarm Tests
Abduction Drills
Hazmat Mgmt
Manifests
Haz Vapor Mon
Permits, Lic
Verify MSDS
Emer Mgmt
Hospital Drills
Clinic Drills
HVA
Fire Prev
Hosp Fire Drills
Clinic Drills
SOC Document
ILSM Measures
Extinguishers
Fire Det Dev
JAN
FEB
X
X
X
MAR
APR
X
X
MAY
JUN
X
X
JUL
AUG
X
X
X
X
SEP
OCT
X
X
NOV
DEC
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
A/R
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
A/R
X
A/R
X
X
A/R
X
A/R
X
A/R
X
X
A/R
X
A/R
X
A/R
X
X
A/R
X
A/R
X
A/R
X
X
Healthcare Engineering Consultants
Comments
Monitoring Regulatory Requirements
Regulatory Compliance Dashboard
Description
General Reqs
SC Meetings
Dashboard Rpt
Leadership Rpt
Evaluations
Policy Review
Safety Mgmt
Hospital Surv
Clinic Surv
Security Mgmt
Alarm Tests
Abduction Drills
Hazmat Mgmt
Manifests
Haz Vapor Mon
Permits, Lic
Verify MSDS
Emer Mgmt
Hospital Drills
Clinic Drills
HVA
Fire Prev
Hosp Fire Drills
Clinic Drills
SOC Document
ILSM Measures
Extinguishers
Fire Det Dev
JAN
FEB
MAR
APR
MAY
JUN
X
X
JUL
AUG
X
X
X
SEP
OCT
X
X
NOV
DEC
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
N/A
N/A
N/A
N/A
X
X
X
X
X
X
X
X
X
X
X
A/R
X
A/R
X
X
A/R
X
A/R
X
A/R
X
X
A/R
X
A/R
X
A/R
X
X
Healthcare Engineering Consultants
Comments
Monitoring Regulatory Requirements
Regulatory Compliance Dashboard (continued)
Description
Fire Prev
Water Devices
Fire Pumps
Ver/Hor Doors
F/S Dampers
Med Equipmt
PM LS Eqmt
PM NLS Eqmt
Util Systems
PM LS Sys
PM NLS Sys
Em Gen Tests
Batt Light Test
Water Tests
HVAC Tests
MGAVS Tests
App Environ
PCRA
Miscellaneous
Eyewash units
Showers
JAN
N/A
FEB
N/A
MAR
N/A
APR
N/A
MAY
JUN
JUL
AUG
SEP
OCT
NOV
DEC
X
W
W
W
X
W
W
W
X
X
W
W
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
A/R
A/R
A/R
A/R
A/R
A/R
A/R
A/R
W
X
W
X
W
X
W
X
W
X
W
X
W
X
W
X
Comments
Key to dashboard symbols:
X – Indicates that action is required during the month indicated; W – Indicates that weekly action is required
A/R – Indicates that action is required when applicable
Key to colored boxes: Red boxes indicate non-compliance (tests were not performed); Yellow boxes indicate partial compliance
(tests have been delayed or not fully completed); Green boxes indicate full compliance (tests satisfactorily completed).
Healthcare Engineering Consultants
Reporting Regulatory Requirements
Hospital Governing Body
Hospital Executive Committee
Hospital EOC Committee
Step 1: Create regulatory
compliance “dashboard” for
the Life Safety/
Construction Subcommittee
Accident and Safety Subcommittee
Hazardous Materials Subcommittee
Life Safety/ Construction Subcommittee
Equipment and Utilities Subcommittee
Emergency Management Subcommittee
Healthcare Engineering Consultants
Reporting Regulatory Requirements
Regulatory Compliance Dashboard for Life Safety/ Construction Subcommittee
Description
Fire Prev
Hosp Fire Drills
Clinic Drills
SOC Document
ILSM Measures
Extinguishers
Fire Det Dev
Water Devices
Fire Pumps
Ver/ Hor Doors
F/S Dampers
PCRA
JAN
N/A
N/A
FEB MAR
N/A
N/A
N/A
N/A
APR
N/A
N/A
MAY JUN JUL AUG SEP OCT
NOV
DEC
X
X
X
X
X
X
X
X
X
X
X
A/R
X
A/R
X
X
A/R
X
A/R
X
A/R
X
X
A/R
X
A/R
X
A/R
X
X
W
W
X
A/R
A/R
X
W
W
W
X
W
A/R
A/R
A/R
A/R
X
W
W
A/R
A/R
Comments
Key to dashboard symbols:
X – Indicates that action is required during the month indicated; W – Indicates that weekly action is required
A/R – Indicates that action is required when applicable
Key to colored boxes: Red boxes indicate non-compliance (tests were not performed); Yellow boxes indicate partial compliance
(tests have been delayed or not fully completed); Green boxes indicate full compliance (tests satisfactorily completed).
Healthcare Engineering Consultants
Reporting Regulatory Requirements
Hospital Governing Body
Hospital Executive Committee
Hospital EOC Committee
Accident and Safety Subcommittee
Step 2: Create regulatory
compliance “dashboard” for
the Hospital EOC Committee
from each subcommittee
“dashboard”
Hazardous Materials Subcommittee
Life Safety/ Construction Subcommittee
Equipment and Utilities Subcommittee
Emergency Management Subcommittee
Healthcare Engineering Consultants
Monitoring Regulatory Requirements
Hospital Governing Body
Hospital Executive Committee
Hospital EOC Committee
Accident and Safety Subcommittee
Step 3: Create a simplified
regulatory compliance
“dashboard” for the Hospital
Executive Committee from
the EOC Committee
“dashboard”
Hazardous Materials Subcommittee
Life Safety/ Construction Subcommittee
Equipment and Utilities Subcommittee
Emergency Management Subcommittee
Healthcare Engineering Consultants
Reporting Regulatory Requirements
Hospital Executive Committee Regulatory Compliance Dashboard
Description
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
Comments
General Reqs
Safety Mgmt
Security Mgmt
Hazmat Mgmt
Emer Mgmt
Fire Prev
Medical Eqmt
Utilities Mgmt
Key to colored boxes: Red boxes indicate non-compliance (tests were not performed); Yellow boxes indicate partial compliance
(tests have been delayed or not fully completed); Green boxes indicate full compliance (tests satisfactorily completed).
Healthcare Engineering Consultants
Reporting Regulatory Requirements
Hospital Governing Body
Hospital Executive Committee
Hospital EOC Committee
Accident and Safety Subcommittee
Step 4: Create a simplified
regulatory compliance
“dashboard” for the Hospital
Governing body from the
Executive Committee
“dashboard”
Hazardous Materials Subcommittee
Life Safety/ Construction Subcommittee
Equipment and Utilities Subcommittee
Emergency Management Subcommittee
Healthcare Engineering Consultants
Reporting Regulatory Requirements
Hospital Governing Body Regulatory Compliance Dashboard
Description
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
Comments
EOC Reqs
Key to colored boxes: Red boxes indicate non-compliance (tests were not performed); Yellow boxes indicate partial compliance
(tests have been delayed or not fully completed); Green boxes indicate full compliance (tests satisfactorily completed).
Healthcare Engineering Consultants
Monitoring Performance Improvement
Performance Improvement
“Attempting to measure and improve
performance on an ongoing basis in the
Environment of Care”
Healthcare Engineering Consultants
Measurement and Improvement
The “PI Continuum”
Very simple
Very complex
Healthcare Engineering Consultants
Measurement and Improvement
What Measurements are Required?
Patient and visitor injuries
Property damage incidents
Staff injuries and illnesses
Security incidents for patients, staff, visitors
Hazmat spills , exposures and related issues
Fire safety problems, deficiencies and failures
Medical equipment problems, failures, user errors
Utility system problems, failures and user errors
Healthcare Engineering Consultants
Measurement and Improvement
What Performance Improvement Measures are
Required for each “EC” area?
 Minimum of seven performance measures
 Should be numerical
 No maximum number
 Should measure performance improvement
 Adopt goals, objectives and benchmarks
 Regular reporting and tracking to SC
Healthcare Engineering Consultants
Selection of “EC” PI Indicators
“EC” Performance Measure Worksheet
“EC” Area: ____________________
Description of
Indicator Type
Performance Measure (PI or regulatory)
Calendar Year: _______________
Numerical
Measurement
Benchmark
Objective
Healthcare Engineering Consultants
Responsible
Department
Reporting
Frequency
Measurement and Improvement
How Should Terms Should be Defined?
Goal: The attempted attainment of “perfection”
Example: No patient falls during the year!
Benchmark: Actual, historical, internal or external data
used for comparative purposes
Example: “X” patient falls occurred last year
Objective: Attempted attainment of “realism”
Example: Reduce patient falls from last year by at least 10%
Threshold: The point at which action is taken
Example: Investigate every patient fall that occurs
Healthcare Engineering Consultants
Monitoring and Improvement
How are “EC” Performance
Improvement Measures Monitored?
Healthcare Engineering Consultants
Monitoring and Improvement
Monitoring of “EC” issues through:
Creation of the “Multi-Disciplinary
Improvement Team”
Safety committee membership and meetings
Communication to leadership
Annual PI initiative recommendation to management
Monitoring of Effectiveness
Selection of numerical performance measures
Establishment of goals, objectives, benchmarks
Aggregation of data (“dashboard” or spreadsheet?)
Healthcare Engineering Consultants
Reporting of “EC” PI Indicators
Performance Improvement Dashboard
Description
of Measure
Safety
Management
Lost time
injuries
Security
Management
Internal theft
(equipment, $)
Hazmat
Management
Decrease in
RMW
Emergency
Management
Call-back
response rate
Fire
Prevention
Average fire
drill score
Medical
Equipment
Maint cost/
device/ month
Utility
Management
Priority I WO
response time
Benchmark
FY 2004
Objective
FY 2005
Jan
Feb
Mar
Apr
21/ year
<1.5 per
month
1
2
1
3
$ 25, 426 for
the year
<$ 2,000
per month
1,200
425
0
1,720
124,560# for
the year
< 9,500#
per month
9,245
9,386
9,142
9,524
68% within
20 minutes
75%
69%
73%
84%
81%
93
91
94
91
87 per drill
average
> 90 per
drill avg
$48.13 per
device/ mo
$45.00/
dev/ mo
53.14
47.86
58.22
39.78
3.2 days
< 3 days
3.1
3.1
2.9
3.0
May
Jun
Jul
Aug
Key to colored boxes:
Green boxes indicate data within the desired objective and an improvement trend
Yellow boxes indicate data at or slightly above the desired objective with no discernible trend
Red boxes indicate data above the desired objective and a negative trend
Healthcare Engineering Consultants
Sep
Oct
Nov
Dec
Trend
Monitoring and Improvement
The “PI Process”
Measurement
Initiative
Implementation
Healthcare Engineering Consultants
Monitoring and Improvement
The “PI Process”
Measurement without implementation
and ongoing monitoring to validate
improvement is of little value!
Healthcare Engineering Consultants
Monitoring and Improvement
Questions?
Healthcare Engineering Consultants