McLaughlin and Kaluzny, Continuous Quality Improvement in Health Care, 3 rd Ed.

4. Design for Quality – requires process ownership, organizational investment, low inherent variability 3. Process Control – statistically based, needs larger samples, case mix adjustments on the fly 2. Measuring & Improving the Process – walk before you run 1. Inspection – take names and kick butts

 Disinterested observer – grand rounds can be an example  Cognitive record of service deliverer - chart  After-the-fact reporting of recipient satisfaction – gets at different constructs  Objective outcome measures – health care system not currently equipped to go there  CYA investigation – inspection at its worst

 Sources of variation  Customers/patients/enrollees  Servers/providers  Processes/systems  Measurements  Information  Interactions among these

 Cause and effect diagram  Histogram  Pareto chart  Check sheet  Control chart  Bar graph  Scatter diagram

 Lots of run charts where there are 3 sigma limits:  Was process ever under control?  Is there a symmetrical loss function?  Real control charts are statistically sophisticated  Time series analysis is important, but don’t overdo it. Statistical needs can vary widely.

. Figure Decisions have been taken to improve the medication delivery process Figure Knowledge about the medication error process.

Who are your Customers, Stakeholders, Markets? What do they expect / require of your services? How you select, design, and improve your services. How you measure your success. Figure 4-3 Sequence of Questions

Manual systems Problem: Adverse Drug Event Policies People Plant & Equipment Procedures similar packaging for different drugs Lack of knowledge Wrong drug selected for patient condition dosage contraindications frequency of administration Policies not followed Unable to read order due to illegible writing 5 Rights of medication administration patient drug dose route time Reliance on memory distractions in work environment Equipment malfunction lack of training Unfamiliar with patient population lack of adverse event reporting Figure 4-9 Root Causes Of Medication Errors

Formulary, purchasing decisions Inventory management Dispense/ distribute medication Obtain Medication- related History Document Medication History Diagnostic/ Therapeutic Decisions Made Medication Ordered Evaluate order Select medication Educate patient regarding medication Order verified and submitted Prepare medication Educate staff regarding medications History-Taking Ordering Pharmacy Management Education Select the correct drug for the correct patient Administer according to order and standards for drug Document administration and associated information Assess and document patient response to medication according to defined parameters Intervene as indicated for adverse reaction/error Administer MedicationMonitor/Evaluate Response Document Medication Inventory Management Administration Management Incident/adverse event surveillance and reporting Surveillance FIGURE 4-7 Flow Chart of Medication Administration Reprinted with permission by VHA and First Consulting Group from the VHA 2002 Research Series publication, Surveillance for Adverse Drug Events: History, Methods and Current Issues by Peter Kilbridge, M.D. and David Classen, M.D. First Consulting Group.

medication ordered is medication in unit stock? request from pharmacy dispensed by pharmacy administered to patient documented in patient’s record no yes observe patient status Figure 4-6 Flow Chart of Medication Administration Process

McLaughlin and Kaluzny, Continuous Quality Improvement in Health Care, 3 rd Ed.

 Direct observation of transaction by third party  Supervisor, mystery shopper, recording device  Cognitive record of process (by provider)  Medical record  Consumer reports of the experience  By patient or family

 Management observation  Employee feedback programs  Work teams/quality circles  Focus groups  Mystery shoppers

 Comment cards  Mail surveys  Point-of-service interviews  Telephone interviews

 Best sources of information about:  Communication  Education  Pain management  Met market place demands for such information  Keep analyses patient-centered

 Measures of preferences – what consumer wants  Evaluations by users  Reports of health care experiences

Buyer-Decision Process

 Patients, obviously, plus:  Physicians – referrals, downstream processes  Facilities  Insurers/ Managed care organizations  Government/ Other regulators  Families  Communities

 Nurse communications  Nursing services  Physician communications  Physical environment  Pain control  Communication about medications  Discharge information  Overall rating of care/ Recommendation to others

 Patient recall times limiting  Evidence of outcomes varies with time  Comparability of intra-institutional data  Comparability of cross-institutional data  Impact on response rates

 Suggested factors to balance:  Finances  Human resources  Internal processes  Customer satisfaction  Remember the Donabedian grid