Quality Improvement at MBSH Samantha Alu, RN, BSN Patient Safety/Quality Improvement Specialist October 25, 2016

25 Bed Critical Access Hospital 11 Room Emergency Department 6 Bed ICU Medical/Surgical Unit Swing Bed Program Surgical Services Department Labor and Delivery Unit 10 Bed Distinct Part Geriatric Psych Unit OP Services: Radiology, Lab, Cancer/Infusion Center, Medical Office Building

Quality Improvement Efforts One Tool we utilize to work on Quality Improvements initiatives/measures is our LDM Boards. We have been utilizing them for about 5 years now.

Lean Daily Management Boards

Lean Daily Management RED is GOOD!!!! From: Culture of Blame Manager Ownership Addressing Symptoms To: Culture of Problem Solving Staff Ownership Addressing Root Cause (s) RED is GOOD!!!!

LDM Board

Data Collection Daily Board Update: After staff determines the metric on the board they will then develop a method to collect the data. All staff will collect the data and in the AM someone is responsible for updating the board prior to 815. Staff will want to review the board and understand the information prior to the report out.

GEMBA Walks Daily Report Out: Every morning at 815 managers and Leadership walk to the boards and staff report out on results Managers and Leadership may ask questions regarding what is being done to improve efforts or may give suggestions on next steps. Staff take feedback back to manager or “owner” of the board and work on next steps: 5 Why Action Plan

Measures Improved by LDM We have utilized the LDM Board to improve several Quality Improvement Initiatives, such as: Median Time to ECG Patients Left Without Being Seen Improving HCAHPS Scores Median time from ED arrival to ED departure for admitted ED patients Readmission Measures Influenza Immunization Early Elective Delivery Aspirin at Arrival

Quality Improvement Based on the results of the data departments will collaborate with each other to determine next steps and process improvement initiatives. The LDM process has helped encourage the collaboration between different departments, building relationships and helping them understand the barriers other departments face. RIE events may be scheduled to help with more complex processes.

Barriers to Quality Improvement and the LDM process: Staff Turnover “Flavor of the Month” Manager and Staff Buy In Consistently Auditing Competing Priorities Once it is removed from the board the issues may come back.

Barriers Overcoming Barriers Show staff the “why” Don’t wait until Monthly meetings to work on projects Front Line staff ownership and/or significant team involvement Owner of the LDM process, acting as a coach to departments Education of nursing and PCT staff during orientation Annual education of Quality Measures

Contact Information: Samantha Alu, RN, BSN Patient Safety/Quality Improvement Specialist Missouri Baptist Sullivan Hospital Phone: 573-468-1182 Email: sja2166@bjc.org