Everyone Has A Role and Responsibility Patient/Family Centered Safe Care: Putting Patients First Quality Improvement and Patient Safety Everyone Has A Role and Responsibility

Putting Patients First – Quality Improvement and Patient Safety A Patient Story from our hospital (Tell a story here about one of your patients and how everyone is a part of ensuring patient safety and quality)

Where Do We Start To Improve Care? Analyze our data, Ask staff Identify an opportunity for improvement Form a Team Collect baseline data Complete Root Cause Analysis Complete Process Flow Map (Chart) Select specific focus to address Prioritize your “cause” Engage staff to create reliable processes At this time, you should have collected your baseline data and completed your root cause analysis and process map. Prioritize Your Cause The cause is most certainly a system issue, not a person issue If it is an individual – you don’t need to do a root cause! Be careful – it is usually a system issue! Discover and apply a systematic approach to assessing nursing home staff in order to support quality. What matters most is not systems and equipment, but is people.

Improving Patient Quality and Safety – A Basic Approach Put Patients First – The Core of All Improvement There are 5 basic phases to walk through an improvement process The quality method may be different but PDSA at core Diverse teams are critical to improvement success

Teams Are the Key To Improvement No one works alone in health care None of us is as smart as all of us Each team member becomes an owner of the change Everyone learns and everyone teaches Teamwork begins to tear down walls and break down barriers between departments If you are not working together, you are not doing your job

Beginning the Team Process Define the purpose of the team Know why each person is on the team Build trust; make decisions by consensus Establish ground rules Set team goals Promote creative and productive behaviors and responses Use small tests of change to create reliable processes

The Improvement Team Should Ask Three Questions: AIM What are we trying to accomplish? MEASURES How will we know that a change is improvement? CHANGES What changes can we make that will result in improvement? Key changes are then implemented in a cyclical fashion

Team’s Role Team designs a plan (Plan) Team creates time-lined actions (Do) Team/assigned individuals measure (Study) Team acts on the outcome of measurements (Act) DO: What Who When Outcome

Phase One – Project Identification Decide on the process that needs improving Form a team Write an aim, What is your goal? Select methodology – the scientific approach Determine measures

Goals Are SMART M easurable A greed to R elative Your Goal should be SMART S pecific M easurable A greed to R elative Time-based (becomes standard process)

Phase Two - Diagnostic Data Collect qualitative & quantitative data Analyze data Acknowledge the problem and Own the solution! How? - Process Flow charts, Root Cause Analysis Ask the patient Brain storm Organizae the informaiton via cause & Effect

Phase Two - Diagnostic Select Your Method to Improvement Focus PDSA Lean / Six Sigma Reliable systems process design CUSP Tools Learning from Defects Daily Goals May be different depending on what is being improved

A Model of Improvement PDCA PDSA Lean Six Sigma Define Control Measure Recognize the problem exists Form Quality Improvement Teams Define the Problem Develop Performance Measures Analyze problem/ process Determine Root Cause Select and Implement Solution Evaluate Ensure Permanence Continuous PDCA Define Measure Improve Control Form quality improvement teams problem performance measures root cause implement solution permanence PDSA Lean Six Sigma Daily control plan Statistical process control Simulation techniques SIPOC Project charter Voice of the Patient Process map Measurement plan FMEA Ishikawa diagram Statistical process control Capacity analysis Pareto analysis Lean process design FMEA Correlation studies Statistical process control Design of experiments Simulation techniques Correlation of variables Confidence intervals Hypothesis testing Regression analysis ANOVA

On The CUSP Adaptive (CUSP) Assemble a CUSP team, Technical – Practices to Prevent Harm Evidence Based Practice 1. Evaluation 2. Systems Analysis 3. Process Development Education on the Evidence 1. Presentation of evidence 2. Fact Sheet 3. Cost Estimator 4. Summary of Professional Organization Recommendations 5. Annotated bibliography Implementation/ Sustaining 1.Checklist 2.Policy / Procedures 3. Protocol s 4. Monitoring 6. Feedback Adaptive (CUSP) Science of Safety 1. Science of Safety presentation 2. Attendance sheet Staff Identify Defects 1.Staff Safety Assessment form 2.Identifying Hazards presentation Senior Executive Partnership 1. Education 2. Briefings Learning from Defects 1. LFD toolkit 2.RCA of each incidence Implement Tools for Teamwork and Communication 1. Daily Goals 2. Shadowing 3. AM Briefing 4. Call List 5. Team Check Up tool 6. TeamSTEPPS Tools Assemble a CUSP team, Partner with a Senior Executive; Baseline Data Quality Improvement Tools 1. PDCA 2. Lean/Six Sigma 3. Reliable System Process 4. TCAB 5. Other Org chart 14

Phase Two - Diagnostic See it! Feel it! Do it! How? Organize it! Voice of the Patient / Individual Process Flow Root Cause Analysis Brainstorm Organize it! Cause & Effect diagram Pareto Charts Run Charts Identify what is the priority process to improve See it! Feel it! Do it!

Phase Three – Interventions: Tests of Change Select the intervention(s) Evidence Based Best Practices Use the selected method: PDSA LEAN/Six Sigma Reliable systems process design CUSP Plan - the change What are we testing? Who is doing the testing? When are we testing? Where are we testing? Plan – the Predictions What do we expect to happen? Plan – Data Collection What data do we need to collect? Who will collect the data? When will the data be collected? Where will the data be collected? Do - Carry out the change; Collect the data; Begin analysis What was actually tested? What happened? What observation were made? What, if any, problems were encountered? Study Complete analysis of data Summarize what was learned Compare data to predictions Act What changes should we make before the next test cycle? What will the next cycle be? Are we ready to implement the change?

Human Factors Must Be Built In To the Intervention Decision aids and reminders built into the system Desired action the default (based on scientific evidence) Redundant processes utilized Scheduling used in design development Habits and patterns know and taken advantage of in the design Standardization of process based on clear specification and articulation is the norm

Phase Four - Impact and Implementation Once the process has been tested and refined make it the standard process Create an Implementation Plan Manage the change Start with the why - create a sense of urgency that is patient centered Peer to peer education Assess competency Spread the Success!

Phase Five – Sustaining and Spreading the Gain Standardization Clearly state the who, what, when, where, how and with what Documentation Training & Education Measurement Provide feedback to all - leadership to staff Assess further areas for improvement Celebrate and Share the Success! Hold each other accountable!

Putting Patients First Constantly Working to Provide Safe Care Together