QHR Monthly Quality Call How to Engage Staff in Quality presented by King’s Daughters Medical Center Friday, April 27, 2012 11:00 AM Central Standard Time Call-in number 1-888-378-4350, passcode 7064020 Welcome and Opening Remarks...................................................Donna Wood, Practice Leader Clinical Operations, QHR Foundation for Quality Culture ……………………………..………..……Merida Johnson, Director Quality Management & Patient Safety, King’s Daughters Medical Center King’s Daughters Medical Center CEO Vision Theoretical Framework Hardwiring Quality Structure Changes Application: Lewin’s Theory of Change Unfreezing: Process Changes Changing: Management Tools 7. Refreezing: Staff Engagement in Quality/PI Activities 8. Questions and Answers Next QHR Quality Call – Friday, May 25, 2012 at 11:00 AM CT: Topic: Engaging Physicians in a Shared Quality Agenda Presenter: Jamie Cox, Senior Consultant, Clinical Operations, QHR

King’s Daughters Medical Center Merida Johnson Director, Quality Management and Patient Safety King’s Daughters Medical Center Brookhaven, Mississippi Merida is a Registered Nurse with more then 30 years experience in Nursing Education and Administration. She received her B.S.N. at Louisiana State University Medical Center at New Orleans and her M.S.N. at the University of South Alabama. Prior to her affiliation with King’s Daughters Medical Center, Merida was the Clinical Operations Officer for LifeCare Hospitals of New Orleans and a Nursing Instructor at Holy Cross College in New Orleans. Currently, Merida is a member of the National Association for Healthcare Quality and serves as a Board Member of the Mississippi Association for Healthcare Quality (MsAHQ) where she is responsible for Continuing Education. She is certified as a Healthcare Quality Professional and a Clinical Preceptor for graduate Nursing students at the University of South Alabama. Merida has presented a poster on “Quality Culture Transformation” at the 2011 National Association for Healthcare Quality’s Educational Conference in Sacramento, California. She is a frequent contributor of patient safety and quality topics to Brookhaven's local newspaper and MsAHQ’s newsletter.

How to Engage Staff in Quality April 27, 2012 King’s Daughters Medical Center Brookhaven, Mississippi Call-in number 1-888-378-4350, passcode 7064020

Foundation for Quality Culture C.E.O. Vision KDMC’s Mission Theoretical Framework Studer’s Pillars of Excellence Lewin’s Theory of Change

Hardwiring Quality Structure Changes “Quality is a Priority” Agenda item for all meetings Hospital Strategic Plan Quality goals and objectives Quality and Performance Improvement Performance evaluation item Annual Departmental PI Presentations

Hardwiring Quality Studer’s Pillars of Excellence Pillars as Agenda Categories High-Middle-Low Conversations Lewin's Theory of Change Unfreezing Change Refreezing Unfreeze Change Refreeze

Unfreezing: Quality Process Changes Rapid Cycle Process Improvement Methodology Short-term projects Repeated PDSA Test Cycles Attractive to Staff Quality Rounding Quality/PI conversations Staff Training

Unfreezing: Change Management Tools Force Field Analysis Driving Forces Restraining Forces Ishikawa Diagram Drill down causes of staff disconnect

Changing: Management Strategies Senior Leadership Support Quality Director as Change Agent Quality Champions Staff-Driven PI Teams Making Quality and PI “child’s play” Timely Rewards and Recognition

Refreezing: Staff Engagement in Quality Activities PDSA Pep Rally – October 2010

Refreezing: Staff Engagement in Quality Activities PDSA Football Tournament – October 2010

Refreezing: Staff Engagement in Quality Activities The Great PI Adventure – May 2011

Refreezing: Staff Engagement in Quality Activities “Hooray for Hollywood” – October, 2011

Refreezing: Staff Engagement in Quality Activities “Washing In The Sink” – January 2012 A staff-created Hand Hygiene Video   View this video on YouTube at: www.youtube.com/watch?v=B8NQxrxQrOY

Questions Merida Johnson, Director Quality Management and Patient Safety, KDMC mjohnson@kdmc.org Please submit ideas or comments to: Donna Wood, Practice Leader, Clinical Operations, QHR Donna_Wood@QHR.com Next QHR Quality Call: Friday, May 25, 2012, at 11:00 am CT Topic: Engaging Physicians in a Shared Quality Agenda Presenter: Jamie Cox, Senior Consultant, Clinical Operations, QHR Legal Disclaimer: Any sample quality program tool is intended to be reviewed and revised by a hospital to meet that hospital’s unique circumstances. Neither these tools nor any quality program tool should be used until it has been adopted by a hospital’s medical staff and governing board. Nothing herein is a substitute for the independent medical or clinical decision-making of any person.