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

2. 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

3. 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.

4. Lean Daily Management Boards

5. 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!!!!

6. LDM Board

7. 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.

8. 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

9. 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

10. 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.

11. 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.

12. 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

13. Contact Information:
Samantha Alu, RN, BSN
Patient Safety/Quality Improvement Specialist
Missouri Baptist Sullivan Hospital
Phone: