1. Performance Improvement
Rockcastle Regional Hospital and Respiratory Care Center, Inc.
Overview

2. Performance Improvement is…..
- A systematic and continuous actions that lead to measureable improvement
Quality improvement work as systems and processes
Focus on patients
Focus on being part of the team
Focus on use of the data
Principles

4. What is PDSA Cycle?
- a systematic series of steps for gaining valuable learning and
knowledge for the continual improvement of a product or
process.
The W. Edwards Deming Institute 2015

5. Plan 1. Plan for a process we want to improve.
2. Identify the measure or indicator for the
process change.

6. Do 1. Implement the process change. 2. Collect data on the measure.
3. Begin data analysis.

7. Study 1. Study the data you collected with the process change.
2. Where the changes implemented as planned?
3. What are the outcomes of the changes?
4. What lessons have we learned?

8. Act * Abandon change 1. Act on the conclusions of your study to
maintain or revise your process.
2. Determine your next steps.
3. Do we?
* Hold gains
* Abandon change

9. Our Model for Improvement?
PDSA

10. Who is involved in Performance Improvement Activities?
Hospital Employees Governing Board Medical Staff All Members of the ORGANIZATION Participate in Performance Improvement

11. Your Role in Performance Improvement
Participate in PI Activities
Communicate opportunities for improvement to immediate supervisor
Incorporate Continuous Quality Improvement into your work

12. Everyone has a role in Patient Safety.
What is your basic role in the safety program?

13. Communicate safety issues
Follow safety guidelines
Be alert for process problems

14. Goals of Patient Safety
Promote a culture safety
“Move away from blame”
Communicate, communicate, communicate
Engage patient in the safety of their care

15. What can I do if I have a concern about safety or quality of patient care?

16. Employee Action Communicate your concern Report to your supervisor
Complete a Reportable Event Form

17. What if I still have a concern after I have reported?

18. Report to Joint Commission
The organization will not take retaliatory disciplinary action because an employee reports concerns to the Joint Commission

19. Philosophy of Performance Improvement/ Safety Program.

20. No Improvement Happens Without Aim.

21. All improvement requires change, but not all change is improvement.

22. Every process is perfectly designed to produce the results that it produces.

23. Complaints are opportunities to improve.

24. Those involved in health care are genuinely committed to doing their best.

25. Non-judgmental improvement replaces finding blame.

26. Performance Improvement focuses on doing the right things right the first time.

27. Lean Concepts in HealthCare
What is Lean?
“The endless transformation of waste into
value from the customer’s perspective.”
- QHR Learning Institute

28. Culture of Lean Thinking
Understand customer value and focuses on key process to continuously increase value
Provide value to the customer through a perfect value creation process that has zero waste
Require development of all team members
Provide a way to do more with less (effort, equipment, time, & spaces) , while meeting customers expectations
Strive for perfection

31. Another view of the 8 Waste……

32. Lean Tool: 5S

33. What does 5S look like?

34. National Patient Safety Goals

35. Patient Identification
Goal 1: Improve the accuracy of patient identification

36. Patient Identification
NPSG :
Use at least two patient identifiers when
providing care, treatment and services.
Applies to: Ambulatory, Behavioral Health Care, Critical Access Hospital, Home Care, Hospital, Laboratory, Long Term Care, Office- Based Surgery
- Patient’s Name
- Patient’s Date of Birth
NPSG :
Eliminate transfusion errors related to patient misidentification.

37. Improve Communication
Goal 2:
Improve the effectiveness of communication among caregivers

38. Improve Communication
NPSG :
Report critical results of tests and diagnostic procedures
on a timely basis.
Applies to: Critical Access Hospital, Hospital, Laboratory

39. Medication Safety
Goal 3: Improve the safety of using medications

40. Medication Safety NPSG.03.04.01:
Before a procedure, label medicines that are not labeled. For example, medicines in syringes, cups and basins. Do this in the area where medicines and supplies are set up.
NPSG :
Reduce the likelihood of patient harm associated with the use of anticoagulant therapy.
Anti-coagulation mgmt. program – protocol
Only oral unit dose products, pre-filled syringes, or premixed infusion bags
Baseline INR for patients being started on warfarin
Dietary services notified of patients on warfarin
Only use programmable pump with giving heparin intravenously
Baseline and ongoing lab tests are required for heparin and LMW heparin therapies
Education to staff, patients, families, and prescribers
Evaluate program and the effectiveness

41. Medication Safety NPSG.03.06.01:
Maintain and communicate accurate patient medication information.
Medication Reconciliation
Record and pass along correct information about a patient’s medicines. Find out what medicines that patient is taking. Compare those medicines to new medicines given to the patient. Make sure the patient knows which medicines to take when they are at home. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor.
Applies to: Ambulatory, Critical Access Hospital, Hospital, Office-Based Surgery

42. National Patient Safety Goals
Reduce the harm associated with clinical alarm systems.
NSPG :Make improvements to ensure that alarms on medical equipment are heard and responded to on time.
Applies to: Ambulatory, Critical Access Hospital, Hospital

43. National Patient Safety Goals
Reduce the risk of health care associated infections.
NSPG : Comply with either the current Centers for Disease Control and Prevention(CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines.
Applies to: Ambulatory, Behavioral Health Care, Critical Access Hospital, Home Care, Hospital, Laboratory, Long Term Care, Office-Based Surgery

44. Health Care Associated Infections
NPSG : Use proven guidelines to prevent infections that are difficult to treat.
Multidrug-resistant infections
NPSG : Use proven guidelines to prevent infection of the blood from central lines.
NPSG : Use proven guidelines to prevent infection after surgery.
NPSG : use proven guidelines to prevent infection of the urinary tract that are caused by catheters.
Applies to: Critical Access Hospital, Hospital

45. National Patient Safety Goals
Reduce the risk of patient harm resulting from falls

46. Reduce Falls NPSG.09.02.01: Reduce the risk of falls.
Applies to: Home Care, Long Term Care

47. National Patient Safety Goals
Prevent health care associated pressure ulcers (decubitus ulcers)
NPSG : Assess and periodically reassess each resident’s risk for developing a pressure ulcer and take action to address any identified risks.
Applies to: Nursing Care Center

48. Risk Assessment
Goal 15:
The organization identifies safety risks inherent in its patient population.
NPSG : Identify patients at risk for suicide.

49. Risk Assessment
NPSG : The organization identifies patients at risk for suicide.
Applies to: Behavioral Health Care, Hospital

50. Universal Protocol Preventing wrong site, wrong procedure, and wrong person surgery

51. Universal Protocol
UP : Conduct a preprocedure verification process.
Applies to: Ambulatory, Critical Access Hospital, Hospital, and Office-Based Surgery
UP : Mark the procedure site
UP : A time-out is performed before the procedure.

52. Communication

53. Communication Read back telephone or verbal orders (critical values)
The individual giving the order verifies the complete order or test result by having the person receiving the information record and “read-back” the complete order or test result .

54. Communication
Below is a list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization.

55. Communication
The organization measures, assesses, and, if needed, takes action to improve the timeliness of reporting, and the timeliness of receipt of critical tests, results, and values by the responsible licensed caregiver.
The organization implements a standardized approach to hand- off communications, including an opportunity to ask and respond to questions.
Shift reporting
Ticket to ride
Reporting to and from MD

56. Communication Effective communication:
Up-to-date information regarding:
Condition
Care
Treatment
Medications
Services
Anticipated changes

57. Patient Involvement

58. Patient Involvement
Identify ways in which the patient and his or her family can report concerns about safety and encourage them to do so.
Hospital provides the following information to the patient:
Infection control measures for hand hygiene practices
Respiratory hygiene practices
Contact precautions according to patient’s condition (documentation required)
For surgical patients, the hospital describes measures that will be taken to prevent adverse events in surgery.
i.e. patient identification, marking of the surgical site, prevention of surgical infections

59. Changes in Patient’s Condition

60. Changes in Patient’s Condition
The organization selects a suitable method that enables health care staff members to directly request additional assistance from a specially trained individual(s) when the patient’s condition appears to be worsening.
The organization encourages patients, families to seek assistance when a patient’s condition worsens.
Formal education on RRT is conducted with staff and LIPs, who may request assistance and those who may respond to those requests.

61. Look-Alike / Sound-Alike Medications

62. Sentinel Events

63. Sentinel Events are: An unexpected occurrence involving Death
Serious physical or psychological injury or risk thereof
The phrase "risk thereof’ includes any process variation for which a reoccurrence would carry a significant chance of a serious adverse event.

64. Sentinel events include:
Rape
Hemolytic transfusion reactions involving blood or blood products.
Surgery on wrong patient or wrong body part.
Unanticipated death or major permanent loss of function related to a health care associated infection.
Homicide of a staff member, LIP, visitor, or vendor while on site.
Events that result in death or permanent disability that are not part of the natural course of the patient’s illness.
Suicide.
Unanticipated death of full-term infant.
Infant abduction or discharge to the wrong family.

65. Your Role in Sentinel or Near Miss Events?
Report any potential issues to supervisor as soon as identified.
Be alert for potential areas that could lead to patient safety issues.

66. QUESTIONS???