1. 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

2. 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)

3. 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.

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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)

11. 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

12. 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

13. 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

14. 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

15. 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!

16. 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?

17. 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

18. 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!

19. 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!

20. Putting Patients First
Constantly Working to Provide Safe Care Together