2.  Current reimbursement standards for hospitals receiving Medicare reimbursement are held to specific clinical core measures  One such measure is the time from door to antibiotic administration for patients with community acquired pneumonia  The standard was based on two research studies that found a relationship between time and morbidity and mortality in the elderly

3.  Antibiotic administration within 4 hours of arrival in random sample of older inpatients with community-acquired pneumonia who had not received antibiotics as outpatients › Decreased mortality › Decreased LOS  Administration within 4 hours › Prevent deaths in the Medicare population, › Offers cost savings for hospitals, › Feasible for most inpatients Houck, P., Bratzler, D., Nsa, W., Ma, A., & Bartlett, J. (2004). Timing of antibiotic administration and outcomes for Medicare patients hospitalized with community acquired pneumonia. Archives of Internal Medicine, 164, 637-644

4.  As an advanced practice nurse you will be held to meet clinical standards  One way to understand causation is through process flow chart  Flowing the process and identifying gaps in care will elucidate opportunities for quality improvement

5.  Picture of the sequence of steps in a process  Maps out the action steps and decisions within a process, from beginning to end  Different steps or actions represented by boxes or other symbols  Help you identify and understand a process

6.  Sources of information: › Chart Audits › Discussions with Providers › Interviews with Patients

7.  Often focus first on index case – › “What happened in this case?”  Then flow chart the usual course of events › “What usually happens?”  Once you have established an overview of the usual process, if needed, you may drill down to progressive levels of detail to understand nuances of the process.

8.  Community-acquired pneumonia improvement team  ER admits - antibiotic administration times much improved  Ongoing delays noted on patients admitted directly to inpatient unit from clinic  Why the delays?

9. Pt arrives on ward Admit orders written Orders taken Off Orders faxed to pharmacy R. Ph. Verifies order Pharm Tech fills order Med given Pt arrives on Unit Admit orders written Orders taken Off Orders faxed to pharmacy R. Ph. verifies order Pharm Tech fills order Med prepared in pharm. Med brought to floor Med placed in med rm Nurse retrieves med Nurse gives med

10. Pt arrives on ward Admit orders written Orders taken Off Orders faxed to pharmacy R. Ph. Verifies order Pharm Tech fills order Med given Pt arrives on ward Admit orders written Orders taken Off Orders faxed to pharmacy R. Ph. verifies order Pharm Tech fills order Med prepared in pharm. Med brought to floor Med placed in med rm Nurse retrieves med Nurse gives med * * * * * * *

11. Pt arrives on ward Admit orders written Orders taken Off Orders faxed to pharmacy R. Ph. Verifies order Pharm Tech fills order Med given Pt arrives on Unit Admit orders written Orders taken Off Orders faxed to pharmacy R. Ph. verifies order Pharm Tech fills order Med prepared in pharm. Med brought to floor Med placed in med rm Nurse retrieves med Nurse gives med * * * * * * * * Only steps for which secondary measurements of time intervals readily available

12. Pt arrives on Unit Admit orders written Orders taken Off Orders faxed to pharmacy R. Ph. verifies order Pharm Tech fills order Med given Only measurable process steps can be captured in time Eleven steps collapsed to seven

13.  Study the patients represented on the flow chart attached. › Where are the areas of greatest delay? › Is any variability in practice noted? › From this information, does the pharmacy appear to be the area where intervention is needed to shorten the time to antibiotic administration? › Do you see any evidence of variation in care that might be contributing to the delays? › What would you consider the most productive areas for intervention?

14.  Mapping out a flow chart may allow to you identify problem areas within the process you are trying to improve.  Within each problem focus area, you will need to dig deeper to understand the cause of the problem.