Transcript: Quality Improvement "If you think adventure is dangerous, try routine. It is lethal." - Paulo Coelho What's Been Going On? Training Program Projects & Support Dental Patient Satisfaction Survey Development PDSA Review Lunch N Learn 80 People 2 Tribes Success Stories Methodologies Quality Tools Launched Webinar Series Training Program New Projects
Transcript: Treatment -turn patient as often as ordered -thorough assessments -recognize the value in taking preventative measures! Why is it important to chart? Concerns Huddles, another way to improve quality. What is a huddle? Summary The interdisciplinary team approach creates teamwork, collaboration, and communication. This improves quality of patient safety and care. A group of healthcare professionals from diverse fields who work in a coordinated fashion toward a common goal for the patient. An example of this team in action is joint rounding. At Menorah, these rounds were done with the nurse, charge nurse, and sometimes pharmacy & dietary. -Risk for infection -Pain management -Patient's low nutritional intake Why do huddles work? Prevention is Key! How could this have been prevented? It's important to remember this team is part of a system of care that affects outcomes for patients and family members. Freedom Rider - Use of data & improvement methods Heather Biggar - Interdisciplinary team & huddles Brian Buhman - Patient background & diagnosis Allison Martinez - Root analysis of the patient situation Sarah Blackman - Provider education Michelle Kim - Charting: Skin Breakdown Kerry Blankenship - Summary of competency Analysis of the Patient Situation Our voice as a patient advocate Appreciate the value of what individuals and teams can do to improve care Identify the "gaps" between local and best practices Use definitive measures to evaluate the effect of the change HAVE THE COURAGE TO SPEAK UP!! *Who was involved? Which departments? *What factors contributed to the patient's skin breakdown? They demand rapid team formation & preparation at the practice level. They allow the team to: *Problem solve *Educate each other *Communicate *Improve quality of care -If you don't chart then..... -Legal matters -Improved quality care of patient with ongoing treatment -Shift changes Much like a football team before a play, the Med/Tele unit at Menorah huddles at the same time and the same place before every shift. -Paraplegic -PVD -Bilateral AKA -Intracranial bleeding -End stage renal disease -Multiple stage IV pressure ulcer wounds Who makes up this team? Interdisciplinary Team Credits Physician(s) Nurse Charge Nurse Nursing Student Wound Care Nurse Respiratory Therapy Occupational Therapy Physical Therapy Dietary Pharmacy Use of data to monitor the outcomes of care processes and use of improvement methods to design and test changes to continuously improve quality and safety of health care systems. Why do you chart? -Chart initial assessment -Chart physical changes (skin integrity & odor) -Pain meds helpful? -What labs were done? Results? Mobility Systemic Process ID Potential Causes Develop Strategies Measured Care A short 5 minute period, prior to shift, when the charge nurse goes over important items. Examples: *Departmental issues *Core measures *Potential problems, like skin breakdown in our patient that Brian will later describe. Education! Patient X Patient History -what movement can the patient tolerate? -how to move the patient appropriately -proper body mechanics -ask for assistance Charting: Skin Breakdown Quality Improvement Definition of Quality Improvement: -Repositioning -Support surfaces -Antibiotics -Cleaning -Packing and bandaging Huddles Fundamental Concept
Transcript: Efficient: Prevent waste of equipment, supplies, ideas and energy Questions to Ask for Patient Centered Care 1. Total Quality Management (TQM) 2. Continuous Quality Improvement (CQI) 3. Continuous Process Improvement, Statistical Process Control, and Performance Improvement (PI) determined by customer needs and expectations health care quality management is specifically related to the quality of health care services provided Customer's perspective must be considered, including interactions with personnel as well as the service they receive. Brittany Jones & Stephanie Gilson Transfer of Accountability rather than a basic update Language of discussion should allow for patient understanding Encourage patient to contribute or ask questions as they feel necessary What is the most important thing I could do for my patient at this moment? How can the patient or family participate in assessing the patient's pain and determine the best pain management plan? How can I assist family members with visiting hours and access to their family member to reduce anxiety and include them as partners in care? patients are subjected to at least one med error per day 25% of patients do not receive care that is recommended, related to socioeconomic/racial reasons 98,000 patients are killed each year from medical errors Caused by: overuse of expensive invasive technology underuse of inexpensive care services error-prone implementation of care that could harm patients and wast money Need for Quality Improvement Chaboyer, W., McMurray, A., Johnson, J., Hardy, L., Wallis, M., & Chu, S. (2009, April). Bedside Handover, One Quality Improvement Strategy to "Transform Care at the Bedside". Journal of Nursing Care Quality, 24(2), 136-142. Cherry, B., Jacob, S. (2014). Contemporary Nursing: Issues, trends, & management. Missouri: Mosby. Transforming care at the bedside. (2015). In Institute for Healthcare Improvement. Retrieved from http://www.ihi.org/Engage/Initiatives/Completed/TCAB/Pages/default.aspx Weston, M., & Roberts, D. W. (2013, September). The Influence of Quality Improvement Efforts on Patient Outcomes And Nursing Work: A Perspective from Chief Nursing Officers at Three Large Health Systems. In The Online Journal of Issues in Nursing. Retrieved from http://www.nursingworld.org/Quality-Improvement-on-Patient-Outcomes.html Equitable: Providing care that does not vary in quality because of gender, ethnicity, location, and socioeconomic status Transforming Care at the Bedside (TCAB) Safe: Preventing injuries from care that is meant to help them Timely: Reducing wait and harmful delays for those who receive and give care Groups of 2 or 3 Short skit on bedside handoff Each group with have a specific handoff characteristic to portray Handoff activity Patient Centered: Providing care that is respectful and responsive to patient preferences, needs and values Effective: Provide services, based on science, to all and only those that could benefit Quality improvement Bedside Handoff Quality Management 6 guiding aims for improvement for every individual and group involved in the provision of healthcare Categories: Safe and reliable care Vitality and Teamwork Patient Centered Care Value-added Care processes Three Cornerstones of Quality Management Bar code med administration Use of smart infusion pumps Available online resources Mandatory education modules for employees Examples of Quality Improvement References Improvements: Use of Rapid Response teams Communication Models Enhance preceptorships and educational opportunities Redesign workspace for efficiency STEEEP
Transcript: Quality Improvement By: Perpetue Obama, Rikira Smith, Tiffany Ekstrom, Catalina Gonzalez, Brianna McNabb, Robyn Calvio, Eric Debrah, & Stephanie Zafra Johnson, Carson, Tucker & Willette, 2003 A Nurse’s role is to be an active participant in a hospital’s quality improvement process “QI strategies models are important to increase hospital response when current systems do not work effectively or when improvement is needed in a system to increase patient outcomes (Wickman et al., 2013)” “Nurses share accountability to ensure quality and safety of the healthcare system (Wickman et al., 2013)” QI disadvantages Lack of research evidence Implementing changes too fast Different QI language QI Implications All nurses share QI responsibility Lifelong QI education Publications of QI process and findings Implement creative QI activities Constant communication and collaboration Haemodialysis staff are at high risk of exposure to blood-borne viruses. Therefore it is important to identify the risks and find ways to decrease them. This QI project was conducted during the 2nd quarter of 2011 until the 2nd quarter of 2012. In this research 19 haemodialysis clinics across Australia and New Zealand were studied. Incident reports on the risk management system were evaluated twice every week for three months. Needlestick injury preventive measures and prevention protocols were implemented in order to reduce the risk of future occurrences. “The majority of sharps-related injuries occur after use and before and during sharps disposal” (Chenoweth, 2013). After staff training sessions and new protocols there was a decrease of 47% in needlestick injuries. “Awareness of needlestick injuries and safe work practices needs to become a part of a dialysis culture with ongoing education, auditing of policy compliance followed immediately by more education and introduction of needle-safe devices” (Chenoweth, 2013). QI: Patient safety and Increased Workflow Proficiency (Bar Code Medication Administration-BCMA) Morriss, et al (2009). Pyxis Quality Improvement Staff on a 28-bed medical telemetry unit learned the steps of effective nurse-led quality improvement through their participation in the Transforming Care at the Bedside initiative. Quality Improvement vs. Traditional Problem Solving Using Plan, Do, Check, Adjust (PDCA) cycles, staff generated and trialed solutions for unit-based problems. The use of PDCA cycles allowed the team to test several solutions to the problem before choosing a simple, inexpensive measure that made a substantial, positive impact on team vitality, patient care quality and safety, and the effectiveness of the care team. Successful implementation Leadership is a crucial component of the nurse-led quality improvement model because formal unit leaders must act as the coaches, supporters, and mentors of staff innovators, especially during the early stages of the process improvement. Identifying nurses willing to engage actively as improvement change agents is imperative to the success of nurse-led quality improvement. The process of nurse-led quality improvement requires a set of skills that must be taught, practiced, and refined to be successful. Comparison of Classes of Medication Errors Between Hospital Systems with BCMA and Ones Without BCMA. The primary cause of error-related inpatient deaths is adverse drug events such as medication errors that result in patient harm. In an effort to reduce medication administration errors and ensure patients safety, the VA hospital implemented the bar code medication administration (BCMA) system in 1995. The BCMA ensures that the correct patient receives the correct medication, the correct dose, at the correct time, via the correct route, and visually alerts nursing staff when the proper parameters are not met. It improves nursing workflow during medication administration by decreasing opportunity for error through workarounds. It is safer for patients, user-friendly, and effective in reducing errors; requires justification for overriding. Reports on its effectiveness indicate reductions in medication error rates ranging from 60% to 93% (Rivish & Moneda, 2010). Quality improvement has a long history in healthcare from Semmelweis who introduced hand washing to medical care to Florence Nightingale who determined that living conditions correlated with deaths of soldiers at army hospitals. More recently, some organizations have adopted lessons of high-reliability science which is the consistent performance of high levels of safety over long periods of time. Three requirements for achieving high reliability: Leadership: leaders must show commitment and support for the process Safety Culture: Encouraging organizational safety culture allows for employees to feel at ease and free of blame when errors/near misses are reported, investigated, and fixed. Robust Process Improvement: systemic approach to dealing with complicated safety issues and guiding the organization to finding and
Transcript: Background Information and Data/Evidence Findings/Results/Outcomes of Interventions Conclusions and Recommendations for Practice DO Establish Service Expectations: Standard response time to call light, Non-clinical personnel guidelines, Adequately fulfill call light requests Provide proper training: Identify responsibilities of support staff, Scripting, Role Play Patient Satisfaction: Improving Responsiveness to Call Lights HCAHPS Question: "During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?" May 2013 MBU scores: 81.8% of patients responded call lights "always" answered Problem statement: In order to maintain and improve call light response time, global standards such as acknowledgment and resolution must be reached National Context: Hospital consumer assessment of healthcare providers and systems (HCAHPS) is a patient satisfaction survey based on core measures and patient perception of care. Why does this matter? Scores are used nationally by companies to determine insurance coverage and reimbursement. Reduces stress and patient stay in hospital. Encourages healing and communication. Reduces medication errors and law suits. Incentives for individual and unit. PLAN "No Pass Zone" Anyone can answer a call bell Responsiveness to Call Lights and the National Context References Bournes, D., & Flint, F. (2003). Mis-takes: Mistakes in the nurse-person process. Nursing Science Quarterly, 16(2), 127-130. DiNapoli, P. P., Turkel, M., Nelson, J., & Watson, J. (2010). Measuring the caritas process: Caring factor survey. International Journal of Human Caring, 14(3), 15-20. Ganz, F. (2012). Tend and Befriend in the Intensive Care Unit. Critical Care Nurse, 32(3), 25-34. doi:10.4037/ccn2012903 Henderson, S. (2003). Power imbalance between nurses and patients: A potential inhibitor of partnership in care. Journal of Clinical Nursing, 12(4), 501-508. doi:10.1046/j.1365-2702.2003.00757.x Knudsen, E. & Grenier, J. (2010). A great patient experience = positive HCAHPS scores [PowerPoint slides]. Retrieved from http://campaignforquality.sites campaignforquality.com/files/presentations/A%20Great%20Patient %20Experience%20-%20Positive%20HCAHPS%20Scores.pdf Lachman, V. (2012). Applying the ethics of care into your nursing practice. Ethics, Law, and Policy, 21(2), 112-116. Regions Hospital. (2012). 2012 Quality Report. Retrieved from: http:// www.regionshospital.com/ucm/groups/public/@hp/@public/documents/ webcontent/cntrb_036843.pdf Suliman, W. A., Welmann, E., Omer, T., & Thomas, L. (2009). Applying Watson's nursing theory to assess patient perceptions of being cared for in a multicultural environment. Journal of Nursing Research, 17(4), 293-300. Tonges, M. (2011). Translating caring theory into practice. The Journal of Nursing Administration, 41(9), 374-381. Viamontes, G. I., & Nemeroff, C. B. (2009). Brain-body interactions: The physiological impact of mental processes -- The neurobiology of the stress response. Psychiatric Annals, 39(12), 975-984. doi:10.3928/00485718-20091124-03 Viamontes, G. I., & Nemeroff, C. B. (2010). The physiological effect of mental processes on major body systems. Psychiatric Annals, 40(8), 367-380. doi:10.3928/00485713-20100804-03 The No Passing Zone initiative does not mean that non-clinical team members are expected to go into a patient’s room and provide clinical care. Simply put, it means that call lights are everyone’s responsibility, and team members are expected to take the time to acknowledge a call light and ask what the patient needs, and then make the connection with the appropriate team member who can assist the patient. Work as of now... Continue compiling Patient Satisfaction Survey comments and reviewing HCAHPS Focus group sessions with RNs, Aides, and Unit Clerks on implementing No Pass Zone Measure response time to call bells Evidence-Based Practice: - Stress caused by external stimuli leads to activation of stress response, including BS increase and anxiety - HCAHPS is evaluated using PEP Audits: must score 100% to receive incentives - Communication is more beneficial to patient healing using Human Caring Theory and reduces medical errors (i.e. always including teaching and follow up on medications and side effects) - Hourly rounding is the foundation ␣ - Restroom rounds - A supplement to hourly rounding , i.e. after meals and before bed ␣- Service Volunteer Rounding programs - "No Pass Zone" PDSA ACT Non-nursing associates can assist with: moving and obtaining equipment assist with making phone calls and answering phone if beyond reach change TV channels or turn TV on/off turn room lights on/off obtain blanket, pillow, towel, washcloth, slippers, etc open and/or close curtains Regions Hospital (St. Paul, MN) piloted a program in 2012 called the No Pass Zone in which every employee takes responsibility to answer a call light. This resulted in a 12 percent improvement in lights responded to within two minutes and a
Transcript: EQUITY Complaint handling Informed Consent Trusted PATHWAYS The GOAL! AVOID WASTE National Voices definition: Equipment Booking procedure Inpatients Ionising Radiation Report Turnaround CUSTOMER CARE PROMISES EFFICIENT Valued Service Improvement Staff Room for DISCUSSION Interventional Procedures YOUR VOICE "I can plan my care with people who work together, to understand me and my carers, allow me control, and bring together services to achieve the outcomes important to me" Privacy and Dignity MRI Safety Waiting Times Drugs and Contrast Media RISK MANAGEMENT Information AIM INNOVATION ACTION CLINICAL EFFECTIVENESS Best Provider of Integrated Care Reliable High Quality Service Facilities Report Accuracy Emergency ISAS Improve Communication with staff SUSTAINABILITY Rewarded FRIENDS AND FAMILY TEST RESEARCH IT / PACS Community ATTRACTIVE RESOURCES Infection Control SAFE EFFECTIVE PATIENT SAFETY Feedback on performance Positive and Negative STAFF EXPERIENCE Intervention Success rate Outpatients INTEGRATED CARE Respected Quality Improvement Sessions PATIENT EXPERIENCE
Transcript: Data Flow Maps & Recommendations - - -blahablah blha Deliverables (take 1) Challenges e-Tool Mock Up Data Flow : Mitigated Areas Questions? 1) Literature Review 2) Summary description of recommended tool 3) Implementation design & Process flow Map 1) Literature review on strategies to improve staff motivation & tools for improved data quality 2) Recommendations based on literature 3) Current data flow highlighting opportunities for improvement & a new data flow incorporating changes 4) A mock-up of an excel tool that would populate a digital MSPP page for easy tracking and transfer of numbers to the paper MSPP monthly report Quality Improvement Our Process Data Flow : Ideal State Deliverables (Revised) Tools for Quality Improvement Introduction --Skype with Efua & modify deliverables Strategies to Increase Motivation Tools for Quality Improvement Implementation Design Recommended Strategies & Tools Data Flow: Current State -Data Quality Assurance -Incomplete Information -Lack of Motivation/Accountability -Tedious & inaccurate calculations 1) 5S dlfslkfslfjl 2) DMAIC dlsjflaksdjflksl The Literature Says... Strategies to Increase Motivation Scope of Work Data Flow : Areas for Improvement
Transcript: Where have we been? Creating a Culture of Safety and Overhauling our Q&S Program "Quality and Safety is a primary focus at Sick Kids Critical Care." - Peter Laussen Developing our Q&S team Developing a Comprehensive Q&S Communication Strategy Where are we now? Local solutions for local problems Building Capacity in the Front Line Stewardship Where are we going? Measurements and Metrics- Local and Real time Enhancing the voice of patients and families in Q&S Modifying the environment to enhance Q&S Sustainability Create a safer environment? Better meet your expectations? Safety and Quality Improvement at Sick Kids Critical Care Unit- A Journey Provide better care? How might we... The Way out
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