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Interview with St David’s Round Rock Medical Center. QPI inVestigators. ST David’s Background. PI. Mission To provide exceptional care to every patient every day with a spirit of warmth, friendliness and personal pride. Values - I.C.A.R.E. I ntegrity C ompassion A ccountability R espect
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Interview with St David’s Round Rock Medical Center QPIinVestigators
ST David’s Background PI • Mission • To provide exceptional care to every patient every day with a spirit of warmth, friendliness and personal pride. • Values - I.C.A.R.E. • Integrity • Compassion • Accountability • Respect • Excellence • Vision • Exceptional Care, Customer Loyalty, Financial Strength QPIinVestigators
ST David’s Quality Awards PI Texas Health Care Quality Improvement AwardAwarded by TMF® Health Quality Institute, the Medicare Quality Improvement Organization for Texas Texas Award for Performance Excellence • Same criteria and process as the Malcolm Baldridge National Quality Award! Awarded to organizations that serve as role models for quality, customer satisfaction, and performance excellence in Texas QPIinVestigators
The Interview PI • Interviewee: • Shannon Kane-Reinhardt RN, BSN, Quality Manager(St David’s Round Rock Medical Center) • Interviewers: • LombeChitundu • Jean Cusick • Yolanda Johnson • Vicki McGinnis • Sharon Royall-Murphy • Interview Date: March 30, 2010 QPIinVestigators
Format of the Interview PI 5 Steps in an Organizational PI Model QPIinVestigators
Identify Performance Measures PI Core Measures SCIP Antibiotic Received Within One Hour Prior to Surgical Incision (SCIP-Inf-1a) QPIinVestigators
Identify Performance Measures PI QPIinVestigators
Measure Performance PI Areas Studied and Data Collection • Create confidential spreadsheet: • Anesthesia Start Date • Admission Date • Antibiotic Administration Route • Antibiotic Name • Antibiotic Received • Birth date • Clinical Trial • Discharge Date • ICD-9-CM Principal Diagnosis Code • ICD-9-CM Principal Procedure Code • Infection Prior to Anesthesia • Laparoscope • Oral Antibiotics • Other Surgeries QPIinVestigators
Measure Performance PI Measurement Ratio QPIinVestigators
Analyze and Compare Data PI • Data added to spreadsheet: • Name of surgeon • Case identifier • Date of surgery • Reason for outlier (why not started on time) • Responsibility (who started antibiotic) • Analyze all outliers OperatingRoomTimeout Checklists QPIinVestigators
Analyze and Compare Data PI QPIinVestigators
Identify Improvement Opportunity PI Multidisciplinary PI Team QPIinVestigators
Identify Improvement Opportunity PI QPIinVestigators
Perform Ongoing Monitoring PI Forces driving ongoing improvement efforts QPIinVestigators
Perform Ongoing Monitoring PI HCAHPS Customer Satisfaction Survey The hospital indicated that the data submitted for this measure were based on a sample of cases. QPIinVestigators