Performance Improvement

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

2. - 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 Performance Improvement is…..

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 • 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 EmployeesGoverning BoardMedical StaffAll Members of theORGANIZATIONParticipate 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 What if I still have a concern after I have reported?

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

18. Philosophy of PerformanceImprovement/ Safety Program.

19. No Improvement Happens Without Aim.

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

21. Every process is perfectly designed to produce theresults that it produces.

22. Complaints are opportunities to improve.

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

24. Non-judgmental improvement replaces finding blame.

25. Performance Improvementfocuses on doing the right things right the first time.

26. National Patient Safety Goals

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

28. Patient Identification • NPSG.01.01.01: 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.01.03.01: Eliminate transfusion errors related to patient misidentification.

29. Improve Communication Goal 2: Improve the effectiveness of communication among caregivers • NPSG.02.03.01: Report critical results of tests and diagnostic procedures on a timely basis.

30. Medication Safety Goal 3: Improve the safety of using medications • 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.03.05.01: 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

31. 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

32. National Patient Safety Goals Goal 6: Reduce the harm associated with clinical alarm systems. NSPG.06.01.01 :Make improvements to ensure that alarms on medical equipment are heard and responded to on time. Applies to: Ambulatory, Critical Access Hospital, Hospital

33. National Patient Safety Goals Goal 7: Reduce the risk of health care associated infections. NSPG.07.01.01: 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

34. Health Care Associated Infections • NPSG.07.03.01: Use proven guidelines to prevent infections that are difficult to treat. • Multidrug-resistant infections • NPSG.07.04.01: Use proven guidelines to prevent infection of the blood from central lines. • NPSG.07.05.01: Use proven guidelines to prevent infection after surgery. • NPSG.07.06.01: use proven guidelines to prevent infection of the urinary tract that are caused by catheters. • Applies to: Critical Access Hospital, Hospital

35. National Patient Safety Goals Goal 9: Reduce the risk of patient harm resulting from falls • NPSG.09.02.01: Reduce the risk of falls.

36. National Patient Safety Goals Goal 14: Prevent health care associated pressure ulcers (decubitus ulcers) • NPSG.14.01.01: 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

37. Risk Assessment Goal 15: The organization identifies safety risks inherent in its patient population. NPSG.15.01.01: Identify patients at risk for suicide.

38. Universal ProtocolPreventing wrong site, wrong procedure, and wrong person surgery UP.01.01.01: Conduct a preprocedure verification process UP.01.02.01: Mark the procedure site UP.01.03.01: A time-out is performed before the procedure. • Applies to: Ambulatory, Critical Access Hospital, Hospital, and Office-Based Surgery

39. Communication

40. 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 .

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

42. 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

43. Communication

44. CommunicationWhat should it include???? • Effective communication: • Up-to-date information regarding: • Condition • Care • Treatment • Medications • Services • Anticipated changes

45. 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

46. 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.

47. Look-Alike / Sound-Alike Medications • Insulin (Novolog, Novolin, Novolog 70/30, Novolin 70/30) • Hydroxyzine, Hydralazine • Doxorubicin (Adriamycin), Doxorubicin liposomal (Doxil) • Levofloxacin, Levetiracetam • OxyContin, Oxycodone • Clonidine, Clonazepam, Clobazam • Trental, Tegretol • Adacel (Tdap), Daptacel (DTap) • Effexor (venlafaxine), Effexor XR (venlafaxine XR) • Cerebyx, Celexa, Celebrex • Seroquel, Sertraline • Divalproex, Divalproex ER • Hydromorphone, Morphine

48. Sentinel Events • 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.

49. 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.

50. 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.