Everyone Has A Role and Responsibility

1. 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

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: 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)

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 Your Goal should be SMART S pecific Measurable Agreed to Relative Time-based (becomes standard process)

11. Phase Two - Diagnostic • Data • Collect qualitative & quantitative data • Analyze data Acknowledge the problem and Own the solution!

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. Lean Six Sigma Define Define Recognize Recognize the problem the problem exists exists Form Quality Form quality Continuous Continuous improvement Improvement Improvement improvement Teams teams Control Control Define the Define the Ensure Ensure problem Problem Permanence permanence Measure Measure PDCA PDSA Develop Develop performance Performance Evaluate Evaluate Measures measures solution Solution Select and Select and Analyze Analyze Improve Implement Improve implement Implement problem/ problem/ solution Solution process process Determine Determine root cause Root Cause Analyze Analyze A Model of Improvement 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. Org chart

15. Phase Two - Diagnostic • How? • 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

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