Quality

1. Quality What It Means at Aultman Hospital

2. VALUE EQUATION Exceed Patient Expectationsby Delivering Outstanding Service Reduce Costs Significantlywhile Maintaining or Improving Quality Service Outcomes Cost Continuously Improve Quality to Deliver Expected Outcomes

3. Everyone is a Member of the Quality Team Staff Physicians Administration Board Members

4. What is Your Role in Quality? • Provide “Aultimate” Customer Service VIP Model Values Impressions Perceptions

5. What is Your Role in Quality? • Promote Good Outcomes • Clinical – “Best Practice” Care, Core Measures • Non Clinical • Clean Environment • Food Preparation • Valet Parking • Safety – Identify Hazards

6. What is Your Role in Quality? • Pass LowCostson to the Community - Conserve Energy and Supplies - Work Efficiently as a Team Within and Across Departments

7. Joint Commission • Regulatory Agency • Set Minimal Performance Standards the Hospital Must Meet to Stay Open • Involves Everyone to Meet the Standards

8. National Patient Safety Goals • Established by Joint Commission • Promote Specific Improvements in Patient Safety • Highlight Problematic Areas in Health Care • Focus on System-Wide Solutions, Wherever Possible

9. National Patient Safety Goal Improve Patient Identification • Use Two Patient Identifiers; - Name and Medical Record Number or - Name and Date of Birth

10. National Patient Safety Goal Improve Communication SBAR S – Situation B – Background A– Assessment R - Recommendations Quickly get important test results to the right provider of care

11. National Patient Safety Goal Safe Use of Medications • Label All Medicines in Syringes, Cups, and Basins (if not already labeled) • Follow established protocols for patients receiving blood thinners

12. National Patient Safety Goal Reduce Infections WASH YOUR HANDS!

13. National Patient Safety Goal Reduce Infections Follow Isolation Guidelines • Color Coded Signs with Visual Cues • Unsure??? • Ask Before Entering • Isolation Signage Remains Posted Until Room Cleaned/Disinfected by Housekeeping

14. National Patient Safety Goal Reconcile Medications • Compare Home Medications to What You are About to Give • Communicate Medication List to Next Care Provider • Provide Complete List of Medications Upon Discharge

15. National Patient Safety Goal Identify Patients at Risk for Suicide • Assess Suicide Risk

16. National Patient Safety Goal Universal Protocol for Eliminating Wrong Site, Wrong Procedure, Wrong Patient Surgery • Hospital Wide Verification Process • Site Marking • “Time Out”

17. Retired National Patient Safety Goal Now Standard of Care Reduce Harm From Falls Identify Patients at High Risk for Falls • Yellow magnet on door frame • Yellow bracelet • Yellow slippers Preventing Falls Is Everyone’s Responsibility

18. Retired National Patient Safety Goal Now Standard of Care Improve Recognition and Response to Changes in a Patient’s Condition Rapid Response Team (RRT) • Patient in Distress • Notify Caregiver • Stay with Patient until Help Arrives • If Necessary Pull Emergency Light in Bathroom

19. Types of ProcessImprovement Tools • PDCA = Plan – Do – Check – Act • FMEA = Failure Mode Effects Analysis • RCA = Root Cause Analysis

20. Process Improvement Tools • Used to Improve Quality of the Care and Services We Provide • Any Employee May Be Asked to Participate

21. Variance/Incident Reporting Report Any Change from Standard Practice/Process • Computer or Paper Variance Report • Available on the Employee Portal • Anyone May Complete • Non-Punitive

22. Safety Suggestions Anyone can communicate a safety suggestion or concern • Enter Safety Suggestions electronically through the Employee Portal • Option available to receive feedback regarding your suggestion/concern

23. Your Role • Report Quality and Safety Concerns • Don’t Be Afraid to Ask Questions • Communicate • Work as a Team

24. Safety is a team effort, as an Aultman Team Member, I will … • Work to Provide a Safe Environment • Always Communicate Safety Concerns • Participate in Safety Education • Recognize Safety Excellence • Contribute My Ideas to Improve Safety • Immediately Stop Any Process if a Safety Concern is Present

25. WelcomeYou are Now Part of theAultman Quality Team