Quality/Performance Improvement Fundamentals

Transcription

1 Quality/Performance Improvement Fundamentals What to do and how to do it Skill Building Session May 29, 2013 Pat Teske, RN,MHA (661)

2 Today Agenda for Today Review ways to strengthen Gap Analysis Review learnings from planning the next PDSA cycle Describe our next webinar

3

4 Getting closer but We still have a way to go

5 Raise your hand and chat Let s try it

6 Please don t put us on hold

7 HEN Topics ADE CAUTI CLABSI EED Falls with Injury HAPUs OB Adverse events Readmisions VAE VTE 7

8 Top 10 Improvements

9 #10 Complete your assignment A S P D Use driver diagram, change package or other resource information & do a tracer to find your gaps Once you identify your gaps plan out a small test of change on the PDSA worksheet for one gap

10 Skill Building Assignment Find you gaps by tracing your actual practice compared to the evidence A gap is the difference between what you should be doing based on the evidence and what you are already doing, or what you are not doing reliably Understand your gaps Why are the gaps occurring? Select one gap Think of one idea something you are not doing now Plan a SMALL Test to determine if this new idea would work in your organization Adopt Adapt Abandon

11 #9 Understand your gaps Lack of education to patients and family Patient non-compliance is the single most common indicator between readmitted patients

12 Examples Education What is your current method of education? Is it a lack of teaching materials? How is teaching done? Is teach back employed? Who is responsible? Compliance Are teaching materials at appropriate health literacy level? What are the patients barriers? 12

13 #8 Know what s a test & what s not Describe your first (or next) test of change

14 Examples Not a Test Develop Protocol for FC insertion and removal Create fall risk assessment tool using Morse Fall Scale Test Try draft protocol with one nurse, one patient and one doctor Test new fall assessment tool with one nurse and one patient Educate staff on new. Get approval for policy Try new. With one or two Test draft policy 14

15 Let s Try it Together How can these test descriptions be strengthened? Monitor all heart failure patients that are admitted Get antibiotics started upon departure from the sending unit Adapt an OB specific assessment screening tool based on ACOG guidelines

16 #7 Plan the details Know Who is THE go to person for this test and who are the people in the test? When (DAY or FEW DAYS) will this test be done and when you will study what happened? Where (SPECIFICALLY) will this test be done? What you are testing?

17 Examples Plan is not clear Responsible person Nursing personnel Better Responsible person Specific name of person responsible for carrying out the test Specific name of individuals who will carry out the test

18 #6 Know what you want to learn If you are testing a new assessment what would you want to learn from the person doing the test? How long it took to complete? Ease of difficulty? What suggestions they have?

19 SSI Example Not for a test SCIP compliance 100% For a test Was medication started on departure to OR? What if any barriers came up? What suggestions do you have?

20 # 5 Clarify timeline When will the actual test occur? When will you study the findings from the test?

21 Example Not Very Strong Do the test - As soon as possible after discharge Review the results of the test Next staff meeting Much Better Do the test - Within 72 hours of 5/20/13 discharges Huddle to review the results of the test 5/24/13 21

22 # 4 Link prediction to measure Prediction Risk assessment will take less than 10 minutes to complete ABX will be started on time PCPs will appreciate post dc call Measure How long did it take to complete risk assessment? Were ABX started on time? Did PCP appreciate call?

23 What would you ask? Testing an insertion check list for a Foley catheter Testing a skin assessment Testing the use of a fall injury prevention protocol Testing educational materials

24 # 3 What are you testing? Describe what you are going to TEST not the outline for your entire program

25 Examples Program Approval by Multidisciplinary Committee Approval by MS Committee Form developed for EHR Policy Completed and approved Training of Unit Staff Launch Risk Assessment Test Test OB specific VTE screening tool with one mom, one physician and one nurse

26 #2 Connect Tests Use findings from first test to make modifications or if none test more broadly

27 Example 1 st PDSA - Check list tested with one nurse - OK 2 nd PDSA Check list tested with another nurse. Couldn t find check list Change color 3 rd PDSA New Green check list tested with 2 more nurses - OK

28 #1 Go slowly to go quickly For lasting change you need to involve the care providers

29 Examples Not tests? Need for change Team of mostly managers Managers approve the change Write a policy Train with in-service or memo Expect the change to happen How about this one? Need for change Convene a team mostly frontline care givers Team plans tests of change (PSDA) cycles Care givers conduct PDSA cycles Implement only after testing Monitor

30

31

32 Now what? Work with your Network Facilitators Refine/complete your gap analysis and PDSA plan Conduct your test Adopt Adapt Abandon Participate in the next webinar

33 Monitoring your progress -webinar Date 6/5/13 Time 10:30 11:30 Topics Covered Why measure? What are the components of a measure? understanding numerators and denominators Outcome vs process measures How much data do you need? Data display Making a run chart Other ways to display data days in between 33

34 Monitoring your progress Skill Building Skill building due to NF by 6/12/13 Finalize a measurement plan for their initiative(s) Send to network facilitator Discuss the amount of data they need to collect and how this will occur Develop a run chart Send to network facilitator Skill building post webinar call 6/26/13, 10:30-11:30 34

35 Any more questions?

36