2016 Quality Management. Sandra Webb BSN RN CIC

Transcription

1 2016 Quality Management Sandra Webb BSN RN CIC

2 Quality Management Department Functions: Core Measures Infection Prevention Patient Safety Officer Performance Improvement

3 Performance Improvement Data is collected, aggregated and analyzed Used to drive decision-making Focus is on processes/systems not people Continuing to evaluate outcomes

4 PDCA Plan Do Check Act

5 Methodology Plan: Identify the root cause Generate possible causes Gather more data Focus on the causes Generate and choose the solution

6 Methodology Do: Develop a plan of action Implement the plan Monitor closely for deviation Collect data on the changes

7 Methodology Check: Analyze the data and check the results Draw conclusions Does the process need fine-tuned? Did it fail? Did it work? What are the costs/benefits? How can the transition be accomplished?

8 Methodology Act: Standardize the change: Flow chart the revised process Revise standards, policies/procedures Communicate to everyone involved Document the project

9 What can you do? Look for ways to improve processes/systems Report ideas/opportunities to Supervisor/Director Serve on teams Assist with collecting data

10 National Patient Safety Goals 2016 Goal 1: Improve the accuracy of patient identification. Patient Identification: Use at least two patient identifiers (name and date of birth) when providing care, treatment or services. The patient s room number or physical location is not to be used as an identifier. Label containers that are used for blood and other specimens in the presence of the patient.

11 Patient Identification Before initiating a blood or blood component transfusion: Match the blood or blood component to the order. Match the patient to the blood or blood component. Use a two-person verification process.

12 Communication Among Caregivers Goal 2: Improve the effectiveness of communication among caregivers. Report critical results of tests and diagnostic procedures on a timely basis. Goal: Report critical results/values within 30 minutes of notification and utilize the read back and verified process. Exception: The telemetry monitor tech will notify the nurse of critical telemetry values. If patient contact does not occur within 2 minutes, the telemetry monitor tech will implement/call a Code Blue.

13 Medication Safety Goal 3: Improve the safety of using medications. Label all medications, medication containers, and other solutions on and off the sterile field in peri-operative and other procedural settings. Note: Medication containers include syringes, medicine cups, and basins.

14 Medication Safety Reduce the likelihood of patient harm associated with the use of anticoagulation therapy. Use approved anticoagulant protocols/power plans Heparin, Lovenox (therapeutic), Coumadin Provide education to the patient/family

15 Medication Safety Maintain and communicate accurate patient medication information. Obtain a complete medication list including medications that are taken as needed (prn), over the counter drugs and herbal supplements. The medication list will be re-evaluated when the patient transfers from one level of care to another. The nurse will review the medication discharge instructions with the patient/family.

16 Medication Safety Emergency Department, Radiology Contrast Testing, Ambulatory Surgery & Office Setting Obtain a list of current medications At discharge, if the physician writes a prescription, provide the patient with instructions regarding the new medications If the provider modifies/changes a long term medication, the entire list of medications will be reviewed with the patient.

17 Clinical Alarm Systems Goal 6: Reduce the harm associated with clinical alarm systems. Educate staff and licensed independent practitioners about the purpose and proper operation of alarm systems for which they are responsible.

18 Healthcare Associated Infections (HAI) Goal 7: Reduce the risk of healthcare associated infections. Hand Hygiene MDRO CA-UTI CLA-BSI Surgical Site Infections Education is provided to appropriate staff

19 Suicide Prevention Goal 15: The organization identifies safety risks inherent in its patient population. Conduct a risk assessment that identifies specific patient characteristics and environmental features that may increase or decrease the risk for suicide Address the patient s immediate safety needs and most appropriate setting for treatment When a patient at risk for suicide leaves the care of the hospital, provide suicide prevention information (such as crisis hotline) to the patient and his or her family

20 Universal Protocol Conduct a pre-procedure verification process. Implement a pre-procedure process to verify the correct procedure, for the correct patient, at the correct site. Note: The patient is involved in the verification process when possible. Identify the items that must be available for the procedure and use a standardized list to verify their availability. At a minimum, these items include the following: Relevant documentation (for example, history and physical, signed procedure consent form, nursing assessment, and pre-anesthesia assessment)

21 Universal Protocol Labeled diagnostic and radiology test results (for example, radiology images and scans, or pathology and biopsy reports) that are properly displayed Any required blood products, implants, devices and/or special equipment for the procedure Match the items that are to be available in the procedure area to the patient.

22 Universal Protocol Marek the procedure site Mark the procedure site before the procedure is performed and, if possible, with the patient involved. The physician performing the procedure will mark the surgical site. A written, alternative process is in place for patients who refuse site marking or when it is technically or anatomically impossible or impractical to mark the site (for example, mucosal surfaces or perineum).

23 Universal Protocol A time-out is performed before the procedure. Conduct a time-out immediately before starting the invasive procedure or making the incision. During the time-out, the team members agree, at a minimum, on the following: Correct patient identity The correct site The procedure to be done

24 Quality Concern Reporting The hospital notifies the public it serves about how to contact hospital management or The Joint Commission to report concerns about patient safety and quality of care via the: Internet Guest Directory (Admission Booklet) Signage throughout the hospitalby Calling (800) or via at

25 Quality Management Questions? Please call Sandra Webb at extension 2124