qpi investigators

QPIINVESTIGATORS

QPIINVESTIGATORS

MissionTo provide exceptional care to every patient every day with a spirit of warmth, friendliness and personal pride.

Values - I.C.A.R.E.• Integrity • Compassion • Accountability • Respect • Excellence

VisionExceptional Care, Customer Loyalty, Financial Strength

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QPIINVESTIGATORS

Texas Award for Performance Excellence

Same criteria and process as the Malcolm Baldridge National Quality Award! Awarded to organizations that serve as role models for quality, customer satisfaction, and performance excellence in Texas

Texas Health Care Quality Improvement Award

Awarded by TMF® Health Quality Institute, the Medicare Quality Improvement Organization for Texas

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QPIINVESTIGATORS

Interviewee: Shannon Kane-Reinhardt RN, BSN, Quality Manager(St David’s Round Rock Medical Center)

Interviewers:• Lombe Chitundu• Jean Cusick• Yolanda Johnson• Vicki McGinnis• Sharon Royall-Murphy

Interview Date: March 30, 2010

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QPIINVESTIGATORS

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Step 5: Perform Ongoing Monitoring

Step 4: Identify Improvement Opportunity

Step 3: Analyze and Compare Data

Step 2: Measure Performance

Step 1: Identify Performance Measures

5 Steps in an Organizational PI Model

QPIINVESTIGATORS

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Core Measures SCIP

Antibiotic Received Within One Hour Prior to Surgical Incision (SCIP-Inf-1a)

QPIINVESTIGATORS

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SCIP-Inf-1a

SurgicalPatients

Reduced risk of post-

operative infections

QPIINVESTIGATORS

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Create confidential spreadsheet:• Anesthesia Start Date • Admission Date• Antibiotic Administration Route• Antibiotic Name • Antibiotic Received • Birth date • Clinical Trial • Discharge Date • ICD-9-CM Principal Diagnosis Code• ICD-9-CM Principal Procedure Code • Infection Prior to Anesthesia• Laparoscope• Oral Antibiotics• Other Surgeries

Areas Studied and Data Collection

QPIINVESTIGATORS

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Measurement Ratio

Number of surgical patients with antibiotics initiated within one hour prior to surgical incision

All selected surgical patients with no evidence of prior infection.

QPIINVESTIGATORS

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Data added to spreadsheet:

Name of surgeonCase identifierDate of surgeryReason for outlier

(why not started on time)

Responsibility (who started antibiotic)

Analyze all outliers

OperatingRoom

Timeout Checklists

QPIINVESTIGATORS

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SCIP Champions

Directors

FrontlineManagers

Staff

Multidisciplinary PI Team

QPIINVESTIGATORS

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Board of Directors

CMO

Quality Executive

Committee

Organization

WideCommunic

ation via Report

Card

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PI Cycle

Computer

SystemChange

s

OR Chartin

g ModuleRollout

PI ProcessIssues

(Outliers)

Process change(s) in other areas

Forces driving ongoing improvement efforts

QPIINVESTIGATORS

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The hospital indicated that the data submitted for this measure were based on a sample of cases.

HCAHPS Customer Satisfaction Survey