Performance Improvement

Begins with

Opportunity

Every new day brings new opportunities

To recognize opportunity is the difference between success and failure

HOW ARE OPPORTUNITIES TO IMPROVE PERFORMANCE IDENTIFIED?

•Patient Satisfaction Surveys

•Staff input through event reports and staff meetings

•Chart Review

•Core Measures

•Peer Review

•Patient Safety Initiatives

•Meeting accrediting agencies requirements

Hospital Leadership determines the priorities based on feedback from patients, staff and physicians. This is documented in the annual Performance Improvement Initiative.

The priorities are reviewed and approved by the Performance Improvement Committee, the Medical Executive Committee, and the Health System Board.

What are the priorities?

Priority Statement:

“Our focus is providing the highest quality of clinical care, patient and employee satisfaction, and financial strength.”

Performance Priorities :

•Core Measurement Performance

•Accreditation – Joint Commission, CARF (rehab) & others!

•Patient Safety Goal Performance

•Financial Performance

•Patient and employee satisfaction

Plan the improvement and continued data collection (step 1)

Do the improvement, data collection, and analysis (step 2)

Check and study the results (step 3)

Act to hold the gain an to continue to improve the process (step 4)

Problem Solving - PI Story - PDCA

PLAN: The first step

1. What do we want to improve?

2. Gather baseline information – how are we doing right now?

3. Get the right people together to discuss the idea.

4. Decide on the first steps in improving this particular process.

1. Implement the plan for change, usually one one step at a time.

2. Is everyone informed who needs to know about the new process? Include physicians, staff and support people.

3. How are we going to know whether the plan is being implemented fully and whether it is making a difference? Decide on measures of success.

DO: The next step

Data

Information

CHECK - translate the data into information

1. How are we doing?

2. What can we do better?

3. Can we identify root causes?

ACT –maintain the gains!

1. How can we keep the improvement going?

2. Do we need to change anything in our original plans? If so, let’s get it done!

The PDCA cycle (Plan, Do, Check, Act) is a natural for healthcare…

In every work area, staff and physicians are focused on taking care of patients in safe, excellent ways. When you have an idea for improvement, take it to your manager or submit an event report. Take action to help us all improve!

Is Performance Improvement the same as Research?

• Key point: if the project involves randomization of patients, or if the aim of the project is to seek knowledge that can be generalized beyond our health system, then it might be research.

• Contacts: Diane Sheppard with the IRB and Cindy McCalla, Hospital Research Compliance Coordinator.

Opportunity to Improve: To decrease the number of foley cath infections. This is important because the infections cause an increase in cost, length of stay, reduced patient satisfaction and is also a patient safety issue. (need, objectives)

We will measure all patients on the unit for a 6 month period of time. The goal is to decrease foley cath infections by 10%. (desired results, population involved)

PCDA Cycle:

P (Plan) - Insure that the patient meets the criteria for a foley. Insure that proper sterile technique is followed.

D (Do) - Implement the plan. Check to see if the patient meets criteria and validate staff sterile technique

C (Check) - What is the number of infections and did the number of days the patient has a foley decrease.

A (Act) - If infections were decreased by 10% - continue to plan. If not, go back to the drawing board.

Another Example

The PDCA cycle at work!