2016 Quality Management - Gordon Hospital Quality Management 2016.… · Quality Management...
Transcript of 2016 Quality Management - Gordon Hospital Quality Management 2016.… · Quality Management...
Quality Management Department
Functions:
Core Measures
Infection Prevention
Patient Safety Officer
Performance Improvement
Performance Improvement
Data is collected, aggregated and
analyzed
Used to drive decision-making
Focus is on processes/systems not
people
Continuing to evaluate outcomes
Methodology
Plan:
Identify the root cause
Generate possible causes
Gather more data
Focus on the causes
Generate and choose the solution
Methodology
Do:
Develop a plan of action
Implement the plan
Monitor closely for deviation
Collect data on the changes
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?
Methodology
Act:
Standardize the change:
– Flow chart the revised process
– Revise standards, policies/procedures
– Communicate to everyone involved
– Document the project
What can you do?
Look for ways to improve
processes/systems
Report ideas/opportunities to
Supervisor/Director
Serve on teams
Assist with collecting data
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.
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.
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.
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.
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
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.
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.
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.
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
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
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)
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.
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).
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
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) 994-6640 or via e-mail at