Department of Quality and Regulatory AffairsBarbara Ann Karmanos Cancer Center 2009

The Karmanos Cancer Center Quality, Patient Safety,

and Performance Improvement

2009

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Quality

• Karmanos Cancer Center (KCC) is committed to delivering the highest quality care possible

• Quality Care at KCC is achieved through: – Continuous Process Improvement (PI)– Promotion of patient safety– Prevention of healthcare/ system errors – Promotion of a state of “regulatory readiness”

(See the Regulatory Readiness Net Learning Module)

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What Is Performance Improvement?

• Performance Improvement:– Utilizes an interdisciplinary approach to improve

quality of care.– Is focused on processes, not people– Goals are:

• To involve the whole organization• Improve work processes• Make patient care safe

– Foundation of KCC quality is the “PDCA” Cycle of continuous improvement

-Plan -Do -Check -Act

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Performance Improvement Model

The Plan-Do-Check-Act cycle was developed by W. Edwards Deming (Deming WE. The New Economics for Industry, Government, Education.)

Plan: •What do we want to change?•Who will carry out the cycle?•Plan for data collection

Do:•Carry out the plan•Collect, record, analyze data•Document problems

Check:•What did we learn?•Did the results support our change?•Summarize lessons learned

Act:•What changes need to be made?•Do we adapt, adopt, abandon?•What is next….. plan!

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PDCA – Plan

• Plan for the change – What are the goals we want to achieve?

• Start by asking a question– What needs to change or what needs to improve?

• Set goals that are measureable

• Goals are determined by– Customer expectations

– Standards of care in order to improve patient outcomes

– Regulatory Requirements

– National Patient Safety Goals

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PDCA – Do

• Do the change or carry out the plan• Collect, record, and analyze the data• Measure goals & outcomes • Data collection & measurement will tell us:

– If we are doing the right thing– If we are doing the right thing well

– How we perform compared to accepted standards/goals.

– How we perform compared to other hospitals and current literature for best practices.

• Document any problems that may arise

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PDCA – Check

• Check to see if the change is successful:– How well are we meeting goals / outcomes?

– What is causing us to meet or not meet them?

– Where should we focus our efforts to improve our processes?

• What did we learn?

• Summarize the lessons learned.

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PDCA – Act

• Act by spreading the change to other areas if the results were favorable. – This means actually changing how you do things.

– Work to maintain and improve good results

• If the change resulted in results that were unfavorable:– Identify what needs to be adjusted to improve the outcome.– Feed information back into the PDCA cycle

• Continue collecting data – This will show you if the “new” procedure is working.

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Performance Improvement“How can you help?”

• Find your own department’s PI bulletin board

• Identify your department’s PI initiatives

• What are your department’s PI results?

• Are they improving?

• How can you help?

• Participate!

• Improvement takes teamwork, teamwork, teamwork

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Patient Safety

• What is patient safety?– Prevention of health care errors– Prevention of injury or harm– Quality patient care

• How can we do this?– By creating a “climate” of safety throughout KCC– By identifying and reporting errors, near misses, and

hazardous conditions through the web based incident management system

– By acting quickly and appropriately when an incident occurs.

– By integrating safety practices into daily work: e.g.• Hand hygiene Involving patients in their own care

• Two patient identifiers Handoff communication

• Time Out Critical test values/results

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Promoting and Maintaining a Climate of Safety

• Leadership will:– Encourage identification and reporting of healthcare

errors or potential harm (incidents) to patients, visitors and employees

– Promote a fair and just environment for reporting and follow-up of healthcare errors.

– Support staff who have been involved in healthcare errors.

– Ensure that patients / families are informed about the results of care, including unexpected outcomes and healthcare errors by the attending physician.

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• Staff will:– Take action to provide necessary care & protect patients if an

unsafe event or healthcare error occurs.

– Report all errors, near misses & hazardous conditions in a timely manner.

– Promote prevention of unsafe events• Stay skilled- complete yearly educational competencies.

• Participate in process improvement efforts and interdepartmental, multidisciplinary improvement teams.

• Share ideas on improving safety with your supervisor.

• SPEAK UP if you see an opportunity to avoid an unsafe practice or violation of policy

• Be familiar with KCC and departmental policies and procedures

Promoting and Maintaining a Climate of Safety

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• Everyone Will Encourage Patients to:– Participate in their own care

– Ask questions

– Tell us how we can improve

Promoting and Maintaining a Climate of Safety

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Quality & Safety Reporting

• What to report:– Errors:

• An unintended act, of either commission or omission• An act that does not achieve its intended outcome.

– Near Miss • Any process variation (error) which did not reach the

patient, employee, or visitor, but could have resulted in a serious adverse outcome.

• Near miss reporting provides KCC with the opportunity to correct processes which could potentially result in future errors.

– Hazardous Condition• Any set of circumstances (excluding the disease or

condition for which the patient is being treated), which significantly increases the likelihood of a serious adverse outcome.

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• How to report:– Tell your supervisor

– Follow KCC’s Incident Reporting Policy (ADM 007)

– Use the web-based incident management system

• Most importantly – Be willing to report healthcare errors or near miss

situations– Remember that the purpose of reporting errors

and near miss events is to promote changes in process that will lead to improved safety for all

Quality & Safety Reporting

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Quality, Patient Safety, and Process Improvement Summary

• KCC is committed to delivering the highest quality care possible

• Performance Improvement is an ongoing effort to find new and better ways of doing things, involves the whole organization and encourages participation by everyone

• KCC’s model for Performance Improvement is Plan-Do-Check-Act

• Patient Safety means we constantly look for ways to prevent healthcare errors, prevent patient harm, and to provide quality care.

• All KCC employees can improve patient safety by identifying and timely reporting of health care errors and near miss events

• Promote prevention of unsafe events by speaking up, participating in hospital and departmental Process Improvement initiatives, maintaining yearly competencies, and helping to create a culture of safety.

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Summary

We hope this Computer Based Learning course has been both informative and helpful. Feel free to review this course until you are confident about your knowledge of the material presented. Click the Take Test button on the left side when you are ready to complete the requirements for this course. Click on the My Records button to return to your CBL Courses to Complete list. Click the Exit button on the left to close the Student Interface.