A multidisciplinary, systematic quality assessment and performance improvement framework

Goal: to improve patient outcomes, reduce the risks associated with patient safety in a manner that embraces the mission of the hospital.

“Problems” are usually due to PROCESS

failures, not PEOPLE failures!

Identify an “opportunity” (problem)

Figure out what happened (the process)

Explore why the process failed Identify possible improvements;

implement those Monitor the improvements

Antibiotic selection Preop dosing time Postop dosing Therapy to prevent VTE (blood clots) Temperature maintenance Glucose control Patient Experience: Nurse communication,

Room cleanliness, info about medications, etc. National Healthcare Safety Network: hospital-

associated infections, employee flu vaccine rates

There were 9 patient falls in 2010. A team began working to reduce the number of falls, research best practices, implemented improvements.

Results: 2010 patient falls = 9 (79 per 100,000 patient days) 2011 patient falls = 5 (44 per 100,000 patient days) 2012 patient falls = 1 (9 per 100,000 patient days) 2013 patient falls = 4 (38 per 100,000 patient days)The improvement has not been sustained;

therefore this project will be revisited

Statistics are posted on HospitalCompare website

Lots of media attention about hospital errors

Many states have laws requiring public reporting of errors

Poor performance results in decreased reimbursement

MOST IMPORTANT: Stellar patient outcomes, doing the right thing the right way for every patient

End of presentation.