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  • 1.  A multidisciplinary, systematic quality assessmentand performance improvement frameworkOur Goal: To improve patient outcomes, andreduce the risks associated with patient safety in amanner that embraces the mission of the hospital.
  • 2. “Problems” are usuallydue to PROCESSfailures, not PEOPLEfailures!
  • 3.  Identify an “opportunity” (problem) Figure Out what happened (theprocess) Explore why the process failed Identify possible improvements;implement those Monitor the improvements
  • 4.  Antibiotic selection Preop dosing time Postop dosing Therapy to prevent VTE (blood clots) Temperature maintenance Glucose control Patient Experience: Nurse communication, Roomcleanliness, info about medications, etc. National Healthcare Safety Network: hospital-associated infections, employee flu vaccine rates
  • 5. 0102030405060708090100DEC JAN FEB809399224491AllPressGAneyPercentagePress Ganey: Extent to which nurses checked ID by DOSInpatientAS
  • 6. There were 9 patient falls in 2010. A team beganworking to reduce the number of falls, researchedbest practices, and 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)
  • 7.  Statistics are posted on HospitalCompare website. Lots of media attention about hospital errors. Many states have laws requiring public reporting oferrors. Poor performance results in decreasedreimbursement. MOST IMPORTANT: Stellar patientoutcomes, doing the right thing the right way forevery patient.
  • 8.  This is the end of presentation. Click on the blueQuiz button next.

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