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.
“Problems” are usuallydue to PROCESSfailures, not PEOPLEfailures!
Identify an “opportunity” (problem) Figure Out what happened (theprocess) 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, Roomcleanliness, info about medications, etc. National Healthcare Safety Network: hospital-associated infections, employee flu vaccine rates
0102030405060708090100DEC JAN FEB809399224491AllPressGAneyPercentagePress Ganey: Extent to which nurses checked ID by DOSInpatientAS
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)
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.
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