

A multidisciplinary, systematic quality
assessment and performance
improvement framework

Goal: to improve patient outc...
“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
Ident...









Antibiotic selection
Preop dosing time
Postop dosing
Therapy to prevent VTE (blood clots)
Temperature mai...
There were 9 patient falls in 2010. A team began
working to reduce the number of falls, research
best practices, implement...







Statistics are posted on HospitalCompare
website
Lots of media attention about hospital errors
Many states hav...
Quality Management Education
Quality Management Education
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Quality Management Education

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Quality Management Education

  1. 1.  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.
  2. 2. “Problems” are usually due to PROCESS failures, not PEOPLE failures!
  3. 3.      Identify an “opportunity” (problem) Figure out what happened (the process) Explore why the process failed Identify possible improvements; implement those Monitor the improvements
  4. 4.         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: hospitalassociated infections, employee flu vaccine rates
  5. 5. 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
  6. 6.      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

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