1. The World ofThe World of
QUALITYQUALITY
Lee Scott RN, BSN, CPHQLee Scott RN, BSN, CPHQ
Director of QualityDirector of Quality
Saint Cloud Regional Medical CenterSaint Cloud Regional Medical Center

2. • What is QualityWhat is Quality
• Performance ImprovementPerformance Improvement
• Regulatory ComplianceRegulatory Compliance
• National Patient Safety GoalsNational Patient Safety Goals
• Public ReportingPublic Reporting
The Quality UmbrellaThe Quality Umbrella

3. Total Quality Management
• Definition: TQMis a management philosophy that enhances
and benefits ourorganization and all people associated with it
by using processes that continuously improve the quality of all
products, services, and outcomes.
• This results in:
– INCREASEDPATIENT SATISFACTION
– INCREASEDPRODUCTIVITY
– INCREASEDPROFITS
– DECREASEDCOSTS
– INCREASEDMARKET SHARE

4. Performance ImprovementPerformance Improvement
•PI looks at our systems and processes and finds
ways to improve them.
- Quality Planning- Who are our customers
and what are our service lines?
-Quality Control- How do we measure our
processes and outcomes (data analysis)
-Quality Improvement- How do we improve
our existing processes and outcomes?
HOW DO WE DO THIS?

5. PDCA- OUR QUALITY METHODOLOGYPDCA- OUR QUALITY METHODOLOGY

6. Analyze the ProblemAnalyze the Problem
Identify a problem
Map the process
Gather & analyze data
Identify possible causes
Plan the improvement
PlanPlan

7. Develop the solutionDevelop the solution
Generate potential solutions
Select a solution
Plan the solution
Implement the solutionImplement the solution
DoDo

8. Evaluate the resultsEvaluate the results
Gather & analyze data on the
solution
Achieved the desired goal?
Yes – go to the next step, ACT
No – go back to step 1, Plan
CheckCheck

9. Standardize the solution
Plan ongoing monitoring
Continue to look for
improvements to refine
ActAct

10. == Continuous Cycle ofContinuous Cycle of
improvementimprovement

11. REGULATORY COMPLIANCEREGULATORY COMPLIANCE
WHO MEASURES SAINT CLOUD REGIONAL MEDICAL CENTER?WHO MEASURES SAINT CLOUD REGIONAL MEDICAL CENTER?
• Joint Commission
• CMS
• ACHA
• OSHA
• CUSTOMER

12. • Non-profit accreditation organization
• Primary hospital accreditation organization
• Accredit > 15,000 facilities in the US
• Develop standards of care
• Performon site surveys every 3 years
• Surveys are unannounced
• Accreditation participation is voluntary
Joint CommissionJoint Commission

13. National Patient SafetyNational Patient Safety
GoalsGoals• Goals that promote specific improvements
in patient safety
• Based on: NEVEREVENTS (sentinel)
– Actual incidents
– Solutions based on current research
• 100% Compliance is required
– Success orfailure publicly reported
– Safety is EVERYONE’S BUSINESS

14. Patient IdentificationPatient Identification
Goal 1: Improve the accuracy of patient identification.
- Patient’s first and last name
- Patient’s date of birth

15. Staff and employees may report to Joint Commission:
- Concerns about safety
- Concerns about quality of care
Hospital will take no disciplinary action!!

16. The Joint Commission website
complaint@jointcommission.org
1-800-994-6610
The Joint Commission
One Renaissance Blvd.
Oakbrook Terrace, IL 60181

17. PublicPublic
ReportingReporting

18. GOALS
• Increase public awareness
• Inform the public of quality activities
• Promote public accountability
Public ReportingPublic Reporting

19. Example: CORE MEASURES
• Pneumonia Care
• Heart Attack Care
• Heart Failure Care
• Surgical Infection Prophylaxis
• Patient Perception
Public ReportingPublic Reporting
St Cloud RegionalSt Cloud Regional
Core MeasuresCore Measures

21. • Required by CMS
• Standardized survey (HCAHPS)
• Measures patient’s perception of care
• Publicly reported
• 27 questions
Patient PerceptionPatient Perception

22. Patient PerceptionPatient Perception
• QUIETNESS OF UNIT AT NIGHT!!
• Roomand bathroomkept clean
• How well nurse listened to patient
• Adequate bathroomhelp
BIGGEST COMPLAINTS

24. WHAT IS
QUALITY?
PEOPLE, PROCESS,
OUTCOMES