This document outlines a multidisciplinary framework for improving patient outcomes and safety. The goal is to embrace the hospital's mission while reducing risks. It describes identifying problems as process failures, exploring why processes failed, implementing improvements, and monitoring results. Examples of quality metrics that could be assessed are listed, such as antibiotic selection and falls prevention. Data on patient falls from 2010 to 2013 is provided, showing improvements were made but not sustained. Statistics are publicly reported and tied to reimbursement, so the most important thing is stellar patient outcomes.

2. 
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.

3. “Problems” are usually
due to PROCESS
failures, not PEOPLE
failures!

4. 
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Identify an “opportunity” (problem)
Figure out what happened (the
process)
Explore why the process failed
Identify possible improvements;
implement those
Monitor the improvements

5. 
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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

7. 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

8. 
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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

9. 
End of presentation.

10. 
End of presentation.