1) A healthcare organization was analyzing sources of inefficiency for nurses, finding that 25% of their time was spent "hunting and gathering" or looking for supplies, equipment, information, and assistance from other staff. 2) Further analysis showed that the top things nurses spent time hunting for were medications from the Pyxis machine (8% of hunting time), floor stock equipment like blood pressure cuffs (5.4%), and supplies (3.8%). 3) A "5 whys" analysis was used to determine the root causes for time spent hunting for floor stock electronic equipment, finding issues like equipment not being returned to the proper storage location or being hoarded by other staff for future patients.

1. Richard Skiff – Synopses of Healthcare Projects
SYNOPSES OF
SELECTED
PROJECTS IN
HEALTHCARE

2. Richard Skiff – Synopses of Healthcare Projects
STEPS TO IMPROVEMENT
• Acknowledge that there
are problems
Easy
• Understand the cause(s)
of the problem
Hard
• Solve the problem
Harder
• Sustain the solution
The real challenge!

3. Richard Skiff – Synopses of Healthcare Projects
WHO IS THE CUSTOMER?
The customer is anyone whose
evaluation of your services has
an impact on your ability to
continue to deliver those
services.

4. Richard Skiff – Synopses of Healthcare Projects
WHAT IS A PROBLEM?
A Problem (or opportunity)
is Something
that is Different
than what it
Should Be.

5. Richard Skiff – Synopses of Healthcare Projects
EMERGENCY DEPARTMENT IMPROVEMENT
ED PROBLEM
AVERAGE LENGTH
OF STAY
© 2013
5

6. Richard Skiff – Synopses of Healthcare Projects
Background Information
• Southeastern US Hospital
• 81 Bed Emergency Department
–
–
–
–
–
26 Bed Major Unit (ESI levels 1-2)
32 Bed Minor Unit(s) (ESI levels 3-5)
12 Bed Major/Minor Transition
10 Bed Behavioral Health Unit
1 SANE room.
• 100,000 visits per year
6

7. Richard Skiff – Synopsis of Healthcare Projects
Improve Key ED Metrics
Average LOS
Door to provider
Average Length of Stay
Minutes
360
300
240
Better
180
120
Jul
Aug Sep Oct
Nov Dec
Jan Feb Mar Apr May
Jun
Average Length of Stay
LWBS
Overall Quality of Care % Excellent
Overall Quality % Exc
% Excellent
100%
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
80%
60%
40%
20%
Better
0%
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
Overall Quality % Exc

8. Richard Skiff – Synopsis of Healthcare Projects
Phase 1: Minor
Treatment Zones
36
37
PA
38
“Yellow Zone”
54
53
52
Green
30
24 Rooms
Waiting
Room
31
32
33
Open 24 hours Lab
Triage and
RR
Soiled Linen
Staffing Varies
Throughout Day
39
55
Discharge
Eyes
“Green” Zone
Nurse 3 Rooms
RR
56
57
29
34
40
35
Supply
11
Stationam to 11 pm
Provider 1 MUS
1 Tech,
Area RR
28
41
Nurse’s
Pyxis
1 PA, 2 RN,
50
51
Station
43
44
Prep
RR
and
58
42
Pyxis
Radiology
59
Holding
“Yellow Intake”
3 Rooms
3 pm to 11 pm
49
48
47
46
45
EMS
1 MD, 2 RN, 1 Tech
Suture Suture Suture
Office

9. Richard Skiff – Synopses of Healthcare Projects
Expand the demonstrated effectiveness of Phase I
FMC ED: Intake Average Length of Stay (ALOS)
300
Baseline: Mean = 240 min
270
Savings of 70
minutes per patient
Savings of 70
by going through
minutes per
Intake Process vs.
patient
Yellow Zone
Trial: Mean = 155 min
240
210
180
150
120
90
Se
p09
O
ct
-0
9
No
v09
De
c09
Ja
n10
Fe
b10
M
ar
-1
0
Ap
r- 1
0
M
ay
-1
0
Ju
n10
Ju
l-1
0
Ap
r- 0
9
M
ay
-0
9
Ju
n09
Ju
l-0
9
Au
g09
60
O
ct
-0
8
No
v08
De
c08
Ja
n09
Fe
b09
M
ar
-0
9
Intake ALOS (min)
Intake Implemented: Mean = 170 min

10. Richard Skiff – Synopsis of Healthcare Projects
“Supertrack”
Phase 2
54
53
52
30
Waiting
Room
31
37
PA
3 Rooms; 1 pm to
10 pm
Green
36
38
32
33
Triage and Lab
Team Intake 1
RR
4 Rooms
Soiled Linen
39
11 am to 11 pm
55
Nurse
RR
56
57
29
34
41
PACS,
Pyxis
50
51
Secretary
43
44
Prep
58
42
RR
and
59
40
35
Supply
Station Intake 2
Team
4 Rooms
Provider
3 pm RR
Area to 11 pm
28
Eyes
Pyxis
Radiology
“Yellow Zone”
15 Rooms
Open 24 hours
Staffing Varies
Throughout Day
49
48
47
46
45
Suture Suture Suture
EMS
Office
Close 1
assignment
to reallocate
staff for
expanded
Team Intake

11. Richard Skiff – Synopses of Healthcare Projects
Phase 2 Improvements
• By focusing a provider (PA or MD), 2 Nurses, and a tech to a
“pod” (a set of treatment rooms in close proximity), we
found a significant improvement in the ability to focus on
patients and patient flow, and therefore reducing the
“Average Length of Stay” and “Left Without Being Seen”
rates.
• We incrementally expanded this concept throughout the
minor treatment zone, making adjustments as needed in
each phase.
• The success was so significant that this process was
expanded to include the entire minor treatment zone.
11

12. Richard Skiff – Synopsis of Healthcare Projects
Phase 3
53
52
Green
No more Supertrack –
incorporated into intake pods
30
Waiting
Triage and Lab
32
31
1 pm – 10 pm PA
10 pm – 6 am PA
55
Nurse
56
57
RR
Pod A Open 1:00 pm to 6:00 am
28
RR
Flex
Room
50
34
Supply
PACS,
Soiled Linen
39
35
Flex
Room
41
11 am – 3 pm PA
43
44
Prep
42
Flex
RR
Room
Pod C Open 11:00 am
to 11:00 pm
and
OB?
Pod D Open 24/7
48
7 am – 4 pm PA
4 pm – 12 am PA
11 pm – 7 am PA
1 hr overlap 11pm to 12 am
40
3 pm – 11 pm MD
51
Flex
Room
49
There is a “Float” PA from 3:00
pm to 8:00 pm
RR
Pod B Open 9:00 am to 11:00 pm
Pyxis
Radiology
3 pm – 11 pm PA
MUS (2)
58
59
33
9 am – 5 pm PA
29
Pyxis
Area
D/C; Flex
Eyes
Station
Provider
38
2 hr overlap 3 pm to 5 pm
Room
Intake Holding: Open 24/7
37
Shared by all pods
D/C; Flex
D/C; Flex
PA
Main Lobby / Waiting Room
54
36
47
46
45
EMS
Shared by all pods
Suture Suture Suture
Office

13. Richard Skiff – Synopses of Healthcare Projects
Pre-Implementation Simulation
• Patient data from a high volume day was analyzed
to “simulate” running all of the Minor Zone as an
Intake Process:
– Total ED Patients
– Minor Zone Patients
– BH Patients Arriving
315
209
23
• Note: No patient treatment times were shortened.
Efficiencies were gained in through improving
patient flow. Patient names are fictitious.

14. Richard Skiff – Synopses of Healthcare Projects
Simulation Results – Minor Zone
Actual
Simulation
Savings
Average Length of Stay
(BH Patients included)
373 min
326 min
46 min
Average Length of Stay
(BH Patients excluded)
241 min
190 min
51 min
Average Arrival to Room
91 min
49 min
42 min
Average Time in Treatment Room N/A
52 min
Maximum # of Patients in Main
Lobby Waiting Room
About 24
14
Left Without Being Seen
9 patients
5 patients
(estimated)

15. From Triage
Kirksey 28
Room
55
Nurse
RR
Station
56
Pyxis
Helms
Provider
57
Area
Weathers
Boyd
Andrade
Triage and Lab
Supply
PACS,
38
Harris
Gillespie
RR
Fox
Waiting
Baker 119
Jefferson
Hendrick
Actual Current Process
32
33
30
31
At 16:00, 18 patients
in Waiting Room with
average wait time of
28
29
34
35
58 minutes to that
point 44 43
50
51
Buford
Green
37
Alabaster
CLOSED
King 29
PA
Gentry
52
Blake 28
36
Spinks
Beck 47
Jones 62
Sinks
Bell 39
Burns
Dillard
Lester
Bean 69
Soiled Linen
39
Eyes
40
Stewart
41
Secretary
RR
Prep
58
Peters
Jennings 98
Beeson 41
Archibald
Bennett 36
53
Bass 104
Hobson 138
Lamar 21
Minton
Kyles 26
Daniels
Main Waiting Room
54
DISCHARGE
Richard Skiff – Synopsis 36 Healthcare Projects
of Brady
Billings 32 Johnson 84
Bergman
42
RR
and
Pyxis
Green
Radiology
59
Bullins
Brewer
Baxter
Wall
Nelson
47
46
45
Grier
Calloway
Stone
Boyd
Allen
Purvis
48
Summers
49
Jessup
Watson
EMS
16:00

16. From Triage
DISCHARGE
Room
Intake Holding
55
57
Watson
Pyxis
Provider
Area
Lamar 21
Beeson 41
Billings 32
Kyles 26
Bennett 36
Blake 28
Kirksey 28
Jones
Jessup
Station
Supply
PACS,
RR
Prep
and
Pyxis
RR
OB?
Daniels
Radiology
48
47
Gillespie
Johnson
49
46
Spinks
Stone
16:29
16:22
16:19
16:15
16:13
16:12
16:10
16:08
16:11
16:30
16:28
16:27
16:26
16:25
16:24
16:23
16:21
16:20
16:18
16:17
16:16
16:14
16:09
16:07
16:04
16:03
16:02
16:01
16:00
16:06
16:05
37
Jefferson BH
38
Harris BH
Soiled Linen
39
Eyes
40
Bell
41
Beane
Secretary
58
59
RR
Alabaster
Stewart
56
RR
Hobson
Nurse
Allen
Triage and Lab
Beck
Bass
Helms
Hendrick BH
Weathers
Waiting
PA
Baxter
Summers
Green
Baker
Brody
Fox
52
Minton
53
Green
54
Jennings
King 29
36
Simulated New
Process
31
32
33
30
At 16:00, 9 patients in
Waiting Room with
average wait time of
28
29
34
35
31 minutes to that
point 44 43
50
51
Bowers
Main Waiting Room
Bergman 36
Richard Skiff – Synopses of Healthcare Projects
45
Suture Suture Suture
EMS
42
Archibald

17. Richard Skiff – Synopses of Healthcare Projects
NURSE EFFECTIVNESS
HOSPITAL PROBLEM:
NURSING STAFF
TIME WASTED
DOING “HUNTING
AND GATHERING”
© 2013
17

18. Richard Skiff – Synopses of Healthcare Projects
What is “Hunting and Gathering?”
Anytime a member of the Nursing Staff has to go
someplace other than his/her immediate area to
get something to provide care to the patient.
– Physical hunting and gathering of equipment,
supplies, and equipment.
– Waiting for information/people/resources
that are not where they are needed when they
are needed.
*In this study, only Nurse hunting and gathering was measured. Hunting and
Gathering should also include all other care givers, including Providers and CNAs.
18

19. Richard Skiff – Synopsis of Healthcare Projects
Scope of Hunting and Gathering
TCAB Overall Scope
Current State
Context Diagram
Patient
Enters
Hunting and Gathering is present
in all aspects of Nursing Care.
Care
Planning
Patient
Assessment
Itterative
Cycle
Admit
Patient to
Unit
Complete
Health
History
Patient
Departs
Evaluate
Patient
Response
Implement
Care and
Treatment
Complete
Patient
Discharge
Med
Administration
Hunting and
Gathering
Admission/
Discharge
Care Planning
Med Administration
19

20. Richard Skiff – Synopsis of Healthcare Projects
Time Spent Hunting and Gathering
Minutes per 12 hr. Nursing Shift Spent.....
These are only
relatively small
snapshots of
time, and results
are for high
level/directional
use only
Shift/Nurse
reporting
Misc 6% ;
7% ; 44 min
51
Med
General nursing duties
scanning min
in patient's room and
from cart
administration of meds
9% ; 1 hr
Hunting and
Gathering is
about 25% of
a Nurse’s day
35% ; 4 hr 10 min
Bothpaper and
computer charting
19% ; 2 hr 14 min
Hunting and
Gathering
25% ; 3 hr 1 min
See Separate Chart
20

21. Richard Skiff – Synopsis of Healthcare Projects
What are they spending time hunting?
Percent of Total Nurse time spent
Hunting and Gathering for………..
Patient
Amenity
2.4%
Info
Med
1.1%
not
in 1st
Pyxis
1.5%
Get Meds from Pyxis
8%
Wait for
Equip/Pyxis
2.6%
Supplies
3.8%
Equipment
5.4%
Hunting and
Gathering is 25% of
total RN time
21

22. Methods and
Procedures
Equipment
Information
Richard Skiff – Synopsis of Healthcare Projects
Floor Stock Electronic
Equipment (Dynamaps,
Pulse Ox, etc.) GG
Provide own d/c
transport GG
Pyxis Discrepancy
Discharge orders W
Med info from pt.
for pharmacy GG
Insulin Witness GG
Transport ancillary
(Radiology, Dialysis,
Wasted med witness GG
Transfers) GG
Charts GG
Floor Stock NonElectronic Equipment
(Wheelchairs, Recliners,
walkers, etc..) GG
Documentation GG
Co-workers GG
Providers GG
Home meds GG
Equipment Failures diagram for
“Fishbone” –
look for working equip
GG, W
reasons why nurses spent time
Take home and gathering
hunting equipment
Duplicate Forms GG
GG = Go Get
Policies GG
Radiology Results GG
HUNTING AND GATHERING
W = Waiting
Food Trays W
Respiratory Therapy
Supplies GG
IV Fluids GG
Linens GG
Checking for missing
meds to be delivered
from pharmacy GG
Nourishment GG
Insulin GG
Coffee, Snacks, Personal
Care items GG
Dressings GG
Load Med Cart GG
Search Multiple Pyxis
GG
Lab
W
X-Ray W
E.V.S. –
Housekeeping W
Home Meds GG
Non stocked
Narcotics GG, W
Blood GG
Stock Outs GG
Supplies &
Amenities
Medications
Ancillary
Services
Focus Area
22

23. Richard Skiff – Synopsis of Healthcare Projects
5 Why Analysis
Hunting and Gathering: Why do we hunt for……
…..Floor Stock Electronic Equipment? (Dynamaps, PulsOx, Scanners, Med Carts, Phones, Bladder Scanners)
Left in
room
Frequent
use by
this
patient
In Use
by
another
No time
to return
to
location
No
designated
place for
equipment
Multiple
storage
places
Why?
Why?
Why?
Why?
Not
Returned to
Proper
Location
Hoarded
Plan to
use for
next
Patient
Not
enough
storage
places
Not
Charged
(Dead
Battery
Why?
Why?
A
Not
enough for
each unit
Improper
use
Overuse
Took focus areas noted in the fishbone
diagram, and generated a “5 Why”
analysis to address issues.
Too far
to walk
to return
Needed
for use
Off unit
(Borrowed or
appropriated
)
Broken
Equipment
shared by
multiple units
Called to
another
task
Specific Task Item
Not
plugged
in
No
place to
plug in
No
Accountability
See A
Past
normal
life
No
Preventative
Maintenance
No
replacement
plan
No PM
Program
Lack of
training
Bad
cords
No Time
to charge
No
charging
schedule
Unknown
charge
time
23

24. Richard Skiff – Synopsis of Healthcare Projects
Hunting and Gathering: Why do we hunt for……
Why?
…...Floor Stock Electronic Equipment? (Dynamaps, PulsOx, Scanners, Med Carts, Phones, Bladder Scanners)
Not enough
equipment
Why?
Unfixable
and not
communic
ated
Why?
Staff
doesn’t
enter the
request
No clear
method for
engineering to
communicate
back to the unit
the status
Don’t
know
how
Process too
cumbersome
Why?
Never
sent for
repair
Why?
Why?
Sent to
Engineering
and not
returned
Borrowed and
not returned
Waiting
for Repair
Gave
back to
wrong
unit
No way to
track
Specific Task Item
No
defined
return
path
Equipment
poorly
labled so
not
returned
Waiting
on parts
No defined
labeling
system
that is
permanent
No replacement
process – not
communicate to
person that can
order
Another
unit
doesn’t
have the
equip they
need
Ineffective
sign out
system
Not
enough
ordered or
purchased
Hoarding
No or
poor
tracking
system
No easy
access to
equipment
Ability to
order equip
is too
complicated
Financial
Constraints
Takes a
long time
to come
after
ordered
Don’t know
how many
we have
No
inventory
guideline
Don’t have
ownership
and a
process
No Process
or Bad
Process
24
When
comes in
not
delivered
to unit

25. Richard Skiff – Synopsis of Healthcare Projects
Hunting and Gathering: Why do we hunt for……
…...Non-Electronic Floor Stock? (Carts, Wheelchairs, Walkers, IV Poles, Bedside Commodes, Recliners, etc.)
Why?
No
Accountability
In a hurry
Not enough
equipment
Went someplace
else and when
came back
equipment was
gone
In use with another
patient
Specific Task Item
Removed
from room
EVS does
Discharge
clean and
removes
equipment
Variable process
and equipment
needs for each
unit
When Unit closed
and equipment
removed and
taken elsewhere
Inventory issue
Borrowed
for another
patient
No Security or
ability to lock unit.
Broken
Missing
parts
Thrown
away
Why?
Why?
Why?
No
ownership
Why?
Why?
People left
equipment in
other area (i.e.
discharge)
25

26. Richard Skiff – Synopsis of Healthcare Projects
NURSE EFFECTIVNESS
HOSPITAL PROBLEM
New Hospital
Opening – Are We
Ready?
© 2013
26

27. Richard Skiff – Synopses of Healthcare Projects
NEW HOSPITAL OPENING
• A new system 60 bed hospital was slated to
open in approximately 70 days.
• Worked with start-up team to determine
process needs/gaps prior to hospital opening.

28. Richard Skiff – Synopsis of Healthcare Projects
Three Main Hospital Value Streams
INPUTS
VALUE STREAMS
Walk-ins
Emergency
Regional
Physician
Offices
Direct
Admit
Procedures
(In /Out Patient)
OUTPUTS
Discharge
into
Community

29. Richard Skiff – Synopsis of Healthcare Projects
High Level Value Streams

30. Richard Skiff – Synopsis of Healthcare Projects
Surgical Services Value Stream
Patient Arrival
Developed Key Quality
Characteristics for each
value stream.
From MD Offices
From
Emergency
From Inpatient
Pre Arrival
Information
Registration
Pre Cert, etc
Patient Info
Name
DOB
Demographics
Insurance
Clinical Information
Procedure/Infusion
Length of Procedure
Allergies
Special Needs
Order for Consent
Regular Orders
Pre-Anesthesia Visit
Medical History and Physical
Pre-op Teaching/instructions
If face to face; RN will notify pt.
Provider Information
Surgeon/MD;
Does Patient need a PAV?
Each stream had three
main steps:
•Patient Arrival
•Patient Treatment
Schedule Patient
Enter into PICIS
•Patient Departure
Patient Arrival
Arrival at Front Desk
Escort to Surgical
Services
Greeter entry into
Smartrak
Escort to ACU
Update Smartrak

31. Richard Skiff – Synopsis of Healthcare Projects
Patient Treatment
Perform Surgery
Pre-Op
Complete Assessment
Pre-Procedure verification
Outside Ancillary Tests
Completed and Charted
The key steps in each
process were
determined, and then
processes needed to
accomplish that task were
identified.
Signed Consents
Site Marked
Prep Patient
Activate RDY button when Pt. is
completely ready
Operating Room
RN go to ACU/Preop to
meet/greeet patient
Transport Patient to OR
Then they were evaluated
for “readiness to open”
Green = Ready to Go
Yellow = Needs some refining
Red = Needs a lot of work
Update Smartrak - Circ RN
MD-Surgeon - Sign and mark
Anesthesia - Interview blocks
Perform Sugery
Upon Completion, Call
ACU/PACU when close to
transporting patient (RNA or RN)
How do Ancillary Services
communicate / hand-off to
Surgery?
- Radiology
- Pathology
- Labs
- Respiratory
- Pharmacy
- ICU
- Wound

32. Richard Skiff – Synopsis of Healthcare Projects
Patient Departure
PACU
Receive Patient and
Report from OR /
ORNA
Patient Recovery
Update in Smartrak
Hand off to Next
Level of Care
These “maps” were jointly
developed and rated by the
functional department, clinical
personnel, administration, related
ancillary services, etc.
Bed Control
ACU
ICU
Med Surg
How do Ancillary Services
communicate / hand-off to
Surgery?
- Radiology
- Labs
- Respiratory
- Pharmacy
- Wound Care
ACU
Patient Report from
OR / CRNA / PACU
From there, the functional areas
were able to focus on “Gaps” prior
to the opening of the hospital.
Patient Recovery
Food and Nutrition
Update in Smartrack
Discharge to
Community
Communicate Discharge Reports
and Instructions
Provider/Nurse
Ask Me Three
Written and Verbal
Vital Signs
Referrals
Insure Feedback and
Follow-up
Movement of Patient
Exit Transportation
Meds/Prescriptions

33. Richard Skiff – Synopses of Healthcare Projects
ULTRASOUND TIME EFFECTIVENESS
PROBLEM:
Uncertainty on the
time effectiveness
of Ultrasound
Technicians
© 2013
33

34. Richard Skiff – Synopses of Healthcare Projects
TIME STUDY PROTOCOL
• Methodology:
Followed one sonographer for an entire shift, logging the
time spent doing his/her normal tasks. Times shown are
only for one sonographer, and do not reflect activities of
others in the department at the time.
SHIFT
# of Patients
# of Exams
Day
8
10
Day
8
8
Evening
8
8
Evening
9
9
34

35. Richard Skiff – Synopsis of Healthcare Projects
Hospital Ultrasound Scheduling Process
Radiology – Ultrasound “Scheduling” Process
Page 1
Order comes
in via Printer
Is order for
today?
Yes
No
Put order in
Future
Basket
Is it an ED
request?
Yes
Put request
in ED Slot
Yes
Print off
Labwork
sheet
Is labwork
complete?
Yes
Add order to
Day Sheet
To A
Yes
Place
request in
“Ready
Patient” slot
To B
No
Will
procedure
need a labwork
check?
No
Call RN and
order
labwork
Yes
Put request
in ED Slot
Continue to
check with RN
until labwork is
complete
No
Is
patient to come
to radiology
unit?
Unit Secretary
No
Go to computer
and print out
Outpatient
schedule
Near end of
shift, fill out Day
Log. Add to day
Log if already
started.
Is the portable
request Stat?
No
To Outpatient
Process
Page 2
Put request in
Portable Slot
Place patient
requests and
Day log into
future basket
At beginning of
day shift, pull
requests from
future basket
Is patient
a Portable, ED,
or Outpatient?
Yes
Is
patient in
ED ?
No
“A”
Attach blank “yellow
sheet” (Hand off
communication tool)
to every inpatient
request.
Call proper unit and
ask for Patient’s RN;
Fill out questions on
Yellow Sheet
To Outpatient
Process
Page 2
Put in 2nd slot
in rack
Put request
in Outpatient
slot
When a
Sonographer, room,
and machine are
available, send for
patient
To ED
Process
Page 2
No
No
Is
Request for a
Portable unit?
Yes
Put request
in Portable
Slot
“B”
Transporter picks
up request
To “Portable”
Process
Page 2
Put front sheet in proper
slot – to keep track of
what patients have been
sent for

36. Richard Skiff – Synopsis of Healthcare Projects
Ultrasound Scheduling Process (cont.)
Radiology – Ultrasound “Scheduling” Process
Outpatient Process
“Portables” Process
ED Process
Page 2
From ED
Page 1
Wait for call from
ED to say that
patient is ready for
exam
Take paperwork
from ED slot, write
“R” on the top of the
sheet, and place it in
the first open
“Ready Patient” slot
Next available
Sonographer
retrieves paper, gets
portable machine,
and goes to ED
Sonographer
performs exam
Are
there more
exams in ED?
No
Return to
department
Yes
From
“Portable”
Page 1
From
“Outpatient”
Page 1
US Supervisor pulls
all “Portable” exam
paperwork out of
“Portables” slot and
place in “Ready
Patient” slot
Next available
Sonographer
retrieves chart, gets
portable machine,
and goes to Patient
location
Sonographer
performs exam
Return to
department
Scheduled
Outpatient
comes to US
Department
US department
processes
paperwork and puts
in next “Ready
Patient” slot
Sonographer
gets paperwork
and patient,
takes to room
Sonographer
performs exam
or procedure
Put completed
paperwork in
stack of
completed exams
Unit secretary takes
batches of
paperwork to
Medical Records
(once or twice a
month)

37. Richard Skiff – Synopsis of Healthcare Projects
Individual Sonographer Process
Sonographer Process
Return
to US
Dept
Check US
“ready”
rack
Is
there an ED
Exam ?
Go to ED
Yes Ultrasound
room
Get
paperwork
from printer
Check
T-system for
room,
relevant info
Get
equipment
ready
Go to Pt
Room
Perform
exam
Return
to ED
US
Room
Enter
results of
exam into
computer
Is there
another ED
Exam ?
No
Yes
No
A
Is there
“Portable”
Exam
Yes
Are
there any
Transcranial
exams?
Yes
Check with
supervisor for
priority
Check
Medical
records for
previous
exams
Get
equipment
ready
Go to Pt
Room
Perform
exam
Did images
transfer from
Portable?
Is there
another Exam
in batch?
Yes
Do these
first
Go to charting
computer,
begin charting
process
Return
to US
Dept
No
Yes
No
No
Sonographer
Does
work-flow allow
Portables
now?
Yes
Enter exam
results into
computer
system
File
paperwork
To A
No
Push images
to computer
Is there an “in
department” exam
or procedure?
No
Do Mandantory
Education, Department
housekeeping,
restocking, professional
development
Yes
Is patient here?
No
Send
transport to
get patient
Yes
Grab
chart
Check
yellow sheet
for issues
Check
Medical
records for
previous
exams
Perform
exam or
procedure
Go to charting
computer,
begin charting
process
File
paperwork
No

38. Richard Skiff – Synopsis of Healthcare Projects
Time Study Results
Ultrasound Time Study: In Room Time - Combined Shifts
70%
65.6%
Found that the ultrasound
department actually had a very high
percent of their time actively
working with patients. Some
improvements could be made at end
of shift procedures scheduling.
60%
Ultrasound Time Study: Combined Shifts
% of Time
50%
40%
50%
44.5%
30%
40%
20%
9.9%
9.3%
10%
5.1%
% of Time
30%
3.6%
2.3%
2.0%
1.9%
0.3%
9:33:45
0:44:29
0:31:30
0:20:15
0:17:45
0:16:15
0:03:58
20%
1:21:15
Examination
Possible
1:27:00
0%
Post Exam
Clean-up
Pre-Exam Prep
Room Prep
Paperw ork
Chart Check
Computer Delay
Delay
Other
Opportunity
10.7%
10.5%
10%
8.1%
3.0%
2.7%
2.5%
2.4%
2.3%
0:44:45
3.8%
0:47:00
6.3%
3.3%
1.0%
Delay
Scan Paperw ork
Behind
Misc
Chart
Admin
Review
Dow ntime
1:05:45
Misc prep
0:19:30
0:58:15
Lunch
0:49:45
1:14:00
Travel
0:52:30
2:03:15
In room Dow ntime Computer
- No
Charting
Patients
2:39:46
3:25:45
3:30:45
14:34:44
0%
Misc
Dow ntime
Other

39. Richard Skiff – Synopses of Healthcare Projects
Opportunity: Waiting for Patients
Why is a Sonographer Waiting for Patients?
–
–
–
–
–
Waiting for Transportation – Why?
End of a Shift - Why?
Waiting for Labs - Why?
No exam/procedure requests
Other

40. Richard Skiff – Synopses of Healthcare Projects
NUCLEAR MEDICINE PROCESS STUDY
PROBLEM:
What are some of
the issues
affecting Nuclear
Medicine?
© 2013
40

41. Richard Skiff – Synopses of Healthcare Projects
Nuclear Medicine Process Study
• Observed Nuclear Medicine and PET for four
shifts, including nights and weekends.
• Collected responses from the “magic wand*”
sheets, as well as from conversations with
staff.
* Staff were asked the question: “If you could wave a magic wand and change
three things in your area, what would they be?

42. Richard Skiff – Synopses of Healthcare Projects
Process Improvement
The Nuclear Medicine and PET Groups were
continually making changes to improve their
department. As one technologist said, “...every
two or three weeks we’re trying something
different to try to make things better.”
This is exactly what we need to encourage –
people who actually do the work having input
and making changes to improve the delivery of
value to the customer.

43. Richard Skiff – Synopsis of Healthcare Projects
Who is Requesting Procedures?
Nuclear Medicine: Breakdown of Procedures
June 13 - December 9, 2010
Emergency,
17.4%
Inpatient,
50.4%
Outpatient,
32.2%
PET Procedures - Requesting "Unit"
Inpatient,
248, 16%
Outpatient,
1286, 84%

44. Richard Skiff – Synopses of Healthcare Projects
Procedures Issues
• CCK and Lasix; RN vs. Technologist injections
• Outpatients with Ports, getting an RN in a
timely manner
• Cardiolytes, getting a PA in a timely manner.
One cardiology practice has recently cut PA
positions – now have to wait for an MD to
monitor.

45. Richard Skiff – Synopses of Healthcare Projects
Scheduling Ideas / Issues
• Mail appointment times and instructions to
outpatients.
• STAT orders to NucMed on 2nd and 3rd shift –
how to know that they are there.
• PET Procedure printing after 3:00 pm
• Possible use of pagers in Waiting room – to let
patients know when to come back

46. Richard Skiff – Synopsis of Healthcare Projects
Transporter Process Improvement
Location of Transports to/from
Other
1.9%
METHODOLOGY:
PET
12.3%
MRI
35.0%
Compiled NucMed
Transporter Log
11/30/2010 –
12/10/2010
10 Days Total
Nuclear Med
26.5%
Rad/Onc
24.3%
Over 60% of
transports are
done for other
departments
than NucMed
and PET

47. Richard Skiff – Synopses of Healthcare Projects
Individual Transporter Data
The percent of time that a transporter was actively
transporting ranged from 39 to 50 %
Transporter
Worked
Minutes
Total
Trips
A
B
C
D
4599
3720
3600
4230
100
81
61
83
10 days X 8
Hrs, less PTO
Calculated
Average
Calculated %
Total
Trips per
of Time
transporting
Hour
Transporting
Minutes
1.3
2280
49.6%
1.3
1847
49.6%
1.0
1391
38.6%
1.2
1892
44.7%
Includes trips taken
with another
transporter
Total Trips times
22.8 minutes per trip

48. Richard Skiff – Synopsis of Healthcare Projects
The percent of time that a transporter was actively
transporting ranged from 39 to 50 %
Transporter
Worked
Minutes
Total
Trips
A
B
C
D
4599
3720
3600
4230
100
81
61
83
10 days X 8
Hrs, less PTO
Includes trips
taken with
another
transporter
Calculated
Average
Calculated %
Total
Trips per
of Time
transporting
Hour
Transporting
Minutes
1.3
2280
49.6%
1.3
1847
49.6%
1.0
1391
38.6%
1.2
1892
44.7%
Total Trips times
22.8 minutes per trip

49. Richard Skiff – Synopses of Healthcare Projects
SYSTEM WIDE ED STROKE IMPROVEMENT
PROBLEM
Individual hospital process
variation affected system
wide ED Stroke Response
times
© 2013
49

50. Richard Skiff – Synopses of Healthcare Projects
ED Stroke Project Methodology
• Observed and process mapped main hospital
and four satellite hospital ED stroke processes
• Process Mapped each Hospital’s processes, and
Gathered ED stroke response data
• Brought all hospitals together to review process
maps
• Determined best practices system wide to
improve ED Stroke response, and began
implementation of those practices

51. Richard Skiff – Synopsis of Healthcare Projects
Main Hospital ED Code Stroke Data
90
18.4
75
tPA Order to tPA Start
60
Minutes
28.9
16
CT Read to tPA Order
CT Complete to CT Read
45
CT Order to CT Complete
25
30
15.4
10.2
15
14.1
11
10
2
0
Mean
Median
Door to CT Order

52. Richard Wide Synopsis of Healthcare Projects
Mission SystemSkiff –ED Stroke Process: Current State Comparison
MEMORIAL
Main Hospital
ANGEL
Satellite #1
BLUE RIDGE
Satellite #2
TRANSYLVANIA
Satellite #3
McDOWELL
Satelilte #4
Denotes Targeted
Best Practice
Notify ED,
start IV
ED notifies
Radiology and
Lab
ED Alerts ED of
incoming possible
stroke, and ETA
Draws blood,
if possible
Notify ED of
inbound
stroke
ED notifies MD,
Radiology, and Lab.
Begin moving Robot when Code Stroke
is called, for all EDs except Memorial
EMS Arrival;
put in ED
room
POV:
Triage makes
first stroke
assessment
Draw Blood
Register pt. at
door if possible
POV: Registration or
Triage recognizes stroke
symtoms
POV:
Registration or
Triage makes
first stroke
assessment; call
“Code Stroke”
If clear “Rule In,” MD orders CT Scan and If CT is busy,
contacts MMH Neurology via phone for
may do EKG
acceptance of transfer, without using
while patient is
telestroke
waiting for CT
Assessment done at
Triage or EMS stretcher
(Preferred) or in ED room
“Clot Box” with
Protocol and
Stroke
supplies
available
Register pt. at
door if possible
If using Telestroke, bring robot
to room. (sometimes while in
CT, sometimes after back in
room.
Decision to admit or
transfer Pt to Memorial
Bring Telestroke
Robot
RN Standing
orders allow
for CT order
CT Scanners alert
Radiology if > 20 min
w/o interpretation
RN Prepares
tPA
RN
administers
tPA
RN Prepares tPA
RN
administers
tPA
RN
administers
tPA
Connect to Neurologist via
Telestroke
Bring Telestroke
Robot
Place patient
in room.
Draw Blood if
possible
Connect to Neurologist via
Telestroke
EMS:
Place patient in room
Start NIH assessment
Draw blood for lab
Register Pt if not done before.
2 “boxes” of tPA
ingredients kept in ED
Omnicell; 2 more in
Pharmacy
Lab samples
taken
MD Assess
Pt. for Stroke
in ED Room
EMT assesses Pt.
Start IV if possible
Perform CBG test
MAMA (only) can call
Code Stroke
RN
administers
tPA
RN or Pharmacist
Prepares tPA
Bedside
POV
Assessment
??
POV:
Notify CT and
Lab; call Code
Stroke
POV:
Registration or
Triage makes
first stroke
assessment
RN
administers
tPA
RN Prepares
tPA
Draw lab samples when
back in ED room, if not
drawn before.
In house radiology available
8-5; after hours use Asheville
Radiology. Consistently good
response times.
RN Standing
orders allow
for CT order
EMS
Assessment
on Stretcher
Dispatch contacts ED
with preregistration
info and ETA
RN Prepares
tPA
tPA Ordered
by Neurologist
Quick
Register Pt.
May also alert
Telestroke
Notify Dispatch with
Name, DOB, and pt.
address
Connect to Neurologist via
Telestroke when back in
room
MD assess for
stroke
Draw blood in
room, if not
done yet
EKG, X-Ray if
ordered by
MD
2 CT Scans:
Plain CT followed by an
Angio CT with contrast
POV:
PACE RN or Triage determines
possible Stroke; either can call
Code Stroke
EMS
Process
Patient
Arrival
Patient
Assessment;
CT
Ordered
CT Scan
CT Read
tPA
Ordered
STK-4 Criteria: Patients administered tPA within 60 minutes of presentation to ED
(Patients admitted to hospital)
OP-23 Criteria: CT read within 45 minutes of presentation to ED:
(Patients “discharged” from ED – i.e. transferred to another hospital)
tPA
Prepared
tPA
Given
Transfer
Protocol
to
Memorial

53. Richard Skiff – Synopses of Healthcare Projects
HOSPITAL SUPPLY CHAIN
CHALLENGE
IMPROVE SUPPLY
CHAIN
EFFECTIVENESS
© 2013
53

54. Richard Skiff – Synopses of Healthcare Projects
PROCESS APPROACH
• Value Stream Map of Materials Distribution
• Process Map of Materials Ordering –
Transactional Processes
• Process Map of Post Product Approval Process

55. Richard Skiff – Synopsis of Healthcare Projects
Materials Distribution: Current State
Map
Lawson or Omnicell Orders
Lawson or Omnicell Orders
Lawson or Omnicell Call Ins (Urgent)
Non-Stock and Misc.
Non-Stock P.O.s and UPS / Fed Ex
Cath Lab / Surgical Procedures
OR Requisition Items
SDC to SPD to OR Deliveries
OR Cases

56. Richard Skiff – Synopsis of Healthcare Projects
Supply Chain Processes: Current State Map
Forms
Need Follow-Up Process Map
Equipment
It does not appear
that there is an
Equipment Review/
Approval Process
Go back to
department for
New form is
created
someplace
No
Yes
Equipment
New Equipment
Request
Clinical
Equipment
Approval
Process
Fill out request
in Ascend
Software
Is it Capital?
(> $5K)
Bidding and
Vendor
Approval
Process
Capital Buyer
gets OK to
purchase
Is item over
$25K
No
Lease or
Use
Agreement
Process
Rental
Equipment
Process
Yes
Review through
MD Buyline
Process
Pass MD
Buyline?
Yes
Place PO with
vendor
Receive
Equipment in
Ridgefield or
designated other
location
Periodic status
updates
between buyer
and vendor
No
Yes
Does
it have Lawson
Number?
Yes
Yes
Is it Biomed?
Go through
Biomed approval
process
Forms
Install
Equipment
Requester
goes to
Printshop
Process
No
No
To A
OR Emergency Totes
Non- Lawson (Special)
Orders
Unit sends in
a requisition
form to
purchaser
Paper/Faxed
Has
this item been
ordered
before?
Yes
Is Vendor
Approved
No
Develop clear
guidelines on what
needs to go through
product review.
Yes
Item Qty meet
“Add to Lawson”
Criteria?
No
Does
item need
Product
Review?
Can it be
purchased
someplace
else?
No
Yes
There is a new Product
Review Process (Value
Analysis Process)
instituted 2/6/13; but it has
not been fully vetted.
Yes
Go through
Lawson approval
process
IT Adds item to
Lawson
Put into
Template or Par
To B
OR
Emergency
Totes
No
Will it be
ordered again?
Post Product
Review
Transactional
Processes.
Mapped 2/21/13
New Entity or
Department to
be set up in
Lawson
Go to Finance to
create; Maps to
“X” Cost Center
Finance sends
out email that
“I’ve created
Cost Center and
its Called Y”
Someone in this
cost center
orders
something
Yes
Hand Held
Orders
(Open
Stock)
Both Stock
and Non
Stock
items
Warehouse
Perpetual
Orders
Materials asks
“Who are you
and what cost
center are you?”
Yes
Is Cost
Center set up in
Lawson?
Materials tries to
determine if this
cost center will
order stuff
Unit
orders via a
Lawson
Template
Unit completes
the order and
releases it
Mtls
coordinator
orders item via
Handheld
(Lawson)
Transmits order
to Mobile Supply
Chain (MSCM)
Item has
reached a Par or
below level in
Warehouse
Lawson
create a PO
for Item?
Are you a
“Requestor”
If so, creates a
requesting
location in
Lawson
Are
Yes
you authorized to
order for this cost
center?
Yes
No
Send computer
services
authorization
form
No
Is there a template
set up?
Yes
When done,
email sent back
to Materials IT
Get
authorization
and set up their
profile
No
Dialog with unit
for needs. Look
to see if there is
“someone like
you.”
Build Template
To C
Sometimes Qty is to be
transferred from
another warehouse
Pick items and
ship
No
WH does “In
Transit” receipt
release and
Decrements
“From” WH
When received at “To”
WH, does release of
“In Transit Receipt”
and increments
receiving WH
Decrements On
Hand Quantity
Omnicell hits a
Re-order point
Query to
Omnicell: “How
are you in stock
level?”
Omnicell creates
an electronic
Requisition file:
“This is what I
need”
Is
it a Stock
Item?
Force a “Job” in
Lawson
Yes
Yes
Lawson looks at
available stock
on hand
C
Lawson creates
a pick ticket in
Warehouse for
each Omnicell
Item is Picked
(Mtls Distribution
VSM)
Prints “Killed”
items at bottom
of ticket
Yes
Lawson “Kills”
Quantity, may
revise with lower
Qty.
Lawson creates
a P.O. for nonstock item
Cycle Count
Correction of
Stock Amounts
in Omnicell
during stocking.
Is enough
quantity?
Lawson sends
an email to
requestor about
Qty change
No
No
Decrements On
Hand Quantity
account
Creates record
of Patient and
Item
Transactional Ordering
Process Map
Ready to order
Warehouse Perpetual
Orders
Omnicell
Orders
Is item
Patient
Chargeable?
Stage to
put on next
truck for
delivery
No
Requisition
created in
Lawson
A Pseudo pick
ticket prints at
“From”
Warehouse
Item is scanned
out of Omnicell
Is there a
tote ready?
Floor Stock Patient
Equipment
Distribution
Process
(exp – IV pumps,
Dynamaps, etc.)
Lawson Template
Items
Hand Held Orders (Open
Stock)
Set up
requesting
location for cost
center.
No, Transfer
Omnicell
Yes
Fax to SDC
Add Vendor to
Lawson
Credit Card
Purchase
No
Lawson
Template
Items
Prints out
Spreadshe
et order
form
Build the
tote
Lawson Template SetUp
B
OR orders
replenishm
ent
emergency
tote
It does not appear
that there is a Recall
Process for products
or equipment
Yes
No
Feedback to
requestor that
item needs to go
through product
review process
Product
Review
Process
Lawson
Template
Set-up
To
B
No
To
B
Is it on a
Template?
Does
Yes
Lawson have Form
Template?
No
A
Non
Lawson
Orders
(Specials
and New
Items)
Requisition to
Materials that
someone needs
more of that
form
Forms
Approval
Process
If only one item on P.O.,
Lawson will not print a pick
ticket.
Buyer revises
order (Quantity,
Price, other)
Lawson routes
P.O. to a Buyer
Create a new
P.O.
Yes
At 5:00 am;
Omnicell
transfers
information into
Medipac
P.O. sits in
Buyer queue as
“Unreleased”
Buyer reviews
P.O.
Revision
needed?
Yes
No
Release item in
Lawson
Is
Yes
Vendor set up
EDI?
Order goes to
GHX (Clearing
House)
GHX sends
order to Vendor
Vendor confirms
order
No
Medipac creates
a patient bill
Vendor
set up
Autofax?
Enough to
fulfill order?
Yes
Yes
Lawson job
looks for
released Autofax
POs
Autofax order to
Vendor
Buyer calls or
faxes vendor
Vendor Confirms
order
No
Lawson prints
out order
Buyer gets Online confirmation
Email from
Autofax to
Vendor;
“I sent P.O.”,
Confirms by Fax
No
Vendor feeds
back expected
ship date
Buyer gets back
with requestor
Is
revised ship
date
OK?
No
Is there a
substitute
available
No
Requestor has
to wait.
Yes
Vendor Ships
Order

57. Richard Skiff – Synopsis of Healthcare Projects
Post Value Analysis
(Product Approval Process Map)
A
B
C
DB I Add:
Type
Cost
Department
CDM (Charge Master #)
Markup Price Scale
(Price to Patient:
“Extended Price”
DB I
Open “Item Class
Template” in
Cerner
Copy and Paste
Item Number
(Lawson) and
Class into
Template
.CSV
After A, B, C, loops, this is the last step in this loop
Cerner exists to have clinical
documentation and make
items patient chargable
After Class, repeat
for Location and
Locator; each
location must be
done separately
E
An item has been
approved Value
Analysis (i.e. Product
Approval) and is to be
made ready for
purchase.
Assumes that the New
Process (2/6/2013) is
in place
Is it a
Surgical
Material?
Yes
Contract
Administrator
sends
information to
Data Base
Specialist:
Contains:
Vendor Product Number
Description
Unit of Measure
Buy
Distribute
Pricing
Par Levels
Contract person
generates letter
of approval
Creates Excel
Spreadsheet with
information and sends
to Database
Specialst II.
100% Manual Entry
Check for
Duplicates in
Lawson
Assign
Lawson
Number to
Item(s)
Upload to
Lawson
“Lawson
Build”
DB II sends Excel
file back to:
DB I
Contracts
Go to Explorer
menu in Cerner;
click
“Execute Query
Output Item Master”
Save resulting file in
.CSV format
File in C:Drive
“Item Master Active”
Open Access,
Delete current “Item
Master Active File”
Import New .CSV file
into Access.
1) “Item Master Active”
2) Create Backup File
Run Query in Access
- produces file.
Compares Lawson
Item Master to Cerner
Item Master –
Produces new items.
Cerner file exported
to “Prod Weekly”
Excel File
New items need to
build in Cerner
Copy and paste
“Prod Weekly” file
into Cerner Items
Upload File .CSV
Cerner Item Master
Template
In Cerner, go to
“Materials
Management
Upload Manager”
A
Import .CSV file
Commit
Check for Errors.
If after “A” loop, then
do not do an error
check.
Go to “B”.
After “B” loop, go to “C”
Are there any
errors?
No
Item built in
Item Master
B
Wait for
Cerner Ops
Jobs
10:00 am;
1:00 pm
Cerner Ops Job
populates
Pricing Tool
Manually to into
each item number
and item location,
click “Group
Complete.”
(Pricing tool
application)
Open Explorer
menu in
Cerner
Run “Pricing
Tool Data” file
Exit Cerner.
Save as
Excel file in
Pricing Tool
Reports
Open Access.
Import Pricing Tool
File and the File
from the Build.
Email to
“Donna” (Cerner
Person)
Save as .CSV
in “Upload
Files for
Donna.”
Manipulate file to add:
Supply (copy and
paste)
Different Header
Add bill code
Add price schedule
cost and mark up.
Go into Excel
and open the
file
Export file to
“Upload Files
for Donna”
Query produces
combined
Excel file:
“Query
Upload.date”
Run Access
Query to
compare the two
files.
Yes
Adds
Ship to Location
Stock/Non-Stock/Facility
Send a letter of
approval to
Team Lead,
Materials, and
Vendor.
Create and send
Change Upload
File (Excel) to
DB II
Manually make
corrections in Lawson
Manually correct
errors in Cerner
No. Comes out of Clinical Materials Product Review
Contracts
uploads file to
Access
Load into “Item Entry
System (Access)
Lawson Number
Approver
Store Location
Vendor Number,
etc.
Chargeable?
No
New Item?
No, it’s a replacement
Is it a
Cerner
Item?
Yes
Send email to
Surgical
Materials
manager
Surgical
materials
manager
determines:
Usage
Locations
Pull vendor Price
File (Access)
and match to
Lawson Build
File
Communicate
change to
various locations
Output file with:
Lawson Number
Vendor Item Number
Price
Unit of Measure
Description
Notify DB I to
make change in
Cerner
Export back to
Excel
Go into Lawson;
Create Vendor
Agreement
Header
Is File over
50 Items?
No
Key in Manually
Contract person
activates
“Release”
function in
Lawson
Item can now be
purchased
Cerner uploads to
Pricing Tool
Yes
DBI adds
additional mfg to
Cerner
Manually change
price in Pricing
Tool (if needed)
Yes
Notify DB II to
make change in
Lawson
Send to DB II
Upload to
Lawson
Lawson creates
file
(Still Access)
Contract
Person(s)
manually review
file to determine
items needing
action
Approver
sometimes has
to “nudge”
contract person
by email
Approver: Go to
Vendor.
Email:
Mfg Code
Usage
Set up contract
Release
Contract
Send to DB II to
Auto Upload
Enters Order Process
at Unit:
Omnicell
Lawson Template
Special Orders
Etc.
Found that this process
takes over 30 steps, and
involves 17 file format
changes!
Communicate to Users that
“Item is available to order.”
The timing of this communication is critical
– to balance ordering with when it will be
available from vendor.
Need to define this process
Buyer Message Item
comes in with
Differences from P.O.
Vendor notifies
Mission their
ETA to ship
stock
Invoice
Receiving
FUTURE STATE
Item is approved
(2/6/13 Process)
Clear message from
Value Advisor to
Execute
Information arrives
from Vendor in
Mission Excel
Template
DB I adds Mission
Specific information
Look for duplicate:
Descriptions
Manufacturing Item
Numbers
Manual fix
Lawson and Cerner
dialog and put out a
final product
Generate exception
report for conflicts.
Fix manually

58. Richard Skiff – Synopses of Healthcare Projects
ADDITIONAL “Projects”
Root Cause
Analysis of Patient
Safety Events
© 2013
58

59. Richard Skiff – Synopses of Healthcare Projects
Patient Safety Events:
Root Cause Analyses Facilitated
•
Neptune Recall
•
Phenobarbital Detox
•
WOW Cart Overheating
•
NICU Freezer Failure
•
Propofol Syringe in Patient
Room
•
Vancomycin Extra Dosage
•
Cardiologist Office Wrong
Echocardiogram
•
Propofol Syringe in NTICU
•
OR Vacuum Reduction
•
Trocar Injury
•
Direct Admit Flu Exposure
•
Physician Office Complaint
•
Surgical Sight Specific Infection