This document summarizes a quality improvement project at a large oncology practice to reduce the response time for symptom management calls. The project team implemented a case management system, reallocated nursing staff, and developed standardized protocols. These changes increased the percentage of symptom management calls receiving a clinical intervention within 2 hours from 54% at baseline to 73% after implementation. The number of non-clinical calls reaching the triage nurse also decreased significantly. The case management system provided data to identify additional opportunities for improvement beyond triage response times.
A Dartmouth Microsystem Assessment was conducted to examine a hospital unit\\’s functionality and to highlight opportunities for improvement. To enhance the gathering of data, a statistical tool was created to measure a wider sample population. The CNL student implemented a more reliable and valid data gathering system. The nurse educator asked to use the graduate student’s tool on the unit and throughout the hospital.
A Dartmouth Microsystem Assessment was conducted to examine a hospital unit\\’s functionality and to highlight opportunities for improvement. To enhance the gathering of data, a statistical tool was created to measure a wider sample population. The CNL student implemented a more reliable and valid data gathering system. The nurse educator asked to use the graduate student’s tool on the unit and throughout the hospital.
Digital Solutions putting the patient at the forefront of Risk ManagementMyMeds&Me
Capturing relevant, essential and complete data at the first interaction
Why surfacing targeted questions and FAQs in-stream maximises the value of the initial contact and reduces low-value follow up.
Digital solutions ensure your REMS and RMP commitments are met with appropriate evidence
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at He...AIDSTAROne
In guidelines released in 2010, the World Health Organization recommends that health facilities integrate prevention of mother-to-child transmission (PMTCT) with maternal, newborn, and child health (MNCH) services to improve patient follow-up and adherence. This report describes the results of an assessment conducted across 70 randomly sampled PMTCT facilities in 14 regions of Tanzania, and the effect of integration on health quality.
www.aidstar-one.com/focus_areas/pmtct/resources/report/assessment_integration_pmtct_within_mnch_services_health_facilities_tanzania
Introduction: The patient’s perception of quality of care is fundamental to utilization of health services. Health utilization would partly depend on clients’ perception of the quality of care.
Methods: A cross-sectional study involving health clients (18 to 70 years) who accessed health services in the Bantama submetro
in the Kumasi metropolis was conducted. A total of 400 clients were recruited from ten health facilities for the study.
Data was collected through interviewing using semi-structured questionnaires using SPSS and analyzed into descriptive and
inferential statistics with STATA 11.
Results: Majority of subscribers assessed healthcare with their National Health Insurance (NHI) cards. Eight percent (8%) had
never accessed healthcare with their NHIS cards. Respondents’ reasons included not falling sick and low quality of healthcare
under the NHIS. Respondents 216 (54%) indicated delays in seeing a doctor, getting laboratories done, and accessing health care as a whole. Seventy-four percent (74%) of the entire population attributed both NHIS and cash and carry systems as the
payment methods associated with delays in health facilities. Clients who viewed the overall the quality of health provision as good or very good were more likely to access healthcare with NHIS card as compared to those who rated the overall health provision as poor or very poor (OR=2.1; p<0.01).
Conclusion: Clients’ perceptions and experiences with quality of health provision influence their utilization of healthcare under the NHIS scheme. Increased enrolment in the scheme should be supported with provision of quality services to enhance clients’ satisfaction.
Objectives:
1.Review the changes in Accreditation Canada expectations for implementing MedRec beginning in 2014.
2.Overview of changes to the ROP structure, for Medication Reconciliation ROPs in the leadership and service-based standards.
3.Direct organizations to additional information, resources, and support.
Click the link to read more http://bit.ly/10LqxjQ
Purpose of the Call:
Review the results of the National VTE audit day
Discuss lessons learned from the audit day – strengths and areas for improvement
Suggest future value of audits and audit tools for your organization
Gather ideas for future steps for implementation of VTE prophylaxis
Click the link below for more information and to watch the recorded webinar.
http://bit.ly/12QiAf5
Showcases digital health implementation in Ontario
hospitals.
Each story is focused around a key challenge,
an explanation of the process taken to address it, and
a reflection on the impact
White Paper - Infection Preventionists: Healthcare’s Guardians at the Gate Ne...Q-Centrix
This white paper examines a key player at the front lines of hospitals’ never-ending battles against HAIs –Infection Preventionists (IPs). It briefly explains their varied roles, responsibilities and new challenges, the difficulty in recruiting these highly sought-after experts, and why and how hospitals should be doing more to help overworked and understaffed IPs be successful. Lastly, it covers new technologies and IP support services that can be integrated into hospitals’ infection control practices.
Communications in US Emergency DepartmentsCory Mann
Emergency Departments have a plethora of communications challenges, with more hand offs and methods of communication used than other areas of hospitals. See the full research findings by Cory Mann Market Insight in the attached report.
Engaging Non-State Actors in Governing Health: Key to Improving Quality of Care?HFG Project
USAID’s Health Finance and Governance (HFG) and the Joint Learning Network hosted an hour-long webinar on engaging non-state actors in governing quality of care. The webinar presented in-country examples of private sector contributions in governing health quality — providing technical inputs on policy development, monitoring health service delivery, and promoting accountability in the health system.
Leveraging Analytics to Identify High Risk PatientsCitiusTech
A predictive analytics platform can help healthcare providers identify which patients and team members could be at the highest risk for severe illness / hospitalization.
Human Papillomavirus Immunization completion rates increased by the use of th...inventionjournals
Human Papillomavirus is the most common sexually transmitted infection in the United States and world wide. Vaccination is a critical public health measure for lowering the risk of cervical genital and anal cancers. Overall vaccination rates in the United States are low. This study highlights the need to change practices in primary care clinics to increase Human Papillomavirus vaccination rates. The study compares vaccination rates before and after the introduction of the American Academy of Pediatrics Tool Kit and a staff training session.
Digital Solutions putting the patient at the forefront of Risk ManagementMyMeds&Me
Capturing relevant, essential and complete data at the first interaction
Why surfacing targeted questions and FAQs in-stream maximises the value of the initial contact and reduces low-value follow up.
Digital solutions ensure your REMS and RMP commitments are met with appropriate evidence
AIDSTAR-One Assessment of the Integration of PMTCT within MNCH Services at He...AIDSTAROne
In guidelines released in 2010, the World Health Organization recommends that health facilities integrate prevention of mother-to-child transmission (PMTCT) with maternal, newborn, and child health (MNCH) services to improve patient follow-up and adherence. This report describes the results of an assessment conducted across 70 randomly sampled PMTCT facilities in 14 regions of Tanzania, and the effect of integration on health quality.
www.aidstar-one.com/focus_areas/pmtct/resources/report/assessment_integration_pmtct_within_mnch_services_health_facilities_tanzania
Introduction: The patient’s perception of quality of care is fundamental to utilization of health services. Health utilization would partly depend on clients’ perception of the quality of care.
Methods: A cross-sectional study involving health clients (18 to 70 years) who accessed health services in the Bantama submetro
in the Kumasi metropolis was conducted. A total of 400 clients were recruited from ten health facilities for the study.
Data was collected through interviewing using semi-structured questionnaires using SPSS and analyzed into descriptive and
inferential statistics with STATA 11.
Results: Majority of subscribers assessed healthcare with their National Health Insurance (NHI) cards. Eight percent (8%) had
never accessed healthcare with their NHIS cards. Respondents’ reasons included not falling sick and low quality of healthcare
under the NHIS. Respondents 216 (54%) indicated delays in seeing a doctor, getting laboratories done, and accessing health care as a whole. Seventy-four percent (74%) of the entire population attributed both NHIS and cash and carry systems as the
payment methods associated with delays in health facilities. Clients who viewed the overall the quality of health provision as good or very good were more likely to access healthcare with NHIS card as compared to those who rated the overall health provision as poor or very poor (OR=2.1; p<0.01).
Conclusion: Clients’ perceptions and experiences with quality of health provision influence their utilization of healthcare under the NHIS scheme. Increased enrolment in the scheme should be supported with provision of quality services to enhance clients’ satisfaction.
Objectives:
1.Review the changes in Accreditation Canada expectations for implementing MedRec beginning in 2014.
2.Overview of changes to the ROP structure, for Medication Reconciliation ROPs in the leadership and service-based standards.
3.Direct organizations to additional information, resources, and support.
Click the link to read more http://bit.ly/10LqxjQ
Purpose of the Call:
Review the results of the National VTE audit day
Discuss lessons learned from the audit day – strengths and areas for improvement
Suggest future value of audits and audit tools for your organization
Gather ideas for future steps for implementation of VTE prophylaxis
Click the link below for more information and to watch the recorded webinar.
http://bit.ly/12QiAf5
Showcases digital health implementation in Ontario
hospitals.
Each story is focused around a key challenge,
an explanation of the process taken to address it, and
a reflection on the impact
White Paper - Infection Preventionists: Healthcare’s Guardians at the Gate Ne...Q-Centrix
This white paper examines a key player at the front lines of hospitals’ never-ending battles against HAIs –Infection Preventionists (IPs). It briefly explains their varied roles, responsibilities and new challenges, the difficulty in recruiting these highly sought-after experts, and why and how hospitals should be doing more to help overworked and understaffed IPs be successful. Lastly, it covers new technologies and IP support services that can be integrated into hospitals’ infection control practices.
Communications in US Emergency DepartmentsCory Mann
Emergency Departments have a plethora of communications challenges, with more hand offs and methods of communication used than other areas of hospitals. See the full research findings by Cory Mann Market Insight in the attached report.
Engaging Non-State Actors in Governing Health: Key to Improving Quality of Care?HFG Project
USAID’s Health Finance and Governance (HFG) and the Joint Learning Network hosted an hour-long webinar on engaging non-state actors in governing quality of care. The webinar presented in-country examples of private sector contributions in governing health quality — providing technical inputs on policy development, monitoring health service delivery, and promoting accountability in the health system.
Leveraging Analytics to Identify High Risk PatientsCitiusTech
A predictive analytics platform can help healthcare providers identify which patients and team members could be at the highest risk for severe illness / hospitalization.
Human Papillomavirus Immunization completion rates increased by the use of th...inventionjournals
Human Papillomavirus is the most common sexually transmitted infection in the United States and world wide. Vaccination is a critical public health measure for lowering the risk of cervical genital and anal cancers. Overall vaccination rates in the United States are low. This study highlights the need to change practices in primary care clinics to increase Human Papillomavirus vaccination rates. The study compares vaccination rates before and after the introduction of the American Academy of Pediatrics Tool Kit and a staff training session.
Les Experts QSE devenu la référence n°1 en Afrique et au Maroc en matière de la Sécurité, la Qualité et l‘Environnement pour les managers et les décideurs, est une plateforme crée par le Cabinet LES EXPERTS QSE.LES EXPERTS QSE est le fruit de Plusieurs années d'expérience en Qualité, Sécurité & Environnement dans des projets d'envergure. Un cumul du meilleur savoir et pratique des grandes multinationales. Nous sommes votre partenaire compétent pour toutes les missions de conseil au Maroc et en Afrique.
Notre objectif: est de vous transférer notre EXPERTISE et améliorer le potentiel de votre STRUCTURE: - Protéger votre image de marque, - Se mettre à l'abri du risque juridique, - Valoriser votre capital humain, - Améliorer la productivité et la performance de vos forces de production.
Notre savoir-faire se fonde sur nos méthodes de travail, où l’expertise et la précision sont de rigueur. Nous nous adaptons donc en permanence aux besoins spécifiques de nos clients et veillons à établir une relation de confiance sur le long terme.Pour toute information supplémentaire contacter: contact@qhseexperts.com
This presentation has the measures to be taken for the safety of patients. It covers the 6 goals
Goal 1: Identify patients correctly
Goal 2: Improve effective communication
Goal 3: Improve the safety of high-alert medications
Goal 4: Ensure safe surgery
Goal 5: Reduce the risk of health care-associated infections
Goal 6: Reduce the risk of patient harm resulting from falls
Lessening the Negative Impact of Human Factors Linking Staffing Variables & P...API Healthcare
In the United States, healthcare is a $2.9 trillion industry, costs $9,255 per capita and consumes 17.4% of the GDP.1 Healthcare is big business, and the way the entire industry conducts business is changing. While hospitals have always been in the business of providing patient care, the care delivery and payment models are undergoing an enormous paradigm shift. It’s no longer about the number of services provided, but instead about the quality of care delivered.
PCMH implementation, highly associated with important outcomes for both patients and providers. The rate of emergency department visits was significantly
lower in sites with more PCMH effective implementation. Efficient PCMH implementation favorably associated with patient satisfaction, staff burnout, quality of care, and use of health care services.
Tasks for discussion week 91. Critique problem and mission stat.docxssuserf9c51d
Tasks for discussion week 9:
1. Critique problem and mission statements.
Team A:
Problem and mission statement: Correct procedure performed on patient by wrong doctor. The team identified the problem did not result in direct patient harm, but the process error had potential to cause direct patient harm. The mission statement included root cause analysis of the event with recommendations for improvement (monitor over 3-month period) and report findings with positive improvement at end of monitoring period.
Team B:
Problem and mission statement: Identified event as sentinel event. Noted full safety procedures in place over past five years. Mission to determine root causes of event and demonstrate successful plan for measurable improvement in three months or less.
Each team’s problem statement provides the appropriate and concise evaluation of the event. Team B’s mission statement provides for a time frame that is shorter for resolution given the gravity of the sentinel event.
2. Analyze team processes, review process flow chart and cause effect diagram, data
presented in two graphs and one table.
The flow chart with the notes on the procedures/practices and policies and the survey with staff with the nurse – physician interaction sharply contrasts with the results of the two bar graphs indicating positive results with training and sign off on universal protocols.
My take away from this is that being checked off on a process and going through the motions of a checkoff can be greatly influenced by the culture of the environment.
3. From the following selections which shaped the root cause discussions at both hospitals, teams selected the red highlighted statements as the two best root causes:
a. Chairman of Surgery is clearly the biggest contributor to the problem, and is the
single root cause, since he caused the near miss/sentinel event.
b. The culture in our OR suite is not conducive to patient safety.
c. The disruptive physician policy at our organization is ineffective in shaping
physician behavior. It needs to be re-written.
d. The Nursing/Physician relationships in our OR suites are compromised by poor
communication skills, ineffective conflict resolution, and no sense of team.
e. From CNO down through nurse managers, the nursing leadership at our
organization is ineffective
f. Educational offerings regarding the NPSGs, Universal Protocol, and Time-out
procedures are clearly lacking, and the single most important root cause of
these events.
g. The turnaround time between cases is reaching crisis proportions and surgical
volume is on a downward trend in both of these hospitals
4. Defend the teams’ position on the choice of these two; however, if you, as a case study team choose alternative root causes from this list given the data presented, defend that position.
Reflecting with my statement in question #2: training in procedures and checkoffs on procedures does not guarantee the outcomes. The culture of safety is related to the abi ...
Our current approach to root causeanalysis is it contributi.docxgerardkortney
Our current approach to root cause
analysis: is it contributing to our
failure to improve patient safety?
Kathryn M Kellogg,1 Zach Hettinger,1 Manish Shah,2 Robert L Wears,3
Craig R Sellers,4 Melissa Squires,5 Rollin J Fairbanks1
ABSTRACT
Background Despite over a decade of efforts to
reduce the adverse event rate in healthcare, the
rate has remained relatively unchanged. Root
cause analysis (RCA) is a process used by
hospitals in an attempt to reduce adverse event
rates; however, the outputs of this process have
not been well studied in healthcare. This study
aimed to examine the types of solutions
proposed in RCAs over an 8-year period at a
major academic medical institution.
Methods All state-reportable adverse events
were gathered, and those for which an RCA was
performed were analysed. A consensus rating
process was used to determine a severity rating
for each case. A qualitative approach was used
to categorise the types of solutions proposed by
the RCA team in each case and descriptive
statistics were calculated.
Results 302 RCAs were reviewed. The most
common event types involved a procedure
complication, followed by cardiopulmonary
arrest, neurological deficit and retained foreign
body. In 106 RCAs, solutions were proposed.
A large proportion (38.7%) of RCAs with
solutions proposed involved a patient death. Of
the 731 proposed solutions, the most common
solution types were training (20%), process
change (19.6%) and policy reinforcement
(15.2%). We found that multiple event types
were repeated in the study period, despite
repeated RCAs.
Conclusions This study found that the most
commonly proposed solutions were weaker
actions, which were less likely to decrease event
recurrence. These findings support recent
attempts to improve the RCA process and to
develop guidance for the creation of effective
and sustainable solutions to be used by RCA
teams.
INTRODUCTION
The problem of morbidity and mortality
from adverse events in healthcare has
undergone over 15 years of intense scru-
tiny, funding, regulation and research
worldwide. Despite dramatically intensi-
fied efforts to increase the safety of the
healthcare system, reports have suggested
that safety has not improved. The adverse
event rate has remained essentially the
same, suggesting that our current solu-
tions to the problem are not working.1–10
This lack of progress persists despite the
devotion of a tremendous amount of
financial and human resources at the
local, state and national levels in an effort
to reduce errors and patient harm.11
One common, resource-intensive, prac-
tice is the root cause analysis (RCA)
process, which is used by most hospitals
in the USA.12–15 The RCA process has
been mandated in response to sentinel
events by the Joint Commission since
1997.16 Although the RCA process has
been presumed to induce change, its
effectiveness has been questioned and
there is not robust literature to support
its efficacy.17 18 In healthcare, there are
reports of difficul.
Getting Right with The Joint Commission's Communication GoalSpok
In pursuit of its mission, The Joint Commission audits and accredits more than 21,000 healthcare organizations and programs for clinical excellence and patient safety. The organization also publishes an annual list of National Patient Safety Goals (NPSG) highlighting specific areas of focus for improvement within the healthcare environment. Improving communications is included in the list as a high priority because communication delays and errors can have serious consequences, for patients as well as hospitals.This webinar explores some of the communication challenges hospitals face and how technology can help them comply with The Joint Commission’s communication goal (NPSG 2).