Steps to performance improvement


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BHM320 – Module 2 Case Study Expectations 1. The following case should be addressed in light of the concepts and material covered in this module. 2. Please answer ALL of the following questions in at least 2 full text pages. 3. The idea is for you to demonstrate YOUR understanding of and critical thinking on the modular topics, by developing this process. The Case Assignment 1. Please read: Robinson, P. (2004). Master the steps to performance improvement. Nursing Management. Chicago: May 2004.Vol.35, Iss. 5; Abstract: All work is a process, and performance improvement is an ongoing journey. Employees in any health care setting should evaluate and review current practices that impact operational performance for their specific location. Frontline patient care delivery staff members need to establish root causes, develop appropriate measuring tools, implement designed action plans, and evaluate outcomes. A bevy of quality improvement examples exists within health care organizations. The staff of Lehigh Valley Hospital/Muhlenberg used the W Edwards Deming Model for learning and improvement. Deming’s “PDSA” cycle examines a four-step process for quality improvement – Plan, Do, Study, and Act. This article presents an example of improving pre-procedure medication delivery incorporating the steps of Deming’s model. For the article – click here 2. Please answer ALL of the following questions: The article discusses Deming’s model, and points out several steps in the TQM implementation process within a healthcare organization. (a) Based on the four step model, how would you implement an improvement in the flow of patients from the emergency room of a hospital to admittance in a ward. (b) Assume the patient arrives after a car accident with some fractures. How do all of the patient’s checks and treatments along the way, “arrive safely” in the admitting ward. Reading Master the steps to performance improvement Paula Robinson. Nursing Management. Chicago: May 2004. Vol. 35, Iss. 5; pg. 45, 4 pgs Abstract (Summary) All work is a process, and performance improvement is an ongoing journey. Employees in any health care setting should evaluate and review current practices that impact operational performance for their specific location. Frontline patient care delivery staff members need to establish root causes, develop appropriate measuring tools, implement designed action plans, and evaluate outcomes. A bevy of quality improvement examples exists within health care organizations. The staff of Lehigh Valley Hospital/Muhlenberg used the W Edwards Deming Model for learning and improvement. Deming’s “PDSA” cycle examines a four-step process for quality improvement – Plan, Do, Study, and Act. This article presents an example of improving preprocedure medication delivery incorporating the steps of Deming’s model. » Jump to indexing (document details) Full Text (1447 words) Copyright Springhouse Corporation May 2004 [Headnote] Plan, Do, Study, and Act to enhance your facility’s patient care initiatives. [Headnote] Abstract: When implementing process improvements, create awareness and include staff members most directly involved with the system. [Nurs Manage 2U04:35(5):45-48] All work is a process, and performance improvement is an ongoing journey. Striving for excellence is a commitment to the continuous pursuit of improving patient care and outcomes, decreasing medical errors, and enhancing patient safety. Employees in any health care setting should evaluate and review current practices that impact operational performance for their specific location. Frontline patient care delivery staff members need to establish root causes, develop appropriate measuring tools, implement designed action plans, and evaluate outcomes. Sound familiar? We use these terms daily in the direct care offered to patients. Enlarge 200% Enlarge 400% Assist staff members to expand this process beyond the traditional roles. Apply what you already know to broaden your vision and approach to nursing care. You may achieve this by focusing on the system itself. Rarely does a single unit have the sole responsibility for all clinical functions. Members involved in improving the system’s performance quality should review current policies. Design compliance efforts to establish a culture that supports the structures and plans that already exist within the network. Keep in mind, though, that you may need to consider research on new evidence-based approaches to provide the best standard of care for a specific patient population. A bevy of quality improvement examples exists within health care organizations. Each facility must decide which model works best for its situation. The staff of Lehigh Valley Hospital/Muhlenberg used the W. Edwards Deming Model for learning and improvement. Deming’s “PDSA” cycle examines a four-step process for quality improvement-Plan, Do, Study, and Act. To plan, you must first understand existing conditions. Then, you can better identify the need for change and move onto doing and studying, where you analyze collected data and change implementation possibilities. Once you’ve initiated implementation, you can study results.1 If you create a successful process and achieve positive outcomes, then you can advance to acting on these practices and incorporating them into daily unit performance. If you encounter negative outcomes, make adjustments until achieving quality improvement.2 The following example of improving preprocedure medication delivery incorporates the steps of Deming’s model. Understanding existing conditions Lehigh Valley Hospital/Muhlenberg staff collected data to reflect the compliance rate of medication arriving at the outpatient surgical unit prior to surgical or diagnostic procedures. To decrease delays and ensure adequate patient preparation, staff targeted the ambulatory staging unit (ASU) and the pharmacy. RNs and an administrative partner from the ASU collected the data used to obtain actual baseline measurements. The administrative partner reviewed completed charts the day before project initiation, placing the first carbon of the physician’s order sheet in a notebook and passing it to the nursing staff for review. The RNs entered the patient’s medical record number and allergies on the order sheet after completing the evening’s preprocedure phone calls. They forwarded this information to the pharmacy. During the initial tracking phase, staff participants tracked missing medications using a compiled list based on the medication needs for that day. After the first month, they calculated the data by using the total number of cases as the denominator and the number of noncompliant charts as the numerator. The data showed that only 12% of all medications ordered preprocedure arrived at the ASU prior to patient admission. This finding highlighted the need for a process improvement initiative that included all interdisciplinary stakeholders in its design and implementation. The design team included the ASU nursing staff, physicians’ office staff, and pharmacy personnel. Analysis Process analysis began with an Internet literature review to establish whether or not benchmarking existed for this particular indicator. Participants then evaluated the facility’s current policies and systems. This information allowed them to explore various strategies that would further efforts toward improving the medication delivery system. Participants also met with pharmacy staff to uncover any issues that impeded the pharmacy from timely medication delivery. They targeted several areas for improvement and developed action plans for the pharmacy and the ASU. Root causes included the following: * Medication requiring refrigeration remained in the pneumatic tube system all night if not retrieved before the unit closed. * Late orders compromised turnaround time, which delayed the availability of the next day’s medication arriving at the unit before it closed. * Pharmacy staff was unable to consistently access patient information and drug history on the computer because certain outpatient registrations weren’t activated in the system. * Lack of communication between ASU and pharmacy staff led to medications not being delivered to the proper location the night before. For example, pharmacy staff sent medications to the holding room rather than to the ASU. * Preprocedure medications for patients lacking a completed history and physical with documentation of allergies delayed pharmacy turnaround time because the allergy information needed to be provided by the patient during the preprocedure phone call. Phone calls made by the evening shift started at 4:30 p.m. and usually took until 7:30 p.m. for completion. * The constant use of stock medication for certain preprocedure orders bypassed medication delivery and preparation safeguards. Implementation and results Identifying the potential causes and contributing factors enabled the team to develop a data collection tool that addressed compliance issues. Staff measured the preceding concerns monthly and addressed changes on an ongoing basis, which grew easier as barriers disintegrated. The dissemination of accurate, timely, and appropriate information between the pharmacy and physicians’ offices supported a collaboration of internal and external teamwork that’s promoting the following positive outcomes: 1. Placing the preprocedure orders (carbon copy) in one workbook enables the nursing staff to review all medication orders. This one task is assigned to evening shift RNs on a rotating basis. When the orders are signed off, pharmacy staff members receive all of the carbons. This enables them to review which medications require refrigeration, making their preparation a priority so that they arrive at the unit before it closes. 2. Enhanced communication with physicians’ offices allows the nursing staff to obtain current allergy information on outpatients, instead of waiting for the preprocedure phone call. This, in turn, enables pharmacy staff to fill the orders early in the day when more staff is available to meet the demands. 3. ASU is divided into three nursing stations with a specific population assigned to each section. Due to staffing in the evening, two units close at 4:30 p.m. Phone extensions from both units are forwarded to the remaining open nursing station, improving communication with the pharmacy. 4. Staff checks the pneumatic tube on an hourly basis and at unit closing to ensure timely removal of medications arriving in this manner. Also, by removing the carrier, pharmacy members are able to continue filling orders throughout the evening. 5. Information services and network computer support staffs assist pharmacy staff in obtaining medical history on patients scheduled to arrive for the next day’s procedure. 6. RNs assist pharmacy personnel with distribution of medication by documenting the destinations on the order sheet carbon copy. All departments receive results via e-mail, enabling staff not directly involved in the process to examine the changes and share in the improvement process. A storyboard of graphs posted in the ASU enables staff to view progress at a glance. Upon reaching its goal of 90% to 100% compliance, the team measured the indicator for four months to ensure consistency. It also performed a six-month follow-up to ensure that ASU continued meeting its target. Standardization and prevention Both disciplines have continued to adhere to the process change; the compliance of pre-procedure medication arrival at the ASU the night before has remained in control for the past 13 months. The improved system is now part of the orientation process for all of the unit’s new RNs and administrative partners. Verifying allergies, marking the correct drug destination, and removing the use of stock medications administered pre-procedure improves patient safety and customer satisfaction. Team members track performance daily and, if a medication is missed, they’re alerted for future trends that may indicate a lack of control with this indicator. Following the information daily enables the staff to troubleshoot potential problems and devise timely interventions, if needed. Lessons learned Process changes need not be complicated. Encourage your staff members to make a difference in their care environment. Instead of complaining about inefficiencies, they can Plan, Do, Study, and Act their way to an enhanced multidisciplinary care delivery. [Reference] References 1. Lehigh Valley Hospital: “Performance improvement plan,” Lehigh Valley Hospital and Health Network Administrative Policy. 2. Ibid. [Author Affiliation] By Paula Robinson, RN,BC, BSN [Author Affiliation] About the author Paula Robinson is a patient care specialist at Lehigh Valley Hospital/Muhlenberg, Bethlehem, Pa.

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