© copyright, the joint commission performance improvement: getting started in your asc dana dunn...
TRANSCRIPT
© C
opyr
ight
, The
Joi
nt C
omm
issi
on
Performance Improvement: Getting Started in Your ASC
Dana Dunn RN, MBA, CNOR, CASCCertified Yellow BeltField Representative, ACAS
Client name/ Presentation Name/ 12pt - 2
© C
opyr
ight
, The
Joi
nt C
omm
issi
on
Learning Objectives
Describe The Joint Commission program for Performance Improvement
Review ready resources to get startedDemonstrate the basic steps to improvement
activities Develop a Performance Improvement Plan
Client name/ Presentation Name/ 12pt - 3
© C
opyr
ight
, The
Joi
nt C
omm
issi
on
Resources
The Center for Transforming Healthcare– Robust Performance Improvement (RPI)– Targeted Solutions Tools (TST)
Joint Commission Resources– “Tools for Performance Measurement in
Healthcare: A Quick Reference Guide 2nd Ed. 2008”
– “Root Cause Analysis in Health Care: Tools and Techniques 4th Ed. 2010”
Client name/ Presentation Name/ 12pt - 4
© C
opyr
ight
, The
Joi
nt C
omm
issi
on
Warehouse of Data
Daily, weekly, monthly, annual data ex,:– Environment of Care– Infection Prevention – Medication Management– Information Management– Patient Satisfaction– Business efficiency– Incident/occurrence reports
Client name/ Presentation Name/ 12pt - 5
© C
opyr
ight
, The
Joi
nt C
omm
issi
on
Performance Improvement
Organization-wide
Ongoing
Data-Driven
Client name/ Presentation Name/ 12pt - 6
© C
opyr
ight
, The
Joi
nt C
omm
issi
on
Leadership
Using DataPlanningCommunicatingChanging PerformanceStaffing
Client name/ Presentation Name/ 12pt - 7
© C
opyr
ight
, The
Joi
nt C
omm
issi
on
Performance Improvement
Governance/ Leadership
EC Plan:Safety/SecurityHazardous M & WFire SafetyEquipmentUtilities
EM Plan: Disaster PrepIC Plan:
HHSSIFlu Vaccine
MM Plan:High AlertLASAControlled Drugs
IM Plan:AccuracyTimely CompletionHIPAAEMR
Contracts:LinenHousekeepingPharmacyBiomed
Pt. Input: SurveysGrievancesPost op Calls
Quality Indicators:IncidentsOutcomesHigh RiskSentinel EventsFocused Studies
Peer Review/HR:CompetenceOutcomesStaffing Ratio
Client name/ Presentation Name/ 12pt - 8
© C
opyr
ight
, The
Joi
nt C
omm
issi
on
Collect Data: Internal/External
AnalyzePrioritizeExplain Why?
Collect Surveillance Data
Measurable Timeframe
How will you achieve the goals?
Basic Steps
Client name/ Presentation Name/ 12pt - 9
© C
opyr
ight
, The
Joi
nt C
omm
issi
on
Processes
Risk AssessmentAnalysisPrioritizeDetermine Goal(s)StrategiesMonitor Strategies- New dataRe-evaluate (Plan Evaluation
Client name/ Presentation Name/ 12pt - 10
© C
opyr
ight
, The
Joi
nt C
omm
issi
on
Risk Assessment Grid
Client name/ Presentation Name/ 12pt - 11
© C
opyr
ight
, The
Joi
nt C
omm
issi
on
Performance Improvement Plan
Position Statement -- Mission Responsibility Scope of Plan Data Collection, Frequency, Analysis Priorities Goals Strategies Evaluation of Plan’s Effectiveness
Client name/ Presentation Name/ 12pt - 12
© C
opyr
ight
, The
Joi
nt C
omm
issi
on
Summary
Leadership – is ultimately accountable for the safety and
quality of care provided.– uses organization-wide planning to
establish structure and processes that focus on quality and safety.
– prioritizes data collection and performance improvement activities.
– evaluates the effectiveness of the planning.
Client name/ Presentation Name/ 12pt - 13
© C
opyr
ight
, The
Joi
nt C
omm
issi
on
More Resources
Ambulatory Surgery Center Association (ASCA)
Becker’s Clinical Quality & Infection Control
Institute for Healthcare Improvement (IHI)
Many more on the web
Client name/ Presentation Name/ 12pt - 14
© C
opyr
ight
, The
Joi
nt C
omm
issi
on
References
The Joint Commission: CAMAC, Comprehensive Accreditation Manual for Ambulatory Care
The Center for Transforming Healthcare: – Robust Performance Improvement– Targeted Solutions Tools
Joint Commission Resources
© C
opyr
ight
, The
Joi
nt C
omm
issi
on
Questions?
Dana Dunn RN, MBA, CNOR, CASC VM: 630-792-6190