8923333quality improvement models presented by donna m daniel phd1401
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Quality Improvement
ModelsPresented by: Donna M. Daniel, PhD
Atlantic Health
Morristown, New Jersey
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Quality Basics eries
!au"ht #y $uality e%perts &or sta' inQuality Improvement (r"ani)ations,Quality Basics &ocuses on the&undamentals o& $uality in areas such asthe history o& $uality improvement,
methods and models, per&ormancemeasurement and other *ey topics.
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Quality Basics:
Quality Improvement Models
Presented by Donna M. Daniel, PhD
September 25, 2!
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Quality Improvement "Models#
$r%ani&ational 'rame(or)s * Quality Mana%ement Models
Baldri%e +valuation Process
IS$ - erti/ication
Balanced Scorecard 0pproach
Quality Improvement Methods
Si1 Si%ma
uman 'actors
3ean or 4PS 4oyota Production System6
PDS0 ycles or Model /or Improvement
Quality Improvement 4heories
7eliability 4heory
Spread 4heory
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Main oncepts
Baldri%e: Performance Excellence
(value/quality service)
IS$ : Performance Excellence
(internal processes)
Balanced Scorecard: Performance Excellence (measurement of business processes and external
outcomes)
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Baldri%e 0(ard
4he Malcolm Baldri%e 8ational Quality
0(ard is an a(ard %iven, by the
President o/ the 9nited States, to
applyin% or%ani&ations that meet
desi%nated criteria.
Mana%ed by 9.S. ommerce
Departments 8ational Institute o/
Standards and 4echnolo%y 8IS46
Malcolm Baldrige
1922-1987
26th Secretary of
Commerce Award As Quality Model
;More than any other pro%ram, the Baldri%e Quality 0(ard is
responsible /or ma)in% <uality a national priority and
disseminatin% best practices across the 9nited States.;
==4he Private=sector ouncil on ompetitiveness
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riteria /or Per/ormance +1cellence
3eadership
Strate%ic plannin% ustomer and mar)et /ocus
Measurement, analysis, and )no(led%emana%ement
uman resource /ocus
Process mana%ement
Business results
4he Baldri%e riteria is a /rame(or) that or%ani&ations can use toimprove their overall per/ormance.
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>ey 4ools
4he Baldri%e riteria does not instruct or%ani&ations to
use any speci/ic improvement tool, but allo(s the
or%ani&ation to select the tool appropriate to their
improvement e//orts.
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In ealthcare?
Baldri%e 0(ard 7ecipients
2@ A 8orth Mississippi Medical enter = 4upelo, MS
25 A Bronson Methodist ospital A >alama&oo, MI
2 A 7obert Cood ohnson 9niversity ospital
amilton A amilton, 8
2E = Baptist ospital, Inc. = Pensacola, '3F Saint
3u)es ospital o/ >ansas ity = >ansas ity, M$
22 = SSM ealth are = a health care system in
/our states I3, M$, $> and CI
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IS$ - erti/ication
IS$ - is a series o/ international standards initially
published in -G! by the International $r%ani&ation /or
Standardi&ation IS$6, Heneva, S(it&erland.
4he standards speci/y re<uirements andrecommendations /or desi%n and assessment o/ a
mana%ement system, the purpose is to ensure products
and services meet customer re<uirements.
IS$ re%istration determines (hether a company
complies (ith its o(n <uality system.
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riteria /or IS$ erti/ication
ustomer 'ocus
3eadership
Involvement o/ People Process 0pproach
System 0pproach
ontinual Improvement
'actual 0pproach to Decision Ma)in%
Mutually Bene/icial 7elationships
oyle, David. IS$ Quality Systems andboo). Butter(orth=einemann 34D, $1/ord, -G
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>ey 4ools o/ IS$
+lowchartin"
Process mappin"
ause and e'ect dia"rams
Plan-Do-hec*-Act ycles
and more
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ealthcare applications o/ IS$
ompanies and health care or%ani&ations re%istered to IS$
have reported si%ni/icant reductions in customer
complaints, improved client relations, decreased employee
turnover and reductions in operatin% costs.-
It supports the business (hile assistin% (ith sa/ety, <uality andimprovement on a continuin% basis. 2
3eelanau Memorial ealth enter improved overall /inancial
per/ormance by - , reduced annual employee turnover /rom
J to -2 , and their lon%=term care /acility no( meets -
o/ their customers e1pectations.E
- K E. Dillon, 3. 7ad, ealthcare and IS$ . 0n intervie( (ith Dr. Michael ra%o. QualityMana%ement, Sept*$ct 22. E=!.
2. Quality Drives Business Improvement in ealthcare.http:**(((.standards.or%.au*S408D07DS*8+CS7$$M*40S*2E-*+03407+*+03407+.4M
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Balanced Scorecard
Developed in the early -Ls by Drs. 7obert >aplan
and David 8orton
Distin%uishin% /eature is based on "(hat companies
should measure in order to LbalanceL the /inancialperspective#
More than a measurement system A a mana%ement
system
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omponents
'or each o/ the /our perspectives, obectives, measures,tar%ets and initiatives are outlined.
3earnin% K Hro(th A 4o achieve our vision, ho( (ill (e
sustain our ability to chan%e and improveN ustomer A 4o achieve our vision, ho( should (e
appear to our customersN
'inancial A 4o succeed /inancially, ho( should (eappear to our shareholdersN
Internal Business Processes A 4o satis/y ourshareholders and customers, (hat business processesmust (e e1cel atN
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Improvement Methodolo%ies
3ean
uman 'actors
Si1 Si%ma
Model 'or Improvement
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Main oncepts
3ean: ↓ CasteF ↑ +//iciency internal processes6
uman 'actors: ↑ Per/ormanceF ↓ Oariation sta//
abilities6
Si1 Si%ma: ↑ Per/ormanceF ↓ Oariation cost savin%,
business %oals6
Model 'or Improvement: ↑ Processes
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3ean 4hin)in%
De/inition
3ean 4hin)in% is a (ay to do more and more (or)(ith less and less=less human e//ort, lesse<uipment, less time, and less space=(hile comin%closer and closer to providin% customers (ithe1actly (hat they (ant.
4he aim o/ lean is to eliminate (aste.
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De/inin% characteristics: - Principles Base your mana%ement decisions on a lon%=term philosophy, even at the e1pense o/ short=
term /inancial %oals.
reate continuous process /lo( to brin% problems to the sur/ace.
9se "pull# systems to avoid overproduction.
3evel out the (or)load.
Build a culture o/ stoppin% to /i1 problem, to %et <uality ri%ht the /irst time.
Standardi&ed tas)s are the /oundation /or continuous improvement and employeeempo(erment.
9se visual control so no problems are hidden.
9se only reliable, thorou%hly tested technolo%y that serves your people and process.
Hro( leaders (ho thorou%hly understand the (or), live the philosophy, and teach it toothers
Develop e1ceptional people and teams (ho /ollo( your companys philosophy.
7espect your e1tended net(or) o/ partners and suppliers by challen%in% them and helpin%them improve.
Ho and see /or yoursel/ to thorou%hly understand the situation.
Ma)e decisions slo(ly by consensus, thorou%hly considerin% all optionsF implementdecisions rapidly.
Become a learnin% or%ani&ation throu%h relentless re/lection and continuous improvement.
The Toyota Way: 14 Management Principles From The World's Greatest Manufacturer. by e//ery 3i)er, . McHra(=ill. 2E.
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>ey 4ools o/ 3ean 4hin)in%
Tools include but are not limited to t!efollowin"
Oalue Stream Mappin%
Process Mappin% Po)a=o)e error=proo/in%6
Pull Systems >anban A "si%nal#6
Oisual (or)place 5S = Sort, Strai%hten, Shine,Standardi&e, Sustain6
On ean !nterprise and "ts Potential #ealthcare $pplications, by Martin, >. ournal /or ealthcare
Quality. Ool 25. 8o 5. Sept*$ct 2E.
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ealthcare 0pplications o/ 3ean 4hin)in%
ospitals that are employin% 3ean 4hin)in%
Denver ealth
ohns op)ins
0lle%heny Heneral 9niversity o/ Io(a ospitals and linics
9niversity o/ Cashin%ton Medical enter
Oir%inia Mason
0tlantic ealth 0nd many more?
e// Mc0uli//e, 4om Moench and oan Cellman, "4he 3ean +nterprise Meets ealth are,# #ospitals
and #ealth %et&ors, anuary -5, 2.
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ospital +1ample
#efore
25
! min.
= -!--
-E2
-
i%h
i%h
Steps
Oalue=0dded Steps
4otal 4ime
Oalue=0dded 4imeQueues
$rders in Process
ando//s
Inspection Steps
Oariation in Methods
Oariation in ycle 4ime
After
2 min.
E2 = 2E
E
5
2
3o(
3o(
22 orporate Strate%ies and Development, 33
22 oan Cellman and 0ssociates, Inc.
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uman 'actors
De/inition
uman 'actors is the science o/ desi%nin% tools, tas)s,
in/ormation, and (or) systems to be compatible (ith the
abilities o/ human users. 4his includes both physical and co%nitive abilities.
Mi*e ilver, MPH, An Introduction to Human +actors - Desi"n &or /se #y Humans.HealthInsi"ht, 0as 1e"as N1, 2334.
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De/inin% characteristics
Dia%nosin% the type error e1ecution errors, plannin%
errors, violations 6
Execution errors = orrect Plan → /ailure in
e1ecution o/ the plan
Plannin" Errors A 'la(ed Plan
$iolations % Intentionally deviated /rom plan →
ne%ative conse<uence not intended
Desi%n interventions based upon the error type
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>ey 4ools o/ uman 'actors
Tools include but are not limited to t!e followin"&
0nalysis 4ools e.%. 0nalytic ierarchy Process, 4echni<ue /or
uman +rror 7ate Prediction, Decision Matri1 /or the 0llocation o/
'unctions6 0ssessment 4ools e.%. Situation 0(areness, Hlobal
0ssessment 4echni<ue, Situation 0ssessment 7atin% 4echni<ue,
Situation Present 0ssessment Method, Situation 0(areness
Oeri/ication and 0nalysis 4ool6
'or a listin% o/ uman 'actor 4ools please see, http:**(((.h/./aa.%ov*Portal*4oolsBy4ype4ally.asp16
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ealthcare applications
HealthInsi"ht5s pilot pro6ect and Quality and a&ety eries
Io(a ealth System IS6 Des Moines, I0 is applyin% human
/actors to their health system. Quote /rom Hail 8ielsen, ISs
Patient Sa/ety 0dministrator, "uman /actors en%ineerin% touches
nearly every aspect o/ patient care, /rom e<uipment use and thephysical environment to sta//in%, (or)load, and patients ability to
use devices prescribed by their clinicians.#
uman /actors en%ineers*en%ineerin% '+6 is reco%ni&ed
as use/ul in criti<uin% medical device desi%n, conductin%
usability testin%, and is credited (ith aidin% remar)ableimprovements in some areas o/ patient sa/ety.
http:**(((.<ualityhealthcare.or%*ihi*4opics*PatientSa/ety*MedicationSystems*3iterature*Improvin%Patien
tSa/etyByIncorporatin%uman'actors.htm
http:**ase.tu/ts.edu*mechanical*+7+3*Publications*0=-.pd/
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Si1 Si%ma
De/inition
Si1 Si%ma is de/ined as "a comprehensive and /le1ible
system /or achievin%, sustainin%, and ma1imi&in% business
success. Si1 Si%ma is uni<uely driven by close understandin% o/
customer needs, disciplined use o/ the /acts, data, and
statistical analysis, and dili%ent attention to mana%in%,
improvin% and reinventin% business processes.#
Pande, P, 8euman, 7, and avana%h, 7. 4he Si1 Si%ma Cay. McHra( ill 2
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De/inin% characteristics
Si1 critical elements
Henuine /ocus on the customer
Data=and /act=driven mana%ement Processes are (here the action is
Proactive mana%ement
Boundary less ollaboration
Drive /or per/ection
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>ey 4ools o/ Si1 Si%ma
4ools include, but are not limited to the /ollo(in%:
Brainstormin%
0//inity
Dia%rammin%
Statistical Process ontrol
4ests o/ Statistical Si%ni/icance
'orce 'ield dia%ram
Balanced Scorecards
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ealthcare application o/ Si1 Si%ma
Bed dischar%e process
7eduction o/ e1ternal, temporary employees
7adiation oncolo%y treatment plannin%throu%hput
ycle time to dia%nose breast cancer
3uc Pelletier, "Beth 3anham on Si1 Si%ma in ealthcare.# (ournal for #ealthcare )uality . Ool
25. 8o 2, March*0pril 2E.
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Model /or Improvement M'I6
De/inition
4he M'I is based on a "trial and learnin%# approach. 4his trial
and learnin% approach revolves around three <uestions.
Chat are (e tryin% to accomplishN 0IM6
o( (ill (e )no( that a chan%e is an improvementN
riteria or Measures6
Chat chan%es can (e ma)e that (ill result in improvementN
4estin% han%es6
'ocusin% on these <uestions accelerates the buildin% o/)no(led%e by emphasi&in% a /rame(or) /or learnin%, the use o/
data and the desi%n o/ e//ective tests or trial.
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De/inin% characteristics
0ddress the E /undamental <uestions
PDS0 ycle
Plan A han%e or 4est
Do A arry out plan
Study A Summari&e 3earnin%s
0ct A Determine 0ction
4o address the items mentioned above this methodolo%y
includes the /ollo(in% steps: Settin% 0ims, +stablish
measures, Select han%es, 4est han%es, Implement
han%es, Spread Improvement
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>ey 4ools o/ M'I
Tools include but are not limited to t!e followin"&
II Brea)throu%h Series ollaborative
PDS0 ycle
7un harts
ontrol harts
Measures: Balance, Process, $utcome
'lo(charts
omparison harts
Standardi&ation
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ealthcare applications o/ M'I
4he Model /or Improvement has si%ni/icantly a//ected
healthcare throu%h the II Brea)throu%h Series
ollaborative (hich incorporates the Model /or
Improvement.
= (((.<ualityhealthcare.or%
= (((.improvin%chroniccare.or%
= (((.ihi.or%
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7evie( o/ the Main oncepts
Baldri%e: Performance Excellence (value/quality service)
IS$ : Performance Excellence (internal processes)
Balanced Scorecard: Performance Excellence (measurement of business processes and external
outcomes)
3ean: 'aste Efficiency (internal processes)
uman 'actors: Performance $ariation (staffabilities)
Si1 Si%ma: Performance $ariation (cost savin"business "oals)
M'I: Processes
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omparison o/ sta// involvement across
methodolo%ies
S3 Mid=3evel 'ront=3ine
Baldri%e i%h i%h i%h to Med
IS$ i%h Med 3o(
BalancedScorecard
i%h Med 3o(
3ean i%h i%h i%h
uman
'actors
Med Med i%h
Si1 Si%ma Med i%h "Belts# Med
M'I Med Med i%h
Rlearly varies by or%ani&ation
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Shared oncepts
Similar concepts /or the si1 methodolo%ies include:
3eadership
Measurement*0nalysis A base decisions on
)no(led%e Product A business*customer*mar)et
People = human resources*mana%ement*sta//
involvement and or satis/action
Processes
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II Spread 4heory: 0 'rame(or) /or Spread
et*up-Target population
-Adopter audiences
-Successful sites
-Key partners
-Initial spread plan
ocial ystem-Key messengers -Communities
-Technical support
-Transition issues
+ o m
m u n i c a t i o n ( a w a r e n e s s , t e c ! n i c a l )
-nowled"e Mana"ement
Measurement and .eedbac
0eaders!ip*Topic is a ey strate"ic initiative
*1oals and incentives ali"ned*Executive sponsor assi"ned
*2ay*to*day mana"ers identified
#etter 3deas-Develop the case -Describe the ideas
From IHI, Boston, Massachusetts
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977+84 C0
Cait /or cardiolo%ist
7eliance on memory
7eliance on memory, lac) o/ability to reco%ni&e /ailure
+D on divert
B+44+7 ID+0
+D activate ath 3ab
Standin% 0S0, beta bloc)erorder /or 0MI
Pharmacist in +D
8o $7 "bloc)in%#
$n Better Ideas
4han)s to Qualis ealth*Sharon +loranta, MD.
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$n Set=9p: 0dopter ate%ories
Innovators
EarlyAdopters
EarlyMajority
LateMajority
Traditionalists
2.5% 13.5% 34% 34% 16%
From Rogers,
1995
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! 3eadership 3evera%e Points
-. +stablish and oversee system=level aims /or
improvement at the hi%hest Board and leadership level
2. 0li%n system measures, strate%y and proects in a
leadership learnin% system
E. hannel leadership attention to system=levelimprovement
. Het the ri%ht team on the bus
5. Ma)e the '$ a <uality champion
@. +n%a%e physicians: 0void "monovo1ople%ia# or
"paralysis by one loud voice#
!. Build improvement capability
II Chite Paper by ames 3. 7einertsen, MD, Michael D. Pu%h* Maureen Biso%nano, "Seven
3eadership 3evera%e Points 'or $r%ani&ation=3evel Improvement in ealth are.#
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$n ommunication:
"ampai%n# concept
Practice Passion Pull
P4A+T3+E: Chat people actually do and ho(
they do it. ou must %et to this level o/ chan%e.
PA356: 'i%ure out ho( to attach theener%ies o/ the people (ho are passionate
about (hat you are tryin% to do.
P700: 0n e//ective campai%n attracts people
rather than e1hortin% them to oin
4han)s to '07*4om Hilmore and Qualis ealth*Sharon +loranta, MD.
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Seven Spreadly Sins
-. Start (ith lar%e pilots
2. 'ind one person (illin% to do it all
E. Be vi%ilant and C$7> 07D+7
. I/ a process (or)ed in the pilot, then it should be spread9808H+D
5. 7e<uire the person (ho drove the pilot team to beresponsible /or hospital=(ide spread
@. 3oo) at de/ects on a Q9074+73 basis
!. +arly on, e1pect mar)ed improvements in outcomes(ithout re%ard to process improvements
4han)s to II and Qualis ealth*Sharon +loranta, MD.
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IIs 7eliability 4heoryII Chite Paper by 4homas 8olan, PhD, 7o%er 7esar, MD,arol araden, PhD, 'rances 0. Hri//in, 774, MP0, "Improvin%the 7eliability o/ ealth are.#
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De/inin% "7eliability#
i%hly 9nreliable TG
-=-
- or 2 /ailures in - cases6 UG=
-=2 5 /ailures or less in - cases6 5
-=E 5 /ailures or less in - cases6 .5
-= 5 /ailures or less in -,6 .
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0ppropriate are Measure(uly +,,- through (une +,,
6ational avera"es as reported to t!e Quality6et data ware!ouse8 lide provided by 2ale '8 #rat9ler 25 MP: 5.MQ :ospital3nterventions Q35 upport +enter8
;<= :i"!
=><> 0ow
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BCB 0ow
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-=2 56 is the $83 %oal /or?.
8on=catastrophic processes
De/inition: /ailure o/ the process does not lead to death or
severe inury (ithin hours o/ the /ailure
-=- per/ormance or (orse is commonly seen in these
processes
Chy are (e operatin% at -=- despite all o/ our talents and
resourcesN
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4hree=tier Desi%n Strate%y
Prevent initial /ailure usin% intent and standardi&ation
Identi/y de/ects usin% redundancy6 and miti%ate
Measure and then communicate the learnin% bac) into
the desi%n process
' 7eliability
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' 7eliability
3evel - chan%es only Step -6
CHF Protocol For All
Admitted Patients
All itemson protocol
done
Protocol Not Used
Portionsof
protocol
not used
50-80%
10-25% 10-25% Best
ffort
10-1
!tandardi"ation mostl# structure
$eminders
Aareness and trainin&
Feed'ac( of data
Hard or(
Usual !trate&ies
)e*el 1
' 7 li bilit
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' 7eliability
3evel - and 3evel 2 chan%es Step 26
CHF Protocol For All Admitted Patients
All items on
protocol doneProtocol Not Used Portions of
protocol not used
50-80% 10-25% 10-25% Best ffort
10-1
*er# patient&ettin& lasi+
re*ieed '#
p,armac# for a d+
of CHF
P,armac# starts
t,e protocol if d+
CHF
Best effort
'arel# 10-2
$eminders 'uilt into s#stem
efault desired action
$edundanc#
!tandardi"e process
)e*el 2 c,an&es at
indi*idual process le*el
' 7eliability
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' 7eliability
3evel - and 2 J %lobal chan%es Step E6
CHF Protocol For All Admitted Patients
All items on
protocol doneProtocol Not Used Portions of
protocol not used
50-80% 10-25% 10-25% Best ffort
10-1
*er# patient &ettin& lasi+re*ieed '# p,armac# for a d+ of
CHF
P,armac# starts t,e protocolif d+ CHF Best effort 'arel# 10-2
Portions of protocol not
used .,i&,est failure modes/!mo(in&
ad*ice .all
patients counseled
a'out smo(in& and
ris( of second ,and
smo(e/
etailed C
instructions .f
protocol on c,art cler(
prints out C instructions,eet at disc,ar&e/
AC use .f
protocol on c,art
p,armac# c,ec(s for use
of AC and calls ifnot ordered/
Best effort
10-2 to a
'arel# 10-3
$elia'ilit# esi&n
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1-!pecif# t,e steps
2-Use 'ot, le*el 1 and le*el 2 c,an&es to attain 10-1
3-!e&ment population to test t,e desi&n
!tandardi"ation to ac,ie*e
10-1 .4ier 1/
10% not done at all10% onl#
partiall# done
dentif# Failures and iti&ate
failures if possi'le to ac,ie*e
10-2 .4ier 2/
Prioriti"e failure modes and
redesi&n steps 1 and or 2 if
articulated &oal ,as not 'een
reac,ed .4ier 3/
1-Utili"e a s#stem le*el redundanc#
2-easure failure rates from step 1
3-o not use unless step one is at least 10-1
1-$edesi&n onl# if articulated &oal not
reac,ed
2-4ac(le one failure mode at a time
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oncepts associated (ith -=2
Decision aids and reminders built in
Desired action the de/ault
7edundant processes utili&ed
Schedulin% used in desi%n
abits and patterns
'alls in radiolo%y
Standardi&ation o/ process is the norm
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Chere can you %o /rom hereNor o( to succeed in spite o/ the $ptions6
4hese tools allo( you to construct (hat you (ish:
Better trained (or) /orce
'ocused attention to obectives*%oals
It is about: Measurin%
7eco%ni&in%
0ccountability
0chievement
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408> $9Donna M. Daniel, PhD
donna.danielVatlantichealth.or%
!E=@@=E2!2
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!han* you &or your participation7
+or additional $uestions or resourcescontact the Per&ormance
Improvement QI( upport enter atpi$iosc8wa$io.sdps.or"
A recordin" o& this session will #eposted on www.MedQI.or"