The World ofThe World of

QUALITYQUALITYLee Scott RN, BSN, CPHQLee Scott RN, BSN, CPHQ

Director of QualityDirector of Quality

Saint Cloud Regional Medical CenterSaint Cloud Regional Medical Center

• What is QualityWhat is Quality

• Performance ImprovementPerformance Improvement

• Regulatory ComplianceRegulatory Compliance

• National Patient Safety GoalsNational Patient Safety Goals

• Public ReportingPublic Reporting

The Quality UmbrellaThe Quality Umbrella

Total Quality Management

• Definition: TQM is a management philosophy that enhances and benefits our organization and all people associated with it by using processes that continuously improve the quality of all products, services, and outcomes.

• This results in:– INCREASED PATIENT SATISFACTION– INCREASED PRODUCTIVITY– INCREASED PROFITS– DECREASED COSTS– INCREASED MARKET SHARE

Performance ImprovementPerformance Improvement

•PI looks at our systems and processes and finds ways to improve them.

- Quality Planning- Who are our customers and what are our service lines?

-Quality Control- How do we measure our processes and outcomes (data analysis)

-Quality Improvement- How do we improve our existing processes and outcomes?

HOW DO WE DO THIS?

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PDCA- OUR QUALITY METHODOLOGYPDCA- OUR QUALITY METHODOLOGY

Analyze the ProblemAnalyze the Problem� Identify a problem� Map the process� Gather & analyze data� Identify possible causes� Plan the improvement

PlanPlan

Develop the solutionDevelop the solution� Generate potential solutions� Select a solution� Plan the solution

Implement the solutionImplement the solution

DoDo

Evaluate the resultsEvaluate the results� Gather & analyze data on the

solution� Achieved the desired goal?

� Yes – go to the next step, ACT� No – go back to step 1, Plan

CheckCheck

� Standardize the solut ion� Plan ongoing monitoring� Continue to look for improvements to ref ine

ActAct

= = Continuous Cycle of Continuous Cycle of improvementimprovement

REGULATORY COMPLIANCEREGULATORY COMPLIANCEWHO MEASURES SAINT CLOUD REGIONAL MEDICAL CENTER?WHO MEASURES SAINT CLOUD REGIONAL MEDICAL CENTER?

• Joint Commission

• CMS

• ACHA

• OSHA

• CUSTOMER

• Non-profit accreditation organization• Primary hospital accreditation organization• Accredit > 15,000 facilities in the US• Develop standards of care• Perform on site surveys every 3 years• Surveys are unannounced• Accreditation participation is voluntary

Joint Commission Joint Commission

National Patient Safety National Patient Safety GoalsGoals

• Goals that promote specific improvements in patient safety

• Based on: NEVER EVENTS (sentinel)– Actual incidents– Solutions based on current research

• 100% Compliance is required– Success or failure publicly reported– Safety is EVERYONE’S BUSINESS

Patient IdentificationPatient Identification

Goal 1: Improve the accuracy of patient identification.

- Patient’s first and last name

- Patient’s date of birth

Staff and employees may report to Joint Commission:

- Concerns about safety

- Concerns about quality of care

Hospital will take no disciplinary action!!

The Joint Commission websitecomplaint@jointcommission.org

1-800-994-6610

The Joint CommissionOne Renaissance Blvd.Oakbrook Terrace, IL 60181

Public Public ReportingReporting

GOALS• Increase public awareness

• Inform the public of quality activities

• Promote public accountability

Public ReportingPublic Reporting

Example: CORE MEASURES

• Pneumonia Care

• Heart Attack Care

• Heart Failure Care

• Surgical Infection Prophylaxis

• Patient Perception

Public ReportingPublic Reporting

St Cloud Regional St Cloud Regional Core MeasuresCore Measures

• Required by CMS

• Standardized survey (HCAHPS)

• Measures patient’s perception of care

• Publicly reported

• 27 questions

Patient PerceptionPatient Perception

Patient PerceptionPatient Perception

• QUIETNESS OF UNIT AT NIGHT!!

• Room and bathroom kept clean

• How well nurse listened to patient

• Adequate bathroom help

BIGGEST COMPLAINTS

WHAT IS QUALITY?

PEOPLE, PROCESS, OUTCOMES