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Quality Improvement 101. Barbara DeBaun, RN, MSN, CIC Kathleen Carrothers, MPH, CPHQ Cynosure Health. Todays Objectives. Describe the elements of process design Explain how to flow chart a process Describe the Model for Improvement Demonstrate 2 Performance Improvement tools. - PowerPoint PPT Presentation


  • Quality Improvement 101Barbara DeBaun, RN, MSN, CICKathleen Carrothers, MPH, CPHQCynosure Health

  • Todays ObjectivesDescribe the elements of process designExplain how to flow chart a processDescribe the Model for ImprovementDemonstrate 2 Performance Improvement tools

  • How Hazardous Is Health Care? (Leape)

  • *

  • 2001

  • 2003: Duke University Medical Center

  • 2007

  • Complexity of Healthcare

    90,000 people in an ICU every dayFive million Americans will receive care in an ICU in a yearAverage LOS in ICU is 4 daysSurvival rate is 68%Average patient requires 178 individual actions per day (suctioning, medication, wound care, etc.)An error is made 1% of the timeAverage of 2 errors/day/patient

    Gawande, A. (2007, December 10). The checklist: If something so simple can transform intensive care, what else can it do? The New Yorker.

  • Why We Come To WorkPick a dotGoals, measure, current performanceMove the dotSelect intervention, PDSAShare the dotThe Heart MotivatesShare a StoryData Drives Decisions

  • 10 Years AgoCentral Line Blood Stream Infections were a part of doing business

    Ventilator Associated Pneumonia was an unfortunate consequence of being sick

    Sepsis was defined as shock from infection and carried a 50% mortality rate

  • 2012: Zero Tolerance

  • The Tennis Ball Exercise

  • How To PlayBreak up into groups of 4-5 peopleSelect - Timer, Scribe, LeaderUsing your tennis balls, spend 5 minutes designing a process that meets the following specifications:Each ball must be touched by each person at least one timeThe ball cannot be passed to the person directly next to youThe balls must be moved from person to personTime your processThe goal is to build a process that meets the design specifications in the shortest amount of timeAfter 5 minutes we will get the best time from each teamYou will then have another 5 minutes to improve your process

  • What Did You Do?

    Formed a teamDesignated rolesBrainstormedDesigned a processMeasured its performanceBenchmarked its performanceAnalyzed the process designRedesigned your processMeasured your new process, etc.

  • Learning PI From Tennis BallsBefore you can improve a process you need to know how it worksListen to all members of your teamEspecially those who are closest to the processShare improvement ideasTry them

  • More Learnings

  • Performance Improvement Tools

  • Facts About FlowchartsUsed to visually explain a process and the interrelationship between process stepsAllows analysis and better understanding of a processGreat way for a workgroup to better understand their environmentExcellent training documents

  • Commonly Used Flowchart ShapesIndicates starting or ending points of process

    Names or describes an individual task or procedure

    Indicates a conditional branch; a question or a decision; a variation in the processStart or EndStart or EndTask or ProcedureBranch

  • StartGather ingredientsPreheat oven to 325 FPrepare baking panBlend water, oil, and eggs in medium bowlAdd mixSpread evenlyBake as directed belowCool completely in panCut and serveSpoon batter into prepared pan Stir until moistenedYummy Example

  • StartGather ingredientsPreheat oven to 325 FPrepare baking panBlend water, oil, and eggs in medium bowlAdd mixSpread evenlyCool completely in panCut and serveSpoon batter into prepared pan Stir until moistenedAre you at high altitude?NoAdd cup flour and addl 2 Tbsps. waterYesPan type?Bake 45-50 minutesGlassMetalBake 40-45 minutes

  • Flowcharts

    Identifies parts of the process where data can be collected

    Serves as a training tool to understand the complete process

  • Flowchart Analysis

    What does your process look like?What does the desired process look like? Compare both charts, looking for areas where they are differentFocus improvement efforts on the differences or areas of rework and delays

  • *Call between MDs office & ORRoom is bookedMDs office faxes paper workComplete?Pt. arrivesPaperwork checked againComplete?Office called & remindedPt. taken to ORPt. held in pre-op for MD to complete paperwork

  • Give It a TryAt your table pick one of the following processes to flowchart:Packing for the last trip you tookPreparing the last meal you cookedGetting here todayDetermine the start and ending point of the process

  • Decisions to MakeDecide on the level of detailSimple macro-flowchart shows only the general process flowDetailed flowchart shows all actions and decision points

  • Go For ItIdentify the major steps in the processWrite each step on a post-it noteArrange the post-it notes in the desired sequenceAdd directional arrows and decision diamondsKeep all yes choices in the same direction

  • Flowchart Analysis

    What does your process look like?What does the desired process look like?Consider flowcharting to compare the real world with the policy Focus improvement efforts on the differences or areas of rework and delays

  • FishboneAlso called cause-and-effect diagramCan reveal key relationships among various variables, and the possible causes provide additional insight into process behaviorOften used in root cause analysisPeopleProcessesEquipment

  • Investigating Practices to Prevent CR-BSI

    Catheter-Related Bloodstream Infection


    Line Colonization/Contamination

    Number ofCatheters and/orLumens




    Staffing Acuity/Time

    Site Selection

    Lack of hand hygiene

    Line inserted withoutusing sterile technique

    Dressing not changed on time

    Dressing not occlusive

    Line accessed without clean technique including alcohol swabbing of access site

    Poor technique when obtaining blood cultures

    More lumens on line than needed

    Line not needed but not removed

    More than one central venous catheter

    No gown, mask, gloves or hair covering during insertion

    Chloraprep not used for skin prep prior to line insertion

    Line manipulation

    Multiple attempts

    Breaks in sterile technique

    Inadequatedraping prior to insertion

    Treatment basedOn false positive/contaminatedblood cultures

    Blood cultures drawn through line and results questionable

    Antibiotic use outside hospital guidelines

    Blood leftIn line/end cap

    Line from ED/field not changed

    Blood at insertion site not removed

    Vascular end caps not changed

    Blood left in end caps

    IV tubing hanging without covered end

    IVF and components not changed according to policy

    Dressing changes done without appropriate supplies

    Inappropriate use of ultrasound devices during line insertion

    TPN infused via existing line

    Inexperienced clinicians

    Resident unfamiliar with policy

    Nurses do not know dressing change due; no dates on dressing

    Policies not written or not current

    Supplemental staff unaware of policy/lack training

    Policy unavailable to medical staff

    Medical staff not supportive of policies

    Internaljugular or femoral site used

    Insertion site near tracheostomy

    Nurses too busy to change dressing

    MD inserts line alone-too busy to get nurse assistance

    Supplemental nursing staff

    Inexperienced nursing staff

    Other opportunity for dressingContamination

    Line inserted via undesirable site (i.e., femoral) not changed

    Line in place but no longer needed

  • The Model for Improvement

    So You Think You Can Change?

  • While all changes do not lead to improvement, all improvement requires change.Thomas Nolan, The Improvement Guide

  • What Are We Trying to Accomplish?

    Developing the teams Aim Statement*

  • From Alice in Wonderland



  • By WHEN?

  • Clear and Unambiguous Target

  • AIM Statements

    Reduce heart failure mortality rate by 40% by September 1, 2012Reduce falls with injury on 4 West to zero by November 30, 2012

  • What Are You Trying to Accomplish?At your tables, for the next 5-10 minutes create an AIM Statement for a project you are working on or planning to start

  • Evaluation and SharingDid your AIM statement:Have a clear numerical goal?Have a bold but realistic goal?Clearly articulate what you want to achieve and by when?Can your AIM statement be given in any elevator?Would you change your AIM statement?If so, what would you change and why?

  • How do you know if a changeis an improvement?

  • Why Measure?How else will you know that the change(s) you made resulted in improvement?

  • LimitationsOne VoiceUseful, not perfectSample

  • Select right measuresRapid resultsAdapt interventions

  • Types of Measures*

  • Process MeasuresWhat you getOutcome MeasureBalance Measures

  • OutcomeProcessBalanceMEASURES

  • How Will We Know If A Change Is An Improvement?At your tables, for the next 5-10 minutes decide what measure(s) will help you know if you have made an improvement

  • Evaluation and SharingDoes the measure(s) you selected allow you to understand if you have made a change? Would you change your measurement plan? If so, what would you change and why?

  • The PDSA CycleWhat will happen if we try something different?Lets try it!Did it work?Whats next?

    Plan Objective Questions & predictions Plan to carry out: Who?When? How? Where?

    Do Carry out plan Document problems


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