PERFORMANCE IMPROVEMENT

1. PERFORMANCE IMPROVEMENT

2. Performance Improvement Defined • A continuous state of “being” • Driven by our mission and vision • That stimulates individuals and teams to look at the way they deliver care & service • To identify the root causes of problems in systems • And to innovate to make improvements

3. THE GOAL: A high-reliability organization • The right care for every patient, every time • Humans are not highly reliable, but systems can be • It is the job of leadership to develop and maintain systems that make it hard for staff to make an error • It is also leadership’s job to hold staff accountable for using the systems

4. Hardwiring Excellence • Into the way we deliver care • Into the way we provide service • Into the way we develop our staff • Into the way we manage our finances • Into the way we grow our business

5. Defining our systems as “pillars” • Growth: methodical approach, well-researched, key stakeholders involved resulting in progress • Finance: planning, managing, charging and billing resulting in a profit margin to sustain current and future needs • People: well-trained, recognized, and rewarded staff resulting in commitment and dedication • Service: consistently exceeding customer expectations resulting in satisfaction

6. QUALITY (of course it has its own slide!) • Safe – do no harm • Effective – achieve the desired outcome • Timely – without delay • Efficient – without waste, without error • Patient-centered – individualized but not discriminatory • RESULT: excellent care

7. But we give good care … PROVE IT!

8. Alright, we will! • Performance scorecard – what gets measured gets managed • BUT … not everything that can be measured is worth managing, and everything that should be managed can not always be easily measured

9. Hospital-wide Performance • Growth: market share, volume • Finance: revenue, expenses, productivity • People: evaluation timeliness • Service: customer satisfaction • Quality: patient safety and best practice

10. Organizational Quality • National Patient Safety Goals: • Medication safety (reconciliation, look/sound alike, concentrations, labeling) • Health-care acquired infections (hand hygiene, deaths are sentinel events) • Falls (reduction program) • Patient identification (2) • Communication among caregivers (order readback, abbreviations, critical values, hand off)

11. Organizational Quality • CMS Core Measures • Surgical Infection Prevention: appropriate antibx given w/in 1 hour of cut time, d/c’d w/in 24 hr of surgery end • Acute Myocardial Infarction: ASA at arrival & d/c, beta blocker on arrival & d/c, 30 min door to drug time for thrombolytic, lipid assessment • Heart Failure: LVF assessment, ace inhibitor for LVSD, complete d/c inst (meds, f/u, wt, diet, activity, sx) • Pneumonia: appropriate antibx w/in 4 hr of arrival but after BC, BC w/in 24 hr if obtained, O2 sat assess • All: smoking cc, pneumococcal & influenza immunization

12. Departmental Performance“With great power comes great responsibility” Ben Parker • Your very own scorecard! • Everyone gets to report on how they are managing their productivity, expenses, staff evaluations and customer service • You decide how you and your staff will measure quality • You decide what processes need improvement and how to improve them

13. “Stop a moment, cease your work, look around you.” Leo Tolstoy • Quality is not about data, graphs, and reports • These are just tools to establish direction for your work • If you don’t know where you’re headed then you’re never lost

14. Data Collection – Essential Elements • Operational definition – describe in quantifiable terms what you will measure & how to measure it consistently (inclusion & exclusion criteria) • Know why you are collecting the data – what will you do with it once you have it? • What stratification will be important to have? • Will you collect all data points or just a sampling? How will you choose the sampling?

15. Data Pitfalls – Watch out! • Misunderstanding about how to collect data • Inaccurate measuring instruments • Cheating/ fear • Poor choice of collection period • Poor sampling techniques • Lost data • Bias

16. Data Analysis – Run Charts • Depicts data over time

17. Data Analysis – Control Charts • Shows trends over time • Uses statistically determined upper and lower limits to define a range of acceptability • Goal is to gain consistency in operation

18. Data Analysis - Histograms • Frequency distribution • Presents data organized in categories

19. Data Analysis – Pareto Charts • Tool to rank-order or prioritize problems, causes of a problem, or categories of some event or issue

20. Data Analysis – Cause & Effect Diagram (Fishbone) • Tool used to identify the multiple causes of any result, outcome, or problem

21. Data Analysis - Flowchart • Create a picture of a process • By outlining each essential step it is possible to streamline areas of overlapping efforts & eliminate unnecessary steps • Can also be used to standardize a step-by-step process

22. “If you want to achieve excellence, you can get there today. As of this second, quit doing less than excellent work.”Tom Watson, IBM founder • Let’s just find the people who are doing less than excellent work and tell them to knock it off and quit ruining it for the rest of us!

23. I’m from the Government & I’m here to help. • Conditions of Participation for Medicare and Medicaid require hospitals to have a hospital-wide QAPI program that focuses on the outcomes of their organization’s services • PPS hospital payments are dependent on this – CAH will soon be too

24. “Never mistake motion for action.” Ernest Hemingway • Quality Assessment and Performance Improvement are about improving care and service • It’s not about fulfilling a duty to country, hospital, or Quality Director

25. “Our plans miscarry because they have no aim. When you don’t know what harbor you’re aiming for, no wind is the right wind.”Seneca, Roman philosopher and statesman 4 BC – AD65 • BHH has an organization-wide plan that gives general direction and outlines the process (FOCUS-PDCA) • Departments build on this framework and set specific meaningful goals

26. “If I had six hours to chop down a tree, I’d spend the first four sharpening the axe.”AbrahamLincoln • Quality Control is about putting routine checks in place to ensure that your service will be safe and effective • It should be documented and is a task that is generally easily shared among staff; we all have an investment in making day-to-day work smoother

27. “The beginning is the most important part of work.” Plato • Quality Assessment is meant to determine where we are at in relation to where we want to be; we have to start somewhere • It needs to be measurable and there needs to be a predetermined benchmark or threshold • CAH PIN studies (stroke, surgical care)

28. “The significant problems we face cannot be solved at the same level of thinking we were at when we created them.”Albert Einstein • Quality/ Performance Improvement is about making changes for the better • It requires setting specific goals and making changes to achieve those goals • It is measurable and needs participation by everyone involved

29. “Opportunity is missed by most people because it is dressed in overalls and looks like work.”Thomas Edison • Failure Mode and Effects Analysis (FMEA) is proactive risk assessment • The object is to identify hazards and put control measures into place to prevent bad things from happening • Root Cause Analysis (RCA) is after the fact – something undesirable has already happened, but we can learn from it and prevent it from happening again

30. Tips for a Successful Year Keep after it – it benefits the patients, the hospital, & you personally Involve your staff; they have some great ideas and will be more likely to buy in to goals and action plans (assign data collection too) “If you put off everything till you’re sure of it, you’ll get nothing done.”Norman Vincent Peale

31. Talk to your comrades in other facilities; they can give you a different perspective Use the process to help you make things better and recognize staff for a job well done Generate a sense of teamwork in your department and with other departments Celebrate your success (no matter how small); reward yourself and your staff “To improve is to change, to succeed is to change often.”Winston Churchill

32. Don’t reinvent the wheel; research best practices; you don’t have to make stuff up Align quality projects with department priorities; we’ve got plenty to keep us busy, we don’t need more busywork “Our life is frittered away by detail. Simplify, simplify.” Henry David Thoreau • Don’t bite off more than you can chew; make your projects worthwhile but not overwhelming • Use the Quality Director as a resource for ideas, data collection and display, etc.

33. Align your quality/ performance improvements with the hospital strategic plan and vision Keep it in front of you; put it on your calendar, your task list, your office door, your monthly staff meeting agenda, your refrigerator, your bathroom Be prepared when you report to your administrative advisor monthly Attitude is everything; this doesn’t have to be a meaningless paper-pushing process; YOU have the power to make it meaningful to you and your staff “Excellence is a habit, not an event.” Aristotle

34. “Celebrate, celebrate!! Dance to the music!” Three Dog Night Find joy in your work; if you don’t, what’s the point?