Quality Improvement at MBSH

1. Quality Improvement at MBSH Samantha Alu, RN, BSN Patient Safety/Quality Improvement Specialist October 25, 2016

2. 25 Bed Critical Access Hospital • 11 Room Emergency Department • 6 Bed ICU • Medical/Surgical Unit • Swing Bed Program • Surgical Services Department • Labor and Delivery Unit • 10 Bed Distinct Part Geriatric Psych Unit • OP Services: Radiology, Lab, Cancer/Infusion Center, Medical Office Building

3. Quality Improvement Efforts • One Tool we utilize to work on Quality Improvements initiatives/measures is our LDM Boards. • We have been utilizing them for about 5 years now.

4. Lean Daily Management Boards

5. Lean Daily Management • From: • Culture of Blame • Manager Ownership • Addressing Symptoms • To: • Culture of Problem Solving • Staff Ownership • Addressing Root Cause (s) RED is GOOD!!!!

6. LDM Board

7. Data Collection • Daily Board Update: • After staff determines the metric on the board they will then develop a method to collect the data. • All staff will collect the data and in the AM someone is responsible for updating the board prior to 815. • Staff will want to review the board and understand the information prior to the report out.

8. GEMBA Walks • Daily Report Out: • Every morning at 815 managers and Leadership walk to the boards and staff report out on results • Managers and Leadership may ask questions regarding what is being done to improve efforts or may give suggestions on next steps. • Staff take feedback back to manager or “owner” of the board and work on next steps: • 5 Why • Action Plan

9. Measures Improved by LDM • We have utilized the LDM Board to improve several Quality Improvement Initiatives, such as: • Median Time to ECG • Patients Left Without Being Seen • Improving HCAHPS Scores • Median time from ED arrival to ED departure for admitted ED patients • Readmission Measures • Influenza Immunization • Early Elective Delivery • Aspirin at Arrival

10. Quality Improvement • Based on the results of the data departments will collaborate with each other to determine next steps and process improvement initiatives. • The LDM process has helped encourage the collaboration between different departments, building relationships and helping them understand the barriers other departments face. • RIE events may be scheduled to help with more complex processes.

11. Barriers • Barriers to Quality Improvement and the LDM process: • Staff Turnover • “Flavor of the Month” • Manager and Staff Buy In • Consistently Auditing • Competing Priorities • Once it is removed from the board the issues may come back.

12. Barriers • Overcoming Barriers • Show staff the “why” • Don’t wait until Monthly meetings to work on projects • Front Line staff ownership and/or significant team involvement • Owner of the LDM process, acting as a coach to departments • Education of nursing and PCT staff during orientation • Annual education of Quality Measures

13. Contact Information: Samantha Alu, RN, BSN Patient Safety/Quality Improvement Specialist Missouri Baptist Sullivan Hospital Phone: 573-468-1182 Email: sja2166@bjc.org