Process Breakdown Analysis and Improvement. Kate Zetler, CORE. CORE DSA A Snapshot. 155 Hospitals 5 Transplant Centers 13 Trauma Centers (Levels1 &2 ) 1 Free-Standing Pediatric Hospital. Process Breakdowns 1 st -3 rd Quarter. First Three Quarters by the numbers…. Ruh-Roh !.
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Kate Zetler, CORE
AGENDA: To reduce Process Breakdowns (timeliness of referrals*) by 60% before year end 2012.
- Responsibility will be of the individual PSLs
- September 1 – December 31, an analysis and interventions
- Modified and uniform presentations to deliver to hospital staff in-services
- Implementation of regular use of clinical trigger cards to be distributed when rounding, in-services, any education opportunities.
-Immediate follow-up (within 24hrs) with key contacts at hospitals when an “Untimely Referral” is made.
- Dashboard used to reinforce Process Measures at individual hospitals
- Straight-forward definitions of a “Process Breakdown”
- Follow up with attending physician within 24 hours of donor case
- Increase of PSL availability on the units to develop relationships.
Bold Requests from Children’s Hospital DAG
1. Need for more consistent communication/ more inclusive huddle between OPC and CHP staff.
Bold Requests from Children’s DAG
2. CHP recognized that virtually none of our OPC staff ever worked in pediatrics, less than half were nurses.