(Mt) – Pima Medical Institute Tucson Performance Data Case Study

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Evaluation of Change The process of continuous improvement can be useful in almost any environment. Going through a cycle of change can help you improve academically, personally, and professionally. The most difficult but probably most important part is coming up with a way to measure and evaluate the changes you’ve made. There are many examples of facilites resolving issues using a quality improvement process. As you read through the case studies, note that the leader and team plan out and follow distinct steps to analyze the problem, determine a potential solution, and implement the solution. A specific problem is identified and a clear goal established, a team selected, and a clear mission/vision provided to that team. Afterward, the change is evaluated using specific criteria to determine its effectiveness. Case Studies of Quality Improvement Initiatives Benchmarking Indicator Matrix Examples of Hospital Quality Measures for Consumers Remember that quality improvement should be a continuous process. Change can be targeted to a specific issue that is identified at a particular time, and it can also be an ongoing goal. In general, the steps of the process are plan, do, check, act. Plan out a change, implement and evaluate it, and then prepare for further action based on the evaluation. Small changes can eventually lead to an overall organizational improvement. Consider some of the ways that a quality improvement effort can be evaluated. Change is never just one thing. While the end goal may be very specific, any action will have expected and unintended consequences. Even the expected consequences should be examined once a quality improvement effort has been completed. Benchmarking is one method that can help a team set and measure goals. In this process, you look at another organization who has achieved what you are trying to accomplish. Gather data that helps you determine how that organization operates, and then use the information to help you implement change. This process can also help a team determine the factors to use to evaluate whether a change was successful at meeting the desired goals. In the Santa Rosa case study, the final step involves evaluation of the improvement process using an indicator matrix. This is a tool that can measure whether the process has had the intended results. An indicator is used to describe a problem: how often it occurs, when and where it occurs, and who is affected by it. Indicators are developed by collecting data and then expressing the data through mathematical formulas or through tables and graphs. Creating a set of indicators when beginning a project allows both a problem and solution to be measured. It also makes it easier to set specific goals, as you can see in the sample indicator matrix. This type of evaluation can be done for any type of improvement effort, whether it’s part of a FMEA tool or root cause analysis. An evaluation tool that allows you to present the results of an improvement process in graphic format or to quantify the change numerically with respect to a particular set of specific measures make it easier for anyone interested in the change—administrators, clinicians, and even patients—to understand the impact it has made. For example, being able to show that patient wait time has decreased from 2 hours to 20 minutes would definitely show that your effort has resulted in positive change. Therefore, it’s important to consider how others will view your results and build that into the process. Instead of thinking of quality management as a closed-ended process, the evaluation should serve as the basis for the next improvement. Again, the information you collect and present is useful for this. Maybe patient wait time was reduced from 2 hours to 1 hour, but you’d like to get it down to 30 minutes. The change you make might be different, but the steps you follow in the process should be the same. Coming up with a process for quality improvement can be valuable no matter who you are. When making changes in any context, keep the end goal in mind as you take the first steps. Team Strategies When you hear the word team, do you immediately imagine a group of football or basketball players? Is the word team used in the context of your workplace? If so, it’s likely that what the managers consider a team doesn’t necessarily function the way your favorite sports team does. While there are star football, basketball, baseball, etc. players, without the rest of the team, those stars couldn’t even play the game. That’s not always the case in a professional setting. Today, healthcare organizations are utilizing teamwork as a means of assuring quality and safety in patient care. The ability to effectively design and manage teams is an essential management skill but one that does not just happen. A successful team must be thoughtfully designed by asking what the purpose of the team will be, how to achieve that purpose, and how to carry out the process. It is not enough to simply just assemble a team and assume that because you have enough people working on something, the effort will be successful. The diverse backgrounds, ideas, and experiences of team members must be acknowledged and conscious effort expended to make the best use of them. This lesson will give insight on selecting, supporting and ensuring the effectiveness of teams with the end goal of providing quality patient care. 66 Section I: The Fundamentals of Quality Management NRC+Picker. 2005. “Eight Dimensions of Patient Care.” [Online information; retrieved 12/20/05.] nrcpicker.com /default.aspx?DN=112,22,2,1,Documents. Pougnet, T. 1996. Presentation at LDS Hospital, Salt Lake City, Utah, May 20–23. Reiling, J. G., B. L. Knutzen, and M. Stocklein. 2003. “FMEA—The Cure for Medical Errors.” Quality Progress 36 (8): 67–71. Scholtes, P. R., B. L. Joiner, and. B. J. Streibel. 2003. The Team Handbook, 3rd edition. Madison, WI: Oriel Inc. Senders, J. W., and S. J. Senders. 1999. “Failure Mode and Effects Analysis in Medicine.” In Medication Errors, edited by M. R. Cohen, 3.1–3.8. Washington, DC: American Pharmaceutical Association. Spath, P. L. 2003. “Using Failure Mode and Effects Analysis to Improve Patient Safety.” Association of Operating Room Nurses Journal 78: 16–37. Walton, M. 1986. The Deming Management Method. New York: The Putnam Publishing Group. Exercise 1 Objective: To practice quality improvement tools by applying them to an improvement effort in an ambulatory care setting. Instructions 1. 2. Read the following case study. Follow the instructions at the end of the case. Case Study Background You have just been brought in to manage a portfolio of several specialty clinics in a large multiphysician group practice in an academic medical center. The clinics reside in a multiclinic facility that houses primary care and specialty practices as well as a satellite laboratory and radiology and pharmacy services. The practice provides the following centralized services for each of its clinics: registration, payer interface (e.g., authorization), and billing. The CEO of the practice has asked you to initially devote your attention to Clinic X to improve its efficiency and patient satisfaction. Access Process A primary care physician (or member of the office staff), patient, or family member calls the receptionist at Clinic X to request an appointment. If the receptionist is in the middle of helping a patient in person, the caller is asked to hold. The receptionist then asks the caller, “How may I help you?” If the caller is requesting an appointment within the next month, the appointment date and time is made and given verbally to the caller. If the caller asks additional questions, the receptionist provides answers. The caller is then given C h a p t e r 3 : T h e M a n a g e r ’s To o l b ox 67 the toll-free preregistration phone number and asked to preregister before the date of the scheduled appointment. If the requested appointment is beyond a 30-day period, the caller’s name and address are put in a “future file” because physician availability is given only one month in advance. Every month, the receptionist reviews the future file and schedules an appointment for each person on the list, and a confirmation is automatically mailed to the caller. When a patient preregisters, the financial office is automatically notified and performs the necessary insurance checks and authorizations for the appropriate insurance plan. If the patient does not preregister, when the patient arrives in the clinic on the day of the appointment and checks in with the specialty clinic receptionist, he or she is asked to first go to the central registration area to register. If there is an obvious problem with authorization, it is corrected before the patient returns to the specialty clinic waiting room. The receptionist has determined that the best way to not inconvenience the caller is to keep him or her on the phone for as short an amount of time as possible. The receptionist also expresses frustration with the fact that there are too many things to do at once. The physician thinks too much of his or her time is spent on paperwork and chasing down authorizations. The physician senses that appointments are always running behind and that patients are frustrated, no matter how nice he or she is to them. Physician’s Point of View Patients are frustrated when asked to wait in a long line to register, which makes them late for their appointment, and when future file appointments are scheduled without their input. As a result of this latter factor, and work or childcare conflicts, patients often do not show up for these scheduled appointments. Patients’ Point of View The office nurse feels that he or she is playing catch up all day long and explaining delays. The office nurse also wishes there was more time for teaching. Office Nurse’s Point of View The billing office thinks some care is given that is not reimbursed because of inaccurate or incomplete insurance or demographic information or that care is denied authorization after the fact. Billing Office’s Point of View On the NRC+Picker website you find the following patient expectations/dimensions of care for adults and children in their outpatient experiences with a hospital or clinic outpatient appointment: • Respect for patients’ values, preferences, and expressed needs • Coordination and integration of care • Information and education • Physical comfort Data 68 Section I: The Fundamentals of Quality Management • • • • Emotional support and alleviation of fear and anxiety Involvement of family and friends Transition and continuity Access to care The clinics have just begun to monitor performance data, and you have one quarter’s worth of data for the clinic: Overall satisfaction with visit Staff is courteous and helpful Waiting room time is less than 15 minutes Examination room waiting time is less than 15 minutes Patient no-show rate Patient cancellation rate Provider cancellation rate Preregistration rate Average number of patient visits per day Range of patient visits per day 82% 90% 64% 63% 20% 11% 10% 16% 16 10–23 Instructions 1. 2. 3. 4. 5. 6. 7. Completely read all of the instructions. Decide which problem you want to focus on as your first priority— the goal for your improvement team. Identify the team members that you would want to participate in this effort and what fundamental knowledge they should bring to the process. Document the current process using a process flowchart. Identify your customers and their expectations. Prioritize opportunities to improve by doing the following: a. Complete an RCA using a fishbone diagram with the following categories: people (patients), people (staff/employees), policies and procedures, and plant (facilities/equipment); b. Describe how you would collect data about how often the root causes contribute to the problem to determine where your greatest opportunity for improvement would be; and c. Design a Pareto chart from the data given in the table above (you may also use hypothetical data to design your Pareto chart). Review the following change concepts (Langley et al. 1996), and identify the ones that may apply to your process: • Eliminate waste (e.g., things that are not used, intermediaries, unnecessary duplication) • Improve workflow (e.g., minimize handoffs, move steps in the process closer together, find and remove bottlenecks, do tasks in parallel, adjust to high and low volumes) • Manage time (e.g., reduce set-up time and waiting time) C h a p t e r 3 : T h e M a n a g e r ’s To o l b ox • Manage variation (create standard processes where appropriate) • Design systems to avoid mistakes (use reminders) 8. Improve the process and document the improved process with a process flowchart or workflow diagram. 9. Decide what you will measure and briefly describe how you would collect the data. 10. You have completed the “Plan” phase of the Shewhart cycle. Describe briefly how you would complete the rest of the PDCA cycle. 11. Save your answers to each part of this exercise. This will become the documentation of your improvement effort. Exercise 2 Objective: To practice an RCA. Instructions 1. 2. Read the following case study. Follow the instructions at the end of the case. Case Study The letter in this case study is adapted with permission from Trina Bingham, master’s in nursing student at Duke University School of Nursing. You are the risk manager of a tertiary-care hospital and have just received the following letter from a patient who was recently discharged from your facility. Dear Risk Manager, Last month, I had surgery at your hospital. I was supposed to have a short, laparoscopic surgery with a discharge by lunch, but it turned into an open surgery with complications. This led to a 4-day hospital stay and discharge with a Foley catheter. Overall, my hospital stay was OK, but I had a situation when the call bell was broken. It was during the night, and I was alone. I needed pain meds. I kept ringing the call bell and no one answered. I used my phone to call the switchboard and no one answered. I didn’t want to yell. My IV began beeping (to be honest I kinked the tubing to make it beep), but no one came with that noise either. Eventually the certified nursing assistant (CNA) came to routinely check my vitals and she got a nurse for me. They switched call bells, but apparently there was an electrical problem, and the call bell couldn’t be fixed until the next day when maintenance was working. The CNA told me to “holler if I needed 69 Level 1 Level 2 . . . . . . Short answers: Follow assignment directions. Write answers in your own words, no copying and pasting from websites or other sources. Use complete sentences and well- formed paragraphs with appropriate syntax. Avoid using contractions and personal pronouns. Proofread, check spelling and grammar prior to submission. Use correct punctuation and capitalization. Informal essays or projects: Incorporate all Level 1 guidelines. Use effective paragraph transitions Include a clear introduction, body, and conclusion. Use Arial or Times 12-point font Double-space your text Set page margins to one inch Use reliable sources, cited properly within the text and listed on a references page when indicated. .



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