Performance Improvement

Question 1

What are you doing in your spaces to improve performance and clinical outcomes?

Answer 1

We hold huddles at the start of each day/shift to discuss our patients and review any patient safety issues.
Know what your area is working on! If you have a performance improvement board or display, direct the surveyors to that area.

Question 2

How does your hospital demonstrate its goal of being the High Reliability Organization?

Answer 2

We have implemented the DHA high reliability model called Ready Reliable Care.

Question 3

Tell us more about Ready Reliable Care.

Answer 3

There are 4 Domains of Change
1. Leadership Commitment – Prioritize RRC at all levels of leadership
2. Culture of Safety – Commit to safety and harm prevention
3. Continuous Process Improvement – Advance innovative solutions and spread leading practices
4. Patient Centeredness - Focus on patients’ safety and quality of care experience

Question 4

What do you do to assure high reliability through use of Ready Reliable Care?

Answer 4

We follow 7 Ready Reliable Care principles
1. Preoccupation with Failure – Drive zero harm by anticipating and addressing risks
2. Sensitivity to Operations – Be mindful of how people, processes, and systems impact outcomes
3. Deference to Expertise –seek guidance from those with the most relevant knowledge and experience
4. Respect for People – Foster mutual trust and respect
5. Commitment to Resilience – Leverage past mistakes to learn, group, and improved processes
6. Constancy of Purpose – Persist through adversity towards the common goal of zero harm
7. Reluctance to Simplify – Strive to understand complexities and address root causes

Question 5

What are the hospitals current quality improvement goals?

Answer 5

1. Improving hand hygiene through use of QRS representatives to train, observe, and monitor hand hygiene compliance.
2. Optimizing the use of Bar Code Medication Administration (BCMA)
3. Improving appropriate use of DVT prophylaxis on inpatient’s.
4. Our hospital’s Failure Mode & Effects Analysis (FMEA) team is working to improve our follow-up appointment booking at time of discharge.

Question 6

How does your leadership show the emphasis for continuous process improvement?

Answer 6

-We have yearly continuous process improvement (CPI) fairs where projects are displayed and the best are sent to compete at regional and national levels within our medical system.
-We also have multiple yearly Lean Six Sigma courses which are open to anyone interested.
-Hour command processes Patient Safety Reports (PSRs) in a non-attribution or manner and encourages submissions.
-It has an established Failure Mode & Effects Analysis (FMEA) team led by Dr. Overbey to analyze high risk processes and make him safer.

Question 7

What is a sentinel event?

Answer 7

A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury.

Question 8

What is a Root Cause Analysis (RCA)?

Answer 8

It is a process for identifying basic or causal factors underlying variation in performance and is conducted following a sentinel event or possible sentinel event. Its goal is to improve systems or processes in order to decrease the likelihood of the event recurring.