1. QUALITY & PERFORMANCE IMPROVEMENT
For Emergency Department Nurses

2. Definition Quality & Performance Improvement are…
Continuous cycles of improvement
Driven by our mission and vision
That stimulate individuals and teams to look at the way they deliver care and services
In order to identify the root causes of problems in our systems and processes
And encourage innovation to make changes that improve them.

3. The Goal of Improvement
To become a “highly reliable” health care organization
Delivering the right care to the right patient, at right time, every time (Sec. Michael Leavitt, HHS, 2007)
Humans are error-prone, not highly reliable
Systems and processes can be highly reliable
The goal of process and systems improvement is to make it hard for staff to make an error, thus making the care & services provided highly reliable

4. Quality Control (QC)
Routine checks are in place that ensure your service or output is safe, accurate and effective
QC is required by licensing agencies, routinely documented and generally easily shared among staff
Examples: temp checks, routine preventive maintenance, running test controls

5. Quality Assurance (QA)
Shows where we are in relation to where we want to be
Compares measured performance to a predetermined benchmark or threshold
Examples: complete medical record documentation; compliance with care guidelines for AMI, HF, pneumonia, stroke patients

6. Quality & Performance Improvement
Use collected data intentionally, to make changes for the better
Opportunities for improvement are identified and prioritized
Specific improvement goals are established
Changes are tested to see if they achieve the established goals
QI/PI rely on measuring progress routinely
Quality Improvement focuses on improving clinical quality
Performance Improvement focus is organization-wide C B A D
A: opportunity identified & vaccination status added to admission assessment
B: standing orders implemented
C: protocol for nurse admin prior to discharge implemented
D: goal achieved

7. But we already give good care …
PROVE
IT!

8. Health care systems as “pillars”
Service: consistently exceeding customer expectations results in increased satisfaction
Clinical Quality: patient-centered care that is safe, effectively, timely, efficient, equitable
People: well-trained, recognized, and rewarded staff bring commitment and dedication to the workplace
Finance: solid planning and management results in a positive margin to sustain current ops and provide future needs
Growth: a well-researched, methodical approach involving key stakeholders results in steady growth
The pillars work together, synergistically, to achieve mission
Quint Studer, Hardwiring Excellence, © 2003

9. Centers for Medicare and Medicaid Services (CMS)
An effective QA/PI program is a condition of participation (required for Medicare/Mcaid payment)
Involves all patient care and other services affecting patient health and safety
Includes nosocomial infections and medication therapy
Includes an annual evaluation of the CAH program

10. More Conditions of Participation
QI/PI program must include the quality and appropriateness of diagnosis and treatment
AMI, HF, pneumonia, surgical site infection prevention
Considers the findings and recommendations from the state Quality Improvement Organization (QIO) and takes corrective action
Takes appropriate remedial action to address deficiencies found through the program, including regulatory survey deficiencies

11. National Patient Safety Goals
Improve medication safety
Reduce healthcare-acquired infections
Reduce the number of patient falls
Use at least two patient identifiers (2)
Improve communication among caregivers
Reduce preventable deaths

12. IHI 5 Million Lives Campaign
Prevent harm from high-alert medications
Reduce surgical complications
Prevent pressure ulcers
Reduce MRSA infection
Deliver evidence-based CHF care
Get boards on board the quality program

13. Department QI/PI Everyone gets to demonstrate how they are…
Exceeding customer expectations
Improving the quality of care and/or services
Developing staff
Managing finances
Growing their service
Department managers & staff will…
Decide how they will measure their performance
Decide what processes need improvement and how to improve them

14. Data Collection “What gets measured gets managed.”
We pay attention to what we are measuring
“BUT … not everything that can be measured is worth managing…”
Measure the most important things
“…and everything that should be managed can’t always be easily measured.”
Use QI/PI to improve things you can actually measure

15. Some ED Nursing Measures
Service: Patient satisfaction survey results
Clinical Quality: All vital signs recorded on arrival, at discharge, and at least every one hour throughout the ED stay
People: all ED nursing staff are BLS or ACLS certified
Finance: reduce utilization of per diem ED staff
Growth: facility works to achieve state trauma receiving center designation

16. The PDCA Improvement Cycle

17. Understanding the Process To Be Improved - Flowchart
Create a step by step picture of a work process
Identify and add missing steps
Streamline areas of overlapping efforts & eliminate unnecessary steps
Standardize the process or system- this means everyone does it the same way

18. Reporting Data with Run Charts
“The ED Nurse explained my discharge instructions in a way I could understand.”
Target
Facility performance

19. Reporting Data with Run Charts
Chest Pain ED Patients: Number of Opportunities Missed to Complete
12-lead EKG within 10 minutes of Arrival
Goal = 0 missed opportunities

20. Reporting Data with Histograms
Per Diem ED Nurse Staff Dollars
Target =
< $1000/mo

21. Tips for Success Start Somewhere
“If you put off everything till you’re sure of it, you’ll never get anything done.”
Norman Vincent Peale
Keep after it – your perseverance benefits the patients, the hospital, the community & you personally
Keep quality reporting on your monthly staff meeting agenda
Share data collection and reporting responsibilities
It helps build competence, teams, and cooperation

22. Tips for Success Don’t Bite off More than You Can Chew
Make your projects worthwhile but not overwhelming
One major improvement project at a time is often enough
Don’t Reinvent the Wheel
Research best practices; borrow from other facilities
Align Projects with the Department’s Priorities
We all have plenty to do; don’t make stuff up

23. Tips for Success Use the Quality Coord/Director as a resource
For ideas about data collection, reporting, display
Be Prepared when it is your turn to report
“Excellence is a habit, not an event.” Aristotle
Attitude is Everything!
This doesn’t have to be a mindless paper-pushing exercise
YOU have the power to make it meaningful

24. Tips for Success “Celebrate, celebrate!!
Dance to the music!” Three Dog Night
Celebrate each success, no matter how small
Reward the entire team

25. Finally…..
Find joy in your work;
if you don’t, what’s the point?