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C C Q Creating a Culture of Quality How Does DCI Target at Risk Clinics Pam Havermann Director of Quality Mgt/Education 3/16/2011A renal community collaboration.

Published byMegan Fletcher Modified over 8 years ago

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Presentation on theme: "C C Q Creating a Culture of Quality How Does DCI Target at Risk Clinics Pam Havermann Director of Quality Mgt/Education 3/16/2011A renal community collaboration."— Presentation transcript:

1 C C Q Creating a Culture of Quality How Does DCI Target at Risk Clinics Pam Havermann Director of Quality Mgt/Education 3/16/2011A renal community collaboration

2 C C Q Creating a Culture of Quality Level 3 in Texas How could we prevent this from happening in other clinics? What were the warning signs we missed? What were some of the things that could have been indicators in this clinic that were not related to outcomes? 3/16/2011A renal community collaboration

3 C C Q Creating a Culture of Quality Question Are outcomes the best marker for an at- risk clinic? – Yes – No 3/16/2011A renal community collaboration

4 C C Q Creating a Culture of Quality We believe that is too late Our goal is to get to the clinic before it affects outcomes How do we do that? 3/16/2011A renal community collaboration

5 C C Q Creating a Culture of Quality Outcomes Hemoglobin 10-12 Hemoglobin <10 Ferritins >= 200 Tsats 30%- 50% Albumin > 4% KT/V >= 1.3 % Treatments with Fistula 2 needles % Catheters >= 90 days 3/16/2011A renal community collaboration

6 C C Q Creating a Culture of Quality Operational % Hepatitis B Management on Time % Leaving Heavy > 1 kg % Leaving Light > 1 kg % Early Terminations > 10 minutes Occurrences or Lack of Occurrences Missed Treatments % Hospitalizations % Hospitalizations where EOC was recorded in DCI system 3/16/2011A renal community collaboration

7 C C Q Creating a Culture of Quality Operational % Treatment flowsheets entered before next treatment Care Plans done on schedule Staff Competencies Employee Turnover Monthly Education completion Use of agency nurses/pcts Time since last survey 3/16/2011A renal community collaboration

8 C C Q Creating a Culture of Quality Soft Indicators Patient Satisfaction Surveys- % completed and results Change in Leadership Complaints “Gut feeling” 3/16/2011A renal community collaboration

9 C C Q Creating a Culture of Quality Review all areas and decide which clinics to target Corporate Nurses/Technicians conduct audit/survey Outcome determines level of oversight by corporate office 3/16/2011A renal community collaboration

10 C C Q Creating a Culture of Quality Future plans To determine through operational and soft indicators clinics that are at risk before it affects outcomes 3/16/2011A renal community collaboration

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