This document outlines a quality assessment and performance improvement framework with the goal of improving patient outcomes and safety. It discusses identifying problems or opportunities through analyzing process failures rather than people failures. Specific areas for improvement are identified such as antibiotic use, temperature control, and patient experience. Data on measures like hospital-acquired infections and fall rates are presented. The importance of transparency through public reporting is noted while emphasizing the most important goal of excellent patient outcomes.

2.  A multidisciplinary, systematic quality assessment
and performance improvement framework
Our Goal: To improve patient outcomes, and
reduce the risks associated with patient safety in a
manner that embraces the mission of the hospital.

3. “Problems” are usually
due to PROCESS
failures, not PEOPLE
failures!

4.  Identify an “opportunity” (problem)
 Figure Out what happened (the
process)
 Explore why the process failed
 Identify possible improvements;
implement those
 Monitor the improvements

5.  Antibiotic selection
 Preop dosing time
 Postop dosing
 Therapy to prevent VTE (blood clots)
 Temperature maintenance
 Glucose control
 Patient Experience: Nurse communication, Room
cleanliness, info about medications, etc.
 National Healthcare Safety Network: hospital-
associated infections, employee flu vaccine rates

6. 0
10
20
30
40
50
60
70
80
90
100
DEC JAN FEB
80
93
99
22
44
91
AllPressGAneyPercentage
Press Ganey: Extent to which nurses checked ID by DOS
Inpatient
AS

7. There were 9 patient falls in 2010. A team began
working to reduce the number of falls, researched
best practices, and implemented improvements.
Results:
 2010 patient falls = 9 (79 per 100,000 patient days)
 2011 patient falls = 5 (44 per 100,000 patient days)
 2012 patient falls = 1 (9 per 100,000 patient days)

8.  Statistics are posted on HospitalCompare website.
 Lots of media attention about hospital errors.
 Many states have laws requiring public reporting of
errors.
 Poor performance results in decreased
reimbursement.
 MOST IMPORTANT: Stellar patient
outcomes, doing the right thing the right way for
every patient.

9.  This is the end of presentation. Click on the blue
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