Quality Improvement Project utilizing FOCUS-PDCA Methodology

1. Improving Cardio-
Pulmonary Resuscitation
Success Rate
Quality Improvement Project using “FOCUS PDCA”
Methodology.
Al-Iman General
Hospital

2. The data obtained over the past year showed great
variation in the success rates of CPR in Al-Iman
hospital with failure rates ranging between 60 to 80
percent monthly.
Find the problem.

3. Impact of the problem:
◦ The hospital was notified being a member of the
comparative data base of ministry of health that its rates
are suspiciously high and far from the benchmark the MOH
is recommending (Steady rate below 60%).
◦ Patient safety was in jeopardy & Joint Commission
International compliance was not achieved.
◦ Physician & hospital top management dissatisfaction from
high failure rate.
Find The Problem.

4. Successful CPR Definition.
◦ Return of spontaneous circulation for more than 20
minutes.
Witnessed CPR Definition.
◦ One is seen or heard by another person or an arrest that is
monitored.
Return Of Spontaneous Circulation.
Includes breathing (more than an occasional gasp),
coughing, movement or a palpable pulse.
These are the definitions adopted by the MOH and used in
the comparative data base of the ministry.
Find The Problem.

5. Total Vs. Witnessed Failure Rate of CPR
From 1/1434 : 12/1434; El-Iman Hospital
70.5%
64.5%
63.20%
57.5%
81%
69%
82.6%
55.2%
64.2%
u= 65.86
----------
u= 61.56
60.3%
58.8%
63.5%
64%
62% 62%
55%
72%
63%
77%
49%
63%
59%
54%
59%
85%
80%
75%
70%
65%
60%
55%
50%
45%
Percentage
Month
Total Failure Rate Witnessed Failure Rate

6. The project mission.
◦ Is to reduce the variation in the process & reach failure
rates below 60% (as to the benchmark provided by MOH).
Find The Problem

7. The team charter included:
◦ Champion: Medical Director
◦ Team Leader: Anesthesia Director.
◦ Facilitator: Quality Director.
◦ Members:
Deputy medical director.
Nursing director.
Anesthesia specialist.
ICU specialist.
Cardiology Consultant.
Medical Specialist.
CPR/Nurse Coordinator.
Organize The Team

8. Clarify Current
Process
1

9. 1
Clarify Current Process

10. Shortage of staff (Anesthesia)
Improper scheduling (Anesthesia)
++ CPR Failure
Rates
Place
Lack of Training (ACLS)
Dead On Arrival included
In the measurement
Crash Carts
Mal-distribution
Pharmacist
Shortage
Crash carts Policy
Not Followed (Open all
The time).
Lack of PPM of
Defibrillators
Lack of regular checks
On supplies
Equipement Patient
Policies
Personnel
Incorrect Policy
Poor compliance to the policy (Not
all the team attend the CPR Incident)
Understand The Variation
Lack of Bleeps
Missing Crash Carts
Nurse Shortage
Materials
Lack of Medications
No Numerical Locks

11. Percentage of Defibrilator Availability and Functioning
69%
Al-Iman Hospital; 12/1434.
15% 15%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Available Working Available Not Working Not Available
Percentage
Status

12. Essential Supplies Availability in Crash Carts
Al-Iman Hospital; 12/1434.
96%
46%
120%
100%
80%
60%
40%
20%
0%
N=520 N=26
Epinephrine Ampoles Airways
Percentage
Supplies

13. In order to verify the causes generated by the
fishbone diagram (by brainstorming) the team
decided to review the failure cases of CPR over the
last three months (Shawal, Dhulqeda and Dhulhaj)
(8-10/1434).
Each case was checked against the generated causes
to verify the most common causes for CPR failure.
112 cases were reviewed by the team.
Understand The Variation

14. Percentage of CPR Done Without Full Team Attendance
37%
Al-Iman Hospital; 8-10/1434.
48%
34%
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
N=42
N=35 N=35
8/1434 9/1434 10/1434
Percentage
Month

15. Percentage of Missing Specialty In Failed CPR Cases
Al-Iman Hospital; 8-10/1434.
N= 81 45%
36%
27% 27%
11%
0%
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
Percentage
Missing Team Member
56

16. Causes Frequency
• CPR policy outdated 112
• Lack of ACLS Training. 112
• Not all Team Attending. 45
• Lack of PPM of Defib. 112
• Missing Defib. 2
• Missing supplies 2
• Patient was DOA 15
• Crash cart Mal distribution (Area
of incident does not have a Crash
Cart in near vicinity).
2

18. According to Pareto rule the following causes
represented 80% impact of the problem (Vital Few):
◦ Outdated CPR Policy.
◦ Lack of ACLS Training.
◦ Lack of PPM of Defibrillators.
Understand The Variation

19. The team suggested the following solutions:
◦ Update CPR policy in compliance to the JCI requirements.
◦ Train & Educate the staff about the policy update.
◦ All Code Blue Team to have ACLS Certificates & Training.
◦ Establish preventive regular maintenance checks for Crash
carts Defibrillators.
◦ Redistribute the crash carts to cover all care areas.
◦ Continuous auditing on CPR service by CPR committee &
Quality department.
◦ Recruitment of more anesthesia staff (until recruitment is
done 2 Anesthesia Doctor will attend in each shift)
Select Remedy

20. ◦ Adding Paramedics to the CPR Team to enhance Chest
Compression quality.
◦ Activate the DNR policy & provide training to staff.
◦ Provide Bleeps to all Code Blue Team.
Select Remedy

21. Selection Matrix
Solution Feasibility Cost
(Inverse Scoring)
Impact Score
Update CPR policy 5 5 5 15
Train & Educate the staff on
3 4 5 12
CPR Policy.
PPM for Defibrillators 3 5 4 12
Recruitment of more
1 1 5 7
anesthesia staff
Anesthesia Schedule
Modifications
3 3 3 9
Purchase New & Redistribute
crash carts
4 1 5 10
Item 1 5
Feasibility Hardest Easiest
Cost Most Expensive Most Cheap
Impact Lowest Highest

22. Selection Matrix
Solution Feasibility
Cost
(Inverse
Scoring)
Impact Score
Provide Bleeps 3 3 4 10
ACLS Training Schedule 3 2 5 10
DNR Policy Training 2 5 3 10
Pharmacy Regular checks
schedule.
5 5 3 13
Item 1 5
Feasibility Hardest Easiest
Cost Most Expensive Most Cheap
Impact Lowest Highest

23. The Selected Remedies in order:
1. Update CPR Policy (15).
2. Pharmacy Regular checks schedule (13).
3. Train & Educate the staff on CPR Policy (12).
4. PPM for Defibrillators (12).
5. Purchase new & Redistribute the crash carts (10).
6. DNR Policy Training (10).
7. ACLS Training Schedule (10).
8. Provide Bleeps (10).
9. Anesthesia Schedule Modifications (9).
10. Recruitment of more anesthesia staff (7).
Select Remedy

24. Plan
ACTION PLAN
Task Responsible Due Date
Update CPR policy. Quality Team &
Anesthesia Director.
1 week
Train & Educate Staff on CPR
policy.
Quality Team & Medical
Director.
Ongoing
PPM for Defibrillator Biomedical Dep. Ongoing
Anesthesia Schedule Modifications Anesthesia Director. Ongoing
Recruitment of Anesthesia staff. Top Management. 6 months
Redistribute the crash carts to
different vicinities
Quality Team &
Pharmacy.
1 month
Purchase New Crash Carts Top Management. 2 months

25. Plan
ACTION PLAN
Task Responsible Due Date
Provide Pagers. Purchasing Dep. 1 month
ACLS Training Schedule CME Dep. 4 months
DNR Policy Training
Quality Team &
Anesthesia Director.
1 month
Pharmacy Regular checks
schedule.
Pharmacy 1 week

26. A pilot to be done for the period of 2 months and
data will be monitored to detect the effectiveness of
the proposed remedies.
Do

27. Check The Results

28. The following modifications were made to the
policy:
◦ All code blue team (Except Ward Nurse) to be ACLS
certified.
◦ For outpatient department cases of arrest, the
Anesthesiologist & Internal medicine physician present in
the clinics will be the first responders till the team arrives
from the hospital main building.
◦ In the crash cart medication policy, in case of code blue the
nurse in charge will contact the pharmacy after the end of
the code to replenish the cart within 30 minutes of the
ward/unit call.
CPR Policy Updates.

29. Percentage of Availability of 5 Sizes of Airway in the
Al Iman General Hospital, 12/1434 to 2/1435
46%
Crash Cart
81%
73%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
1 2 3
Percentage
12/1434 1/1435 2/1435
Month
N=26

30. Total Vs. Witnessed Failure Rate of
From 12/1434 : 3/1435; El-Iman Hospital
64%
58%
56%
59%
56%
53%
65%
60%
55%
50%
45%
40%
35%
30%
CPR
12/1434 1/1435 2/1435
Percentage
Month
Total Failure Rate Witnessed Failure Rate

31. Percentage of CPR Done Without Full
Al-Iman Hospital; 8-10/1434.
33%
Team Attendance
29%
25%
34%
32%
30%
28%
26%
24%
22%
20%
12/1434 1/1435 2/1435
Percentage
Month

32. Percentage of Missing Specialty In
Al-Iman Hospital; 12/1434 -2/1435.
27%
Failed CPR Cases
45%
11%
27%
25%
30%
0% 0%
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
Medical Specialist Anesthesia ICU Nurse Ward Nurse
Percentage
Team Member
Before After

33. Recruitment of more Anesthesia staff couldn’t be
achieved during the pilot time.
Adding the paramedics to the Code Blue team to
enhance quality of chest compressions could not be
achieved due to their busy schedule and limited
number.
DNR was not approved from the directorate to apply.
Restrictions

34. All the solutions implemented during the pilot are
sustained.
The team will keep continuous monitoring over the
process to maintain the gains and ensure
compliance to the modified process changes.
Act.

35. Control
Variable
How
Measured
Where
Measured
Standard Who
Analysis
Who
Acts
What
Done
 Total
CPR
Failure
Rate.
Retrospect
ive
Document
Review of
CPR
Sheets.
In
Clinical
Audit.
Below
60%
Quality
Dep.
CPR
Commit
tee.
Further
Analysis To
Determine
Causes for
Relapse.
 Witnesse
d CPR
Failure
Rate.
Retrospect
ive
Document
Review of
CPR
Sheets.
In
Clinical
Audit.
Below
60%
Quality
Dep.
CPR
Commit
tee.
Further
Analysis To
Determine
Causes for
Relapse.
 Availabil
ity of
Essential
Supplies
in Crash
Carts.
Direct
Observatio
n.
All
Hospital
Units.
100% Quality
Dep.
CPR
Commit
tee.
Nurses
should
check
supplies
per shift.
 Defab.
Availabil
ity &
Function
ing.
Direct
Observatio
n.
All
Hospital
Units.
100% Quality
Dep.
CPR
Commit
tee.
Regular
PPM.
Defab.
Testing/shif
t

36. Further Improvement Opportunities
Team Decided to Start a second phase for the
project addressing “Code Rapid” process which will
lead to better CPR outcomes.
Acting on early warning signs detection & Rapid
intervention will definitely improve CPR success
rates.