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QPI INVESTIGATORS

QPI inVestigators

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Interview with St David’s Round Rock Medical Center. QPI inVestigators. ST David’s Background. PI. Mission To provide exceptional care to every patient every day with a spirit of warmth, friendliness and personal pride. Values - I.C.A.R.E. I ntegrity C ompassion A ccountability R espect - PowerPoint PPT Presentation

Text of QPI inVestigators

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QPIinVestigators

Interview with St Davids Round Rock Medical Center

QPIinVestigators

ST Davids BackgroundMissionTo provide exceptional care to every patient every day with a spirit of warmth, friendliness and personal pride.

Values - I.C.A.R.E.Integrity Compassion Accountability Respect Excellence

VisionExceptional Care, Customer Loyalty, Financial Strength PI2QPIinVestigators

ST Davids Quality AwardsTexas Award for Performance Excellence

Same criteria and process as the Malcolm Baldridge National Quality Award! Awarded to organizations that serve as role models for quality, customer satisfaction, and performance excellence in Texas

Texas Health Care Quality Improvement Award

Awarded by TMF Health Quality Institute, the Medicare Quality Improvement Organization for Texas PIQPIinVestigators

The InterviewInterviewee:

Shannon Kane-Reinhardt RN, BSN, Quality Manager(St Davids Round Rock Medical Center)Interviewers:

Lombe Chitundu Jean Cusick Yolanda Johnson Vicki McGinnis Sharon Royall-Murphy

Interview Date: March 30, 2010 PITeam Responsibilities:

Lombe Chitundu: Jean Cusick:Yolanda Johnson:Vicki McGinnis:Sharon Royall-Murphy:4QPIinVestigators

Format of the Interview PI5 Steps in an Organizational PI Model The interview was structured around 5 steps in an Organizational Process Improvement Model All Interview questions are in bold type and the mandatory questions from the Project Instructions are enclosed in ** Follow-up questions to Shannon are followed by ??? (3 question marks)

What is the name and/or steps in the PI Model used at St Davids ???

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Identify Performance Measures PI

Core MeasuresSCIPAntibiotic Received Within One Hour Prior to Surgical Incision (SCIP-Inf-1a)** What was the area of inquiry? **

Process Improvement specific to Core Measures published by the Joint Commission

Measure Set: Surgical Care Improvement Project (SCIP) Measure: SCIP-Inf-1a Antibiotic received within one hour prior to surgical incision

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Identify Performance Measures PI** Why was this a performance improvement issue? **

The risk of infection increases progressively with greater time intervals between administration and skin incision. This relationship was observed whether antibiotics preceded or followed skin incision (either too early or too late). Opportunities to improve care have been demonstrated (evidence-based) and timely administration has been recommended through the Core Measures.

Was this a systems, process, or outcomes improvement? Type of Measure: Process Outcomes Improvement

Who was the customer? Surgical patients

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Measure Performance PI

Create confidential spreadsheet: Anesthesia Start Date Admission Date Antibiotic Administration Route Antibiotic Name Antibiotic Received Birth date Clinical Trial Discharge Date ICD-9-CM Principal Diagnosis Code ICD-9-CM Principal Procedure Code Infection Prior to Anesthesia Laparoscope Oral Antibiotics Other Surgeries

Areas Studied and Data Collection ** How was the PI issue studied? **

Identified all areas where customers were affected by the process changeIdentified data element requirements from SCIP Standards (SCIP-Inf-1a) : are all these data elements collected to identify the population for the denominator???Data compiled into confidential spreadsheet(s)Measured initially over a 3 month period which helped determine a baseline for benchmarking.An area of concern was who would start the process (for the antibiotic treatment) -Must be physician driven and must be an area that maintains responsibility to the patientthroughout the surgical procedure

Retrospective data sources include administrative data and medical records???Who was responsible for collecting data???What were the sources??? Electronic health records??? 8QPIinVestigators

Measure Performance PIMeasurement Ratio How is the PI issue measured?

Identify performance measurement from SCIP Standards (SCIP-Inf-1a) Numerator Data Elements: Anesthesia Start Date Antibiotic Administration Date Antibiotic Administration Time Surgical Incision Time Denominator Data Elements: All selected surgical patients with no evidence of prior infection selected = population requirements from SCIP Standards (SCIP-Inf-1a)Frequency of data collection daily collection and reported monthly Improvement noted as: an increase in the rate (process improvement). 9QPIinVestigators

Analyze and Compare Data PI Data added to spreadsheet: Name of surgeonCase identifierDate of surgeryReason for outlier (why not started on time)Responsibility (who started antibiotic)

Analyze all outliersOperatingRoom

Timeout Checklists What analysis and comparisons are performed against the data?

Data added to confidential spreadsheet to identify the outlier, reason, and who was responsible Internal data comparisons performed against data collected over time Identify Outliers antibiotic not started one hour prior to surgery Antibiotic must be started within one hour of surgery; 1 hour 1 minute is considered an outlier. The OR Timeout Checklists are utilized in this analysis

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Analyze and Compare Data PI

** What QI toolbox (or Reporting) techniques are used? **

Aggregate PI measures, from spreadsheet, to create percentile data dashboard (Report Card) monthly for staff and physician committee. Trend Analysis as input into ongoing PI efforts related to outlier gaps Public reporting of SCIP performance measure as part of Core Measures

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Identify Improvement Opportunity PIMultidisciplinary PI Team ** Was a PI team used? **

A multidisciplinary, or cross-functional, team of highly motivated people able to drive change.The team was highly collaborative with only some difficulty because of physicians work schedules.

How often did the PI team meet?

Monthly meetings, although it could change according to progress levels

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Identify Improvement Opportunity PI** What recommendations were made? **

Anesthesiologist was recommended for sole responsibility to administer antibiotic because Anesthesiology ispart of the OR Timeout Checklist procedure which includes if and when antibiotic was started. Vancomycin needs to be given over two hour period, thus needs to be started before patient enters pre-op.

To whom was the opportunity communicated? and how?

Internal communications to the Board of Directors, CMO, Quality Executive Committee, as well as organization-wide using a Dashboard Report Card of measures and percentiles.13QPIinVestigators

Perform Ongoing Monitoring PIForces driving ongoing improvement efforts** How would you evaluate this PI process as described by the staff? **Shannon used the word PROUD! to describe the overall staff reaction.

What tools or methods or used to periodically reassess effectiveness of the process?

When 10 outliers occur within ??? timeframe, further analysis is required to look at every outlier anddetermine where the breakdown occurred; a different process may require change each time.

PI team maintains constant communication with other areas to keep processes up to date.The PI process has been through several iterations and improvements have been realized over a year. 14QPIinVestigators

Perform Ongoing Monitoring PI

The hospital indicated that the data submitted for this measure were based on a sample of cases.HCAHPS Customer Satisfaction Survey

What measures are used for customer satisfaction and how is it measured?

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey;Patients are called at home by a third party and results are publicly reported as outcome measurement.

What actions are taken if performance doesnt meet expectations?

Doctors receive a letter regarding outliers which affects peer reviews.Nurses are counseled by supervisor regarding outliers.

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