Sample CQI

8/11/2019 Sample CQI

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Errors of TPR Sheet at

the NeuroSurgery Ward ofSouthern Philippines

Medical Center Adenir , Angelie Dixil Fortugaliza, Ria

Bandala , Aize Mondragon ,

DominiqueBarriga , Henry Torno , Rizaluz

Zabala , Heidee Joy



Introduction



STEP 1 Reason for

ImprovementMULTIVOTING

A Proper donning of ICU watchers’ gowns

B Lack of suction machines

C Documentation Errors in TPR sheet

D Unrepaired electrical socket

E Inappropriate type of garbage bin

F Unrestricted implementation of visiting hours

G Inability to give prescriptions on time

H No emergency lights

I Presence of stray cats and pests

J Insufficient hand washing liquid/ soap

K Inadequate supply of personal protective equipment (PPE) per shift

L Need for continuous learning training/ updates on neurological assessment

M Usage of medication tray per patient for primary nursing approach

O Enhancement of NVS Assessment Form

Theme Letters Themes



L Need for continuous learning training/ updates

on neurological assessment

O Enhancement of NVS Assessment Form

C Documentation Errors in TPR sheet

TOP 3Theme

Letters Themes



Theme Selection Matrix

THEMES CUSTOMER(S)IMPACT ONCUSTOMERS

NEED TOIMPROVE

OVERALL RANK



Step 2 Current Situation

Proportion of Completeness of Medication sheet of Philhealth charts at Medical Ward for

First Quarter of 2007

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jan Feb March

Complete

Incomplete



Problem Statement:

From January 1 to March 31, 2007,

66% of medication sheet of Phil Healthpatients’ charts at the Medical Ward of

Davao Medical Center were incomplete;

thus causing delays in PHIC claims andreimbursement.

Target for Improvement:

By the end of December 31, 2007,Incomplete medication sheet at the

Medical Ward will be reduced to 30%.



IncompleteMedication

sheet

Nurse

Process

Materials

Step 3: Analysis



Step 4 Countermeasures



c on anProblem Statement:

From January 1 to March 31, 2007, 66% of medication sheet of Phil Healthpatients’ charts at the Medical Ward of Davao Medical Center wereincomplete; thus causing delays in PHIC claims and reimbursement.

Target for Improvement:By the end of December 31, 2007, Incomplete medication sheet at the

Medical Ward will be reduced to 30%.

Counter-

measures

Practical

Methods

Tasks Resources WhoDoes

Start

Date

End

Date

How

Done

Compliance

with

Standards

Of nursing

Practice on

docu-

mentation

Re-

orientation

Seminar on

docu

mentation

Every

Other

month

Prepare

Training

materials

Visual

aids

On

Standards

of

Nursing

Practice

Hosp.

Guidelines

and

policies

Vilma L.Comoda,

Elizabeth

Barriga,

Lani Paler,

Charito

Barga-

mento,

Christine

Aquino

Aug. 15,

2007

July 152008

Coordinated

with

Training

office and

assistant

chief nurse

For schedule

Of staff



Step 5 Results

Proportion of Completeness of Medication sheet

of Phil health charts at Medical ward in 2007

0%10%

20%30%

40%50%

60%70%80%90%

100%

J A N

M A

R C H

M A Y

J U L Y

A U G

O C T

D E C

COMPLETE

INCOMPLETE

I

N

T

E

R

V

EN

T

I

O

N

BEFORE AFTER

----------------------------------------------

Target 30%



Step 6 Standardization



Step 7 Future Plans

Documents

Sample CQI