QPIINVESTIGATORS
QPIINVESTIGATORS
MissionTo 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
PI
QPIINVESTIGATORS
Texas 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
PI
QPIINVESTIGATORS
Interviewee: Shannon Kane-Reinhardt RN, BSN, Quality Manager(St David’s Round Rock Medical Center)
Interviewers:• Lombe Chitundu• Jean Cusick• Yolanda Johnson• Vicki McGinnis• Sharon Royall-Murphy
Interview Date: March 30, 2010
PI
QPIINVESTIGATORS
PI
Step 5: Perform Ongoing Monitoring
Step 4: Identify Improvement Opportunity
Step 3: Analyze and Compare Data
Step 2: Measure Performance
Step 1: Identify Performance Measures
5 Steps in an Organizational PI Model
QPIINVESTIGATORS
PI
Core Measures SCIP
Antibiotic Received Within One Hour Prior to Surgical Incision (SCIP-Inf-1a)
QPIINVESTIGATORS
PI
SCIP-Inf-1a
SurgicalPatients
Reduced risk of post-
operative infections
QPIINVESTIGATORS
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
QPIINVESTIGATORS
PI
Measurement Ratio
Number of surgical patients with antibiotics initiated within one hour prior to surgical incision
All selected surgical patients with no evidence of prior infection.
QPIINVESTIGATORS
PI
Data added to spreadsheet:
Name of surgeonCase identifierDate of surgeryReason for outlier
(why not started on time)
Responsibility (who started antibiotic)
Analyze all outliers
OperatingRoom
Timeout Checklists
QPIINVESTIGATORS
PI
QPIINVESTIGATORS
PI
SCIP Champions
Directors
FrontlineManagers
Staff
Multidisciplinary PI Team
QPIINVESTIGATORS
PI
Board of Directors
CMO
Quality Executive
Committee
Organization
WideCommunic
ation via Report
Card
QPIINVESTIGATORS
PI
PI Cycle
Computer
SystemChange
s
OR Chartin
g ModuleRollout
PI ProcessIssues
(Outliers)
Process change(s) in other areas
Forces driving ongoing improvement efforts
QPIINVESTIGATORS
PI
The hospital indicated that the data submitted for this measure were based on a sample of cases.
HCAHPS Customer Satisfaction Survey
Recommended
