University Health System

University Health System

 

“Readiness Rounds gave us the structure to deploy sustainable
performance improvement at a rapid pace.”

Pete Valdez, M.D., University Health System

  

  

Case Study – Patient Safety & Quality

 

The Challenge

Executive Management had a high level of urgency regarding measuring and improving patient safety and quality. They identified the need for a process to deploy a culture of constant readiness; the status quo was unacceptable. It was recognized that the huge volume and disparity of data sources to execute this improvement was a major hurdle to effective implementation.

The Objective

University Health System had several goals it wanted to achieve:

• Instill a “culture” of Patient Safety and Quality throughout the organization
• Implement a process that was supportive and educational for all staff
• Install a system to easily show trends, celebrate success, and sustain and continue the improvement process
• Create a methodology to focus the organization on performance-improvement priorities
• Design a system that proactively assessed the status of Patient Safety & Quality
• Implement a structured yet flexible approach to ensure that changing needs could be accommodated
• Ensure that any items needing correction were captured and monitored to ensure correction
• Implement dashboards at all levels of organization to communicate results
• Streamline existing processes and eliminate duplicate efforts
• Readily demonstrate progress
• Hold managers accountable for ongoing improvement
• Produce consolidated data for regulatory reporting

 

The Solution

Senior Management and the Quality Management team agreed on overall objectives.  Senior Management committed to support the deployment effort by reviewing results weekly and insisting that subordinates follow the process. Sterling Readiness Rounds was adopted as the platform for the Patient Safety & Quality process.

• The existing tracer conducted by managers to gather focused review data was immediately converted to Readiness Rounds.
• A focused Universal Protocol Data effort was done using Readiness Rounds to aggregate the data.
• The Closed Medical Record Review was converted to the Readiness Rounds  template, customized, and deployed in two weeks.
• The Environment of Care rounding was deployed shortly thereafter.
• An Integrated (INTRA) tracer using Readiness Rounds was agreed to and deployed, then sent  using a pdf to decentralized specialized nursing staff to conduct.
• The existing Medication Management tracer was incorporated into the Readiness Rounds format and sent using a pdf to pharmacy inspectors to conduct.
• Follow-up notices to correct failing items were generated from Readiness Rounds.
• Dashboards were distributed throughout the organization, and reviewed for trends and any focused improvement needed.

 

The Results

• Speed of Deployment: All major modules were deployed in under 6 months.
• Huge Improvement: The first 5 months of the deployment showed a more than 9% increase in Patient Safety & Quality results.
• Focus on Top 10: With a dashboard approach designed to focus all management on top failing items, significant gains were quickly realized.
• Failing Items: Items that failed were indeed corrected.  No more than 25 items appeared beyond the established time period to correct.
• Dashboards: With department-specific dashboards many managers generated independent action providing significant momentum to improvement.
• The Joint Commission:  A recent 5-day unannounced survey resulted in a short list of recommendations.

 

The Future

• Priority: Continue to reinforce Quality and Safety as a culture of “doing the right things every time” throughout the organization.
• Consistency: Enhance question structure to incorporate University Health System expectation to further improve the consistency of the process.
• Accountability:  With a process that is widely understood, move the emphasis to insisting that managers focus on improving their specific areas of responsibility.
• Expansion: Review other rounding/auditing processes for inclusion to reduce duplication of effort.