Wishard Health Services

7% increase in Patient Safety & Quality in 6 months

Over 100,000 quality observations annually consistently aggregated for performance improvement

Wishard Health Services

Case Study – Patient Safety & Quality

 

The Challenge

Senior management wanted to upgrade the data collection process for rounding and manage process to drive sustainable improvement in patient safety and quality.  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

Wishard Health Services 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

Nursing Management and the Quality Management team agreed on overall objectives.  Nursing Management committed to support the deployment effort by assigning tracer specialists and committing time to training and tracer implementation. The Environment of Care management had utilized Sterling Readiness Rounds for three years and it was agreed to adopt this tool as the platform for the expanded Patient Safety & Quality process.

• The existing Leadership rounding  was immediately converted to the Readiness Rounds process
• Nursing management adopted the Readiness Rounds INTRA tracer template which was deployed in 30 days.  It was decided to customize the process “on the fly” rather than delay implementation with internal review.
• 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: INTRA and Leadership rounds were fully implemented in under 60 days.
• Huge Improvement: The first 6 months of the deployment showed a more than 7% 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.  Accountability for follow up at Department level was clearly established
• Dashboards: With department-specific dashboards many managers generated independent action providing significant momentum to improvement.
• Correlation: The results provided objective conformation of items needing improvements and provided focus on item and department that require improvement.

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 Wishard Health Services expectation to further improve the consistency of the process.
• Accountability:  With a process that is widely understood, move the emphasis to insisting that manager’s focus on improving their specific areas of responsibility.
• Expansion: With a facility wide focus on improvement established additional tracers/audits (Closed Medical Record / Medication Management) will be progressively added
• Periodic Performance Review: With an annual rate of over 100,000 quality observations being aggregated Readiness Rounds produces results by Chapter/Standard/EP. This data will be the basis for preparing The Joint Commission Periodic Performance review using an objective provable data source.

 

 

” Readiness Rounds provided us the framework to drive sustainable performance improvement”

Le Ann Blue, Chief Nursing Officer

 

“This process enables us to establish accountability for Patient Safety and Quality throughout the organization.”

Crissy Lough,   Director Quality & Risk Management