The Joint Commission s Core Measure Sets

Transcription

1 The Joint Commission s Core Measure Sets 1) Acute Myocardial Infarction (AMI) 2) Children s Asthma Care (CAC) 3) Heart Failure (HF) 4) Hospital Based Inpatient Psychiatric Services (HBIPS) 5) Hospital Outpatient Department Measures 6) Perinatal Care (PC) 7) Pneumonia (PN) 8) Stroke (STK) 9) Surgical Care Improvement Project (SCIP) 10) Venous Thromboembolism (VTE) 2011 TPHA Annual Conference 1

2 1) Elective Delivery No elective delivery less than 39 weeks 2) Cesarean Section 3) Antenatal Steroids 4) Healthcare associated bloodstream infections in newborn 5) Exclusive breast milk feeding Data (Input) Analysis (Transformation) Interpretation (Output) 2011 TPHA Annual Conference 2

3 Data (Input) Analysis (Transformation) Interpretation (Output) Six Sigma is a process-focused strategy and methodology for Quality Improvement whether in manufacturing, business or healthcare. It defined a systematic approach to Process Improvement. It s not just about improving cycle time but about decreasing errors which translates into saving lives and saving valuable resources TPHA Annual Conference 3

4 Define the problem Measure the defects and process operation Analyze the data and discover causes of the problem Improve the process to remove causes of defects Control the process VOC DOE SPCC Fishbone Diagram Pareto Chart FMEA SIPOC Histogram Run Chart 2011 TPHA Annual Conference 4

5 Compliance Rate ( ) Month Compliance Rate Month Compliance Rate Month Compliance Rate Month Compliance Rate Jan Jan Jan Jan Feb Feb Feb Feb Mar Mar Mar Mar Apr Apr Apr Apr May May May May Jun Jun Jun Jun Jul Jul Jul Jul Aug Aug Aug Aug Sep Sep Sep Sep Oct Oct Oct Oct Nov Nov Nov Nov Dec Dec Dec Dec They can work to improve the system They can distort the system Or, they can distort the data 2011 TPHA Annual Conference 5

6 PACU Arrival Temps of Arrival Temps<36 C (96.8 F) Hospital Hospital Hospital The Voice of the Process 0 Average Temp and Less Spread of Temps are Desired Hospital 2 PACU Average = 7.55 of pts. Expected High = Expected Low=0 Hospital 3 PACU Average = 7.75 of pts. Expected High = Expected Low=0 Hospital 1 PACU Average = 4.23 of pts. Expected High = 6.71 Expected Low=1.76 Target is 0 (We want PACU Temp to = 36C) 3 standard deviations Less than a 0.27 chance that we are wrong about spotting a signal (Less Kick butt, good job) Quarterly numbers masks the problem. Patients don t feel averages! If ou want to hit our target temp of 0 < 36 C then ou must change our process 2011 TPHA Annual Conference 6

7 No data have meaning apart from their context Trust no one who can not, or will not, provide the context from their figures Graphs make data more accessible to the human mind than do tables. Tables of values should accompany most graphs Numerical summaries of data (Avg., Histograms, and Ranges) may supplement graphs, but they never replace them. While every data set contains noise, some data sets may contain signals. Therefore, before you can detect a signal you must filter out the noise. Process behavior charts filter out the noise of routine variation by construction of the limits. The distinction between signals and noise is the foundation for every meaningful analysis of data. The first mistake is Interpreting Noise (normal variation) as if it were a Signal (assignable cause) The second mistake is Failing to Detect a Signal when it is Present TPHA Annual Conference 7

8 2011 TPHA Annual Conference 8

9 2011 TPHA Annual Conference 9

10 Example: Admission Orders to L& D for an Elective C-Section 2011 TPHA Annual Conference 10

11 Compliance Rate ( ) No Elective Delivery less than 39 weeks Month Compliance Rate Month Compliance Rate Month Compliance Rate Month Compliance Rate Jan Jan Jan Jan Feb Feb Feb Feb Mar Mar Mar Mar Apr Apr Apr Apr May May May May Jun Jun Jun Jun Jul Jul Jul Jul Aug Aug Aug Aug Sep Sep Sep Sep Oct Oct Oct Oct Nov Nov Nov Nov Dec Dec Dec Dec TPHA Annual Conference 11

12 2011 TPHA Annual Conference 12

13 Obstetrical Carepath (final version) 2011 TPHA Annual Conference 13

14 Define the problem Measure the defects and process operation Analyze the data and discover causes of the problem Improve the process to remove causes of defects Control the process 2011 TPHA Annual Conference 14

15 1) No elective delivery less than 39 weeks 2) Surgical Care Improvement Project (SCIP) 3) Venous Thromboembolism (VTE) Year Admissions to NICU with gestational age of 36 0/7 to 38 6/7 weeks Average admissions per month The delta (1/1/11 9/3/11) TPHA Annual Conference 15

16 THE DELTA (the decrease in the # of infants admitted to NICU compared to last year) 86 Average length of stay 7 Total # of infant days in a year 602 Average daily facility cost plus physician cost per day $1,500 Dollars Saved in one year $903,000 Don't fall into the knee jerk reaction trap and make changes in your process without plotting your data in a control chart. What does you control chart (process behavior chart) tell you. Is there normal variation or is there exceptional variation. Is there a trend? Do you have a stable process? Variation is the enemy Follow the Duck DMAIC Statistical software: Minitab, MS Excel 2011 TPHA Annual Conference 16

17 Issue: Too many mothers and babies are readmitted to hospital within 7 10 days of discharge. TM A Mother s Touch Postpartum Protocol Direct mothers to their first postpartum physician visit. Your postpartum appointment is at 3pm tomorrow. Please call if you need to cancel or re schedule. Monitor the well being of the mother. Check your surgical incision daily. Contact your doctor if appears red or inflamed, or if there s drainage from the incision. Engage in real time depression screening. How are you? Rate your emotional well being on a scale of 1 to 5. Reply 1, 2, 3, 4, or 5. (with 5 being very happy) Conduct real time patient satisfaction surveys. How would you rate your postpartum care experience on a scale of 1 to 5? Reply 1, 2, 3, 4, or 5. (with 5 being excellent) Remind mothers & caregivers to review discharge protocols. Review you postpartum discharge instructions daily. Click here or visit samplesite.com Call your doctor if you have any of the listed symptoms TPHA Annual Conference 17