2. 
A multidisciplinary, systematic quality
assessment and performance
improvement framework
Goal: to improve patient outcomes,
reduce the risks associated with patient
safety in a manner that embraces the
mission of the hospital.

3. “Problems” are usually
due to PROCESS
failures, not PEOPLE
failures!

4. 




Identify an “opportunity” (problem)
Figure out what happened (the
process)
Explore why the process failed
Identify possible improvements;
implement those
Monitor the improvements

5. 







Antibiotic selection
Preop dosing time
Postop dosing
Therapy to prevent VTE (blood clots)
Temperature maintenance
Glucose control
Patient Experience: Nurse communication,
Room cleanliness, info about medications, etc.
National Healthcare Safety Network: hospitalassociated infections, employee flu vaccine
rates

7. There were 9 patient falls in 2010. A team began
working to reduce the number of falls, research
best practices, implemented improvements.
Results:
 2010 patient falls = 9 (79 per 100,000 patient days)
 2011 patient falls = 5 (44 per 100,000 patient days)
 2012 patient falls = 1 (9 per 100,000 patient days)
 2013 patient falls = 4 (38 per 100,000 patient days)
The improvement has not been sustained; therefore
this project will be revisited

8. 




Statistics are posted on HospitalCompare
website
Lots of media attention about hospital errors
Many states have laws requiring public
reporting of errors
Poor performance results in decreased
reimbursement
MOST IMPORTANT: Stellar patient outcomes,
doing the right thing the right way for every
patient