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QI Projects
Tamer Gharaiybah, RN, MSN
Risk Management and Patient Safety Coordinator
Al-Ahsa Hospital
CQI Department
Objective
• To discuss Emergency Room (ER) Project
• To discuss Troponin I project
• To discuss Prevent Falling Down Proje...
Emergency Room (ER) Project
• The overall goal of the project was to compose health care in ER fit with
hospital mission a...
CQI Department
4
Find
• problem in ER mostly related delaying in health care provided in ER
which is directly increases th...
CQI Departemnt 5
Organize
• Organized team was being formed in ordered to review the process and
identify the reason of de...
 Clarify
• Clarifying existed problem by comparing the expected outcome with actual
performance.
CQI Departemnt 7
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
mar apr may jun jul aug sept oct nov dec
Boarding Time indicator in ER 2015
Understanding
• study conducted over one month to evaluate the waiting time and summarize
the problems in ER as well valid...
0
1000
2000
3000
4000
5000
6000
Figure 1: Trend of ER visit number per month
2014-2015
Series 1
Selecting
• To prioritize the performance improvement in ER, we matched the
problem with priority matrix of indicators.
• ...
PLAN
• The overall goal of the project was to compose health care fit hospital
mission and vision.
• to reform ER structur...
DO
Supportive services director was responsible to achieve the objective.
Redesign ER structure to fit the extension numb...
CHECK
• After expansion, the waiting time indicator showed decrease in percentage
to the half. For instance, in January an...
Act
• The project has been already finished
• It is under monitoring
Point of Care-Troponin I
Find
• Data obtained from CAREWARE system showed that turnaround time was
more than 1 hour for pa...
Organize
• The team involved from head of LAB, ER, head nurse, supportive
maintenance, and CQI.
CQI Departemnt 17
Clarifying
• existed problem by comparing the expected outcome for TAT with actual
performance
• The expected outcome shou...
0
10
20
30
40
50
60
70
80
90
10-2015 11-2015 12-2015 01-2016 02-2016 03-2016
percentage of sample taken more than 1 hour
Understanding
• Collected specimens were sent to lab without prioritizing Troponin I. In lab,
the technician did not know ...
CQI Departemnt 21
PLAN
• The overall goal of the project was to compose health care fit hospital
mission and vision.
• Obj...
DO
CQI Departemnt 22
• In the literature, the easiest method is applying Point of Care (POC) in EMS
to avoid result delayi...
• Supportive maintenance was responsible to provide POC kit.
• Head of laboratory revised POC policy.
• Lab technician wil...
prevent Fall Down Project
CQI Departemnt 24
 To do a comprehensive assessment for all patient admitted
 To prevent patie...
CQI Departemnt 25
Organized team.
 CQI director
 Risk mngt & PT coordinator
 ICU head nurse
 ECU head nurse
 Nursing Educator
Radiolog...
Clarifying
• Morse Scale was revised carefully.
• There was error in printed scale which mean the result scale for patient...
CQI Departemnt 28
• In pediatric scale; error in printing humpty dumpty scale.
• There is no process to check equipment may cause fall for r...
Understanding
• Lack proper Assessment as well no clear intervention to prevent fall is the
major cause of fall in the hos...
PLAN
To Implement valid fall assessment tool
To implement comprehensive fall prevention program involving
intervention
C...
DO
Fall prevention policy completely changed to new comprehensive program.
Assessment tool was changed from Morse scale ...
CQI Departemnt 33
CQI Departemnt 34
QI project
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QI project

  1. 1. QI Projects Tamer Gharaiybah, RN, MSN Risk Management and Patient Safety Coordinator Al-Ahsa Hospital CQI Department
  2. 2. Objective • To discuss Emergency Room (ER) Project • To discuss Troponin I project • To discuss Prevent Falling Down Project CQI Department 2
  3. 3. Emergency Room (ER) Project • The overall goal of the project was to compose health care in ER fit with hospital mission and vision. • FOCUS PDCA has been adapted to improve health care in ER.
  4. 4. CQI Department 4 Find • problem in ER mostly related delaying in health care provided in ER which is directly increases the boarding time more than 3 hours.
  5. 5. CQI Departemnt 5 Organize • Organized team was being formed in ordered to review the process and identify the reason of delaying
  6. 6.  Clarify • Clarifying existed problem by comparing the expected outcome with actual performance. CQI Departemnt 7
  7. 7. 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% mar apr may jun jul aug sept oct nov dec Boarding Time indicator in ER 2015
  8. 8. Understanding • study conducted over one month to evaluate the waiting time and summarize the problems in ER as well validated data. CQI Departemnt 9
  9. 9. 0 1000 2000 3000 4000 5000 6000 Figure 1: Trend of ER visit number per month 2014-2015 Series 1
  10. 10. Selecting • To prioritize the performance improvement in ER, we matched the problem with priority matrix of indicators. • 1. Minimize rate of patients wait more than 3 hours • 2. Reporting urgent and emergent lab and radiology result • 3. Adherence to policy triage cases and physician documentation.
  11. 11. PLAN • The overall goal of the project was to compose health care fit hospital mission and vision. • to reform ER structure and extend number of beds. CQI Departemnt 12
  12. 12. DO Supportive services director was responsible to achieve the objective. Redesign ER structure to fit the extension number of beds. 4 beds were added to be totally 11 beds. Also pediatric clinic is opened in ER at time off OPDs CQI Departemnt 13
  13. 13. CHECK • After expansion, the waiting time indicator showed decrease in percentage to the half. For instance, in January and February the percentage of waiting time indicator was 6.6 and 7.39, respectively. • Regarding patient complain, it showed decrease in 1st quarter in 2016 comparing with 4th quarter 2015. CQI Departemnt 14
  14. 14. Act • The project has been already finished • It is under monitoring
  15. 15. Point of Care-Troponin I Find • Data obtained from CAREWARE system showed that turnaround time was more than 1 hour for patient coming to ER. CQI Departemnt 16
  16. 16. Organize • The team involved from head of LAB, ER, head nurse, supportive maintenance, and CQI. CQI Departemnt 17
  17. 17. Clarifying • existed problem by comparing the expected outcome for TAT with actual performance • The expected outcome should match hospital policy to reflect hospital vision and mission. According to hospital policy (LAB-QM-POST-7), the expected TAT is 1 hour. CQI Departemnt 18
  18. 18. 0 10 20 30 40 50 60 70 80 90 10-2015 11-2015 12-2015 01-2016 02-2016 03-2016 percentage of sample taken more than 1 hour
  19. 19. Understanding • Collected specimens were sent to lab without prioritizing Troponin I. In lab, the technician did not know which sample should be prioritize as it is emergent. CQI Departemnt 20
  20. 20. CQI Departemnt 21 PLAN • The overall goal of the project was to compose health care fit hospital mission and vision. • Objective: to avoid delay in result and to report panic value within 1 hour for troponin
  21. 21. DO CQI Departemnt 22 • In the literature, the easiest method is applying Point of Care (POC) in EMS to avoid result delaying. For instance, study showed that the result of troponin was available on average in 15 versus 83 minutes for the laboratory result (A.J., J., J., & J., 2005).
  22. 22. • Supportive maintenance was responsible to provide POC kit. • Head of laboratory revised POC policy. • Lab technician will educate ER nursing staff how to use the kit. CQI Departemnt 23
  23. 23. prevent Fall Down Project CQI Departemnt 24  To do a comprehensive assessment for all patient admitted  To prevent patient fall during hospitalization  Improvement done using FOCUS PDCA. • Find • Received OVR Monthly regarding patient fall down, and this is against target indicator. • should be no incidence as it is one of international patient safety goal.
  24. 24. CQI Departemnt 25
  25. 25. Organized team.  CQI director  Risk mngt & PT coordinator  ICU head nurse  ECU head nurse  Nursing Educator Radiology supervisor Physiotherapy supervisor CQI Departemnt 26
  26. 26. Clarifying • Morse Scale was revised carefully. • There was error in printed scale which mean the result scale for patient at high risk for fall will be low risk and vice versa. • Morse scale lacking assessment for change in elimination status which is the most reason leading for fall. CQI Departemnt 27
  27. 27. CQI Departemnt 28
  28. 28. • In pediatric scale; error in printing humpty dumpty scale. • There is no process to check equipment may cause fall for reason such as wheel chair, IV stand, or beds. • Medications may cause fall integrated in the Morse scale without sensitivity consideration. CQI Departemnt 29
  29. 29. Understanding • Lack proper Assessment as well no clear intervention to prevent fall is the major cause of fall in the hospital. CQI Departemnt 30
  30. 30. PLAN To Implement valid fall assessment tool To implement comprehensive fall prevention program involving intervention CQI Departemnt 31
  31. 31. DO Fall prevention policy completely changed to new comprehensive program. Assessment tool was changed from Morse scale to Johns Hopkins Fall risk Assessment Tool (JHFRAT). (CQI Director). Educate the staff how to implement JHFRAT (Nursing educator) Set comprehensive intervention for scale (Head nurses). Prepare checklist for equipment checking (OPD head nurse) Check equipment either daily or weekly (Nurses and end users). CQI Departemnt 32
  32. 32. CQI Departemnt 33
  33. 33. CQI Departemnt 34
  • WaheethAli

    Mar. 10, 2018
  • cetdmgh

    Feb. 19, 2017

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