Quality Improvement Plan Page 12
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32CROUSE HOSPITAL QUALITY IMPROVEMENT PLAN 2013
•
Educates the entire staff in the quality improvement process and the use of CQI
tools and techniques, including statistical process control, and helps ingrain the
use of this body of knowledge into the organizational culture.
•
Within PDSA is the Six Sigma DMAIC model; a set of tools outlined in five
chronological phases:
•
Develop a clear project charter that identifies processes to be
Define:
improved that are relevant to customer needs and that will provide significant
benefits to the hospital.
•
Measure: Determine the baseline and target performance of the process, define
key input and output variables and validate the measurement system.
•
Analyze: Use data to find the root cause of the problem; to understand and
quantify their effect on process performance.
•
Improve: Identify process improvements to optimize process outputs and
reduce variation.
•
Document, monitor and assign accountability for sustaining gains
Control:
made by the process improvements.
The DMAIC approach when combined with PDSA ensures that a standardized approach
to process improvement is followed and that the voice of the customer is reflected within
the process improvement.
In addition to the PDSA and DMAIC approach, lean healthcare principles will be applied
throughout the process redesign. Lean Healthcare includes tools such as:
•
Identify and Eliminate Waste:
1. Overproduction (making extra/unnecessary copies)
2. Waiting (Equipment, signatures)
3. Motion (searching for charts/medication
4. Transport ( constantly moving equipment from one place and back)
5. Over processing (Ordering more test then what is required)
6. Inventory (Excessive office supplies, medication in excess of usage)
7. Errors (Redraws, wrong patient, medication errors)
•
5S
1. Sorting (when in doubt move it out)
2. Set – items in order (a place for everything and everything in its place)
3. Shine (clean is lean)
4. Standardize (reduce variation through standardization)
5. Sustain through education and communication
These are two tools of many that will focus attention on non value added activities that
increase cost and reduce patient satisfaction.
Performance
improvement
initiatives
are
conducted
at
the
lowest
practical
organizational level of involvement and include interdepartmental or multi-disciplinary
representation in most instances. This team approach to quality improvement serves
several important purposes: Quality improvement teams will establish quality, cost or
service targets as appropriate for the improved or redesigned process, establish time
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