In the context of our recent converstations highlighting how complex health systems are NOT design to expect failure I took a critical look at some of the CQI initatives I have been involved with and realized that more often then not, these projects were often doomed very near to inception,

 

Often QI is felt to be a quick, logical change to streamline or create greater efficiency or generate better results. They rarely sound difficult on paper. But they are set up to fail. Here a few thoughts going into our project commitments today to keep in mind.

 

Failure to:

Pick a specific, attainable goal (ie: too broad topic, too grand scale)

–This is where your SMART AIM statement should guide you

Understand the process or environment

–Compete analysis with a proper PROCESS MAP and FISHBONE diagram is necessary no matter… Continue reading →

Near miss to significant event.

 

I was trying to distill Nance to a few quick sentences and came up with:

Expect failure to achieve success

If you want peace, prepare for war

This is achieved via teams, not individuals

Attitude / culture and environment are paramount

 

Here are a few “open to anyone ideas” for QI / safety from the session 6/7

Rn activated protocols that allow them to dose OTC medications via a flow sheet for common issues such as pain, fever, sleep, allergic symptoms

Safety net system should have the capacity to analyze trends in the marco-data to identify themes / repeat event.

PCP initiative to increased number of advanced directives on file for their panel based on CAM scores to decrease uncertainty about wishes at end-of-life.

Video informed consents that present a visual, standardized model for the patients / family to improve understanding, evidence-based approaches… Continue reading →

Hello all, this is my first blog post ever.

Interesting line from today which I figured to be a fitting title. Will be brief here, and let you in on my intent to use part of my time in Marseille to brainstorm ideas (with the help of other residents and faculty) to effect small, cumulative change to get all of us “closer to zero.” To that end my blog will consist of various ideas (open for all) that pertain to possible patient safety and QI project in no specific order:

From session ONE:

1) Post-discharge clinic time slots for inpatient providers to follow up with recent discharges in a timely manner. This is done currently at the DVMC and would decrease 30-day readmission as well as improve transitions of care and also decrease burden on already busy PCPs.

2) Protected time for critical communication (handoffs / consents): minimize pages, RN… Continue reading →