Performance Improvement Initiative Needed

elkpark · Jan 17, 2010

Doesn't it make the most sense to identify some performance issue on your unit that needs improving, rather than just looking around for a generic idea?? What could your unit be doing better? Most facilities have some sort of ongoing monitoring process that identifies areas that need improvement -- what data are you collecting on an ongoing basis, and what do those results show? Hospitals are required (by state and federal regs) to have an ongoing, continuous QA/QI/PI/whatever-we're-calling-it-this-year process, and that process usually generates the information that generates specific PI projects. Is your hospital doing something different?

L/DRNinMO · Jan 20, 2010

I agree. I'm not saying that we couldn't improve on a variety of areas, I was hoping for some ideas on areas that I may not have considered. Sometimes when we look at the same things over and over, it's difficult to see something different. I was curious as to what other areas of the country was looking at/working on.

elkpark · Jan 20, 2010

When JCAHO or CMS (or your state) comes to survey, they will want to see that you have a QA/PI process in place that collects data --> identifies areas of improvement --> initiates PI projects --> measures results (collects data), all in one big, continuous loop (that is, that your improvement projects are generated from the data you've collected on your unit). Have you talked with your hospital's QA/PI/whatever-we're-calling-it department about this? There's usually a coordinated, facility-wide system/process that each individual unit is participating in.

L/DRNinMO · Jan 21, 2010

Our current QI is Med recon (if we figure that one out I'll let everyone know!), we have recently done a QI to improve our on-time procedure starts. I was just hoping to get some more practice specific ideas. There is not much help within the hospital as most PI revolves around Best In Class ect. in which we do not have anything on the BIC scorecard.

I think I am going to look at pain control for circs. as our orders state tylenol 30 min prior and 4 hours after. I am doubting that the 4 hours after is occuring. I think that may be something that we look at. I appreciate your input.

elkpark · Jan 21, 2010

I'm sorry to hear your facility PI program is not much help -- it's a shame there's so much variation from hospital to hospital! Some places are really working hard to have a good program, and some are just "going through the motions." You can certainly be more aggressive about pursuing issues on your unit than the overall facility is being. Best wishes!