QI ProjectsTamer Gharaiybah, RN, MSN

Risk Management and Patient Safety Coordinator

Al-Ahsa HospitalCQI Department

CQI Department 2

Objective

• To discuss Emergency Room (ER) Project• To discuss Troponin I project• To discuss Prevent Falling Down Project

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.

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CQI Department

Find

• problem in ER mostly related delaying in health care provided in ER which is directly increases the boarding time more than 3 hours.

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Organize

• Organized team was being formed in ordered to review the process and identify the reason of delaying

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Clarify

• Clarifying existed problem by comparing the expected outcome with actual performance.

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Boarding Time indicator in ER 2015

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Understanding • study conducted over one month to evaluate the waiting

time and summarize the problems in ER as well validated data.

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Figure 1: Trend of ER visit number per month 2014-2015

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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.

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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.

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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

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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.

Act

• The project has been already finished • It is under monitoring

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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.

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Organize

• The team involved from head of LAB, ER, head nurse, supportive maintenance, and CQI.

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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.

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90percentage of sample taken more than 1 hour

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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.

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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

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DO

• 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).

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• 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.

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prevent Fall Down Project

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.

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Organized team.

CQI director Risk mngt & PT coordinator ICU head nurse ECU head nurse Nursing EducatorRadiology supervisorPhysiotherapy supervisor

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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.

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• 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.

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Understanding

• Lack proper Assessment as well no clear intervention to prevent fall is the major cause of fall in the hospital.

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PLAN

To Implement valid fall assessment toolTo implement comprehensive fall prevention program involving

intervention

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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).

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