Bainbridge

595 Lyndon Road

Cuba, New York 14727

Phone 716-676-3635

Fax 716-676-2404

[email protected]

Taking Control in an Era Of Intolerance

Darlene D. Bainbridge & Associates, Inc. ©

595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]

Quality lives when:

our structures and systems maximize the potential

that we will get it right the first time.

our structures and systems minimize the risk that an

error will make it all the way to the patient.

our structures and systems ensure that our care is

consistent with the newest knowledge that offers our

patients optimal health and well being.

our structures and systems maximize the potential for

our patients to trust us and be loyal to us.


595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]

James Reason 1990


595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]


595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]

Margin for Quality

Hu

man

Perfo

rman

ce

Performance Demand

Performance Potential

Margin for

Quality

(change)

FatigueDistractionStressSkill Deficits

New ServicesShort StaffingNew Outside RequirementsDownsizing

595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]

595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]


595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]


595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]

595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]

Health care is in trouble because the costs associated with “poor quality” are just too high!


595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]

Cost of Poor Quality Rework (getting it right on the second try)

Diagnostics (cost of discovering what went wrong)

Dealing with patient complaints

Re-inspections

Write-offs

Penalties

Liability costs

Non-payment for never events

Non-payment under pay-for performance

Loss of reputation and goodwill

Soft quality

Loss of patient volume

Staff turn-over

Cost of defensive medicine


595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]

595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]

Cost of Quality Program Quality program overhead (staff, equipment, etc.)

Quality control activities

Quality auditing

Preventive maintenance

Diagnostics (cost of discovering what went

wrong)

Inspection preparation and rework

Re-inspections

Practice of defensive medicine

Accreditation readiness

Managing your change management engine (cost

of implementing improvement plans and managing

them to hold the new performance


595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]

595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]

Today’s Quality Programs:

Structures and systems that promote getting it right

the first time

Defenses that minimize the risk of an error making it

all the way to a patient

Structures and systems that deliver care consistent

with the newest knowledge that offers patients optimal

health and well being within the constraints set by their

disease processes

Interactions that maximize the potential our patients

will trust us and be loyal to us


595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]

595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]

The act of benchmarking

Practice + Practice + Practice Practice +

PROCESS

(Procedure)


Practice +

595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]


595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]

Protecting Our Patients Today

Time-outs in the Operating Room

Writing “Not Here”

Validating With Patient

Frontline Care Givers

Marking Surgical Sites

PATIENT

595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]


595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]

The Oldest Living Defense in Depth

Electronic Validation and Flags

Pharmacy Validation

24 Hour Chart Checks

Individual Transcribing Work

Double Noting by Nurses

PATIENT

595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]


Orie

nta

tio

n

Qu

alit

y Im

pro

ve

men

t

Ris

k M

anagem

ent

595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]

Quality Improvement Quality

595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]

Bringing It All Together Under One


595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]


595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]

Quality

Assurance

Quality

Improvement

Performance

Improvement


595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]

Risk

Prevention

Risk

Management

Quality

Assurance

Quality

Improvement

Performance

Improvement


595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]

Infection Control

Do we live by the

standards of good

infection control and

prevention in order to

protect our patient,

workforce and public?

Do we take

appropriate actions to

improve our infection

control practices

when the opportunity

is identified and strive

to be better for

tomorrow than we are

today?

595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]


Risk

Prevention

Quality

Assurance

Quality

Improvement

Performance

Improvement

Do we advance

organizational

performance by ensuring

that infection control

proactively makes the

appropriate contributions

to any multidisciplinary

improvement initiatives

where the risk of

infection can be a

variable.

595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]

Utilization Review

Do we ensure the effective

utilization of services and

resources in the delivery of

patient care to ensure the

delivery of the best

possible care and protect

our patients in a fiscally

responsible manner ?

Do we take appropriate

actions to improve our

utilization of resources

in the delivery of

patient care when the

opportunity is

identified and to

always strive to be

better for tomorrow

than we are today?

595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]


Risk

Prevention

Quality

Assurance

Quality

Improvement

Performance

Improvement

Do we advance

organizational

performance by ensuring

that utilization review


appropriate contributions

to any multidisciplinary


where the resource

allocation can be a

variable.

595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]

Safety

Do we comply with current

standards and practices of

safety to protect our

patients, workforce and

public for physical harm?

Do we take

appropriate actions to

make our physical

environments safer

when the opportunity

is identified and to

strive to always be

better tomorrow than

we are today?

595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]


Risk

Prevention

Quality

Assurance

Quality

Improvement

Performance

Improvement

Do we advance

organizational

performance by

ensuring that safety


appropriate

contributions to any

multidisciplinary


where the risk of

physical harm can be a

variable.

595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]

Utilization

Review

HIPAA

PrivilegingCredentialing

Safety

EducationPeer Review Orientation

Infection

Control

Risk

Prevention

Risk

Management

Quality

Assurance

Quality

Improvement

Performance

Improvement


595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]

Quality defines and manages the standards that create the patient experience to be what today’s environment demands

Patient satisfaction measures our success in creating the right patient value propositions


595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]

Effective quality programs in today’s environment are largely dependent on the existence of systems designed to get things right the first time and defenses that minimize the risk of errors making it all the way to the patient.


595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]

Minimal

Compliance

Standards

Clinical

Standards

Service

Standards

Compliance Making Organization

Strategically Successful


595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]


Come Visit Us Where We Strive for

Good

595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]


Come Visit Us Where Strive for

Excellence

595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]


595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]

An effective quality

safety net manages

the patient

experience to a

successful

conclusion!


595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]

The Patient Experience

The Patient Experience


595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]

Does your quality program:

maximize the potential for your people to get it right the first time?

minimize the risk that an error will make it all the way to the patient?

ensure that your care is consistent with the newest knowledge that offers our patient optimal health and well being?

ensure that your structures and systems maximize the potential for your patients to trust you and be loyal to you?


595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]

Does your quality program:

invest your quality resources wisely in order to

maximize the return on your investment?

minimize the operational, financial and

reputational impact of “poor quality”?

bake a great patient experience?


595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]

Our future is our choice. Those decisions we make today are a choice up and until tomorrow arrives. They then become our reality.

595 Lyndon Road


Phone 716-676-3635

Fax 716-676-2404

[email protected]


Bainbridge

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