Part 6: The Monitoring and Reporting Challenge Healthcare Engineering Consultants What is the most...

Part 6: The Monitoring and Reporting Challenge

Healthcare Engineering Consultants

What is the most effective method to provide EC

monitoring and reporting?

Monitoring Regulatory Compliance


How should regulatory compliance be monitored?

Monitoring Regulatory Requirements


Regulatory Compliance Dashboard

Description JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC CommentsGeneral Reqs

SC Meetings X X X X X XDashboard Rpt X X X X X XLeadership Rpt X X X XEvaluations XPolicy Review XSafety Mgmt

Hospital Surv X XClinic Surv X XSecurity Mgmt

Alarm Tests X X X X X X X X X X X XAbduction Drills X XHazmat Mgmt

Manifests X X X X X X X X X X X XHaz Vapor Mon X X X XPermits, Lic XVerify MSDS XEmer Mgmt

Hospital Drills X XClinic Drills XHVA XFire Prev

Hosp Fire Drills X X X X X X X X X X X XClinic Drills X X X XSOC Document XILSM Measures A/R A/R A/R A/R A/R A/R A/R A/R A/R A/R A/R A/RExtinguishers X X X X X X X X X X X XFire Det Dev X X X X



Regulatory Compliance Dashboard

Description JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Comments General Reqs SC Meetings X X X X Dashboard Rpt X X X X Leadership Rpt X X Evaluations X Policy Review X Safety Mgmt Hospital Surv X Clinic Surv X Security Mgmt Alarm Tests X X X X X X X X Abduction Drills X X Hazmat Mgmt Manifests X X X X X X X X Haz Vapor Mon X X X Permits, Lic X Verify MSDS X Emer Mgmt Hospital Drills X Clinic Drills HVA Fire Prev Hosp Fire Drills X X X X X X X X Clinic Drills X X X SOC Document ILSM Measures N/A N/A N/A N/A A/R A/R A/R A/R A/R A/R A/R A/R Extinguishers X X X X X X X X Fire Det Dev X X X



Regulatory Compliance Dashboard (continued)

Description JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Comments Fire Prev Water Devices X X X Fire Pumps W W W W W W W W Ver/Hor Doors X F/S Dampers Med Equipmt PM LS Eqmt X X X X X X X X PM NLS Eqmt X X X X X X X X Util Systems PM LS Sys X X X X X X X X PM NLS Sys X X X X X X X X Em Gen Tests X X X X X X X X Batt Light Test X X X X X X X X Water Tests X X X HVAC Tests X X X MGAVS Tests X X X X X X X X App Environ PCRA N/A N/A N/A N/A A/R A/R A/R A/R A/R A/R A/R A/R Miscellaneous Eyewash units W W W W W W W W Showers X X X X X X X X

Key to dashboard symbols: X – Indicates that action is required during the month indicated; W – Indicates that weekly action is required A/R – Indicates that action is required when applicable Key to colored boxes: Red boxes indicate non-compliance (tests were not performed); Yellow boxes indicate partial compliance (tests have been delayed or not fully completed); Green boxes indicate full compliance (tests satisfactorily completed).

Reporting Regulatory Requirements


Hospital Governing Body

Hospital Executive Committee

Hospital EOC Committee

Accident and Safety Subcommittee

Hazardous Materials Subcommittee

Life Safety/ Construction Subcommittee

Equipment and Utilities Subcommittee

Emergency Management Subcommittee

Step 1: Create regulatory compliance “dashboard” for the Life Safety/ Construction Subcommittee



Regulatory Compliance Dashboard for Life Safety/ Construction Subcommittee

Description JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Comments Fire Prev Hosp Fire Drills X X X X X X X X Clinic Drills X X X SOC Document ILSM Measures N/A N/A N/A N/A A/R A/R A/R A/R A/R A/R A/R A/R Extinguishers X X X X X X X X Fire Det Dev X X X Water Devices X X X Fire Pumps W W W W W W W W Ver/ Hor Doors X F/S Dampers PCRA N/A N/A N/A N/A A/R A/R A/R A/R A/R A/R A/R A/R

Key to dashboard symbols: X – Indicates that action is required during the month indicated; W – Indicates that weekly action is required A/R – Indicates that action is required when applicable Key to colored boxes: Red boxes indicate non-compliance (tests were not performed); Yellow boxes indicate partial compliance (tests have been delayed or not fully completed); Green boxes indicate full compliance (tests satisfactorily completed).











Step 2: Create regulatory compliance “dashboard” for the Hospital EOC Committee from each subcommittee “dashboard”











Step 3: Create a simplified regulatory compliance “dashboard” for the Hospital Executive Committee from the EOC Committee “dashboard”



Hospital Executive Committee Regulatory Compliance Dashboard

Description JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Comments General Reqs Safety Mgmt Security Mgmt Hazmat Mgmt Emer Mgmt Fire Prev Medical Eqmt Utilities Mgmt

Key to colored boxes: Red boxes indicate non-compliance (tests were not performed); Yellow boxes indicate partial compliance (tests have been delayed or not fully completed); Green boxes indicate full compliance (tests satisfactorily completed).











Step 4: Create a simplified regulatory compliance “dashboard” for the Hospital Governing body from the Executive Committee “dashboard”



Hospital Governing Body Regulatory Compliance Dashboard

Description JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Comments EOC Reqs

Key to colored boxes: Red boxes indicate non-compliance (tests were not performed); Yellow boxes indicate partial compliance (tests have been delayed or not fully completed); Green boxes indicate full compliance (tests satisfactorily completed).

Monitoring Performance Improvement

Performance Improvement“Attempting to measure and improve

performance on an ongoing basis in the Environment of Care”


Measurement and Improvement

The “PI Continuum”


Very simple Very complex


What Measurements are Required?

Patient and visitor injuries

Property damage incidents

Staff injuries and illnesses

Security incidents for patients, staff, visitors

Hazmat spills , exposures and related issues

Fire safety problems, deficiencies and failures

Medical equipment problems, failures, user errors

Utility system problems, failures and user errors



What Performance Improvement Measures are Required for each “EC” area?

Minimum of seven performance measures

Should be numerical

No maximum number

Should measure performance improvement

Adopt goals, objectives and benchmarks

Regular reporting and tracking to SC


Selection of “EC” PI Indicators


“EC” Performance Measure Worksheet

“EC” Area: ____________________ Calendar Year: _______________

Description ofPerformance Measure

Indicator Type (PI or regulatory)

NumericalMeasurement

Benchmark Objective ResponsibleDepartment

ReportingFrequency


How Should Terms Should be Defined? Goal: The attempted attainment of “perfection”

Example: No patient falls during the year!

Benchmark: Actual, historical, internal or external data used for comparative purposes

Example: “X” patient falls occurred last year

Objective: Attempted attainment of “realism”

Example: Reduce patient falls from last year by at least 10%

Threshold: The point at which action is taken

Example: Investigate every patient fall that occurs


Monitoring and Improvement

How are “EC” Performance Improvement Measures Monitored?



Monitoring of “EC” issues through:

Creation of the “Multi-Disciplinary Improvement Team”

Safety committee membership and meetings

Communication to leadership

Annual PI initiative recommendation to management

Monitoring of Effectiveness

Selection of numerical performance measures

Establishment of goals, objectives, benchmarks

Aggregation of data (“dashboard” or spreadsheet?)


Reporting of “EC” PI Indicators


Performance Improvement Dashboard

Description of Measure

Benchmark FY 2004

Objective FY 2005

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Trend

Safety Management

Lost time injuries

21/ year <1.5 per month

1 2 1 3

Security Management

Internal theft (equipment, $)

$ 25, 426 for the year

<$ 2,000 per month

1,200 425 0 1,720

Hazmat Management

Decrease in RMW

124,560# for the year

< 9,500# per month

9,245 9,386 9,142 9,524

Emergency Management

Call-back response rate

68% within 20 minutes

75% 69% 73% 84% 81%

Fire Prevention

Average fire drill score

87 per drill average

> 90 per drill avg

93 91 94 91

Medical Equipment

Maint cost/ device/ month

$48.13 per device/ mo

$45.00/ dev/ mo

53.14 47.86 58.22 39.78

Utility Management

Priority I WO response time

3.2 days < 3 days 3.1 3.1 2.9 3.0

Key to colored boxes: Green boxes indicate data within the desired objective and an improvement trend Yellow boxes indicate data at or slightly above the desired objective with no discernible trend Red boxes indicate data above the desired objective and a negative trend


The “PI Process”


Measurement Initiative Implementation


The “PI Process”


Measurement without implementation and ongoing monitoring to validate

improvement is of little value!


Questions?


Part 6: The Monitoring and Reporting Challenge Healthcare Engineering Consultants What is the most...

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