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QUALITY IMPROVEMENT USING FOCUS-PDCA MODEL PHARMACY DEPARTMENT 1
Transcript of Quality Improvement Using FOCUS-PDCA MODEL - The …asq.org/public/wqm/quality-improvement-u… ·...
QUALITY IMPROVEMENT USING
FOCUS-PDCA MODEL
PHARMACY DEPARTMENT
1
FIND OPPORTUNITY FOR IMPROVEMENT 2
Jan Feb Mar Apr May Jun Jul Aug SepMedication Error 0 1 0 0 0 1 0 0 0
Organize a Team3
Anu Augustian HOD- Pharmacy Abdul Kareem Chief Pharmacist Elizabeth Schulze Chief Nursing Officer Khairunnisa Shallwani Education and Training
Coordinator/ Quality Dept. Shaheena Surani Infection Control
Coordinator/ Quality Dept. Haitham Naeem HOD- ER Rejimol Benny HOD- General Ward 2 Dr. Ammar Hassan General Practitioner Bincy Kurian Senior Executive- HR
Clarify the current process4
Uncover the Root Causes5
The Quality Improvement Team identified many possible reasons through brain storming which is plotted using a fish bone model.
Under reportingOf Medication
Error
Policy
People
Plant
Process
No supervision during the Medication process
No orientation for doctor
No competency checklist
Lack of Medication Error identification by patient
No processNo requirement
Lack of patient / family education on Medicationerror
Lack of interest
No regular feedbackFrom pharmacy
No aware of the importance
No audit
No enforcement to report error
Ineffective CommunicationNo open communication
Fear of consequences/Threat of losing the job
Lack of standard procedures
Fear
No risk management program
Lack of improvement projects
Barriers in reporting medication error
Threat of seniors
No monitoring of policy
No system in place
Lack of awareness
No time to read policy
No audits by pharmacist
Lack of medication tracking
No online system for medicationadministration
Lack of time
Fear of punishmentLack of awareness of medication error
Lack of educationIncrease workload and less staff
Increase turn over
Fear of legal liabilitiesError not consider worthy to report
Fear of punishment
Fear of punishment
Fear of consequencesEffect on performance
appraisalProfessional threat
Low self esteem
Confusion between medicationError and near misses
FISHBONE DIAGRAM USED TO IDENTIFY ROOT CAUSES
6
Root Cause Verification7
To confirm the reasons and collect data the following techniques are used:
-Personal Interview- Observation
Uncover/Verify Root Causes
OCCURRENCE
SL No ReasonsNo of
Responses
% Cumulative %
1 Increase workload 29 15.76 15.762 Fear of punishment 27 14.67 30.433 Fear of consequences 26 14.13 44.564 No regular feedback by pharmacy 24 13.04 57.65 Error not considered as error to report 18 9.78 67.386 No audit by pharmacy 14 7.61 74.997 No orientation regarding the process 12 6.52 81.518 Low self esteem 9 4.89 86.499 Unaware of policy 5 2.72 89.21
10 Lack of interest to report 5 2.72 91.9311 No risk Management program 5 2.72 94.65
8
Uncover/Verify Root Causes
OCCURRENCE
SL No ReasonsNo of
Responses
% Cumulative %
12 No system in place 5 2.72 97.3713 No reinforcement by HOD 3 1.63 9914 Lack of awareness for Medical Error
reporting 2 1 100TOTAL 184
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Pareto Diagram Used to Verify Root Causes
10
15.7630.43
44.5657.6
67.3874.99
81.51 86.49 89.21 91.93 94.65 97.37 99 100
0
5
10
15
20
25
30
35
Increase
workload
Fear o
f punish
ment
Fear o
f consequence
s
No regu
lar feedback
by pharm
acy
Error n
ot consid
ered as erro
r to re
port
No audit by p
harmacy
No orientation re
garding the proce
ss
Low se
lf-este
em
Unaware of policy
Lack of in
terest to
report
No risk M
anagement p
rogra
m
No syste
m in place
No reinforce
ment by H
OD
Lack of a
wareness for M
edical E
rror r
ep...
REASONS
Num
ber o
f Res
pons
es
0102030405060708090100
Series1Series2
Select The Improvement Using The Solution Selection Matrix
Proposed Solutions
Cost. is it cost effective
?20
Leadership support?
25Practical?
15Acceptance
20
Is time effective
? 20
Total Score900
1. Ensure appropriate staffing 80 125 90 100 120 5152. Train for Managing Time effectively 80 125 105 100 120 5303. Ensure mix skill staff assignments to all units 100 50 150 100 120 5204. Plan staff leaves ahead of time for Annual 120 200 150 100 120 6905. Have a planner for leaves 120 200 150 100 120 6906. Provide assuring and correct information regarding the
process 140 150 90 100 140 6207. Reduce the extent of punishments 160 200 120 160 140 7808. Provide continues education as per hospital policies and
procedures 140 150 90 100 140 6209. Share the medication error cases within unit staff
meetings 80 125 105 100 120 53010. Encourage Medical Error reporting with positive
feedback and less consequences 140 150 90 100 140 62011. Plan monthly audit schedule for each unit 120 200 150 100 120 69012. Provide monthly data to all unit heads regarding
Medication error 140 150 90 100 140 62013. Pharmacy must release quarterly action plan for the
audit results 120 200 150 100 120 69014. Spot checking by pharmacy for the proper medication
usage process. 80 100 60 80 100 42015. Offer medication safety session to all new staff and a
refresher after 3 months 160 200 120 160 140 78016. HOD will review Medication error and its types with staff
as an ongoing process. 140 150 90 100 140 620
11
Select The Improvement Using The Solution Selection Matrix
Proposed Solutions
Cost. is it cost
effective ? 20
Leadership support?
25Practical?
15Acceptance
20
Is time effective ?
20
Total Score900
17. Empower staff by timely and updated education regarding medication administration and medication safety 120 200 150 100 120 690
18. Provide Channels to ventilate their anxieties and fears 140 150 90 100 140 62019. HOD works as an advocate for her staff and provide
support as required. 120 200 150 100 120 690
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Plan the ImprovementSl No Areas of
improvement Plan Responsible Person Cost Date of Completion
1 Fear of Punishment Reduce the extent of punishments CNO/ HOD/HR Nil Nov. 2013
2Error not considered as error to report/ No orientation
Offer medication Safety session to all new staff and a refresher after 3 monthsOVR process flow to all units
PharmacyEducatorHOD
AED 1000 Ongoing Nov.
2013
3 Increase workload Plan staff leaves ahead of time: Annual
HRCNOHODDuty Managers
Nil Nov. 2013ongoing
4No regular feedback by pharmacy/ less frequent Audits
Plan monthly audit schedule for each unit
Pharmacy HOD Nil
Nov 2013ongoing
5No regular feedback by pharmacy/ less frequent Audit
Pharmacy must release quarterly action plan for the audit results
Pharmacy NIL Oct, 2013ongoing
13
Plan the ImprovementSl No Areas of
improvement Plan Responsible Person Cost Date of Completion
6 Low self esteem
Empower staff by timely and updated education regarding medication administration and medication safety
EducatorHODCNO
Nil NOV 2013On going
7 Low self esteem
HOD works as an advocate for her staff and provide support as required
HODCNO Nil Nov. 2013 on
going
8 Fear of Punishment/ Consequences
Share the medication error cases with in unit staff meetings and during Medication safety sessions
CNOEducatorPharmacyHR
NilNov. 2013 on going
9Fear of Punishment/ Consequences
Provide continuous education as per hospital policies and procedures
EducatorHODHR
Nil Nov. 2013 on going
10Fear of Punishment/ Consequences
Encourage Medication Error reporting with positive feedback and less consequences.
HODCNOHR
NilNov. 2013 on going
14
Plan the Improvement
Sl No Areas of improvement Plan Responsible Person Cost Date of
Completion
11Less frequent Audit / No regular feedback by Pharmacy
Spot checking by pharmacy for the proper medication usage processProvide monthly data to all unit heads regarding Medication Error
Quality Dept.Pharmacy Nil Dec. 2013
ongoing
12Error not considered as error to report/ No orientation
HOD will review medication error and its types with staff as an on going process
HOD Duty Managers Nil Dec. 2013
ongoing
13 Low self esteemProvide channels to ventilate their anxieties and fears
HODCNODuty Managers
Nil Dec. 2013 ongoing
14 Increase workload Train for managing Time Effectively
HREducatorHOD
Nil Nov. 2013
15
Plan the Improvement
Sl No Areas of improvement Plan Responsible Person Cost Date of
Completion
15 Fear of Punishment/ Consequences
Share the medication error cases within unit staff meetings
HODHRCNO
Nil Nov. 2013 Ongoing
16 Increase workload Ensure mix skill staff assignments in all units
CNOHRHOD
Nil Nov 2013
17 Increase workload
Ensure appropriate staffingIntroduce training for staffing plan as per unit requirement
CNOHRHOD Educator
Nil
Nov 2013
2014 Planner
18 Low self esteem
Encourage staff to verbalize their issues of reportingHead nurse encourage staff to report
HOD Nil Nov 2013
16
Do17
Some Planned Solutions were implemented over a period of two months and the others are on going.
Check did it works?18
Medication Error Report
BEFORE AFTER
Improvement Noticed19
Medication error reporting has been increased
Support system is available for staff to ventilate their feeling
Audit schedule planned Sharing of medication error report on
quarterly bases Action plan by pharmacy was shared and
will be done on regular bases
Act: Maintain the Gain20
Ongoing education Support system for staff to share
their fears and anxiety Staff is aware of different types of
medication errors and knows how to report: noted during session.
Audits & reports by pharmacy
THANK YOU!!!
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