What You Need to Know What You Need to Know aboutabout

FOCUS PDCAFOCUS PDCA

A Nine Step A Nine Step Process Guide Process Guide

to Quality to Quality Improvement Improvement

F-O-C-U-SF-O-C-U-S

FindFind a process that needs improvement a process that needs improvement OrganizeOrganize a team who is a team who is

knowledgeable in the processknowledgeable in the process ClarifyClarify the current knowledge of the the current knowledge of the

processprocess UnderstandUnderstand the causes of variation the causes of variation SelectSelect the potential process the potential process

improvementimprovement

P-D-C-AP-D-C-A PlanPlan the improvement/data the improvement/data

collectioncollection DoDo the improvement/data the improvement/data

collection/data analysiscollection/data analysis CheckCheck the data for process the data for process

improvementimprovement ActAct to hold the gain/continue to hold the gain/continue

improvementimprovement

FF--O-C-U-SO-C-U-S

FindFind What is the process?What is the process? Is there a simple clear description Is there a simple clear description

of the process? of the process? What are the process problems?What are the process problems? Who will benefit from the Who will benefit from the

improvement in the process?improvement in the process? How does it fit within the How does it fit within the

hospital’s system and priorities?hospital’s system and priorities?

Find:Find: Example from Example from AUBMCAUBMC

Operative Report DictationOperative Report DictationOperative report dictation should be Operative report dictation should be

done within 24 hours post surgery done within 24 hours post surgery (47.5%, December 2003). (47.5%, December 2003).

Result: Result: incomplete Medical Recordsincomplete Medical Records discrepancy discrepancy inaccuracy (no details and inaccuracy (no details and

specifications)specifications) incomplete information in the incomplete information in the

Operative ReportOperative Report

FF--OO--C-U-SC-U-S OrganizeOrganize

Determine team size, members Determine team size, members who represent various levels in who represent various levels in the organization.the organization.

Select members who know and Select members who know and work with this process.work with this process.

Is technical guidance and support Is technical guidance and support available? available?

Document the progress of the Document the progress of the team.team.

Organize:Organize: Example from Example from AUBMCAUBMC

Task Force CreationTask Force Creation

Medical Records Medical Records AdministratorAdministrator

Chief of StaffChief of Staff Dean of the Faculty of Dean of the Faculty of

Medicine, Medicine, Performance Performance

Improvement CommitteeImprovement Committee

F-OF-O--CC--U-SU-S ClarifyClarify

Who are the customers?Who are the customers? What are their needs?What are their needs? What is the actual flow of the What is the actual flow of the

process? process? Is there needless Is there needless

complexity/redundancy? complexity/redundancy? What are the outcomes/best way What are the outcomes/best way

for the process to work?for the process to work?

Clarify:Clarify: Example from Example from AUBMCAUBMC

Dictation by phoneDictation by phone

Not user friendly.Not user friendly.Causing frustration Causing frustration among surgeons. among surgeons.

Dictation not Dictation not performed on time.performed on time.

F-O-CF-O-C--UU--SS UnderstandUnderstand

What are the major causes of variation?What are the major causes of variation? Which key characteristics are Which key characteristics are

measurable?measurable? What.. Who.. Where.. When.. How will What.. Who.. Where.. When.. How will

data be collected? data be collected? Does the data reflect common or Does the data reflect common or

special cause?special cause? Which causes of variation can we Which causes of variation can we

change to improve the process? change to improve the process?

Understand: Understand: Example from Example from AUBMCAUBMC

Operative Report DictationOperative Report Dictation Dictation by phone within AUBMC.Dictation by phone within AUBMC. Voice message system. Voice message system. Not user friendly. Not user friendly. No insert, delete, correct, or No insert, delete, correct, or

backwards options.backwards options. Introduce an improved system. Introduce an improved system. Interface with the existing telephone Interface with the existing telephone

and the intranet facility at the and the intranet facility at the AUBMC.AUBMC.

F-O-C-UF-O-C-U--SS SelectSelect

Select a portion of the Select a portion of the process to improve.process to improve.

Determine the actions that Determine the actions that needs to be taken to needs to be taken to improve the process.improve the process.

Must be supported by Must be supported by documented evidence.documented evidence.

Select:Select: Example from AUBMCExample from AUBMC Update the processUpdate the process

Purchase new software Purchase new software with more options with more options available for the available for the surgeons to use. surgeons to use.

Dictation available via Dictation available via internet access through internet access through the AUB website.the AUB website.

PDCA

CYCLE

PP--D-C-AD-C-APlan Plan

What is the process improvement What is the process improvement to be piloted?to be piloted?

Who will do the pilot?Who will do the pilot? How will it be piloted?How will it be piloted? Where will it be tested?Where will it be tested? When will it be tested?When will it be tested? What data must be collected to What data must be collected to

measure the improvement?measure the improvement?

Plan:Plan: Example from AUBMCExample from AUBMC Obtain administrative approval for Obtain administrative approval for

the purchase of the new system.the purchase of the new system. Purchase and install the new Purchase and install the new

dictation system.dictation system. Educate users.Educate users. Implement the existing rules on Implement the existing rules on

suspension of operative privileges of suspension of operative privileges of the surgeons. the surgeons.

Monitor compliance and prepare Monitor compliance and prepare monthly statistical reports. monthly statistical reports.

Obtain the CNS support.Obtain the CNS support.

Pocket size leaflets issued by Medical Records Department to all Surgeons

PP--DD--C-AC-ADoDo

The improvement.The improvement.Data collection.Data collection.Data analysis.Data analysis.

Do:Do: Example from AUBMCExample from AUBMC

Purchase the updated Purchase the updated dictation system .dictation system .

Implement in AUBMC (as of Implement in AUBMC (as of August 26, 2004). August 26, 2004).

Train the surgeons on the use Train the surgeons on the use of the new system. of the new system.

Percentage of operative Percentage of operative reports dictated.reports dictated.

Compliance with the operative Compliance with the operative report dictation policy.report dictation policy.

P-DP-D--CC--AACheckCheck

The results and lessons learned.The results and lessons learned. Did the process improve as Did the process improve as

expected?expected? Does the data support the Does the data support the

improvement?improvement? How could the team efforts be How could the team efforts be

improved?improved?

Check:Check: Example from Example from AUBMCAUBMC

Result: Marked Result: Marked improvement in the improvement in the dictation process dictation process

Percentage: from Percentage: from 47.5% to 80.3% in 47.5% to 80.3% in June 2006.June 2006.

P-D-CP-D-C--AAAActct

What parts of the improved What parts of the improved process need to be standardized?process need to be standardized?

Policies or procedures to be Policies or procedures to be revised?revised?

Who needs to be made aware of Who needs to be made aware of the change?the change?

What are the next steps in What are the next steps in CONTINUOUSLY improving this CONTINUOUSLY improving this process?process?

Act:Act: Example from AUBMCExample from AUBMC

High degree of utilization High degree of utilization among Surgeons (80.3%).among Surgeons (80.3%).

Hospital-Wide indicators Hospital-Wide indicators (monthly monitoring).(monthly monitoring).

FOCUS PDCAFOCUS PDCA Joint Commission Joint Commission

requirement.requirement. AUBMC AUBMC PIPI Plan. Plan. Departments expected to Departments expected to

show documented evidence show documented evidence of using of using FOCUS-PDCA FOCUS-PDCA model.model.

All AUBMC Departments/Services are All AUBMC Departments/Services are encouraged to submit to the encouraged to submit to the Accreditation Office a similar Accreditation Office a similar storyboard on any issue or process storyboard on any issue or process where where FOCUS-PDCAFOCUS-PDCA methodology methodology was applied in their was applied in their departments/services.departments/services.

Best storyboard will receive Best storyboard will receive an award and certificate of an award and certificate of achievement.achievement.

THANK YOU!!THANK YOU!!