...A. The sentinel event was related to respiratory arrest secondary to conscious sedation procedure. There were several factors that played a role which included high patient census, poor staffing, alarms dismissed by staff members, patient was left unmonitored, and no supplemental oxygen initated prior to the procedure. When the patient was pulseless no CPR was initiated until the code team arrived and critical interventions were delayed by the emergency room staff. The patients medication reconciliation or history weren’t reviewed by the emergency room physician. Tripple doses of intravenous valium and dilaudid were given without a lapse in time. The patient was elderly and on chronic oral opioid medications. “Normally these types of medications are administered with low doses and titrated per patient’s sedation level. Patient, monitoring or sedation level weren’t assessed between doses. This event is known as a sentinel event. In any situation that causes injury, or death a root cause analysis must be completed and reported to the Joint Commission. B. To implement a change in the conscious sedation procedure a team or committee needs to be established. All staff in the emergency room can become active participants by joining a committee or subcommittee. These main categories may include patient characteristics, task factors, individual staff members, team factors, work environment, and organizational management (IHI, 2014)...
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...y Name: Institution: Course: Tutor: Date: Organizational Systems & Quality Leadership Introduction The core objective of health care is to provide high-quality care to all patients to guarantee positive health outcomes. This principle is a major driver for the commitment of nurses and other care providers. Care providers are required to work in collaboration and include patients in the process of care. Nurses form the core of health care delivery in all facilities. The role they play in the coordination of care is essential for the professionalism of care providers. In the process of care delivery, it is important to understand the medical history of the patient to determine the most appropriate interventions to employ. Care providers should employ interventions that are besides guaranteeing positive health outcomes address the needs and interests of the patient. It is important to include family members in the treatment program since they understand the patient and his needs better. This paper employs Root Cause Analysis approach together with the Failure Mode and Effect Analysis to determine the impact of the events that resulted in the death of a patient Mr. B. A. Root cause analysis The principal purpose of the Root Cause Analysis is to conduct an evaluation of the highest level of the problem to identify the actual cause. In the case scenario, the root cause analysis rules out the possibility of inadequate patient assessment as a contributor to the factors...
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...A. Root Cause Analysis A root cause analysis (RCA) is a “systematic approach to understanding the causes of an adverse event and identifying system flaws that can be corrected to prevent the error from happening again” (Huber & Ogrinc, 2010). The root cause analysis is used to determine why the problem occurred in the first place and to identify the cause of a problem using a specific set of steps (Mind Tools, n.d.). The RCA team which consists of interprofessionals who are knowledgeable of the issues and processes related to the incident and the people who are involved in the incident should be formed first before the RCA meeting takes place (Huber & Ogrinc, 2010). In the given scenario, the team includes the emergency department (ED) physician (Dr.T), the RN (Nurse J), the LPN (Mr.B’s LPN), the risk manager, the ER nurse manager, the ER nurse educator, and the quality improvement professional. These members would meet and would discuss the causative factors, errors and hazards that caused Mr.B’s sentinel event. The root cause analysis process has five steps. The first step in conducting a RCA is defining the problem (Mind Tools, n.d.). In the given scenario, the problem is the unexpected death of Mr.B. The second step is collecting the data (Mind Tools, n.d.). It is very important to record and report the data as accurately and as completely as possible. Mr. B’s vital signs, pain scores, laboratory values, and history of medication administered during the situation must...
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...QI uality mprovement in FOCUS Your Rapid-Cycle Improvement Guide to Achieving Results Quality Improvement in Focus Rapid-Cycle Improvement Getting Started Table of Contents Introduction........................................................................................................................... page 3 . Getting Started....................................................................................................................... page 5 Find a Process to Improve...................................................................................................... page 7 Organize to Improve the Process. .......................................................................................... page 8 . Clarify Current Knowledge of the Process............................................................................ page 11 Understand Sources of Process Variation............................................................................. page 13 Select the Process Improvement.......................................................................................... page 15 Appendix Worksheet A: Identifying Areas for Improvement. .............................................................. page 16 . Worksheet B: Developing a Team Worksheet...................................................................... page 17 Worksheet C: Team Meeting Notes....................................................
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...CHECK: Assess the measurements and report the results to decision makers * ACT: Decide on changes needed to improve the process Deming's PDCA cycle can be illustrated as follows: Deming's focus was on industrial production processes, and the level of improvements he sought were on the level of production. In the modern post-industrial company, these kinds of improvements are still needed but the real performance drivers often occur on the level of business strategy. Strategic deployment is another process, but it has relatively longer-term variations because large companies cannot change as rapidly as small business units. Still, strategic initiatives can and should be placed in a feedback loop, complete with measurements and planning linked in a PDCA cycle. To illustrate the relationship of business unit processes to strategic processes, we may construct two nested PDCA cycles: This 'wheel within a wheel' describes the relationship between strategic management and business unit management in a large company. There are actually several separate business units, of course, each with its own set of metrics, goals, targets and initiatives. But this figure illustrates the...
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...THE CASE FOR A MODEL OF CARE Contemporary health care systems are constantly challenged to revise traditional methods of health care delivery. These challenges are multifaceted and stem from: 1. novel pharmacological and non-pharmacological treatments; 2. changes in consumer demands and expectations; 3. fiscal and resource constraints; 4. changes in societal demographics in particular the ageing of society; 5. an increasing burden of chronic disease; 6. documentation of limitations in traditional health care delivery; 7. an increasing emphasis on transparency and accountability, 8. evidence based practice (EBP) and clinical governance structures; and 9. the increasing cultural diversity of the community. These challenges provoke discussion of the necessity of developing services around a model of care. What do we mean by a model of care? Ambiguity exists in the literature, with the terms, model of care, nursing model, philosophy, paradigm, framework and theory often used interchangeably, despite referring to diverse, yet parallel concepts (Tierney 1998). In their recent review of the literature, the Queensland Government (Australia) reported that they found no consistent definition of ‘model of care’ (Queensland Health 2000). They concluded that a model of care is a multidimensional concept that defines the way in which health care services are delivered (Queensland Health 2000). More specifically, Davidson and Elliott...
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...on its ability to be effective and efficient. Culture can be a critical barrier to leveraging new knowledge and implementing technical innovation (Helfrich et al, 2007). This paper will first provide an overview and analysis of the cultures and subcultures of two Ontario healthcare organizations - Trillium Health Centre (THC) and Credit Valley Hospital (CVH) in the context of a recent voluntary merger of the two organizations. The paper will then examine the impact of the dominant and sub- organizational cultures on the capability of the two organizations to be more effective, efficient and patient focused, as will the ways in which these cultures create barriers to current change efforts. Finally, the paper will identify recommendations for the merged leadership of the organizations to consider in order mitigate the identified cultural barriers in order to support future change efforts. A Cultural Overview THC and CVH are large community hospitals located within the Mississauga Halton Local Health Network (MH LHIN), serving a population of over a million people. Both organizations provide comprehensive primary, secondary and tertiary services to the communities and the region. Clinical program planning in the...
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...A1: Sentinel Event Describe the Sentinel Event On September 14 at 12:30pm, pediatric patient Tina was involved in what was thought to be a child abduction. After arriving at the hospital that morning, Tina’s mother checked Tina in with the registrar. The registrar collected Tina’s demographics and insurance information and entered it into the medical records. She made copies of ID’s and insurance cards and had Tina’s mother sign all necessary paperwork for Tina’s surgery. The registrar did not ask for any information regarding the custody of Tina because it was not a part of her job duties. Once admitted, the Pre-op nurse greeted Tina and her mother. The Pre-op nurse had Tina’s mother sign all consent forms for the surgery. She then helped Tina get gowned up and began the pre-op assessment on Tina, started her IV and administered her pre-op medications. According to the Pre-op nurse, Tina’s mother did inform her that she’d be doing something with her son during Tina’s surgery. Tina’s mother gave the Pre-op nurse her name and number, which the Pre-op nurse wrote down in her notepad, so she could be called when the surgery was done. The OR Nurse had very strong feelings on the lack of communication between departments. She said that she has witnessed many issues and seen many problems arise due to a lack of communication and understanding across departments. She strongly believes that working more closely with security would eliminate some of this issues in the future. Following...
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...Introduction There is an increasing need for better management of Long Term Conditions (LTC) within Primary Health Care (PHC) that requires practice development processes and adaption to models of care that are person centred. Within my clinical setting implementation of a pilot scheme is underway with a common vision to work alongside the accompanying community pharmacy for better sharing of knowledge and information to enable optimum care for our mutually registered LTC patients. Analysis of evidence based practice, facilitation of roles and responsibilities, and appropriate health care frameworks will support how a plan is being developed that reflects nursing management and integrated service collaboration towards best health outcomes. Important to note that throughout this essay, reference will be made to Long Term Conditions, Chronic Conditions and Chronic diseases, these terms all relate to the same context. Evidence Mismanagement of chronic conditions is the leading cause of hospitalisations in New Zealand (NZ) (National Health Committee, 2007). The mantra ‘better, sooner, more convenient’ targets the role that primary health care in NZ must assume in order to reduce acute hospital admissions, through better management of patients with chronic conditions and, active support of high needs populations (Ministry of Health, 2011). The World Health Organisation (WHO, 2005) define long term / chronic conditions as having one or more of the following descriptions...
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...the team to include the member’s roles, and importance of diversity within the team. The team will focus in a meaningful way using self-assessment, and awareness of self-reflective techniques. I will use PDAC to monitor whether the strategy was effective in increasing patient and family centered care. Self-Assessment Tool The PFCC tool was used to evaluate Medical Center Health System (MCHS) see attached. Setting Description Medical Center Hospital System (MCHS) is an acute care, not for profit regional 402 bed Level II Trauma Center, located in West Texas of the Permian Basin. It serves a 130,000 community along with the surrounding 17 counties. It is the most comprehensive healthcare provider in the area. Founded over 65 years ago, it has grown from one facility into a family of healthcare provider’s delivering a broad range of advanced medical services to the people of West Texas. The hospital serves these communities with a high level of...
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...As per Joint Commission standards Nightingale community Hospital is reporting within 45 days a Sentinel Event that occurred at our hospital last week. To summarize this event; 3 yr old T.G. was admitted to the Ambulatory Surgery Unit (ASU) for a routine procedure with Dr. Carlos Munoz. After a brief visit with the registrar to fill out all appropriate paperwork the patient and her mother waited in the pre-admission area. The patient and her mother were then called into pre-admission. The Pre-operative nurse proceeded to go through the standard steps prior to being taken into surgery. According to the nurse an assessment was completed, the patient was changed into a surgical gown, and her belongings taken care of. An IV was started, appropriate labs were drawn, the informed consent was signed and information about the length of surgery and recovery time were discussed with the patients mother. The mother stated to the pre-operative nurse that she would be leaving the hospital to attend to another child, she left her cell phone number with the Pre-Operative Nurse who proceeded to write this number into a personal notebook that she carries. The specific instructions to the pre-op nurse were to call the mom when the surgery was over. At this point the patient was ready for surgery, at the appropriate time the patient was taken to surgery and care transitioned into the care of the OR nurse, surgeon and the OR staff. Upon completion of the surgery the patient was transferred from...
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...Using Simulation Modeling to Improve Patient Flow at an Outpatient Orthopedic Clinic Thomas R. Rohleder, PhD Division of Health Care Policy and Research Mayo Clinic 200 First Street SW Rochester, Minnesota 55905 tel: 507-538-1532 Email: rohleder@mayo.edu Peter Lewkonia, MD Faculty of Medicine University of Calgary Calgary, Alberta Diane Bischak, PhD Haskayne School of Business University of Calgary Calgary, Alberta Paul Duffy, MD Faculty of Medicine University of Calgary Calgary, Alberta Rosa Hendijani Haskayne School of Business University of Calgary Calgary, Alberta July 2011 Abstract We report on the use of discrete event simulation modeling to support process improvements at an orthopedic outpatient clinic. The clinic was effective in treating patients, but waiting time and congestion in the clinic created patient dissatisfaction and staff morale issues. The modeling helped to identify improvement alternatives including optimized staffing levels, better patient scheduling, and an emphasis on staff arriving promptly. Quantitative results from the modeling provided motivation to implement the improvements. Statistical analysis of data taken before and after the implementation indicate that waiting time measures were significantly improved and overall patient time in the clinic was reduced. Keywords: Outpatient Clinic, Discrete Event Simulation, Process Improvement, Patient Waiting I. Introduction Visiting hospital outpatient clinics is a very common way for...
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...Using Simulation Modeling to Improve Patient Flow at an Outpatient Orthopedic Clinic Thomas R. Rohleder, PhD Division of Health Care Policy and Research Mayo Clinic 200 First Street SW Rochester, Minnesota 55905 tel: 507-538-1532 Email: rohleder@mayo.edu Peter Lewkonia, MD Faculty of Medicine University of Calgary Calgary, Alberta Diane Bischak, PhD Haskayne School of Business University of Calgary Calgary, Alberta Paul Duffy, MD Faculty of Medicine University of Calgary Calgary, Alberta Rosa Hendijani Haskayne School of Business University of Calgary Calgary, Alberta July 2011 Abstract We report on the use of discrete event simulation modeling to support process improvements at an orthopedic outpatient clinic. The clinic was effective in treating patients, but waiting time and congestion in the clinic created patient dissatisfaction and staff morale issues. The modeling helped to identify improvement alternatives including optimized staffing levels, better patient scheduling, and an emphasis on staff arriving promptly. Quantitative results from the modeling provided motivation to implement the improvements. Statistical analysis of data taken before and after the implementation indicate that waiting time measures were significantly improved and overall patient time in the clinic was reduced. Keywords: Outpatient Clinic, Discrete Event Simulation, Process Improvement, Patient Waiting I. Introduction Visiting hospital outpatient...
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...Needs Assessment for Quality In order for a hospital to survive the competition in today’s healthcare world, a hospital must be aware of opportunities to grow and reduce costs and be supported by Total Quality Management Process. The TQM process helps the hospital to create new products, ensure the standards of quality and client satisfaction and deliver improved services. In addition, the TQM process also helps in improving a company's bottom line profits by increasing operating efficiencies, eliminating waste, and creating working conditions conductive to productivity and company growth. The employees must work in healthy environments, which maximizes their efficiencies and enables them to perform at their best levels. In both the short-term and long-term, the quality improvement process pushes the company from different angles to achieve strategic goals and plans. One of the important processes of patient care is proper medical documentation and updated medical records. Description of chosen process Accurate and complete medical documentation is the responsibility of medical transcriptionists. However, the challenges to medical transcriptionists and the medical transcription industry are complex and varied. Pressures associated with cost, demand, workforce limitations, technological development, globalization, policy and awareness issues come together to create a picture that changes depending on one’s perspective and point of view. Trying to assemble these factors...
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...Case report: Paediatric Orthopaedic Clinic 1- What is capacity utilization at every step in the process? What is the direct resource utilization? Using the data provided in the case, we are able to compile all data necessary to compute the capacity utilization at the clinic. Activity | # of Staff | Available time | Activity time | Number of Patients | Time needed | Utilization10 | | | /Staff | Total | N | F | N | F | N | F | Total | | 1. Front Desk | | | | | | | | | | | | a. Registration | 3 | 180 | 540 | 5 | 5 | 32 | 48 | 160 | 240 | 400 | 74 % | b. Verification | 3 | 255 | 765 | 9 | 4 | 32 | 48 | 288 | 192 | 480 | 63 % | 2. Radiology Department | | | | | | | | | | | | a. X-ray imaging | 6 | 240 | 9603 | 11 | 11 | 32 | 40.8 | 352 | 448.8 | 800.8 | 83 % | b. Development of X-rat | -1 | 240 | 9604 | 7 | 7 | 32 | 40.8 | 224 | 285.6 | 509.6 | 53%8 | c. Diagnostic reading and comments | 3 | 240 | 4805 | 5 | 5 | 32 | 40.8 | 160 | 204 | 364 | 76% | 3. Hand-off X-ray to Clinic | | | | | | | | | | | | a. Collection of X-ray | 3 | 2556 | 7657 | 2 | 2 | 32 | 40.8 | 64 | 81.6 | 145.6 | 19% 9 | b. Filing/exam room prep | 1 | 255 | 255 | 2 | 2 | 32 | 48 | 64 | 96 | 160 | 63% | 4. Examination Room | | | | | | | | | | | | a. Surgeon | 1 | 255 | 255 | 7 | 4 | 32 | 14.4 | 224 | 57.6 | 281.6 | 110% | b. Resident | 1(2)2 | 255 | 255 | - | 7 | - | 33.6 | - | 235.2 | 235.2 | 92% | c. Cast technician...
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