The manager’s toolbox
This chapter introduces tools for continuous improvement and patient safety. It discusses four types of continuous improvement tools: identifying customer needs, documenting processes, diagnosing problems, and monitoring progress. Specific tools are described like process flowcharts, fishbone diagrams, and run charts. Patient safety tools include failure mode and effects analysis (FMEA) and root cause analysis. A case study finding describes a patient issue with a broken call bell at night. A root cause analysis using a fishbone diagram identified that policies and procedures from the QA Manager and Nursing Director were not defined for night staff. Recommendations include defining proper policies/procedures, setting standard operating procedures, training nurses, and periodic equipment checkups.
The manager’s toolbox
- 1. CHAPTER: 3 THE MANAGER’S TOOLBOX PRESENTED TO: Prof. K.V.S.S.N Murty PRESENTED BY: Dr. Apurva Sharma Dr. Satyam Kumar
- 2. FOCUS To introduce commonly used continuous improvement and patient safety tools. To practice using continuous improvement and patient safety tools.
- 3. CONTINUOUS IMPROVEMENT TOOLS These are of 4 types: Identifying customer and stakeholder expectations Documenting a process Diagnosing the problem Monitoring progress
- 4. Identifying customer needs Asking and observing. Focus groups. On the basis of literature.
- 5. Documenting a process Process flowchart Work flow diagram Lead- time analysis
- 6. Diagnosing the problem Fishbone diagram Check sheet Pareto diagram
- 7. Monitoring progress Run charts
- 8. PATIENT SAFETY TOOLS FMEA- Proactive Root cause analysis- investigative tool
- 9. CASE STUDY- FINDINGS After discharge, patient wrote letter to hospital. Laparoscopic surgery turned into open surgery. Call bell was broken in night. Patient phoned to nursing station but no one answered. Certified nursing assistant (CNA) came. Call bell fixed, but electricity problem. Nurse asked patient to yell & left closing the door.
- 10. DATA WE COLLECTED People participated- director of nursing, Q.A Manager, nurse. Event occurred in NIGHT. Service impacted- maintenance department, nursing department. Full services impacted- electrical dept. human factors were relevant to the event- ignorance equipment performance- because of call bell broken, patient got dissatisfied with room.
- 11. controllable factors- if nurse can come on first phone call, the outcome was little bit effected. Staff- staff is qualified but proper indications not given
- 12. Root Cause Analysis Fish bone diagram. Main causes- Policies & procedures Equipment's & resources Patient factors Work environment Communication Task factor Team factor
- 13. Root cause The Q.A Manager did not defined the policies for night shift staff. Q.A Manager is the root cause of the problem but at the same time we cannot deny that Nursing director also did not defined SOP’s for nurses.
- 15. RECOMMENDATIONS Proper policies and procedures should be defined by the Q.A Manager and Nursing Director. Standard operating procedures are set for all staff in the hospital. Training program for nurses. Maintenance staff should be in night plus electrical backup. Periodic checkup of all equipments in hospital.
- 16. THANK YOU!