problemEWWRWER4423244423244324-solving.pptx

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1. Management Practices for Sustainability Module 3: Problem Solving and Escalation AHRQ Safety Program for Ambulatory Surgery AHRQ Pub. No. 16(17)- 0019-4-EF May 2017

2. A Frontline Management System To Promote Safety Standard Work * Quality improvement

3. What Is a Problem? What Is a Solution? Concept Example Problem : An undesirable gap between an expected state and the actual state of a system. (1) Expected: Each operating room team will use an agreed-to script during procedure timeouts. (2) Actual: On May 23 at 10:30 a.m., two team members did not audibly speak at the timeout. (3) Problem: Less than 100 percent of team gave an audible check. Solution : Closes the undesirable gap between the expected state and the actual state. A type 1 solution closes the immediate gap. A type 2 solution prevents recurrence of the gap in the future. (1) Type 1: Supervisor observing the surgical team on May 23 at 10:30 a.m. intervenes to ask team members to audibly confirm "ready." (2) Type 2: Supervisor works with staff to understand the cause of the problem and acts to prevent recurrence.

4. How Do Problems G et F lagged? Most problems are identified by staff or are observed by supervisors. The daily huddle gives you a place and time every day to speak up about problems observed by team members. Weekly observation of procedures and work methods by the supervisor, as actually performed, is another primary source. The supervisor can also bring observations to the daily huddle.

5. Four Problem Boxes

6. Apply the Model for Improvement To Improve Your Problem Solving What are you trying to accomplish? Reduce the number of recurring problems How will you know that a change is an improvement ? Fewer problems of the same kind flagged in huddle and observed at work What can you change to make an improvement ? Try the Problem Triage flowchart as your initial guide

7. Apply the Model for Improvement T o Improve Your Problem Solving–2 Plan : Lay out the specifications of your test Do : Conduct the test Study : Review how the test went and lessons learned Act : Integrate your learning into your next test or into daily practice 7

8. Escalation for Frontline Clinical Issues Safety issues arise at the front line that require immediate action by staff Facilitate escalation by using CUS I am Concerned I am Uncomfortable This is a Safety issue Example of the CUS-style escalation process is in the component kit for this module

9. Tips Problem solving as we've described aims to achieve and maintain reliable performance If your organization has a standard problem-solving method, learn to use it Understand the tools for root cause analysis that your center applies to investigate and document harm events Incorporate routine use of CUS into frontline work; ensure broad staff understanding and comfort with use