project MASS hospital on how to apply quality tools.pptx

quality tool

1. SIX SIGMA IMPROVEMENT PROJECT

2. The old building long time ago 1811

3. The main campus nowadays

4. Mass General is dedicated to being as accessible and accommodating as possible for patients, visitors and staff with disabilities.

5. Our Mission & Core Values Understanding of and consideration for each individual's physical, social, psychological and environmental circumstance is fundamental to our practice.

6. We have been one of the best hospitals in USA ,but unfortunately some problems started to appear as one of my best doctors has preformed a wrong operation so as the CEO of this hospital I have decided to get the best six sigma doctors in USA to prevent the occurrence of such issues David Torchiana , MD Chairman and CEO Massachusetts General Physicians Organization

7. The six sigma team Dr. Soha Galal , deputy CEO ( CHAMPION) Dr. Amr Mohab (MASTER BLACK BELT) Dr. Ahmed Hany Dawoud ( BLACK BELT) Dr. Mohamed Fakhry Orthopedic dep director ( GREEN BELT) Dr. Ahmed Hamd El Allah OR director ( GREEN BELT) With the collaboration of the quality department

8. DMAIC

9. DEFINE DEFINE

10. Project title Minimizing the risk of wrong site of surgery and wrong procedure

11. Project Description: what is the “Practical Problem ” Busy operating room, Delays and changes in the room and personnel before the procedure, Language barrier, Break from preprocedural routine, Change in key personnel during the procedure, and Inattention by the nurses that was fostered by placement of clinical computer monitors in a way that diverted the nurses’ gaze away from the patient.

12. Project Scope Use a proven, systematic approach to analyze specific breakdowns in patient care and discover their underlying causes to develop targeted solutions that solve these complex problems . T he project teams measure the magnitude of the problem, pinpoint the contributing causes, develop specific solutions that are targeted to each cause, and thoroughly test the solutions in real life situations. Although invasive surgical procedures occur in many settings, the scope of this project include all procedures performed in the operating room and all regional blocks performed by anesthesia either in the preoperative area or the operating room. Within the project scope, the timeframe begins at the time a procedure is scheduled for surgery and ends with incision.

13. Goals Main Goal is “to reduce the risk of wrong site surgery, all potential errors must be identified from scheduling to the operating room .” Sub-Goals: to improve the accuracy of patient identification by using two patient identifiers and a “time-out” procedure before invasive procedures. to eliminate wrong-site, wrong-patient, and wrong-procedure surgery using a preoperative verification process to confirm documents, and to implement a process to mark the surgical site and involve the patient/family .

14. Business B enefits Reduce the number of defective cases (defects are the causes of risks that could result in wrong site surgery ) in surgical booking; in pre-op; and in the operating room. Decrease the incidence of cases containing one or more defects in surgical booking; in pre-op/holding; and in the operating room.

15. Roles and Responsibilities Circulating Nurse Holding the informed consent & Preoperative Checklist Calls on Anesthesia to respond to “Patient’s name and date of birth.” Anesthesia Provider Once the patient label on the anesthesia record is confirmed with the patients ID bracelet. Verbally replies with the patient's name and date of birth Surgeon Concurs with Patient Identification and STATES the procedure, side and site, and patient position. Also concurs the required implants, special equipment, blood availability, and diagnostic studies are present if applicable. DVT Prophylaxis Plan Antibiotic Plan Circulating Nurse Allergies confirmed. Solicits concurrence with each team member individually If there is any break in the above procedure, the circulating nurse must contact OR Manger immediately.

16. Time Frame (Proposal) to From Time line 1/11/2011 Project starts 7/11/2011 1/11/2011 define 17/11/2011 7/11/2011 measure 25/11/2011 17/11/2011 analyze 25/1/2011 25/11/2011 improve 1/2/2011 25/1/2011 control 1/2/2012 Project complete

17. MEASURE

18. Measurement Introduction of first names and roles which are written on the whiteboard Review critical information Do we have the correct patient? Is the correct side or site marked? Has the procedure been agreed upon? Have antibiotics been given? Identify and Mitigate Hazards Surgery : Discuss plans for the surgical procedure: Describe critical steps Provide team with pertinent information, including problems the may be encountered Ask team: If something were to go wrong with this procedure, what would it be, and how could we prevent the problem? Risks during procedure, such as bleeding, fluid loss Surgeon suggests, “If anyone has a concern during the case. Please let me know.”

19. Measurement (cont.) Anesthesiology : Discuss all relevant issues: Patient co-morbid disease that will increase risk Aspects of surgery that increase risk, such as need for IV access Availability of blood products Interventions to prevent complications Nursing : Discuss all relevant issues: Are all necessary instruments a available? Will any special equipment be considered? Plan for breaks (relieving nurse to introduce himself or herself when switching )

20. ANALYZE

21. delays &Chang of the room busy OR interruption of the surgeon OR schedule and personnel before operation with in pt consultation The nurse responsible for marking the site sitting the monitors far from changing of nursing time nursing area no regular checking on supplies during operation Miss understanding of time out bad quality markers no marking for the incision site Language barrier fostered nurse insufficient amount of supplies Wrong site /wrong procedure OR work process Working personnel Management supplies

22. Pareto analysis problem cause score The nurse failed to mark the right side Lack of knowledge and timeout protocols 15 delays &Chang of the room Too much work load 5 changing of nursing time Poor organization 10 Language barrier Poor organization 10 Miss understanding of time out Lack of knowledge and timeout protocols 30 no marking for the incision site Lack of knowledge and timeout protocols 20 interruption of the surgeon OR schedule Poor organization 10 bad quality markers Alcohol based ink 20

23. Pareto chart

24. IMPROVE

25. NOTICE : Advanced Practice Registered Nurses (A.P.R.N.) The site does not need to be marked for bilateral structures. Mark the site or sites before the procedure is performed (involve the patient in site marking process). The mark is unambiguous and used consistently throughout the procedure. The mark is made at or near the procedure site, sufficiently permanent to be visible after skin preparation and draping. For patients who refuse site marking or when it is technically or anatomically impossible or impractical to mark the site.

26. Perioperative Process Flowchart Patient in waiting area Verify clearly the correct procedure,for the correct patient,at the correct site APRN using Checklist Call for Senior Head Nurse Of OR to verify Checklist Single or Multiple sites?? Patients refusing site marking or technically or anatomically impossible or impractical to mark site Pateint in OR involve the patient in the verification process Sign Checklist by Patient and APRN Single site protocol Multiple sites protocol Apply Procedure Braclet Identify the items that must be available for the procedure using checklist P atient waiting for his turn

27. Time-out immediately before starting the procedure: Patient in OR The time-out involves the immediate members of procedure team: the Surgeon,his assistants,anesthesia , circulating nurses, OR technician. APRN using Checklist Single or Multiple sites?? involve the patient in the Time out by showing his procedure braclet Single site protocol Multiple sites protocol Identify the items that must be available for the procedure using checklist N.B. Surgeons on Duty in OR are not allowed to respond to any distractors outside OR . If So, verification procedure is repeated OR Head Nurse using Checklist All Members sign Under the patients consent A nother time-out needs to be performed before starting each procedure . APRN rechecks before procedure using Checklist Patient in Recovery Room Surgeon fills operat . details immediately APRN & OR head nurse signs

28. CONTROL Make sure the problem stays fixed Evaluate solutions and plans, maintain the gains by standardizing process and anticipate next steps To ensure that any deviations from target are corrected before they result in defects.

29. Project Deliverables The patient, when possible, should participate in the verification process by reviewing the consent form, identifying himself or herself as the patient, and identifying the procedure. After that, the surgeon marks the surgical site, with input from the patient if possible; site marking is no longer the nurses' responsibility. The use of alcohol-based preparations that may erase the marking ink has been discontinued . The time-out is to occur once the patient is in the final position, prepped and draped, just before the incision is made. During the time-out, the patient's identity, the site, and the procedure are again verified. The surgical scrub nurses are instructed not to hand the knife to the surgeon until the time-out is finished .

30. Approach Pre-procedure or pre-operative verification. This verification ensures that all documents are available prior to the start of the procedure. Missing information and/or discrepancies must be addressed before the start of the procedure. This verification includes: Patient Identification with Two Identifiers (patient name, Medical Record number, date of birth) History and Physical in the Medical Record Signed Consent in the Medical Record with the correct procedure verified Site Marked and Verified (the patient should be involved in site marking if possible). The site must be marked and verified for procedures involving right/left distinction, multiple structures (e.g., fingers, toes), or multiple levels (as in spinal procedures). The site must be marked with a “YES” so that the mark will be visible after the patient has been prepped and draped. In most cases, the provider performing the procedure will be responsible for marking the site .

31. Approach Time Out (final verification). The Time Out is a deliberate pause in activity involving clear communication (that includes active listening and verbal confirmation of the patient, procedure, site and side) among all members of the surgical/procedural team. The procedure is not started until any questions or concerns are resolved. The Time Out includes verifying: Correct patient identity Correct procedure verified with consent Correct site and side (verified with site marking as per policy ) Correct patient position Availability of correct implants and any special equipment or requirements

32. Thank You for Your Time Team Members: Dr. Mohamed Fakhry Dr. Soha Mohamd Galal Dr. Amr Mohab Dr . Ahmed Hamd El Allah Dr. Ahmed Hani Presented to Dr. Ossama Mossallam