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Ground ImprovementFull description
Continous Improvement
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keselamatan pasien
Patient Safety
Patient Safety
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Full description
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Ed SheeranFull description
Team 10
Full 40k Kill Team RulesFull description
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Project Documentation
Full description
9/14/2015
Institute for Healthcare Improvement: Failure Modes and Effects Analysis Tool Process Data Report
Failure Modes and Effects Analysis (FMEA) Tool
Patient Flow Improvement Team United States HospitalCommunity Aim: Reduce the ER Wait Times by 30% in three months by improve patient flow throughout the hospital setting. Reduce LOS in ER by reducing bed wait times in ICU/Med/Surg\ Reduce LOS in ER by reducing TAT from Ancillary Services Process Data Date: 05/25/2009 Step
Description
1
Patient Presents to Registration in ED
Failure Mode
Causes
Structual set up of ED. First Current Process/Set up to see Pt is Registration Clerk. Both need visualization Registration and ED Nurse/Triage
Step
Description
2
Registration to Triage
Effects Non Clinical Person Visualizing/Prioritizing Patient Care Complaints. One person working with many patients coming to ED Door
Failure Mode
Causes
Effects
Registration Clerk (Only one on most shifts). No overflow back up plan. No active communication. No hand off of patient to nurse except on paper in a basket.
Location of Registration and Triage. Nurse not aware of pending patients to register who made need early intervention. No use of overflow registration staff, then triage nurse
Bottleneck in ED. Safety issue with other pending patients waiting to be seen while on ED clerk is registering.
Step
Description
3
Triage until MD Sees Patient
Failure Mode
Causes
Wide Variation in the timeframe that the patient is seen between ER Physicians
One physician does have a Delay in Treatment heavier load than other Increase in ER LOS physicians, however, organization on the front end does play a role with regards to nursing notification and visuals that the patient is ready
Step
Description
4
ED Orders for AncillaryProtocol vs MD orders
Effects
Failure Mode
Causes
Effects
No orders are entered before the ancillaries are called to the ER No hand off between the ancillaries
No communication tool or stratification of which ancillaries are called to perform testing first
Delay in results of testing Increase in overall ER LOS
Step
Description
5
Prioritize Ancillary Order Priority
Failure Mode
Causes
No organized fashion to call ancillary for testing. No prioritization methodology. No hand off between ancillary
Lack of order organization. Increased LOS in ER Prioritization. Communication Delay in getting test results of when one test was completed
Step
Description
6
ED order for RT services to RT in ED
Effects
Effects
Occ Det Sev RPN Actions 10
10
10 1000 Relocate Registration and Triage. Consider utilizing the OP Registration Area for ED and use the current Registration area for nursing Triage with slight structural change for privacy Consider glass see out/not see in.
Occ Det Sev RPN Actions 8
8
8
512 Have Registeration Back UP Overflow Plan ED Registration for first patient. Dayshift will back up second registration and third back up is triage nurse. Revamp Triage area with moving ED Registration and put Triage in area where nurse can see out but n
Occ Det Sev RPN Actions 10
6
6
360 Triage Organization and Flow of patients through the ER. Reevaluate current flow of patients in the ER
Occ Det Sev RPN Actions 10
10
8
800 Hand Off and Prioritization of orders and call to ER Lab, Respiratory and Radiology Reprioritized based on patient complaint
Occ Det Sev RPN Actions 10
10
6
600 Organized Whiteboard to note when the testing has been completed and results back
Failure Mode
Causes
Timely and ccordinated RT Services are not always entered appropriately.
Lack of coordination of Delayed Treatment orders based on patient need Increased LOS in ER
10
6
7
420 Coordination of all testing between ancillary
Same as Lab and Radiology TAT from MD to see patient to orders Triage to MD see patients
Multiple causes outlined in the attached minutes of the FMEA team meeting. Various TAT for various physicians
10
7
9
630 Actions will be the same for all ancillary Get Orders upfront and call ancillary over the radio for
Increased LOS in ER Delay in DX Delay in Treatment for the patient
Institute for Healthcare Improvement: Failure Modes and Effects Analysis Tool Process Data Report faster TAT
Step
Description
7
ED Order for Lab to Lab in ED
Failure Mode
Causes
Effects
Increase in taking off orders MD writing orders for labs Some labs are automatic based on symptoms per medical staff approved protocol
Time MD to see patient to write orders Triage time is not monitored correctly
Delay in Labs Delay in Diagnoses Increase in LOS in ER
Step
Description
8
ED order for Radiology to Pt to Radiology
Failure Mode
Causes
Time to Triage Communication Time from Triage to MD Phones/Beepers take time seeing patient MD Orders for nursing to enter into the STAR system Notification of ancillary TAT for ancillary to get to ER
Effects Increased LOS Delay in Radiology Results Delay in DX and Discharge
Step
Description
9
Lab and RT TAT from obtaining specimen to results and for RT blood gases to results and TX Times
Failure Mode
Causes
Effects
No specific proof of TAT for No automation in Lab and RT. No guidance as to where the ancillary procedures. Need to TAT must be collected issues are occuring for final monitor TAT and report on manually. TAT (Order to Response or actions to improve Response to obtaining the specimen or Collection to Results) Step
Description
10
Radiology TAT from taking xray to film/ultrasound/CT for MD Review
Failure Mode
Causes
Effects
TAT not monitored. Cannot work on the areas of delay without monitoring where in the process the delays are occuring
No automation to collect TAT time information from order to response to results.
Delay in TX Increased LOS in ER No direction to focus improvement efforts without TAT data collected at all entry points
Step
Description
11
Test Results to MD Decision to Admit/DC
Failure Mode
Causes
No data collected on TAT from Results Available until MD Decision on how to treat, discharge and/or admit
Data not available. Pro Med Increased LOS possible but for MD was discontinued for T no validation of which point Sheet or points in the patient flow was delaying overall timeliness of treatment, admission and/or discharge
Step
Description
12
Time to MD Decision to Discharge to Discharge of Pt
Effects
Failure Mode
Causes
Effects
Multiple issues with TAT as far as once decision is made to discharge, how efficient is the discharge process in the ED. Notification Time until Discharge? Instructions. Barriers to Discharge. Psych Patients have extended LOS
No automatic process to track the TAT of Readiness for Discharge/MD order until final Discharge out of the system
Increase overall LOS Decreased Patient Satisfaction Satisfaction Scores are lowest i n the System
Step
Description
13
Time Order to Admit until Pt to Unit/Floor
Failure Mode
Causes
Effects
Barriers to Admission is the number one apparent delay and cause of increased LOS. No formal data collected, however, resistance to admission were noted at each ER Meeting
Lack of teamwork mentality on the floor Nightshift appeared to be the #1 barrier for admitting patients.
Increased LOS Decreased Patient Satisfaction No Hand off Communication/Limited
Occ Det Sev RPN Actions 10
6
9
540 Improve the TAT of MD to see patient Improve the TAT for Triage Improve coordination of ancillary testing
Occ Det Sev RPN Actions 10
7
9
630 Use Radio for communication to come to ER Coordinate with all other ancillary Educate Radiology regarding TAT and expectations
Occ Det Sev RPN Actions 10
8
10
800 Start collecting TAT for response to ED and TAT for specimen to results Report at weekly meetings Improvements will be noted in the minutes
Occ Det Sev RPN Actions 10
8
10
800 Start collection of data for TAT at all entry points order to response. Response to Film Film to results
Occ Det Sev RPN Actions 10
8
10
800 Start Data collection at all points of care in the ED and report on the TAT in the ED for all areas
Occ Det Sev RPN Actions 10
5
10
500 Monitor the TAT from MD discharge time until patient final disposition. Actions are noted in the FMEA Team Meeting Minutes Patient Flow TAT Flowsheets are reviewed each meeting See Attached
Occ Det Sev RPN Actions 10
10
9
900 Accountability by the managers for their staff in the expectation that a patient needing admitted was priority and that they would be admitted and hand off performed in a timely and accurate manner See Actions in Team Minutes
Calculated Totals Total Risk Priority Number for the process
9292
Occ: Likelihood of Occurrence (110) Det: Likelihood of Detection (110) NOTE: 1 = Very likely it WILL be detected
