National Quality Improvement Project in … · improvement and the IHI Model for Improvement to...

Background:

Effective, reliable and speedy decontamination of endoscopes is key

to supporting the effective running of a Day Services endoscopy list

and facilitate unplanned “add in-patients” onto the daily list without

over running or cancelling a patients procedure. Maximising the

reliability and efficiency of the decontamination process is a critical

factor in delivering safe, effective care every time for every patient.

Aim:

To provide one additional high level disinfected endoscope to

facilitate an extra endoscope procedure slot each working list day by

January 2018.

Walk/Observe the pathway of the patient :

Methods for Improvement :

The team used the data from the National Tracking System to measure for

improvement and the IHI Model for Improvement to implement change using

Plan Do Study Act (PDSA) cycles.

Results

The Team provided a minimum of

one additional scope by improving

the efficiency of the decontamination

process allowing one additional patient

to be treated every day .

National Quality Improvement Project in Decontamination of Reusable Endoscopes Marina Byrne Corbett (CNM2), Mark Spencer (HCA), Marie Gorman (CNM1) Naas General Hospital

Driver Diagram :

Our Decontamination Project Improvement Driver Diagram identified

Primary and Secondary Drivers and specific ideas to bring about

change.

Endoscope Washer Disinfector ( EWD) Upgrade

WD 440 (Old EWD) WD 440 PT (New EWD )

New EWD Cycle Times /Endoscope Type

Variation in Endoscope

Reprocessing Capacity per Day Scope Activity and Utilisation

Mapping the process identified multiple factors

which may impact on maximising the efficient

running of the Day Services endoscopy list.

In November 2017 the Team met with the

Endoscopy User Group. The project team used,

run charts, pareto charts and process mapping to

highlight the patient referral pathway:

demonstrate to the User group the baseline

scope utilization per day and highlight areas

where utilization could be increased through

efficiencies.

The Quality improvement Foundation Programme

Project Proposal was introduced to the

Endoscopy User Group , together with their smart

aim; to “provide equipment to allow one extra

procedure to be performed per day”.

Mapping of the process opened discussions

around clinical and operational factors which may

influence the provision of “add in-patient slots” to

the daily list for example, referral form review,

patient criteria review, protected procedure slots .

Inpatient Referral Process

Mapping the process

Conclusion/Benefit’s:

Measurable benefits our project has delivered and is forecast to deliver:

Patient Experience:- Waiting times for inpatients have been reduced

Patient Outcomes:- Speedy diagnosis based on procedure result

Patient Access & Flow:- Quicker access to procedure and shorter hospital stay .

Staff: - Morale improvement ,better “buy in “ reduced feeling of

being overwhelmed by waiting procedures – everyone working together !

Waste reduction: - endoscope disinfection capacity is maximised due

to increases efficiencies as a result of new Endoscope Washer Disinfector.

reduced cycle times.