CHAPTER: 3

THE MANAGER’S

TOOLBOXPRESENTED TO:

Prof. K.V.S.S.N Murty

PRESENTED BY:

Dr. Apurva Sharma

Dr. Satyam Kumar

FOCUS

To introduce commonly used continuous

improvement and patient safety tools.

To practice using continuous improvement and

patient safety tools.

CONTINUOUS

IMPROVEMENT TOOLS

These are of 4 types:

Identifying customer and stakeholder

expectations

Documenting a process

Diagnosing the problem

Monitoring progress

Identifying customer needs

Asking and observing.

Focus groups.

On the basis of literature.

Documenting a process

Process flowchart

Work flow diagram

Lead- time analysis

Diagnosing the problem

Fishbone diagram

Check sheet

Pareto diagram

Monitoring progress

Run charts

PATIENT SAFETY TOOLS

FMEA- Proactive

Root cause analysis- investigative tool

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.

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.

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

Root Cause Analysis

Fish bone diagram.

Main causes-

Policies & procedures

Equipment's & resources

Patient factors

Work environment

Communication

Task factor

Team factor

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.

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.

THANK YOU!