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Operational Quality Improvement
Caroline LeGarde, Administrator, Johns Hopkins Department of DermatologySeptember 14, 2012
Operational Quality ImprovementDesigning Safe and Efficient Systems and Spaces
Operational Quality Improvement Initiatives
• Dashboard for Safety & Quality
• Access Initiative
• Safety & Teamwork – SAQ Results & Toolsy
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Overview of Department
• Leadership Team and Faculty– Chairman & Administrator: Dr. Sewon Kang, Caroline LeGarde
– Physician Advisor/Safety Officer: Dr. Janis Taube
• 6 of 16 faculty members joined in early FY10, new management team hired in FY10‐11
FY12 = “Stabilization” year FY12 = Stabilization year
• Process changes & safety/teamwork focus Culture change taking root
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FY12/13 Safety Initiatives & Dashboard
• Safe: Phototherapy adverse events, Specimen labeling errors
• Effective: Hand hygiene
• Timely: Days to next new appointment, Results reporting (biopsy result explained to patient & d d)documented)
• Patient‐centered: Access center
• Efficient: Dermatopathology TAT
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Safe: Phototherapy adverse events
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Safe: Phototherapy adverse events
FY12
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New phototx LPN
New UVA1 box
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Teamwork & Communication
Treatment NursePhysician
Assess & prescribe
Administer & report
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Follow‐up
lProtocol Consistency: Phototherapy “Pathway”
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Timely: Days to next new appointment
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FY12
No‐shows: Why they are so Bad• Delays in treatment, lack of continuityy , y
• Pushes back other appointments, must book further out than necessary
• Volume variability –difficult to schedule
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difficult to schedule
• Lost revenue, poor use of staff & doctor time
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No‐shows: The Old Strategy
• Reduce days to next appointmentReduce days to next appointment• Appointment letter
• Automatic Televox phone call 5 days before
• Day before phone call from staff
• Day‐of phone call to reschedule if no‐show
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Day of phone call to reschedule if no show
No‐shows: The Old Strategy Results
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No‐show Policy: the New Strategy
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No‐shows: The New Strategy Results
Prep., Comm’n
Go Live!
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to Stake‐holders
Live!
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No‐shows: The New Strategy Results
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No‐show Policy: Implementation
G d i ti & i• Good communication & no surprises
one month notice to stakeholders
Reminders: (1) time of scheduling, (2) appt. letter, (3) 2‐day prior phone calls , (4) signs in clinic
new separate phone line option to cancelnew separate phone line option to cancel
• Consistent application
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Sustained results of NSFPrep.,
Comm’nto Stake‐holders
FY12 Go Live!
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No‐show Policy: Results to Date
• Suddenly patients care!Suddenly patients care!
• Sooner appointments opening frequently
• Higher show rate = 4 extra pts. / day
• Started with one hospital‐based adult clinic, rolled out to Pediatric Dermatology clinic
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Patient‐centered: Access Initiative
Access Challenge = Multiple phone numbersAccess Challenge Multiple phone numbers
• One doctor → one scheduler
• Weak back‐up plan or cross coverage
• Difficult to monitor quality or accuracy
• Difficult to roll out new protocols
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Access Services
410‐955‐5933
How to make a Derm. appointment: 2009
JHOC PedsDerm GSS Bayview Melanoma
Immuno.
Access Services
Mohs Surg.
410‐955‐2049 410‐847‐3767 410‐550‐0503410‐550‐0315410‐550‐0724 410‐955‐2992
410‐614‐1022410‐614‐6204410‐614‐6686
410‐955‐1588
410‐955‐1573410‐502‐2082410‐955‐3865410 955 8662
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410‐955‐8662410‐955‐3397410‐955‐1570410‐502‐6778410‐614‐0255410‐955‐2163
20+ Phone Numbers!
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410‐955‐5933
How to make a Derm. appointment: 2011
JHOC PedsDerm GSS Bayview Melanoma
Immuno.
Access Services
Mohs Surg.
410 955 5933
410‐955‐1573 410‐955‐2049 410‐847‐3767 410‐550‐0503 410‐614‐1022
410‐955‐1588
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410‐955‐2992
8 Phone Numbers
410‐955‐1588
How to make a Derm. appointment: 2012
410‐955‐5933
JHOC PedsDerm GSS Bayview
Immuno.
Access Services
Mohs Surg.
410‐955‐1573 410‐955‐2049 410‐847‐3767 410‐550‐0503
Co‐located
JHOC, PedsDerm, GSS, Bayview, Immuno. & Melanoma
410‐955‐5933
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410‐955‐2992
1 Phone Number(or the number you already have)
410‐955‐1573 410‐955‐2049 410‐847‐3767 410‐550‐0503 410‐955‐2992
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Roll‐out Plan for Access Initiative
• Hired manager and 6 incremental FTEs –will be 12 agents total
• Moved one division at a time
Partnered with faculty for every change
Standardized all phone trees (with patient input)
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Standardized all phone trees (with patient input)
Clarified & simplified protocols
Monitored metrics
Thank you for calling the Johns Hopkins Department of Dermatology
GSSAppointment #410‐847‐3767
ToMake an Appt.
To Change or Cancel an Appt.
ForPrescription
Refills
ForLab or Biopsy Results or to
speak to a Nurse
For OurFax number and Address
To Hear These Options Again
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Patient‐centered: Access Initiative
• Focus on accurate and timely scheduling with service excellence (metrics!)
• Ongoing education for staff about Derm.
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Access Metrics
• Pick carefully what to measurePick carefully what to measure
• Transparency + Consistency = Trust
• Reinforce the right things and tie back to patient safety = Engagement
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Access Metrics
• Pick carefully what to measure
• Transparency + Consistency = Trust
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The New Access Challenges
• Capacity! “Hopkins Family”, international, Executive Health, readmission prevention
• Retraining our patients – resetting expectations
• Message flow
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Message flow
• QA/QC
• Retaining staff – critical impact of turnover
SAQ: Climbing out of the Danger Zone
• Focus on teamwork & safetyy
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SAQ Results – Teamwork & Safety
Clinic Staff 24% higher vs 2009‐10Med. Staff 13% higher vs 2009‐10
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Clinic Staff 23% higher vs 2009‐10Med. Staff 40% higher vs 2009‐10
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Most Improved Units in Teamwork Climate
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Armstrong Institute for Patient Safety and Quality
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0
2009 TW Climate 2011 TW Climate*only includes units with data in both years
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Most Improved Units in Safety Climate
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0.5
0.6
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0
2009 Safety Climate 2011 Safety Climate
Dermatology Results –Medical Staff
40 13 33 20 4036 21
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Dermatology Results –Clinic Staff
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Teamwork & Safety Tools
• Effective (unified) leadership
– Clinic manager + Medical Director + RN
• Consistent communication
– Safety & Service “S&S” meetings, newsletters
– Manager daily memos to all
Scripting• Scripting
– “Safety, safety, safety”
– “In response to staff/resident/faculty feedback…”
– Gallup survey Q12 language09/18/2012 36
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Creating Spaces for Teamwork
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Teamwork Spaces – the “Pod Bridge”
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Teamwork Spaces – the “Pod Bridge”
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Teamwork & Safety = Learning Together
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Our Newest Tool: Mini‐RCA
• Same format as traditional RCA
• Multi‐disciplinary – involve staff, residents, faculty
• Gather facts
Discuss processes & systems• Discuss processes & systems
• Implement change
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Example: Mini‐RCA
• 4/24/12 (Tues PM) Dr. X + resident performed punch biopsy
• 1 week later, Dr. X noted that results had not been received, pending path report
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not in EPR
• Specimen not received by Pathology
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FY12/13 Safety Initiatives & Dashboard
• Safe: Phototherapy adverse events, Specimen labeling errors
• Effective: Hand hygiene
• Timely: Days to next new appointment, Results reporting (biopsy result explained to patient & d d)documented)
• Patient‐centered: Access center
• Efficient: Dermatopathology TAT
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Recommended
