Eliminate VAP Coaching Call
February 7, 2013
Objectives
• Share Daily Rounding Data Collection Process
Methods
• Introduce Process Mapping
• Highlight Next Steps
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Group Discussion
• When PEEP and Fi02 are measured
– Who documents it?
– Where is it documented?
• For other process measures, e.g., HOB => 30 degrees,
use of oral care, etc.
– Who documents it?
– Where is it documented?
• Who enters the data into the Patient Safety and Quality
portal?
• How do you manage coverage of these activities on
off-shifts, weekends, holidays and vacations?
• How do you know if your process is working?
• Who is responsible for training the data collectors?
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Process Mapping
Process Map
• Process maps (also known as process diagrams or
flowcharts) allow teams to
– Visualize a process
– Identify the actual flow or sequence of events in a
process
– Identify problem areas and unnecessary steps
– Come to agreement on the steps of the process
– Examine which activities may impact the process
performance
– Compare and contrast actual versus ideal flow to identify
improvement opportunities and maximize efficiency
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Creating a Process Map
1. Determine the boundaries
of the process
– Clearly define where the
process starts (input) and ends
(final output)
2. Determine the steps in the process
– Brainstorm a list of all major activities, inputs,
outputs, transfers, handovers and decisions from
the beginning of the process to the end
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Creating a Process Map
3. Sequence the steps
– Arrange the steps in the order they are carried out.
– Sequence what is, not what should be.
– Don’t draw in the arrows yet.
– HAVE FUN!
Consider using Post-It® Notes so you can move steps
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Creating a Process Map
4. Draw the process map
– Label each step in a way
that is understandable to
everyone.
– Document who carries
out the step.
– Add arrows to show the
direction of the flow of
each step in the process.
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Creating a Process Map
5. Test the process map
– Validate the map.
– Follow the people who
carry out the process
and adjust the map as
needed to reflect
the current process.
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Creating a Process Map
6. Finalize the process map
– Is this process being run the
way it should be?
– Are people following the process
as charted?
– Are there obvious complexities or redundancies that can
be reduced or eliminated?
– How different is the current process from an ideal one?
– Draw an ideal Flowchart. Compare the two (current
versus ideal) to identify discrepancies and opportunities
for improvements.
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Considerations
• Minimize the potential for staff burnout by
distributing responsibilities among many.
• Identify which steps can be carried out
by non-clinical staff and delegate
accordingly.
• Think about how can you tweak the
environment (i.e., the systems) to better
support the process and minimize the
likelihood for “cutting corners.”
• How will you know if your process is
working as designed?
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• Take our Pit Stop challenge!
• Create a map or flowchart documenting your
current processes for daily rounding data
collection – weekdays and weekends.
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You will be judged on:
1. Submitting by March 8 to [email protected] or fax 410-379-8239
2. Level of detail in the process map/flowchart
- Include what, how, and who
- Hand-drawn maps accepted!
3. Identification of opportunities for improvement/problem areas
- e.g., unnecessary steps, bottlenecks, lack of coverage, etc.
4. Description for how the process will be modified to overcome problem
areas
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Next Steps
1.
Daily Rounding Data Collection
– Continue to collect.
– Submit data to Patient Safety and Quality portal
https://armstrongresearch.hopkinsmedicine.org/Default.aspx
2.
VAE Collection
– Continue to collect.
– Submit January data into NHSN when module becomes available (expected mid
February)
3.
4.
Participate in Quarterly Interview
Accessing the Social Networking Site
– Instructions available at:
http://www.mhaonline.org/File%20Library/Quality/Eliminate%20VentilatorAssociated%20Pneumonia/Connecting-to-the-Social-Networking-Site.pdf
5.
Hospital Survey on Patient Safety Culture (HSOPS)
– Prepare to conduct survey.
– If conducted in the last 12 months, results can be uploaded to the Patient Safety and
Quality portal
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Next Webinar
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February 14 Content Call at 2:00 PM
Audio: 800-779-9891
Pass code: 4757941
Web link:
https://connect.johnshopkins.edu/cuspevap/
Questions?
• Maryland Participants
– Karol G. Wicker, MHS
– Phone 410-540-5056
– [email protected]
• Pennsylvania Participants
– Mary Catanzaro, RN BSMT CIC
– Phone 717-756-3958
– [email protected]
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