Select a problem in the training area

The tool FOUCS – PDCA

what is it ?

Apply them to solve the problem and improve work in training?

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EFFECTS OF IMPLEMENTATION OF FOCUS-PDCA MODEL TO DECREASE

PATIENTS’ LENGTH OF STAY IN EMERGENCY DEPARTMENT
Mohammed Alshahrani

1
and Amal Alsulaibaikh

2

Consultant of Emergency and critical Medicine, College of medicine, University of Dammam

.

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ABSTRACT

Introduction: Boarding patients in emergency department (ED) is a universal problem in all

health care sectors, facilitating patients flow in and out of the emergency department is an important

step to improve patients and staff satisfaction and even patients outcome. Objectives: To study the

effect of implementing one of the quality improvement methods, the FOCUS-PDCA in decreasing

patients length of stay in the ED. Methods: Multidisciplinary team was formed and the process of

finding opportunity, organizing team, Clarify the process, understand the process and select the desired

outcome followed by (Plan-Do-Check-Act ) process over six months period at the Emergency

department of a university hospital setting. A consensus-based approach was performed to identify

areas of improvement with time limits and responsible assigned personal. Results: After

implementation of the above suggestions for the period of 6 months, the data was collected to study the

rate of ER overstay. Overall, the rate of ER overstay was reduced from 9.81/1000 to 6.92 per 1000

patients, demonstrating a 29.5% decrease [Figure 1]. This performance improvement project was

achieved significant improvement (P =0.030).Conclusion: FOCUS-PDCA quality improvement

method was effective in reducing emergency department patients’ length of stay.

INTRODUCTION

Emergency department (ED) crowding has been

described as the most serious problem that

endangers the reliability of health care system

worldwide [1]

It has been reported to cause delays in

diagnosis, delays in treatment, decreased quality

of care, and poor patient outcomes.
[2,3]

According to the Joint Commission on

Accreditation of Healthcare Organizations

(JCAHO), over one half of all “sentinel event”

cases of morbidity and mortality secondary to

delays in treatment occur in hospital EDs, and

ED overcrowding has been cited as a

contributing factor in 31% of these cases.
[4]

The true causes of ED overcrowding are much

more complex,[
3,5]

and include, inadequate

inpatient bed capacity, higher severity of

illness, and hospital system restructuring.

Hospital bed shortages have been studied as

factors that potentially affect crowding. Non

availability of ED beds because they are

occupied by admitted patients waiting for

transfer from the ED to inpatient units restrict

the EDs capacity to accept new arrivals and

consume EDs resources
[6-7].

Because the main causes of ED overcrowding

seem to originate outside the ED, the only way

to truly alleviate ED overcrowding is to focus

our attention on system-wide reform. In this

project, we used FOCUS-PDCA methodology

looking for improvement process. The (PDCA)

method was presented first time by a quality

expert Dr. Edwards Deming in 1950’s.
8

This process helps in identifying and solving

problems and also applicable for the continuous

quality improvement of various clinical

aspects.
9

The FOCUS-PDCA is an improvement

methodology that many organizations use to

guide their improvement efforts. It’s simply a

formalized process for improvement and we

aimed here to achieve shortening the ED length

of stay of our patients by applying this

methodology.

METHODS

Study Settings

This study was conducted at King Fahd Hospital

of the university, University of Dammam, Saudi

Arabia during the process of attaining Joint

Commission International accreditation during

the period from Jan to June 2015. As a measure

to improve the quality emergency services, one

critical issue consists of overcrowding in

Emergency department. From the KPI annual

report 2014, researchers found that the rate of

patients who stay longer than 6 hours in the ER

was 9.2 /1000 patients, where six hours is the

internal target. Accordingly, the researcher

decided to use FOCUS-PDCA Model with an

objective to reduce the ER overstay. The study

was conducted for the duration of 6 months and

necessary process redesign was carried during

this period for obtaining optimal results.

Statistical analysis

Data’s were presented by mean with standard

deviation. Control charts were used to measure

the variation of the process. Performance

improvement after implementation of the

project was tested by using independent sample

t-test. All the analysis were performed using

MINITAB version 17. P value less than 0.05

was considered to be significant.

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RESULTS

FOCUS-PDCA

The quality improvement methodological

framework adopted in this study is based on

FOCUS-PDCA Model. The Quality tools and

techniques and the strategies adopted in each

phase of FOCUS-PDCA to optimize the ER

overstay is described below:

Find an opportunity
The rate of ER overstay 9.2 per 1000 patients as

per the key performance report of 2014, it was

inferred that there is need to reduce the ER

overstay, which had been identified as one of

the critical factor contributing to dissatisfaction

among ER patients.

Organize a team

To accomplish this project, a special team was

formulated and its consisted of Team leader (ER

consultant ), Laboratory representative,

Radiology Superintendent, Nursing quality

officer, there are 2 IT specialty, 1 special ER

nurse and a supporting staff from the Quality

office of the hospital. The primary objective of

the team is to improve and optimize the ER

overstay.

Clarify the process

This phase involves documentation and

evaluation of the existing systems in various

processes of ER services. The team members

was explored all the issues related with ER stay

process and its described below, it was carried

out using process flow chart to analyze all the

staps starting from the arrival of patients in ER

and continued with sequential activities until the

patients stay more than 6 hours in ER

.

Understand the process

In order to find out the reasons for the delay in each of the sub processes of the ER overstay, a root

cause analysis was carried out and it is depicted below:

Significant causes for ER overstay were depicted below (Figure 1), its indicate that most of them were

due medical re-evaluation.

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Select a desired outcome

To decrease 20% from the rate of patient who are staying in Emergency Department more than 6 hours

by the end of august 2015.

Plan

A plan for optimal solution of ER overstay was made and circulated to all responsible persons to

ensure the improved process [Table 1]

Table 1: The process plan to sustain and control the process for long run
Item Action Plan

Transportation for ER STAT samples to laboratory

• Re-educate porters regarding STAT samples
• Have a STAT lab in the ER
• To increase no. of porters

Medical re-evaluation: Junior doctors are seeing the patients then the

seniors: They are hesitate to call the consultants

• To send consultancy policy to all department heads to be aware
about it.

• Monitor the process of consultation
• Validity the data accuracy

Bed availability /ICU bed not available/ non-eligibility
Whenever the bed is not available, inform medical director to find a

bed even in another ward or service.

DO

In this phase, after formation the action plan the team members were implemented the following things

along with optimal plan.

• Continuous education to all ER staffs
• Reasons for Overstay should be discussed frequently during the Unit Staff Meeting, Administration

Meeting and performance improvement opportunities be explored and shared through the ER units.

• Complete the issue on the action plan that is assigned to each member
Check the Improvement (Analysis of the data)

After implementation of the above suggestions for the period of 6 months, the data was collected to

study the rate of ER overstay. Overall, the rate of ER overstay was reduced from 9.81/1000 to 6.92 per

1000 patients, demonstrating a 29.5% decrease [Figure 1]. This performance improvement project was

achieved significant improvement (P =0.030) [Table 2]

Figure 1: Effectiveness of FOCUS-PDCA model

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Table 2: Independent t-test for testing the Project improvement

Time period N Mean S,D Mean diff. P value

Before PI 9 9.81 2.07

2.89

0.030
After PI 6 6.92 2.24

Act

The improvement strategies were adopted in the plan will be continued until getting the most feasible

solution. In addition, the team members were updated by the process owners on a monthly basis

through data tracking and also for getting optimal of solution for ER overstay the following things

should be adopted:

• Transparent bed management through proper Bed Management systems
• Use a protocol for common conditions.
• Focus on efficient use of the available bed particularly through admission and discharge planning.

DISCUSSION

FOCUS-PDCA is easy to learn quickly, and

with time It keeps everyone focused on the

improvement effort. The structure of the process

encourages focus and accountability for

completing assigned tasks. It gets employees

(and volunteers) involved in the process of

problem solving. This improvement model

places value on the wisdom and experience of

front-line workers (employees or volunteers)

and encourages the use of their expertise. It

provides a plan and steps for improvements.

These plans help to eliminate the frustrations

that come with working in an environment that

allows organizational problems to dictate

internal processes, instead of the opposite. In

this quality improvement project we prove that

the FOCUS-PDCA method shortened the

overstaying time in the emergency department

and improved over all patients flow and

satisfactions. Such improvement usually its

reflected on patients outcome. Studies have

shown that delayed admission especially in

critically ill patients in emergency department

worsen their outcome, Chalfin and his group

found that critically ill emergency department

patients stays in ER more than 6-hr delay before

being transferred to ICU had more length of

hospital of stay and mortality also.
10

his suggests

the need to identify factors associated with

delayed transfer as well as specific determinants

of adverse outcomes. FOCUS-PDCA was used

in many improvement projects in clinical

practice, Oyvind and colleagues proved that the

FOCU-PDCA made Change and improvement

in health care achievable despite limited

financial resources.
11

Also in critical care

practice using the FOCUS-PDCA found to

reduce severe pain and stress-related events

while moving ICU-patients which is associated

with a decrease of serious adverse events on

those group of patients.
12

CONCLUSION

Based on the results of this study, it seems that

FOCUS-PDCA is an effective quality

improvement method that helped in decreasing

overstaying in ED which is a vey challenging

problem in clinical practice.

REFERENCE

1.Pines JM, Hilton JA, Weber EJ, Alkemade

AJ, Al Shabanah H, et al. (2011) International

perspectives on emergency department

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2 Lewin Group (for the American Hospital

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American Hospital Association Survey of

Emergency Depart

3 Derlet RW, Richards JR. Overcrowding in the

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proceedings of the Academic Emergency

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6.Cooke MW, Wilson S, Halsall J, Roalfe A

(2004) Total time in English accident and

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8.Schneider PD. FOCUS-PDCA ensures

continuous quality improvement in the

outpatient setting. Oncol Nurs Forum

1997;24:966.

9.Redick EL. Applying FOCUS-PDCA to solve

clinical prblems. Dimens Crit Care Nurs

1999;18:30-4

10. Chalfin

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=Likourezos%20A%5BAuthor%5D&cauthor

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ED%20study%20group%5BCorporate%20A

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Care Med. 2007 Jun;35(6):1477-83.

11.Oyvind Thomassen1*, Clifford Mann2, Juma

Salum Mbwana3 and Guttorm

Brattebo1Emergency medicine in Zanzibar:

the effect of system changes in the emergency

department. International Journal of

Emergency Medicine (2014) 8:22

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de Lattre1, Claudine Gniadek1, Julie Carr1,

Mathieu Conseil1, Marie-Pierre Susbielles1,

Boris Jung1,3, Samir Jaber1,3 and Gérald

Chanques1,3Decreasing severe pain and

serious adverse events while moving

intensive care unit patients: a prospective

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“http://dx.doi.org/10.1186%2Fcc12683″10.11

86/cc12683.

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file:///C:\Users\Karam\Downloads\HYPERLINK%20%22http:\dx.doi.org\10.1186\cc12683%2210.1186\cc12683

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file:///C:\Users\Karam\Downloads\HYPERLINK%20%22http:\dx.doi.org\10.1186\cc12683%2210.1186\cc12683

QUALITY IMPROVEMENT USING
FOCUS-PDCA MODEL
PHARMACY DEPARTMENT
*

FIND OPPORTUNITY FOR IMPROVEMENT
*
  Jan Feb Mar Apr May Jun Jul Aug Sep
Medication Error 0 1 0 0 0 1 0 0 0

Organize a Team
*
Anu Augustian HOD- Pharmacy
Abdul Kareem Chief Pharmacist
Elizabeth Schulze Chief Nursing Officer
Khairunnisa Shallwani Education and Training Coordinator/ Quality Dept.
Shaheena Surani Infection Control Coordinator/ Quality Dept.
Haitham Naeem HOD- ER
Rejimol Benny HOD- General Ward 2
Dr. Ammar Hassan General Practitioner
Bincy Kurian Senior Executive- HR

Clarify the current process
*

Uncover the Root Causes
*

The Quality Improvement Team identified many possible reasons through brain storming which is plotted using a fish bone model.

FISHBONE DIAGRAM USED TO IDENTIFY ROOT CAUSES
*

Under reporting
Of Medication
Error

Policy

People

Plant

Process

No supervision during the Medication process

No orientation for doctor

No process

No requirement

No competency checklist

Lack of Medication Error identification by patient

Lack of patient / family education on Medication
error

Lack of interest

No regular feedback
From pharmacy

No aware of the
importance

No audit

No enforcement to report error

Ineffective Communication

No open communication

Fear of consequences/
Threat of losing the job

Lack of standard procedures

Fear

No risk management program

Lack of improvement projects

Barriers in reporting medication error

Threat of seniors

No monitoring of policy

No system in place

Lack of awareness

No time to read policy

No audits by pharmacist

Lack of medication tracking

No online system for medication
administration

Lack of time

Fear of punishment

Lack of awareness of medication error

Lack of education

Increase workload and less staff

Increase turn over

Fear of legal liabilities

Error not consider worthy to report

Fear of punishment

Fear of punishment

Fear of consequences

Effect on performance
appraisal

Professional threat

Low self esteem

Confusion between medication
Error and near misses

Root Cause Verification
*
To confirm the reasons and collect data the following techniques are used:

-Personal Interview
– Observation

Uncover/Verify Root Causes
*
OCCURRENCE
SL No Reasons No of Responses % Cumulative %
1 Increase workload 29 15.76 15.76
2 Fear of punishment 27 14.67 30.43
3 Fear of consequences 26 14.13 44.56
4 No regular feedback by pharmacy 24 13.04 57.6
5 Error not considered as error to report 18 9.78 67.38
6 No audit by pharmacy 14 7.61 74.99
7 No orientation regarding the process 12 6.52 81.51
8 Low self esteem 9 4.89 86.49
9 Unaware of policy 5 2.72 89.21
10 Lack of interest to report 5 2.72 91.93
11 No risk Management program 5 2.72 94.65

Uncover/Verify Root Causes
*
OCCURRENCE
SL No Reasons No of Responses % Cumulative %
12 No system in place 5 2.72 97.37
13 No reinforcement by HOD 3 1.63 99
14 Lack of awareness for Medical Error reporting 2 1 100
TOTAL 184

Pareto Diagram Used to Verify Root Causes
*

Chart4

Increase workload Increase workload

Fear of punishment Fear of punishment

Fear of consequences Fear of consequences

No regular feedback by pharmacy No regular feedback by pharmacy

Error not considered as error to report Error not considered as error to report

No audit by pharmacy No audit by pharmacy

No orientation regarding the process No orientation regarding the process

Low self-esteem Low self-esteem

Unaware of policy Unaware of policy

Lack of interest to report Lack of interest to report

No risk Management program No risk Management program

No system in place No system in place

No reinforcement by HOD No reinforcement by HOD

Lack of awareness for Medical Error reporting Lack of awareness for Medical Error reporting

REASONS
Number of Responses
29
15.76
27
30.43
26
44.56
24
57.6
18
67.38
14
74.99
12
81.51
9
86.49
5
89.21
5
91.93
5
94.65
5
97.37
3
99
2
100

Sheet1

REASON NO. OF RESPONSES % C. %

Increase workload 29 15.76 15.76

Fear of punishment 27 14.67 30.43

Fear of consequences 26 14.13 44.56

No regular feedback by pharmacy 24 13.04 57.6

Error not considered as error to report 18 9.78 67.38

No audit by pharmacy 14 7.61 74.99

No orientation regarding the process 12 6.52 81.51

Low self-esteem 9 4.89 86.49

Unaware of policy 5 2.72 89.21

Lack of interest to report 5 2.72 91.93

No risk Management program 5 2.72 94.65

No system in place 5 2.72 97.37

No reinforcement by HOD 3 1.63 99

Lack of awareness for Medical Error reporting 2 1 100

TOTAL 184

Sheet1

REASONS
PERCENATGE

Sheet2

Sheet3

Select The Improvement Using The Solution Selection Matrix
*
Proposed Solutions Cost. is it cost effective ?
20 Leadership support?
25 Practical?
15 Acceptance
20 Is time effective ? 20 Total Score
900
1. Ensure appropriate staffing 80 125 90 100 120 515
2. Train for Managing Time effectively 80 125 105 100 120 530
3. Ensure mix skill staff assignments to all units 100 50 150 100 120 520
4. Plan staff leaves ahead of time for Annual 120 200 150 100 120 690
5. Have a planner for leaves 120 200 150 100 120 690
6. Provide assuring and correct information regarding the process 140 150 90 100 140 620
7. Reduce the extent of punishments 160 200 120 160 140 780
8. Provide continues education as per hospital policies and procedures 140 150 90 100 140 620
9. Share the medication error cases within unit staff meetings 80 125 105 100 120 530
10. Encourage Medical Error reporting with positive feedback and less consequences 140 150 90 100 140 620
11. Plan monthly audit schedule for each unit 120 200 150 100 120 690
12. Provide monthly data to all unit heads regarding Medication error 140 150 90 100 140 620
13. Pharmacy must release quarterly action plan for the audit results 120 200 150 100 120 690
14. Spot checking by pharmacy for the proper medication usage process. 80 100 60 80 100 420
15. Offer medication safety session to all new staff and a refresher after 3 months 160 200 120 160 140 780
16. HOD will review Medication error and its types with staff as an ongoing process. 140 150 90 100 140 620

Select The Improvement Using The Solution Selection Matrix
*
Proposed Solutions Cost. is it cost effective ? 20 Leadership support?
25 Practical?
15 Acceptance
20 Is time effective ?
20 Total Score
900
17. Empower staff by timely and updated education regarding medication administration and medication safety 120 200 150 100 120 690
18. Provide Channels to ventilate their anxieties and fears 140 150 90 100 140 620
19. HOD works as an advocate for her staff and provide support as required. 120 200 150 100 120 690

Plan the Improvement
*
Sl No Areas of improvement Plan Responsible Person Cost Date of Completion
1 Fear of Punishment Reduce the extent of punishments CNO/ HOD/HR Nil Nov. 2013
2 Error not considered as error to report/ No orientation Offer medication Safety session to all new staff and a refresher after 3 months
OVR process flow to all units Pharmacy
Educator
HOD AED 1000
Ongoing Nov. 2013
3 Increase workload Plan staff leaves ahead of time: Annual HR
CNO
HOD
Duty Managers Nil Nov. 2013
ongoing
4 No regular feedback by pharmacy/ less frequent Audits Plan monthly audit schedule for each unit Pharmacy
HOD Nil Nov 2013
ongoing

5 No regular feedback by pharmacy/ less frequent Audit Pharmacy must release quarterly action plan for the audit results Pharmacy NIL Oct, 2013
ongoing

Plan the Improvement
*
Sl No Areas of improvement Plan Responsible Person Cost Date of Completion
6 Low self esteem Empower staff by timely and updated education regarding medication administration and medication safety Educator
HOD
CNO Nil NOV 2013
On going
7 Low self esteem HOD works as an advocate for her staff and provide support as required HOD
CNO Nil Nov. 2013 on going
8 Fear of Punishment/ Consequences Share the medication error cases with in unit staff meetings and during Medication safety sessions CNO
Educator
Pharmacy
HR Nil Nov. 2013 on going

9 Fear of Punishment/ Consequences
Provide continuous education as per hospital policies and procedures Educator
HOD
HR Nil Nov. 2013 on going

10 Fear of Punishment/ Consequences
Encourage Medication Error reporting with positive feedback and less consequences. HOD
CNO
HR Nil Nov. 2013 on going

Plan the Improvement
*
Sl No Areas of improvement Plan Responsible Person Cost Date of Completion
11 Less frequent Audit / No regular feedback by Pharmacy Spot checking by pharmacy for the proper medication usage process
Provide monthly data to all unit heads regarding Medication Error Quality Dept.
Pharmacy Nil Dec. 2013 ongoing
12 Error not considered as error to report/ No orientation HOD will review medication error and its types with staff as an on going process HOD
Duty Managers Nil Dec. 2013 ongoing
13 Low self esteem Provide channels to ventilate their anxieties and fears HOD
CNO
Duty Managers Nil Dec. 2013 ongoing
14 Increase workload Train for managing Time Effectively HR
Educator
HOD Nil Nov. 2013

Plan the Improvement
*
Sl No Areas of improvement Plan Responsible Person Cost Date of Completion
15 Fear of Punishment/ Consequences Share the medication error cases within unit staff meetings HOD
HR
CNO Nil Nov. 2013 Ongoing
16 Increase workload Ensure mix skill staff assignments in all units CNO
HR
HOD Nil Nov 2013

17 Increase workload Ensure appropriate staffing
Introduce training for staffing plan as per unit requirement CNO
HR
HOD
Educator Nil Nov 2013

2014 Planner
18 Low self esteem Encourage staff to verbalize their issues of reporting
Head nurse encourage staff to report HOD Nil Nov 2013

Do
*
Some Planned Solutions were implemented over a period of two months and the others are on going.

Check did it works?
*
Medication Error Report

BEFORE AFTER

Improvement Noticed
*
Medication error reporting has been increased
Support system is available for staff to ventilate their feeling
Audit schedule planned
Sharing of medication error report on quarterly bases
Action plan by pharmacy was shared and will be done on regular bases

Act: Maintain the Gain
*
Ongoing education
Support system for staff to share their fears and anxiety
Staff is aware of different types of medication errors and knows how to report: noted during session.
Audits & reports by pharmacy

THANK YOU!!!
*

Under reporting
Of Medication
Error
Policy
People
Plant
Process
No supervision during the Medication process
No orientation for doctor
No competency checklist
Lack of Medication Error identification by patient
No process
No requirement
Lack of patient / family education on Medication
error
Lack of interest
No regular feedback
From pharmacy
No aware of the
importance
No audit
No enforcement to report error
Ineffective Communication
No open communication
Fear of consequences/
Threat of losing the job
Lack of standard procedures
Fear
No risk management program
Lack of improvement projects
Barriers in reporting medication error
Threat of seniors
No monitoring of policy
No system in place
Lack of awareness
No time to read policy
No audits by pharmacist
Lack of medication tracking
No online system for medication
administration
Lack of time
Fear of punishment
Lack of awareness of medication error
Lack of education
Increase workload and less staff
Increase turn over
Fear of legal liabilities
Error not consider worthy to report
Fear of punishment
Fear of punishment
Fear of consequences
Effect on performance
appraisal
Professional threat
Low self esteem
Confusion between medication
Error and near misses
15.76
30.43
44.56
57.6
67.38
74.99
81.51
86.49
89.21
91.93
94.65
97.37
99
100
0
5
10
15
20
25
30
35
Increase workload
Fear of punishment
Fear of consequences
No regular feedback by pharmacy
Error not considered as error to report
No audit by pharmacy
No orientation regarding the process
Low self-esteem
Unaware of policy
Lack of interest to report
No risk Management program
No system in place
No reinforcement by HOD
Lack of awareness for Medical Error rep…
REASONS
Number of Responses
0
10
20
30
40
50
60
70
80
90
100
Series1
Series2