Wednesday, December 08, 2010

Push pins give a safety and quality update

#IHI It is not a scientific survey, but these push pins give a sense of what's working and what's not in process improvements in the health care field. The boards were posted at the IHI Annual Forum. Forum participants were asked to use red pins to indicate processes "that continue to challenge you" and green pins are the ones "for which you have demonstrated success." If you compared these year to year, you could get a sense of the general progress of process improvement in hospitals and physician practices. I include just a few examples.


Bart Windrum said...

Paul, I wish I had known about and seen this on-site. It's a stunning synopsis of treatment aspects that I'd like to know about, for knowing will help me advocate. If you have pix of all the categories I'd really like to see them. I have personal patient-family history with med reconciliation (albeit *not* at xfr), and I've recently learned that medication error sits atop the list of bad errors. This gives me new insight into how I might approach future meds snafus (we've experienced two identical ones in the past year, one each in a CO and a FL hospital, where an at-risk inpatient was denied her own admitting-surgeon-preapproved pain meds on the correct schedule, for two different reasons -- both letting hospital policy trump patient safety). Knowing what providers are dealing with and troubled by can help me advocate for my hospitalized loved ones.

Mark Graban said...

All of the red dots for medication reconciliation jumped out at me and Helen Zak. Our friends at ThedaCare (a system in Wisconsin) have really defeated that problem - they have gone almost FOUR YEARS without a single med rec problem in their "collaborative care" units.... very impressive. So how do we share that know how?

Anonymous said...


If Thedacare has solved med reconciliation, it can only be described as a breakthrough. May I suggest you can share that know how by submitting it to the Joint Commission's leading practice library:

- although this only makes it available to JC fee-paying hospitals, and not to the public( such as patients, who could wave it at their own hospitals).
Or to JC's Targeted Solutions tool in their Center for Transforming Healthcare. I am not sure how these two entities interact.

nonlocal MD

Jeffrey said...

Hi Paul,

Interesting post. Could you clarify the "Transitioning Out of the Hospital" process?

Is this discharging a patient, transferring a patient to another hospital, or all of the above?

Thank you.

Anonymous said...

Both, I would think.

Anonymous said...

While the sample is not scientific, it is meaningful to remember that these are hospitals sending staff to IHI, and therefore, most likely to have Q and S higher as operational priority. Unlike the common shoulder-shrugging that is heard from admin and physicians in daily discourse, there was real intolerance at IHI for poor processes. The green pins should be labeled for use as resources for others. Time for some site visits?

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EMS Man said...

Transitioning out of hospital is the tail end of the patient/bed flow process. This includes transitions to LTAC's, SNF's, home, hospice, hospital etc. There is currently a group working on the challenges presented by these transitions called the Care Transitions Forum. It is moderated by the IHI and Massachusetts Health Data Consortium. We curently have participants from all sides of the issue to allow for multiple points of view. A great group that I enjoy being part of!

Jon said...

I think this is a great way to identify those areas for possible improvement that people are struggling with. Medicines reconciliation is obviously as much a struggle internationally as here in Wales.

This is a great idea to canvass opinions in a forum scenario.