Welcome to our session on "Why Focus on Quality Improvement?" I'm Melody Malone with TMF Health Quality Institute and I know it may seem silly to even ask this question, "Why focus on quality improvement?" We all probably think we do pretty good each day, even putting our best foot forward. And I'm sure you work hard every day to get "it" right, whatever "it" might be. But somehow, we still make mistakes, right? We still have errors; we still have harm. So I want you to think about a few questions...
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As I ask you these questions, I want you to begin engaging with me and raise your hand if you agree, even if you're in the room by yourself. So you would be saying, "Yes" if you said you believe that failure is a bad thing. Or, "Yes" to, "Do you believe that failure is not an option?" Or, "Yes" to, "Do you believe that failure is inevitable?" And what about, "Do you believe that finding the right person responsible is important?" Well failure and fault or let's call it what it is, blame, are virtually inseparable in most households as well as most organizations. Some organizational cultures thrive on finding fault or blame; blaming someone for failures. As you will see the thinking of quality improvement has a different perspective. As we discuss the issue of why focus on quality improvement, keep in mind your feelings about these questions. I ask you to be open to challenging your point of view. And why focus on quality improvement any more or now? Because there is wisdom in learning from failure. This is incontrovertible, yet organizations that do it well, that learn well from their failures, are very rare. Becoming a learning organization requires the organization to embrace errors and learn, learn, learn, learn, learn, from them. They learn and then move that learning forward. They use that same learned lesson over and over as they move on to new projects and new opportunities for improvement. Learning organizations also realize that rarely is one person at fault for a failure. There are many small and large reasons for a failure. A learning organization seeks to find those reasons or to use some QI terminology, root causes. ^M00:02:55One of the things that's important as we talk about learning from the data; we want to learn from our mistakes and errors, but we have to view errors from a data point of view in order to learn so we must collect and analyze data. However we must never forget the potential human toll as a result of both clinical errors and failures in our business practices. Even though we will speak a lot about data in our quality improvement work, we must always remember that every resident matters, every staff member matters, and every visitor and guest matters. Every piece of data actually may have been a hurt to a human being or has the potential to hurt someone. So as we work on how do we learn from the data, how do we present harm, we want to learn so that we get better at reducing our failure rates, so we stop hurting people, and have fewer near misses. A near miss is a potential error that did not really cause any harm because someone caught it first. But even through identifying near misses and implementing quality improvement methodology, we can help to reduce near misses in the future. To prevent harm, we have to improve our systems to the point that they're tight and sustainable over time. And so back to our main question; why focus on quality improvement? Well let me ask you this; is it ok to cause someone harm? And say your answer with your out-loud voice. I'll bet you said, "No," right? Nod your heads with me; yeah, you said, "No," and I think that's reasonable. And is it ok to harm someone when we give them a healthcare acquired infection or HAI or healthcare acquired condition or a HAC? Say that again. That's probable not ok, right? So let me ask you one more question; who should pay for healthcare harm? If you take your car in for an oil change and it gets a dent, who pays for it? Probably the oil change place, right? Well all these years, the insurance providers have paid for our mistakes; they've paid for the medicine, the extra treatments, and the staff time to take care of our mistake. And is that right or should the healthcare institution be paying for its own mistakes? Well we're starting to see that because hospitals already have reduced payments for their not present on admission issues and it may be coming to nursing homes; we'll just have to see what the future brings. But regardless, it's an opportunity for us to focus on quality improvement because keep in mind one of the costs of our failures is our staff; it's on our staff. Do we take it out on them? If someone makes a mistake and you fire them, what does that do to the staff? Well it's all hard on the staff. Remember whenever there's been an error that hurt someone, someone else did that error so they're hurting as a result of the harm that they've inflicted. So when there's staff turnover because we fired somebody for a mistake, its hard on the staff that stay behind because they may have to work short or just have a sense of loss or that failure, that firing, may be demotivating. It's hard on the office folks who have to process new employees. It adds a lot of extra work. It's hard on the residents; change is hard for them too. And each change adds more variation to your system because new people bring old ways that may not match your policies, your ways, or your corporate culture. So when we look at why focus on quality improvement, there's a great return on the investment for quality improvement. Less errors equal less harm and less harm is going to equal fewer complaints or injuries or staff turnover. And when we have less of all that negative stuff going on, then we have much better outcomes overall for everybody involved. We have much better outcomes for the residents, for the staff, for the business, and our business practices overall. And never forget fewer issues can get you better survey outcomes and higher public scores. As we become a learning organization, we learn to fail forward. And what I mean by that is we've used those lessons learned in the past to improve the future. A learning organization brings those past lessons learned forward to the future to help them design better systems and better methodologies for operating. As we move on in our future sessions on quality improvement, each session is designed to worth within the entire system to really help your teams move through the process of quality improvement and to support your efforts to train your staff in easy to learn, short sessions. We hope that as you walk through this quality improvement journey you will find many reasons to put in the efforts to change practices and processes in your organization. Your next steps are pretty simple; we encourage you to go to our website and check out all the tools and resources available for you. One of those tools and resources is the QAPI at a glance document. There's a great assessment in there towards the back I strongly encourage you to complete. It will help you on your journey to quality improvement. If you have any questions, feel free to contact us. We'd be happy to work with you.