FOUCS – PDCA
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.
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2 Lewin Group (for the American Hospital
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8.Schneider PD. FOCUS-PDCA ensures
continuous quality improvement in the
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11.Oyvind Thomassen1*, Clifford Mann2, Juma
Salum Mbwana3 and Guttorm
Brattebo1Emergency medicine in Zanzibar:
the effect of system changes in the emergency
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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
interventional study
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18. doi: HYPERLINK
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86/cc12683.
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file:///C:\Users\Karam\Downloads\HYPERLINK%20%22http:\dx.doi.org\10.1186\cc12683%2210.1186\cc12683
file:///C:\Users\Karam\Downloads\HYPERLINK%20%22http:\dx.doi.org\10.1186\cc12683%2210.1186\cc12683
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