University of Colorado Hospital

Focus-PDCA
Performance Improvement Team Worksheet
Department Pulmonary
Date 10/18/13
Primary Contact Person Suz Averill
!tension 87579
(F) Find a Process to Improve (name the process !escri"e the "e#innin# an! en!in# steps in
the process name the customers serve!$ state %hy it is important to %or& on this no%'(
"pportunity #tatement$
A!e)uate *esources+ ,avin# enou#h support to provi!e )uality patient care %hile per-ormin#
a!missions an! !ischar#es e--iciently( .he /apacity *0 pro1ect is an important pro1ect to %or& on
no% "ecause sta-- are !issatis-ie! %ith chan#es since the unit transition( .his %ill a!!ress *0
concerns an! allo% *0s more time on their shi-t to as& )uestions solve pro"lems an! care -or
patients(
Steps+
1( Pre2survey+ Assess sta-- nee!s an! concerns(
3( 4mplement /apacity shi-ts
3( Post2Survey+ *eassess sta-- nee!s an! concerns a-ter implementation(
Circle all that apply$
Dimension of Performance$ 5imensions o- health care per-ormance are those !e-ina"le
pre-era"ly measura"le attri"utes o- the system that are relate! to its -unctionin# to maintain
restore or improve health care(
2 fficiency 2 #afety
2 #taff #atisfaction 2 ffectiveness
2 Patient Centeredness 2 /ontinuity
Prioriti%ation$
2 ,i#h *is& 2 ,i#h 4mpact on Per-ormance
- Hi&h 'olume 2 Hi&h Potential for Improvement
- Pro(lem Prone 2 Supports /ritical Success 6actors
- 7o% 8olume 2 Patient #afety

(O) Organize a team that knows the process:
List Team Members:
Suzannah Averill2*elie- /har#e *0 hea!in# the pro1ect
Sarah 9llin#ton25ay /har#e *0
:en!y /yriac&s25ay /har#e *0 an! Pro1ect ;entor
<rittany /yriac&s25ay /har#e *0
;olli Passehl20i#ht /har#e *0
=ames Scha!ler2 0i#ht /har#e *0
>aycee Shis&o%s&y2?nit ;ana#er
Staci A!en2?nit 9!ucator
An#ie 5uncan2Sta-- *0 /ouncil /hampion %ho trac&s 6@/?S2P5/As -or our ?nit
;e#an ;c Pai#e An#ie =un# ,ayley ; <rent2 *0s intereste! in %or&in# /apacity
shi-ts
(C) Clarify the current knowledge
What do we know about the process?
:e have !ou"le! in size as a unit -rom 18 to 3A "e!s an! continue to have one /har#e *0( As
the /har#e 0urse has !ou"le the !aily activities it is more !i--icult -or them to "e a resource to 13
sta-- mem"ers instea! o- A( *esources are especially thin -or a!missions an! !ischar#es( :ith
an increasin#ly #eneral me!icine population %e are seein# an increase in patient turnaroun!( :e
%oul! "ene-it -rom a /apacity nurse as an eBtra set o- han!s !urin# pea& a!mission hours since
the /har#e *0 is no lon#er a"le to -unction in this role( .he /apacity *0 coul! also help o--loa!
/har#e *0 !uties "y "ein# a #eneral resource
(U) nderstand sources of !ariation:
Why are we looking at this process? Why is the process not going the way planned?
;any *0s have eBpresse! concern a"out increase! %or&loa! an! !ecrease! support !ue to the
increase! size o- the unit an! chan#e in patient population( At this time hirin# a secon! /har#e
*0 is not %ithin the "u!#et(
(S) "elect the impro!ement:
/apacity shi-t -rom 150023100 to support "oth !ay an! ni#ht shi-t %ith shi-t transition( .he
/apacity nurse also serves as a resource to "oth the sta-- an! /har#e *0( .his allo%s /har#e
*0s to %or& on pro1ects an! atten! meetin#s(
(P) #lan the impro!ement:
*elie- char#e *0 Suz Averill to help lea! an! or#anize the implementation/eBpectations -or
/apacity shi-ts( Suz to roll out e!ucation to Sta-- *0s "y presentin# role eBpectations in sta--
meetin#s( :or& %ith nurse mana#er to i!enti-y -inancial "arriers(
(D) $mplement the impro!ement:
/apacity *0 shi-ts to "e#in in 5ecem"er( @ptimally si#n up %ill "ecome availa"le on Sharepoint(
(C) Check the results:
6ollo%2up *0 satis-action survey in 3 to A months(
.rac& a!mission chartin# compliance !ataC
.rac& clean to occupy timesC
(A) %ct to hold the gain:
050D4C
/ompliance %ith a!mission chartin#C
)epeat PDCA as needed and maintain documentation in your department*