D u k e Details - Advanced Clinical Practice - Duke University

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Performance Improvement (PI) and Balanced ScorecardWhere can I find out about the BSCand Performance Improvement effortsin my area?Throughout DUH there are storyboards that shareperformance improvement activities. They areupdated monthly and link local PI efforts with DUHpriorities, using the BSC format.• Look for your area storyboard• Contact your manager or local PIrepresentative• Visit the Performance Services website athttp://psweb.dukehealth.orgWhat are the current PI project(s) foryour area?________________________________________________________________________________________________________________________________________________________________________My area project(s) include _ ______________________________________________________________What work has been done to improve theperformance?_ __________________________________________________________________________________________________________________16s
sHow do we know if our patients aresatisfied with their experiences?DUH surveys our patients’ satisfaction levels toidentify ways to improve the quality of services andthe care we provide. A random sample of patientsfrom the following areas receive surveys: Inpatient,Ambulatory Surgery, Emergency Department,hospital-sponsored outpatient tests and treatments(e.g. radiology, PT/OT), behavioral health, andhospital-based clinics.The results of these surveys are regularly communicatedto hospital leadership and managementwho communicate the results to staff. PerformanceServices staff and other employees establish teamsto review the data and develop performanceimprovement initiatives to improve performance.DUH priority patient satisfaction areas of opportunityfor us to focus on include:• Meeting a patient’s emotional and spiritualneeds.• Informing patients and families about theircare and any delays they may experience.• Including patients in decisions regardingtheir treatment.• Responding to patients and families’concerns and complaints.• Informing patients and families about thedischarge process.Some sample initiatives you may see in your areainclude:• Leadership and Charge RN Rounding• Patient Admission Folder and DischargeEnvelopes• Patient Communication Boards• Real Time Surveys• Strive for Five ProgramFind out the most recent patient satisfaction surveyresults for your area and/or the hospital.Patient Satisfaction17
Page 7 and 8: sWhat are Duke University Hospital
Page 9 and 10: sHow is DUH continuing to enhance t
Page 11 and 12: sImprove the Safety of Using Medica
Page 13 and 14: sImprove the recognition and respon
Page 15 and 16: sAccurately and Completely Reconcil
Page 17 and 18: sHow do we measure our success?At D
Page 19: sWhat does Performance Improvementm
Page 23 and 24: sWhat is a sentinel event?A sentine
Page 25 and 26: sWhat should be included in an SRSr
Page 27 and 28: sWhat are key points regarding how
Page 29 and 30: sWhat can you do to protect patient
Page 31 and 32: s• Schedule laxatives/diuretics
Page 33 and 34: sWhat types of precautions are used
Page 35 and 36: sWhat are acceptable temperature ra
Page 37 and 38: sHow do you know the hazardousmater
Page 39 and 40: sGuards (sometimes referred to as f
Page 41 and 42: sCompetency validation occurs in on
Page 43 and 44: sCoworkers’ competencies may be i
Page 45: sAssessment data collected by the d
Page 49: sLabel all medications, medication
Page 52 and 53: Restraints and SeclusionThe patient
Page 54 and 55: Container Management Policy: addres
Page 56 and 57: EMTALAThe Interfacility Transfer Su
Page 58 and 59: As a Health Team Member, Magnet mea
Page 60 and 61: ANA Code of Ethics for Nurses - est
Page 63 and 64: Call 911 to report fire, major radi

D u k e Details - Advanced Clinical Practice - Duke University

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