Tweaks to PI Plan lead to more focused approach

New additions have breathed new life into the 2015 Performance Improvement (PI) Plan, “Operation: Excellence.”

Recently, a list of interventions has been added to address the plan’s four areas of focus: People, Quality and Safety, Service and Growth, and Efficiency.

For example, a De-Clutter Initiative was launched in April to remove equipment from hallways in Ruby Memorial. Non-essential equipment is now housed in a central storage area and accessible through a new on-line ordering system. This intervention is helping to address the goal of improving the cleanliness score on the inpatient HCAHPS survey.

Also, many of the metrics have been changed from percentages to numerals, which makes the numbers more relatable to staff.

“We want everybody to think in terms of individual patients, not the numbers,” Frank Briggs, vice president of quality and patient safety, said. “I think that shows everybody that they can make a difference.”

Interventions were developed from a variety of sources, including staff and leaders. The goal is to establish organization-wide interventions that will benefit patients and affect staff across disciplines and units.

One of the biggest PI Plan success stories so far is the reduction in Clostridium difficile (C. diff) infections. The number of patients who acquired C-diff infections last year totaled 97. Through March, the total is only 15, following the adoption of three interventions, each focused on quality patient care.

C. diff is an infection that affects the intestines, causing intense diarrhea. The spore-forming bacterium preys on people in hospitals, nursing homes and other medical facilities and is a major public health challenge.

An ongoing effort to address capacity challenges has also reduced diversion and transfers significantly.

Diversion occurs when ambulances are turned away because the Emergency Department at Ruby Memorial is at maximum capacity. Capacity also affects patient transfers from other facilities; they can only be accommodated when there are beds available in the hospital.

Through May, only one patient had been diverted to another healthcare institution. New observation beds have helped ease capacity issues that lead to transfers, Briggs said.

A new seven-bed observation unit opened in April on 2 East, in the location of the former Merlin training rooms.