University of Colorado Hospital

Focus-PDCA
Performance Improvement Team Worksheet
Department Medical / Surgical Progressive Care Unit Date August 22
nd
, 2014
Primary Contact Person Becky Breidenstein, R !tension !"#"!
(F) Find a Process to Improve (name the process, describe the beginning and ending steps in
the process, name the customers served; state why it is important to work on this now).
Opportunity Statement
The process is to Improve Inpatient and Outpatient Laboratory pecimen !rror.
"eginning with coming up with a p#an to prevent errors, educating sta$$ on new
imp#ementation, beginning date o$ new process, and setting a time$rame $or how #ong the
tria# process with go on. The customers served are the patients. It is important to address
this prob#em now due to the increase in specimen errors on % &'(, primari#y #abe#ing
errors that are occurring.
Circle all that apply:
Dimension of Performance: )imensions o$ hea#th care per$ormance are those de$inab#e,
pre$erab#y measurab#e, attributes o$ the system that are re#ated to its $unctioning to maintain,
restore, or improve hea#th care.
* !$$iciency * a$ety
* ta$$ atis$action * !$$ectiveness
* &atient 'enteredness * 'ontinuity
Prioritization:
* +igh ,isk * +igh Impact on &er$ormance
- +igh -o#ume * +igh &otentia# $or Improvement
- &rob#em &rone * upports 'ritica# uccess .actors
- Low -o#ume * &atient a$ety

Other//////////////////////////////////////////////////////////
(O) Organize a team that knows the process:
List Team Members:
Laboratory Task .orce0 "ecky "reidenstein, ,1; Timothy &ratt, ,1; 2anna &etrie, ,1;
3e##y %cIntosh, ,1; 'ameron 1orris, '#inica# Lab cientist; 'ourtney 4est, ,1; 2oseph
2a5inski, )irector o$ 6nci##ary +ea#th Techs; %arcee &au#, ,1 %anager.
(C) Clarify the current knowledge
What do we know about the process?
There have been an increasing amount o$ specimen #abe#ing errors on % &'( and
throughout the hospita# over the past year. 78*9:; o$ the errors are due to e<tra #abe#s in
the bioha5ard bags that are di$$erent o$ that on the specimen.
(U) nderstand sources of !ariation:
Why are we looking at this process? Why is the process not going the way planned?
ince there is an increase in errors, by imp#ementing this new process, I am hoping to
improve patient sa$ety and decrease the amount o$ specimen errors.
!ducation is needed to a## sta$$ members in the imp#ementation o$ the new process.
The process was a cu#ture and practice change $or the unit and it took a #earning curve to
get sta$$ to comp#y to the new process on a regu#ar basis.
(S) "elect the impro!ement:
+aving each specimen co##ector write his=her emp#oyee number on the #abe# at the
bedside whi#e co##ecting the specimen.
(P) #lan the impro!ement:
%et with Lab Task$orce and invo#ved >ua#ity a$ety 6dvocates $or guidance. !mai# sent
to a## sta$$ on % &'( and 6nci##ary +ea#th Techs that co##ect specimens on % &'(,
in$orming them o$ the new tria# that wi## begin .ebruary ?7
th
, ?8@7. In addition to the
emai#, the sta$$ on % &'( was given a one*on*one in*service to ensure understanding o$
the tria# process. 1ame, signature and emp#oyee numbers were co##ected $rom sta$$ on
% &'( to ensure accountabi#ity $or co##ection.
(D) $mplement the impro!ement:
One week be$ore the tria# began, I sent out an emai# to remind the sta$$ that the process
wi## begin on .ebruary ?7
th
, ?8@7. 6$ter the process was imp#emented, I $o##owed up with
an emai# one week, two weeks and one month a$ter the process had begun.
(C) Check the results:
%onitor a$ety Inte##igence $orms that have been reported by the c#inica# #ab regarding
any specimen errors that have occurred. 4atch $or the trend o$ errors that occur on a
month#y basis.
(A) %ct to hold the gain:
ince there has been an improvement in the amount o$ errors that have been reported, I
knew I needed to keep my co*workers invo#ved and in$ormed about the amount o$ errors
that we as a unit were having. I send out emai#s to keep the sta$$ we## in$ormed and ask to
make sure that I have answered any Auestions that they may have.
Repeat PDCA as needed and maintain documentation in your department.