SPA & Self Enquiry Part I

................................................................................................................................................................. 2
SPA 1.1 (LED.1) ................................................................................................. 4
Self Enquiry 1.1 (LED.1) ................................................................................... 10
SPA 1.2 (LED.2) ................................................................. 12
Self Enquiry 1.2 (LED.2)..................................................... 16
SPA 2.1 (STM.1)................................................................................................................... 18
Self Enquiry 2.1 (STM.1) ...................................................................................................... 22
SPA 2.2 (STM.2) ..................................................................................... 24
Self Enquiry 2.2 (STM.2)......................................................................... 28
SPA I-3.1 / (PCF.1) ...................................................................................... 30
Self Enquiry 3.1 / (PCF.1) ........................................................................... 33
SPA I-3.2 (PCF.2) ................................................................... 34
Self Enquiry I - 3.2 (PCF.2) .................................................... 40
SPA I - 3.3 (PCF.3) ........................................................................................................................ 41
Self Enquiry 3.3 (PCF.3)................................................................................................................. 45
SPA I-4.1 (MAK.1) ................................................................ 47
Self Enquiry I 4.1 (MAK.1) ................................................ 52
SPA I - 4.2 (MAK.2)................................... 54
Self Enquiry I 4.2 (MAK.2) ..................... 58
SPA I-5.1 (HRF.1) ..................................................................................................... 59
Self Enquiry I - 5.1 (HRF.1)a .................................................................................... 68
SPA I - 5.2 (HRF.2) .............................................................................................. 69
Self Enquiry 5.2 (HRF.2) ...................................................................................... 76
SPA I-6.1 ...................................................................................................................... 77
SPA I - 6.2 ..................................................................................... 82
Self Enquiry I 6. ........................................................................................................ 85
. Hospital Survey on Patient Safety Culture ................................................................................ 87
.1 Are We Making Progress as Leader ....................................................................................... 94
.2 Are We Making Progress () ......................................................... 99


SPA (Standards Practice Assessment)
SA (self assessment) SPA P P practice


SPA

HA 60
(TQA/MBNQA)
. SPA

(systematic approach)

(
)
.
.

context
study learning PDSA

Self Enquiry
Enquiry

. enquiry
internal survey

o
o

o
o

o
o

o
o
self enquiry guide
core values

. . HA
HA .

I-1
SPA 1.1 (LED.1)

.
.
(1) .
.
.

HA/HPH
o
o

o ( 18 )



HA/HPH

HA/HPH

(2)
. ( 1.2)
(3) ,
, , , ,
, .

(1)
(priority ) (2)
(3) ,
, , ,
,
(4) (5)


, ,

, , ,





internet,
,
(Community of Practice),




(sensitive)

(4) .

Patient Safety Goals : SIMPLE
( One Staff One
Issue
)


Patient Safety Leadership Walkround

( RCA )
( Human Factors Engineering)

Morning Brief, Safety Brief, ,
Patient
Safety Culture Survey AHRQ

Leadership Walkround

.
(1) , , .
.
/ ,
, .

/ (
/ )

(empowerment)
/
/

(empowerment)

() (
) ()

(2)
.
.



(-Hoshin)
(
)

Self Enquiry 1.1 (LED.1)

core values visionary leadership

key word

(), (), (
)
.

Key word

,
, ,

10

 () , ,

/ ,
,

(empower)

11

SPA 1.2 (LED.2)

.
.
(1)
, , ,
, .

(governance system)
()
o
o

(),

(
)
(2) .
.

12


competency (managerial competency)

o
o
o
o /
o

Managerial competency

.
(1) /
/ .
.
.

o
o

o ( recycle,
, , green environment)

13


()

,
,
(2)
.

Personal Ethics (Morality)

autonomy
(trustworthiness & honesty)

(basic justice; being fair)

(benevolence: doing good)

Professional Ethics
(impartiality; objectivity)
(openness; full disclosure)
(confidentiality)
Due diligence / duty of care

o
o
o
o
o /
o
o

14

o
o



(
)

15

Self Enquiry 1.2 (LED.2)

core values visionary leadership, community/social responsibility, professional

ethics
(governance system) .
()
o
o

o
o
o
o /
o

Personal Ethics (Morality)
Professional Ethics

(impartiality; objectivity)
autonomy
(openness; full disclosure)
(trustworthiness & honesty)
(confidentiality)

Due diligence / duty of care

(basic justice; being fair)

(benevolence: doing good)

16

o , , ,
, /, , , ,

2-3
.

o
o
o
o .

( )

17

I 2
SPA 2.1 (STM.1)

.
.
(1)
.
. .

o (strategy) :
, , , ,
, , ,
,
o (strategy development)



o
o
o
o
o

o (,
, )
o

18


(potential blind spot)
(SWOT)
o

o


o

o 5

5




5
(
)

potential blind spot ( SWOT )
(2) /
,
.

19

o /


o
o
/

(life cycle)

SWOT

.
(1) . (
)

20

(2) ,

.
(3)
.

o
o
o
o
o

o
o

o
, (customization),
, ,
, ,
, , ,
, ,

21

 , ,
( )

Self Enquiry 2.1 (STM.1)

core values visionary leadership

(strategy)
: , ,
, ,

.
.,

22

.
.
.

(potential blind spot)

potential blind spot

23

SPA 2.2 (STM.2)

.
.
(1) ,
.
.

/

/
/


/




o

(2)
. .
.

24

(3) .

(4)
.
.

o
o
o
o
o

/
/

25



(5) .
/ .

(
HA/HPH IV )
dashboard
cascade

.
2.2 (5)
.

.

2.2 (5)

o
o
o ,
, ,

26

o
o
o

27

Self Enquiry 2.2 (STM.2)

core values focus on results, focus on staff, teamwork, empowerment, learning

.

28

29

I 3 /
SPA I-3.1 / (PCF.1)

/
.
. /
(1) / .
/ .

o
/

/ (
.)
o
( .)
/ .

/ .
/ .

30

(2) /
/ . / .
.

web

/
/
/
/ /
() /

1
/
/

o
Momma Test

, / ,

31

 /
(3) / / ,
/ , .

/
( Appreciative Inquiry
)

o /
o /
o /

/
(
3
)
(4)
.

( ,
, )

32

Self Enquiry 3.1 / (PCF.1)

/
.

/
(
.)

web

/ .

/ .
(segment) /
/

/

.
/

(
)
.

33

SPA I-3.2 (PCF.2)

/
. /
.
. /
(1) / , ,
.

/

o

o
o
good practice
/ ( Appreciative Inquiry dialogue)

mini-research ()

o
o (
)

o .

Good practice .

34

(2) / .

/
.
o .
o .
o


o internet
o

o
, patient representative, voice record
()

o
o
o .

.
.

35

(3) / .
.

(customer complaint management system)

o
o
o
o
o
o (
)
o
(
root cause)

o . ()
o

36

(4) /
.

o
o
o (

)

. /
(1) /
. /
.

o

o internet

o
top box

37

o
.

/
/
/
(2) /
.

actionable feedback
o /
o proactive

o
o

(3)

/

o
o

38

o (

)

39

Self Enquiry I - 3.2 (PCF.2)

/
. /
.

core values patient / customer focus

/ .

:
/

.
.

/

/

(feedback)

40

SPA I - 3.3 (PCF.3)

.
.
(1)

1.
2.
3.

4.
5.
6.

7.
8.

9.
10.

(
FMEA )

o (medical
necessity)
o

41

 Good practice

.
(1)
.

(2) .

(3) .

(4) .

o
o

o

42

(5)
.

OPD, expose
,

(6) .

[ 3.3 (1) ]

Good practice (
)

.
(1) .

.

o
o

o
o

43

(2) .

o
o
o

o
o

o

o

(3) .

o ()

o

Good practice (
)

44

Self Enquiry 3.3 (PCF.3)

core values patient / customer focus

10
1.
2.
3.

4.
5.
6.

7.
8.

9.
10.

(
FMEA) .

10

45

 (medical necessity)

( )

46

I 4
SPA I-4.1 (MAK.1)

.
.
(1) / /
, ,
, .

performance measurement
system
o (alignment)
o (integration)

o (/)
o

47

 (
scorecard catch ball Hoshin planning )


composite score

Tree diagram
(2)
.

(comparative data and information)
o

o





( .
)

48



(3) ,
.

o
o
o (

)

.
(1) .
.
, ,
.

( 3
)

o (analysis)

49

o ,
,





o
o
o .

(2)
, .
(3)
.

(
)

50

 2-3

51

Self Enquiry I 4.1 (MAK.1)

.

core values management by fact, focus on results
.
,
,

.
.
. .

.
.

monitor

service profile

.
.

52

53

SPA I - 4.2 (MAK.2)

/ / .
.
.
(1) / / / /

. .
(2) .
(3)
.
(4)
.

. /
/ / /
.

o
o
o
o

COBIT (Control Objectives for Information and related
Technology) 4 , IT,
IT,

54

.
: ,
/ ,
,
, .

. .
( explicit knowledge tacit
knowledge


o Community of Practice
, scientific evidence ,
,
,
o
, benchmark
,
o good practice best practice
2

55

o
gap analysis , Human Factors Engineering
,

o
o
o ()
o
o
o Peer Assist
AAR , ,

Good practice .

.
(1)
.
(2) .

o (accuracy)
o (reliability)

56

o (timeliness)
o (security)
o (confidentiality)

57

Self Enquiry I 4.2 (MAK.2)

/ / .
.

core values learning

58

I 5
SPA I-5.1 (HRF.1)

. .
.
(1) .

( )

o
staff engagement

o

o

.
o

59


o



o




o
( )
()

( )

(2)

()

(good
performance)
o
o

60

o /

(CoP) intranet
o
(open door policy)
intranet
o

o
(catch ball technique Hoshin planning)

Good practice /

(3) (staff performance management system)
, / / ,
.
.

performance management system

o Performance Management System-PMS

3

o

61

PMS

strategic priorities

(
performance plan

PMS PMS
,
,
PMS compliance

strategic priorities
( )
PMS
PMS

PMS
( 3 )
PMS

PMS compliance (
)
.

Strategic priorities PMS

PMS

62

 PMS ( PMS
)

.
(1)








()

o
o
o
o (tacit knowledge)
(explicit knowledge)
o
o .
o
o
o technical skill non-technical skill (
)

63


learning need, ,
,
, , ,
learning need
o
o (Learning need)
o competency
o

o

o
o
o
o
o

o


o

(
)
learning need / (
)

leaning need

64

(2)






()

o learning need

o
o
o I-1.1

learning need / ()
(3)
.

o Reactive evaluation
o Learning evaluation
o Behaviour evaluation

o Result evaluation

65



(4) .
.

,
, ,

succession plan, competency ,
(candidate), ,

.
(1)
, .

I-5.1 (1)

66

(2) /
IV /
. ( . )

/ IV

67

Self Enquiry I - 5.1 (HRF.1)a

. .

(staff engagement)

68

SPA I - 5.2 (HRF.2)

.
.
.
(1) .
.

(staff
capability)


o core competency

o technical competency
o managerial competency

(2) .

.
.

69


requirement
( /
)
requirement

(3) :


/ /

core values

(
)

Good practice

70

(4) .

, ,
.

o
o

()

.
(1)
. . (
II-3.1 )
(2)
.

(
)
(
)

71

.
(1) .

(
)

(2)
.

72

(3)
HIV , , ,
.

CDC


o sprains, strains, contusion, cuts, punctures
o (
)

expose

(4)

.

73

(5)
.

o
o
o

o
o


()

(6) .

2
o
o influenza, MMR, varicella, DPT, meningococcal vaccine
2

http://www.health.state.ny.us/prevention/immunization/toolkits/docs/hospital.pdf

74



(7) .

.

/ ,
, 3 / / ,

/ /

/
/

Post exposure prophylaxis HIV, HVB, rabies

75

Self Enquiry 5.2 (HRF.2)

.
.

.
.

76

I 6
SPA I-6.1

/ , ,
.
.
(1)
.

( CLT )
(organizations areas of greatest expertise)

o Mercy Health System (MBNQA winner 2007)
1) partnering with physicians to create and maintain an effective integrated healthcare
delivery system
2) engaging employees and physicians using the Servant Leadership Philosophy and the
COE model, which provide a balanced approach to patient focused care
o

77


3P PDSA process management

(2) (
) .

o Sharp HealthCare (MBNQA winner 2007) enterprise
Emergency Care, Home Care, Hospice Care, Inpatient Care, Long-term-care, Mental
Health Care, Outpatient Care, Primary / Specialty, Rehabilitation, Urgent Care

o /
software,
., ,

o value creation process

o
o

78

.
(1) .
. (
)
(2) ()
. ( /
)
(3) /


.

Process Management
o (key work process) 3 (

)
(healthcare process)
(business process)




(support process)


o ()
o (Design)
o (Action)

79

o (Learning)
o (Improvement)
Process Management PDSA 3P

o PDSA service
profile (
)
o 3
( service profile
II III)




IC

o

(process requirement)

o
o /
human factors engineering

()

80

.
,

.

.
. .
o

o

o
o
o
o
o
.

81

SPA I - 6.2

/ .
.
(1)
().
.
.
(2) .
.
(preference) .
(3) .

.

.

.

/ / /

82

o
o .

o

o
o


o ()
o lean
Defects rework:

Overproduction:

Waiting: portable X-ray

Not using staff talents:

Transportation:

Inventory:
Motion:

Excessive processing:

o
o 1 HA
o
Process Management
o

( IT )

83

o

o

.
PDSA

.
PDSA

84

Self Enquiry I 6.

/ .

service profile


process requirement (
) process requirement
requirement

85

86

 . Hospital Survey on Patient Safety Culture

10-15
(event) ( error), ( mistake), ( incident),

( accident), ( deviation),

(Patient safety)

SECTION A: /

clinical area

1
c

a. Many different hospital units/No specific unit (/)

b. Medicine (non-surgical)

g. Intensive care unit (any

type)

l. Radiology

c. Surgery

h. Psychiatry/mental health

m. Anesthesiology

d. Obstetrics

i. Rehabilitation

n. Other, please specify:

e. Pediatrics

j. Pharmacy

f. Emergency department

k. Laboratory

87

Strongly
Disagree Disagree Neither
d
d
d

Agree
d

Strongly
Agree
d

c
c
c
c

d
d
d
d

e
e
e
e

f
f
f
f

g
g
g
g

6. ..........................

c
c

d
d

e
e

f
f

g
g

7.
.....................................................................

c
c
c
c

d
d
d
d

e
e
e
e

f
f
f
f

g
g
g
g

c
c

d
d

e
e

f
f

g
g

c
c
c
c
c

d
d
d
d
d

e
e
e
e
e

f
f
f
f
f

g
g
g
g
g

1. ................................................
2. ................................
3. , ...
4. .........................
5.
..................................................................................................................

8. (held against
them) ................................................................................................................
9. ..........................
10. (by chance) ....
11. ..........................................
12.
.......................................................................................................
13.
.......................................................................................
14. (crisis mode)
...........................................................................................................
15. ..............
16. (mistake)
...............................................................................................................
17. ............................................
18. (error) ..........

88

SECTION B:

1. (says a good word)

..................
2.
.....................................................................
3.
(shortcuts) .....
4.
..........................................................................................................

Strongly
Disagree Disagree Neither
d
d
d

c
c
c
c

d
d
d
d

Agree
d

Strongly
Agree
d

f
f
f
f

g
g
g
g

e
e
e
e

SECTION C: Communications

1.
..............................................................................................................
2.
.......................................................................
3. (errors)
...........................................................................................................................
4. .........
5. (errors)
................................................................................................................
6. .................................

Never
d

Rarely
d

Sometimes
d

Most of
the time
d

Always
d

c
c

d
d

e
e

f
f

g
g

c
c
c
c

d
d
d
d

e
e
e
e

f
f
f
f

g
g
g
g

89

SECTION D:

Never
d

Rarely
d

Sometimes
d

Most of
the time
d

Always
d

1. (mistake)
, ...............................

2. (mistake)
............................................................

3. (mistake)
......................................

SECTION E: (Patient Safety Grade)

A
Excellent

B
Very Good

C
Acceptable

D
Poor

E
Failing

SECTION F:

1.
.....................................................................................................
2. ...............................................
3. ............................
4. ....
5.
..........................................................................................................
6.
.......................................................................................................
7. ....................
8.
(top priority) .....................................................................
9.
..........................................................................

Strongly
Disagree Disagree Neither
d
d
d

Agree
d

Strongly
Agree
d

c
c
c
c
c

d
d
d
d
d

e
e
e
e
e

f
f
f
f
f

g
g
g
g
g

c
c
c
c

d
d
d
d

e
e
e
e

f
f
f
f

g
g
g
g
90

10. ...
11. .......................................................

c
c

d
d

e
e

f
f

g
g

91

SECTION G:

12 , 1
c a.
c b. 1 - 2
c c. 3 - 5

c d. 6 -10
c e. 11 - 20
c f. 21

SECTION H:

1
1.
c a. 1
c b. 1 5
c c. 6 - 10

c d. 11 - 15
c e. 16 - 20
c f. 21

2.
c a. 1
c d. 11 - 15
c e. 16 - 20
c b. 1 5
c f. 21
c c. 6 - 10
3.
c a. 20
c d. 60 - 79
c b. 20 - 39
c e. 80 - 99
c c. 40 - 59
c f. 100
4.
c a.
c
c
c b. /
c c. LVN / LPN
c
c d.
c
c
c e. (Attending/Staff Physician)
c f. /
c
c g.
c

h.
i.
j.
k.
l.
m.
n.

/

Respiratory Therapist

(, EKG, , )

5.
c a.
c b.
6.
c a. 1
c b. 1 - 5
c c. 6 - 10

c d. 11 - 15
c e. 16 - 20
c f. 21

92

SECTION I:

93

 .1 Are We Making Progress as Leader

A Message to Leaders


Malcolm Baldrige

Are We Making Progress As Leaders? Are We Making Progress?

40
(, ,
, , )

94

CATEGORY 1: LEADERSHIP
1a (
1b
1c
1d

)
(
)

1e
1f
CATEGORY 2: STRATEGIC PLANNING
2a
2b
2c
2d
2e

()

CATEGORY 3: CUSTOMER AND MARKET FOCUS

3a

95

3b
need and want
3c

3d

3e

CATEGORY 4: MEASUREMENT, ANALYSIS, AND

KNOWLEDGE MANAGEMENT
4a
4b
4c fit

4d

4e
CATEGORY 5: WORKFORCE FOCUS
5a
5b
5c
5d
5e
5f

96

CATEGORY 6: PROCESS MANAGEMENT

6a

6b
6c

6d /
CATEGORY 7: RESULTS
7a
7b
7c
7d
7e
7f
7g
7h
7i

97

98

 .2 Are We Making Progress ()

() A Message to Leaders


Malcolm Baldrige

Are We Making Progress? Are We Making Progress As Leaders?

() Are We Making Progress?

40
(, , , ,
)

99

CATEGORY 1: LEADERSHIP
1a (
1b
1c
1d

)
(
)

1e
1f
CATEGORY 2: STRATEGIC PLANNING
2a
2b
2c
2d
2e

()

CATEGORY 3: CUSTOMER AND MARKET FOCUS

3a
3b need and want

100

3c

3d

3e
CATEGORY 4: MEASUREMENT, ANALYSIS, AND
KNOWLEDGE MANAGEMENT
4a
4b
4c fit

4d

4e
CATEGORY 5: WORKFORCE FOCUS
5a
5b

5c
5d
5e
5f
CATEGORY 6: PROCESS MANAGEMENT
6a
6b
6c

101

6d /
CATEGORY 7: RESULTS
7a
7b
7c
7d
7e
7f
7g
7h
7i

102