Consultation and Technical Assistance


Due to the rapidly changing healthcare environment, leaders at University of Missouri Health Care (MUHC) recognized the need to transition to making improvement work part of everyone’s job at MUHC in order to continue to provide the best care to our patients, but at a lower cost. The new focus emphasized the need for all employees, from frontline to the CEO, to engage their knowledge, skills and efforts into improvement work in all areas of MUHC: Clinical Care, Support Services, and Administration.

This recognition led to the creation of a new Corporate Goal related to quality improvement project engagement (QI Goal) in Fiscal Year 2014 (FY14). This new goal required all MUHC employees to be actively involved in quality improvement work throughout the year using the Plan-Do-Study-Act (PDSA) Methodology. In the beginning, the projects on which employees worked were self-selected; employees were given the power to identify problems and find ways to fix them as part of their job. MUHC now aims to take a more systematic approach to project selection, still incorporating employee feedback and engagement, to ensure that the QI work conducted ties directly to Departmental Performance Goals and MUHC Corporate Goals.

Since FY214, the QI Goal has evolved tremendously. Each year, MUHC works to build capacity in employees with QI/PI knowledge throughout all levels of the organization—this includes the development of MUHC leaders as QI/PI coaches, increasing the knowledge-base of employees regarding the PDSA Methodology and key QI/PI tools, and improving the comfort level of all employees in using the methodology and tools when conducting their QI/PI projects. Tying the QI Goal to individual employee evaluations has also raised the bar in terms of accountability of employees and Managers and has subsequently led to improved quality of project work and documentation of that work.
In order to assess the achievement of the MU Health QI Goal, a method of tracking individual employee participation was developed by CHCQ in FY-2014 to document each employee’s QI/PI initiative information. In FY-2016, a completely new tracking system—the MUHC QI Tracker—was developed by CHCQ which continues to document employee achievement of the QI Goal, but also aims to better facilitate organizational learning related to improvement work within MU Health. With the updated tracking system, employees can now enter more detailed information describing their QI/PI work including: aim statement, problem statement, changes/interventions made by the team to achieve an outcome, baseline and post-intervention data related to process and outcome metrics, linkage to MUHC’s Corporate Performance goals, spread and scale ability of the project, and general comments/lessons learned. The MUHC QI Tracker also facilitates Manager and Supervisor accountability by requiring specific approvals for each project in order for projects to count towards the goal, and for staff to achieve various evaluation levels of achievement on their Performance Review related to the FY-2016 QI Goal.

To facilitate organizational learning, advanced reports related to the QI Goal and viewing specific QI/PI project information were developed and opened to all MUHC employees in FY-2016 on the MUHC QI Tracker. These reports allow all employees to: 1) track their progress towards the QI Goal, 2) search through all projects currently entered into the tracking system in a number of different ways, and 3) view the portfolio of projects specific to a selected Executive Leader within MUHC related to the MUHC Corporate Performance Goals. The search functionality allows for all employees to search through the quality improvement projects entered into the MUHC QI Tracker. Employees can use this functionality to find projects deemed successful by an MUHC Leader to learn about how and why the project was successful, find projects similar to their own to find new ideas for potential interventions, find projects addressing a problem they are experiencing in their unit/department to learn how others have successfully or unsuccessfully addressed the problem, and a number of other criteria. This search functionality will allow MUHC employees to learn from one another and will allow the organization as a whole to better understand the QI work being conducted and potential areas that aren’t being addressed but should be.

In order for MUHC employees to conduct quality QI/PI projects, it is essential they have access to QI/PI-dedicated educational resources. To facilitate staff access to QI/PI training resources, a dedicated QI Resources tab was developed by CHCQ and placed on the MUHC QI Tracker—this resource contains over 300 regularly updated video links to describing use of a wide range of QI/PI tools, and QI/PI software applications. Staff can access these links on demand to facilitate individual or group viewing. CHCQ controls development and maintenance of the site content and actively works to keep resources up to date.

In addition to resources provided within the MUHC QI Tracker which facilitate self-learning, in-person QI/PI educational opportunities are available to employees. In addition to PI-LDP, ACT, and the Supervisor/Manager Modules (all structured educational programs offered by CHCQ), in FY-2016 employees in CHCQ as well as the Office for Clinical Effectiveness began working as organizational QI Representatives. Each “QI Rep” was assigned to MUHC Managers and have acted as dedicated resources to those departments providing just-in-time QI/PI education, assisting by request in the development of quality QI/PI projects, and answering questions related to project entry and the resources available on the MUHC QI Tracker.

The goal of the project was to improve the efficiency of the inpatient medication distribution and delivery process at MUHC. The number of medication credits, missing medications, and first dose deliveries processed led to large amounts of rework and excess motion for nursing and pharmacy staff. The proposed intervention was to move from delivering medications once per day to three times per day, so that more medication updates were captured. Results were studied post-intervention to evaluate improvement. Adjusting for increased patient volumes, results were even more favorable than predicted by the model. Overall, total doses dispensed from the pharmacy was reduced 8.3%.
The goal of the project was to decrease non-value added steps in the checkout process for Ellis Fischel cancer patients by 25% by implementing the first one-stop scheduling for all follow-up services needed within the health system. Prior to the intervention, 40% of the time patient check out at Ellis Clinic required a Patient Service Representative (PSR) to call another area(s) to schedule exams. An additional 12% of check outs required the PSR to leave desk to ask for overbook permission or order clarification before the patient could be scheduled. The proposed intervention was to provide cross-training for Ellis PSRs to schedule for UH Radiology services and scheduling into other MUHC clinics. The post-intervention data showed that the cross-training efforts were able to greatly reduce scheduling calls to other clinics.
The University Hospital Outpatient Pharmacy suffers from extensive wait times that discourage recently discharged patients as well as employees from utilizing its services. The long waits are primarily due to ineffecient workflows and customer flows caused by the space constraints and layout of the pharmacy location. The goals of this project were to reduce customer wait times in the current space and develop recommendations for a more efficient, patient centered outpatient pharmacy in its newly planned location. For the initial goal of improving customer wait times in the current setting, the proposed method of improvement was adding a second cash register to be tested in a simulation model. For the second goal of developing recommendations for the layout of the new outpatient pharmacy, a workflow analysis of pharmacy employees' movements was conducted by manual capture by an observer. The collected data was used to determine the most frequently traveled pathways and to identify more efficient workflows that could be implemented in the new space. Instead of adding a dedicated second cashier, it was determined to be more cost efficient to utilize an existing resource as a floating cashier. The floating cashier would only be required to be away from typical duties between 16 and 31 minutes on average per day. This small time investment would reduce the average customer wait time in the queue by 45% to 60% and decrease total wait time by up to two hours per day. A spaghetti diagram of the current outpatient pharmacy was constructed to highlight key workflow areas to be incorporated into the new pharmacy design.
Communication among patients, faculty, and staff plays a large role in patient experience, satisfaction, and outcomes and is one of the key areas of improvement being targeted by MUHC. Patients interact with a number of different physicians, nurses, techs, support staff, etc. during a hospital stay, especially in a teaching academic center like MUHC. MUHC has established the Clinical Leaders' Quality Improvement Program (CL-QIP) to train MUHC service line medical director and nurse manager dyads quality improvement methodologies with a focused effort on improving communication scores. CL-QIP conducted an exercise to assess whether patients knew their attending physician and primary nurse at the time of rounding. The results showed that only 65% of patients were able to accurately identify their attending physician and 79% of patients were able to accurately identify their attending nurse.
In early 2012, a process improvement team was formed with the specific aim to reduce surgical site infection (SSI) in patients having elective hip and knee surgery with implants by 50% by the end of CY2013. The specific skin decolonization protocol chosen included a paired product from SAGE and 3M consisting of 2% Chlorhexidine (CHG) wipes the night before surgery, applied by the patient, a viscous betadine nasal swab applied by the nurse in the pre-operative area followed by a second application of the 2% CHG in the pre-operative area. The implementation of, and adherence to, a pre-operative skin decolonization protocol reduced the standard infection ratio for patients with hip and knee arthroplasty by half. This protocol is now being spread to patients undergoing surgeries by different specialists.
For the past three years, outdated supplies have been the most cited compliance issue in health care institutions. The goal of this project was to develop a standardized process for handling, quantifying, and reducing outdated supplies throughout MUHC. The plan was to develop a systematic process to handle expired and short-dated supplies, collect baseline data on the amount and types of outdated supplies that existed, and eventually expand the process throughout MUHC. As of March 2013, over 10,000 items with a total cost of over $120,000 had been entered from data collected from the outdated supply bins. The next steps are to develop plans for addressing the top five supply categories in coordination with the Par Optimization Project, continue to educate and encourage employees to use the bins, and develop long-term data collection and monitoring plans.
As of October 25, 2011, MUHC had a Cleanlines/Quietness performance score of 60.9%, which ranked MUHC in the bottom 35th percentile. In order to raise the performance score, a methodology called 5S (Sort, Set in Order, Shine, Standardize, and sustain) was created to organize work areas for improved workflow efficiency and effectiveness. For this project, the five S's were used as guideliness to help members decide on what items were necessary in each room, where the items should be placed, how to keep rooms clean, and to standardize these processes across the hospital. MUHC reached the 76th percentile for the April 2012 through December 2012 performance period, which exceeded the goal of 75th percentile.
A Lean methodology known as 5S (Sort, Set in Order, Shine, Standardize, and Sustain) was adopted to organize areas in the University Hospital Sterile Processing Department (SPD). Initially, SPD employees participated in Lean 5S training to establish a basic understanding of the methodologies and how it pertained to achieving the department's goals. The frontline staff were then invited to engage in using the 5S principles to redesign their work areas. The new designs were generated quickly and they were inexpensive to implement.
Thousands of patients are admitted to MUHC facilities annually and these patients enter from a variety of access points. Attempts are made to tailor the information received by the patient to that patient's hospital experience but there is significant variation. This leads to patients being unprepared for their hospitalization, uncoordinated care planning, and delivery during hospitalization that impacts overall satisfaction with MUHC. The goal of the project was to implement a tool to standardize the process of distributing information to patients based on patient's needs in order to improve communication of patients care and satisfaction of hospital stay. The solution was to institute a journal, My Heath Care Journal, that contains information for patients that can be used before, during, and after their hospital stay.
In March 2010, a team of nurses was formed establish a reliable follow-up call process to assure patients have their immediate needs met within 72 hours of a discharge. The nurses were tasked with defining scripts and content, establishing measurements for successful calls, and providing resources for making calls. The goal was to place a follow-up phone call within 72 hours to at least 85% of patients discharged to home from an inpatient stay, observation stay, or ED visit.
Lack of standard work and effective communication between physicians, nurses, and staff makes discharging patients in a safe and timely manner more difficult. Prior to the project, discharges on a medical-surgical unit were often delayed, making patients and staff unhappy. Following the implementation of standard work to alert all staff of pending discharges, a nurse to coordinate the daily discharge activities, and daily huddles for nursing and ancillary staff, the discharges on this unit were less hectic, more predictable, and more satisfying to patients and staff.
A delayed first start surgical case can easily cascade into a multitude of inefficiencies throughout the day and the total number of completed cases will decrease. The goal of the project was to increase the number of first start cases wheeled out of the Main OR holding by the scheduled start time to a room ready operative suite to 100%. The project team used several Lean Tools to improve on-time first start cases and reduce the delay duration for delayed first start cases.
In the atmosphere of a busy delivery room, there are a number of processes that take place during the first hour of life for the mother and her newborn with both requiring frequent assessment and interventions post-delivery by multiple staff. The goal of the project was to improve the maternal newborn experience at the time of birth within ninety days. The project team ananlyzed the current processes, applied change models to the current processes, and implemented the improved processes.
The Affordable Care Act (ACA) added a section to the Social Security Act (SSA) establishing the Hospital Readmissions Reduction Program, which requires the Center for Medicare & Medicaid Services (CMS) to penalize acute care inpatient prospective payment system hospitals (IPPS) with excess readmissions through reduced payment, effective for discharges beginning 10/1/2012. There were several existing reports and methodologies for reporting MUHC readmissions, however, no such monitoring tool that followed the CMS algorithm. In an attempt to help MUHC better manage readmissions, the MUHC Inpatient Readmission Dashboard Project was undertaken. The MUHC Inpatient Readmission Dashboard is interactive and allows the user to filter and analyze readmissions based on CMS criteria and measures.
The Affordable Care Act (ACA) added a section to the Social Security Act (SSA) establishing the Hospital Readmissions Reduction Program, which requires the Center for Medicare & Medicaid Services (CMS) to penalize acute care inpatient prospective payment system hospitals (IPPS) with excess readmissions through reduced payment, effective for discharges beginning 10/1/2012. There were several existing reports and methodologies for reporting MUHC readmissions, however, no such monitoring tool that followed the CMS algorithm. In an attempt to help MUHC better manage readmissions, the MUHC Inpatient Readmission Dashboard Project was undertaken. The MUHC Inpatient Readmission Dashboard is interactive and allows the user to filter and analyze readmissions based on CMS criteria and measures.
The Affordable Care Act (ACA) added a section to the Social Security Act (SSA) establishing the Hospital Readmissions Reduction Program, which requires the Center for Medicare & Medicaid Services (CMS) to penalize acute care inpatient prospective payment system hospitals (IPPS) with excess readmissions through reduced payment, effective for discharges beginning 10/1/2012. There were several existing reports and methodologies for reporting MUHC readmissions, however, no such monitoring tool that followed the CMS algorithm. In an attempt to help MUHC better manage readmissions, the MUHC Inpatient Readmission Dashboard Project was undertaken. The MUHC Inpatient Readmission Dashboard is interactive and allows the user to filter and analyze readmissions based on CMS criteria and measures.