Patient Identification performance improvement rate

OPD nursing team

2015.11.20

Plan

Do

Check

Act

P C A D

Organization

NO Name Roles NO Name Roles

1 박리정 Team Leader 8 양국희 Improvement and evaluation

2 최연희 Assistant manager 9 박애희 Data Analysis and Statistics

3 차혜정 Improvement and evaluation 10 하재경 Data Analysis and Statistics

4 박진아 Improvement and evaluation 11 김민숙 Data Collection

5 오현철 Improvement and evaluation 12 조혜진 Data Collection

6 이산희 Improvement and evaluation 13 권희정 accounting

7 오성진 Improvement and evaluation 14 임아름 Secretary

Team and Roles Team and Roles

Meetings Meetings

2014, March to August (7times)

P C A D

Key indicators

Division Contents

Topic Performing rate of Patient Identification

Numerator Cases of patient identification using

the two indicators

Denominator The number of patients confirmed to perform

observation

Goal Achieving 100%

※ the two indicators: : Name and Hospital number or name and birth date

P C A D

Status grasp

Current Situation Current Situation

P C A D

< Same name and birth date rate in NHIMC >

5,488cases 70cases

4cases 1case

Case of two

people

Case of three

people

case of four

people

Case of six

people

(Patients: 10,976)

(Patients: 210)

(Patients: 16) (Patients: 6)

Status grasp

Patient Identification of visit places Patient Identification of visit places

Pre - inspection

- Period : 2014. 2.27~3.8 (11days)

- Progress : Survey observations using a checklist (Exemplification)

- Subjects : Observed 3,120 cases

92.8%

6.3% 4.6% 6.9%

0

20

40

60

80

100

Reception desk

Before treatment

During treatment

After treatment

Patient Identification

of visit places

P C A D

(Unit: %)

Status grasp

Patient Identification by Occupation Patient Identification by Occupation

Pre -inspection

- Period : 2014.2.27~3.8 (11days)

- Progress : Progress : Survey observations using a checklist (Sample survey)

-Subjects : 3,120cases need to Identifying patients

• The highest rate(53.9%) of patients confirm

performed by nurses while the lowest rate(4.6%)

of patients confirm performed by doctor

• Using the ‘name’ to confirm

the patients in most cases

P C A D

4.6%

53.9%

26.7%

0

20

40

60

Doctor Nurse Assistants

Patient Identification by

Occupation (Unit: %)

Cause Analysis

The difficulty of verification

Circumstance Patients

Nurse System

Busy work Sensitive personal information respond to the confirmation

Lack of education

Neglect duty of bringing the hospital card

Long explanation makes next patient wait

They want people to recognize themselves

Patients confirmed the importance lack of awareness

Lack of time for explaining

Medical cards are issued only on the first floor

The lack of promotion on importance of patient confirm

Don’t have main PR department

Excessive care per patient

Dislike to tell social security number

So far confirmed patients with name

Omission of confirming patient saving the time

Lack of education

Fish-bone Diagram(Factors) Fish-bone Diagram(Factors)

P C A D

Can’t close the session

Improvement of provision

4-Block matrix 4-Block matrix

• Strengthen the description

• Patient compliance check process

• Adjust the number of patients

per treatment session

• Enhances education

• Standardized patient identification process

carried out (During treatment)

(name, Hospital number or birth date)

• recommended carry hospital card and

Issuing hospital card

• Reinforcements • Campaign, Poster making

• Check mark whether the patient guide

production and utilization

• Information for enhanced patient identification

• Promote the importance of patient confirmaiton

by doctors

Controllable

Effic

ient

P C A D

Improvement Activities 1

Make and publishing poster Make and publishing poster Inserting information message on the CRT monitor Inserting information message on the CRT monitor

Eff

icie

nt

Recognition of the importance of

promoting patient identification

An information message tells the patient to

confirm the importance standby.

P C A D

Improvement Activities 2 Utilize alternative medical card Utilize alternative medical card

Giving alternative handouts

Who did not bring

their hospital cards.

⇒ Showing these handouts making

medical staff identify patients

P C A D

Improvement Activities 2

Utilize alternative Handouts Utilize alternative Handouts

Recorded in i-SIS

Check the patient and recored Check the patient and recored

P C A D

Improvement Activities 3

Staff training- repeat education (once a week) Staff training- repeat education (once a week)

Repeat and practice standardized

information message

< Front desk >

- Hello? What's your name?

- May I see your hospital card or a receipt?

- During treatment, check once more for

correct patient identification.

<Before treatment>

- Good morning?

- We will first check your name and

hospital number or birth date.

- May I see your hospital card or a receipt?

- Show once more after you meet doctor.

P C A D

Improvement Activities 4

‘‘

To verify the correct patient admission, please

bring your medical card.

Patients can be issued medical card on the first floor Desk

Insert promotional phrases in

‘Patients instruction guidance’

P C A D

Improvement Activities 5

Best Staff awards Best Staff awards

Excellent staff participated

actively in the selection of the

correct patient identification

"voucher" award

P C A D

Effectiveness of activities

Patients confirmed to perform rate Patients confirmed to perform rate

Post-survey

- Period : 2014. 8.1~31 (1month)

- Progress : Survey observations using a checklist

(Sample survey)

- Subjects : 3,120cases need to Identifyng patients

- 대상 : 환자확인이 필요한 행위 3,120건 27.8%

41.4%

66.9%

90.3%

0

20

40

60

80

100

Pre-survey

(2.27~3.8)

Before

Improvement

(4.1~4.30)

After First

improvement

(6.1~6.30)

After second

improvement

(8.1~8.31)

Total perform rate (Unit:%)

25.5%

23.4%

- Patient identification rate after

performing preliminary

research activities improved

62.5% compared to the

second rise

- Improvement activities before

and after it was found that

p-value <0.001 were

significant in the Chi-square

test performed using the SPSS

Ver.21 to compare the

performance rate

P C A D

Effectiveness of activities

Perform rate in details Perform rate in details

4.6%

53.9%

26.7%

75.8%

96.9% 94.5%

0

20

40

60

80

100

Doctors Nurses Assistants

Pre-survey After second improvement

(Unit:%)

59.9% incresed

28.3% increased

54.3% increased

(2014.2.27~3.8) (2014.8.1~31)

Patient Identification by Occupation

(2014.2.27~3.8) (2014.8.1~31)

92.8

6.3 4.6 6.9

99.7

75.8

92.7 93.2

0

20

40

60

80

100

Desk medical

office

Before

treatment

After

treatment

Pre-survey After second improvement

(Unit:%)

Patient Identification of visit places

59%incresed

61%incresed 72%incresed

P C A D

Effectiveness of activities

Issued rate of hospital card Issued rate of hospital card

1000

1200

1400

1600

1800

2000

January February March April May June July August September October

P C A D

Before improvement After improvement

Effectiveness of activities

Post management Post management

P C A D

Post-management Patients Identification rate slightly decreased. Sharing the results with staffs Hospital regularly broadcasting Importance of patients confirmation Confirmed that the result is maintained

(Unit:%)

0

20

40

60

80

100

Q4 2014 Q1 2015 Q2 2015 Q3 2015

Patient identification Total OPD

• Patient identification activities by hospital

- Selected agents for monitoring

& had monthly meeting.(2015.7)

- Start the hospital regular broadcast (2015.8.)

- Poster contest (2015.9.)

- Standardization of Patient identification

Conclusions and Recommendations

conclusion

• 62.5% increased accurate patient identification performed rate

• Doctors showed the highest improvement in 59.9%

• After confirmation patient care performed 72% improved

Suggestion

• Need to establish a safe culture with accurate patient identification

• Keeping monitoring and feedback to improve patient confirmation

with doctors

P C A D