Order Description
obj:
1. Critically analyse quality frameworks to identify evidence-based best practice and knowledge that can be applied to the health or social care setting.
2. Critically apply the concepts of Structure, Process and Outcome (SPO) in examining a quality or patient safety improvement initiative in a service.
3. Carry out a quality improvement process using PDSA cycles and associated quality improvement tools.
4. Plan how you would monitor and evaluate a quality improvement initiative using “real time” and “before and after” data.
Good evidence of care: Opportunities for improvement:
• explaining well to the Dr
• Dr explaining the whole history and diet restrictions
• good care by paramedic • careless on the phone
• interruptions in ER
• 3 hrs waiting
• not listening to the patient
• no respect verbally and physically
• reading from the screen and no patient education • not listening to the needs of the family
• bathroom on her own
• disgruntled consultant
• consent form procedure
• increasing oxygen without looking at screen reading
• no teamwork

Categorization of key patient quality and safety issues:
Safety Efficient & effective service Patient-centeredness Timeliness of services
Positive • • Warden comprehensive communication
• Family doctor comprehensive communication
• Paramedic comprehensive communication
• Paramedic involved the family • •
Negative • No documentation of patient’s case
• No bed rails in ER
• Not checking her file before giving drink
• Letting patient go to the toilet alone
• No site of surgery or IV drop
• No checklist
• Incorrect info on consent form
• Surgeon went ahead although patient is not prepared • Staff nurse’s low quality of delivering the message with no patient education
• Staff nurse misusing the policies
• Inattentive surgeons • Interruptions in ER
• No patient rights respect and no privacy
• Disgruntled staff
• No patient education
• Drinking and chatting over her head • Family Dr to go to her home
• Nurse to check on patient in ER
• Ignored for the first 3 hours

? Identify the problem and gaps
? Risk management
? Time wasted ? lean
? Improve communication e.g. GP should get feedback from SHO on phone or logged details on system (reporting policy)
? Consent form process was inappropriate ? was there a policy? Why was it not followed?
? “Measures promote behavior” ? issues had to be resolved in ER within 4 hours
? Root-cause analysis
? Faulty structure (water on floor) ? Faulty Process (old patient went to toilet alone) ? Faulty Outcome (patient fell and required surgery)
? Is there a policy? E.g. identification, reporting, consent form, documentation, surgery preparation