University of Colorado Hospital

Focus-PDCA
Performance Improvement Team Worksheet
Department !lectrophysiolo"y Department
Date #$%&$'&(#
Primary Contact Person )aura Iminski Hess !*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).
-pportunity .tatement
In the !lectrophysiolo"y Department /!P01 2e area a procedural area that performs
pacemaker /PP301 intracardiac defi4rillators /ICD0 device implants and a4lations for our
patients5 6endor representatives /670 provide us 2ith the necessary kno2led"e1 medical
device implants and other supplies for every case5 In order to maintain in accordance 2ith
UCH Policy and Procedures and to 4e advocates for our patients1 I created a ne2
department standard to meet the specific needs of our department5 The department
standard includes sur"ical attire1 criteria for 678s to 4e in the la4$control room1 approved
non-UCH persons in la4 as consented 4y the patient5
Circle all that apply
Dimension of Performance Dimensions of health care performance are those definable,
preferably measurable, attributes of the system that are related to its functioning to maintain,
restore, or improve health care.
- fficiency - !afety
- !taff !atisfaction - ffectiveness
- "atient #enteredness - #ontinuity
Prioriti9ation
- $igh %isk - $igh &mpact on "erformance
- $igh 'olume - $igh "otential for &mprovement
- "roblem "rone - !upports #ritical !uccess (actors
- )ow 'olume - "atient !afety

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(O) Organize a team that knows the process:
List Team Members:
+anager, Dena -eilman
+edical Director, Dr. .ill !auer
"hysician, Dr. .endy /0ou
(C) Clarify the current knowledge
What do we know about the process?
/here is a policy and procedures in place for the 1%2s regarding visitors in the 1% but our
manager and physicians were re3uesting a department specific guideline for the '%2s to be
accountable to as well as our participation with them.
(U) nderstand sources of !ariation:
Why are we looking at this process? Why is the process not going the way planned?
.e can host anywhere from one to over ten '%2s during any given day in our small department.
'%2s are present for almost each and every case we do. /heir role in patient care is essential as
they provide the supplies and product specific knowledge for our implants and ablations.
$owever, the vendor relations were becoming very informal with '%2s coming unannounced to
the control room, not consistently badging in to %ep/ra4, having multiple '%2s present for one
case (when only one is needed) and not being easily identifiable in the room. 5lso, after a chart
review, it was found that our patients were not being consented to the presence of the '% in their
procedure. /his is especially important as it is a patient2s right to know who is involved in their
care, 6ust as we identify and consent to physician2s and anesthesia who are directly involved in a
patient2s case.
(S) "elect the impro!ement:
5fter consulting with my manager and physicians, it was decided to create a new standard
specific to our department and distribute to the '%2s and educate staff and make the e4pectation
that all are to be accountable for its content.
(P) #lan the impro!ement:
%eview policy and procedures for the 1% and 51%7 recommended standards and guidelines;
complete a random si4 month chart audit for vendor names on consents; create new department
specific standard, educate staff.
(D) $mplement the impro!ement:
/he new standard was distributed to lead '%2s and staff educated about new guideline and
e4pectation. & also discussed new guideline at #'# 1perations +eeting to department managers
and director.
(C) Check the results:
1ne measurable way was to do a chart audit of compliance of vendor names8company on patient
consents, which has improved by over 9:; since initiation of new guideline. 1ther noticeable
improvements are '%2s are consistently donning the red vendor bouffant hats and having only
one vendor at a time for each case.
(A) %ct to hold the gain:
+y plan is to again educate staff about the policy, especially since we have several new staff
members who have started in our department. 5s staff, we have been creating a culture of
change in upholding the e4pectations of the department standard. & am also going to attend
another #'# 1perations +eeting and give the results of the consent audits to the department
managers and director.
7epeat PDCA as needed and maintain documentation in your department5