The Science Journal of the American Association for Respiratory Care

2010 OPEN FORUM Abstracts

IMPLEMENTING A CLINICAL SERVICE IMPROVEMENT TEAM TO ENSURE BEST PRACTICE

Garner G. Faulkner, Richard Ford, Jan Phillips-Clar, Deneen LeBlanc, Susan Herzig, Donald Pearman, Elsie Collado-Koman, Marcia Teal; Respiratory Care, UC San Diego Health System, San Diego, CA

BACKGROUND: In order to maintain a high functioning team, provide exceptional care, and adopt best practices through rapid cycle performance improvement processes, we often face many challenges. These challenges are often inclusive of coordinating the efforts of many, communicating what needs to be done, and overcoming the natural resistance to change. To aide in changing current practice and ensuring the entire team is engaged and well coordinated, we developed a Clinical Service Improvement Team (CSI). METHOD: We recognized key stakeholders responsible for the implementation or change of current clinical practice. These key stakeholders were inclusive of leadership responsible for policy/protocol development, education/training, front line supervisors, information system documentation, and those accountable for regulatory compliance and budget. A weekly meeting was scheduled in coordination with our Medical Directors meeting. An on line mechanism, accessible to all stakeholders, was developed in order to identify issues, capture discussion, identify action steps, target timelines, assign responsibility, and track status. RESULTS: The group has met weekly and the structured mechanism to capture ideas and implement change has enabled us to respond rapidly and ensure all concerns are considered. Discussion and action steps are also deferred for additional review by the Medical Director, another department/hospital committee, or our Partner in Leaders group which is a shared governance team within the department. Over 100 changes have been addressed in the first six month period. Examples include: implementing a method to address bagging our patients on Bleomycin therapy, implementing RT training for A-line draws, begin process to implement the use of point-of-care ABG analysis, adjust policy on APRV to meet current practices, and formalize an action plan to address equipment failure reporting. CONCLUSION: The creation of the CSI team has aided in the communication between our key stakeholders and effectively improved our clinical practice at UC San Diego. The existence of the team ensures that those factors that can sabotage, change or create resistance to change are minimized. Sponsored Research - None