the NeuroSurgery Ward of Southern Philippines Medical Center Adenir , Angelie Dixil Fortugaliza, Ria Bandala , Aize Mondragon , Dominique Barriga , Henry Torno , Rizaluz Zabala , Heidee Joy
Introduction STEP 1 Reason for Improvement MULTIVOTING
A Proper donning of ICU watchers gowns B Lack of suction machines C Documentation Errors in TPR sheet D Unrepaired electrical socket E Inappropriate type of garbage bin F Unrestricted implementation of visiting hours G Inability to give prescriptions on time H No emergency lights I Presence of stray cats and pests J Insufficient hand washing liquid/ soap K Inadequate supply of personal protective equipment (PPE) per shift L Need for continuous learning training/ updates on neurological assessment M Usage of medication tray per patient for primary nursing approach O Enhancement of NVS Assessment Form Theme Letters Themes L Need for continuous learning training/ updates on neurological assessment O Enhancement of NVS Assessment Form C Documentation Errors in TPR sheet
TOP 3
Theme Letters Themes Theme Selection Matrix
THEMES CUSTOMER(S) IMPACT ON CUSTOMERS NEED TO IMPROVE OVERALL
RANK
Step 2 Current Situation Proportion of Completeness of Medication sheet of Phil health charts at Medical Ward for First Quarter of 2007 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Jan Feb March Complete Incomplete Problem Statement: From January 1 to March 31, 2007, 66% of medication sheet of Phil Health patients charts at the Medical Ward of Davao Medical Center were incomplete; thus causing delays in PHIC claims and reimbursement. Target for Improvement: By the end of December 31, 2007, Incomplete medication sheet at the Medical Ward will be reduced to 30%. Incomplete Medication sheet Nurse Process Materials Step 3: Analysis Step 4 Countermeasures Action Plan Problem Statement: From January 1 to March 31, 2007, 66% of medication sheet of Phil Health patients charts at the Medical Ward of Davao Medical Center were incomplete; thus causing delays in PHIC claims and reimbursement. Target for Improvement: By the end of December 31, 2007, Incomplete medication sheet at the Medical Ward will be reduced to 30%.
Counter- measures Practical Methods Tasks Resources Who Does Start Date End Date How Done Compliance with Standards Of nursing Practice on docu- mentation
Re- orientation Seminar on docu mentation Every Other month
Prepare Training materials
Visual aids On Standards of Nursing Practice Hosp. Guidelines and policies
Vilma L. Comoda, Elizabeth Barriga, Lani Paler, Charito Barga- mento, Christine Aquino
Aug. 15, 2007
July 15 2008 Coordinated with Training office and assistant chief nurse For schedule Of staff
Step 5 Results Proportion of Completeness of Medication sheet of Phil health charts at Medical ward in 2007 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% J A N M A R C H M A Y J U L Y A U G O C T D E C COMPLETE INCOMPLETE I N T E R V E N T I O N BEFORE AFTER ---------------------------------------------- Target 30% Step 6 Standardization Step 7 Future Plans