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PRACTICE EXERCISE 7: IMPROVING A PERFORMANCE GAP IN YOUR ORGANIZATION

Objectives

• To provide an opportunity for managers to be involved in a performance improvement effort using the actual identified needs in their own organizations.

• To practice improvement approaches in a safe and controlled setting.

Note: Implementing the results of this exercise in your own organization is not required. However, the exercise requires you to think through and document all of the steps in the exercise as if you were actually conducting this effort in your organization.

Instructions

1. Describe one of the performance gaps you identified in Exercise 6: Organizational Self-Assessment or a performance gap that you are aware of in the scope of your defined work unit or responsibilities.

2. Briefly describe the process(es) or function(s) that makes up this performance area.

Spath, P., & Kelly, D. L. (2017). Applying quality management in healthcare : A systems approach, fourth edition. Health Administration Press.Created from franklin-ebooks on 2023-02-08 00:21:55.

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3. List whom you would invite to participate in your improvement effort and why you selected them.

4. a. State and critique several possible goal statements for this improvement effort. Use the following Goals Worksheet to organize your thinking.

b. Based on your critique, select the goal you will use for the improvement effort.

Goals Worksheet

Goal Statement Type of Goal Pros Cons

5. Practice the purpose principle (chapter 6) by asking yourself the following questions: – What am I trying to accomplish?

– What is the purpose of the process(es) identified in question 2?

Spath, P., & Kelly, D. L. (2017). Applying quality management in healthcare : A systems approach, fourth edition. Health Administration Press.Created from franklin-ebooks on 2023-02-08 00:21:55.

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303Pract ice Lab 303

– Have I further expanded the purpose? What is the purpose of my previous response?

– Have I further expanded the purpose? What is the purpose of my previous response? (Continue expanding the purpose, if needed.)

– What larger purpose may eliminate the need to achieve this smaller purpose altogether?

– What is the right purpose for me to be working on? (Describe how this purpose differs or does not differ from the original purpose.)

6. Review your selected goal from question 4. After completing the purpose questions in question 5, does this goal still seem appropriate? If not, redefine the goal of your improvement effort.

7. Is the process (or processes) from question 2 still the appropriate process to improve? If not, describe the process(es) you will improve.

8. Describe the customers of the process and their expectations or requirements.

9. Describe a performance measure for this process, how the data are collected, and a graph that could be used to display the measurement results. This performance indicator may be the original from which you determined this performance gap.

Spath, P., & Kelly, D. L. (2017). Applying quality management in healthcare : A systems approach, fourth edition. Health Administration Press.Created from franklin-ebooks on 2023-02-08 00:21:55.

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10. Document the process steps as they are currently carried out using a high-level flowchart.

11. Practice identifying mental models (chapter 8): – Identify at least two mental models that may be interfering with

achieving a higher level of performance from your process. What actions are associated with these mental models?

– Describe an alternative mental model for each that could enhance the improvement of your process. What actions are associated with the alternative mental model?

12. Identify and apply any additional quality improvement tools (see chapter 12) that may help you better understand how to improve your process. Show your work.

13. If your process is to be the best practice for the community, describe your ideal vision for this process. To help create your vision, ask yourself the following questions: – What would your process contribute to the overall organizational

performance or effectiveness?

Spath, P., & Kelly, D. L. (2017). Applying quality management in healthcare : A systems approach, fourth edition. Health Administration Press.Created from franklin-ebooks on 2023-02-08 00:21:55.

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305Pract ice Lab 305

– What would patients and families who are receiving care as a result of your process, or who are influenced by your process, say about their experience with your organization?

– What would employees involved in your process say about the process?

– What would colleagues around the country who came to learn from your best practice say about your process?

14. Improve your process. – Determine if you are solving a problem associated with an existing

process or creating a new process.

– Review your original and revised improvement goal(s).

– Review the purpose of your process.

– Review your customers’ expectations.

Spath, P., & Kelly, D. L. (2017). Applying quality management in healthcare : A systems approach, fourth edition. Health Administration Press.Created from franklin-ebooks on 2023-02-08 00:21:55.

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– Review the mental models you selected.

– Review what you learned from question 12.

– Redefine the starting and ending points of your process as needed to support the purpose.

– Based on the previous information, document the ideal process that will achieve the purpose you described, using a high-level flowchart.

– Check your process against the goal you set for your improvement effort.

15. Review the measure from question 9. Is this measure still appropriate for your ideal process? If not, what should you measure?

16. Review your goal and your purpose. Will these measure(s) help you determine if you are working toward your goal and carrying out your purpose?

Spath, P., & Kelly, D. L. (2017). Applying quality management in healthcare : A systems approach, fourth edition. Health Administration Press.Created from franklin-ebooks on 2023-02-08 00:21:55.

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307Pract ice Lab 307

17. Describe any unintended consequences to any other area, department, process, or entity inside or outside of your organization if you change your process. What measure(s) would help you to be on the alert for them?

18. Describe how the measures from questions 15 and 17 fit into a balanced set of performance measures for the organization.

19. For your defined performance measures, describe – How you would collect the data

– What type of graph you would use to report the data

– How often you would report the data

– With whom and how you would share the data for review on a regular basis

20. You have defined the purpose and described the ideal process. Determine the ideal structure to carry out this process—that is, by whom and how the process should be carried out to best achieve the purpose.

Spath, P., & Kelly, D. L. (2017). Applying quality management in healthcare : A systems approach, fourth edition. Health Administration Press.Created from franklin-ebooks on 2023-02-08 00:21:55.

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21. Describe an implementation plan that takes into consideration the concepts described in chapter 12.

Spath, P., & Kelly, D. L. (2017). Applying quality management in healthcare : A systems approach, fourth edition. Health Administration Press.Created from franklin-ebooks on 2023-02-08 00:21:55.

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PRACTICE EXERCISE 8: TEAMWORK AND PATIENT SAFETY

Objective

To better understand how inadequate teamwork practices can cause a sentinel event and what needs to be done to prevent similar events from occurring.

Instructions

1. Common teamwork barriers that can lead to a sentinel event include these problems: – Inconsistency in team leaders – Lack of time to meet and interact as a team – Hierarchy – Defensiveness – Not speaking up – Conventional thinking – Varying communication styles – Unresolved conflict – Distractions – Fatigue – Heavy workload – Misinterpreting cues – Lack of role clarity

Source: M. Leonard, A. Frankel, T. Simmonds, and K. Vega. 2005. Achieving Safe and Reliable Healthcare: Strategies and Solutions. Chicago: Health Administration Press.

Spath, P., & Kelly, D. L. (2017). Applying quality management in healthcare : A systems approach, fourth edition. Health Administration Press.Created from franklin-ebooks on 2023-02-08 00:21:55.

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