{"id":419,"date":"2024-11-06T17:25:14","date_gmt":"2024-11-06T17:25:14","guid":{"rendered":"https:\/\/iims.uthscsa.edu\/isrn\/?page_id=419"},"modified":"2024-11-06T17:25:14","modified_gmt":"2024-11-06T17:25:14","slug":"turning-quality-upside-down-using-a-perfect-storm-to-change-quality-performance-culture","status":"publish","type":"page","link":"https:\/\/iims.uthscsa.edu\/isrn\/resources\/ereading-room\/abstracts\/turning-quality-upside-down-using-a-perfect-storm-to-change-quality-performance-culture\/","title":{"rendered":"Turning Quality Upside Down: Using a Perfect Storm to Change Quality Performance Culture"},"content":{"rendered":"

[vc_row][vc_column width=”2\/3″][vc_column_text css=””]<\/p>\n\n\n\n\n\n
Primary Author:<\/td>\nCynthia A. Oster, PhD, MBA, APRN, CNS-BC, ANP<\/td>\n<\/tr>\n
Co-Principal Investigators\/Collaborators:<\/td>\nKathleen Bradley<\/td>\n<\/tr>\n
Organization:<\/td>\nPorter Adventist Hospital<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Abstract<\/h2>\n

Background<\/h3>\n

Practitioners often perceive care delivered as \u201cexcellent\u201d whereas a regulatory agency expects \u201cperfect\u201d care. \u201cA perfect storm is a convergence of independent events that form an environment never experienced before\u201d (Fields, 2006). Three prevailing winds or barriers to exemplary blood and blood product administration practice, \u201cfailure to see,\u201d \u201cfailure to move,\u201d and \u201cfailure to finish\u201d converged to create the perfect storm that threatened our culture of excellence (Kerfoot, 2010).<\/p>\n

Purpose<\/h3>\n

The purpose of this project is to demonstrate how to achieve and sustain an organizational culture of personal and professional accountability within the global context of a healthcare system by transforming quality monitors to enculturate a no-fail exemplary practice environment.<\/p>\n

Materials & Methods<\/h3>\n

Evidence supporting \u201cperfect\u201d blood product administration practice was collected during a 24 week period. An organizational culture of transparency broke through staff \u201cfailure to see\u201d the need for change. Clinical audits mitigated \u201cfailure to move\u201d by making the \u201cperfect\u201d clinical practice destination clear for all departments. Audits created movement to ensure staff adhered to the \u201cno failure\u201d regulatory and professional blood administration standards related to consent, verification, documentation, teaching and adverse reactions (Patel, 2010). Fatigue inherent to \u201cfailure to finish\u201d was diminished through motivating and energizing champions of change placed to reinforce, encourage and reward professional accountability.<\/p>\n

Results<\/h3>\n

Sixteen patient care areas audited 100% (n = 2638 units) of blood products administered for adherence to regulatory standards between June 11 and December 1, 2010. \u201cNo failure\u201d or \u201cperfect\u201d care was no deviation from regulatory standard without exception. \u201cPerfect\u201d care was hardwired and enculturated into clinical practice by week 18.<\/p>\n

Conclusion<\/h3>\n

A \u201cperfect storm\u201d environment brought about redesign of leadership roles, performance measures and professional accountability. Utilization of a detailed audit strategy led to a no-fail practice culture and global improvements in blood administration safety throughout a healthcare system.<\/p>\n

\u00a9 Improvement Science Research Network, 2011[\/vc_column_text][\/vc_column][vc_column width=”1\/3″]