Background: Before beginning a quality improvement initiative, it is important to understand existing practices. This tool is intended for use in describing key processes in your organization where KPC infection prevention activities could/should be happening. Quality Improvement Organizations (QIOs) have developed this tool to provide a guide to identify and evaluate key processes of care.
Instructions: Have the implementation team identify and define every step in the current process for pressure ulcer prevention.
- When defining a process, think about staff roles in the process, the tools or materials staff use, and the flow of activities.
- Everything is a process, whether it is admitting a resident, serving meals, assessing pain, or managing a nursing unit. The ultimate goal of defining a process is identifying problems in the current process.
Use: Determine if there are gaps and problems in your current processes, and use the results of this analysis to systematically change these processes.
- Take time to brainstorm and listen to every team member.
- The process must be understood and documented.
- Make each step in process very specific.
- Use one Post-It Note, index card, or piece of scrap paper for each step in the process.
- Lay out each step, move steps, and add and remove steps until the team agrees on final process.
- If the problem is that a process does not exist (for example, there is no current process to screen for pain upon admission and readmission), then identify the related processes (for example, the process for admission and readmission)
- If process is different for different shifts, identify each individual process.
Example: Process for making buttered toast
|1||Check to see if there is bread, butter, knife, and toaster.|
|2||If supplies are missing, go to the store and purchase them.|
|3||Check to see if the toaster is plugged in. If not, plug in the toaster.|
|4||Check setting on toaster and adjust to darker or lighter as preferred.|
|5||Put a slice of bread in toaster.|
|6||Turn toaster on.|
|7||Wait for bread to toast.|
|8||When toast is ready, remove from toaster and put on plate.|
|9||Use knife to cut pat of butter.|
|10||Use knife to spread butter on toast.|
1. Identify the steps of your defined process
Press for details. At the end of the gap analysis, compile the results in a document that displays each step so that team members have the map of the current process in front of them during the team discussion.
2. Team discussion
Evaluate your current process as you define it:
- What policies and procedures do we have in place for this process?
- What forms do we use?
- How does our physical environment support or hinder this process?
- What staff is involved in this process?
- What part of this process does not work?
- Do we duplicate any work unnecessarily? Where?
- Are there any delays in the process? Why?
Continue asking questions that are important in learning more about this process.