7. Quality and Safety Flashcards by J L

six dimensions of healthcare quality

* \_\_\_\_
* \_\_\_\_
* \_\_\_\_
* \_\_\_\_
* \_\_\_\_
* \_\_\_\_-centered

safe
timely
effective
efficient
equitable
patient

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What is a system

How to improve:
• Must have a desire to ____
• ____
• ____

improve
ideas
execution

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3 questions and 4 steps

what are we trying to accomplish? (1)
how will we know a change is an improvement? (2, 4)
what change will we make? (3)
set an ____
establish ____
develop ____
test ____

aim
measures
changes
change

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Step 1: Set an Aim
● What are we trying to accomplish?
○ How \_\_\_\_?
○ For \_\_\_\_?
○ By \_\_\_\_?

good
whom
when

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Step 2: Establish Measures
How will we know a change is an improvement?
■ \_\_\_\_ measures 
■ \_\_\_\_ measures 
■ \_\_\_\_ measures

outcome
process
balancing

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Step 2: Establish Measures
○ Outcome measures 
\_\_\_\_ are we going?
○ Process measures
\_\_\_\_ are we doing?
○ Balancing measures
What \_\_\_\_ is happening?

where
what
else

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● Change = ____?

improvement

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Step 3: Developing changes

○ Eliminate \_\_\_\_
○ Improve workflow
○ Optimize \_\_\_\_
○ Enhance the
provider-patient
relationship
○ Change the work
\_\_\_\_
○ Manage time
○ Manage \_\_\_\_
○ Improve the design of
products
○ Design systems to
prevent \_\_\_\_

* \_\_\_\_ improves the work environment 
* Fix errors and prevent - \_\_\_\_

waste
inventory
environment
time
errors
music
redundancy

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Step 3: Developing changes
● Improve workflow
Ensure rescue drugs are kept in a ready to ____ state
● Optimize inventory
Ensure rescue drugs are ____ available
● Change the work environment
Have a licensed dental
____ on staff
● Manage variation
Update office protocols to be consistent with ____
guidelines for conscious sedation of pediatric patients
● Design systems to prevent errors
Create ____ for your
protocols, make them readily available and easy to use

go
consistently
anesthesiologist
ADA
checklists

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Step 4: Testing changes

Linking PDSA Test Cycles
Can link different ____ cycles together
Based off of small ____ changes

PDSA

incremental

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Using Data for Improvement

Research
Data collection:
Gather enough data to ____ study for effect and control for all known confounders

Quality improvement
Data collection:
Gather just ____ data to inform improvement, and only collect data on ____ confounders as needed (i.e., balancing measures)

authoritatively
enough
1-2

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• Level 1: Project‐level measures: 
		○ Outcomes
			§ Reduced \_\_\_\_
			§ No \_\_\_\_
	• Level 2: Process‐level measures 
Processes 
• Availability of rescue drugs; did yoga teacher show up?
	• \_\_\_\_
• School budget ; \_\_\_\_ staff satisfaction

stress
deaths
balancing
clinic

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How would you measure this?
• Many ways to measure “access”
– Number of ____ to third next available
appointment
– Number of ____ in reception area
– % of “good” or “very good” answers on ____
– Average # ____ clinicians are available

days
minutes
surveys
hours

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Which is a complete definition?
• ____ index
• Percentage of patient encounters in compliance with ____ protocol
• Number of ____ available

plaque
oral hygiene
toothbrushes

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Which is a complete definition?
• Plaque index
– Which ____ will you use? ____ will measure it?
• Percentage of patient encounters in compliance with oral hygiene protocol
– How do you define a “patient encounter”? How will you ____ the percentage? What if a patient is discharged mid-day?
• Number of toothbrushes available
– What ____ are you including in the count of toothbrushes? How do you define “available” — what if the dispenser is ____, but the
closet is full?

index
who
calculate
area
empty

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Key questions for measurement

• What is the \_\_\_\_ you need to collect?
• Who is \_\_\_\_ for collecting the data?
• How \_\_\_\_ will the data be collected?
• How will the data be \_\_\_\_?
Make measurement as \_\_\_\_ as possible!

data
responsible
often
collected
simple

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Simplify through sampling
• Simple ____ sampling
• ____ stratified random sampling

random

proportional

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Using data for improvement

Research
Results evaluation:
____- and post-assessment

Quality Improvement
Results evaluation:
regular assessment with ____ charts

pre

run

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Getting better or worse?

• ____ chart

run

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Using data for improvement

Research
Method:
One ____ test with a ____ hypothesis; control ____ as much as possible

Quality improvement
Method:
rapid ____ tests with a hypothesis that cahnges as learning takes place; no effort to control ____

large
fixed
bias

sequential
bias

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Building Degree of Belief

Iterative test cycles; can be ____
Increase size: ____X rule
Broaden scope: Test in many different ____

concurrent
5
conditions

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no improvement - make the next test cycle ____

improvement - increase ____ or scope of next test cycle

smaller

size

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Patient safety

• Patient safety:
– “The absence of ____ to a patient during the process of health care” (WHO)

• Harm:
– “____ physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment, or hospitalization, or that
results in death” (IHI Global Trigger Tool)

• There is always the possibility of a complication, why you have a patient sign a ____

preventable harm
unintended
consent form

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Redefining harm
• Today’s “unpreventable events” are only an innovation away from being preventable.
• Providers once accepted a small number of central line-associated bloodstream infections (CLABSIs) as an unavoidable complication of care — i.e., not “____.”
• Broadening the definition helps providers think more critically about systems of care.

harm

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``` When is a patient harmed in dentistry? • ____ • Inflamed gingiva • ____ injury • Hospitalization • ____ ```

headaches pulpal death

Why is healthcare so dangerous? What factors about health care make it inherently prone to be unsafe? • Looked to the ____ industry on how to become more safe

aviation

``` Why is healthcare so dangerous? • ____ • Equipment • ____ • Change • Every patient is ____ • Limited time and resources • ____ areas ```

drugs communication unique gray

How do we achieve safety? * Errors usually aren’t the fault of ____ providers * Improving safety will require ____ and improved ____ and analysis to build better ____

individual leadership data collection system

how does harm occur error and harm! • Errors and harm aren't always the ____

same

Two types of errors • ____ conditions • ____ failures

latent | active

Latent conditions • Things that are more likely to make an error occur Being ____ Being poorly ____

tired | trained

Active failures • Latent conditions lead to active ____

failures

Swiss Cheese Model • Multiple ____ of checking to prevent errors

layers

What type of error is it? • You forget to tell your patient to schedule a follow-up appointment. ____ • You try to give your patient a pamphlet on healthy eating but grab one on sleep hygiene. ____ • You don’t wash your hands because you’re distracted. ____ • You don’t wash your hands because you don’t feel like you have time. ____ • You misdiagnose your patient’s pain. ____

``` lapse slip lapse violation mistake ```

Systems Approach to Error • Focusing largely on the conditions under which individual ____ and care teams work • Designing in ____ and defenses to avert errors • Minimizing the conditions that lend themselves to ____ • Putting mechanisms in place to ____ the effects of unsafe acts that may inevitably occu

providers workflow violations mitigate

Two Types of Mental Processes • Automatic thinking – Rapid and effortless – Like riding a bike or driving a car – Prone to errors of ____ (i.e., ____, ____) • Controlled thinking – Conscious, can be ____ and deliberate – Solving a problem or making a ____ decision – Prone to errors of ____ (i.e., ____)

``` execution slips lapses slow tough planning mistakes ```

Cognitive Errors • As we think, ____ — mental “short cuts” — simplify thought processes based on patterns and past experiences. – We’re able to assess a situation quickly, but miss things. • Examples: – Physician assumes unconscious patient’s odor of alcohol is “just another drunk,” missing hypoglycemia diagnosis – Pharmacist delivers incorrect medication because of look-alike packaging – Nurse ignores critical alarm because there are so many false alarms the nurses have become ____

heuristics | desensitized

What Factors Make Errors More Likely to Occur? • What factors make errors more likely to occur? ``` Imagine any of these scenarios: – A physician diagnosing a patient – A dentist doing a restoration – A pharmacist filling an order – A nurse delivering treatment • Think about the automatic and controlled thinking involved in these tasks. ```

YAY

What Factors Make Errors More Likely to Occur? Internal factors, i.e., psychological and physiological states – ____, stress, ____, illness, attitude, memory External factors, i.e., environmental forces – ____, light, ____, work schedule, training, rules or procedures, distractions, language barriers ``` Cognitive biases (____ especially) – ____, confirmation bias, attribution error ```

``` fatigue hunger noise temperature diagnosis anchoring ```

How can we prevent errors? • Vigilance and hard work can be effective to a point, but we cannot sustain performance by merely trying ____ and paying attention. • Human factors ____ strives to understand how people perform under different circumstances in order to build safer systems. – Principles from ____, physiology, physics, and biomechanics

hard engineering anatomy

Example of Changing Systems • Over the past 20 years, patient deaths due to anesthesia have declined from 1 in 5,000 to 1 in 200,000+ • Key changes: – ____ valves (different brands of machines used to use clockwise and counter-clockwise inconsistently) – Avoiding reliance on memory through ____ – Promoting teamwork by encouraging nurses and others to ____ up

standardizing checklists speak

Strategies to Prevent Error * ____ * Standardize * Use forcing functions and ____ * Use redundancies * Avoid reliance on ____ * Take advantage of habits and patterns * Promote effective ____ * Automate (carefully)

simplify constraints memory team functioning

Match the Example to the Strategy • Double-checking someone’s work Use ____ • A computer alerting someone of a potential error ____ • Removing a step in a process ____ • Storing things that need to be used together in the same place Take advantage of ____ • A system that requires a piece of information to save Forcing ____

``` redundancy automate simplify patterns function ```

The Risks and Rewards of Technology • ____ has often been heralded as the solution to mitigate and prevent human error — and it can be – EMRs, bar-coding, computerized ____ order entry systems, intravenous infusion pumps • However, new technologies and challenges in implementing them also create new hazards – Alert ____, poor design, over reliance

technology prescriber fatigue

Best Practices • Design processes to be ____ first; then use technology to ____ and standardize. • Actual users test technology in ____ situations. • ____ (symptoms of poorly designed systems) can lead to serious error. • Users should not be overly reliant on technology, still perform double-checks when reasonable, and accept that ____ can still occur.

effectiv real-world workarounds error

Example • 64 yo M presents to the ED with COPD exacerbation resulting from a mild respiratory tract infection • He is treated with oral steroids and inhaled bronchodilators, and symptoms improve • On hospital day 3, the patient complains of pain in his leg, a symptom of deep vein thrombosis (DVT) – The team realizes the admitting doctor had not ordered prophylaxis for DVT What went wrong? • The patient did not receive standard treatment to prevent the formation of ____. What are some possible reasons why this error occurred?

DVT

What went wrong? * The physician may simply have ____, perhaps distracted thinking about the case * Perhaps it is a ____ process to enter the order * The main cause, most likely, is the system relies on the admitting physician to ____ this step in addition to other decisions regarding acute medical management.

forgotten cumbersome remember

How should the hospital respond? • Punish the physician? Probably not – This error most likely stemmed from system problems • Review the case, looking for opportunities to improve? ____ – One potential solution: Embed a decision prompt for ordering DVT prophylaxis into the workflow • Don’t call attention to the error, to avoid making the physician feel bad? ____ – Errors and near misses are improvement opportunities • Disclose the error to the patient? ____ – If a blood clot is confirmed, an apology is likely warranted

yes no probably

Features of a Culture of Safety * Staff are comfortable expressing their ____. * Problems aren’t ____ under the rug. * People know they will not be ____ or blamed for system-based errors.

concerns swept punished

Why is teamwork important? • A team is a group of people who work together in a coordinated way to achieve a ____ goal. • One person cannot provide all the expertise needed to care for patients. • Health care teams can help or hinder safety – 80 percent of serious adverse events are related to ____. – When wrong-site surgeries occur, there is usually somebody who could have prevented it — but didn’t ____ up.

common miscommunication speak

What is a ‘culture of safety’? • What features of the working environment would make you feel safe in a health care setting? – As a ____r – As a ____

provider | patient

What is a ‘culture of safety’? • People treat each other with ____. – Everyone is encouraged to speak up about safety concerns. – People are not unfairly blamed. • It is ____ to talk about mistakes and errors. – People learn from these events and treat them as opportunities to improve. • Each team member understands that his or her actions contribute to safety or the lack of safety.

respect | safe

Psychological Safety • People know their concerns will be openly received and treated with respect. – Anyone can ask ____ without looking stupid. – Anyone can ask for feedback without looking incompetent. – Anyone can be respectfully critical without appearing negative. – Anyone can suggest innovative ideas without being perceived as disruptive.

questions

Accountability • Following an error, people ask the following questions: – Did the individuals intend to cause ____? – Did they come to work drunk or impaired? – Did they do something they knew was ____? – Could two or three peers have made the same mistake in similar circumstances? – Do these individuals have a ____ of involvement in similar events?

harm unsafe history

Teamwork and Communication ``` • Strong teams take these actions: – ____ ahead – Reflecting back – Managing ____ – Communicating clearly • As an individual, you must ____ up! – No matter how much forethought has gone into a particular process, there will inevitably be problems that providers will discover along the way. ```

planning risk speak

Planning Ahead & Reflecting Back • Briefings: Teams discuss the ____ and the expected outcome, often before a procedure. – Everyone knows what’s supposed to happen and can recognize things outside the plan as problems. • Debriefings: At the ____ of an event, teams identify what happened, what the team members ____, and what they can do better next time.

plan completion learned

Critical moments • ____ language assigns designated words or phrases to indicate escalating concern. – “I need a little clarity.” – “I am concerned,” “I feel scared.” (CUUS: ____, ____, ____, ____) • ____-challenge rule allows a subordinate to take action if a superior is ignoring repeated concerns about safety.

``` critical concerned uncomfortable unsafe scared two ```

Individual Actions to Promote a Culture of Safety * Follow safety ____. * Speak up when you have concerns. * Listen to ____, colleagues, and mentors. * Take care of ____.

protocols patients yourself

Follow Safety Protocols ``` • Examples: – Patient ____ – Alarms – Specimen ____ and handling – Equipment disinfection/sterilization – Hand ____ • Working around problematic policies and procedures can lead to patient harm — if the policy doesn’t work, say something. ```

identifiers labeling washing

Speak Up • Speak up when... – There is a problem with a ____ or procedure – You see something happening that puts patients or providers at ____ – You are involved in an error or near miss • ____ reporting systems allow organizations to review and improve unsafe conditions.

policy risk voluntary

Listen to Teammates and Patients • Simply talking to the people you work with — and listening to what they have to say with an open mind — is a first step toward building trust and teamwork. • Patients know themselves and the resources they have to help them promote their health and manage their health care. – Encourage ____ and families to participate in care and decision-making at the ____ they choose.

patients | level

Take Care of Yourself • Stress and fatigue significantly impair performance (____% cognitive decline after one night of missed sleep) • Burnout is high in the ____ workforce (25–60% among practicing physicians) • Recommendations: – Try not to ____ yourself – Take breaks for ____, yoga, meditation – Connect with ____ and friends

``` 25 health care overextend exercise family ```