7. Quality and Safety Flashcards
six dimensions of healthcare quality
* \_\_\_\_ * \_\_\_\_ * \_\_\_\_ * \_\_\_\_ * \_\_\_\_ * \_\_\_\_-centered
safe timely effective efficient equitable patient
What is a system
How to improve:
• Must have a desire to ____
• ____
• ____
improve
ideas
execution
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
Step 1: Set an Aim ● What are we trying to accomplish? ○ How \_\_\_\_? ○ For \_\_\_\_? ○ By \_\_\_\_?
good
whom
when
Step 2: Establish Measures How will we know a change is an improvement? ■ \_\_\_\_ measures ■ \_\_\_\_ measures ■ \_\_\_\_ measures
outcome
process
balancing
Step 2: Establish Measures ○ Outcome measures \_\_\_\_ are we going? ○ Process measures \_\_\_\_ are we doing? ○ Balancing measures What \_\_\_\_ is happening?
where
what
else
● Change = ____?
improvement
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
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
Step 4: Testing changes
Linking PDSA Test Cycles
Can link different ____ cycles together
Based off of small ____ changes
PDSA
incremental
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
• 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
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
Which is a complete definition?
• ____ index
• Percentage of patient encounters in compliance with ____ protocol
• Number of ____ available
plaque
oral hygiene
toothbrushes
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
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
Simplify through sampling
• Simple ____ sampling
• ____ stratified random sampling
random
proportional
Using data for improvement
Research
Results evaluation:
____- and post-assessment
Quality Improvement
Results evaluation:
regular assessment with ____ charts
pre
run
Getting better or worse?
• ____ chart
run
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
Building Degree of Belief
- Iterative test cycles; can be ____
- Increase size: ____X rule
- Broaden scope: Test in many different ____
concurrent
5
conditions
no improvement - make the next test cycle ____
improvement - increase ____ or scope of next test cycle
smaller
size
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
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
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
