Appendix A: Quality Improvement Measurement and Analysis Methods Flashcards
Error
failure of a planned action to complete as intended or use of the wrong plan to achieve a goal
Adverse Event
an injury resulting from a medical intervention
- not due to the patient’s underlying condition
- may or may not be due to an error
- may or may not be preventable
- if the adverse event is viewed as a result of an error, it is considered preventable
Misuse
an avoidable complication
-prevents patients from receiving the full potential benefit of services
Overuse
potential for harm that exceeds the possible benefit from a service
Underuse
failure to provide a service that would have produced a favorable outcome for the patient
Near Miss
recognition that an event occurred that might have led to an adverse event
-an error almost happened, but staff or the patient/family caught it before it became an error
Active Error
an error that results from noncompliance with a procedure
Omission
missed care; left out or secluded
-considered an error
Common Errors
- Falls
- Medication errors
- Development of pressure ulcers due to inadequate skin care
- Surgical errors; wrong site
- Diagnosis; wrong diagnosis, incomplete diagnosis
- Wrong patient identification
- Lack of timely response
- Development of nosocomial infections
- Wound infections
- Not washing hands
- Equipment failure
- Inappropriate use of restraints or used in an unsafe manner
- Documentation errors/inadequate documentation
- Poor discharge planning/directions
Sentinel Event
unexpected events that happen to patients -result in major negative outcomes such as an unexpected death or critical physical or psychological complication that can lead to major alteration in the patient’s health
Examples of High Risk for Errors and/or Reduced Quality of care
- Working in Silos
- Joint Commission Annual Safety Goals
- Handoffs
- Medication reconciliation
- Workaround
- Health Literacy
High Risk Factor for Errors: Working in Silos
not working as a team or using poor communication
-individuals or pairs working with little consideration of others who may be working on the same issue, with the same patient
High Risk Factor for Errors: Handoffs
a handoff occurs when a patient experiences a change in provider or setting and there is a transfer of responsibility
High Risk Factor for Error: Workaround
occurs when staff use a shortcut to get something done
- do not complete all the steps
- substitute different steps in a process
- happens when staff are behind; rather than figure out the problem, they use a workaround
High Risk Factor for Error: Health Literacy
example: if the patient does not understand the discharge directions or cannot read them, an error could occur
Agency for Healthcare Research and Quality inpatient quality indicators
- Volume indicators/measures
- Mortality indicators/measures for inpatient procedures
- Utilization indicators/measures
Volume Indicators/measures
proxy or indirect measures of quality, based on counts of admissions during which certain intensive, high-technology, or highly complex procedures were performed
- based on evidence
- suggesting hospitals that perform more of these procedures may have better outcomes for them
Mortality indicators/measures for inpatient procedures
includes procedures for which mortality has been shown to vary across institutions
-evidence that high mortality may be associated with poorer quality of care
Utilization indicators/measures
examine procedures whose use varies significantly across hospitals and for which questions have been raised about overuse, underuse, or misuse
Primary Data
data collected from firsthand experience
Secondary Data
collected by others
Prevalence
proportion of the population that has a condition or risk factor
Incidence
rate of occurrence
Benchmarking
measuring quality across healthcare organizations based on same standards
Report Cards
a published report that provides information about the quality of care for a healthcare organization or provider
Incident Reports
healthcare organizations require that certain incidents, such as medication errors, are reported in written form using a standard form
-provides a record and helps in tracking errors for improvement
Root-cause analysis (RCA)
method used by many healthcare organizations today to analyze errors
- supporting the recognition that most errors are caused by system issues and not individual staff issues
- in-depth analysis
- identify causes and then consider changes that might be required to reduce risk of reoccurrence
Failure mode and effects analysis (FMEA)
a tool that provides a systematic, proactive method for evaluating a process to identify where and how it might fail and to assess the relative impact of different failures in order to identify the parts of the process that are in most need of change
Plan-do-study-act (PDSA)
process that is used in planning
-four steps followed to reach effective results
Employee surveys
written questionnaires used to get information from employees on a particular topic
-example: staff safety
Patient/Family surveys
written questionnaires used to get information from patients/families on a particular topic
ex: patient and/or family views of quality care and experience while hospitalized
Flow Charts and Decision Trees
methods used to describe a process so it can be clearly understood to improve the process or use to help identify when a process is not effective
Patient Safety Indicators (PSI)
set of indicators providing information on potential in-hospital complications and adverse events following surgeries, procedures, and childbirth
-used to help hospitals identify potential adverse events that might need further study
Interviews
one-on-one collection of data that can be done in person or on telephone
Observation
using staff or outside individuals to watch a procedure or work process and collect data on what occurs
-information is then used to track errors or improvement
Quality Measures
tools that help measure or quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems that are associated with the ability to provide high-quality health care and/or that relate to one or more quality goals for health care
-goals include safety, timely, efficient, effective, equitable, patient-centered (STEEEP) and timely care
Time-out
during a procedure, the team may use a checklist to confirm the right patient, site, and procedure
-if any staff member thinks there may be an error, that staff member can call a stop to any actions so that correct information can be determined
Checklist
a consistent method for ensuring that what needs to be done is done
-is simple and requires limited, if any, training to use it
Situation-background-assessment-recommendation (SBAR)
structured method of communication that is used to improve communication
Rapid Response Team (RRT)
team of critical care experts who can be called if there is concern about failure to rescue so as to respond quickly to complex and critical needs of patients
Huddle
means by which a team gets together periodically during a shift to discuss critical issues
Change of Shift Report
- clinical reports are given routinely
- for bringing new staff coming on up-to-date regarding patient status
- opportunity to discuss quality and safety concerns for individual patients or for the unit or team as a whole
Safety Walkarounds
staff walk through the unit or area of the healthcare organization and identify any safety concerns they may see that would apply to patients, families and visitors, and staff
-information is then used to plan improvement including prevention measures
Crew resource management (CRM)
communication method used in aviation to improve communication and decision making, providing a clear structure for the process
Surveillance
ongoing assessment of patient status to identify problems and/or prevention of potential problems
- nurses are primarily responsible for surveillance
- not doing surveillance may result in failure to rescue
Universal protocol for preventing wrong site, wrong procedure, or wrong person surgery
requires staff to utilize the following steps:
- preprocedure verification
- site markings
- use of time-outs
Early Warning System (EWS)
a physiological scoring system typically used in medical-surgical units before patients experience catastrophic medical events
-this is what triggers the use of the rapid response team to prevent failure to rescue
Morbidity and mortality conferences
held in many hospitals on a routine basis to discuss patient care and outcomes
Trigger Points
clues that there may be an adverse reaction
Electronic medical/health record
- documentation mostly commonly done via electronic methods
- improves timely communication and have a positive impact on care
Computerized physician/provider order-entry system (CPOES)
used to improve the process of physician ordering, usually reducing time and errors
-associated with electronic medical records
Computerized decision support (CDS)
offers providers an effective method to improve decision making
Use of other technology
increased use of technology in healthcare delivery has assisted in improving timely communication that meets the need at the time
Bar Coding
used routinely in medication administration and other times when identification of patient and action need to be ensured
