Ch. 15 Organizing and Evaluating PI Flashcards
Exam 4
When is the trust between pt and clinicians broken?
When medical events occur
Who bears the ultimate responsibility for the quality of pt care provided? AKA everything that occurs
The board of directors
NOTE: not involved in day-to-day events
How are performance improvement and patient safety activities communicated throughout the healthcare organization?
- Planning
- Meetings
- Training/education
JC and CMS want evidence of… as part of accredidation
time spending on quality and safety activities
NOTE: >25% of the time
Basic hospital org chart
Board of Directors
CEO
C-suite leaders
staff
SWOT Analysis
Strength
Weakness
Opportunity
Threat
NOTE: must have an attribute and impact (and how to address it)
How long should a SWOT analysis be?
Short; ONLY top few
SWOT: Which components are internal and external?
Strength (internal)
Weakness (internal)
Opportunity (external)
Threat (external)
Who decides the scope and focus of
performance monitoring and data collection activities?
The organization’s leaders
What are the three criteria in setting priorities for improvement activities?
- High-risk
- high-volume
- problem- prone processes
JC requires data on ______ (6)
- Medication mngmt
- blood and blood product use
- restraint and seclusion use
- Bahavior mngmt and treatment (psych ward)
- invasive procedures
- Resucitation (+ outcomes)
Board of directors _____ plan implementation to the PI and patient safety council
delegates
What is the responsibility of the pt safety council in implementing PI plan? (3)
- defines which committees/dept/staff
- Data collection
- Assessing findings
4 factors that come into play when evaluating the PI plan
- Approach is org-wide
- Collaboration
- If needs redesign
- Effectiveness
Components of Program Reviews: Executive Summary
1 paragraph long summary of most imp things
Components of Program Reviews: Types of Improvement Opportunities (4)
- Patient-focused improvements
- Organizational improvements
- Ongoing measurements
- Quality data reporting
Components of Program Reviews: PI structure
How council came about planning the PI
How often does BoD meet?
Quarterly
What is the purpose of dashboards?
Provides visual information that can be used for making management decisions
Ethics committee
EVERYTHING is confidential for ethical violations
Utilization and Documentation Standards Committees
Checking the utilization of resources and if documentation is up to standards
Credentials committee
Verify credentials
