Class 9 Management of Health Care Quality Flashcards
Systematic approach aimed at discovering the causes of close calls and adverse events for the purpose of identifying preventative measures
▪ Uses a team of 5-6 people
▪ Work to isolate primary cause of event from incidental
factors that may or may not have contributed ▪ Aim is to redesign system to eliminate root cause or
mitigate impact
1 Root Cause Analysis
Four categories of harmful events:
▪ 46% healthcare and medications ▪ 30% infections ▪ 20% procedure related ▪ 4% patient accidents
The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.
Healthcare quality
What are factors that might reduce access to healthcare?
6 Attributes of Health Care Quality
Safe
Effective
Efficient
Define Attributes of Health Care Quality
Equity
Timeliness
Patient Centeredness
Attribute that
Addresses needs of populations served
Effective
are result of human fallibility and poor system design
Errors
▪ Question and intervene to address unsafe practice
▪ Admit mistakes
▪ Support a climate of trust that supports openness
CNA Code of Ethics
The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. (Goal)
Quality
A philosophy of health care culture that emphasizes customer satisfaction, innovation, and employee involvement. (Philosophy)
Quality management
An ongoing process of innovation, prevention of error, and staff development that is used by institutions that adopt the quality management philosophy. (Process)
Quality improvement
Principles of quality management
▪ Operates most effectively within a flat, democratic,
organization structure.
▪ Managers and workers must be committed to quality
improvement.
▪ Goal is to improve systems and processes, not to assign
blame.
▪ Patients define quality
▪ Quality improvement process focuses on outcomes
▪ Decisions must be based on data.
Benefits of quality management
▪ Greater efficiency and proactive planning ▪ Increases patient safety and quality care ▪ Enhanced job satisfaction
▪ Provides resources and removes barriers
▪ Provides education
▪ Implements QI systems
▪ Defines procedures for immediate response to errors in care
▪ Lead culture of safety
Senior Nurse Leader
Someone that responsibility are:
▪ Goal is to improve the system
▪ Educate all employees about QI strategies
▪ Free flow of communication
▪ Embracing non punitive error reporting
▪ Encouraging vigilance in identifying potential risks
▪ Creating partnerships with patients to promote communication about safety issues
Senior Nurse Leader
▪ Accountable for quality performance
▪ Provides time for staff to participate in QI
▪ Provide guidance to staff
▪ Uses data to measure effectiveness of improvement
Nurse manager
▪ Follow policy/procedure ▪ Keep current - EBP ▪ Reports quality and safety issues to manager ▪ Participates actively in QI ▪ “What can I do to improve situation?”
Nurse/Follower
▪ Defined outcomes used to validate the quality and effectiveness of care.
▪ Identifies ways to define, categorize, and measure quality.
Donabedian Quality of Care Framework
health care model which aims to
- decrease waste
- increase quality of care
Lean Management System
- has good leaders
- no trouble attracting staff
- empowering
- (focused in hospitals in the US)
Magnet Hospital Designation
Systematic approach aimed at discovering the causes of close calls and adverse events for the purpose of identifying preventative measures.
Root Cause Analysis
▪ Uses a team of 5-6 people
▪ Work to isolate primary cause of event from incidental
factors that may or may not have contributed
▪ Aim is to redesign system to eliminate root cause or
mitigate impact
Root Cause Analysis
- Identify adverse event
- Assemble the team
- Develop initial flow diagram of processes leading to event
- Interview all people involved & review documentation
- Develop cause & effect diagram
— Actions & conditions that caused event
— Includes communication problems, policy, procedure &
human error leading to event - Identify contributing factors 7. Develop system redesign 8. Measure outcomes
Root Cause Analysis Process
Risk Management Framework
▪ Identify risk ▪ Assess risk ▪ Manage risk ▪ Report risk
Systematic identification, assessment & prioritization of risks. Development & implementation of strategies to reduce adverse events.
Risk Management
Advocate for patients & families to ask questions, to be informed and to take part in decision-making
Canadian Patient Safety Institute
is committed to helping healthcare organizations and healthcare providers learn about leading practices to improve patient safety.
Manitoba Institute for Patient Safety
• Develops, shares and promotes patient safety resources
• Hosts and sponsors patient safety education
• Advises on patient safety related policy and legislation
• Raises awareness about patient safety issues and our organization
Manitoba Institute for Patient Safety
