Class 9 Management of Health Care Quality

Question 1

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

Answer 1

1 Root Cause Analysis

Question 2

Four categories of harmful events:

Answer 2

▪ 46% healthcare and medications ▪ 30% infections ▪ 20% procedure related ▪ 4% patient accidents

Question 3

The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.

Answer 3

Healthcare quality

Question 4

What are factors that might reduce access to healthcare?

Question 5

6 Attributes of Health Care Quality

Answer 5

Safe
Effective
Efficient
Define Attributes of Health Care Quality
Equity
Timeliness
Patient Centeredness

Question 6

Attribute that
Addresses needs of populations served

Answer 6

Effective

Question 7

are result of human fallibility and poor system design

Answer 7

Errors

Question 8

▪ Question and intervene to address unsafe practice
▪ Admit mistakes
▪ Support a climate of trust that supports openness

Answer 8

CNA Code of Ethics

Question 9

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)

Answer 9

Quality

Question 10

A philosophy of health care culture that emphasizes customer satisfaction, innovation, and employee involvement. (Philosophy)

Answer 10

Quality management

Question 11

An ongoing process of innovation, prevention of error, and staff development that is used by institutions that adopt the quality management philosophy. (Process)

Answer 11

Quality improvement

Question 12

Principles of quality management

Answer 12

▪ 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.

Question 13

Benefits of quality management

Answer 13

▪ Greater efficiency and proactive planning ▪ Increases patient safety and quality care ▪ Enhanced job satisfaction

Question 14

▪ Provides resources and removes barriers
▪ Provides education
▪ Implements QI systems
▪ Defines procedures for immediate response to errors in care
▪ Lead culture of safety

Answer 14

Senior Nurse Leader

Question 15

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

Answer 15

Senior Nurse Leader

Question 16

▪ Accountable for quality performance
▪ Provides time for staff to participate in QI
▪ Provide guidance to staff
▪ Uses data to measure effectiveness of improvement

Answer 16

Nurse manager

Question 17

▪ Follow policy/procedure ▪ Keep current - EBP ▪ Reports quality and safety issues to manager ▪ Participates actively in QI ▪ “What can I do to improve situation?”

Answer 17

Nurse/Follower

Question 18

▪ Defined outcomes used to validate the quality and effectiveness of care.
▪ Identifies ways to define, categorize, and measure quality.

Answer 18

Donabedian Quality of Care Framework

Question 19

health care model which aims to
- decrease waste
- increase quality of care

Answer 19

Lean Management System

Question 20

• has good leaders
• no trouble attracting staff
• empowering
• (focused in hospitals in the US)

Answer 20

Magnet Hospital Designation

Question 21

Systematic approach aimed at discovering the causes of close calls and adverse events for the purpose of identifying preventative measures.

Answer 21

Root Cause Analysis

Question 22

▪ 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

Answer 22

Root Cause Analysis

Question 23

1. Identify adverse event
2. Assemble the team
3. Develop initial flow diagram of processes leading to event
4. Interview all people involved & review documentation
5. Develop cause & effect diagram
   — Actions & conditions that caused event
   — Includes communication problems, policy, procedure &
   human error leading to event
6. Identify contributing factors 7. Develop system redesign 8. Measure outcomes

Answer 23

Root Cause Analysis Process

Question 24

Risk Management Framework

Answer 24

▪ Identify risk ▪ Assess risk ▪ Manage risk ▪ Report risk

Question 25

Systematic identification, assessment & prioritization of risks. Development & implementation of strategies to reduce adverse events.

Answer 25

Risk Management

Question 26

Advocate for patients & families to ask questions, to be informed and to take part in decision-making

Answer 26

Canadian Patient Safety Institute

Question 27

is committed to helping healthcare organizations and healthcare providers learn about leading practices to improve patient safety.

Answer 27

Manitoba Institute for Patient Safety

Question 28

• 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

Answer 28

Manitoba Institute for Patient Safety