Clinical Quality and Safety

Question 1

What is quality improvement (QI)?

Answer 1

A formal approach to the analysis of performance and systematic efforts to improve it.

US Agency for Healthcare Research and Quality: “Doing the right thing, at the right time, in the right way, for the right person—and having the best possible results.”

Question 2

What is the Joint Commission?

Answer 2

A national safety organization that accredits and certifies over 20,500 organizations and programs in the U.S. (78% of U.S. hospitals).

Decides national patient safety goals and ORYX measures based on sentinel events, integrating these performance measures into the accreditation process.

Question 3

What is a sentinel event?

Answer 3

An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function.

Can generate national patient safety goals.

Question 4

When finding sources of error, is it better to take a person-based approach or a system-based approach?

Answer 4

• A system-based approach finds the error 85% of the time: build system defenses, recognize that >85% of errors are blameless; no blame/no shame culture promotes near miss reporting
• A person-based approach finds the error 15% of the time: uncouple a person’s unsafe act from the institution, isolate unsafe acts from the system; blame/shame system stifles near miss reporting

Question 5

What is a root cause analysis?

Answer 5

An RCA is a structured retrospective approach (vs. HFMEA, which is prospective) to an unexpected bad outcome, using representatives of all tiers of care (e.g., physicians, nurses, pharmacists, etc.). Focuses on human factors and system vulnerability characteristics that contribute to error, and away from personal blame.

Question 6

What is a healthcare failure mode and effect analysis?

Answer 6

An HFMEA is a structured prospective approach (vs. an RCA, which is a retrospective approach) to a potential bad outcome.

ex) A sister hospital has an unexpected bad outcome. Your hospital undergoes an HFMEA to ensure that it does not occur for your patients and staff.

Question 7

What are some important aspects of performance management?

Answer 7

• 2-item patient identification system
• Bracelets with fall risks, allergy, DNR, etc. notifications
• Hand washing
• Standard precautions and alerts
• Personal protective equipment (PPE)

Question 8

What is an external peer review process?

Answer 8

An EPRP is an examination performed by an independent organization. The results are sent to the Joint Commission.