Exam 1 - Continuous Quality Improvement, Root Cause Analysis, and Patient Safety Flashcards
What is quality?
Doing the right thing, at the right time, and in the right way for the person/customer consistently
Early evidence of quality assessment and quality control come from the ____ time
Pre-industrial
How did quality USED TO be shown?
People and reputation
What did the industrial revolution and factory system mark the initial decline of?
Employee’s sense of empowerment and autonomy in the workplace
What resulted in the Pure Food and Drug Act of 1906 being created?
The degradation in quality — particularly factory produced meats near Chicago
What did the Pure Food and Drug Act of 1906 create?
The FDA
What is the FDA responsible for?
Ensuring quality for food and drugs for human consumption
What does the Pure Food and Drug Act of 1906 require?
Prescription drugs to meet minimum strength and purity standards
Labeling standards for food and drugs
What was established through the Pure Food and Drug Act of 1906?
The USP and National Formulary
What happened due to the initial inspection process becoming faulty?
The quality assurance process was reduced to sampling inspections through tables and statistical control
Data and stats introduced as an element of quality
Acceptance sampling established
What is acceptance sampling?
“Middle of the road” approach between no inspection and 100% inspection
Who popularized acceptance sampling?
Dodge and Romig
What was the 1st instance of popularized acceptance sampling?
Testing of bullets during WWII
If you test all the bullets, you wouldn’t have any left
If none are tested, malfunctions may occur
What is the main purpose of acceptance sampling?
To decide whether the lot is likely to be acceptable
NOT to estimate the quality of the lot
Where can we see acceptance sampling in healthcare?
Pharmaceutical manufacturing, lots
Antibiograms
ISO certification for clean rooms
What types of measures are used for quality assurance?
Process
Outcome
Structure
(POS because you’re making sure the product isn’t a POS)
Structure quality measurements
Physical equipment
Facilities
Raw materials
People
(The who and where)
Process quality measurements
How the system works
How is healthcare provided
Outcome quality measurements
Final product
Results
Health status
Does is make a difference?
Process
Group of activities that takes an input, adds value to it, and provides an output
Why did process mapping and control starts become popular?
To create a standard work and limit variation
Process mapping is an ___ phase of quality improvement
Early
What does process mapping involve?
Defining exact steps in a process through symbols, roles, and data
What can process mapping illustrate?
The complexity of work
What does process mapping help to define?
Standard work
What do statistical control charts show?
Variance in a process through data
The ___ the control limits, the ___ variation in the process
Tighter
Less
When should you use a statistical control chart?
Controlling ongoing processes by finding & correcting problems as they occur
Predicting the expected range of outcomes from a process
Determining whether a process is stable
Analyzing patterns of process variation from special causes or common causes
Determining if quality improvement project should aim to prevent specific problems or to make fundamental changes in the process
What is standard work?
A way to ensure consistency and allow for improvements over time
When should you use standard work?
- When consistency is essential
- When you have procedures that need to be repeated regularly
- You want to continually improve
Is quality assurance retrospective or prospective
Retrospective and reactive
What does quality assurance determine?
Fault or faulty products
Quality assurance sets a ____ standard to achieve
Minimum
Is quality improvement retrospective or prospective?
BOTH
What is quality improvement aimed to do?
Improve the system or a process
Quality improvement ___ where you are and ____ ways to make it better
Measures
Determines
What does quality improvement avoid?
Blame
If there is an error, it’s a result of the system NOT the individual
The Joint Commission quality improvement
Organizational leadership roles
Data driven decisions
Measurement criteria
Focus on process
What did organizations participating in the joint commission quality improvement commit to?
Continuous quality improvement
Heart failure core quality measures
LVF assessment
ACEI if appropriate
Smoking cessation offered
Acute MI core quality measures
Aspirin
Beta blockers
ACEI if applicable
Pneumonia core quality measures
Antibiotic within 4 hours of admin
Pneumococcal screening
Surgical antibiotic care quality measures
Appropriate antibiotic given within 1 hr prior to first incision
Why were these quality measures for certain conditions and situations selected?
Statistically proven to improve outcomes in patients
Improved outcomes for patients =
Cost savings for payers
Goals of core quality measures
ID high value, high impact, evidence based measures to promote better health outcomes, and providing useful info for improvement, decision making, and payment
Align measures across public and private payers to achieve congruence in the use of measures for quality improvement, transparency, and payment purposes
Reduce the burden of measurement by eliminating low value metrics, redundancies, and inconsistencies in measure specifications and quality measure reporting requirements across payers
Who makes the core quality measures?
The core quality measures collaborative (CQMC)
Who is involved in the CQMC?
Healthcare leaders
Consumer groups
Medical associations
Health insurance providers
What does the CQMC do?
Work together to develop and recommend core sets of measures by clinical area
What are core quality measures used for?
Federal rule making
Where can the core quality measures be included?
In the CMS standards of participation
What do core quality measures influence?
Reimbursement rates across payers
What makes healthcare orgs want to improve?
Tying quality to payment incentives
IHI Triple Aim
- Improving the pt’s experience of care, including quality and satisfaction
- Improving health of the population
- Reducing the cost of healthcare
Dimensions of the IHI triple aim
Population help
Experience of care
Per capita cost
(PEP)
Outcome measures of population health
Heart outcome such as:
- mortality
- healthy life expectancy
- health/functional status
Disease burden
Behavioral and physiological factors
Outcome measures of experience of care
Standard questions from patient surveys
Set of measures based on key dimensions such as safe, effective, timely, efficient, and equitable
Outcome measures of per capita cost
Total cost per member of the population per month
Hospital and emergency dept utilization rate and or cost
What is the expansion of the triple aim?
Including “improving provider experience” as a 4th dimension
What did the post pandemic quality organizations like the American College of Cardiology recommend?
A quintuple aim adding equity
Quintriple aim
- Improved pt experience
- Better outcomes
- Lower costs
- Clinician well being
- Health equity
When, why, and by who were the National Safety Goals est?
In 2002 by the Joint Commission to help accredited orgs address specific areas of concern regarding pt safety
When was the 1st set of national safety goals effective by?
Jan 1, 2003
How does the joint commission determine the highest priority pt safety issues?
Form input from practitioners, provider orgs, purchasers, consumer groups, and other stakeholders
What have prior goals centered around?
Reducing infection rates
Safe med dispensing — LASA
Reducing error prone abbreviations
Increase vaccine reporting/records
NPSG.03.04.01
Label all meds, med containers, and other solutions on and off the sterile field in perioperative and other procedural settings
NPSG.03.05.01
Reduce the likelihood of pt harm associated w/ anticoagulant use
NPSG.03.06.01
Maintain and communicate accurate pt med info
What did the joint commission do in 1996?
Adopted a formal sentinel event policy to help hospitals that experience serious adverse events improve safety and learn
What do sentinel events require?
Evaluation of corrective actions essential to reduce risk and prevent further pt harm
What is the definition of a sentinel event?
Unexpected occurrence involving a death or serious/psychological injury (or risk thereof)
What does serious injury include?
Loss of limb or function
Can an event be considered sentinel even if the outcome was NOT death, permanent harm, severe temporary harm, or intervention required to sustain life?
YES
A sentinel event signals a need for immediate ___ and ___
Investigation
Response
Types of sentinel events
Unintended retention of foreign object
Fall related events
Suicide events
Wrong pt, wrong site, wrong procedure
Delay in treatments
Criminal events
Operation/post-op complications
Perinatal events
Fire related events
What can be considered med error events?
High alert meds
LASA
Abbreviations
Medication rec
What is a failure modes and effect analysis (FMEA)?
Systematic, proactive method for evaluating a process to ID how and where it may fail
What does a FMEA review?
Failure
Modes and causes
Effects
Analysis
In FMEA what is there an emphasis on?
Prevention
How does the joint commission determine the level of corrective action that should take place?
Ranking the findings on a modified FMEA scale
What is a root cause analysis?
A process to ID factors which could have led to the event
What does a root cause analysis focus on?
Systems and processes
Why are root cause analyses needed?
To improve care and outcomes for the pt
What personnel do root cause analyses include?
Anyone involved in care or w/ knowledge of the event
What is identified in a root cause analysis?
1-3 key factors which if changed, would likely prevent future undesirable outcomes
What do root cause analyses use?
Various tools, including A3 mapping, Pareto chart (vertical bar graph), priority matrix, or a fishbone diagram
Impaired judgement
Caregiver’s thinking was impaired by:
- illegal/legal substances
- cognitive impairment
- severe psychological stressors
Discipline to impaired judgement
Warranted if illegal substances were used
The caregiver’s performance should be evaluated to see if temporary suspension would be helpful
Help should be actively offered to caregiver
Malicious action
Caregiver wanted to cause harm
Discipline to malicious action
Proceedings are warranted
Caregiver’s duties suspended immediately
Reckless action
Caregiver knowingly violated a rule and/or made a dangerous choice
Decision appears to have been made w/ little or no concern about risk
Discipline for reckless action
May be warranted
Caregiver is accountable and needs retraining
Caregiver should participate in teaching others the lessons learned
Risky action
Potentially unsafe choices
Faulty or self-serving decision making may be evident
Discipline for risky action
Held accountable and receives coaching
Caregiver should participate in teaching others lesson learned
Unintentional error
Error occurs when caregiver is working appropriately and in pt’s best interests
Discipline for unintentional error
Not accountable
Participate in investigating why error occurred & educate others on results
Reckless action: if three other caregivers w/ similar skills & knowledge would do the same in similar circumstances
System supports reckless action and requires fixing
The caregiver is probably less accountable for the action and system leaders share in the accountability
Risk action: if 3 other caregivers w/ similar skills and knowledge would do the same in similar circumstances
System supports risky action and requires fixing
Caregiver is probably less accountable for the action and the system requires fixing
Unintentional error: if 3 other caregivers w/ similar skills and knowledge would do the same in similar circumstances
System supports error and requires fixing
System’s leaders are accountable and should apply error proofing improvements
What is an A3 analysis core to?
Toyota management system
What does an A3 report guide?
Dialogue and analysis
What is an A3 report?
Report that identifies the current situation and establishes:
- goal and root cause
- range of possible counter measures
- best countermeasure
- means to put it into practice
- evidence issue has been addressed
What does a fishbone diagram include?
- Human factors
- Equipment
- Environmental factors
- Communication factors
- Policy, procedure, practice factors
What human factors are found in fishbone diagrams?
Staffing
Scheduling
Orientation
Training
Competency
Supervision
What equipment factors are found in fishbone diagrams?
Preventative maintenance
Failure
Availability
User error
What environmental factors are found in fishbone diagrams?
Physical
Culture
Quality control
Safety
HAZMAT
Emergency preparedness
Communication factors found in fishbone diagrams
Among staff
Staff & pt/family
Physician & staff
Physician & pt/family
Between levels of care, units, external facilities
Policy, procedure, and practice factors found in fishbone diagrams
Assessment
Monitoring
Care planning
Pt/family education
Care & treatment protocols
Pt identification
Pt observation
Method of continuous quality improvement
Plan
Do
Check
Act
(PDCA)
Plan
Diagnose the problem
Develop interventions
Do
Carry out your plan
Check
Look at your results
What do they tell you?
Act
Decide what further actions should be taken to improve
Performance improvement
- Meed w/ specific
