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Patient Safety > Exam 1 - Continuous Quality Improvement, Root Cause Analysis, and Patient Safety > Flashcards

Exam 1 - Continuous Quality Improvement, Root Cause Analysis, and Patient Safety Flashcards

1
Q

What is quality?

A

Doing the right thing, at the right time, and in the right way for the person/customer consistently

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2
Q

Early evidence of quality assessment and quality control come from the ____ time

A

Pre-industrial

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3
Q

How did quality USED TO be shown?

A

People and reputation

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4
Q

What did the industrial revolution and factory system mark the initial decline of?

A

Employee’s sense of empowerment and autonomy in the workplace

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5
Q

What resulted in the Pure Food and Drug Act of 1906 being created?

A

The degradation in quality — particularly factory produced meats near Chicago

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6
Q

What did the Pure Food and Drug Act of 1906 create?

A

The FDA

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7
Q

What is the FDA responsible for?

A

Ensuring quality for food and drugs for human consumption

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8
Q

What does the Pure Food and Drug Act of 1906 require?

A

Prescription drugs to meet minimum strength and purity standards

Labeling standards for food and drugs

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9
Q

What was established through the Pure Food and Drug Act of 1906?

A

The USP and National Formulary

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10
Q

What happened due to the initial inspection process becoming faulty?

A

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

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11
Q

What is acceptance sampling?

A

“Middle of the road” approach between no inspection and 100% inspection

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12
Q

Who popularized acceptance sampling?

A

Dodge and Romig

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13
Q

What was the 1st instance of popularized acceptance sampling?

A

Testing of bullets during WWII

If you test all the bullets, you wouldn’t have any left

If none are tested, malfunctions may occur

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14
Q

What is the main purpose of acceptance sampling?

A

To decide whether the lot is likely to be acceptable

NOT to estimate the quality of the lot

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15
Q

Where can we see acceptance sampling in healthcare?

A

Pharmaceutical manufacturing, lots
Antibiograms
ISO certification for clean rooms

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16
Q

What types of measures are used for quality assurance?

A

Process
Outcome
Structure

(POS because you’re making sure the product isn’t a POS)

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17
Q

Structure quality measurements

A

Physical equipment
Facilities
Raw materials
People

(The who and where)

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18
Q

Process quality measurements

A

How the system works
How is healthcare provided

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19
Q

Outcome quality measurements

A

Final product
Results
Health status
Does is make a difference?

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20
Q

Process

A

Group of activities that takes an input, adds value to it, and provides an output

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21
Q

Why did process mapping and control starts become popular?

A

To create a standard work and limit variation

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22
Q

Process mapping is an ___ phase of quality improvement

A

Early

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23
Q

What does process mapping involve?

A

Defining exact steps in a process through symbols, roles, and data

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24
Q

What can process mapping illustrate?

A

The complexity of work

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25
Q

What does process mapping help to define?

A

Standard work

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26
Q

What do statistical control charts show?

A

Variance in a process through data

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27
Q

The ___ the control limits, the ___ variation in the process

A

Tighter
Less

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28
Q

When should you use a statistical control chart?

A

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

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29
Q

What is standard work?

A

A way to ensure consistency and allow for improvements over time

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30
Q

When should you use standard work?

A
  1. When consistency is essential
  2. When you have procedures that need to be repeated regularly
  3. You want to continually improve
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31
Q

Is quality assurance retrospective or prospective

A

Retrospective and reactive

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32
Q

What does quality assurance determine?

A

Fault or faulty products

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33
Q

Quality assurance sets a ____ standard to achieve

A

Minimum

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34
Q

Is quality improvement retrospective or prospective?

A

BOTH

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35
Q

What is quality improvement aimed to do?

A

Improve the system or a process

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36
Q

Quality improvement ___ where you are and ____ ways to make it better

A

Measures
Determines

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37
Q

What does quality improvement avoid?

A

Blame

If there is an error, it’s a result of the system NOT the individual

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38
Q

The Joint Commission quality improvement

A

Organizational leadership roles
Data driven decisions
Measurement criteria
Focus on process

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39
Q

What did organizations participating in the joint commission quality improvement commit to?

A

Continuous quality improvement

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40
Q

Heart failure core quality measures

A

LVF assessment
ACEI if appropriate
Smoking cessation offered

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41
Q

Acute MI core quality measures

A

Aspirin
Beta blockers
ACEI if applicable

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42
Q

Pneumonia core quality measures

A

Antibiotic within 4 hours of admin
Pneumococcal screening

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43
Q

Surgical antibiotic care quality measures

A

Appropriate antibiotic given within 1 hr prior to first incision

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44
Q

Why were these quality measures for certain conditions and situations selected?

A

Statistically proven to improve outcomes in patients

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45
Q

Improved outcomes for patients =

A

Cost savings for payers

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46
Q

Goals of core quality measures

A

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

47
Q

Who makes the core quality measures?

A

The core quality measures collaborative (CQMC)

48
Q

Who is involved in the CQMC?

A

Healthcare leaders
Consumer groups
Medical associations
Health insurance providers

49
Q

What does the CQMC do?

A

Work together to develop and recommend core sets of measures by clinical area

50
Q

What are core quality measures used for?

A

Federal rule making

51
Q

Where can the core quality measures be included?

A

In the CMS standards of participation

52
Q

What do core quality measures influence?

A

Reimbursement rates across payers

53
Q

What makes healthcare orgs want to improve?

A

Tying quality to payment incentives

54
Q

IHI Triple Aim

A
  1. Improving the pt’s experience of care, including quality and satisfaction
  2. Improving health of the population
  3. Reducing the cost of healthcare
55
Q

Dimensions of the IHI triple aim

A

Population help
Experience of care
Per capita cost

(PEP)

56
Q

Outcome measures of population health

A

Heart outcome such as:
- mortality
- healthy life expectancy
- health/functional status

Disease burden

Behavioral and physiological factors

57
Q

Outcome measures of experience of care

A

Standard questions from patient surveys

Set of measures based on key dimensions such as safe, effective, timely, efficient, and equitable

58
Q

Outcome measures of per capita cost

A

Total cost per member of the population per month

Hospital and emergency dept utilization rate and or cost

59
Q

What is the expansion of the triple aim?

A

Including “improving provider experience” as a 4th dimension

60
Q

What did the post pandemic quality organizations like the American College of Cardiology recommend?

A

A quintuple aim adding equity

61
Q

Quintriple aim

A
  1. Improved pt experience
  2. Better outcomes
  3. Lower costs
  4. Clinician well being
  5. Health equity
62
Q

When, why, and by who were the National Safety Goals est?

A

In 2002 by the Joint Commission to help accredited orgs address specific areas of concern regarding pt safety

63
Q

When was the 1st set of national safety goals effective by?

A

Jan 1, 2003

64
Q

How does the joint commission determine the highest priority pt safety issues?

A

Form input from practitioners, provider orgs, purchasers, consumer groups, and other stakeholders

65
Q

What have prior goals centered around?

A

Reducing infection rates

Safe med dispensing — LASA

Reducing error prone abbreviations

Increase vaccine reporting/records

66
Q

NPSG.03.04.01

A

Label all meds, med containers, and other solutions on and off the sterile field in perioperative and other procedural settings

67
Q

NPSG.03.05.01

A

Reduce the likelihood of pt harm associated w/ anticoagulant use

68
Q

NPSG.03.06.01

A

Maintain and communicate accurate pt med info

69
Q

What did the joint commission do in 1996?

A

Adopted a formal sentinel event policy to help hospitals that experience serious adverse events improve safety and learn

70
Q

What do sentinel events require?

A

Evaluation of corrective actions essential to reduce risk and prevent further pt harm

71
Q

What is the definition of a sentinel event?

A

Unexpected occurrence involving a death or serious/psychological injury (or risk thereof)

72
Q

What does serious injury include?

A

Loss of limb or function

73
Q

Can an event be considered sentinel even if the outcome was NOT death, permanent harm, severe temporary harm, or intervention required to sustain life?

A

YES

74
Q

A sentinel event signals a need for immediate ___ and ___

A

Investigation
Response

75
Q

Types of sentinel events

A

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

76
Q

What can be considered med error events?

A

High alert meds
LASA
Abbreviations
Medication rec

77
Q

What is a failure modes and effect analysis (FMEA)?

A

Systematic, proactive method for evaluating a process to ID how and where it may fail

78
Q

What does a FMEA review?

A

Failure
Modes and causes
Effects
Analysis

79
Q

In FMEA what is there an emphasis on?

A

Prevention

80
Q

How does the joint commission determine the level of corrective action that should take place?

A

Ranking the findings on a modified FMEA scale

81
Q

What is a root cause analysis?

A

A process to ID factors which could have led to the event

82
Q

What does a root cause analysis focus on?

A

Systems and processes

83
Q

Why are root cause analyses needed?

A

To improve care and outcomes for the pt

84
Q

What personnel do root cause analyses include?

A

Anyone involved in care or w/ knowledge of the event

85
Q

What is identified in a root cause analysis?

A

1-3 key factors which if changed, would likely prevent future undesirable outcomes

86
Q

What do root cause analyses use?

A

Various tools, including A3 mapping, Pareto chart (vertical bar graph), priority matrix, or a fishbone diagram

87
Q

Impaired judgement

A

Caregiver’s thinking was impaired by:
- illegal/legal substances
- cognitive impairment
- severe psychological stressors

88
Q

Discipline to impaired judgement

A

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

89
Q

Malicious action

A

Caregiver wanted to cause harm

90
Q

Discipline to malicious action

A

Proceedings are warranted

Caregiver’s duties suspended immediately

91
Q

Reckless action

A

Caregiver knowingly violated a rule and/or made a dangerous choice

Decision appears to have been made w/ little or no concern about risk

92
Q

Discipline for reckless action

A

May be warranted

Caregiver is accountable and needs retraining

Caregiver should participate in teaching others the lessons learned

93
Q

Risky action

A

Potentially unsafe choices

Faulty or self-serving decision making may be evident

94
Q

Discipline for risky action

A

Held accountable and receives coaching

Caregiver should participate in teaching others lesson learned

95
Q

Unintentional error

A

Error occurs when caregiver is working appropriately and in pt’s best interests

96
Q

Discipline for unintentional error

A

Not accountable

Participate in investigating why error occurred & educate others on results

97
Q

Reckless action: if three other caregivers w/ similar skills & knowledge would do the same in similar circumstances

A

System supports reckless action and requires fixing

The caregiver is probably less accountable for the action and system leaders share in the accountability

98
Q

Risk action: if 3 other caregivers w/ similar skills and knowledge would do the same in similar circumstances

A

System supports risky action and requires fixing

Caregiver is probably less accountable for the action and the system requires fixing

99
Q

Unintentional error: if 3 other caregivers w/ similar skills and knowledge would do the same in similar circumstances

A

System supports error and requires fixing

System’s leaders are accountable and should apply error proofing improvements

100
Q

What is an A3 analysis core to?

A

Toyota management system

101
Q

What does an A3 report guide?

A

Dialogue and analysis

102
Q

What is an A3 report?

A

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

103
Q

What does a fishbone diagram include?

A
  1. Human factors
  2. Equipment
  3. Environmental factors
  4. Communication factors
  5. Policy, procedure, practice factors
104
Q

What human factors are found in fishbone diagrams?

A

Staffing
Scheduling
Orientation
Training
Competency
Supervision

105
Q

What equipment factors are found in fishbone diagrams?

A

Preventative maintenance
Failure
Availability
User error

106
Q

What environmental factors are found in fishbone diagrams?

A

Physical
Culture
Quality control
Safety
HAZMAT
Emergency preparedness

107
Q

Communication factors found in fishbone diagrams

A

Among staff
Staff & pt/family
Physician & staff
Physician & pt/family
Between levels of care, units, external facilities

108
Q

Policy, procedure, and practice factors found in fishbone diagrams

A

Assessment
Monitoring
Care planning
Pt/family education
Care & treatment protocols
Pt identification
Pt observation

109
Q

Method of continuous quality improvement

A

Plan
Do
Check
Act
(PDCA)

110
Q

Plan

A

Diagnose the problem
Develop interventions

111
Q

Do

A

Carry out your plan

112
Q

Check

A

Look at your results
What do they tell you?

113
Q

Act

A

Decide what further actions should be taken to improve

114
Q

Performance improvement

A
  1. Meed w/ specific

Patient Safety (11 decks)

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