Leadership Flashcards
What is an outcome measure
Measure that indicates the result of the performance of a process or function
Typically undesirable outcome- SSI rates
What are the types of measurement?
Outcome measure
Process measure
What is process measure?
Focuses in a process or the steps in a process that lead to specific outcomes
Used to evaluate quality if linked to an outcome. Example use of sterile barriers to reduce CLABSI
Hand hygiene compliance
Methods of calculation
What is a Numerator
The event being measured.
Falls, VAP, UTI, etc
What is the denominator?
Population at risk
What are the 3 ways performance measures are calculated?
Rate
Continuous variable
Ratio
What is prevalence rate?
Calculation includes existing cases during a time period.
All pts with CAUTI, both new & existing cases on day one in an LTAC
What is continuous variable?
Calculated when many results are possible. Days in the hospital, minutes to treatment, wait time
What is ratio- based measure
Depends on the relationship btwn 2 counted sets of data and may not have a value of zero or greater
SIR - dividing the number of observed SSI by expected SSI a
What is risk adjusted data or stratified?
Stratifying SSI data by pt status, duration, or wound class
What is a PI team?
Tool to deploy quality focus culture or process
Gap analysis
Technique to determine the steps necessary to take a move from s currant state to a desired state.
Identified gaps in process
Root cause analysis
Retrospective look at adverse outcomes and determines what happened, why it happened and what can be done to prevent it again
Investigate major incidence sentinel events and errors
Avoids blames, considers human factors, redesign for a safer system
Uses tree design for responsibility
Team summarizes, identifies causes, strategies about process redesign
Failure mode effect analysis FMEA
Determine a process to study, carries a risk of harm Content experts Flow diagram identify steps Brainstorm possible reasons for failure Determine actions to eliminate Redesign the process Identify outcome measures
FMEA
Failure- lack of success
Mode-process or way things are done
Effects- consequences of an action
Analysis- detailed examination of a process
SWOT analysis
Investigate public health issues
Improve healthcare outcomes
Points out what an organization should plan for
How to use resources to guide efforts
Six sigma
Precision and accuracy
Eliminates waste.
Six Sigma (DMAIC)
Define the customer, project boundaries, improve processes
Measure performance of the process involved
Analyze data collected
Map the process to determine root causes &improvement opportunities
Improve the target process by designing creative solutions to fix problems
Keep the process on the new course
List the functions of an IP program
Obtain & manage critical data and information (surveillance)
Develop and recommend policies and procedures
Intervene directly to prevent the transmission of infectious disease
Educate and train HCW, patients, and caregivers
What is the goal of an IP program?
Protect the patient
Protect the HCW, visitor, & others in the health care environment
Accomplish the previous two goals in a cost effective manner when possible
Areas to access the quality of the IP program
Customer satisfaction Appropriateness Efficacy Timeliness Availability Effectiveness Efficiency
How to determine IP surveillance plan
Mandated reporting requirements
Procedures, service lines, surgeries
New equipment, instruments, procedures
Patient demographics - diseases common to a patient population or risk factors
What is included in the mission statement
Defines purpose, focus, and context for all department activities
Sets boundaries for their activities
Supports the overall institutional mission
Why the program exists
What is a vision statement
Picture of where the IP program wants the organization to go
Focus on strategic advantages
Add value to others
What are topics of communication for nursing
Changing regulations Surveillance rates ER situations - outbreaks Employee practices that need improvement Education about emerging pathogens Product recall info Recommendations to change practice Assist in root cause analysis
Topics for medical staff
Surveillance rates & ICP minutes Procedural issues involving physicians ER situations Changing legislation & regulations Recommendations to change practice
What is PDSA
Plan- identify responsibilities of the person, resources, risks and goals
Do-implement strategies specified in the plan to achieve goals
Study- collect and display data about goal achievement
Act- continual change I order to achieve goals and stay abreast of new developments
What is a run chart?
Graph that displays observed data in a time sequence
What is a histograms
Graphical representations visual impression of the distribution of data
Fishbone diagram
Show the cause of a certain event
Commonly used to identify potential factor causing an overall effect
What is a Pareto chart
Contains both bars and line graph with individual values represented in descending order by bars.
Communication with risk management
Product recalls
Pt names from exposure risks/incidents
Notification of inappropriate actions that place pts at risk of infection
Follow up results from pts with infection exp risk
Notifying them of a need for root cause because if death or disability
What is a strategic plan
Direction the organization will go in the future to meet mission, vision goals
Analysis of the organization
Conclusions about what an organization must do as a result of issues
Action planning
TJC a requirements for strategic plan
Prioritize the identified risk for acquiring infection
Set goals - unprotected exposures, transmission r/t procedures, equipment, devices, supplies
Describe activities for surveillance
Describe process for evaluation
When is a Case control study used?
The outcome is known and have to find the risk factors
What is a cohort study?
Risk factors are known and want to determine the outcome.
What is a randomized control study
Want to alter the risk or outcome
Human factors
Environmental, organizational, and job factors and human individual characteristics which influence behavior at work in a way that affects health and safety.
What human factors contribute to errors?
Limited memory capacity (5-7 pieces in short term memory)
Negative effects of stress & associated cognitive tunnel vision used to compensate and focus in highly intense situations.
Negative influence of fatigue and sensory overload
Overdependence on multi tasking skills if staff in complex work environments
What is a functional manger?
Most common type spin an organization, person who had authority over an organizational unit. Functional managers have ongoing responsibilities and are not usually directly affiliated with project teams, other than ensuring that goals and objectives are aligned with the organization also overall strategies and vision.
Vision statement
Answers the WHAT
A picture of the future of the IP program.
Long term
Focus on strategic advantages
Add value to others
Mission statement
Why does the program exist?
Mission is more concrete and tangible
Common purpose
Core values
How does the program function on a day to day basis
Six sigma DMAIC
Define Measure Analyze Improve Control
