Module 1: Introduction to Quality Management Flashcards
Variables in the Imaging Department
- Equipment
- Image receptor system
- Quality of image processing
- Viewing or display conditions
- Competency of the technologist
- Support Staff
- Observer and Interpreter
define quality care as providing patients with appropriate service in a technically competent manner, good communication skills, shared decision-making, and cultural sensitivity
The National Academy of Medicine
3 Levels of Determined Quality
- Expected Quality
- Perceived Quality
- Actual Quality
In what year has the United States healthcare been affected the diagnostic imaging departments and their ability to provide quality care
1980s
Legislation and Government Regulation
- Safe Medical Devices Act. (SMDA) 1990
- Mammography Quality Standards Act (MQSA) 1992
- Mammography Quality Standards Reauthorization (MQSRA) 1998.
- Improvement for Patients and Providers Act of 2008.
- Occupational Safety and Health Administration (OSHA).
- Food and Drug Administration.
Accreditation Procedures
- The Joint Commission (TJC)
- Philosophy of quality assurance (QA)
- Total Quality Management (TQM)
STANDARDS, REGULATIONS, AND QUALITY MANAGEMENT
- QUALITY MANAGEMENT PROGRAM
- STANDARD
- ACCREDITATION
- REGULATION
must incorporate standards and regulations that must be met for healthcare organizations to remain in business.
QUALITY MANAGEMENT PROGRAM
- defined and promoted by a professional body or organization by which the quality
of practice or service can be evaluated. - are viewed as the minimum, rather than the maximum, expectation of care.
STANDARD
used to assess organizations and determine whether they meet the minimum established standards.
ACCREDITATION
Two organizations for Accreditation
- American Society of Radiologic Technologists (ASRT)
- American Registry of Radiologic Technologists (ARRT)
written into local, state, or federal law that are employed in controlling, directing, or managing an activity organization or system.
REGULATION
HIPAA
Health Insurance Portability and Accountability Act.
HIPAA of 1996, also known as the Kennedy Kassebaum Act or ————
Public Law 104-191
was enacted to simplify healthcare standards and save money for healthcare businesses by encouraging electronic transactions.
HIPAA / Kennedy Kassebaum Act / Public Law 104-191
5 national standards for healthcare e-commerce
- ELECTRONIC PATIENT RECORD SYSTEM
- STANDARD ELECTRONIC FORMATS
- STANDARD IDENTIFIERS AND CODES
- Codes used to encode all healthcare data
- PATIENT INFORMATION
This created a new national standard for the administrative, technical, and physical safety of protected health information (PHI).
ELECTRONIC PATIENT RECORD SYSTEM
insurance transactions such as: enrollment, encounters, and claims (transaction standards) This standard
requires the implementation of a uniform set of codes and forms, such as the American National Standards Institute (ANSI)
STANDARD ELECTRONIC FORMATS
- institutions, personnel, diagnoses, and treatments. National Identifier Standards: Employers Identification Number (EIN). Health Plans (Payers ID) and Healthcare Providers.
STANDARD IDENTIFIERS AND CODES
Four categories of Codes used to encode all healthcare data
- ICD-9 - Diseases
- ICD-10 - Injuries
- CPT-4 - Prevent, Diagnose, treat or manage diseases
- HCPCS - Substance, Equipment, and Supplies
confidentiality and privacy rules: This created a new
national standard for the privacy of protected health information.
PATIENT INFORMATION
TJC, formerly known as The Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) was founded in _____________ as a _____________
1951, non-profitable organization
In what year when did TJC began requiring hospitals and other healthcare providers to perform
and document specific quality assurance procedures for these facilities to obtain
accreditations.
1970s
in what year did TJC used the concept of quality assurance and quality control,
requiring systematic monitoring and evaluation with the responsibility left to the
medical director or department head.
Before 1991
Evolution of CQI
- TQM - Total Quality Management
- TQC - Total Quality Control
- TQL - Total Quality Leadership
- TQI - Total Quality Improvement
- SQC - Statistical Quality Control
Concept of process improvement through CQI
- 85/15 Rule
- 80/20 Rule
85/15 Rule
85% the problem lays in the system
15% of the problems can be traced back to personnel causing the problem
80/20 Rule
80% of the problem are results,
20 % of the causes.
Parts of the Process
- Supplier
- Input
- Action
- Output
- Customer
an individual or entity that furnishes input to a process (person, department, organization) or one who provides the institution with goods and
services.
Supplier
information or knowledge necessary to achieve the desired outcome or everything used to produce one or more outputs from a process.
Input
means or activity to achieve the desired outcome or the steps or activities carried out to convert inputs to output.
Action
refers to the desired outcome, results, product, or characteristics that satisfy the customer or one or more outcomes or physical products emerging from a process.
Output
refers to a person, department, or organization that needs, uses, or wants the desired outcome or process.
Customer
According to this person, the customer determines what constitutes quality. this can be broken down into the following groups.
W. Edwards Deming
groups or individuals within the organization such as referring physicians, Hospital Employees, Departments, and department
employees.
Internal customers
outside the organization, such as patients, families, thirdparty payers, and the community.
External Customer
Comprehensive Control Plan
- Data collection trackers such as patient waiting time and repeat analysis.
- Control Chart or other information display tools.
- Action Plan trackers with responsibility and timelessness to address out of control situations.
- Review Mechanism.
CLASSIFICATION OF METRICS
- Financial
- Utilization
- Cost/Productivity
- Clinical Performance
- Patient Safety
- Patient Satisfaction
- track the financial performance of the healthcare system from a business perspective (usually standard financial/accounting data).
Financial Metrics
Characterize the number and type of essential services rendered, the sources used, and the care availability.
Utilization Metrics
reduces supply/labor costs and increases productivity
Cost/Productivity metrics
also known as patient outcome data- measures the quality of patient care, such as mortality rates and accuracy of diagnosis.
Clinical Performance metrics
metrics that characterize preventable medical mistakes that
are made.
Patient Safety metrics
measure satisfaction from a patient’s perspective.
Patient satisfaction metrics
5 MAJOR CATEGORIES OF KEY PROCESS VARIABLES
- Manpower
- Machines
- Materials
- Environment
- Policies
refers to the personnel involved in this process.
Manpower
refers to the equipment used in the process
Machine
refers to the type and quality of materials used.
Materials
refers to the physical and psychological aspects of the people involved in the process
Environment
refers to the steps in the procedures or policy manual used in the process
Policies
COMPONENTS OF A QUALITY MANAGEMENT PROGRAM IN DIAGNOSTIC IMAGING
- EQUIPMENT QUALITY CONTROL
- ADMINISTRATIVE RESPONSIBILITIES
- RISK MANAGEMENT
- RADIATION SAFETY PROGRAM
- RECORD-KEEPING SYSTEM
- CORRECTIVE ACTION
Quality management program involves evaluation of equipment performance to
ensure proper image quality as well as patient safety.
EQUIPMENT QUALITY CONTROL
involves the establishment of various processes to accomplish specific department tasks that are required, such as a departmental procedure manual for performing diagnostic procedures.
ADMINISTRATIVE RESPONSIBILITIES
ability to identify potential risks to patients, employees, and visitors at healthcare
Institutions and establish processes that would minimize these risks is extremely
important to healthcare organizations.
RISK MANAGEMENT
to ensure that patient exposure is kept As Low As Reasonably Achievable
(ALARA) and that department personnel, medical staff, and members of the
general public are protected.
RADIATION SAFETY PROGRAM
ADMISTRATIVE RESPONSIBILITY
- Threshold Acceptability
- Communication Network
- Patient Comfort
- Personnel Performance
- includes levels of accuracy, sensitivity, and specificity of diagnosis.
- also includes the number of radiographs per examination, the amount of radiation
per examination, and the performance thresholds of the equipment.
Threshold Acceptability
Proper communication includes report, dictation, transcription, and distribution to
the ordering physician and other interested parties.
Communication Network
Convenience and privacy should be provided within reasonable limits in diagnostic imaging departments.
Patient Comfort
Factors of Patient Comfort
- Patient Scheduling
- Preparation
- Waiting time
- Ambient room temperature
- Politeness and consideration of personnel.
Policies should be developed to ensure that diagnostic personnel perform their
duties within accepted professional standards for proper equipment operation,
critical thinking, and interaction with patients and other personnel.
Personnel Performance
It’s necessary to document that quality management and quality control procedures are being implemented and comply with accepted norms.
Record-Keeping System
must be taken and documented if equipment or personnel are not performing to accepted standards.
Corrective Action
is the system or process for identifying, analyzing, and evaluating risks and
selecting the most advantageous method for minimizing them.
RISK MANAGEMENT
chance of damage to an organization.
Risk
is to maintain quality patient care and a safe environment for employees and
visitors while conserving the healthcare institution’s financial resources
Purpose of Risk Management
freedom from accidental injury or death and its a dimension of healthcare quality
Safety
failure of a planned action to achieve an outcome
Error
dentifying the potential risks to patients, employees, students, and visitors to the
diagnostic imaging department.
Risk Analysis
this risk can be reduced by having the appropriate policies and procedures and
ensuring that employees know and follow procedures.
Risk to Patient
this risk can be reduced by implementing appropriate policies and procedures
Risk to employees and Medical staff
to address the healthcare institution’s responsibility or the incident’s outcome.
POLICIES AND PROCEDURES
Fundamental Concept of Effective Risk Management Program
- Risk Analysis
- Written Policies and Procedures
- Record Keeping
- Employee Education
- Periodic Inspection
Fundamental Concept of Effective Risk Management Program
potential hazards and risks that can occur.
Risk Analysis
Fundamental Concept of Effective Risk Management Program
reduce all risks and deal with incidents as they occur.
Written Policies and Procedures
Fundamental Concept of Effective Risk Management Program
to document all policies and procedures that have been
implemented.
Record Keeping
Fundamental Concept of Effective Risk Management Program
inform of all policies and procedures and seek employee input to identify and reduce further risk.
Employee Education
Fundamental Concept of Effective Risk Management Program
Ensure all policies and procedures are being implemented.
Periodic Inspection
RADIATION SAFETY PROGRAM - FEDERAL AGENCIES
- FDA (FOOD AND DRUG ADMINISTRATION
- NRC (NUCLEAR REGULATORY COMMISSION)
- OSHA (OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION)
AGENCIES UNDER FDA
- Center for Devices and Radiological Health (CDRH)
- Center for Device Regulatory, Radiation Health and Research (CDRRHR)
agency that is responsible for enforcing both equipment standards and radiation
safety practices
NRC (Nuclear Regulatory Commission)
This agency is responsible for establishing standards for safety and monitoring
the workplace environment, including the requirements for occupational exposure
to radiation, handling and disposal of hazardous materials, universal precautions
(Tier 1) for protecting employees from infectious diseases, and personal
protective equipment.
OSHA (Occupational Safety and Health Administration)
3 CLASSIFICATIONS OF ALL MEDICAL DEVICES
- Class 1- General Control
- Class 2 - Special Control
- Class 3 - Premarket Approval
Categories of all Medical Devices
subject to least regulatory control and present minimal potential for harm to the user.
Class 1- General Control
Categories of all Medical Devices
for which general controls alone are insufficient to assure safety and effectiveness.
Class 2 - Special Control
Categories of all Medical Devices
This is the most stringent device regulatory category. this category, insufficient information exists to ensure safety and effectiveness solely
through general or special control.
Class 3 - Premarket Approval
