Module 3 Flashcards
An evidence- and risk-based comprehensive system that promotes a culture of patient safety, sets policies and procedures to minimize or reduce healthcare-associated infections (HAIs) in hospitals and other healthcare settings, monitors compliance, and
addresses the need to continuously improve.
Section A: Planning and Implementing Risk‑Based IPCPs
Infection prevention and control program (IPCP)
A diagnostic tool for identifying trends and interventions that will help prevent and control
infections.
Section A: Planning and Implementing Risk‑Based IPCPs
Risk assessment
Section A: Planning and Implementing Risk‑Based IPCPs
Professionals who make sure that healthcare workers and residents are doing all the things they should to prevent infections. (APIC)
Section A: Planning and Implementing Risk‑Based IPCPs
Infection preventionist (IP)
The group of people responsible for carrying out all aspects of the IPCP as delegated by facility leadership; the core of this team includes the IP, the chair of the IPC committee, the healthcare epidemiologist (if this position is staffed at the facility), and possibly someone responsible for occupational health or administration.
Section A: Planning and Implementing Risk‑Based IPCPs
IPC team
The set of values, guiding beliefs, or ways of thinking that are shared among members of an organization.
Section A: Planning and Implementing Risk‑Based IPCPs
Organizational culture
Any negative impact event involving one or more patients in a healthcare setting, including but not limited to sentinel events, drug-related errors, HAIs (including surgical site infections), technical or nontechnical competency errors, diagnostic mishaps,
therapeutic mishaps, or process errors.
Section A: Planning and Implementing Risk‑Based IPCPs
Adverse event
An event resulting in death or serious physical or psychological harm or the risk thereof.
Section A: Planning and Implementing Risk‑Based IPCPs
Sentinel event
An event in which the unwanted consequences were prevented because there was a recovery by planned or unplanned identification and correction of the failure.
(AHRQ)
Section A: Planning and Implementing Risk‑Based IPCPs
Near-miss
An external failure in a plan due to reduced intentionality.
Section A: Planning and Implementing Risk‑Based IPCPs
Slip
An internal failure occurring from failures of memory and memory storage.
Section A: Planning and Implementing Risk‑Based IPCPs
Lapse
An integrated approach to emergency preparedness planning that focuses on capacities and capabilities that are critical to preparedness for a full spectrum of emergencies or disasters; the approach is specific to the location of the provider or supplier and considers the particular types of hazards most likely to occur in their areas. (Federal Register)
Section B: Infection Prevention and Control Risk Assessments and Plans
All-hazards approach
A tool that helps ensure that each list element is thoroughly considered or reviewed, that nothing is missed; checklist elements should reflect evidencebased good p
Section B: Infection Prevention and Control Risk Assessments and Plans
Checklist
Methods to promote the use of evidence-based practices to improve healthcare quality.
Section B: Infection Prevention and Control Risk Assessments and Plans
Implementation science
A process of meeting quality standards and assuring that care reaches an acceptable level. (CMS)
Section C: Planning for Quality Assurance and Performance Improvement
Quality assurance
An ongoing continuous cycle that focuses on resident clinical outcomes, customer satisfaction, and service.
Section C: Planning for Quality Assurance and Performance Improvement
Performance improvement
A snapshot of an organization’s intended future.
Section C: Planning for Quality Assurance and Performance Improvement
Vision statement
A description of the organization’s purpose or goal; used to guide decision making and actions.
Section C: Planning for Quality Assurance and Performance Improvement
Mission statement
A quantitative tool that provides an indication of an organization’s performance in relation to a specified process or outcome.
Section C: Planning for Quality Assurance and Performance Improvement
Performance measure
A measure that assesses features of a healthcare organization or clinician relevant to its capacity to provide healthcare. (CMS)
Section C: Planning for Quality Assurance and Performance Improvement
Structural measure
A performance measure that looks at a system from multiple angles or dimensions to avoid unintended consequences from a change in a different part of the system.
Section C: Planning for Quality Assurance and Performance Improvement
Balancing measure
A type of performance measure designed to evaluate the processes or outcomes of care associated with the delivery of clinical services, to allow for intra- and interorganizational comparisons to be used to continuously improve resident health outcomes, and to focus on the appropriateness of clinical decision making and implementation of these decisions.
Section C: Planning for Quality Assurance and Performance Improvement
Clinical measure
The level below which the process being used to reach a higher goal needs revision or improvement.
Section C: Planning for Quality Assurance and Performance Improvement
Minimum performance threshold
Evaluates whether findings can be repeated consistently when applied to new populations, to different institutions, or by different individuals. (Quality Indicator Study Group)
Section D: Implementing Quality Assurance and Performance Improvement
Reproducibility
A systematic, proactive method for evaluating a process to identify where and how it might fail and to assess the relative impact of different failures in order to identify the parts of the process that are most in need of change.
Section D: Implementing Quality Assurance and Performance Improvement
Failure mode and effect analysis (FMEA)
A process for identifying the basic or causal factors that underlie variation in performance.
Section D: Implementing Quality Assurance and Performance Improvement
Root cause analysis (RCA)
A technique to compare best practices with current processes and determine the steps to take to move from a current state to a desired future state.
Section D: Implementing Quality Assurance and Performance Improvement
Gap analysis