Module 6: Initiatives In Health Care Quality Improvement Flashcards
Per the Institute of Medicine, how is quality defined?
When health services increase the likelihood of desired health outcomes and are consistent with current professional knowledge.
Per the Institute of Medicine how is safety defined?
The prevention of harm to patients.
Per the Institute of Medicine how is patient safety defined?
Freedom from accidental or preventable injuries caused by medical care.
What must a system of care delivery focus on in order to support quality and safety?
- Preventing errors
- Learning from errors that do occur
- Building on a culture of safety that involves health care professionals, organizations and patients.
What experiment had this conclusion: failure is not the result of the participants’ performance but rather a bad process.
The red bead experiment
What are zero-gravity thinkers?
People who might have little expertise about a particular problem or situation but they offer fresh ideas that are nor bound by an existing knowledge base.
What 2 reports by the Institute of Medicine shifted the focus from issues of access to quality in improvement?
To Err is Human in 1999 and Crossing the Quality Chasm in 2001.
What concerns did To Err is Human in 1999 and Crossing the Quality Chasm in 2001 raise?
Raised serious concern about quality and safety.
The report estimated that 98k people die each year as a result of medical errors in US hospitals and that preventable adverse events alone account for 8.8 billion in health spending.
What is total quality management?
A management approach to long-term success through customer satisfaction in which all members of an organization participate in improving processes, products, services, and the culture in which they work.
What is the Baldrige Award?
The program that recognize and improve performance of the nation’s businesses, hospitals, schools, non profit organizations and government agencies.
What organization was founded in 2000, made up of large employers and other health care purchasers with a common goal to drive giant leaps forward in quality and safety of US health care
Leapfrog Group
What is lean in health care?
Process improvement approach that focuses on:
1. Defining value from the patient point of view
2. Mapping value streams
3. Eliminating waste to create continuous flow
How is lean applied in health care?
Lean is often coupled with the plan do study act (PDSA) cycle, also known as the Deming cycle
What are the 8 types of waste that Lean strives to eliminate?
- Defects
- Overproduction
- Transportation
- Waiting
- Inventory
- Motion
- Over-processing
- Skills or human potential
What is High Reliability Organizations (HRO)?
HRO’s function under difficult and demanding conditions yet have fewer problems than one might expect because they have learned how to manage the unexpected and learn from past experience.
What are the 5 characteristics of HRO’s?
- Preoccupation with failure
- Reluctance to simplify
- Sensitivity to operations
- Deference to expertise
- Commitment to resilience
Under HRO, what is preoccupation with failure?
Everyone is always thinking about potential failure. Near misses are viewed as opportunities to learn about system issues and potential improvement
Under HRO, what is reluctance to simplify?
People resist simplifying their understanding of work processes and how and why things succeed or fail in their environment.
Under HRO, the bag is sensitively to operations?
Big picture thinking of situational awareness. What is going on around them and how the current state might support or threaten safety.
Under HRO, what is deference to expertise
Knowing that under a crises or emergency, the person with greatest knowledge of the situation may not be someone with the highest status or seniority.
Under HRO, what is commitment to resilience?
The team always assumes the system is at risk for failure so they practice performing rapid assessments of and responses to challenging situations.
Explain how a checklist helps with errors in repetitive procedures?
Because the human mind is capable of 90% rate of accuracy, using a checklist ensures that all proper steps are completed in the correct order.
What is safety culture under Crossing the Quality Chasm?
“The biggest challenge to moving toward a safer health system is changing the culture from blaming individuals for errors to one in which errors are treated not as personal failures, but as opportunities to improve the system and prevent harm.”
The CDC doesn’t report ________ ________ as cause of death. But if it were recorded then this would be ranked the country’s 3rd leading cause of death after heart disease and cancer.
Medical errors
