NIS document ch2 Flashcards
definition of quality
Merriam-Webster defines quality as “a high level of value or excellence.”
What is the definition of “quality of care” by The institute of Medicine?
“the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”
“the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”
definition of “quality of care” by The institute of Medicine
How does “quality of care” relate radiology?
“the extent to which the right procedure is done in the right way, at the right time, and the correct interpretation is accurately and quickly communicated to the patient and referring physician. The goals are to maximize the likelihood of desired health outcomes and to satisfy the patient.”
What are two important dimensions of quality?
excellence. consistency.
How does an organization achieve consistent excellent performance?
performance must be monitored to ensure consistent quality by performance standards or measurements.
goals to achieve consistent excellent performance?
The goals are two fold:
1) maximize the likelihood of health outcomes desired by the patient and
2) satisfy the patient. In other words, optimizing health outcomes and patient experience are both important goals of healthcare.
Who is the ultimate arbiter of “quality”?
the patient
We must understand and seek to achieve consistent excellence from the perspective of the patient—which may differ from ours.
What is the major goal of quality?
decreasing unnecessary variation, both in processes and outcomes. In a practice with multiple professionals, this generally requires those professionals to collaborate in developing and adhering to practice standards based on the evidence.
Refers to measuring and testing elements of performance to ensure that standards are met and correcting instances of poor quality.
quality control
what is quality control
Refers to measuring and testing elements of performance to ensure that standards are met and correcting instances of poor quality.
a radiologist reviews and corrects errors in a radiology report before finalizing it.
quality control
What is quality assurance?
Refers to a process for monitoring and ensuring performance quality in an organization. PREVENTION using PROCESSES
standardized report templates to minimize errors in reporting accompanied by verification of appropriate use with audit-based performance metrics.
quality assurance
Refers to activities designed to improve performance quality in an organization in a systematic and sustainable way.
quality improvement
radiologists agree to improve consistency in reporting using standardized radiology report templates, implement those templates, monitor radiology reports and make necessary adjustments, and ensure that consistency is maintained through feedback and accountability
quality improvement
what is quality improvement
Refers to activities designed to improve performance quality in an organization in a systematic and sustainable way.
what is transparency
Exposing errors allows them to be more easily detected so they can be corrected and their causes addressed.
Exposing errors allows them to be more easily detected so they can be corrected and their causes addressed.
transparency
Who published a report entitled, “Crossing the Quality Chasm: A New Health System for the 21st Century.”
Institute of Medicine
What is important to know about the IOM’s 2001 quality chasm report?
all healthcare stakeholders should work together to improve healthcare by reducing the burden of illness, injury and disability
IOM commitee six things
SEPTEE. Safe. Effective. Patient centered. Timely. Efficient. Equitable.
Safe. Effective. Patient centered. Timely. Efficient. Equitable.
six things from “Crossing the Quality Chasm: A New Health System for the 21st Century.”
ACGME and ABMS describes these six core competencies that all physicians should attain:
LSsbKCP
- practiced based Learning and improvement
- patient care and procedural Skills
- Systems-Based knowledge
- medical Knowledge
- interpersonal and Communication skills
- Professionalism
What is practice-based learning and improvement?
Shows an ability to investigate and evaluate patient care practices, appraise and assimilate scientific evidence, and improve the practice of medicine.
Shows an ability to investigate and evaluate patient care practices, appraise and assimilate scientific evidence, and improve the practice of medicine.
practice-based learning and improvement (core competency for residents)
Provide care that is compassionate, appropriate, and effective treatment for health problems and promote health.
patient care and procedural skills (core competency for residents)
patient care and procedural skills (core competency for residents)
Provide care that is compassionate, appropriate, and effective treatment for health problems and promote health.
systems-based practice (core competency for residents)
Demonstrate awareness of and responsibility to the larger context and systems of healthcare.
medical knowledge (core competency for residents)
Demonstrate knowledge about established and evolving biomedical, clinical, and cognitive sciences and their application in patient care.
What is interpersonal and communication skills?
Demonstrate skills that result in effective information exchange and teaming with patients, their families, and professional associates (e.g., fostering a therapeutic relationship that is ethically sound; using effective listening skills with nonverbal and verbal communication; and working both as a team member and, at times, as a leader).
What is professionalism?
Demonstrate a commitment to carrying out professional responsibilities, adhering to ethical principles, and being sensitive to diverse patient populations
Who wrote “To Err is Human”?
National Academy of Sciences’ Institute of Medicine
How many deaths per year attributed to human errors in healthcare?
44,000 to 98,000
What are the findings of the “To Err is Human: Building a Safer Health system”?
The report’s findings that between 44,000 and 98,000 in-hospital deaths per year were attributable to medical errors made national headlines, including a suggestion that an epidemic of death from medical errors exceeded that from motor vehicle accidents, breast cancer, or AIDS.
How much do medical errors cost the society?
The report projected total societal costs of medical errors to be between $17 billion and $29 billion.
What is the definition of medical error by “To Err is Human: Building a Safer Health system”?
the failure of a planned action to be completed as intended
the use of a wrong plan to achieve an aim, with the highest risk for errors occurring in high-acuity environments such as the ICU, OR, or ED.
According to “To Err is Human: Building a Safer Health system”, what are several fundamental factors contributing to the errors?
1) the decentralized nature of the healthcare delivery system (or “nonsystem,” as the report calls it)
2) the failure of licensing systems to focus on errors
3) the impediment of the liability system to identify errors
4) the failure of third party providers to provide financial incentive to improve safety.
According to “To Err is Human” what can most errors be attributed to?
unsafe systems and processes of care. AND human error.
What is the only strategy to decrease medical errors?
To design safety into systems and processes of care.
What is the definition of diagnostic error?
“the failure to
(a) establish an accurate and timely explanation of the patient’s health problem(s)
or
(b) communicate that explanation to the patient.”
Who is considered the key team member in the collaborative efforts required to prevent diagnostic error?
patients
Why is diagnostic error underappreciated?
Data on diagnostic error are sparse, few reliable measures exist
Often the error is identified only in retrospect.
A poll commissioned by the National Patient Safety Foundation in 1997 found that approximately ______________________ of those surveyed had experience with diagnostic error, either personally or through a close friend or relative.
A poll commissioned by the National Patient Safety Foundation in 1997 found that approximately one in six of those surveyed had experience with diagnostic error, either personally or through a close friend or relative.
On average, _________%of postmortem exams were associated with diagnostic errors that might have affected patient outcomes.
On average, 10% of postmortem exams were associated with diagnostic errors that might have affected patient outcomes.
What is the significant contributor to diagnostic errors with respect to radiology according to 2015 IOM report?
failures in communication
What are two major parts of Communication?
CONVEYANCE: transmission information from a sender to a receiver
CONVERGENCE: verification, discussion, and clarification
CONVEYANCE:
transmission information from a sender to a receiver
transmission information from a sender to a receiver
Conveyance
verification, discussion, and clarification
convergence
CONVERGENCE:
verification, discussion, and clarification
organization that, despite operating in a high-stress, high-risk, complex environment, continually manages its environment mindfully, adopting a constant state of vigilance that results in the fewest number of errors.
Definition of a high reliability organization
Definition of a high reliability organization
organization that, despite operating in a high-stress, high-risk, complex environment, continually manages its environment mindfully, adopting a constant state of vigilance that results in the fewest number of errors.
What key features does a culture of safety encompass?
ABCC: Acknowledge, blame free, collab, commitment
Why is authority gradients bad?
there is fear of punishment for errors, quality and safety problems are rarely reported to senior leadership.
undermine the safety culture
increase the difficulty of accurately measuring error rates
Available validated surveys for measuring and achieving culture of safety
AHRQ’s Patient Safety Culture Surveys and the Safety Attitudes Questionnaire.
According to just culture, the response to error is predicated on the outcome of the event? T/F
FALSE
In this model, the response to an error or near miss is predicated on the type of behavior associated with the error, not the outcome or severity of the event.
What is reckless behavior?
firmly established safety norms are willfully ignored
such as a physician who refuses to perform a time out before surgery, may merit firm—possibly punitive—action, even if no patients were harmed.
What is at-risk behavior?
those persons who engage in at-risk behavior— e.g., workarounds of convenience, such as failing to communicate critical results, that could subvert established safety precautions—probably underestimate the risks of their actions. These persons are counseled or coached in the Just Culture Model
firmly established safety norms are willfully ignored
such as a physician who refuses to perform a time out before surgery, may merit firm—possibly punitive—action, even if no patients were harmed.
reckless behavior
What is the primary focus of a safe-reporting system?
the patient
the event
the processes and systems to identify opportunities for sustainable improvement.
NOT the person making error as long as the individual was not acting recklessly.
what is the “second victim”?
The term “second victim” has been coined for a healthcare worker who is traumatized by an error or adverse patient event in which they were involved.
These individuals often feel an intense sense of guilt, sorrow, and anxiety, and may even exhibit signs similar to post-traumatic stress disorder. Many hospitals have begun to develop internal programs to identify, console, and advocate on behalf of such individuals.
disciplinary action for human error
console
innocent human error, even if this error resulted in significant patient harm, would be consoled since human errors are considered to be inevitable and not necessarily the result of negligence.
disciplinary action for reckless behavior
punishment/sanctions
disciplinary action for at-risk behavior
coach
