Organizing and Evaluation PI Flashcards
who bears ultimately responsibility for quality of pt care
BOD, expected to spend more than 25% of time on quality and safety activities
responsibility of BOD
expected to spend more than 25% of time on quality and safety activities
develop plans, monitor, assess
hire employees to implement procedures to assess and improve the quality of important functions
ex of hosp PI org chart
BOD > Hospital director meeting = medical staff department meetings = medical exec committee > PI and pt safety council > various councils
Strategic Planning four aspects
strength
weakness
opportunity
threat
SWOT- ex of strength in rural HC
local, creative
exp physician
trained staff
central location
strong commitment
transport
SWOT- weakness ex in rural HC
no specialty, primary care
lack of funds
loss of key staff
pt load
lack of tech
SWOT- opportunity ex of rural HC
org and tech
local leader participation
coordination with NGO
improved safety sys
telemedicine for specialty
strong referral sys
SWOT- threats ex of rural HC
no govt budget, inflation
pt prefer them
loss of alliances
misinformation
competitors has new products
PI plan design purpose
evaluate all existing, new, modified, and high risk processes
PI
designing, measuring, assessing, and improve process of carrying out task
PI activities are planned in a
collaborative and interdisciplinary manner
how is perform measures defined or selected?
criteria either defines or selects measures from external source
what happens to PI data
sys collected, aggregated, and analyzed on ongoing basis
criteria for setting priorities on what to improve
more opportunities than can be acted upon - choose only a few
high risk, high volume, problem prone problems,
degree of adverse impact on pt care if improve opportunity left unsolved
degree of which pt safety is improved
JC requires data reported on
med manage
blood produce use
restraint and seclusion use
behavior manage and treatment
operative and invasive procedures
resuscitation and outcomes
implementation of PI delegated from BOD to
PI and pt safety council
what does delegated council define
which committee, departments, and staff are responsible for data collection, assessing, and reporting findings
figure out scope and focus of what is measure, freq and intensity of data collection
PI plan evaluation (4)
- whether approach to PI plan is planned sys and org-wide
- whether approach to PI plan is collab
- whether approach needs redesign, due to changes in strategic plan of org
- whether prog was effective in PI
Program review
explains the need for PI and what priorities were selected, how priorities were addressed in PI plan
component of program review
executive summary - what is main problem or state of program (most important info)
overview
PI structure- who will be responsible
improvement opportunities
- pt focused, ongoing measurements, quality data reporting
PI team activities- what is being done
other components of program review
customer satisfaction
risk exposure
HR development
accreditation/licensure
PI program effectiveness and recommendations
managing BOD PI activities
in charge of coordinating program to services and departments
monitor clinical and nonclinical program
reporting frequency, format, timing- need updates
dashboard
provides valuable info that is in easily readable format and can be used as guide for making manage decisions
standing med staff committees
ethics, credentials, pharm/therapeutics, utilizations, documentation standards, environmental safety, departmental
