Quality and Safety Flashcards
Define a process measure.
A measure of the processes performed by a system. For example, data showing how often pharmacologic DVT prophylaxis is ordered is a process measurement.
Define an outcome measure.
An outcome measure quantifies an outcome regardless of the processes which influenced it. For example, the total number of DVTs (regardless of whether or not prophylaxis was ordered/administered) is an outcome measurement.
Define a balancing measure.
Balancing measures monitor for new problems which may arise following the implementation of a given process measure. For example, if a hospital puts processes in place to decrease length of stay, the readmission rate would be a reasonable balancing measure.
Name the four elements of the PDSA cycle.
Plan, do, study, act
Is FMEA (failure modes and effect analysis) used before or after an adverse outcome occurs?
FMEA is a process improvement tool used to identify how a process might fail and what the impact of that failure will be. It fits in the do/study/act portion of the PDSA cycle and is a proactive way to diagnose parts of a new or existing process that need revision before a bad outcome occurs. The hope is to prevent a sentinel event before it happens.
Define sentinel event.
A sentinel event is an unexpected occurrence, unrelated to the expected course of care, involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function.
What is a root cause analysis, and what are its component parts?
A root cause analysis is a tool used to analyze serious adverse events or near misses. Each RCA uses a structured method that includes data collection, record review, and participant interviews to determine the sequence of events that resulted in the error.
What do six sigma projects attempt to accomplish?
Six stigma projects attempt to reduce variation in order to increase quality by making a process more predictable and effective.
Name a goal of lean management.
The main goal of lean management is to enhance customer value by eliminating waste.
What is a just culture?
A just culture eliminates punishment for an unintentional human error and instead focuses on redesigning process flaws to improve patient safety.
Why do hospitals use HCAHPS (hospital consumer assessment of health care providers)?
HCAHPS is tied into hospital reimbursement and the scores are publicly reported.
