Quality Control Flashcards
Who published To Err is Human and in what year?
The IOM in 1999
The IOM made these recommendations in 1999
- National patient safety goals
- Collecting evidence based knowledge on health care errors
- Voluntary and mandatory reporting of errors
- Getting practitioners and institutions involved in non-punitive reporting so that errors can be reported and fixed
This is the lead federal agency that works to improve patient safety, quality, and efficiency
AHRQ (Agency for healthcare research and quality).
- They are directed and funded by congress to provide evidence based solutions and tools to prevent medical errors.
The annual AHRQ report answers what three questions?
- What is the current status of health care quality/access/disparities?
- How have these changed over time?
- Where are these improving and where are these getting worse?
What did the patient safety and quality improvement act of 2005 do?
- Improved patient safety and quality by encouraging voluntary and CONFIDENTIAL reporting of adverse events.
- It also created patient safety organizations (PSOs) to analyze the anonymously reported events to look for patterns of failure.
How is quality monitored in a hospital?
- Peer review
- Risk management
- CQI programs
What is risk management?
- It’s purpose is to decrease the hospital’s exposure to liability
- tries to prevent patient injury, litigation, and financial loss
Anesthesia risk management
- Preventing injury
- Following standards of care
- Proper documentation
- Patient/customer service
What is the national practitioner databank?
It keeps records on
- malpractice payments
- actions taken against provider licenses (even if no formal action ends up being taken)
- DEA actions
- actions taken by credentialing bodies
- Basically, keeps tabs on all the bad shit on people’s records.
What is the difference between quality assurance and quality improvement?
Quality Assurance:
- Focused on adverse outcomes and the providers involved.
- Sought to blame.
- Looked to see if the actions taken were meeting standards.
- This had negative connotation and quality was not promoted because no one wanted to speak up when mistakes were made
Quality Improvement
- More positive connotation
- Emphasized improvement rather than blame
- Looks at mistakes as learning opportunities
What is the Donabedian Quality of Care Framework?
(3 parts and their definitions)
Improving health care delivery by measuring and improving a system’s structure, process, and outcomes.
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Structure = Organization of the facility and staff, patient care ratios, standards of organization, available equipment, etc
- Ex- Are poor patient ratios contributing to medication errors?
- Do standard tests for certain diagnoses exist?
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Process = How was the care conducted?
- Was it coordinated and sequential?
- Did the H&P take place?
- Were vitals monitored continuously?
- Was a BB given within 24 hours?
- Ex- Is a lack of a thorough H&P contributing to negative outcomes system-wide?
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Outcomes: Following the patient’s care,
- is the patient’s health status better, worse, or the same?
- Ex- Nerve injury rates, unplanned overnight admission in SDS, M&M rates, etc.
What is a standard?
A behavior/practice/skill that a provider must perform 100% of the time
What is an indicator?
Something that measures the process or outcomes of a hospital
- ex- are people giving BBs, doing the machine checkout, etc.
What is criteria?
Criteria defines the acceptable incidence of an event.
- Ex- The criteria for excellence in SDS is no more than 2% of SDS patients requiring extended stays in the PACU related to PONV
What is an adverse outcome?
A bad outcome for a patient.
- These are rare in anesthesia.
- Hard to tell if this is because of QI programs or just a random variation.
