quality improvement Flashcards
qi d
combined efforts of hcp, pt, fams, resarchers, planners, pauerts, educaots
to make changes > betwer pt oucome (health
sys perdormance (Care
progessional development (learning
key groups invovled in qi progect
project lead
surpervisor
qi team or impovement speciailist
wider team
proect lead
drive project forward
devleop + implement improvement ideas
urpervisor
sneoir clinical
give expert advice
qi team or impovement speciailist
expwrt adivce
or suport implementaxn + evaluaxn of change
wider team
support of collaeages > implement + sustain chamge
improvement model key qus
what try accomplish
howknow impvoemnt change
wat change > i,r[pve,emt
eg mod
pdsa plan do study act cyle
what try accomplish
what impve = specific pt cohort , groups target
l test change = measurable
by how much impvoe by = achevable
-baseline der Realistic
qhen achieve = time bound
how know change impvovment
outocme
process
balacning
clinical audit
report harm never/ near miss
pdsa
reflective learning cycle
aim = continuous improvement
llearn from small sclae changes tested 1 at a time
review
mod for improcemnet
expanded verxn of pdsa
performancce benchmark
compare performance to standards
or sme else performance
healthcare dialure modes + effects analsis
check at every stpe what can go wrong
to find out underlying cause> risk
lean/ 6 sigma
eliminate waste/ chance for defect
process map
pt journey
from when arrive at hospital> dishcarge
elements devallue or give vaue w services?
statistical proces control
certainamount data as baseline
sma eamount data post intervenxn
compare 2 data sets + c if improve
root cause analusis
start w prod
docus on find sol
until reach root cause
targ rot cause + try resolve
communicax tools
eg sbar
starndardised
technolicial innovaxns
changes to sys w tech
eliminate chnace for defect
eg prev human errors
decizn trees
consider poss impact of decizn
= come up deif scenarios after decixn
process measure
evaluate impact of process being changed or intro
evalueate uptae of intervenxn
balancing
unintetnded conseq bc of intetvenxn
plan in pdsa
obectice
predict
who what ehen wehere what data
do
try test on small scale
focument probs + unexpected obsevaxn
study
analyse data
comapre data to
summarise + reglect predixn
act
regine change, based on what learned from test
paln mods for next test
end result pdsa
adopt change
adapt chnage + do another pdsa
abdanfom change + another pdsa
how oclelct robust data
plana for data collexn + ensure consistend
clear operaxnal d for each measure
clear on excluxn
aware of pos stratfiiers
dec varauxn eg si, conds
baseline data d
intial dat collected b4 pdsa
f baseline
evluate impact of intervenxn
reocmmened no baseline data pts
20-30
ty charrts
bar
run
Statistical Process Control (SPC)
run chart
darta plot over time
often w median
spc +Ve
more useful for qi than run charrts
spc hw
mean as centre line
upper + lower control limit
control limit
3 sd from mean
common cause variaxn
if all data pts win control limits , data under control
exoect further data between control limits
speciical cause variaxn
rules tell when data not under control
+ smg happened to cage way data behaves
rules sv
astronomical pt = outside limits
8+ consecutive pts anove /below mean line
trend - 6+ consecgtutrive inc or dec pts
2 of 3 cpsecgiove pts win 1sd control limits
15+ consectuvie pts win 1sd of mean (inner 1/3 chanrt
stop the line
- say what u c
2say what concerned about
swy what want to happen to keep pt safe
stop the line
Components of a good safety
culture:
Good levels of reporting • Whistle-blowers treated fairly • Just culture • Learning from incidents - LEG • Freedom to Speak Up • Pro-active identification of latent errors • Creating psychological safety – A