Quality Improvement Flashcards
Structured approach to enhancing healthcare services and patient outcomes
Healthcare quality improvement
What are the focuses of performance improvement?
- clinical outcomes
- customer satisfaction
- service
Responsibilities of the infection preventionist in quality improvement
- broad continuous quality improvement studies
- usage of systematic programs and tools
- determining program outcomes for patient safety
What report drove changes in quality infection prevention and control programs?
Institute of medicine report “to err is human” and “crossing the quality chasm”
According to the institute of medicine what are the six aims of care?
- Equity
- Safety
- Effectiveness
- Patient centeredness
- Timeliness
- Efficiency
What are the three tools for quality improvement?
Strategic plans
Performance improvement teams
Analysis tools
Systematic process that organizations use to define their long-term objectives and goals and determine the most effective means of achieving them while aligning with their mission and values
Strategic planning
What are the key phases for strategic planning?
Organizational analysis
Conclusion drawing
Action initiation
Describe organizational analysis as part of strategic planning
Evaluates the institutions current state, strength, weaknesses, opportunities, and threats
Describe the IPC strategic plan
- process of risk prioritization
- strategies for limiting exposure and transmission
- continuous evaluation and adaptability
Describe the performance improvement team
- Foster commitment and a unified direction
- view organizations as interconnected systems
- collaborative and multidisciplinary
Methods to sustain productivity on performance improvement team
1) diverse team
2) role clarity
3) consistent brainstorming (and senior members mentor and guide team)
4) team norms (dos and donts)
5) guidance and and support (navigate team conflicts)
6) evolution
What are the quality analysis tools?
- Gap analysis
- root cause analysis
- failure mode effect analysis
- strength, weaknesses, opportunities, and threat analysis
- the plan, do, study, act performance improvement model
Best quality assessment tool compares how an organization currently operates and how it wants or ought to operate
Gap analysis
This quality analysis tool is retrospective analysis of adverse outcomes it aims to discover the underlying causes for incidents and provide insights that can be used to redesign or modify systems
Root cause analysis
How to perform a root cause analysis
- multidisciplinary teams
- structured interview and document reviews
- tools like the fishbone diagram
Quality analysis tool that’s a proactive approach to identify potential failures in a process
Failure mode effect analysis
How to perform a failure mode effect analysis
- Selection of high risk processes
- Creation of flow diagrams
- Rating failure is for severity and probability
Quality analysis tool that assesses internal strengths and weaknesses and the external environment with opportunities and threats
SWOT analysis
What are the parts of the SWOT analysis
1) strengths - what do you do well
2) weaknesses- where do you need to improve
3) opportunities- what are your goals
4) threats- what obstacles do you face
Quality assessment tools that focuses on process optimization specifically reducing variation and eliminating non-value added steps
Six sigma and the lean approach
What is the dmaic improvement process?
Part of six sigma
- Define the project goals and customer deliverables (d)
- measure the process to determine current performance and quantify the problem (M)
- analyze and determine the root cause of the defects (A)
- improved process by eliminating defects (I)
- control future process performance so improved process doesn’t degrade (C)
This quality assessment model test strategies, scrutinizes outcomes, fine tunes the approach based on feedback, and then test again
The plan do study act model
How to make decisions about quality improvement
- multi voting
- goal directed checklist
- process control, charts, graphs, and clinical practice guidelines
Describe multivoting
- prioritization technique after brainstorming
- narrows down areas of focus
- efficient method for goal determination
examples of visual tools for analysis
-Run charts for trends over time
-Fishbone diagrams for identifying cause
-paretocharts for categorization and prioritization
What are the two kinds of variation
Special cause variation
Common cause variation
Describe special cause variation
- anomalies
- process is not predictable
- management action required
Describe common cause variation
+ inherent
+ Natural fluctuation
+ Management action not required
Who are the external stakeholders that shape clinical practice guidelines
Public health department and regulatory agencies
What are the expectations of clinical practice guidelines from external stakeholders?
- evidence-based practice and rule compliance
- monitoring performance
- alerts for potential health hazards or infectious outbreaks
Who are the internal stakeholders for clinical practice guidelines
Healthcare personnel
What are the clinical practice guidelines for internal stakeholders?
+ routine reduction of infection exposure
+ Receive an analyze surveillance data
+ Review program policies
+ Continuous education on infection prevention
How to measure customer expectations
- satisfaction surveys
- complaint hotline
- open dialogues
- suggestion based interviews
Statistical process control chart
Study changes in process over time and measures processes and outcomes, determine special cause / common cause variation
