Quality Improvement & Patient Safety

Question 1

The Bottom Line

Answer 1

-at least 250,000 deaths per year are due to medical errors in the US

Question 2

Patients experience…

Answer 2

at least one medical error per day

Question 3

how many without insurance

Answer 3

29mil

Question 4

how many do not recieve recommened care

Answer 4

25percent

Question 5

average lag between the discovery of tx and their incorporation into routine patient care

Answer 5

17 years

Question 6

causes of poor quality and outcome

Answer 6

• overuse of expensive technology
• underuse of inexpensive care service
• error-prone implementation of care that could harm patients and waste money
• poorly organized and uncoordinated HC delivery system

Question 7

Who was the original nursing quality improvement officer?

Answer 7

• florence nightingale

- identified poor living conditions was leading cause of death of soliders at army hospitals

Question 8

High reliability organizations

Answer 8

• nuclear power industry
• commercial air
• flight decks of aircraft carriers

-all share an overrarching atmosphere of collective mindfulness

Question 9

collective mindfulness

Answer 9

-all engaged and believe in vision/goal

Question 10

two other features of collective mindfulness

Answer 10

1. decrease deficiences by improving processes, recognize potential failures and report
2. organizations - “safety culture”

Question 11

Three additional requirements for acheiving high reliability in HC

Answer 11

1. leadership is up to board of trustees
2. safety culture - trust, report, and improve
3. robust process improvement

• begins with honest self-assessment
• replication of best practices (decrease variability)
• training of staff

Question 12

Cornerstones of Quality Care

Answer 12

how is quality measured by our patients?

• by patients needs/expectations/wants being met
• personal interactions with nurse, personnel
• care is individualized, considering needs and values (PCC)
• timeliness
• patient has a sense of control
• transparency
• needs are anticipated
• efficient use of resources, supplies
• cooperation, communication

Question 13

STEEEP

Answer 13

S: safe (preventing injuries)

T: timely (decrease patient wait times)

E: effective (EBP)

E: efficient (prevent waste)

E: equitable (care does not vary)

P: patient centered (respectful and responsive for all individuals)

**6 guiding aims for improvement

Question 14

Principles of Quality Improvement

Answer 14

• Analyze/Understand Process
• Select key aspects of process to improve
• Establish the TARGET to guide improvement
• Collect and plot data
• Interpret results
• Implement improvement action and evaluate effectiveness

Question 15

Flowcharts

Answer 15

steps in process

Question 16

Pareto charts

Answer 16

breaks down problems into its parts-key aspects

Question 17

Cause and effect diagrams

Answer 17

fishbone diagrams

-ID causes of problem in structured format

Question 18

Failure mode and effects analysis

Answer 18

FMEA - ID failures before they occur and minimize risk

Question 19

Root cause analysis

Answer 19

-ID factors that influence variability

Question 20

PDCA

Answer 20

P: Plan, develop an action based on 3 questions above

D: Do, take actions to test

C: Check, make refinements to plan as needed

A: Act, implement the changes in the real work setting

*fluid process, always with patient safety in mind

Question 21

Standardization

Answer 21

???

Question 22

Joint Commission

Answer 22

Accrediation

• Core Measures
• Sentinel Events
• NPSG
• Never Events

Question 23

Agency for Health Care Admin

Answer 23

ACHA

-state of florida

Question 24

Center for Medicare and Medicaid Services

Answer 24

CMS

-hospital acquired conditions

Question 25

The Role of the Nurse

Answer 25

• delivery of quality patient care
• monitor and initiate
• nursing quality indicators
• inter/intra professional collaboration communication to team
• lead by example
• patients first/patient safety
• be active in the process