Wk 2: CNS role in quality improvement

Question 1

IOM Quality definition

Answer 1

The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge

Question 2

Aims of Quality Care

Answer 2

1. safe- avoid injury from care that is intended to help them
2. effective- service based on scientific knowledge to those who benefit
3. Patient-centered
4. Timely- reduce wait time or harmful delays
5. Efficient- avoid waste
6. Equitable- provide care that does not vary in quality

Question 3

Pay for performance healthcare system

Answer 3

quality is a mandate for financial survival

Question 4

Quality Improvement considerations

Answer 4

what to accomplish, how will we know change is an improvement, what change will make improvement

Question 5

Benchmark

Answer 5

HC organizations identify and report on quality released benchmarks. NDNQI, CMS, NQF

Question 6

Benchmark measures

Answer 6

AHRQ National Quality Measures Clearinghouse and NQF website

Question 7

Internal benchmarking

Answer 7

Used to identify best practices within organization, compare best practices and compare current practice over time.

Question 8

External benchmarking

Answer 8

using comparative data between organizations to judge performance and ID improvements that have proven successful in other organizations

Question 9

Sentinel Event

Answer 9

Component of quality monitoring: an unexpected occurrence involving death or serious physical or psychological injury, or risk thereof.
Serious injury is loss of limb of function.

Question 10

Never events

Answer 10

NQF lists 29 never events. Inexcusable events that should never happen in HC regardless of circumstances. Non reimbursable serious HA events

Question 11

Root Cause Analysis (RCA)

Answer 11

retrospective approach to error analysis- rigorous application of established qualitative techniques

Question 12

Steps in RCA

Answer 12

Data collection- what happened
Data Analysis- sequence of events, goals of underlying factors- how event happened and ID failures. Establish why if happened if latent failures

Question 13

Failure Modes and Effects Analysis (FMEA)

Answer 13

forward logic- predicting a problem in system before they occur. Preventative strategy. Superior to RCA

Question 14

Fishbone Diagram

Answer 14

cause and effect diagram, useful in brain storming- ID causes.

Question 15

AHRQ mission

Answer 15

improve quality, safety, efficiency, and effectiveness of HC for all americans.