Chapter 1-Intro to Quality Management

3 levels of Quality
Expected, Perceived, Actual
Expected Quality
level of quality of the product or service that is expected by the customer
Perceived Quality
customer’s perception of the product or service.
Customer’s perception is highly subjective
Actual Quality
uses statistical data to measure outcomes and considers all factors that can influence the final outcome
Safe Medical Devices Act (1990)
Mammography Quality Standards Act (1992)
Mammography Quality Standard Reauthorization Act (1998)
Occupational Safety and Health Administration
Environmental Protection Agency
Food and Drug Administration
The Joint Commission-Hospital accreditation agency
Quality Assurance
Total Quality Management
Cost of Quality
expense of not doing it right the first time
Frederick Winslow Taylor
Father of Scientific Management
Consumer-Patient Radiation Health and Safety Act (Public Law 112-90)
addresses unnecessary repeat examinations, QA, referral criteria, radiation exposure and unnecessary mass screenings
Medicare Improvement for Patients and Providers Act (2008)
Responsible for monitoring workplace environment, including requirements for occupational radiation exposure and chemicals in found in processing solutions
Death from a medical device or death from a malfunctioning piece of equipment must be reported to
FDA and Manufacturer
Within 10 working days
Serious Injury from a malfunctioning device or piece of equipment must be reported to
Manufacturer if know, FDA if Manufacturer not known
Within 10 working days
Annual Report of Death and Serious Injury Due to:
FDA by January 1
Health Insurance Portability and Accountability Act (1996)
Protected Health Information
DNV Healthcare Inc
Det Norske Veritas
Global foundation from Norway
Very similar to TJC
Quality Assurance (QA)
all encompassing management program used to ensure excellence in healthcare through systematic collection and evaluation of data
Enhances patient care
Quality Control (QC)
part of QA that deals with the techniques using in monitoring and maintaining the technical elements of the systems that affect the quality of images
Continuous quality improvement
85/15 Rule
Process in place is the cause of the problem 85% of the time
People or Personnel are the problem 15% of the time
82/20 Rule
80% of the problems are the result of 20% of the causes
is a ordered series of steps that help achieve a desired outcome
Group of related processes
individual or entity that furnishes input
Or provides the institution with goods or services
A variable factor that influences the next portion in the process
Information or knowledge necessary to achieve desired outcomes
A variable factor that influences the next portion in the process
means or activity used to achieve the desired outcome
A variable factor that influences the next portion in the process
refers to the desired outcome, result, product or characteristic that satisfy the customer
Person, Department or organization that needs or wants the desired outcome
Internal Customer
Groups or individuals in the organization
Doctors, other departments, hospital employees
External Customer
People outside the organization: patients, families, community and third party payers
Key Process Variables
Components of any process that may affect the final outcome
5 Major Key Process Variables
personnel involved in a process
refers to equipment used in a process
type and quality of materials used in process
physical and psychological aspects on people involved in the process
Steps in procedure or policy manual that have been used in the process
Group process used to develop a large collection of ideas WITHOUT regard to merit or validity
Focus Group
small group that focuses on a particular problem and then hopefully develops a solution
Quality Improvement Team
group of individuals who implement the solutions that were derived by the focus groups
Quality Circles
composed of supervisors and workers from the same department working together to identify potential problems in a department
used after brainstorming to dismiss nonessential or nonrealistic ideas
used after brainstorming
an agreement on most important ideas
Work Teams
team focus on solving a complete problem or completing and entire task
Root Cause Analysis
Problem Solving Teams
teams work on specific tasks and meet to solve particular problems
5 Whys
used to explore cause and effect relationships
developed by Toyota
Thought Process Map
5 steps of Thought Process Map
1-define projects goals
2-list knows and unknowns
3-ask grouped questions focusing on unknowns
4-sequence and link the the questions
5-identify possible tools to be used
TJC 10 Step Process
monitoring and evaluation process as mechanism for satisfaction and accreditation
Adverse Event Indicator
untoward, undesirable, and usually unanticipated event that is caused by a medical management rather than the underlying disease or condition
Adverse events prolong hospitalization , produce a disability at discharge or both
Sentinel Event
unexpected event causing death or serious physical or psychological injury
Sentinel Event Indicator
identifies and individual or series of events that is significant enough to trigger further review each time it occurs
Aggregate Data Indicator
Quantifies a process or outcome related to many cases
Appropriateness of Care
whether the type of care is necessary
Continuity of Care
degree to which the care/intervention for the patient is coordinated among practitioners or organizations
Effectiveness of Care
level of benefit when services are rendered under ordinary circumstances by average practitioners for typical patients
Efficacy of Care
level of benefit expected when healthcare services are applied under ideal conditions and the best possible outcomes
Efficiency of Care
outcome obtained when the highest quality of care is delivered in the shortest amount of time with the least expense and positive outcome for patients
Safety in the Care Environment
degree to which the risk of intervention and the risk in the care environment are reduced for the patient and others
Timeliness of Care
degree to which the care/intervention is provided to the patient at the most beneficial or necessary time
Delivery of healthcare within a reasonable amount of time with minimal waiting
Cost of Care
cost of healthcare delivery that is reasonable of the marketplace
Availability of Care
degree to which appropriate care/intervention is available to public
Cycle for Improving Performance
Systematic planning and implementation are key to design of any function or process
defined by TJC as collection of valid and reliable data to demonstrate effectiveness and efficiency of care
translating data collected during measurements into information that can be used to change process and improve performance improvement
Baseline Performance
comparison of current performance levels with those occurring previously (Example: Comparing repeat reject rates from last year to this year)
Desired Performance Limits
patients and physicians expect a certain level of performance
should be compared with the level achieved and as indicated in current data
Organizations can set own limits
Practice Guidelines and Parameters
procedures developed by professional societies, expert panels or in house to use best practice for diseases
Performance Measurement System
consisting of one or more automated databases that facilitate performance improvements in healthcare organizations
comparing one organizations performance standard with another organizations
Can be internal or external
Internal Benchmarking
compares performances within the best practices of the organization
External Benchmarking
compares performances with outside organizations
once knowledge is gained through measurements and analysis, actions can then be taken to improve processes
SWOT Analysis
Can be helpful in matching resources and capabilities to the competitive environment in which it operates
F-Focus-choose problem and describe it
A-Analyze-learn about problem, collect and analyze data
D-Development-develop solution/plan
E-Execute-implement and monitor the results, adjust as needed
F-Find a process to improve or problem to solve
O-Organize a team that knows how to process and work on improvement
C-Clarify the problem and knowledge of the process
U-Understand the problem and causes of process variation
S-Select method to improve the process
Combines the FOCUS principals and PDCA principals
Failure Mode and Effectiveness Analysis
analysis of potential failure within a system
Six Sigma
management strategy that seeks to identify and remove the causes of error in business
Consists of 5 steps
Six Sigma Steps
Lean Process Improvement
systematic approach to identifying and eliminating waste, where waste is defined as any non valued task