"Healthcare Quality Chapter 6, 7, 8, 9, 10 and 11

are used to measure performance, collect and display data, and monitor performance.
Quantitative tools
are used to generate ideas, set priorities, maintain direction, determine problem causes, and clarify processes.
Qualitative tools
An interactive decision- making technique designed to generate a large number of creative ideas.
A group decision- making technique used to reduce a long list of items to a manage- able number by taking a series of structured votes.
A structured form of multi-voting used to identify and rank issues.
Nominal group technique
used by improvement teams to organize ideas and issues, gain a better understanding of a problem, and brainstorm potential solutions.
Affinity diagrams Charts
are a structured brainstorming technique used to identify all possible causes of an effect (a problem or an objective). They are also called fishbone diagrams because the lines connecting major cause categories resemble the backbone of a fish. Relationship between the outcome and the factors that influence them.
Cause and effect diagrams
Improvement teams can use a ______ ______ (sometimes called a selection matrix or prioritization matrix) to systematically identify, analyze, and rate the strength of relationships between sets of information. This type of matrix is especially useful when considering a large number of decision factors and assessing each factor’s relative importance. Teams frequently use this tool to select improvement priorities and evaluate alternative solutions.
decision matrix
Before developing solutions, teams need to confirm that they have found the underlying causes of a performance problem. The ____ _____ tool helps an improvement team dig deeper into the causes of problems by successively asking what and why until all aspects of the situation are reviewed and the underlying contributing factors are considered. Teams often uncover multiple underlying root causes during this exercise.
five Whys
, sometimes referred to as process maps, are used to document the sequence of events in a process or to develop an optimal new process during the solution stage of improvement. They can be used to detect unexpected complexity, problem areas, redundancies, unnecessary steps, and opportunities for simplification. They also help teams agree on process steps and examine activities that most influence performance.
A flowchart is considered ___ _____ because minor steps in the process have not been included.
high-level flowchart
maps all the steps and activities that occur in the process and includes decision points, waiting periods, tasks frequently redone, and feedback loops.
A detailed flowchart
shows detailed process steps and the people involved in each step. This is particularly useful for mapping processes in which information or services are passed between people and groups. It also may reveal unclear responsibilities, missing information, and unshared expectations that contribute to performance problems.
deployment flowchart,
In a ____ _____ flowchart, the major steps in a process are arranged sequentially across the top and the detailed steps are listed under each major step
top-down flowchart
is a visual representation of the movement of people, materials,paperwork, or information during a process.
A workflow diagram
Questionnaires or interviews used to obtain information from a group of individuals about a process, product, or service.
Forms containing questions to which subjects respond.
Formal discussions between two parties in which information is exchanged.
A subgroup of respondents derived from the target population.
Survey sample
Ranges of answers from which the survey respondent can choose.
Response scales
The number of respondents who complete a survey out of the number who received the survey, usually expressed as a percentage; can also apply to individual questions. This is how many you might get back.
Response rate
A technique for identifying and visualizing the relationships between significant forces that influence a problem or goal.
Force field analysis
A tool used to identify groups and individuals who will be affected by a process change and whose participation and support are crucial to realizing successful outcomes.
Stakeholder analysis
is a diagram that shows the tasks needed to complete an activity, the people or groups responsible for completing the tasks, and an activity schedule with dead- lines for task completion.
A planning matrix
is a graphic planning matrix that displays project activities as bars measured against a horizontal time scale. Most electronic spreadsheet programs have templates for creating this kind of chart.
A Gantt chart
A plan to eliminate the cause of undesirable performance or make good performance even better.
Improvement plan
A tool that visually communicates the major elements of an improvement project.
Quality storyboard
The measurable capability of a process, procedure, or health service to perform its intended function in the required time under commonly occurring conditions.
An important aspect of quality is
A group of individuals organized to work together to accomplish a specific improvement objective.
Improvement team
Charters the improvement team, provides initial improvement goals, monitors team progress, and supports the team
An organization’s senior leaders or decision makers.
Helps manage discussions about the process during team meetings, usually by asking questions (e.g., How do we want to make this decision? What points can we agree on?) Supports the Team Leader. Asks questions.
Coordinates project assignments and communication with external parties, removes barriers, and keeps the project on track
Team leader
Captures ideas, decisions, action items, and assignments on a flip chart or whiteboard for later transcription into a written summary of the project
Keeps track of time during project meetings
Participates in discussions, decision making, and other team tasks such as gathering data, analyzing information, assisting with documentation, and sharing results. Be personally committed to achieving goals.
Team member
How many members should a team have?
5 to 10
A description of the performance problem that needs to be solved.
Problem statement
Established guidelines for how an improvement team wants to operate; norms for behavior. Established in the beginning.
Ground rules
◆preparing the meeting agenda and distributing it at least one day in advance,
◆keeping the meeting focused on the agenda,
◆encouraging participation by all team members,
◆fostering an environment in which team members feel safe expressing their ideas, and
◆distributing the last meeting’s minutes before the next meeting.
team leader responsibility’s
The team meets and works together for the first time.
Team members “jockey” for position and struggle for control.
Team members adjust to one another and feel comfortable working together.
The team begins to function as a highly effective, problem-solving group.
Preventable adverse events or near misses during provision of healthcare services.
Medical errors
The quality or condition of being safe; freedom from danger, injury, or damage.
An event that results in unintended harm to the patient and is related to the care or services provided to the patient, rather than to the patient’s underlying medical conditions.
Adverse event
The purpose of patient safety performance measurement is to discover and fix problems before an ____ ______occurs.
adverse event
, sometimes called occurrence reports, are paper or electronic forms used to document potential or actual patient safety concerns.
Incident reports
five practices that are important to increasing the quantity and quality of employee incident reports:

1. Protect people involved against _____ ______ (as far as is practical).

2. Allow _____ ________ or deidentify the reporter.

3. Separate the agency or department collecting and ____ the ____ from those that have the authority to institute disciplinary proceedings and impose sanctions.

4. ________ rapid, useful, accessible, and intelligible feedback to the reporting community.

5. Make _______ easy.

1. disciplinary proceedings
2. confidential reporting
3. analyzing the reports
4. Provide
5. reporting
In 2005, the federal government passed the Patient Safety and Quality Improvement Act (Patient Safety Act), which included plans to develop a national database of _____ ______ ______.
patient incident information
made possible the creation of a nationwide network of patient safety organizations (PSOs)
The Patient Safety Act
Primary and fundamental origins of undesirable performance.
Root causes
for the purpose of gathering and analyzing information about patient incidents from providers in all states. To qualify as a PSO, an organization must have expertise in identifying risks and hazards in the delivery of patient care, determining the underlying causes, and implementing corrective and preventive strategies.
patient safety organizations (PSOs)
Projects aimed at improving patient safety follow the same steps as any other project does:

1. Define the _______ goal.
2. _______ current practices.
3. Design and ______ ________.
4. Measure ________.

1. improvement
2. Analyze
3. implement improvements
4. success
Systematic assessment of a process to identify the location, cause, and consequences of potential failure for the purpose of eliminating or reducing the chance of failure
Failure mode and effects analysis (FMEA)
The FMEA technique promotes systematic thinking about the safety of a patient care process in terms of the following questions:

◆What could go _____?
◆What will be the ______ if something goes wrong?
◆What needs to be done to prevent a ____ ______ when something does go wrong?

1. wrong
2. result
3. bad result
An improvement model that involves identifying and analyzing potential failures in healthcare processes or services for the purpose of reducing or eliminating risks that are a threat to patient safety.
Proactive risk assessment
The process of collecting and evaluating information on hazards associated with a process, which involves a brainstorming session to develop a list of all failures that could occur in each step.
Hazard analysis
Different ways a process step or task could fail to provide the anticipated result.
Failure modes
In some FMEA models a criticality score is assigned to each potential failure on the basis of the following criteria:

1. _______: the probability that the failure will occur

2. ________ the degree of harm the patient will experience if the failure occurs

3. ________ the likelihood that the failure will be detected before patient harm occurs

1. Frequency
2. Severity
3. Detection
Ranking of potential failures according to their combined influence of severity and frequency and probability of occurrence.
The most important process failures to prevent, according to criticality scoring results.
Critical failures
A structured process for identifying the underlying factors that caused an adverse event.
Root cause analysis (RCA)
An adverse event involving death or serious physical or psychological injury (or the risk thereof) that signals the need for immediate investigation and response. Human error is the biggest cause.
Sentinel event
Since 1996, organizations accredited by ____ ______ ______ have been required to conduct an RCA following a sentinel event.
The Joint Commission
is an incident that did not result in death or injury but could have; only by chance was the patient not harmed.
A near miss
is an accident investigation technique undertaken to find and fix the fundamental causes of an adverse event. It is similar to any improvement method that follows the steps of the Plan-Do-Study-Act cycle.
Root cause analysis
IOM (2000) report To Err Is Human involved the role of ______ in preventing medication errors: They also could provide a major safety check in most hospitals, clinics, and practice. They should know which medications they are taking, their appearance, and their side effects, and they should notify their doctors of medica- tion discrepancies and the occurrence of side effects.
If a mistake occurs and a patient is harmed, _______ in some states and The Joint Commission standards require disclosure of unanticipated outcomes of care to the patient or her representative
A discipline that applies scientific know-how to a process, procedure, or health service process so that it will perform its intended function for the required time under commonly occurring conditions. A study between people, science and policy.
Reliability science
techniques based on reliability science are sometimes called
human factors engineering
Performance reliability can be measured in various ways. The simplest way is to measure _____ _____ or ______. The number of actions that achieve the intended results are divided by the total number of actions taken.
process output or outcomes
US healthcare organizations currently perform at the ____ percent level of reliability, meaning they have a failure rate of 1 in 10
Reliability ratings are important for ____ _____ _______ purposes. Reliability science has demonstrated that certain process improvements are more likely to create consistent quality.
healthcare quality improvement
rely on qualified people doing what they believe is the right thing
Less than 80% reliability
Implement basic failure prevention strategies, such as the following:
•Standard protocols/procedures/order sheets
•Personal checklists
•Common equipment
•Feedback on compliance
•Awareness and training
80-90% reliability
Implement sophisticated failure prevention and basic failure identification and mitigation strategies, such as ***Using redundant processes***
95% reliability
Gather information to understand which failures are occurring, how often they occur, and why they occur. Then redesign the system to reduce these failures using sophisticated failure prevention, identification, and mitigation strategies
99.5% reliability
To move beyond 99.5% requires technology and advanced system design that often involves significant resource investments
Better than 99.5% reliability
Strength of Various Improvement Actions
•Warnings and labels
•New procedure/policy
• Memos
• Training
•Additional study/analysis
Strength of Various Improvement Actions
•Checklist/cognitive aid
•Increase in staffing/decrease in workload
• Redundancy
•Enhanced communication (e.g., read back)
•Software enhancements/modifications
•Elimination of look-alikes and sound-alikes
•Elimination/reduction of distractions (e.g., sterile medical environment)
Strength of Various Improvement Actions
•Architectural/physical plant changes
***•Tangible involvement and action by leadership in support of patient safety ****
•Simplified process, with unnecessary steps removed
•Standardized equipment, process, or care map
•New-device usability testing before purchasing
•Engineering control or interlock (forcing functions)
Monitoring _____ _______ process changes on the basis of reliability science is the starting point to achieving consistently high quality.
Performance Designing
Planning, organizing, directing, and control- ling healthcare products in a cost-effective manner while maintaining quality of patient care and contributing to the organization’s goals.
Utilization management (UM)
Appropriate and consistent with diagnosis and, according to accepted standards of practice in the medical community, imperative to treatment to prevent the patient’s condition or the quality of the patient’s care from being adversely affected.
Medically necessary
Failure to provide appropriate or necessary services, or provision of an inadequate quantity or lower level of service than that required.
Provision of healthcare services that do not benefit the patient and are not clearly indicated or are provided in excessive amounts or in an unnecessary setting.
Use of medical services and supplies, commonly examined in terms of patterns or rates of use of a single service or type of service, such as hospital care, physician visits, and prescription drugs.
To jump-start the guideline development effort, in 1990 the (AHRQ)—then known as the Agency for Health Care Policy and Research—published a methodology for developing guidelines and began sponsoring clinical practice guideline development task groups
Agency for Healthcare Research and Quality
UM involves the three basic quality management activities: measurement, assessment, and improvement.
Utilization Management functions
is the term typically used to describe the measurement Utilization review and assessment tasks, whereas UM is a broad term that encompasses all three activities.
Utilization review
Performance-based payment arrangements that control costs directly or indirectly by motivating providers to improve quality and reduce inappropriate utilization.
Pay-for-performance systems
A method of determining medical necessity and appropriateness of services before the services are rendered.
Prospective review
An assessment of patient care services that is completed while those services are being delivered to ensure appropriate care, treatment, and level of care.
Concurrent review
A method of determining medical necessity and appropriateness of services that have already been rendered.
Retrospective review
A practicing physician who supports utilization review activities by evaluating appropriateness of admissions and continued stays, judging the efficiency of services in terms of level of care and place of service, and seeking appropriate care alternatives.
Physician advisor
The website of the ____ ____ ___ _____ ______(HCUP), sponsored by AHRQ, contains the largest collection of hospital care data in the United States.
Healthcare Cost and Utilization Project
Form of a job aid or support tool that provides some type of information or instructions.

Descriptions of key patient care interventions for a condition, including diagnostic tests, medications, and consultations, which, if completed as described, are expected to produce desired outcomes.

Clinical paths
are job aids that provide step-by-step instructions on how to perform tasks. These instructions are usually found in checklists, treatment protocols, and physician order sets.
Standards of care
Formal outlines of care; treatment plans.
is a process by which patient needs are met as they transfer from one environment to another.

Evaluation of patients’ medical and psychosocial needs for the purpose of determining the type of care they will need after discharge from a health- care facility.

Discharge planning
Experienced healthcare professionals (e.g., doctors, nurses, social workers) who work with patients, providers, and insurers to coordinate medically necessary and appropriate health- care services.
Case managers
The ______ Conditions of _______ require hospital boards to convene a utilization review committee to carry out utilization-related functions
Medicare Conditions of Participation
All providers that care for Medicare patients—hospitals, long-term care facilities, home health agencies, rehabilitation facilities, and so on—are required to conduct ____ ______, but only some are required to designate a UM committee.
UM activities
All health plans accredited by the ____ _____ ___ _____ ______ (NCQA 2012) must have a written UM plan, and many state regulations governing health plans have similar requirements.
National Committee for Quality Assurance
The individuals, group, or agency with ultimate legal authority and responsibility for the overall operation of the organization; often called the board of trustees, board of governors, or board of directors.
Governing body
that describes the organization’s quality infrastructure and required quality management activities.
Quality management plan
physician and professor of public health at the University of Michigan from 1966 to 1989, became internationally known for his research on healthcare improvement. Prior to his death on November 9, 2000, he identified “the determination to make it work” as the most important prerequisite to ensuring quality of care: “If we are truly committed to quality, almost any mechanism will work. If we are not, the most elegantly constructed of mechanisms will fail”
Avedis Donabedian,
The governing body or ____—usually called the board of trustees, board of governors, or board of directors—is a group of people who have ultimate legal authority and responsibility for the operation of the healthcare organization, including quality management activities.
the Board
The responsibility for implementing quality management activities throughout the organization lies with ________—the chief executive officer, the chief operating officer, the vice presidents, and other senior leaders. In contrast to the board’s high-level role, administration ensures that day-to-day quality management operations are meeting the organization’s needs.
, often called the quality council, performance improve- ment committee, or quality and patient safety committee, guides all measurement, assessment, and improvement activities. Sometimes an individual, rather than a committee, fulfills this role.
The quality coordinating committee
The 2012 Medicare Conditions of Participation (CoPs) for Hospitals and Joint Commission accreditation standards require that hospitals have an organized medical staff. A hospital’s medical staff is composed of physicians, dentists, and other professional medical personnel who provide care to the hospital’s patients independently.
the Medical staff
A formal organization of physicians and dentists with the delegated responsibility and authority to maintain proper standards of medical care and plan for continued betterment of that care.
Organized medical staff
All _______ and services in a healthcare organization participate in quality management activities. Managers of these and services are responsible for overseeing performance in their respective areas. Manager involvement in quality management activities includes, but is not limited to, the following responsibilities:

◆ Providing leadership oversight for departmental quality management activities

◆ Measuring, assessing, and improving clinical and operational performance

◆ Ensuring the competence of people working in the department

◆ Identifying opportunities to improve performance in the department and throughout the organization, and helping to achieve these improvements

◆ Reporting the results of departmental quality management activities to departmental staff, oversight committees, and the board

is the administrative head of quality management functions and may be a member of the organization’s senior administrative team. T
The quality director
or patient safety officer. Oversight of patient safety improvement activities may include evaluating patient incident data, facilitating root cause analyses and other patient safety improvement projects, and coordinating the flow of patient safety information throughout the organization.
Patient safety coordinator.
provides input to the senior administrative team and to the medical staff on issues related to physician performance measurement and improvement activities. The quality advisor works closely with the quality director and the president of the medical staff to ensure appropriate medical staff participation in quality management activities.
The physician quality advisor
The document describing the organization’s structure and process for measuring, assessing, and improving performance may be called a_____ _____ ____ , a performance improvement plan, a quality and patient safety plan, or one of a number of other descriptive titles. The purpose of the plan is to serve as a blueprint for quality and patient safety in the organization.
quality management plan
The plan describes each quality management stakeholder and its responsibilities. Some plans describe infrastructure and stakeholder activities in great detail and are several pages long. Plans do not need to describe every element, however.
Quality Management infrastructure
To improve __________, an organization must have the will to improve, the capacity to trans- late that will into positive change, the infrastructure necessary to support improvement, and an environment hospitable to quality. The last factor—environment—relates to the organization’s culture.
is a system of shared actions, values, and beliefs that guides the behavior of an organization’s members.
Prevalent patterns of shared beliefs and values that provide behavioral guidelines or establish norms for conducting business.
Organizational culture
Quality leaders have long recognized the importance of culture as a driver of .
performance excellence
An organization’s ______—its culture—influences the success of quality management activities.
Leaders must create a _____ that supports their organization’s goals and, when necessary, change that culture to encourage continuous improvement.
Nominal Group Techniques involves five steps, 1st step
team leader first states the problem and clarifies it if necessary to ensure everyone understands its nature and consequences.
Nominal Group Techniques involves five steps, 2nd step
each team member silently records potential solutions to the problem and does not discuss them with other team members (as in silent brain- storming).
Nominal Group Techniques involves five steps, 3rd step
each person shares one idea with the group, and the leader records the idea on a flip chart. The process is repeated until all solution ideas have been recorded.
Nominal Group Techniques involves five steps, 4th step
the team clarifies the ideas listed on the flip chart. The leader may ask some team members to explain their ideas. Comments from other members are not allowed during the explanation. The goal in this step is to ensure that everyone in the group understands the suggested solutions.
Nominal Group Techniques involves five steps, 5th step
the team votes on the ideas silently. Team members are asked to select five ideas they think are most effective, record them on separate index cards, and rank them in order of importance.
Cause and effect diagrams sometimes called..
Ishikawa diagrams or fishbone
decision matrix are sometimes called
selection matrix or prioritization matrix
Workflow diagram, more info…
The diagram can also illustrate general relationships or patterns of activity among interrelated processes (e.g., all processes occurring in the radiology department). are used to document how work is executed and to identify opportunities for improvement.
common type of workflow diagram?
Floor plan of a work site
_____ response rates are unlikely to produce valid, reliable feedback.
Stakeholder analysis can be grouped into four categories
Are all stakeholder equal
A _____ chart is a graphic planning matrix that displays project activities as bars measured against a horizontal time scale.
_________ ____________communicate more information and clues about intentionality through graphs and pictures than through words
Quality Storyboards
Improvement team members
-Team leader
Identified five practices as important to increasing the quantity and quality of employee incident reports (O’Leary and Chappell 1996):
1. Protect people involved against disciplinary proceedings (as far as is practical). 2. Allow confidential reporting or deidentify the reporter. 3. Separate the agency or department collecting and analyzing the reports from
those that have the authority to institute disciplinary proceedings and impose
sanctions. 4. Providerapid,useful,accessible,andintelligiblefeedbacktothereportingcom-
munity. 5. Make reporting easy.
_____ the federal entity responsible for administering the PSO provisions of the Patient Safety Act, has certified 77 PSOs in 30 states and the District of Columbia.
The FMEA technique promotes systematic thinking about the safety of a patient care process in terms of the following questions:
-What could go wrong?
-What will be the result if something goes wrong?
-What needs to be done to prevent a bad result when something does go wrong?
patient safety organizations
Failure mode and effects analysis
Root cause analysis (
The Joint Comission
Agency for Healthcare Research and Quality
Healthcare Cost and Utilization Project
Utilization management
The infection control coordinator,
usually a nurse,The goal of risk management is to protect the organization from financial losses that may result from exposure to risk.
Organizational Culture
is the root of many performance problems.