Introduction to healthcare quality management

Improvement team
A group of individuals organized to work together to accomplish a specific improvement objective
This team’s role is to analyze and eliminate undesirable, unpredictable, or unworkable performance situations
improvement team
People of all levels in the organization may be part of this team
improvement team
Project participants
Team leader
Team members
an individual or group that decides to initiate an improvement project
Role of sponsor
charter the improvement team, provides initial improvement goals, monitors team progress, and supports the team
Role of Team leader
coordinates project assignments and communication with external parties, removes barriers, and keeps the project on track
Role of Facilitator
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 upon?)
Role of Recorder
Captures ideas, decisions, action items, and assignments on a flip chart or whiteboard for later transcription into a written summary of the project.
Role of Timekeeper
Keeps track of time during project meetings
Role of Team member
Participates in discussions, decision making, and other team tasks such as gathering data, analyzing information, assisting with documentation, and sharing results
Problem statement
A description of the performance problem that needs to be solved
The sponsor clearly defines the performance problem that needs to be solved by writing a ___________ ___________
Problem statement
An ideal project initiation, the sponsor creates a written __________ incorporating all the aforementioned elements; project goal
description of the system or process to be improved
time frame for project completion
project scope
and team members
A project goal needs to be _____________ in some way; numeric or percentage
improvement team members who have little or no knowledge of the process under consideration and have no vested interest in the outcome of the project
ground rules
Established guidelines for how an improvement team wants to operate; norms for behavior
safety programs
Purpose of these programs is to provide an environment in which hazards are eliminated or minimized for employees, staff, patients, and visitors
root cause
Primary and fundamental origins of undesirable performance
events or occurrences that could have led or did lead to undesirable results
physical, human, or administrative controls incorporated into a process to identify and correct errors before a patient is harmed
reportable events
reported to Joint commission; incidents, situations, or processes that contribute to–or have the potential to contribute to–patient injury or that degrade the provider’s ability to provide safe patient care
Patient Safety Organizations (PSOs)
Groups that have expertise in identifying risks and hazards in the delivery of patient care, determining the underlying causes, and implementing corrective and preventive strategies
sentinel event
an adverse event involving death or serious physical or psychological injury (or the risk thereof) that signals the need for immediate investigation and response
near miss
Any process variation that does not affect the outcome or result of an adverse event but carries a significant chance of an adverse outcome if it were to recur; also known as a close call
risk reduction strategies
Actions undertaken to reduce or eliminate the root cause of an adverse event