Quiz #2 Hospitals

What is a just culture

"focuses on identifying and addressing systems issues that lead individuals to engage in unsafe behaviors, while maintaining individual accountability by establishing zero tolerance for reckless behavior. Just organizations focus on identifying and correcting system imperfections, and pinpoint these defects as the most common cause of adverse events. Just culture distinguishes between human error (e.g., slips), at-risk behavior (e.g., taking shortcuts), and reckless behavior (e.g., ignoring required safety steps), in contrast to an overarching 'no-blame' approach

1. What is the JCAHO and what is their role in a hospital?

(you may need to google this answer) is an independent, not-for-profit group in the United States that administers voluntary accreditation programs for hospitals and other healthcare organizations; seeks to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.

6. What three industries contribute to the science of safety?

Engineering, Aviation, and Nuclear Power

What is a safe patient practice?

A patient safety practice is a type of process or structure whose application reduces the probability of adverse events resulting from exposure to thehealthcare system across a range of diseases and procedures.1The care we deliverand the way we deliver it should have the least potential to cause patient harm andthe greatest potential to result in an optimal outcome for the patient. Patients assume that this is what we do when we take care of them.

AHRQ's annual National Healthcare Quality Report

AHRQ's annual National Healthcare Quality Report

5. What is an adverse event?

Any injury caused by medical care. An undesirable clinical outcome that has resulted from some aspect of diagnosis or therapy, not an underlying disease process. Preventable adverse events are the subset that are caused by error.

7. As we strive to improve patient safety, what three issues need to be considered?

As healthcare professionals strive to improve patient safety, issues such as risk analysis, public policy, and regulation must be considered.

According to To Err is Human how many Amercians die each year as a result of medical errors?

At least 44,000 the number could be as high as 98,000

What are the categories of quality improvement tools? Cause analysis Evaluation and decision making Process analysis Data collection and analysis Idea creation Project planning and implementation Knowledge transfer and spread technique

Cause Analysis Once a gap in quality has been identified, the next step is usually to figure out why actual performance is lagging behind optimal performance or benchmarks. This process is known as cause analysis; Five Whys, Cause-and-Effect/Fishbone Diagram, Evaluation and Decision Making Deciding exactly where in a system to intervene to bring about change often involves a more quantitative approach to cause analysis. Visualizing data can help to identify correlations and patterns to help guide decisions.; Scatter Diagram, Pareto Chart Process Analysis Many improvement initiatives target changes in process to achieve better outcomes. Fully understanding an existing or proposed process is a vital step in improvement.; Flowchart, Failure Mode and Effects Analysis / Mistake Proofing, Data Collection and Analysis Identifying measures, setting benchmarks, and trending performance data lie at the heart of quality improvement. Various methods emphasize the ability to understand variation and recognize when trends represent true change.; SMART Aims, Run Charts and Control Charts Idea Creation When a team is seeking solutions to a quality problem, stakeholders should be engaged and encouraged to think broadly. The best solution might not be the one the team thinks of first, and outside opinions might be necessary to better understand how a proposed solution will affect real people and processes. Not all ideas are created equal. Project Planning and Implementation Once a countermeasure is chosen, the team must begin implementing the new process or equipment. Depending on the nature of the countermeasure, this step may be extremely complex. Tools that help to organize, prioritize, and communicate are vital to keeping the team on track.; Stakeholder Analysis, Checklists, Matrix Knowledge Transfer and Spread Techniques A key aspect of any quality improvement effort is the ability to replicate successes in other areas of the organization. Failure to transfer knowledge effectively can cause an organization to produce waste, perform inconsistently, and miss opportunities to achieve benchmark levels of operational performance. Barriers to spread and adoption (e.g., organizational culture, communication, leadership support) can exist in any unit, organization, or system.; Kaizen Blitz/Event, Rapid-Cycle Testing and Pilots

Crossing the Quality Chasm:

Crossing the Quality Chasm:

2. What are the componenets of a quality management system?

Ensuring reliable processes, Decreasing variation and defects (waste), Focusing on achieving better outcomes, Using evidence to ensure that a service is satisfactory

3. What is the scope of the problem?

Errors in healthcare; 98,000 individuals die every year in hospitals as a result of medical errors and that 2% of hospitalized patients experience a preventable adverse event; Sufficient numbers of these events result in serious harm.

What was significant about the IOM's 2000 publication To Err is Human?

Exposed the severity and prevalence of these problems in a way that captures the attention of a large variety of key stakeholders for the first time

4. What are the principles of a just culture?

Human behaviors within a just culture can be described as follows: HUMAN ERROR = An inadvertent slip or lapse. Human error is expected, so systems should be designed to help people do the right thing and avoid doing the wrong thing. Response: Support the person who made the error. Investigate how the system can be altered to prevent the error from happening again. AT-RISK BEHAVIOR = Consciously choosing an action without realizing the level of risk of an unintended outcome. Response: Counsel the person as to why the behavior is risky; investigate the reasons they chose this behavior, and enact system improvements if necessary. RECKLESS BEHAVIOR (NEGLIGENCE) = Choosing an action with knowledge and conscious disregard of the risk of harm. Response: Disciplinary action.

4. What is the real problem?

Is Harm, Not Errors; The harm that occurs is impressive when the financial, resource utilization, and healthcare system impact is evaluated; however, the immeasurable costs are reflected in the life experiences of the patients who are harmed and their loved ones and friends.

7. Who requires hospitals to collect and use safety data?

Joint Commission and the Centers for Medicare & Medicaid Services (CMS)

Leading a Culture of Safety (ACHE) - long document - focus on these six things

Leading a Culture of Safety (ACHE) - long document - focus on these six things

Crossing the Quality Chasm: What was significant about this report?

Offered a new framework for a redesigned US health care system.. Provides a blueprint for the future that classifies and unifies the components of quality through six aims for improvements

What did To Err is Human focus on?

On patient harm and medical errors in an unprecedented way, presenting them as perhaps the most urgent forms of quality defects

3. What is a patient safety event?

Patient safety event: An event, incident, or condition that could have resulted ordid result in harm to a patient.

What are the six dimensions of quality? And to what does each refer? Safe- Timely- Effective- Efficient- equitable - Patient-centered-

Safe- Harm should not come to patients as a result of their interactions with the medical system. Timely- Patients should experience no waits or delays when receiving care and service. Effective- The science and evidence behind healthcare should be applied and serve as standards in the delivery of care. Efficient- Care and service should be cost-effective, and waste should be removed from the system. equitable - Unequal treatment should be a fact of the past; disparities in care should be eradicated. Patient-centered- The system of care should revolve around the patient, respect patient preferences, and put the patient in control.

4. What is a sentinel event?

Sentinel event:† A subcategory of Adverse Events, a Sentinel Event is a patient safety event (not primarily related to the natural course of the patient's illness or underlying condition) that reaches a patient and results in any of the following: oDeath oPermanent harm

8. What are national patient safety goals?

The Joint Commission's yearly patient safety requirements based on data obtained from the Joint Commission's Sentinel EventDatabase and recommended by a panel of patient safety experts.

What second report was mandated by Congress? And what did it focus on?

The National healthcare disparities report and it focused on prevailing disparities in health care delivery as it relates to racial factors and socioeconomic factors. he National Healthcare Disparities Report, focus on "prevailing disparities in health care delivery as it relates to racial factors and socioeconomic factors in priority populations" (42 U.S.C. 299a- 1(a)(6)). AHRQ's priority populations include women, children, people with disabilities, low-income individuals, and the elderly. The combined reports are fundamental to ensuring that improvement efforts simultaneously advance quality in general and work toward eliminating inequitable gaps in care. These reports use national quality measures to track the state of health - care and address three questions: 1. What is the status of healthcare quality and disparities in the United States? 2. How have healthcare quality and disparities changed over time? 3. Where is the need to improve healthcare quality and reduce disparities greatest?

5. What are the three main categories of reasons for errors? (lack of integration of clinical decision support systems in one)

The lack of integration of clinical decision support systems, the paucity of training in patient safety for professionals, and the lack of organizational leadership to achieve safer systems all contribute to each of the errors that get reported.

o. Standard terminology -

a document comprising terms, definitions, descriptions, explanations, abbreviations, or acronyms.

k. Standard -

a minimum level of acceptable performance or results, or excellent levels of performance, or the range of acceptable performance or results. TheAmerican Society for Testing and Materials defines six types of standards

p. Standard guide -

a series of options or instructions that do not recom-mend a specific course of action.

m. Standard specification -

a statement of a set of requirements to be sat-isfied and the procedures to determine whether each of the require-ments is satisfied.

q. Standard classification -

a systematic arrangement or division of prod-ucts, systems, or services into groups based on similar characteristics.

i. patient safety practice -

a type of process or structure whose application reduces the probability of adverse events resulting from exposure to the health system across a range of conditions or procedures

6. What qualities make up a safety culture?

a. Staff and leaders that value transparency, accountability, and mutual respect.4n b. Safety is everyone's first priority.4n c. Behaviors that undermine a culture of safety are not acceptable, and thus should be reported to organizational leadership by staff, patients, and families for the purpose of fostering risk reduction.4,10,12n d. Collective mindfulness is present, wherein staff realize that systems always have the potential to fail and staff are focused on finding hazardous conditions or close calls at early stages before a patient may be harmed.10 Staff do not view close calls as evidence that the system prevented an error but rather as evidence that the system needs to be further improved to prevent any defects.10,13n e. Staff who do not deny or cover up errors but rather want to report errors to learn from mistakes and improve the system flaws that contribute to or enable patient safety events.6Staff know that their leaders will focus not on blaming providers involved in errors but on the systems issues that contributed to or enabled the patient safety event.6,14n f. By reporting and learning from patient safety events, staff create a learning organization.

Why is taxonomy important in patient safety? P. 10

a.Without taxonomy which is our current system we will not be able to keep track of events to measure change; a common language is also necessary; need to understand patient safety concepts with the same meaningfulness; therefore, your charge is to understand the patient safety taxonomy in the context of your workplqace, its improvenemt effort and the patients you serve;

What is the relationship between quality and safety?

a. in essence, when our care is safe, we do no harm andhave the lowest potential to do harm through the processes we use and the prac-tices we adopt. When we provide the highest quality of care, we make choices and deliver care that has the greatest potential to achieve the best outcome possible forour patients. b. -- opportunity costs are created; healthcare providers must assess opportunity costs to understand the true cost of any course of action. If we ignore opportunity costs, we may produce the illusion that the benefits of achieving the highest standards of safety cost nothing at all. These unseen opportunity costs are hidden costs incurred. --- t is sometimes hard to compare the benefits and losses of alternative courses of action, it is not necessarily so difficult in patient safety. -- One way to identify opportunities to improve safety is to apply the practices of continuous quality improvement -- o apply this practice from a patient-centered perspective.

The priciples and tenents of patient safety

a. ●Healthcare professionals are intrinsically motivated to improve patientsafety because of the ethical foundation, professional norms, and expecta-tions of our respective disciplines. b. ●Organizational leaders are responsible for setting the standards for achievingsafety at the highest level and will do so in response to societal expectations. c. ●Consumers are becoming increasingly aware of the healthcare safety prob-lem and are not accepting of it. d. ●There is substantial room for improvement of healthcare systems and prac-tices that will result in a reduction in both error potential and harm.

6. What is an error?

an act of commission (doing something wrong) or omission (failing to do the right thing) that leads to an undesirable outcome or significant potential for such an outcome.

e. Active error -

an error that occurs at the level of the front-line operator and whose effects are felt almost immediately

b. Accident -

an event that involves damage to a defined system that disrupts the ongoing or future output of the system.2 Accident is another word for the event itself and not the causes that supersede it

c. Adverse event—

an injury resulting from a medical intervention.2 Adverse events may occur because of error or because of an intrinsic negative reaction not related to error. Adverse events may come about because of both error and non-error causes. For example, a patient may have an adverse drug event. This may occur because the patient could not tolerate the particular chemical structure of the drug and as a result experienced a harmful effect.

s. Microsystem -

an organizational unit built around the definition of repeatable core service competencies. Elements of a microsystem include (1) a coreteam of healthcare professionals, (2) a defined population of patients, (3) carefully designed work processes, and (4) an environment capable of linking information on all aspects of work and patient or population outcomes to support ongoing evaluation of performance

a. Taxonomy -

are the systematic arrangement of entities in any field into categories or classes based on common characteristics such as properties, morphology, and subject matter; organizes our ideas into relationships that have meaning. lobal, professional, and sometimes practice-setting specific.;

f. Latent error -

errors in the design, organization, training, or maintenance that lead to operator errors and whose effects typically lie dormant in the system for lengthy periods of time

d. Error -

failure of a planned action to be completed as intended or use of a wrong plan to achieve an aim; the accumulation of errors results in accidents. Errors can include problems in practice, products, procedures, and systems.2 There are different types of errors. The taxonomy describing error is in the context of systems.

h. Patient safety -

freedom from accidental injury; ensuring patient safety in-volves the establishment of operational systems and processes that minimize the likelihood of errors and maximize the likelihood of intercepting them when they occur.2The concept of patient safety includes both responding to and preventing errors.

What are the four levels of the healthcare system?

improving the quality of healthcare in the STEEEP focus areas requires change to occur at four different levels, as shown in exhibit 1.1. Level A is the patient's experience. Level B is the microsystem where care is delivered by small provider teams. Level C is the organizational level—the macrosystem or aggregation of microsystems and supporting functions. Level D is the external environment, which includes payment mechanisms, policy, and regulatory factors. The environment affects how organizations operate, operations affect the microsystems housed within organizations, and microsystems affect the patient.

l. Standard test method -

procedure for identifying, measuring, and evaluating a material, product, or system.

n. Standard practice -

procedure for performing one or more specific operations or functions.

g. Human factors -

study of the interrelationships between humans, the tools they use, and the environment in which they live and work.2Human fac-tors testing and evaluation is a field of methodologies to assess the effectiveness and suitability of any human-system interface

5. What is the role of leaders in patient safety? (n=6)

the Role of Hospital Leaders in Patient Safety Hospital leaders and staff provide the foundation for an effective patient safety system by doing the following: Promoting learning Motivating staff to uphold a fair and just safety culture Providing a transparent environment in which quality measures and patient harms are freely shared with staff Modeling professional behavior Addressing intimidating behavior that might undermine the safety culture Providing the resources and training necessary to take on improvement initiatives

j. quality of care -

the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.2 Donabedian points out that depending on where we are located in the system of care and the nature and extent of our responsibilities, several formulations of quality are legitimate. In general, quality of care is inclusive of care by practitioners and other providers, care received by the patient, and care received by the community. These are levels of care that can be assessed for quality