SADmin Exam 3
How does one utilize the CQI process to implement a QI project?
background---> methods ---> results ---> conclusions and recommendations [then repeat]
failure mode and effects analysis (FMEA)
before a sentinel event to assess what could go wrong with a process
prospective analysis
before an event; example: errors/ near n
histogram
graph that displays frequency distributions for unique categories of measure; useful for determining the overall shape of the data, data distribution, and variation in data
step 3 of HFMEA
graphically describe the process
For every $1 in drug expenditures...
healthcare spends $1 in ADE related costs and 1/3 are considered preventable!
value-driven health care
healthcare that is selected based upon relative value to other alternatives, not just on quality
leading causes of death in the US
heart disease, cancer and unintentional injuries; unintentional injuries are growing in number
functions of the joint commission
helps organize and strengthen patient safety efforts, strengthens community confidence in the quality and safety of care, treatment and services, provides a competitive edge in the marketplace
basic characteristics of CQI
identifies measures of quality, is patient-centered, collects and analyzes quality using statistical process control tools, and focuses on continually improving the system
ISMP list of confused drug names
includes look-alike and sound-alike name pairs
What type of pharmacy has the highest percentage of closed claims?
independent or individually owned pharmacy or pharmacy franchise
3 key elements to the proper functioning of the pharmaceutical care system
initiating therapy, monitoring therapy, managing therapy
plan data collection methods
inspection points, focus groups/surveys, chart review, observation, spontaneous report
examples of root causes
insufficient patient diagnosis increases probability that wrong med is used, use of abbreviation that could be misinterpreted was used so increase chance of wrong drug, pharmacist/physician training concerning med abbreviation errors may lead to failure to recognize AZT is used for 2 different drugs, high workload expectations created form of not clarifying prescriptions with prescriber, absence of policy about abbreviations, multiple interruptions during dispensing process
characteristic of healthcare quality
involvement of the structures, processes, and outcomes of care, dependence on one's perspective - asses from multiple perspectives, assessment of multiple dimension of care- high quality in one area of care may not make up for poor quality in another, evaluation is relative - made in comparison to something else
quality improvement
involves a sequence of actions taken by the effectiveness of QI depends a great deal on the process employed and the process of QI begins with the way a problem is approached; formal approach to analyzing and improving processes in systems
To identify problems well...
it is important to have a method for collecting key variable that signal quality and analyzing them statistically to identify undesirable trends
Amikin is commonly confused with
kineret
personal and environmental contributing factors
lack of communication, failure to comply with policy, lack of knowledge, lack of patient counseling, inattentional blindess
Using systems thinking what "leverage points" are mentioned in the article?
laws, no cell phone area, breaks, tech double checking RX entry, warning messages
Agency for Healthcare Research and Quality (AHRQ)
lead Federal agency charged with improving the safety and quality of America's health care system. AHRQ develops the knowledge, tools, and data needed to improve the health care system and help Americans, health care professionals, and policymakers make informed health decisions.; Programs intended to: ○Advance pharmacy health literacy practices through quality improvement ○Improve communication between pharmacy staff and patients ○Provide training for community pharmacists on opioid safety and drug monitoring programs
alprazolam is commonly confused with
lorazapam
medical error disclosure suggestions
make disclosure mandatory, training on effective/sincere apology, do not procrastinate, and protect staff who report incidents
How does quality improvement approach problems?
map the process, identify quality measures, collect and statistically analyze measures, use analysis to guide future actions
results of the CQI process
measure your chosen measures then enter data and analyze them
A key part of the CQI process is...
measurement
quality indicators
measures that indicate potential for negative outcomes
clinical pharmacy key performance indicators
med. reconciliation on admission, drug therapy problems, interprofessional patient care rounds, patient education during hospital stay, patient education at discharge, medication reconciliation at discharge
regulation of health care quality
minimum standard of care to prevent patient harm
What standard operating procedures were discussed?
no breaks, only 1 pharmacist filling, counseling, and giving vaccinations , no time to focus
How do pharmacist approach problems in practice?
not addressing quality problems (avoidance, denial, unimportant, denying responsibility, procrastinating), linear thinking (simplistic approach to problem solving), and systems thinking (approach the recognizes the complexity of most problems
reason's swiss cheese model
notes all of the missed safety checks that lead to a mishap occurring...each layer of cheese provides opportunity for defense or another step of failure (all the holes line up to lead to a patient safety incident); latent conditions: poor design, procedures, management decisions etc.
drug therapy problems
number of drug therapy problems addressed by a pharmacist per admission
how has performance of pharmacies and pharmacists been measured in the past?
number of prescriptions dispensed, percent of generic dispensing, speed of dispensing, customer satisfaction revolving around convenience, depth of stock, formulary compliance, competitive prices, labor cost per prescription, ratio of new prescriptions to refills, and prescription sales
How is a measure calculated?
numerator is people who actually receive the action and the denominator is people who are eligible to receive the action - people who are not eligible for the action for specific defined reasons
Amicar is commonly confused with
omacor
concurrent DUR
ongoing monitoring of drug therapy during the course of treatment
sampling
only measure a portion of the output of a system
issue with vincristine treatment
only supposed to be given IM, not intrathecal - mistake leads to death with vincristine being neurotoxic
cornerstones of value-driven health care
quality standards, price standards, effective use of health information technology, creating positive incentives for high-quality efficient health care
aggregate data indicators
rate based like # of dispensing errors per # prescriptions or continuous like average overall patient satisfaction scores
IOM report offers...
recommendation for pharmacists who want to improve the quality of their services
CMS meaningful measures framework
reduce burden, eliminate disparities, track to measurable outcomes and impact, safeguard public health, achieve cost savings, improve access for rural communities
framing
refers to how a question is set up to be answered - perspective taken, elements of the problem to be considered, criteria used to choose one solution over another; helps simplify the problem by including some information and excluding others
strategies for health care quality
regulation, continuous quality improvement, marketplace competition, payment incentives
two types of problem identification
retrospective analysis or prospective analysis
retrospective DUR
review of drug therapy after the patient has received the medication
5 rights for medication safety
right patient, right drug, right dose, right time, right route
causation in root cause analysis
root cause statement must show cause and effect; human error must have a cause
IOM's quality dimensions
safe, effective, patient-centered, timely, efficient, equitable
Drug use process
seek care --> problem diagnosed --> treatment regimen chosen --> prescription sent to pharmacy --> pharmacy fills prescription --> patient picks up prescription
S in FOCUS
selective which change to make to improve quality must center on a change of such a magnitude as to practically see a tangible improvement in the process
sentinel event indicator
serious events that require further investigation each time it occurs; undesirable but avoidable events; individual event that signals the need for investigation
factors contributing to errors
slips (attention diverted from task at hand) and mistakes (error in problem solving, lack of knowledge or information, clinical decisions based on assumptions or on previous experience)
examples of medication safety alerts
smart pump custom concentration without hard "low concentration" alerts, avoid multidose vials in the operating room (leads to infections)
PDCA cycle
step 1. plan a change, step 2: do it on a small scale, step 3: study the impact of the do stage, step 4: act on the results
the first two steps in solving any quality problem
step 1: recognize you have a problem 2. clearly define what the problem is
Considering this is the workforce you are entering, what things can you as a group think of that will be under your control once you're pharmacists than can help create a better prescription fill system?
swap roles to avoid burn out
framing biases
tendencies to frame questions in ways that hinder systems thinking, restricts assumptions, and results in poor solutions; defining problems with solutions, anchoring, confusing symptoms with problems
framing bias
the context in which the information is considered
confirmatory bias
the decision maker acknowledges only evidence that will confirm his or her hypotheses
representativeness bias
the decision maker assess the likelihood that an object or a person belongs to a given class
hindsight bias
the decision maker can easily predict an event after it has occurred
ignoring negative evidence bias
the decision maker can more easily consider the presence of evidence than the absence of evidence
ego bias
the decision maker warps probability estimates in a self-serving way
regret bias
the decision maker would regret a decision, and thus may overestimate the probability of its occurrence
quality
the degree to which health services (structure, processes) for individuals and populations increase the likelihood of desired health outcomes (outcomes) and are consistent with current professional knowledge; evaluation of the performance of medical providers (structures, processes) according to the degree to which the process of care (processes)increases the probability of outcomes desired by patients and reduces the probability of undesired outcomes (outcomes)
Donabedian's Framework: outcome
the end result attributable to healthcare services/products
Where are the most problematic issues on a pareto chart?
the left side
value-based purchasing
the many ways purchasers are attempting to measure and improve the quality of care received for the money spent
confusing symptoms with problems
the problem identified is a symptom of a bigger problem; does little to solve the real problem
DUR Rejections
third party payers do prospective DUR-mandated by OBRA 90 federal law for Medicaid, requires review before filling a prescription usually due. to (high dose, drug interaction, excessive utilization, etc.)
punitive safety culture
those who make an error are held personally responsible, regardless of the root cause; what we are used to
IOM findings on healthcare quality
to err is human, crossing the quality chasm, health professions education, preventing medication errors
step 1 of solving quality problems: recognize that you have a problem
to solve a problem, you must first be aware that it exists. This is difficult because many problems are the result of gradual change.
tools used in health care quality analysis
tools for investigation error causes: root cause analysis and failure mode and effects analysis
What are essential for identifying and monitoring quality?
tools of statistical process control like run charts, control charts, histograms, and pareto charts, sampling and benchmarking
What is a healthcare performance measure?
tools used to quantify the quality or cost of healthcare provided to patients; allows us to gauge the quality of care that is provided and help use understand whether and how much improvement activities improve care and outcomes
knowing the "truth"
truths are deeply ingrained assumptions and generalizations about the world that blind us and effect our decisions
control chart
type of run chart that is used in SPC and serves asa visual aid to distinguish between common and special-cause variations; comprised of a series of measurements over time and three horizontal lines, which represents the upper control limit, mean, and lower control limit
purpose of root cause analysis
understand cause and effect
U in FOCUS
understanding the variation in the current process to determine the frequency of the problem further directs the solution for change as well as resources necessary to make the change
examples of healthcare quality problems
underuse, overuse, misuse
categories of drug related problems
untreated indications, improper drug selection, subtherapeutic dosage, overdosage, failure to receive drug, adverse drug reaction, drug interactions, and drug use without indication
the case for statistical process control
uses statistical tools/techniques to detect changes in quality; overcomes faulty memory, inability to detect gradual change
Drugs most often involved in pharmacist malpractice cases
warfarin, corticosteroids, hypoglycemic agents, digoxin, amoxicillin and phenytoin
steps of root cause analysis
what happened? (dont after a sentinel event) Why did it happen? and what can we do to prevent recurrence?; causation, actions, outcome measures
conclusions and recommendations of CQI process
what is the bottom line? what owrked? what could be done better? what recommendations for further improving the process can you make
defining problems with solutions
when an individual has a solution in mind when defining a problem, thus blinding him/her to other potential solutions
anchoring
when initial data or impressions anchor subsequent thoughts and decisions; pushes toward some solutions and away from others
using a pharmacist-centric view of the world
when our professional identity blinds us to relevant information or limits our viewpoint to the boundaries of their pharmacist position
step 2 of solving quality problems: define what the problem is
when problem solving, it is important to remember that how the problem is defined helps determine how it will be solved. We want to know how to prevent it.
common retail pharmacy medication errors
wrong medication like BP instead of asthma and ear drops into of eye drops, and chemotherapy agent instead of BP meds
5 main categories of prescribing errors
wrong patient, wrong dose/strength/frequency, wrong formulation, and wrong quantity
Donabedian's Framework for measuring the quality of health care
S-P-O framework: structure, process, outcome
F in FOCUS
finding the problems involves using systems in the organization to detect unsafe, inefficient, or ineffective process
to solve problems, you must...
first recognize that you have them, and second, define the problem in a way that leads to the best solution using a systems approach to quality improvement
PQA
"National quality organization dedicated to improving medication safety, adherence and appropriate use." "Optimizing Health by Advancing the Quality of Medication Use" (Mission Statement); PQA tracks performance measures, monitoring measures (medication therapy problem resolution), and quality improvement indicators.; Created as an organization to unify prescription drug programs and their focus on quality improvement. PQA collects and measures development trends in the healthcare industry that can be applied within the field of pharmacy. The organization's main focus is to improve safety, adherence, and appropriateness
healthcare cost and utilization project
-Nation's most comprehensive source of hospital care data, including information on in-patient stays, ambulatory surgery and services visits, and emergency department encounters. HCUP enables researchers, insurers, policymakers and others to study health care delivery and patient outcomes over time, and at the national, regional, State, and community levels.
How many prescription fill errors occur for every 1,000 prescriptions filled?
1 to 3
USP 5 system elements for safe environment
1. individual characteristics 2. tasks performed 3. tools/technologies used 4. status of physical work environment 5. support within the organizations
4 R's of Medical Error Disclosure
1. reporting (have a policy, include critical info) 2. reaching out (have an appointed spokesperson, meeting b/w patient/family) 3. Review (root cause analysis) 4. Resolution (provide all pertinent findings to patient family, etc.)
cockpit management principles
10,000 feet rule (most things go wrong below 10,000 feet); activities such as eating meals, engaging is non-essential conversations within the cockpit and non-essential communications between the cabin and cockpit crews, and reading publication not related to the proper conduct of the flight are not required for the safe operation of the aircraft
incidence of adverse events
134 million adverse events occur year in hospitals in LMICs, contributing to 2.6 million deaths annually due to unsafe care.
estimated cost of medication errors annually
42 billion dollars
average annual ADE related costs
76.6 billion
estimated drug expenditures in 1995 compared to 2000
80 billion vs. 177.4 billion
pareto principle
80% of your quality output comes from 20% of what you do
PQA measures within Medicare Part D star Ratings
D12 = medication adherence for diabetes meds, D13 = med. adherence for hypertension, D14 = med. adherence for cholesterol, D15 = MTM program completion rate for CMR
How does reporting of med errors and near misses help?
Knowing what lead to the error or near miss can allow us to focus on avoiding the root cause
shared mental model
Knowledge, expectations, conceptualizations, and other cognitive representations that members of a group have in common pertaining to the group and its members, tasks, procedures, and resources.
just safety culture
focus in on the cause of the error and therefore errors caused by system failures are not punished; reckless or negligent behaviors that lead to errors are punished
medication error
any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient or consumer; has the potential to lead to inappropriate medication use and the potential to result in patient harm; DOES NOT HAVE TO RESULT IN ADVERSE EVENT
acetic acid for irrigation is commonly confused with
glacial acetic acid
AHRQuality indicators
are measures of health care quality that use readily available hospital inpatient administrative data to measure and track clinical performance and outcomes. AHRQ develops Quality Indicators to provide health care decisionmakers with tools to assess their data.
magnitude of adverse events
as many as 1 in 4 patients are harmed whilst receiving primary and ambulatory health care
step 2 of HFMEA
assemble the team
drug utilization review
authorized, structured, ongoing review of prescribing, dispensing and use of medication
What is the first thing we need to consider to understand medication errors?
drug use process
What systems were identified in the NYT article that may be problematic for patient safety?
automatic refill system is problematic, fill quotes
assumptions of linear thinking
each problem has a single cause, the solution will only affect the problem and nothing else, and once implemented, a solution will remain "solved"
The Health Care Effectiveness Data and Information Set
developed to measure performance on key dimensions of care and service
How do we generally recognize problems?
deviation from the past performance, deviation from the plan, and outside criticism
Beers Criteria
A list of medications that are generally considered inappropriate or should be monitored when given to elderly people
HFMEA
A systematic method of identifying and preventing problems BEFORE they occur
cause-and-effect (fishbone) diagram
A tool that helps teams identify, explore, and display in increasing detail, all of the possible causes related to a problem or condition in order to discover its root cause(s).
example of attempt of FDA to fix a root cause of medication errors
FDA requires color changes to duragesic pain patches to aid safety - they were originally clear and people would forget to take off the old one before applying the new one
organizations that are important to medication safety
FDA, Joint commission on Accreditation of Healthcare Organizations, World Health Organization, Institute for Safe Medication Practices, the United States Pharmacopoeia, American Society of Health-System Pharmacists
most common CQI model
FOCUS-PDCA
When considering a case where a medication error has occurred, what questions should be asked?
How would you classify this drug related problem? Who was at fault, How would you report this or would you report it? What ways could you think to prevent an error like this in the future?
examples of improvements made in pharmacies to decrease medication errors
ISMP strongly recommends against dispensing and administering IV vincristine in a syringe; illumination, magnifying lenses and task lighting have proven reduction in medication errors
Which of the following administers the pharmacist licensing exams - NAPLEX/MPJE?
NABP
Amaryl is commonly confused with
Reminyl
National committee for quality assurance NCQA
Reviews and accredits managed health care plans, practices/providers and other organizations (voluntary) and Develops quality standards and measures that are applicable across organizations; Publicly available "Report Cards"; programs include Health Plan Accreditation, Diabetes Recognition Program, Hedis: Healthcare Effectiveness and Data Information Sets (One of healthcare's most widely used performance tools. Look at the effectiveness of care, access, availability, and risk adjustment); organization structure: ❏12-person leadership team ❏Board of directors ❏Stakeholders; ❏Accredits pharmacy companies (i.e., Envolve Pharmacy Solutions) in utilization management so that companies can improve how they deal with overall drug management
How does the joint commission operate?
The Joint Commission requires an on-site evaluation to receive accreditation and certification. The on-site evaluation assesses compliance with the standards of the Joint Commission and the quality of improvement. ****Departments/Advisory Councils: Health Systems Corporate Liaisons, Nursing Advisory Council, Patient and Family Advisory Council, Patient Safety Advisory Group ***Those involved: comprised of individuals with expertise in each field The Joint Commission accredits, the Advisory Council's objective is to assist in driving The Joint Commission's mission of evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value through our accreditation programs ***Health Care Organizations benefit from the Joint Commission because certification and accreditation shows patients the high quality of care the organization has. ***Pharmacy Specific Significance: For more than 25 years, the Joint Commission has helped pharmacies transform their practices by meeting and exceeding rigorous performance standards driving sustainable quality and safety improvements.
joint commission
The mission of The Joint Commission is 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; evaluates and accredits more than 22,000 health care organizations and programs across the country; standards are the basis of an objective evaluation process that can help health care orgnaization measure, assess and improve performance; focus on important patient, individual, or resident care and organizaiotn functions that are essential to providing safe, high quality care
Institute for Safe Medication Practices (ISMP)
The only non profit organizations devoted entirely to preventing medication errors. Their mission is to advance patient safety worldwide by empowering the healthcare community, including consumers to prevent medication errors. Their vision is to be the premier independent, patient safety organization leading the effort to prevent medication errors and adverse drug events.; ISMP National Medication Errors Reporting Program, ISMP National Vaccine Errors Reporting Program, ISMP Consumer Medication Errors Reporting Program; ○Evaluate current pharmacy systems and optimize them, identify areas of improvement, and track these efforts to ensure improvement. Goal of this organization is to advance patient safety by reducing medication errors.
ergonomics (human factors)
The study of workplace equipment design or how to arrange and design devices, machines, or workspace so that people and things interact safely and most efficiently; the study of all the factors that make it easier to do the work in the right way; interaction between humans and the system in which they work; non-technical skills (task management, multidisciplinary team working, risk perception and prediction, decision making and recognition of personal and technological limitations)
swiss cheese model of adverse events
each slice of cheese is a barrier to error propagation and holes represent failures in the barriers; education, training, policies, technology, communication, checklists
The Joint Commission "Do not Use" List
U (unit), IU, QD or QOD, trailing zero (x.0) or lack of leading zero (.x), MS, and MSO4 or MgSO4
VA-NCPS Triage Questions
a criminal act? patient assessment? staff training or competency? equipment? work environment? information lacking/misinterpreted? communication? policies/procedures/rules? personnel or personal issues?
Centers for Medicare and Medicaid Services (CMS)
a federal agency that administers the nation's major healthcare programs including Medicare, Medicaid, and CHIP. It collects and analyzes data, produces research reports, and works to eliminate instances of fraud and abuse within the healthcare system.; Accreditations/ measures / reporting requirements: compiles information from other sources in order to set guidelines for Medicare and Medicaid programs [Departments: Medicare, Medicaid, Private Insurance, Regulations, Research and Statistical analysis, and Outreach and Education.]; ●communicates with private insurance companies to offer Medicare Part D insurance to offer prescription drug coverage to those eligible under Medicare. ●It also helps eligible individuals sign up for medicaid which helps them cover their prescription drugs as well.
PQA measures significantly contribute to...
a plan's star rating due to the heavy weighting of the intermediate outcome
standard operating procedures
a standard operating procedure is a protocol which details how a certain procedure should be carried out every time it is performed; in high risk industries
continuous quality improvement
a systematic, organization approach for continually improving all processes that deliver quality services and products
confirmation bias
a tendency to search for information that supports our preconceptions and to ignore or distort contradictory evidence
pareto chart
a type of histogram that categorizes data according to the most frequent issues on the left to the least frequent on the right
good performance indicators
accurately assess the quality process, quantitative, reliable, sensitive, simple
Acetaminophen is commonly confused with
acetazolamide
Acetazolamide is commonly confused with
acetohexamide
Accupril is commonly confused with
aciphex
step 5 of HFMEA
actions and outcomes measures; action options: control/accept/eliminate, actions or rationale for stopping; who will be responsible for the plan? implement the plan!
Donabedian's Framework: process
actions associated with quality; process of reviewing prescriptions, evaluating/reviewing patient profile
What are some of the new measures of performance being developed and used?
adherence rates with chronic medications, medication error rates, rates of patients achieving therapeutic goals, rates of patients receiving immunization, and patient satisfaction with counseling about new prescriptions, verbal and written information about medicine, and other elements of pharmacist care
Altocor is commonly confused with
advicor
root cause analysis
after a sentinel event to determine WHY the error happened; an iterative process. as more becomes known about the error, the use should go back to question and reassess what they learn; want to identify solutions
retrospective analysis
after an event; example: after an event
Food and Drug Administration (FDA)
agency within the U.S. Department of Health and Human Services . The FDA's mission is to protect the public health by ensuring safety, efficacy, and security of human and veterinary drugs, biological products, by ensuring the safety of food supply, cosmetics, and products that emit radiation.; ○The FDA regulates and approves all drugs before/after they enter the pharmaceutical market. They also regulate medical devices and other medical products (ie. vaccines). They are able to recall problematic products and monitor adverse effects on drugs, vaccines, and devices.
amantadine is commonly confused with
amiodarone
amiloride is commonly confused with
amlodipine
Abelcet is commonly confused with
amphotericin B
Ambisome is commonly confused with
amphotericin B
The National Committee for Quality Assurance
an entity that produces report cards for physicians and health care plans
sentinel event
an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof
medication misadventure
any iatrogenic hazard or incident associated with medications; a very broad term
reasons for focusing on quality of care
belief in and commitment to quality healthcare as a public good, growing awareness of gaps in safe, effective and person-centered care. increasing concerns about substantial practice variations in standards of healthcare delivery, renewed emphasis on improving patient outcomes in the context of currently popular value-based healthcare ideas, expectation from the public, media and civil society, with a growing public demand for transparency and accountability, increasing understand of the critical importance of trust services for effective preparedness for outbreaks or other complex
What values are considered to be acceptable on a control chart?
between the upper and lower control limits
________ in decision-making can blind us to the true causes of problems.
bias
problems associated with assigning causes and choosing solutions
biases/heuristics: availability, ego, hindsight, confirmation bias, emphasizing errors of commission, framing
In CQI, small changes have....
big accumulated impact; short QI cycles lead to many small improvements
methods of CQI process
break the intervention and data collection down into steps and detail practical considerations - what steps are needed, and determine the who/what/where/when/how each will be accomplished; lsit process and/or outcomes measures necessary tp determine if goals were met; determine what data are already being collected and what measures exist; plan the statistical analysis, making sure you will collect all information needed.
run chart
can identify performance patterns and trends by showing how a variable changes over time
systems thinking
causes are complex and solutions have consequences; problems have multiple causes and the solution could have a variety of different effects (intended effect, problem not solved, or unintended effect)
develop strategies to minimize biases
challenge the limitations you place upon your problems, reframe the question from multiple viewpoints (find the definition that satisfies the most), question assumptions about the truth. research conditions under which truth is wrong
quality control consists of
checking the quality after production (REACTIVE), throwing out defects and changing elements of the process if too many defects are detected, otherwise, continue with the status quo
methods of some possible CQI process interventions
checklists, double checks, assess to info, simplify/standardized procedures, minimize distractions, think clinically, patient counseling, communication, culture of safety, and technology
C in FOCUS
clarifying the problem especially taking into consideration perspectives of all stakeholders
assessing effectives of solutions with root cause analysis
collect and evaluate outcome measures to determine if the intervention worked
comprehensive unit-based safety program
combines improvement in safety culture, teamwork, and communication together with a checklist of proven practices for preventing healthcare-associated infections.
Joint commission data continues to demonstrate the importance of _________ in patient safety.
communication [1995-2005: ineffective communication; identified as root cause for nearly 66 percents of all reported sentinel][2010-2013- ineffective communication among top 3 root causes of sentinel events reported]
benchmarking
comparing your system with the best practices of other - exposes you to others' perspectives and methods and encourages competition
step of HFMEA
conduct a hazard analysis - list all possible ways a process can fail; use worksheet. determine a severity and probability rating, determine the hazard score, decide whether to proceed
availability bias
confuses the ease of remembering an incident with the probability that an incident will occur
SPC is the use of statistical techniques to measure change in systems because:
consistency is important in quality products and services, statistical analysis detects inconsistency, and help differentiate acceptable and unacceptable inconsistency (variability)
just culture model sets goals for an organization, including
creating an environment of internal transparency around risk, striving to understand why human errors occur within the organization, striving to understand why at-risk behaviors occur within the organization, learning to see common threads in order to prioritize risk and interventions, working with staff to design systems that reduce the rate of human error and at-risk behavior or mitigate their effects, learning when to console and when to coach employees, limiting the use of warnings and punitive actions to the narrow circumstances where such use benefits organizational safety, avoiding traditional organization biases by focusing on the risks inherent in systems and behavioral choices, not the actual outcome of events, using data to build both unir and organization models of risk, and learning to measure risk, at both the unit and organizational levels
pay for performance (P4P)
current/past system rewards quantity, not quality. Need to align payment structure with professional goals of improved quality of care; includes value-based purchasing and rewards quality and/or efficiency
Medication misadventures are an important cause of...
death, patient harm and healthcare costs
What can reduce the impact of heuristic biases?
decision-making techniques
developing good problem statements
define the broad problem in a single statement, identify sub-problems which related to broad problem, consider including perspective in problem statement (try to identify how people with other perspectives would frame the problem), question any assumptions and constraints placed on the problem definition
step 1 of HFMEA
define the scope or topic
HFMEA process
define the topic, assemble the team, graphically describe the process, conduct a hazard analysis (identification and evaluation of potential hazards that are likely to produce harm in specific process if not controlled), identify actions and outcome measures
uses of provider report cards
encourage continuous improvement, motivate performance improvement through benchmarking, generate external pressure and identifying best practices
blame free safety cullture
encourage reporting of errors as there was no risk of punishment regardless of the cause of the error
prospective DUR
evaluation of a patient's drug therapy before medication is dispensed
personal and environmental contributing factors to medication errors
excessive task demand, personal characteristics, extra-organizational factors, work environment, intra-organizational factors, interpersonal factors
Which of the common factors contributing to errors that we discussed Wednesday are most likely related to the environment and culture described?
excessive workload, attention diversion
format of provider report cards
explanation of measurement, various performance measures, provide previous results for the provider/organization, provide benchmarks based on peer groups
ways to measure CQI
failure mode and effects analysis (FMEA) and root cause analysis
inattentional blindness
failure to detect stimuli that are in plain sight when our attention is focused elsewhere
research has shown that pharmacists failure in 2 are the most common explanations for wrong drug dispensing errors:
failure to separate sound-alike-look-alike drugs and failure to check the drug against the label and the actual prescription
Agency for Healthcare Research and Quality is an accrediting organization. T/F
false
What are common complaints from pharmacists that could contribute to the frequency of medication errors?
feeling pressured or intimidated to meet metrics, feeling concerned about losing their job, and no breaks
FOCUS of CQI model
find the problem, organize a team, clarify current problem, understand the causes of the process variation, and select an opportunity for change
O in FOCUS
organizing the team comprised of major stakeholders in the process, the content experts, as well as front-line staff
national academy medicine
originally known as the national academy of sciences then national academy of medicine
Who does one benchmark with?
other departments, pharmacies and industries
3 people involved in assessing health care quality
patient, provider and payer
potential uses of pharmacy quality measures
pharmacies (compare quality across pharmacies and regions/compare quality over time), insurers (assess pharmacies within plan networks/promote quality of networks to payers), consumers and payers (choose pharmacies and reward quality with P4P) and outcomes researchers (examine quality trends and comparative effectiveness research)
What healthcare professional plays an integral role in medication processes?
pharmacist
examples of SPO and medication therapy management
pharmacist --> counseling --> adherence/drug effectiveness; warfarin clinic --> dosage monitoring --> no bleeding events
PDCA of CQI model
plan the change, do the change, check for improvement, act to hold gain
medication error classifications
prescribing error, omission error, wrong time error, unauthorized drug error, improper dose error, wrong dosage form error, wrong drug preparation error, wrong administration technique, deteriorated drug error, monitoring error, compliance error
Donabedian's Framework: structure
presence of something reasonably associated with quality; pharmacy, pharmacy hours, pharmacist to technician ratio
CQI efforts must provide information and answer questions in the following areas
primary aim of the improvement, key stakeholders in affecting change, measures showing that improvement has occurred, and taking actions to ensure and sustain improvement
aspects of pharmacy quality
product quality, interpersonal aspects of care, technical aspects of care
medication reconciliation on admission
proportion of patient who receive documented admission medication reconciliation (as well as resolution of identified discrepancies) performed by a pharmacist
interprofessional patient care rounds
proportion of patients for whom pharmacists participate in interprofessional care rounds to improve medication management
medication reconciliation at discharge
proportion of patients who receive documented discharge medication reconciliation and resolution of identified discrepancies by a pharmacist
patient education during hospital stay
proportion of patients who receive education from a pharmacist about their disease (s) and medication (s) during their hospital stay
patient education at discharge
proportion of patients who receive medication education by a pharmacist at discharge
DURs are classified in three categories
prospective, concurrent, retrospective
actions and outcomes of root cause analysis
provider put diagnosis on prescription, educate/policy about abbreviations, decrease interruptions, culture/policy about clarifying prescriptions
If _____ is not measured, there is no way of telling if or how much you improved.
quality
What is one of the most frequently quoted principles of health policy?
quality
The primary alternative to quality improvement
quality by inspection (quality control); the more reactive approach to QI, checks for defects
quality versus value
quality is what you get, cost is what you pay, and value is the ratio of quality/cost
healthcare performance measures
quality measures, KPIs, provider report cards
WHO definition of quality
quality of care is the degree to which health services for individuals and populations are effective, safe, and people-centered
donabedian definition of quality
quality of care is the kind of care which is expected to maximize an inclusive measure of patient welfare, after one has taken account of the balance of expected gains an d losses that attend the process of care in all its parts (ability to achieve desirable objectives using legitimate means)