General Systems Theory
theory that organizations are a system composed of many subsystems and embedded in larger systems, and that organizations should develop communication strategies that serve both
The organization outputs clinical outcomes and a better QOL. They then receiv
inputs; system or throughputs; outputs; outputs; feedback; input
General Systems Theory: Comes from a systems perspective
>>You are part of the system & have a direct impact on the organization depending on patient care. Concern arises with harm to the organization, finances or patient
-The _______ include money, peopl
Systems thinking ; Process mapping
______- goal is to identify the gap in the system & not to merely point blame at one person
________- duty to think about the process and how to improve
To Err is Human; medical errors and system failures; Louise H. Batz; Medical errors; Crossing the Quality Chasm;
-safe
-timely
-effective
-efficient
-equitable
-patient centered;
National Patient Safety Goals; systematic; medical errors; sentinel
Evolution of National Quality Strategy:
1999: IOM, _____
-Call to action
-Thousands of preventable deaths attributable to ______ and _______
>>Johns Hopkins followed up and confirmed
>>________: Knee replacement. Received too many narcotics and sedatives.
Health Professions Education; Quality & Safety Education for Nurses (QSEN); Center for Medicare&Medicaid Innovation; performance; value; Transforming Care at the Bedside; bedside; RRT; Bedside
Evolution of National Quality Strategy:
2003:
IOM Report - _______:
Education Community
-_____________: a national nursing initiative to develop and implement competencies for safe, high quality nursing practice
Practice Community
-The ___________
-Pay-fo
safe; patient-centered; timely; equitable; effective; efficient
Six aims for healthcare quality:
_____: avoiding injuries to patients from the care that is intended to help them
_____: providing care that is respectful of and responsive to individual patients
_____: reducing waits and sometimes harmful delays for pati
Patient Protection & Affordable Care; health; experience; more affordable
Common Agenda per National Quality Strategy (USDHHS): The _______________ Act Goals -
1. Improve _____ of American public
2. Improve _______ in healthcare system
3. Make healthcare _______
-Gave regulators (CMS) the authority to dictate and monitor patien
Quality
the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge
Total Quality Management (TQM), Quality Improvement, Process Improvement; Quality Improvement
_______(TQM)
_________(QI)
__________(PI)
All terms are interchangeable
-_____: to use data to monitor outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality & safety of healthcare systems
>>R
outcomes; customer; Proactive; ALL; right; proactively; process; scientific; continuous; Inspection; Retrospective; Reactive; Standards; a few
Quality Improvement:
-Systematic process to improve ________
-Based on ______ needs
-_______ approach
-Responsibility of _____
Doing the _____ thing
-Meeting the needs of customers _______
-Quality performance of work ______
-Using a ______ approach with
quality; Internal; External
Customers define _____
-_____ customers: doctors, lab workers, anyone on payroll
-_____ customers: patients and providers not on payroll
>>Surveys assess patient experience
>>Engage and empower the customer
structure, process, and outcome; structure; process; outcome
Avedis Donabedian Model of Quality: the 3 main components are ________
-______: stable elements that make up the health care system; how is care organized?; resources or tools
-_____: interaction between patients and providers; what is done?; use of the t
performance; Structure; Process; Outcomes of nursing care; Patient safety indicators; reporting; Quality Core Measures
Quality Indicators: Used to examine hospital ______ and patient care outcomes
-Nursing sensitive indicators:
>>______: internal characteristics (e.g., supplies, technology, budget, supply of nursing staff, skill level, and education/certification of staff
Efficiency of care
the correlation between resources needed to provide quality care and the quality outcomes from the delivery of health care services
Ex. Cost of care per Medicare beneficiary
Structure of Care
Monitors the presence of a mechanism or system is in place that supports the delivery of quality health care
Ex. Presence of electronic health records or electronic prescribing systems
Process of care
Evaluates whether the patient received certain elements of care as defined by evidence-based health care related to the patient's diagnosis
Ex. Documentation that aspirin was given for all patients admitted with MI
Intermediate outcome
Examines the result of health care processes during the hospital stay that support patient outcomes
Ex. Mortality rates for specific patient populations
Patient-centered care
Track the patient's experience with the health care org and health care providers
Ex. Survey of patient's perception of the care received
Standards of care
legal requirements for nursing practice that describe minimum acceptable nursing care
Nursing quality indicators
________: patient falls, with injury, pressure ulcers, staff mix, nursing hours per patient day, RN job satisfaction, RN education and certification, pediatric pain assessment cycle, restraint prevalence, HAI, nurse turnover
Standards of care; appropriateness; application
_________: legal requirements for nursing practice that describe minimum acceptable nursing care to ensure high quality care to patients
-reflect the knowledge and skills ordinarily possessed and used by nurses actively practicing
-the ANA develops for pr
Structure; Process; Outcomes; standards of care
Donabedian's Framework:
_______: Characteristics of institutions and providers
______: What is done to the patient?
_______: What happens to the patient?
-written value statements that form rules applied to key processes and results that can be expected w
Problem; Improvement; metric; historical data; evidence; Donabedian's Framework; chain of command; improvement team
10 Basic Steps of Quality Improvement (1-5):
1. Identify the _____/Opportunity for _______
-You notice a practice issue or gap in desires vs performance. Can you find data on the problem to prove the issue? Is the problem important to patient care, goals,
extent; financial; interventions; research evidence; Rapid Cycle Testing (PDSA); sustainment; Champions; Quality Assurance Monitoring
10 Basic Steps of Quality Improvement (6-10):
6. Determine the _____ of the problem (benchmark, gap analysis, fishbone, system/process diagram, etc.)
-Collect data through surveys, interviews, regulatory agencies, complaints, and quality metrics like proc
Benchmarking
an improvement process in which an organization measures its strategies, operations, or internal process performance against that of best-in-class organizations within or outside its industry, determines how those organizations achieve their performance l
Internal Benchmarking; External Benchmarking
____________
-Using data from within the organization as comparison
ex. Methodist MSICU looks at data behind CVICUs lows fall rates
___________
-Compares what you are doing against what others are doing
>>Hospitals report their fall rates to the CMS which
Safety; Safety culture; Safety Climate
Patient Safety Goals - To Err is Human (100K/year)
______: Freedom from accidental injury
________: the outgrowth of the larger organization culture and emphasizes the deeper assumptions and values of the organization toward safety.
>>Rooted in policy, mi
Error; error of execution; error in planning; outcomes; Active; Latent; latent error; Reason's; Accident
Patient Safety Concepts
______: the failure of a planned action to be completed as intended (________) or the use of the wrong plan to achieve an aim (________)
Errors are directly related to ________
Types of Errors:
______ error: type of incident that i
Misuse; Overuse
Patient Safety Concepts
______: Avoidable complications that prevent patients from receiving full potential benefit from a service
-Ex. Patient receives a med that is not prescribed and that conflicts with his allergies causing anaphylaxis
_______: The po
Adverse event
Patient Safety Concepts:
_____ is an injury resulting from a medical intervention and it is not due to the underlying patient condition
Never events; Failure to rescue; responded
Patient Safety Concepts:
______ are certain occurrences in which CMS will never pay for reimbursement
________ is the inability to recognize a patient's negative change in status from an underlying illness or complication of medical care in a timely manne
Work-arounds
Patient Safety Concepts:
____: when one does not follow the rules and/or works around the rules or correct actions of a patient care process or a work process in order to save time
-Ex: Correct action to follow up about a potential drug interaction from t
Near-miss
Patient Safety Concepts:
_____: Recognition that an event occurred that might have led to an adverse event
>>Almost happens but the nurse recovers
Sentinel Event
Patient Safety Concepts:
_____: an event that had a negative patient outcome (unexpected death, serious physical or psychological injury, or serious risk)
>>Must report to TJC
>>ex. A patient commits suicide while in the hospital for treatment of depressi
Root Cause Analysis (RCA)
Patient Safety Concepts:
______: An in-depth analysis of an error to assess the event and identify causes and solutions
>>Use if a sentinel event occurs
>>Internal process to identify the system or process issue and prevent future occurrence
technology; human operators; organization; high-risk situation; defenses; defenses; incident; recovery; near miss or adverse patient outcome
Eindhoven Model Adapted for Nursing
-Failure can occur in ____ such as equipment, ______ in not following rules, or in the _______ P&P
-These failures lead to a _________
-If there are adequate ______ in place then there will be no adverse patient outcome
Incident or variance reports; recognize; documentation; anonymity; Hesitancy; reporting requirements; lawsuits; change
__________:
A confidential document that describes any patient or staff accident while the person is on the premises of the organization
Barriers to Error Reporting:
-Inability to ________ errors
-Burdensome ________
-Lack of ________
-________
-Unclear _
familiar; why; Five Whys; impartial; What happened?; Why did it happen?; How to prevent it from happening again?; human; processes and systems; why; risks; improvement
Root Cause Analysis:
What is the Process?
-Interdisciplinary, involving experts from the frontline services/staff
-Involving those who are the most ______ with the situation
-Continually digging deeper by asking ____ at each level of cause and effect - Th
Proactive; before; Retrospective; Sentinel; JC
Failure Mode and Effect Analysis:
-_______ ID and risk reduction
-QM and risk mgmt
>>Analysis ______
RCA:
-_______ approach to error identification after the mistake has occurred
-Sequence of events
-______ events
-Multidisciplinary team
>>Employees direc
potential errors; misses; actual; prevention; Just culture; No shame, No blame
Culture of Safety:
-A blame-free environment in which staff can practice and openly discuss _______ errors, near _____, or _____ errors
-Based on _______ not punishment
________: culture where staff are willing to come forward with info about errors so ev
High Reliability Organizations (HROs)
Organizational Culture and Changing Culture
________: Organizations that establish and maintain high quality and safety expectations for patient care delivery and keep rates of quality and safety failures near zero
-Organizational quality and safety suppo
Preoccupation w/ failure; Reluctance to Simplify; Sensitivity to operations; Resilience; Deference to expertise
5 Health Care Process Characteristics in High Reliability Organizations (HROs):
1. _________
>>Be alert to near-miss events, recognize weaknesses in health care systems early
2. __________
>>Recognize complexity of work and don't focus on easy-fix causes
Safe Harbor; prior
A process that protects a nurse from employer retaliation and licensure sanction when a nurse makes a good faith request for peer review of an assignment or conduct the nurse is requested to perform and that the nurse believes could result in a violation
Good faith
Taking action supported by a reasonable factual or legal basis.
>>It precludes misrepresenting the facts surrounding events under review, acting out of malice or personal animosity, acting from a conflict of interest, or knowingly or recklessly denying a
Safe Harbor Act; patients; professional; good faith; liability; safe harbor; orally; prior; nurse supervisor; Peer review
________: 2007 statute within the NPA in Texas
-Designed to help the nurse protect _____ and maintain _____ status
-Invoke Safe Harbor in ______ meaning that the RN believes the requested conduct violates their duty to a patient and that belief is one a r