Conditions of Participation (COP)
regulations require that providers develope, implement and maintain and effective organization wide, data driven quality assignment and performance improvement program
The Joint Commission (TJC)
is a not-for-profit nongovernmental entity that offers voluntary accredition programs for all types of health care facilties . provides education, leadership, and objective evaluation and feedback to health care organizations in the quest for health care
TJC has sponsered
comparative performance measurement project that involves collection and analysis of data recieved from accredition hospitals
what 4 core measures did hospital performance focus on?
acute myocardial infaction, heart failure, community acquired pneumonia and preganacy and related conditions.
Who did NCQA sponser?
Health Care Effectiveness Data and Information Set (HEDIS)
HEDIS
a comporativer performance measure project that evaluates a healthplan clinical and administrative system.
Leap frog Group
a collaboration of large employers came together in 1998 came together to see how purchasers could influence the quality and affortability of health care.
leapfrog identified what hospital quality and safety practices
computer physcian order entry, evidence-based hospital refferal, and intensive care unit (ICU) staffing by physcians experienced in crital care medicine.
Pay for Performance (P4P)
a payment system implewmented by some health plans that financally rewards providers who achieve specific quality or patient safety goals
fundemental principles for Pay for Performance are
common performance measuresfort providers,significant health plan finicial payments based on that performancewith each plan independently deciding the source, amount, payment method for its incentive program.
input
refers to materials or resources used in a process such as x-rays and radiographers time
output
is a product of a process such as transcribed records document or a complete diagnostic test
outcome
is the end results of a process such as a complete health record or a patients satisfactory physcial condition after a surgical procedure
efficiency
refers to doing the right thing or using an acceptable rational resources used to output or outcome achieved
effectiveness
refers to doing the right thing EX. using only the apporiape diagnostic test to establish a treatment plan that returns a patient to a state of wellness is effective
evidence based medicine (EBM)
to select the right thing to do for a patient . involves the use of current best medicine evidence in making decisions about the care of an individual patients ex (BAYER ASPIRIN) using guideline developed through research in making clinical decisions
Clinical Practice Guidelines
specific procedures or protocols for medical professionals to follow for a patient with a partidiagnostic or medical condition based on researchcular
indicator
is a quantive measure of an aspect of patient care is a screen or flag that indicates areas for more detailed analyis
National Quality Forum (NQF)
created in 1999 to develop and implement a national stragety for health care quality measurement and reporting
Performance Measure
is a genetic term used to describe a particular value of chacteristic designed to quantify input, output, outcome, efficiency,or effectiveness
In 1990 great emphysis was placed on
need for public accountability of providers and insurers to furnish comprehensive high quality healthcare at an acceptable cost
Avedis Donabedian
defined a comprehensive approach to assessing quaility of care by using measures tht examine structures, processes, and outcomes associated with the delivery of health care.
Data Quality
to achieve their potiental value, performance measures must be valid and reliable
Validity refers to
degree, extent and extent
Validity
assesses relevance,completeness,accuracy ands correctness
Validity measures
how well a data collection instrument, labatory test, medical record abstract, or other data source measures what it should measure
Health Information Management (HIM)
professionals play a vital role in ensuring valaid and reliable data collection
Performance Assessement
an assessement that involves a periodic review of performance measurement results sometime called evaluation, appraisal or rating
Performance Improvement
when an opportunity for improvement is identified, an improvement activity is undertaken
Performance improvement involves
an investigation of the cause of undesirable performance and implemations of solutions
Dr. Shewhart's
PDCA plan, do, check act
Plan for Improvenments
how, what,develop and process measures
Do
do the improvement actions
check results of improvement actions
compare the effets of the process changes with the predicted outcomes
Act on the Evidence
make changes permanent, run new trials, revise improvementy actions or whatever is approiate to the findings
W. Edwards Deming
PDSA plan, do, study, act
Rapid Cycle Improvement (RCI)
applied to improving both the operational aspects of health care delivery and clinical care process
RCI is based on
PDSA Model
PDSA Model uses
accelerated method (usually less than 4 to 6 weeks per improvement cycle)to collect and analyize data and make informed changes based on that analysis
Six Sigma
has roots in manufacturing industry 1980 motorola began an initiative to elimate defects and improve the effeciency of its operations
Six Sigma Five Steps
define, measure, analyze, improve, and control
Lean
1980 Japenese success in global marketplace brought QI philosophiesand techiniques to international attention
Lean started in
Manufacturing sector hteses principles are now gaining popularity in services sectors also in health care
Lean Principles
Eliminate waste and retain only valued added activities,concentrate on improving valued added activities, respond to the voice of the customer and optimize processes across the organization
Central Tenet of Lean thinking
value providing 'PERFECT" value to the customer by using only value adding processes and eliminating waste in health care MEANS add value to the service provided to patients, their families and other customers
Value chain
the whole process or linked processes
Benchmarking
is the act of comparing one's performance to high-quality performance
Brainstorming
is a structured but flexible process designed to maximize the number of ideas generated by a group of people
Brainstorming requires
a leader who serves primarily as a faciliator and recorder and a team of 6 to 10 persons brought togehter to generate ideas about a particular performance issue
Flowcharts
are graphic representations of a sequence of activities or steps in a process
Cause-and-effect Diagrams (fishbone diagrams)
useful tool for solving complicated problems by helping people see the relationship between performance factors and an end result
What is useful in the plan phasse of the PDCA cycle
Fish bone diagram or cause-and-effect diagram
Histograms
graphic representations of frequency distributions useful identifying whether the variable that exists in the frequency distribution is normal or skewed
To construct a histogram
create a verticle and horizonal axis,grouping or classes must be continous data
continous data is placed on
Horizontal axis, shown on contignous bars
frequency of occurance is placed on
vertical axis, height of the bar representing the count
Bar graph
is used to report count values of categorical data, such as number of outpatients visits for each day of the week
Pareto Chart
similar to bar graphs, primary diffrence is that occurrences plotted on this chart are ordered form largest to most frequent occuring category
to create a pareto chart
first select data then determine the standard for comparision
line chart (run chart)
provides a simple visual method of monitoring performance trends over time
Control Charts
special type of line graph used to monitor performance add another deminsion to performance analysis statistically in control
Who issues the National Patient Safety Goals
TJC
National Patient Safety Goals have
influenced adoption of safer patient care practices in all provider sites
Why dis TJC publish National Patient Goals in 2003
promote specific change intended to improve patient safety
Patient Safety Improvement
actions undertaken by individuals and organizations to protect health care recipients from being harmed by the effects of health care services
are incident reports put in medical record
no
incident reports
paper-based or electronic reports completed by health care professionals when an incident occurs
Ensuring Patient Safety Involves
establishment of operational systems and process that minimize the likehood of errors and maximize the likelihood of intercepting them when they occur
Root Cause Analyses
a systematic investigation process that occurs after a complication or adverse event that resulted in a patient injury caused by medical management rather by the underlying disease or condition of the patient
examples of Sentinel events are
event that results in unanticipated patient death or major permanent loss of function, suicide of patient in round-the-clock care, unanticipated death of a term infant, infant abduction or given to wrong parent, hemolytic transfusion reaction, surgery on
risk
event or situation that could potententially result in an injury to an individual or in finicial loss to the HCO
Risk Management
encompasses all pollicies, procedures, and practices directed at reducing risk and subsequent liability for injuries that occur in the organizations immediate enviroment
Best protection Risk management stragety is
prevention
prevention requires
identifying and monitoring high-risk and problem prone processes and physcial plant locations
National Committee For Quality Assurance (NCQA)
is a private not-for-profit organization established in 1991. they acredit a variety of organizations from health maintance organizations to prefered provider organizations and each accredition program had distinct performance management requirements.
NCQA
sponsers the healthcare Effectiviness data and information set (HEDIS)
National Quality Award
some health care leaders seek to advance performance by voluntairily participitating in quality awards programs at state and national levels.
Baldridge National Quality Award
established by congress in 1987 to recognize organizations for their achivements in quality and business performance and to raise awareness about the importance of quality and performance excellence as a competive edge.
Quality Improvement QI
to improve the process of delivering care and thereby increase customer satisfication with the quality of care
Clinical Practice Guideline
statement opf the right thing to do for patients with a particular diagnosis or medical condition
structure measure
indirectly accesses care by looking at certain provider characteristics and the physcial and organizational resources available to support the delivery of care.
Process Measure
focus on what is done durning the delivery of health care services. most common measure used to evaluate the quality of health care services
Outcome Measures
looks at end result of the patient encounter with the health care system (commonly used is patients mortality rates)
guess practice guidelines is also known as
cliniocal practice guidlines
develop of a performance measure involves
identify what you want to know, identify the raw data necissary for creating the measure and define a data collection strategy.
performance assessment is sometimes called
evaluation, appraisal or raing
perfomance assessment
involves a formal periodic review of performance measure results
performance data should help people answer
what is current performance, is there a trend over time, should we take any action, what kind of action, what contributes the most to undesirable performance and are we focussing on the highest priority actions
pdca stands for
plan, do, check,act
PDCA
paln, do, check, and act
Plan
for improvements
do
the improvement actions
check
results of improvement actions effect of process changes
act
on the evidence
PDSA
plan, so, study, and act
six sigma has steps they are
define, measure, analyze, improve and control
Rapid cycle improvement
sucessfully applied to improving both the operational aspects of health care delivery and clinical patient care process
RCI is based on
PDSA model using an accredited method to collect and analize data and make informed changes based on that analysis
internal benchmarking
compares performance between functonal areas or departments within an orgqanization
external benchmarking
sometimes called performance benchmarking is used to close the gap between an organizations performance and that of other organizations
affinity diagrams
may be used to bridege the gap between idea generation and organization of the ideas. after brainstorming used to organize and prioritize information into clusters or categories
decision martix
multidimensional tool is used to organize and categorize information into more usable form for decision making purposes
force field analysis
is a tool that also shows the relationship between performance variables and outcomes.
correlation analysis
detrmines the strangth, direction, and statistical significance of a relationship between one or more performance variables.
TJC joint commission issues
national patient safety goals yearly have strongly influenced the adoption of safer patient care practices at all sites
patient safety improvement involves
the familar prformance management building blocks, measurement, and improvement
safety improvement
ensuring patient safety involves the establishment of operational systems and process that minimize the likelihood of errors and maximize the liklihood of intercepting them when they occur
proactive risk assessment
patient safety improvement projects which are proactive these projects are initiated prospectively for the purpose of avoiding an undesirable event
risk management activities
are directed at preventing or reducing finicial loss, allocating funds for compensable events and diminishing negitive public image resulting from injury claims
potentially compensable event (PCE)
adverese occurance usually involving a patient that could result in finicial obligation for the healthcare organization (HCO)
loss prevention
requires idsentifying and monitoring high-risk and problrem-prone processes and physcial plant locations
loss reduction
focuses on a single incident or claim and requires immediate response to any adverse occurrence
utilization management
are intended to insure thst facilities and resources are used appropiately to meet the health care needs of patients
UM building block of performance management
measurement, assessment and improvement
Medicare COP
hospitals must have a process for reviewing services furnished by the institution and by members of the medical staff to patients entitled tobenefit under the Medicare and Medicade programs
the um function involves what activities
prospective review, concurrent review,dicharge planning/case management and retrospective review
prospective review process
is initative before a pateints actually needs serviceif insurance company requires pre approval befor services then the um gathers information on the patients condition to see if it is necessary for this service and try to get approval for it to happen
IS/IS intensity of service/severity of illness
describe where services should be provided(intensity) on the basis of the level of the patients impairment (severity)
concurrwnt reviews
need of services is assessed stimultaneously with provision of care
retrospective review
occurs after care had been rendered
licened independent practioners (LIPs)
should perform only the services that they are qualified through education, training and experience
credentialing
is defined as the process of evaluating an individuals knowledge and experience against a standard to determine whether the individual is qualfied to perform certain tasks
credentialing process is
objevtive mechanism used by the HCO governing body to demostrate accountability for professional staff practice behaviors and association clinical outcomes
credentialing process starts
when a physcian or LIP applies for mrembership to the hospital organized medical staff.
credentialing proff should include
education and training, liability insurance coverage, current licensure, clinical competence, and satisfactory health status
privalage delineation
refers to the process of determining the procedures and services a physcian or LIP is permitted to perform under the jurisdiction of the HCO
peer review
review of patients records is another way medical staff evaluates performance of physcians and LIP.
peer review evaluation
evaluated by people who have similar trainig , work in similar work in similar envirments and have similar profeciency in a clinical practice area or speciality
infectious control
process of preventing the speading communiclal diseases with compliance of legal requirements
realability
refers to consticiency between uses of a given instruement or methods
absence of defects
presence of value exteneded by customer