quality assurance Flashcards
what is quality improvement (QI)
an approach to continuous study and improvement of the processes of providing health care services to meet the needs of patients and others
quality improvement (QI) synonyms
continuous quality improvement (CQI)
continuous improvement (CI)
total quality management (TQM)
what is quality assurance (QA)
deals with people. involves outcome analysis (was the diagnosis promptly prepared, distributed, and filed for subsequent evaluation)
what is the joint commission on accreditation of healthcare organizations (JCAHO)
ten step monitoring and evaluation process. resolves identified patient care problems.
QA monitors proper:
patient scheduling, reception, and preparation.
JCAHO ten step QA program
- assign responsibility
- delineate scope of care
3 identify aspects of care
4 identify outcomes affecting the aspects of care
5 establish limits of the scope of assessment
6 collect and organize data
7 evaluate care when outcomes are reached
8 take action to improve care
9 assess and document actions
10 communicate information to organization-wide QA programs
what is quality control (QC)
deals with instrumentation and equipment
a program of QC is designed to ensure that:
expected outcomes are achieved through optimal equipment performance
QC–preventative maintenance initiative (PMI)
periodic scheduled monitoring of equipment performance (usually annually). usually makes major repairs unnecessary
a successful QC program has 3 steps
1 acceptance testing
2 routine performance monitoring (PMI)
3 maintenance
what is continuous quality improvement (CQI)
a plan that integrates QA, QC, and assessment into a complex system wide improvement program.
CQI–QC measures
radiation output, mechanical integrity of treatment and simulation units, brachytherapy sources and equipment
CQI–QA measures
aspects of treatment planning, delivery and patient care
CQI–assessment
peer review and audit mechanism. use cause and effect diagrams/ “fishbone” diagrams
quality improvement team
composed of ALL the staff in the radonc department who interact with the patient and family. each individual makes contributions to the quality of care and level of patient satisfaction.
QI activities–physicians
active participation in QA activities: chart review, morbidity and mortality, review and development of departmental policies, port film preview, patient and family ed, and completion and review of incident reports
QI activities–physicists/dosimetrists/engineers
develop and carry out the QC program. weekly and final physics reviews of tx records
QI activities–radiation therapists
active participation in QA and QC activities: warm up procedures, preforms QC tests, verify presence of completed and signed RX and consent forms, reviews RX and TX plan on each patient prior to 1st TX, deliver accurate treatment per RX, accurately record treatment delivered, take and review portal images ** , eval health status of the patient daily before tx, participate in patient & family ed, provide care and comfort to meet needs of patient
QI activities–radiation nurses
perform nursing assessment on each new patient (determine physical and psychological status, evaluate educational needs & evaluate effectiveness of ed program) & monitor patient’s health status on routine or as needed basis throughout course of TX (order, evaluate, and record blood counts. evaluate and record weights).
QI activities–departmental support staff
gathers pertinent information and prepares the treatment chart before the patients initial visit, contacts patient and/or family to set up appointments, gives instruction regarding information to be brought with the patient, greets and assists patient and family daily (sets tone for entire rt treatment encounter)
QI committee
aka improvement committee. report to the medical director and are repsonsible for: the development and monitoring of the QI program activities, collecting and evaluating data, determining areas for improvement, implementing changes and evaluating the results of the actions taken.
development of a QI plan
GOALS: 1 plan promotes ongoing collection of info on all aspects of care.
2 uses the info to verify and identify areas in need of improvement
3 implement action to modify quality of care
4 assess effectiveness of actions taken
5 report findings to department and hospital wide
flowchart
pictorial representation of the steps necessary in a process. helps in identifying the steps in a process and who is responsible for those actions.
flowchart standardized shapes
ovals to identify the beginning or the end of a process.
rectangles indicate an action to be taken.
diamonds represent a decision to be made.
