Flashcards in Test 1 Deck (33):
Who was Florence Nightingale
She decreased crowding and improved sanitation in British military hospitals, founder of modern nursing
Who was Earnest Codman?
Boston surgeon with a knack for studying medical outcomes
What is underuse?
Neglecting to give patients necessary medical care under best practices
What is overuse?
Giving drugs or treatment without medical justification
What is misuse?
Essentially medical errors
How does Donabedian define quality health care?
Health care that is delivered through the right structure, using the right processes, and produces good outcomes. (structure, processes, outcomes)
IOM Six aims for improvement:
Safety (no harm to the patient).
Effectiveness (no underuse or overuse)
Timeliness (avoid unintended waiting that doesn't benefit the patient)
Experience, Pop health, and reduce cost, improve work life of providers
What should scorecards include?
Measures of healthcare performance, financial performance, customer assessment, internal assessment, innovation
What does HCAHPS stand for?
Hospital Consumer Assessment of Healthcare Providers and Systems
Freedom from accidental injury
use of an incorrect plan, or failure to execute as needed
Cause of injury to a patient
Damage to patient caused by medical care
Can errors, adverse events caused by errors, and adverse events no caused by errors be preventable?
Unsafe acts by people interacting with patients: slips and mistakes
Design faults or faults in the established procedures
What is the bad apple approach?
Eliminate the bottom 2.5% of your providers constantly
How did process improvement change the typical bad apple approach?
individual performance was no longer the sole determinant of overall performance, big focus on system errors
What is the model for improvement?
What makes a good aim statement?
Quant target, timeline, specific aspect of care
Well crafted measure?
Good definition, specifies quantity and unit of measure, population, no ambiguity
Criticisms of RCA
Focused on uncovering single fundamental reason for error, hindsight bias, organizational politics bias, weak recommendations, rarely follow up to concerns
Lean is also known as
Key tool of lean:
value stream maps
Focus of: PDSA, Lea, Six-Sigma
Improve particular process, eliminate waste, decrease variation
What is TeamSTEPPS
Team training based on Crew Resource Management (CRM), improve safety for short-duration teams in high-risk, high-stress situations
TeamSTEPPS behavioral routines:
Huddles, debriefs, SBAR communication, handoff checklist sequences