Continuous Quality Improvement and Healthcare Safety

Vocabulary flashcards based on the Continuous Quality Improvement and Healthcare Safety lecture topics.

Healthcare Quality and Healthcare Safety

Interconnected core principles of patient care that go hand-in-hand, where deficiencies in quality directly compromise safety.

Intrinsic Motivation

Internal motivation driven by personal satisfaction, values, or inherent interest rather than external rewards.

Extrinsic Motivation

Motivation driven by external rewards, financial incentives, recognition, or penalties.

PDSA Cycle

A four-stage iterative model (Plan, Do, Study, Act) used for testing changes and driving continuous quality improvement. iterative cycles

● Small-scale testing (build as confidence grows –

adapting according to feedback and learning)

● Use of data over time (to understand the impact of

change)

Kaizen Event

a focused, 3- to 5-day intensive workshop where a multidisciplinary team pauses regular duties to analyze and re-engineer a specific operational bottleneck or process

involves relatively simple fixes that improve work processes without going through the whole PI process and without the need to involve other departments

Lean

a quality improvement technique often seen in the manufacturing sector- the concept of implementing value and eliminating waste

Six Sigma

Methodology that uses statistics for measuring variation in a process with the intent of producing error-free result

thegoal is to satisfy customers by producing quality products, with a focus on variation reduction, waste elimination, and improved efficiency (Hessing n.d.).

Leader Standard Work

t consists of structured daily, weekly, and monthly routines that guide leaders to proactive process verification, problem-solving, and continuous improvement

SMART Goals

A framework for setting objectives that are Specific, Measurable, Achievable, Relevant, and Time-bound.

High Reliability Organizations (HROs)

Organizations operating in complex, high-risk environments that maintain exceptional safety records by constantly focusing on failure prevention and mindfulness.

operate “under trying conditions and persistently have fewer than their fair share of crises

HRO Preoccupation with Failure

A key characteristic of High Reliability Organizations where any small error or near-miss is viewed as a critical symptom of systemic weakness.

Josie King Case

The Josie King case at Johns Hopkins Hospital in 2001 involving preventable medical errors led to the establishment of the Josie King Foundation. The foundation pioneered vital patient safety measures, including Condition H and Rapid Response Teams. The 18-month-old toddler Josie King died on February 22, 2001, from severe dehydration and a medication error caused by a breakdown in hospital communication. While recovering from burns at Johns Hopkins Hospital, her extreme thirst and lethargy were dismissed by staff, and a nurse mistakenly injected her with methadone despite a doctor's order to withhold narcotics and vocal protests from Josie's mother. Her heart stopped shortly after the injection, leading to brain death.

Benchmarking

is another means of identifying systems, processes, and outcomes for improvement. Benchmarking is the systematic comparison of the products, services, and outcomes of one organization with those of a similar organization (external benchmarking), or the comparison of one unit to another unit within the same organization (internal benchmarking)

The Big Bang of CQI

refers to the pivotal historical turning point sparked by the release of two landmark reports by the Institute of Medicine (IOM): To Err Is Human: Building a Safer Health System (1999/2000) and Crossing the Quality Chasm: A New Health System for the 21st Century (2001

Fiduciary Responsibility

The legal, ethical, and moral obligation of governance boards and health system leaders to manage organization resources wisely and in the best interest of patients and stakeholders.

Root-Cause Analysis (RCA)

a structured problem-solving process used to find and fix the fundamental, underlying reasons for an issue rather than just treating its visible symptoms\

steps: define the problem, collect data, identify casual factors, find the root cause, implement solutions, montier/review.

Sentinel Event

involve significant injury to or the death of a patient or an employee through avoidable causes

Quintuple Aim

an expanded healthcare framework used to guide quality improvement, performance optimization, and management across health systems. It builds upon previous models by adding a fifth core dimension to address systemic fairness. [1, 2, 3]

• Triple Aim: Improved patient experience, better population health, and lower costs.

• Quadruple Aim: Added clinician and staff well-being.

• Quintuple Aim: Added health equity (added last)

Fifth Element of the Quintuple Aim

Health equity, which was added later to ensure all individuals have fair access to optimal healthcare outcomes.

Economic Return of CQI

The financial reality of CQI, which rarely generates direct revenue but rather yields value by avoiding costs related to harm, inefficiency, and poor quality.

System-Focused Error Approach

The core QI belief that when healthcare failures occur, the primary focus must be on evaluating systemic process breakdowns rather than placing individual blame.

EMR Implementation Outcomes

Electronic Medical Record initiatives that are not universally successful and require structured change management and execution strategies to achieve intended goals.

Pioneers of Healthcare Quality

Maude E. Callen : The Angel of Hell Hole

● Robert Latou Dickinson

● *Lavinia Lloyd Dock

● *Roswell Park

● Nicholas J. Pisacano

● *Ernst P. Boas

● Mary Steichen Calderone

Florence nightingale

evolution/history of quality in healthcare

W. Edwards Deming is the father of quality management and introduced concepts such as continuous improvement and total quality management, which have been pivotal in shaping modern healthcare quality practices.

avedis donabedian

is a key figure in healthcare quality evaluation, best known for his "Structure-Process-Outcome" model which provides a framework for assessing the quality of care based on organizational structures, the processes of care, and the resulting patient outcomes.

quoted “ultimately, the secret of quality is LOVE, if you have love, then work backward to monitor and improve the system”

plan

Plan the change (objective, identify issues, set targets)

Do

do the test or change (implement change, educate staff)

study (check)

collect data, assess results, gather feedback

act

adjust, modify strategies, standardize

positive of pdsa

allows teams to test small, low-risk changes before launching a full-scale project, which saves resources and prevents large failures

negative to pdsa

involve oversimplification, lack of rigorous implementation, and high risk of failure when used incorrectly

performance management

is “a gauge used to assess the performance of a process or function of any organization”