quality improvement

healthcare quality

increased likelihood of desired health outcomes

consistent

healthcare quality attributes

• safe

• effective

• timely

• efficient

• equitable

• patient centered

quality improvement

improve quality and safety of health care systems

• Joint Commission

quality improvement programs aim to…

monitor, assess, improve healthcare quality

those involved in quality improvement

• healthcare professionals

• pt

• families

• researchers

• payers

• planners

• educators

key principles of quality improvement

• understand system and processes

• focus on pts

• team building

• data driven decisions

QSEN

quality and safety education for nurses

core competencies

• pcp

• informatics and tech

• evp

• QI

• safety

• teamwork and collaboration

root cause analysis (RCA)

• what happened?

• why did it happen?

• how can you prevent the error again?

sentinel event

a mistake that results in patient harm

stronger actions

• physical changes to environment

• engineering controls to force use to complete an action

• simplify process

• standardized equipment/process

• involved in leadership to support safety

immediate actions

• inc staff/dec workload

• modify software

• eliminate/reduce distractions

• checklist/cognitive aid

• read back communication

• eliminate look alike terms and soundss

• enhance documenting/communication

• redundancy

weaker actions

• double check

• warning and labels

• new procedures/memorandum and policy

• training/more training

• study/analysis

reporting

• include all actions

• report to staff from highest management down

just culture

• from american nurses association

• recognises that individuals should not be held responsible for system failures

• recognizes that errors are predictable between between human operators and the systems that they work

• does not tolerate conscious disregard of clear risk to patients or gross misconduct