NUR 214 Quality Improvement Flashcards

Comprehensive vocabulary flashcards covering Quality Improvement principles, benchmarking, safety events, and Just Culture theory for NUR 214.

Quality Improvement (QI)

Systematic, continuous actions that lead to measurable improvement in health care services and patient health status; also known as CQI or TQM.

PDSA Cycle

A 4-step process for testing change: Plan (identify problem/design test), Do (small scale implementation), Study (evaluate effect), and Act (adopt, adapt, or abandon).

4 HRSA Core Principles of QI

Focus on systems & processes, focus on patients, focus on being part of the team, and focus on use of data.

Quality by Inspection

An older quality model that finds and removes deficient workers, leading to fear-based environments where errors are hidden.

Quality as Opportunity

A modern quality model that finds improvement opportunities through teamwork, openness, and learning.

Internal Benchmarking

Comparing performance data between units within the same organization, such as fall rates on 2N vs. 3N.

Competitive Benchmarking

Comparing a facility's performance against other hospitals or agencies, such as a CAUTI rate versus the state average.

Functional Benchmarking

Comparing similar processes between different organizations, such as the medication reconciliation process.

Best Practice Benchmarking

Comparing organization performance against top-performing organizations nationally using data like NDNQI benchmark data.

Root Cause Analysis (RCA)

A systems-focused, non-punitive deep dive to determine the underlying causes of why an error happened, rather than just what happened.

Human Error

An unintentional mistake with no malicious intent, responded to with consolation and system review.

At-Risk Behavior

Cutting corners that seem minor but increase risk; responded to with coaching and education.

Reckless Behavior

A conscious disregard for a known, substantial risk; the only behavior that warrants disciplinary action and punishment.

Near Miss

An error that did NOT reach the patient but could have; requires a report and provides valuable QI data.

Adverse Event

An error that DID reach the patient resulting in possible or minor harm; requires an incident report.

Sentinel Event

A safety event resulting in temporary severe harm, permanent harm, or death; requires immediate notification and investigation.

Never Event

Extremely rare, severe errors that should not happen; hospitals are not reimbursed for any care associated with these events.

Leapfrog Protocol

Requirements following a never event: apologize to the patient/family, waive all related costs, and report to an external agency.

Incident Report

A QI and risk identification tool (also called a Variance Report) used for anything out of the ordinary; it is NOT part of the medical record.

5-Step QI Cycle

1. Establish Standard/Benchmark, 2. Collect Data, 3. Perform RCA if standard not met, 4. Take Corrective Action, 5. Reevaluate.

Just Culture

A culture where errors are viewed as system failures rather than personal failures, encouraging open and safe reporting.

Punitive Culture

A fear-based culture where staff avoid reporting errors due to individual blame and punishment.