Quality PPT

What duty do healthcare organizations have to their communities?

To provide safe, quality care and show evidence of meeting care standards.

Who regulates healthcare quality?

Regulatory agencies, like The Joint Commission.

What does The Joint Commission do?

It’s an independent, not-for-profit organization that sets and evaluates standards for quality and safety in healthcare organizations.

Who informs regulatory agencies?

Advisory bodies, like QSEN (Quality and Safety Education for Nurses).

What is QSEN’s overall goal?

To prepare nurses with the knowledge, skills, and attitudes (KSAs) to improve safety and quality in health care systems.

What does the IOM define as healthcare quality?

The degree to which health services increase the likelihood of desired outcomes and align with current professional knowledge.

How do providers define quality?

As outcomes from interventions based on science that are effective and cost-efficient.

How do nurses define quality?

As safe, compassionate, culturally competent care supported by teamwork and communication.

How do managers define quality?

As the balance between service volume, resources, and patient satisfaction.

How do patients define quality?

Often through perceptions, feelings, and overall impressions of care.

What is the Quadruple Aim?

A framework for high-value care: better outcomes, better experience, lower cost, and better work life for providers.

What are the six domains of quality according to the IOM?

Safe, Timely, Effective, Efficient, Equitable, Patient-Centered.

What are the three components of evaluating quality care?

Structure, Process, and Outcome.

What is the purpose of the HCAHPS survey?

To assess patient satisfaction in areas like communication, pain control, cleanliness, and discharge planning.

What is "Hospital Compare"?

A public website that reports hospital performance data.

What is PQRS?

The Physician Quality Reporting System, linking provider performance to financial incentives.

What is a medical error according to the IOM?

A failure to carry out a planned action as intended or using the wrong plan.

Define a Near Miss.

A potential error that did not reach the patient due to chance or early intervention.

Define an Adverse Event.

An error that reached the patient and caused moderate to severe harm.

Define a Sentinel Event.

A severe error resulting in death or serious harm.

What is the Swiss Cheese Model?

A visual model showing how multiple layers of defense can fail when gaps align, allowing an error through.

What is Root Cause Analysis (RCA)?

A method used to identify underlying system issues contributing to errors, especially sentinel events.

What is the "5 Whys" technique used for?

To dig deeper into why an issue occurred by repeatedly asking "Why?"

What are Active Failures vs. Latent Failures?

Active failures are unsafe acts by individuals; latent failures are system issues like poor staffing or training.

What is the PDSA cycle?

Plan-Do-Study-Act — a method for testing and refining quality improvement efforts.

What is a culture of safety?

An environment where safety is prioritized and errors can be reported without fear of blame.

What factors support a culture of safety?

Non-punitive error reporting, teamwork, leadership support, and resource allocation.

Why is data important in quality management?

It identifies gaps, drives improvement, informs patients, and determines reimbursement.

What is value-based purchasing?

A system that links hospital payment to quality measures and patient satisfaction.

What is the basis of patient satisfaction and reimbursement under the ACA?

Communication between health care staff and patients.

Which organization is responsible for evaluating hospitals based on safety and quality standards?

A. CMS
B. QSEN
C. The Joint Commission
D. CDC

✅ Answer: C. The Joint Commission
Rationale: The Joint Commission is a regulatory body that evaluates healthcare organizations on quality and safety.

Which of the following best describes the goal of QSEN?

A. To conduct hospital inspections
B. To train new physicians
C. To prepare nurses to improve quality and safety
D. To regulate medication errors

✅ Answer: C. To prepare nurses to improve quality and safety
Rationale: QSEN focuses on educating nurses with the knowledge, skills, and attitudes to enhance healthcare systems.

A nurse reports an error without fear of punishment. This is an example of which concept?

A. Regulatory oversight
B. Culture of safety
C. Root cause analysis
D. Sentinel event

✅ Answer: B. Culture of safety
Rationale: A culture of safety promotes error reporting in a blame-free environment to improve care.

Which of the following is a latent failure in the Swiss Cheese Model?

A. Giving the wrong dose of medication
B. Not verifying patient ID before surgery
C. Understaffing and poor management
D. Failing to lock a med cart

✅ Answer: C. Understaffing and poor management
Rationale: Latent failures are system-level issues that set the stage for active errors.

What is the purpose of the "5 Whys" method in quality improvement?

A. To track medication administration
B. To document incident reports
C. To explore root causes of a problem
D. To conduct patient satisfaction surveys

✅ Answer: C. To explore root causes of a problem
Rationale: The “5 Whys” technique is used to understand the deeper reason why a problem occurred.

Which quality measurement tool directly impacts hospital reimbursement through patient feedback?

A. PQRS
B. HCAHPS
C. RCA
D. QSEN

✅ Answer: B. HCAHPS
Rationale: HCAHPS surveys measure patient satisfaction and are tied to Medicare/Medicaid reimbursement.