Quality & Safety

safety is an ___________________ and ___________________ of pharmacy quality

indicator and outcome

error

failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim

medical errors are the _____________ leading cause of death in US

3rd

dosing errors comprise ____________ of medical errors

1/3

common reasons for medication errors

failure to communicate drug orders, illegible handwriting, wrong drug selection from drop down menu, look alike sound alike, errors of dosing units or weight based

Health Information Technology and Clinical Health Act (HITECH)

promote the adoption and meaningful use of health information technology (HIT) through use of EHRs with tougher penalties for HIPAA compliance

E-iatrogenesis

patient harm is caused at least in part by the application of health information technology

prescribing errors are reduced by __________ with CPOE

48%

AHRQ quality definition

doing the right thing for the right patient, at the right time, in the right way to achieve the best possible results

Total Quality Management

organization efforts to instill and make a permanent climate where employees continuously improve products and services that customers will find of value

quality assurance

all the planned activities that can be demonstrated to provide confidence that a product or service will fulfill requirements for quality

quality control

the inspection of implemented techniques and activities to ensure they are fulfilling requirements for quality

what is often involved in quality control

testing or inspection to confirm conformance or non-conformance to standards or requirements

quality improvement

consists of systematic and continuous actions that lead to measurable improvement in healthcare services and health status of targeted patient groups; framework used to systemically improve the ways care is delivered to patients

goal of Six Sigma & Lean

drive out variances

purpose of lean

reduce waste (time, transportation, excess inventory)

Six Sigma & Lean

method to improve business process, increase performance, improve profits, morale, and quality of products and/or services; delivers customer value through efficient operations and quality standards

focuses on efficiency through the minimization of waste and delays

lean

focuses on quality and consistency, through process improvement and variation reduction

six sigma

quality methods and tools

PDSA cycle, DMAIC, DMADV, control charts, histograms, pareto charts, cause and effect diagram, process flow diagram

quality method that focuses on improving existing processes

DMAIC

quality method that focuses on creating new products and processes

DMADV

PDSA

plan, do, study, act

included in plan for PDSA

set improvement goals, predict what will happen, plan the cycle (who, where, what and how), decide what data to gather

included in do for PDSA

carry out plan, document any problems encountered and observations, gather data

included in study for PDSA

fully analyze data, compare data to predictions, examine learning

included in act for PDSA

what changes need to be made to the next cycle, if no changes, roll out improvement

DMAIC

define, measure, analyze, improve, control

define in DMAIC

define the project goals and customer (internal and external) deliverables

measure in DMAIC

measure the process to determine current performance and quantify the problem

analyze in DMAIC

analyze and determine the root cause(s) of the defects

improve in DMAIC

improve the process by eliminating defects

control in DMAIC

control future process performance so improved process doesn't degrade

DMADV

define, measure, analyze, design, verify

similarities between DMAIC and DMADV

reduce number of defects, use facts and statistics for solutions

_____________ defines a business process and its applicability

DMAIC

_____________ measures current business performance

DMAIC

_____________ analyzes process to find root cause of defect

DMAIC

_____________ defines customer needs in relation to a product or service

DMADV

_____________ measures customer needs and specifications

DMADV

_____________ analyzes process for satisfying customer needs and specifications

DMADV