Ch 18: Performance Improvement - HEIT 220: Principles of Leadership

Outcome indicators

Measure the actual results of care for patients and populations, including patient and family satisfaction

Outcome measures

Document the results of care for individual patients as well as for specific types of patients grouped by diagnostic category

Process measure

Focus on a process that leads to a certain outcome, meaning that a scientific basis exists for believing that the process, when executed well, will increase the probability of achieving a desired outcome.

Process redesign

The steps in which focused data are collected and analyzed, the process is changed to incorporate the knowledge gained from the data collected, the new process is implemented, and the staff is educated about the new process

Productivity indicators

A set of measures designed to routinely monitor the output and quality of products or services provided to an individual,
a healthcare organization, or one of its constituent parts; used to help determine the status of a productivity bonus.

Utilization management (UM)

Composed of a set of processes used to determine the appropriateness of medical services provided during specific episodes of care

Accountable Care Organization (ACO)

A network of physicians, hospitals, and other healthcare providers and suppliers working to gether to coordinate and improve care for patients
with Medicare

Agency for Healthcare Research and Quality (AHRQ)

An agency within HHS. Mission is to improve the quality, safety, efficiency, and effectiveness of healthcare for all Americans

Cause-and-effect diagram

(also known as Fishbone diagram) An investigational technique that facilitates the identification of the various factors that contribute to a problem

Common-cause variation

Variation that is inherent within the system

Data abstracts

A defined and standardized set of data points or elements common to a patient population that can be regularly identified in the health records of the population and coded for use and analysis in a database management system

DNV GL Healthcare

A voluntary
accreditation organization that has operated in
the US since the late 1800s but is relatively new to
healthcare

Financial indicators

A set of measures designed to routinely
monitor the current financial status of a healthcare organization or one of its constituent parts.

Force-field analysis

Identifies specific drivers of and barriers to an organizational change, so that positive factors can be reinforced and negative factors reduced

High Reliability Organization (HRO)

Organizations that focus on creating an environment that eliminates or minimizes error

Internal customers

such as employees. The employees receive services from other areas in the organization that make it possible for them to do their jobs

ISO 9001 certification

Part of a PI system required to conduct business in certain foreign countries

The Joint Commission

Emphasizes PI in their accreditation standards

Lean

A process improvement methodology focused on eliminating waste and improving the flow of work processes

Six Sigma

Uses statistics for measuring variation in a process

Medication Reconciliation

The process that monitors and confirms that the patient receives consistent dosing across all healthcare facility transfers, such as on admission, from nursing unit to surgery, and from surgery to the intensive care unit.

National patient safety goals (NPSGs)

Outlines the areas of organizational practice that most commonly lead to patient injury or other negative outcomes that can be prevented if standardized procedures are used.

Opportunity for improvement

A healthcare structure, product, service, process, or outcome that does not meet its customers' expectations and, therefore could be improved

Performance improvement (PI)

The continuous study and adaptation of a healthcare organization's functions and processes to increase the likelihood of achieving desired outcomes

Performance indicators

a measure used by healthcare organizations to assess the quality, effectiveness, and efficiency of their services.

Performance measurement

The process of comparing the outcomes of an organization, work unit, or employee against pre-established performance
plans and standards

Potentially compensable event

An occurrence, such as an accident or medical error that may result in personal injury or loss of property to patients, staff, visitors, or the healthcare organization.

Process indicators

Measure steps in a process and tasks people, or devices do, from conducting appropriate tests, to making a diagnosis, to carrying out a treatment

Quality indicators

Standards against which patient care is measured to identify a level of performance for that standard

Risk management program

Link risk management functions to the related processes of quality assessment and PI.

Root-cause analysis

A technique used in performance improvement initiatives to discover the underlying causes of a problem. Analysis of a sentinel event from all aspects (human, procedural, machinery, material) to identify how each contributed to the occurrence of the event and to develop new systems that will prevent recurrence.

Run chart

Displays data points for a specific time frame to provide information about performance

Sentinel event

Describes an occurrence with an undesirable outcome usually happening only once

Special-cause variation

Factors outside of the system may cause variations

Statistical process control chart

A type of run chart that includes both upper and lower control limits and indicates whether a process is stable or unstable

Statistics-based modeling

The use of analytical and graphical techniques to assist in the display and interpretation of raw data. Two common statistical-based modeling techniques are run charts and process control charts

Structure indicators

Measure the attributes of the healthcare setting, such as number and qualifications of the staff, adequacy of equipment and facilities, and adequacy of organizational policies and procedures

Systems thinking

An objective way of assessing work-related ideas and processes with the goal of allowing people to uncover ineffective patterns of behavior and thinking and then finding ways to make lasting improvement

Time ladders

Support the collection of data that must be oriented by time; they specify intervals of time necessary to address the problem under consideration listed down the right side of one, two, or three columns

Affinity grouping

Allows the team to organize similar ideas into logical grouping

Benchmark

A systematic comparison of one healthcare organization's measured characteristics with those of another similar organization or with internal, regional, or national standards

Brainstorming

A technique used to generate a large number of creative ideas from a group.

Checksheet

A data collection tool that records and compiles observations or occurrences.

Claims management

The process of managing the legal and administrative aspects of the healthcare organization's response to injury claims (injuries occurring on the healthcare organization's property)

Clinical practice guidelines

Developed to standardize clinical decision-making.

Clinical protocols

Detailed, step-by-step instructions used by healthcare practitioners to make knowledge-based clinical decisions directly related to patient care

Customer

someone who pays for goods or services

Dashboards

The display of the most important information needed to achieve one or more objectives that has been consolidated... so it can be monitored at a glance

External customers

People outside the organization for whom it provides services. Ex: patients, third-party payers, and the department of health

Flow chart

A graphic tool that uses standard symbols to visually display detailed information, including time and distance of the sequential flow of work of an individual or a product as it progresses through a process

Incident or occurrence report

A structured tool used to collect data and information about any event not consistent with routine operational procedures, such as a wrong-side surgery or foreign body left in following surgery

Inputs

Data entered into a hospital information system

Multivoting technique

A variation of the nominal group technique and serves the same purpose

Nominal group technique

A process used to reach consensus about an issue or an idea that the team considers most important.

Outputs

The outcomes of inputs into a system

Patient advocacy

A patient representative (sometimes called an ombudsperson) responds personally to complaints from patients and their families.

Risk

Any occurrence or circumstance that might result in a loss

Scorecards

Tools that present metrics from a variety of quality aspects in one concise report

Six Sigma

Disciplined and data-driven methodology for getting rid of defects in any process

Standard

A written description of the expected features, characteristics, or outcomes of a healthcare-related service

Structured brainstorming

The team leader or facilitator asks team members to create their own list of ideas.

Unstructured brainstorming method

Results in a free flow of ideas