ACS Introduction to Quality Improvement Practice Flashcards

Flashcards covering Module 1: Introduction to Quality Improvement, medical terminology, and the ACS Quality Framework.

What is the primary difference between a healthcare regulation and accreditation?

Regulations are government-issued rules of order carrying out legislation and judicial rulings, whereas accreditation is an approval process by independent, nongovernmental bodies certifying that an institution or individual meets specific standards.

How does the National Academy of Medicine (NAM) define quality in healthcare?

The degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.

How does the World Health Organization (WHO) define patient safety?

The absence of preventable harm to a patient during the process of health care and reduction of risk of unnecessary harm associated with health care to an acceptable minimum.

What formula expresses healthcare value according to Michael Porter?

$$\text{Value} = \frac{\text{Quality}}{\text{Cost}}$$

What estimate of annual patient deaths in the United States is attributed to healthcare quality and safety issues?

Between $44,000$ and $98,000$ annual patient deaths.

What annual monetary loss is associated with gaps in care due to missed opportunities, waste, and harm?

$$\$765\text{ billion}$$

What are the six domains of quality in the STEEEP model?

Safe, Timely, Effective, Efficient, Equitable, and Patient-centered.

In the Donabedian Model, what are structure measures?

Physical and organizational aspects of care settings, such as number of hospital beds, nurse-to-patient ratios, qualifications of medical staff, and electronic prescribing software.

In the Donabedian Model, what are process measures?

Measures that indicate whether care is delivered correctly, such as appropriate use of preoperative antibiotics and administration of postoperative DVT prophylaxis.

In the Donabedian Model, what are outcome measures?

Measures indicating what actually happens to patients as a result of care, such as mortality rates, postoperative complications, and infection rates.

What is the purpose of balancing measures in quality improvement evaluation?

To track unintended consequences or collateral damage caused by a quality improvement project, such as increased readmission rates following an accelerated recovery protocol.

What cost savings did Henry Ford Hospital achieve by reducing average patient length of stay by 1.54 days?

Saved $\$2\text{ million}$ per year while increasing general surgery billings by $\$2.25\text{ million}$ per year.

What reduction in surgical site infections (SSIs) and cost savings did Surrey Memorial Hospital achieve over two years?

Reduced general and vascular surgery SSIs by $5.7\%$ and breast surgery SSIs by $13.3\%$, saving more than $\$2.7\text{ million}$.

What financial and clinical impact resulted from Geisinger Community Medical Center's ICU reduction initiative?

A $66\%$ reduction in odds of ICU admission and mechanical ventilation, resulting in an estimated savings of $\$259,811.11$.

What organization was formed in the 1950s by ACP, AHA, AMA, CMA, and ACS to accredit hospitals complying with CMS Conditions of Participation?

The Joint Commission.

What federal agency provides Quality Indicators used by CMS on its Hospital Compare website?

Agency for Healthcare Research and Quality (AHRQ).

What are the four key principles identified by the ACS to measurably improve care quality and increase value?

Set the standards, build the right infrastructure, use the right data, and verify with outside experts.

What medical term refers to an acute disturbance of attention, awareness, and cognition in older patients?

Delirium.

What is the definition of Enhanced Recovery After Surgery (ERAS) pathways?

Evidence-based pathways of care designed to achieve early recovery after surgical procedures, typically incorporating preoperative counseling, nutritional optimization, and standardized pain management.

In medical terminology, what severity levels of pressure ulcers are classified as 'never events'?

Category 3 and Category 4 pressure ulcers.

What does the abbreviation VTE stand for, and what two clinical conditions does it encompass?

Venous thromboembolism; it encompasses deep vein thrombosis (DVT) and pulmonary embolism (PE).

What is the SEP-1 Bundle?

A standardized bundle of treatments used to manage sepsis, including antibiotic and fluid administration, blood cultures, and bedside clinical evaluations.

What is critical illness polyneuropathy?

Muscle weakness in critically ill patients caused by nerve disease, often associated with difficulty in weaning patients from mechanical ventilation.

What is a pneumothorax?

A collapsed lung caused by air escaping from the lung into the space between the lung and the chest wall.

What is the primary function and target setting of the ACS Quality Framework?

To guide and evaluate small-scale, local, clinician-led surgical quality improvement efforts across hospitals.

What evaluation findings from 50 surgical improvement projects led to the development of the ACS Quality Framework?

Projects fulfilled a mean of only $36\%$ of 39 framework criteria (ranging from $0\%$ to $72\%$), showing significant deficits in project planning, documentation, cost evaluation ($3\%$ score), and stakeholder value assessments.

What are the three core phases and eight components of the ACS Quality Framework?

Planning (Problem Detailing, Aim Specification, Strategic Planning), Conducting (Process Evaluation, Outcome Evaluation, Cost Evaluation), and Reflecting (Knowledge Acquisition, End-of-Project Decision-Making).

How do small-scale quality improvement initiatives differ from large-scale and individual-scale initiatives?

Small-scale initiatives are local, service-line, or surgeon-group efforts led by frontline clinicians or staff without hospital-wide scope; large-scale initiatives are well-funded, expert-led, IRB-approved studies published in journals like NEJM or JAMA; individual-scale initiatives are unmeasured self-improvements without data collection.

What four core management documents are included in the ACS Quality Framework Toolkit?

The ACS Quality Framework Submission Form, Project Charter, Communication Plan, and Data Plan.

What are the key details of the ACS Quality Improvement Course: The Basics?

A self-paced 6-module online course taking approximately $20\text{ hours}$ to complete, costing $\$249$, and offering CME/CNE credits.

What four measure categories are included in the Donabedian Model for evaluating healthcare quality?

Structure measures, Process measures, Outcome measures, and Balancing measures.

What three primary phases categorize the eight components of the ACS Quality Framework?

Planning, Conducting, and Reflecting.