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What are the six dimensions of quality in healthcare as defined by the Institute of Healthcare Improvement (IHI)?
The six dimensions of quality in healthcare, according to the IHI, are safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. These dimensions serve as essential aspects to assess and improve the quality of healthcare services.
What does Quality Improvement include/involve?
Ideology
Contextual Framework
Healthcare System Program
Small Projects: Often aimed at specific small-scale improvement projects.
What is the definition of ideology?
System of ideas that form the bases of our policy and practice.
What is the definition of a contextual framework?
A contextual framework refers to the systematic use of Quality Improvement (QI) methodologies to enhance healthcare practices. It involves the structured application of QI techniques and strategies to analyze, assess, and improve various aspects of healthcare delivery, with the goal of optimizing the quality, efficiency, and safety of healthcare services within a specific context or setting.
What does a healthcare system program involve?
A healthcare system program encompasses continuous initiatives and measurement efforts aimed at maintaining and regulating the quality of care provided within a healthcare system. These programs are designed to monitor and enhance the quality of healthcare services, ensuring they meet established standards and objectives.
What are small projects in the context of healthcare improvement?
Small projects in healthcare improvement typically refer to specific, focused initiatives designed to make incremental and localized improvements within a healthcare system. These projects aim to address specific issues, enhance processes, or achieve particular objectives on a smaller scale, contributing to the overall quality and efficiency of healthcare services.
What was the key finding of the "To Err is Human" study published by the Institute of Medicine in 1999?
The "To Err is Human" study reported that medical errors cause a significant number of deaths, ranging from 44,000 to 98,000 annually in the United States. It also highlighted the substantial economic costs associated with these errors, including over $9 billion per year in lost productivity and nearly $2 billion per year in hospital costs. The study emphasized the existence of gaps between what should be done in healthcare and what is actually done, calling for improvements in patient safety and healthcare quality.
What where the reaction and response to the 1999 study?
Extent of the problem was previously unknown and shocked the general public.
Congressional hearings were subsequently held.
Government agencies, professional groups, accreditation organizations, and insurers quickly developed programs and reporting systems.
Ushered in the current paradigm of quality improvement and patient safety.
Altered definitions and sentiments..
What was the perception of medical errors before the "To Err is Human" study?
Before the "To Err is Human" study, medical errors were often perceived as isolated incidents resulting from the incompetence of healthcare professionals, with the assumption that these professionals had good intentions and were working diligently. The study challenged this perception by highlighting the systemic nature of medical errors and emphasizing the need for broader improvements in healthcare safety.
How did the perception of medical errors change after the "To Err is Human" study?
After the "To Err is Human" study, medical errors were no longer seen as solely the result of individual incompetence or the actions of healthcare professionals. Instead, they were recognized as a product of a complex healthcare system. The study emphasized that holding individuals or organizations accountable would not, by itself, make the healthcare system safer. This shift in perception highlighted the need to address systemic issues and implement broader safety measures.
What were the characteristics of a "good provider" in healthcare before the "To Err is Human" study?
Before the "To Err is Human" study, a "good provider" in healthcare was characterized by encyclopedic knowledge, mastery of rescue care, independence, availability, and a deep understanding of physiologic experiences.
What are the characteristics of a "good provider" in healthcare after the "To Err is Human" study?
After the "To Err is Human" study, a "good provider" in healthcare is characterized by being a team player within a system, a learner and manager of information, focused on prevention, using evidence-based medicine, and being patient-centered.
What were the 4 major recommendations left by ERR is Human study?
Formation of a National center for Patient Safety within the AHRQ
Recognized that healthcare was a decade (or more) behind other industries.
Establishing a mandatory and voluntary error reporting system.
Federal legislation would protect reports that have no serious consequences.
Recognizing the role of consumers, professionals, and accreditation groups in quality improvement.
Working to build a culture of safety.
What are the dimensions of quality in healthcare identified in the "Crossing the Quality Chasm" study from 2001?
The "Crossing the Quality Chasm" study identified six dimensions of quality in healthcare, including patient safety, effectiveness, patient-centeredness, timeliness, care efficiency, and equity.
What goals were recommended by the Institute of Medicine (IOM) to achieve improvements in healthcare quality, as outlined in the "Crossing the Quality Chasm" study?
The IOM recommended the following goals:
Evidence-based medicine.
Transparency in healthcare.
Accessibility to patient information and records.
Institutions using performance metrics.
Large investments in training and technology.
What were some key provisions of the Patient Protection and Affordable Care Act (ACA), also known as Obamacare, related to healthcare quality and delivery?
The ACA included the following provisions related to healthcare quality and delivery:
Mandated public reporting of core safety measures.
Introduction of core metrics, report cards, and patient feedback polls.
Incentives for the adoption of electronic medical records by hospitals.
Transition of Medicare from a fee-for-service payment model to a bundled payment model.
Promotion of accountable care organizations (ACOs) through sharing cost savings from value-based care.
LO: Understanding the Basic Principles of Quality Improvement and Current Practices of Quality Improvement.
What are the Different groups that play different roles in healthcare improvement
Government:
Professional and Accreditation Groups: Leapfrog: A PSO (patient safety organization)
Consumers:
CMS (Center for Medicare/Medicaid)
Different groups play different roles in healthcare improvement: Government:
What is mandated public reporting of core safety measures in healthcare, and how does it relate to core measurements and the Hospital Compare website?
Mandated public reporting of core safety measures in healthcare involves the requirement to report key safety and efficacy metrics related to hospital care. These core measurements cover various medical conditions, including acute myocardial infarction (AMI), heart failure (HF), pneumonia, surgical care, children's asthma care, venous thromboembolism (VTE), and stroke, among others. The data collected is made available to the public through a "report card" that can be accessed on the Hospital Compare website. This allows individuals to compare hospitals based on these core measurements, helping them make informed decisions about their healthcare providers.
What is Leapfrog, and how does it influence quality and affordability in healthcare?
Leapfrog is a Patient Safety Organization (PSO) formed by several Fortune 500 companies with the aim of influencing the quality and affordability of healthcare. They base their healthcare and health insurance purchases on encouraging quality and involving consumers in the decision-making process. Leapfrog provides a Leapfrog Safe Practice Score, which is presented in a report-card-like format, encompassing safety and core measurements to help consumers make informed choices about healthcare providers.
How do consumers use public reporting and report cards produced by Patient Safety Organizations (PSOs) to influence the healthcare market?
Consumers use public reporting and report cards from PSOs to steer the healthcare market toward high-value, low-cost care. For example, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey and report card provide a representation of patient experiences for a hospital, helping consumers make informed decisions about their healthcare choices.
Where are CMS (Center for Medicare/Medicaid) Core Measurements reported?
CMS Core Measurements are reported to various organizations, including directly back to Medicare, the Joint Commission, and the National Patient Safety Foundation, which is within the Agency for Healthcare Research and Quality (AHRQ).
LO: QI Ethical Principles
Quality improvement activities are considered to be a normal part of healthcare operations. (As long as what ethical standards are met)
Social or scientific validity: What’s being investigated is important/valid enough to pursue.
Fair participant selection
Favorable risk-benefit ratio: minimal risk is present.
Respect for participants: Data should be non-identifiable.
Informed Consent: Consent to inclusion in minimal-risk QI activities is part of the patient’s consent to receive treatment. Pt should be asked for informed consent to be included in specific QI activities if they impose more than minimal risk.
Independent review: Accountability for QI integrated is in clinical care accountability. (Should receive ethical review that is appropriate to the level of risk).
LO: The difference between QI and Research
Can QI be research
QI can be research
QI can be published and can be considered research if published.
You should always file QI projects with your institution's IRB if you are impacting patient care or if there is even the smallest possibility you will publish your project.
What is the difference between QI and research?
In research, you create a hypothesis, set a control for your environment, and then implement your change to evaluate. You will then obtain your results (unbiased conclusion either for or against the hypothesis ).
In QI, you have a predetermined outcome that you are trying to reach. You start with your aim, but must work within your usual environment and go through cycles of experimentation to reach your aim.
LO: Understand the Basic Methodologies for Quality Improvement; Lean, Six Sigma, PDSA, IHI Model for Improvement
What is Lean, and how does it focus on maximizing customer value and minimizing waste?
Lean is a methodology that aims to maximize customer value while minimizing waste. It involves optimizing and mapping workflows to eliminate wasteful steps. Lean focuses on process efficiency and uses the Kaizen cycle, which means making continuous improvements and involving all employees in the improvement process. An example of Lean in a hospital setting is the "just in time" system, where downstream demand drives upstream production, ensuring that essential items, like medications, are delivered to patients' rooms promptly.
What is Six Sigma, and how does it focus on reducing defects in a process to an error rate of 6 standard deviations (3.4 ppm)?
Six Sigma is a methodology aimed at finding and fixing defects in a process to reduce the error rate to 6 standard deviations, equivalent to 3.4 defects per million opportunities (ppm). It focuses on measuring the problem, identifying its root cause, and ensuring reproducibility. Six Sigma employs the DMAIC cycle (Define, Measure, Analyze, Improve, and Control) and the "5 Whys" technique to systematically address issues. An example of Six Sigma in healthcare is Root Cause Analysis (RCA) for a safety event and protocol standardization, focusing on effectiveness and standardization.
What is Lean Six Sigma, and how does it combine principles from Lean and Six Sigma methodologies in healthcare?
Lean Six Sigma is a combined approach that integrates principles from both Lean and Six Sigma methodologies in healthcare. It aims to eliminate wasteful steps in processes and streamline the flow between these steps, as seen in Lean. Additionally, it focuses on reducing variability and optimizing outcomes at each step, which is in line with the Six Sigma methodology's emphasis on reducing defects and ensuring effectiveness. This combination seeks to improve efficiency and effectiveness within healthcare systems.
What is the PDSA cycle, and how does it work in healthcare improvement?
The PDSA (Plan, Do, Study, Act) cycle is a methodology developed by Edward Deming in the 1950s and is used for continuous improvement in healthcare and other fields. It involves a four-step process:
Plan: This step entails breaking down the task or aim into specific actions or objectives.
Do: Implementation of the plan.
Study: Evaluation and analysis of the outcomes to identify areas for improvement.
Act: Making necessary changes based on the study phase and then testing the revised process or action again. This cycle is repeated iteratively to achieve continuous improvement in healthcare processes and outcomes.
What is the IHI Model for Improvement?
What are the key considerations to address before starting a PDSA (Plan, Do, Study, Act) cycle in healthcare improvement?
Before initiating a PDSA cycle in healthcare improvement, it's crucial to address several key considerations by answering the following questions:
Plan, Do, Study, Act: Breaking down the task/aim into steps, evaluating the outcome, improving on it, and then testing it again.
What is the specific aim or goal of the improvement project?
How will you know if a change is an improvement (what are the measurable outcomes)?
What changes can be tested to achieve the desired improvement?
What is the plan for implementing the proposed changes?
How will you gather data and study the results to determine the impact of the changes?
What actions will be taken based on the study phase to further refine and optimize the process or action?
LO: Understand how to use and how to write a strong Aim Statement.
AIM statement: Serves as a
mission statement for a QI project.
It is not a hypothesis.
It is a goal and a predicted outcome.
Set at the beginning of the product (as a pitch)
Using a literature review can be very helpful in determining the relevancy/realistic nature of certain goals.
Use the SMART mnemonic to help create a strong Aim statement.
LO: Understand the types of QI measurements and their various strengths and weaknesses.
What is the purpose of an AIM statement in a Quality Improvement (QI) project, and how can the SMART mnemonic assist in creating a strong AIM statement?
The AIM statement in a Quality Improvement (QI) project serves as a mission statement for the project. It is not a hypothesis but rather a goal and a predicted outcome set at the beginning of the project. The SMART mnemonic is a helpful tool in creating a strong AIM statement. SMART stands for:
Specific: The AIM statement should clearly define the specific goal of the project.
Measurable: It should include metrics or indicators to measure success.
Achievable: The goal should be realistic and attainable within the project's scope.
Relevant: The AIM statement should be relevant to the project's purpose and objectives.
Time-bound: It should specify a timeframe for achieving the goal. Using a literature review can be beneficial in determining the relevancy and realistic nature of the AIM statement's goals, ensuring they are well-informed and aligned with existing knowledge and research.
How can the impact or changes brought on by a Quality Improvement Project be determined, and what are the key measurement categories used in this process?
To determine the impact or changes brought about by a Quality Improvement Project, it's essential to define the measurements. There are four key measurement categories used in this process:
Structure Measures: These assess the attributes and resources in a healthcare system, such as staffing levels, facilities, and equipment.
Process Measures: These evaluate the actions or steps taken in delivering healthcare, ensuring that the appropriate processes are followed.
Outcome Measures: These assess the results or effects of healthcare interventions, focusing on patient health, satisfaction, or other relevant outcomes.
Balance Measures: These aim to maintain a balance between different aspects of care, such as cost-effectiveness, resource allocation, and quality of care.
By measuring and analyzing data within these categories, healthcare organizations can determine the effectiveness of their improvement efforts and whether changes made represent real improvements.
What does "Structure Measurement" involve in a Quality Improvement (QI) project, and can you provide an example?
In a Quality Improvement (QI) project, "Structure Measurement" assesses the attributes and resources within a healthcare system. This measurement category focuses on physical equipment, the number of available resources, and facilities. For example, it might involve evaluating the number of diabetes educators or physical therapists available in a healthcare setting. An intervention related to structure measurement could include adding more resources or monitoring the availability of items like hand sanitizer dispensing stations for patients.
What are the benefits of using "Structure Measurement" in Quality Improvement (QI) projects?
Versatility: A single structure measure can be linked to various Quality Improvement (QI) outcomes, allowing for a comprehensive assessment of different aspects of healthcare.
Clarity: Structure measurements are often straightforward and easy to define, making them accessible for evaluation and analysis.
What are the weaknesses of using "Structure Measurement" in Quality Improvement (QI) projects?
Limited Outcome Linkage: Structure measurements may not be strongly correlated with actual patient outcomes, making it challenging to determine their direct impact on quality improvement.
Lack of Actionability: Often, changes related to structural components may require higher-level institutional modifications, making them less actionable for immediate improvement.
What is "Process Measurement" in Quality Improvement (QI) projects?
Process measurement involves assessing the specific performance of a QI project system as planned. It frequently examines how compliant healthcare providers are with specific quality improvement processes. For example, it can be measured as the percentage of patients with diabetes who had their HbA1C levels checked in the past 6 months. This type of measurement is widely used in QI projects to evaluate the adherence to established processes, particularly when certain recommended actions are not consistently implemented.
LO: Learn different QI tools and understand their application.
How can we go about determining what kind of change will result in an improvement?
We can use QI tools to determine/help plan our strategy…
Helps to understand the “baseline system” (What change can we make that will result in improvement).
There is no set kind or number of tools for a given problem.
Tools are most effective in a collaborative setting (getting multiple perspectives and input).
Avoid Analysis Paralysis
Do not let perfect be the enemy of good.
What are the benefits of "Process Measurement" in Quality Improvement (QI) projects?
Reflects the care that patients receive.
Is directly actionable, allowing for targeted improvements.
Does not require or need risk adjustment, as it focuses on assessing whether healthcare providers are adhering to established processes and guidelines, which is something that should be consistently done.
Process measurement is valuable for evaluating and enhancing the consistency and quality of healthcare processes.
What are the weaknesses of "Process Measurement" in Quality Improvement (QI) projects?
May or may not be tightly linked to outcomes, as the relationship between adherence to processes and patient outcomes can vary.
Data collection for process measurement can be challenging in some cases, although it can also be easier depending on the specific process and available data sources.
Understanding these weaknesses is important for designing effective QI projects and selecting appropriate measures.
What is "Outcome Measurement" in Quality Improvement (QI) projects?
Outcome measurement involves assessing the impact of a core measurement or intervention on patient outcomes. For example, it may measure the number of patients who experienced adverse outcomes or improvements in health status as a result of a QI project. It focuses on the ultimate effects of the intervention on patients.
Outcome measurement is a critical aspect of QI projects as it helps determine whether the changes made result in meaningful improvements in patient health and overall quality of care.
What are the weaknesses of "Outcome Measurement" in Quality Improvement (QI) projects?
May be rare to observe (small sample size)
Will require a risk adjustment.
May be very difficult to influence (things like mortality are multifaceted problems that will require multifaceted solutions/interventions).
What are the benefits of "Outcome Measurement" in Quality Improvement (QI) projects?
Usually is highly valid
Reflects ultimate treatment goal/QI impact on patient outcome
Understandable by most users/audiences
What is a balance measurement in the context of quality improvement?
Balance Measurement refers to the assessment of the impacts on other systems or outcomes resulting from an intervention, often involving unintended or negative consequences. An example of this can be seen when an intervention designed to help patients lower their cholesterol accidentally lowers it to unhealthy levels.
No benefits/weaknesses as balance measurements should always be evaluated in tandem with other measurement systems.
What is a Fishbone Diagram?
A Fishbone Diagram is a visual tool used to analyze and identify the various causes and barriers contributing to a specific problem or undesirable outcome. It is structured with headings that categorize causes based on their distinctions, making it useful for understanding the multifaceted nature of the issue. The diagram assists in planning interventions and strategies for quality improvement projects.
What is a Process Map and its basic key elements?
A Process Map is a visual representation of a workflow that uses specific symbols for different elements:
Circle/Oval: Represents the start and finish points of the process.
Square: Signifies a step or process that needs to be completed.
Diamond: Marks a decision point, typically with a yes or no outcome. Process maps are helpful for clarifying processes, making quality improvement (QI) goals clear to the healthcare team, and demonstrating a timeline to ensure that QI goals are reasonable and achievable.
What is the Circle/Oval in the Process Maps:
Represents the start and finish points of the process.
What is the Square in the Process Maps:
Signifies a step or process that needs to be completed.
What is the Diamond in the Process Maps:
Marks a decision point, typically with a yes or no outcome. Process maps are helpful for clarifying processes, making quality improvement (QI) goals clear to the healthcare team, and demonstrating a timeline to ensure that QI goals are reasonable and achievable.
A Priority Matrix can be helpful following studying the results and looking through the literature. Give an example of this.
Example given: Student hand-washing behaviors on clinical rotations.
Low cost and high impact are usually the quickest “wins” and are usually good things to focus on for a quality improvement project.
Usually the most actionable interventions.
LO: Understand how to use a Run Chart and Control Chart.
While in the study phase of PDSA, we will want to plot our data in a
Run Chart/Control Chart to analyze QI performance.
What is a Run Chart and how is it used in quality improvement?
A Run Chart is a graphical tool used in quality improvement to track and analyze changes in a measurement over time. It typically includes the following components:
Establishes a goal: The chart defines a specific goal or target.
Median value (Center line): The median value or central line represents the baseline or average measurement.
Shift: A shift occurs when there are six or more consecutive data points above or below the median line, indicating a significant change in the process.
Trend: A trend is observed when there are five or more consecutive data points that show a sequential increase or decrease, suggesting a systematic pattern.
Astronomical Data: These are extreme outliers that fall well outside the typical range of data points. They are also important to identify and investigate. Run charts help visualize data patterns, detect shifts or trends, and track progress toward quality improvement goals.
What is a Control Chart?
A Control Chart is a graphical tool used in quality control to monitor processes and determine if they are under stable conditions. It defines upper and lower control limits to assess whether variations in the process are within an acceptable range. Control Charts are commonly used in various industries to ensure quality and consistency.
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