Quality Assurance Overview

goal of quality assurance

continual quality improvement by minimizing variables

improvement process

need to recognize issues or concern, collect data to study the problem and its’ frequency, implement change with the intent to improve the process, then collect and study data again to confirm improvement has occurred and is sustained

quality assurance

focus on quality of services provided

quality control

focus on equipment to ensure operation within required tolerances

regulations that have had a large impact on medical imaging

safe medical devices act (SMDA)

mammography quality standards act (MQSA)

title 21 of the code of federal regulations

safe medical devices act (SMDA)

mandates that any serious injury or death due to a medical device be reported

mammography quality standards act (MQSA)

requires mammography facilities to be approved by the FDA

title 21 of the code of federal regulations

regulations regarding radiation safety

food and drug administration (FDA)

government regulatory body that impacts medical imaging

American college of radiology (ACR)

professional organization for radiologists

sets standards for field of radiology

CARE Act

federal legislation that requires educational training for those persons operating ionizing radiation

HIPAA

regulations regarding patient information and patient confidentiality

Det Norske Veritas (DNV)

an organization that accredits hospitals

TJC

national hospital accrediting body

participation is voluntary, but reimbursement is contingent on accreditation

TQI

total quality improvement

sentinel event

an unexpected occurrence causing death or serious injury, or an event that has the potential to cause death or serious injury

can be physical or psychological

requires immediate action

root cause analysis

is done to find the causes and implement change to prevent future sentinel events

risk management

identify areas of potential risk

goal is to provide quality pt care in a safe environment

Florece Nightingale

first to use systematic approach to analyzing data on morality rates in hospitals

Edwards Deming

introduced total quality management in Japan after WWII

focus on the process

create an environment that is not punitive

people who are involved in a process known best how things work

empower the quality team to make and implement decisions

provide the resources the quality team needs to get the job done

eliminate variations in the process to reduce the opportunity for errors

types of quality improvement teams

quality circles, work teams, problem solving teams

tools used in problem-solving

brainstorming

focus groups

multi-voting

consensus

process improvement programs

plan/do/check/act

SWOT analysis

FOCUS
FADE
FMEA

six sigma & lean

information analysis tools

flowcharts

cause/effect diagrams

histograms

pareto chart

scatter plot

trend chart

control chart