Study Guide - Exam 1
1. Quality Improvement (QI) & Patient Safety
Key Terms
Healthcare quality: The degree to which services increase the likelihood of desired outcomes and are consistent with evidence-based practice.
Stakeholders: Anyone impacted by quality (patients, nurses, physicians, payers, regulators).
Benchmarking: Comparing one organization’s performance against best practices.
Bundles: Sets of evidence-based interventions grouped together (e.g., CAUTI bundle).
Sentinel event: Unexpected occurrence involving death or serious harm. Requires Root Cause Analysis (RCA).
RCA: Retrospective process identifying all causes of an event. Often uses Ishikawa/Fishbone diagram.
Incident reports: Internal tool to track and prevent errors; not for punishment.
Types of Audits
Audit Type | Definition | Example |
Outcome | Measures results | Pressure ulcer rates |
Process | Evaluates if care is done correctly | Hand hygiene compliance |
Structure | Assesses environment/resources | Nurse–patient ratios |
Timing: Retrospective (after care), Concurrent (during care), Prospective (before care).
6 Dimensions of Quality (IOM – Crossing the Quality Chasm)
Safe – avoid harm
Effective – evidence-based
Patient-centered – respect values
Timely – reduce delays
Efficient – reduce waste
Equitable – no disparities
Mnemonic: “STEP-EE”
QI vs QA vs Research
QI = improve processes (local, ongoing).
QA = assure minimum standards met.
Research = generate new knowledge.
2. Influences on Quality
The Joint Commission (TJC)
Accreditation: 3-year, needed for CMS reimbursement.
Sentinel Events: require RCA → find root causes, prevent future harm.
ORYX: outcome reporting, national comparisons.
National Patient Safety Goals (NPSG): yearly, target common errors (ID, med safety, infection control).
CMS (Centers for Medicare & Medicaid Services)
Pay-for-performance → quality linked to payment.
Hospital Value-Based Purchasing → reimbursement tied to outcomes.
Penalties for readmissions, CLABSI, CAUTI, VAP, HAPI.
Other Influences
Group | Focus | Why Important |
NDNQI | Nursing-sensitive indicators (staffing, falls, pressure injuries) | Compares units nationally |
NCQA | Accredits managed care (uses HEDIS measures) | Focus on prevention |
Leapfrog | Employer-driven, 4 safety standards (CPOE, safe practices, ICU staffing) | Pushes transparency |
HCAHPS | Patient survey (communication, responsiveness, cleanliness, discharge) | Tied to reimbursement |
3. Systems Thinking & CAS
Systems Thinking = look at interconnections, not isolated issues.
Complex Adaptive Systems (CAS) = healthcare is dynamic, unpredictable, adapts to change.
Swiss Cheese Model
Active failure = direct error (wrong dose given).
Latent failure = system flaw (poor staffing, policy gaps).
Error occurs when all “holes” line up.
4. Organizational Structure (Chapter 12)
Formal structure = written, official (org charts).
Informal structure = unwritten communication/power networks.
Key Concepts
Span of control = # of subordinates reporting to one manager.
Chain of command = hierarchy of authority.
Centrality = location in communication network.
Matrix structure = dual authority (e.g., unit + project manager).
Shared governance = nurses share decision-making → improves satisfaction & outcomes.
Magnet status = recognizes excellence in nursing practice.
Culture vs Climate
Culture = values, beliefs, norms.
Climate = perceptions/feelings (e.g., morale).
5. Change Theories (Chapters 7 & 8)
Lewin’s 3 Phases
Unfreezing – recognize need for change.
Movement – implement plan (driving > restraining forces).
Refreezing – stabilize, integrate into norm.
Mnemonic: U-M-R → Unfreeze, Move, Refreeze
Change Strategies
Rational/Empirical – facts persuade change.
Normative/Re-educative – peer influence.
Power/Coercive – authority/mandate.
Resistance Factors
Flexibility, evaluation of situation, anticipated consequences, perception of gains/losses, trust in leadership.
6. Planning & Strategic Change
Planning Principles
Must align with mission/goals.
Needs flexibility + evaluation.
Requires data collection, realistic targets, stakeholder involvement.
Types of Planners
Type | Approach |
Reactive | After problem occurs |
Inactivist | Avoid change |
Pre-activist | Future only, disregard past/present |
Proactive | Integrate past, present, future |
Tools
SWOT Analysis = Strengths, Weaknesses, Opportunities, Threats.
Planning Hierarchy = Mission → Philosophy → Goals → Objectives → Policies → Procedures → Rules.
🌟 Quick Memory Tricks
Quality = STEP-EE (Safe, Timely, Effective, Patient-centered, Efficient, Equitable).
Lewin = UMR (Unfreeze, Move, Refreeze).
Audit Types = “OPS” (Outcome, Process, Structure).
Planning Hierarchy = My Pretty Grandma Only Plays Piano Regularly (Mission, Philosophy, Goals, Objectives, Policies, Procedures, Rules).