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Quailty Assurance

what are minutes Used to track team progress and activities; CRAF method- Conclusions, Recommendations, Actions and Follow-up
how often should PI teams report their progress to the organization’s PI and Safety Council? (at a minimum) Quarterly
what is a storyboard Explains work to those unfamiliar with the PI process
what are some rules to keep in mind when creating storyboards Map the board out in advance with labels for each section; Prepare clean boards for group presentation and display; Keep detailed information in a team record binder for reference; plan the presentation to fit the size of the storyboard; Use large fonts
What types of information are displayed on storyboards? Performance measures, quality initiatives, emphasizing an organization’s mission within its community and communicating ongoing efforts to provide the community with the best healthcare
what is a customer Someone who received a product or service from an organization.
What are the 2 categories of customers? Internal: Individuals within organization who receives product or service from someone else in the organization or department. External: Individuals from outside the organization who receive products or services from within the organization.
what are some of the methods used to collect data on customer satisfaction? Survey tools, interviews and direct observation
What are the differences between surveys and interviews Surveys require significant investment of time. Easier to aggregate data from a survey; composed of structured responses. Interviews are often easier to use because they consist of open-ended questions. Reponses to interview questions must be analyzed to
What are two types of interviews Structured and unstructured interviews
Know the differences between structured and unstructured interviews (page 102) unstructured: the sequence of questions is not planned in advance, conducted in a friendly, conversational manner; helpful when interviewer is trying to uncover preliminary problems. Funneling: moving questions from a board theme to a narrow theme in an u
What is the definition of standard precautions? (page 169) can be defined as the use of infections prevention and control measures to protect against possible exposure to infections agents
What is the definition of a healthcare associated or nosocomial infection? Infections that occur in healthcare facility
Community acquired infection? Infection that was present in the patient before admission
in the ongoing surveillance step to preventing and controlling infectious disease, in what four areas are surveillance activities conducted Employee health, facility vaccine, environment, food prep are
What kinds of education do healthcare employees received about infection control? Evaluate all the means of transmission of infection throughout the facility and develop educational programs that promote disease prevention
Process Icon When actions are being performed by human participants
Decision Icon participants must evaluate the status of the process
Connector Icon where the analysis skips to another common point of the process
Terminator Icon end of a process
Manual Input Icon participants must record data in paper-based or computer based formats
two patient rights Freedom from all forms of abuse or harassment, Privacy protection. Information and participation in decision making
What is a potentially compensable event? Occurrences involving injury or property
What is risk management? Managing the organization’s risk exposure and improve its processes so that the threat of liability is minimized
What types of things are involved? Investigating incidents and directed by legal support.
What is the goal? to spot patterns in incidents and through an intense investigative process, identify problems or concerns.
What is an occurrence report? carefully structure the collection of data, information, and facts in a relatively simple format
What is a near miss? valuable tool for evaluation of processes and procedures, especially in high risk areas or areas of high volume.
What is a root cause analysis? Findings that are determined process issues and new solutions to prevent sentinel events from occurring.
When is root cause analysis used? when there are frequently occurring sentinel events
What kinds of educational activities does the risk manager develop? hand-washing techniques, needle safety protocol, Nation al Patient Safety Goals- Universal protocol, fall-risk prevention, surgical fire prevention
What is an advocate? A person who represents the rights and interests of another individual as though they were the person’s own, in order to realize the rights to which the individual is entitled, obtain needed services and remove barriers to meeting the individuals needs.
What is a cause and effect diagram? Structures the root cause analysis and helps the investigators to be sure that they have examined the situation from all perspectives.
When is cause and effect diagram used? Root-cause analysis
What is another name for it? Fishbone diagram
Credentials are the recognition by healthcare organizations of previous professional practice responsibilities and experiences commonly accorded to licensed independent practitioners.
Certifications are usually conferred by a national professional organization dedicated to a specific area of healthcare practice.
Licenses are conferred by sate regulatory agencies.
What is a licensed independent practitioner? Someone who holds a license to practice on their own, doesn’t need to be supervised What are clinical privileges?
What topics should be included in new employee orientation? Organizations mission, vision, values, PI program, life safety procedures, infection control practices, specific job duties
What are the four elements that must be present to prove malpractice? Duty, Breach of Duty, Damages/ Injury, Cause
What is tort law? A wrongful act committed against a person or piece of property, a civil action as opposed to a criminal act or breach of contract
definition of discoverable Information that is not shielded and can be introduced at trial to support a patient’s malpractice action against a physician and/ or hospital.
HCQIA – what is it, what does it do? Health Care Quality Improvement Act is the federal stature designed to make the peer review process more effective by reducing the fear or legal liability on the part of participants.
What responsibilities do physicians and hospitals have to disclose adverse events to patients and their families? A factual explanation of the circumstances surrounding the adverse event, an explanation of the impact of the adverse event on the patient’s treatment including treatment that may otherwise not have been necessary, steps that will be taken to correct or m
Created by: kwimbe01