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Accreditation Standards

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Statements of expectation set by a competent authority concerning a degree or level of requirement, excellence, or attainment in quality or performance.

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Assessment

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Use of performance information to determine the degree to which an acceptable level of quality has been achieved.

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Continuous improvement

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System in which individuals in an organization look for ways to do things better, usually based on understanding and control of performance variation.

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Governing Board

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Individuals, groups, or agency with ultimate legal authority and responsibility for overall operation of an organization; sometimes called board of trustees

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Healthcare Quality

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Degree to which health services for individuals and population increase like the likelihood of desired health outcomes and are consistent with current professional knowledge.

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Improvement

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Planning and making changes to current practices so performance will be better in the future.

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Measurement

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Collection of information for the purpose of understanding current performance and seeing how performance changes over time.

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Medical staff executive committee

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Leadership group of a hospital's organized medical staff that exercises primary authority over activities of the medical staff and over performance of individuals with hospital clinical privileges

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Misuse

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Health services misuse includes incorrect diagnoses as well as medical errors and other sources of avoidable complications

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Overuse

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Overuse occurs when a health service is provided even though its risk of harm exceeds its likely benefit.

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Patient safety

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Actions taken to reduce the risk of patients being unintentionally harmed by effects of healthcare services.

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Processes

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Collections of actions following prescribed procedures for bringing about a result

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Quality Management

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Way of doing business which continuously improves products and services to achieve even better levels of performance.

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Quality management plan

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Written description of the organizational structure, responsibilities, procedures, processes and resources supporting an organization's quality management system

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Quality Management System

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Organizational structure, responsibilities, procedures, processes and resources supporting the design, measurment, assessment and improvement of key functions and key processes, sometimes referred to as the quality program or performance improvement program

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Stakeholder

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Person, group, organization, or entity with a direct or indirect stake in an organization because it can affect or be affected by that organization's actions, objectives and performance

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Underuse

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Occurs when a health service is not provided though it would have been medically beneficial

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Providers

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Any organization or individual that is licensed or trained to give healthcare.

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Purchasers

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Any organization or individual that pays for healthcare services either directly or indirectly.

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Consumers

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Any recipient of healthcare services.

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Key Dimensions of Healthcare Quality Identified by the Institute of Medicine

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Safe Effective Patient-Centered Timely Efficient Equitable

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Three Primary Activities of Quality Management

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measurement assessment improvement

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Quality is the responsibility of

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everyone working in healthcare

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Case Manager

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this individual often a nurse or social worker, helps coordinate patient services among and between caregivers and provider sites.

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compliance officer

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This individual helps assure the organization adheres to external regulations and accreditation requirements related to quality management

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Health Data Analyst

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this individual gathers, evaluates and reports information in support of various quality management activities--may have clinical, health information management or informatics expertise

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Infection control practitioner

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this individual collects and analyzes health data related to patient infections and disseminates information on prevention of infections--typically filled by nurse, physician, epidemiologist or medical technologist

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Patient representative

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this individual serves as a liaison and primary customer service contact for patients and family members--often gather patient and family complaint data for performance measurment purposes

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Patient safety officer

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this individual oversees patient safety improvement activities which may include evaluation of patient incident data, facilitation of safety improvement projects and coordination of information flow about patient safety among relevant administrative and medical staff committees

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Physician advisor

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this individual serves as a full or part-time quality management advisor-- works closely with the quality department and medical staff president to ensure appropriate physician participation in, and communication of, quality management activities--may serve as advisor for UM activities

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Quality Director

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this individual serves as the administrative head of the quality department and performs or coordinates functions assigned to that department-- assists senior leadership in facilitating compliance with quality-related accreditation standards, government regulations and purchaser requirements

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Risk Manager

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this individual provides guidance and assistance in support of liability control programs including reporting and analysis of patient and employee incidents and identification and control of liability risks throughout the organization

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Utilization Coordinator

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this individual is involved in resource management activiites to prevent underuse and overuse of services--determine appropriateness of care--collect utilization-related data for quality management purposes

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CMS and NCQA requires a quality management plan but

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TJC does not but is implied that it is desirable

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Quality management is the means by which high quality patient care is maintained and improved in all levels of the system --

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individual, departmental and organizational

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What involves gathering information to determine current levels of performance?

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Measurement

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What involves finding the cause of performance gaps and implementing interventions to correct cause of undesirable performance?

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Improvement

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What involves evaluating current levels of performance to determine if there are gaps between expected and actual quality?

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Assessment

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What are the Core Elements of a quality management system?

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--leadership oversight and accounability --quality infrastructure, including routine meetings with cross-departmental representation --performance measurement of key clinical and service areas --activities aimed at improving performance in clinical and service areas --involvement of stakeholders and transparency of performance data

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What is the range of groups involved in the quality management system of a healthcare organization?

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Board Senior Leaders Second Tier Groups Third Tier Groups Quality Management Support Services

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Who is responsible for ensuring continuous quality improvement and for establishing and cultivating a culture of safety?

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The Senior Leaders (president, chief operating officer, vice presidents, medical director)

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Quality management oversight committees or councils: coordinates quality management activities, evaluate the performance of physicians involving credentialling, privileging, and PPEs

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Second Tier Groups (Medical staff executive committee in hospital)

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Any number multi-disciplinary committee or group formed to support various areas of quality management:

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3rd tier groups (cancer committee) Medical staff and administrative committees

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Quality Management Support Services: vary considerably among organizations:

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Case Manager Compliance Officer Health Data Analyst Infection control practitioner Patient representative Patient safety officer Physician advisor Quality Director Risk Manager Utilization Coordinator

Chapter 1 Healthcare Quality Management Introduction – Flashcards

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