CC Nov 2015 HigInh Reliability Organization

echoecho's version from 2015-12-13 18:45


Question Answer
In a 1999 book titled, "To Err is Human. Building a Safer Health System", the Institute of Medicine (IOM) estimated as few as _____ and as many as ____ people died annually as a result of preventable medical errors?46,000; 96,000
Define medical error?the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim
Medical errors cost between ___ to ___ billion dollars in necessitated additional care, lost income, household productivity and disability per year?17; 29
In 2009 follow-up article, title "To Err is Human - To Delay is Deadly", estimated the number of preventable deaths to bell in excess of _____/year although admitting that this estimate was conservvative?100,000
The Centers for Disease Control and Prevention (CDC) estimated ____ deaths occurring from hospital-acquired infections?99,000
The above conservative number is equal to losing a _____ ____ per day?jumbo jet
In the most recent update on website, the estimated number of deaths is _____ per year or the equivalent of ___ jumbo jets/day?440,000; 4
Both works, concluded that a majority of errors did not result from what? But resulted from what?1) lack of funding, patient overload, individual recklessness or the actions of a particular group (that is not a "bad apple" problem) 2) faulty systems, processes and conditions that led people to make mistakes or failed to prevent them
The Institute of Medicine (IOM) cautioned that instituting a system for blaming individuals would NOT prevent others from making similar mistakes. Instead it suggested a 4-tier strategy for making improvement. List these 4 strategies?1) establish a national focus to create leadership, research, tools and protocols to enhance the know edge base about safety 2) identify and learn from errors by developing a nationwide, public, mandatory reporting system and encourage healthcare organizations and practitioners to develop and participate in voluntary reporting systems 3) raise performance standards and expectations for improvements in safety through the actions of oversight organizations, professional groups and group purchasers of health care 4) implement safety systems in healthcare organizations to ensure safe practices at the delivery level
Two of the important take-away points from the IOM were creating what 2 things?1) a "culture of safety" 2) designing a health system to be safer at all levels, making it harder for people to do something wrong and easier for them to do it right
List the topics that were around before the IOM reprot in an effort to improve the quality of health care?1) professional education 2) peer review 3) systems engineering 4) reporting quality of outcomes 5) awarding/punishing providers based on performance
More recently, health care organizations have begun to take lessons from the science of "_____ ______" which studies industries that manage increased risk extremely well?high reliability
List 2 examples of industries that have demonstrated key features that facilitate the maintenance of excellence in safety?1) commercial aviation 2) nuclear power
The 2 above industries have an atmosphere of "_____ ______" about even the smallest indications of potential failures and an unwavering desire to fix small safety or quality issues at an early state, when they are the easiest to fix?collective mindfulness
In addition to collective mindfulness, what other two goals doe high reliability orgnaizations (HROs) have?1) demonstrate a culture of safety that constantly seeks to ensure sustainable safety over long periods of time 2) utilization of tools to improve their processes as part of system of robust process improvements
In 2008, the Agency for Healthcare Research and Quality (AHRQ) codified recommendations for the adoption of HRO principles into health care. List the 5 key concepts essential for any improvement initiative to succeed and which are consistent with safe, high-quality care?1) sensitivity to operations (awareness of systems and processes affecting patient care) 2) reluctance to simplify (search for true and not simplistic reasons patients are at risk 3) preoccupation with failure (use near misses as targets for improvement rather than signs of partial success 4) deference to expertise (pay attention to the opinions of care providers and patients) 5) resilience: prepare for how to respond to and correct system failures
What two principles were not part of the AHRQ 5 key concepts?1) maximizing cost efficiencies 2) searching to establish technologic superiority
Specifically addressing hierarchical organizations, what was the AHRQ recommendation?it recommended the de-emphasis on hierarchy as a necessary prerequisite for organizations to prevent and respond to safety problems
HROs (high reliability organizations) require staff communication at ___ every level in sharing information and concerns. Why?1) every 2) because the most experienced or "senior" person may not have all the information with which to make the best decisions and, consequently, should listen and respond to the insights of staff that understand system processes and patient needs
What is one of the strongest proponents of HRO principles in the application of health care?TJC (The Joint Commission)
TJC was founded when? For what purpose?1) 1951 2) as a formalization of hospital inspection 20,500first drafted by the American College of Surgeons in 1917
TJC certifies more than _______ healthcare organizations and programs in the US?20,500
In 2008, TJC founded what amalgamation of hospitals and health systems that collect data to develop target solutions to complex healthcare issues?the Center for Transforming Healthcare
What does the Center for Transforming Healthcare offer?multiple, robust process improvements (RPI) tools that help health care organizations measure their actual performance, find barriers and introduce solutions to move toward excellence in safety
The Joint Commission promotes a 5-component culture of safety model that guides an organization through stages of safety "maturity". List these?trust, accountability, identifying unsafe conditions, strengthening systems, assessment
At each stage of organization maturity (beginning, developing, advancing, approaching), there is clear and ____ - _____ progress in improvement?step-wise
The Joint Commission also promotes what two goals?1) robust process improvement 2) high reliability
One of the strongest sets of tools recommended by the Joint Commission provides _____ assessments of safety systems and organizational defenses ("strengthening systems") within a healthcare organization?proactive
List the specific tools recommended in proactive assessments?1) failure modes and effects analysis (FMEA) by using "what if" questions to anticipate and prevent high-risk scenarios 2) medication safety risk assessment (MSRA) of the Institute for Safe Medicine Practices 3) contingency diagrams which are brainstorming to generate a list of potential problems 4) potential problem analysis (PPA) which analyzes what could go wrong in a plan under development 5) process decision program chart (PDPC) which is a systematic method to detect problems in a developing plan and building in contingencies4
What is Root Cause Analysis (RCA)?an important part of the process improvement and is a "retroactive" tool designed to identify risk reduction opportunities with organizational process, often as a result of a system failure or medical error.
*** SUMMARY = It is important to create a "culture of safety" and design a health system to be safer at all levels, making it harder for what? and easier for people to do what?1) harder for people to do something wrong 2) easier to them to do it right
*** SUMMARY = The Joint Commission actively promotes a 5-component culture of safety model that guides an organization through stages of safety "maturity". List these?1) trust 2) accountability 3) identifying unsafe conditions 4) strengthening systems 5) assessment
*** SUMMARY = The Agency for Healthcare Research and Quality (AHRQ) codified 5 recommendations for the adoption of HRO principles into health care. List these?1) sensitivity to operatives 2) reluctance to simplify 3) preoccupation with failure 4) deference to expertise 5) resilence