Ch 1 & 2 QM

3 levels of Quality
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Terms in this set (163)
TJCThe Joint Commission-Hospital accreditation agencyQAQuality AssuranceTQMTotal Quality ManagementCost of Qualityexpense of not doing it right the first timeFrederick Winslow TaylorFather of Scientific ManagementConsumer-Patient Radiation Health and Safety Act (Public Law 112-90)addresses unnecessary repeat examinations, QA, referral criteria, radiation exposure and unnecessary mass screeningsMIPPAMedicare Improvement for Patients and Providers Act (2008)Responsible for monitoring workplace environment, including requirements for occupational radiation exposure and chemicals in found in processing solutionsOSHADeath from a medical device or death from a malfunctioning piece of equipment must be reported toFDA and Manufacturer Within 10 working daysSerious Injury from a malfunctioning device or piece of equipment must be reported toManufacturer if know, FDA if Manufacturer not known Within 10 working daysAnnual Report of Death and Serious Injury Due to:FDA by January 1HIPPAHealth Insurance Portability and Accountability Act (1996)PHIProtected Health InformationDNV Healthcare IncDet Norske Veritas Global foundation from Norway Very similar to TJCQuality Assurance (QA)all encompassing management program used to ensure excellence in healthcare through systematic collection and evaluation of data Enhances patient careQuality Control (QC)part of QA that deals with the techniques using in monitoring and maintaining the technical elements of the systems that affect the quality of imagesCQIContinuous quality improvement85/15 RuleProcess in place is the cause of the problem 85% of the time People or Personnel are the problem 15% of the time82/20 Rule80% of the problems are the result of 20% of the causesProcessis a ordered series of steps that help achieve a desired outcomeSystemGroup of related processesSupplierindividual or entity that furnishes input Or provides the institution with goods or services A variable factor that influences the next portion in the processInputInformation or knowledge necessary to achieve desired outcomes A variable factor that influences the next portion in the processActionmeans or activity used to achieve the desired outcome A variable factor that influences the next portion in the processOutputrefers to the desired outcome, result, product or characteristic that satisfy the customerCustomerPerson, Department or organization that needs or wants the desired outcomeInternal CustomerGroups or individuals in the organization Doctors, other departments, hospital employeesExternal CustomerPeople outside the organization: patients, families, community and third party payersKey Process VariablesComponents of any process that may affect the final outcome5 Major Key Process VariablesManpower Machines Materials Environment PoliciesManpowerpersonnel involved in a processMachinesrefers to equipment used in a processMaterialstype and quality of materials used in processEnvironmentalphysical and psychological aspects on people involved in the processPoliciesSteps in procedure or policy manual that have been used in the processBrainstormingGroup process used to develop a large collection of ideas WITHOUT regard to merit or validityFocus Groupsmall group that focuses on a particular problem and then hopefully develops a solutionQuality Improvement Teamgroup of individuals who implement the solutions that were derived by the focus groupsQuality Circlescomposed of supervisors and workers from the same department working together to identify potential problems in a departmentMultivotingused after brainstorming to dismiss nonessential or nonrealistic ideasConcensusused after brainstorming an agreement on most important ideasWork Teamsteam focus on solving a complete problem or completing and entire taskRCARoot Cause AnalysisProblem Solving Teamsteams work on specific tasks and meet to solve particular problems5 Whysused to explore cause and effect relationships developed by ToyotaTPMThought Process Map5 steps of Thought Process Map1-define projects goals 2-list knows and unknowns 3-ask grouped questions focusing on unknowns 4-sequence and link the the questions 5-identify possible tools to be usedTJC 10 Step Processmonitoring and evaluation process as mechanism for satisfaction and accreditationAdverse Event Indicatoruntoward, undesirable, and usually unanticipated event that is caused by a medical management rather than the underlying disease or condition Adverse events prolong hospitalization , produce a disability at discharge or bothSentinel Eventunexpected event causing death or serious physical or psychological injurySentinel Event Indicatoridentifies and individual or series of events that is significant enough to trigger further review each time it occursAggregate Data IndicatorQuantifies a process or outcome related to many casesAppropriateness of Carewhether the type of care is necessaryContinuity of Caredegree to which the care/intervention for the patient is coordinated among practitioners or organizationsEffectiveness of Carelevel of benefit when services are rendered under ordinary circumstances by average practitioners for typical patientsEfficacy of Carelevel of benefit expected when healthcare services are applied under ideal conditions and the best possible outcomesEfficiency of Careoutcome obtained when the highest quality of care is delivered in the shortest amount of time with the least expense and positive outcome for patientsSafety in the Care Environmentdegree to which the risk of intervention and the risk in the care environment are reduced for the patient and othersTimeliness of Caredegree to which the care/intervention is provided to the patient at the most beneficial or necessary time Delivery of healthcare within a reasonable amount of time with minimal waitingCost of Carecost of healthcare delivery that is reasonable of the marketplaceAvailability of Caredegree to which appropriate care/intervention is available to publicCycle for Improving PerformanceDesign Measure Assess ImproveDesignSystematic planning and implementation are key to design of any function or processMeasuredefined by TJC as collection of valid and reliable data to demonstrate effectiveness and efficiency of careAssesstranslating data collected during measurements into information that can be used to change process and improve performance improvementBaseline Performancecomparison of current performance levels with those occurring previously (Example: Comparing repeat reject rates from last year to this year)Desired Performance Limitspatients and physicians expect a certain level of performance should be compared with the level achieved and as indicated in current data Organizations can set own limitsPractice Guidelines and Parametersprocedures developed by professional societies, expert panels or in house to use best practice for diseasesPerformance Measurement Systemconsisting of one or more automated databases that facilitate performance improvements in healthcare organizationsBenchmarkingcomparing one organizations performance standard with another organizations Can be internal or externalInternal Benchmarkingcompares performances within the best practices of the organizationExternal Benchmarkingcompares performances with outside organizationsImproveonce knowledge is gained through measurements and analysis, actions can then be taken to improve processesSWOT AnalysisCan be helpful in matching resources and capabilities to the competitive environment in which it operatesSWOTS-Strenghts W-Weakness O-Opportunities T-ThreatsFADEF-Focus-choose problem and describe it A-Analyze-learn about problem, collect and analyze data D-Development-develop solution/plan E-Execute-implement and monitor the results, adjust as neededFOCUSF-Find a process to improve or problem to solve O-Organize a team that knows how to process and work on improvement C-Clarify the problem and knowledge of the process U-Understand the problem and causes of process variation S-Select method to improve the processFOCUS-PDCACombines the FOCUS principals and PDCA principalsPDCAP-Plan D-Do C-Check A-ActFMEAFailure Mode and Effectiveness Analysis analysis of potential failure within a systemSix Sigmamanagement strategy that seeks to identify and remove the causes of error in business Consists of 5 stepsSix Sigma Steps1-Define 2-Measure 3-Analyze 4-Improve 5-ControlLean Process Improvementsystematic approach to identifying and eliminating waste, where waste is defined as any non valued taskQualitycharacteristics of a product or service that bears on its ability to satisfy stated or implied needs and a product or service that is free of defectsquality is Not a programit is an approach to businessQuality is defined by the customer throughhis/her satisfactionquality is aimed at performance excellence-anything less is an improvement opportunityquality increases customer satisfaction, reduces cycle times and cost andeliminates errors and reworkDemings 14 point systemsystem that focuses on high quality, cost-effective products; if inventories are low, good relationships with suppliers were made, and jobs were performed more efficiently, then better quality products would be produced at a lower costQuality assurance (QA)procedure that defines and ensures maintenance of standards within prescribed tolerancestotal quality management (TQM)management philosophy in which processes are refined with goal of improving performance in response to customer needs and expectationscustomeranyone who is affected by a product or serviceexternal customerrecipient of product and services that do not belong to the organization that produces theminternal customerthose who belong to the organization that produces products and servicesempowermentlevel or degree to which managers allow employees to act independently within their job descriptionscontinuous quality improvement (CQI)focused on mgt philosophy for providing leadership, structure, training, and an environment to improve all organizational processes continuouslysix sigmaa data-driven approach for improving quality by removing defects and variations in processesKaizen approach5S program is key to thethe 5 essential steps in leanIdentify which features create value for internal or external customers Document the value stream Improve flow Let customer pull product or service through the process (provide product/service only when customer wants it) Perfect the processFocusFind a process to improve Organize a team that knows the process Clarify current knowledge of the process Understand causes of process variation Select the process improvement -- all part of the PDCAISO 9001 standardsGeneral requirements for quality mgt system Management responsibilities for quality policies and customer focus and satisfaction Resource management Product realization Measurement, analysis, and continual improvement -- these are all whatwhat is ISO 9001a series of standards are a group of 5 individual but related international standards on quality mgtkeys to excellencedeveloped by School Nutrition Association; keys are: administration, marketing and communications, nutrition, nutrition education, and physical activity, and operationssentinel eventsan unexpected occurrence involving death or serious physical or psychological injury, or risk thereofcontinuous quality improvementJoint comission uses what mgt approachthe joint commissionA key source of standards for improving the quality and safety of pt carekaizenjapanese philosophy that places emphasis on making continuous and small, incremental improvements in process on a daily basis rather than large, revolutionary changesquality circlessmall groups of employees who work together on quality improvement projectsreengineeringradical redesign of business processes for dramatic improvementprocessa group of activities that produce a product or serviceleanusing less resources to make products customers want with fewer defects in mass productiontheory of constraintstheory encouraging a concentration on exploring and elevating constraints that slow production or serviceconstraintsomething that limits an organization from reaching its goalsquality function deployment (QFD)methodology to help organizations transform the voice of the consumer into products and servicesbenchmarkingcomparison against best performance in the fieldcause and effect diagram(also called Ishikawa or fishbone diagrams) illustration of factors that may influence or cause a given outcomepareto analysisanalysis that focuses on the most important causes to solve problemsroot cause analysisanalysis focusing on identification of the root cause of a given problemflowchartgraphical representation of steps in a processfailure mode and effects analysis (FMEA)analysis that identifies potential failures in a process, evaluates the severity of the consquences, and plans for eliminating or minimizing the impact of the failurevalue stream mapflowchart that documents processes and flows to help determine which processes add valuecheck sheettool for collecting data about observationshistogrambar graph that displays frequency distribution of datawhat mgt approach uses DMAICsix sigmawhat mgt appraoch uses the 5S prgramKaizenthe 5 essential steps in leanIdentify which features create value for internal or external customers Document the value stream Improve flow Let customer pull product or service through the process (provide product/service only when customer wants it) Perfect the processthe mgt approaches to improving performance includequality assurance, total quality mgt, continuous quality improvement, six sigma, Kaizen, reengineering, lean, theory of contraints, and quality fxn deploymentcause and effect diagrams, pareto analysis, root cause analysis, and scatter diagramsthe types of cause analysis includeflow charts, failure mode and effect analysis and value stream mapthe types of process analysis includecriteria of Malcolm balride national quality awardleadership, strategic planning, customer focus, measurement/analysis/ knowledge mgt, workforce focus, operations focus and results are all criteria forleadershiptype of focus: the company's leadership system, values, expectations, and public responsibilitiesstrategic planningtype of focus: the effectiveness of strategic and business planning and deployment of plans, with a strong focus on customer and operational performance requirementscustomer focustype of focus: how the company determines customer requirements and expectations, enhances relationships with customers, and uses customer information to improve and identify opportunities for innovationmeasurement, analysis, and knowledge mgttype of focus: the effectiveness of information collection and analysis to support customer-driven performance excellence and marketplace successworkforce focustype of focus: the success of efforts to realize the full potential of the workforce to create an engaged and high-performance organizationoperations focustype of focus: the effectiveness of systems and processes for assuring the quality of products and services and organization sustainabilityresultstype of focus: performance results, trends, and comparison to competitors in key business areas, including customer satisfaction, financial, marketplace, human resources, suppliers and partners, operations, governance, and social responsibilitythe types of data collection analysis includecheck sheets, histograms, control charts, and scatter diagramsplan-do-check-act and grantt chartsthe types of project planning and implementation includethe tools used in process improvement includebenchmarking, cause analysis, process analysis, data collection analysis, and project planning & implementationthe greek term 'sigma' meansstatistical unit of measurejapanese term 'kaizen' meansgood changeThe components of TQMIntense focus on the customer Concern for continual improvement Focus on process Improvement in quality of everything the company does Accurate measurement Empowerment of employeescontrol chartgraphical record of process performance over timescatter diagramgraphical presentation of relationship between two variables plotted on horizontal and vertical axesplan-do-check-act (PDCA)model for coordinating process improvement projectsgrant chartbar chart used to show a project scheduleSix sigma uses what approachDMAICD (DMAIC)Define the project goalsM (DMAIC)Measure the current performance of the processA (DMAIC)analyze and determine causes of defectsI (DMAIC)improve the process by eliminating defectsC (DMAIC)control and standardize future process performance