HCM520 Final Review 2024 PDF

Final review 2024 by fatimah alenezi HCM520 final review answer 1. Know which level of healthcare represents the system that encompasses all other levels The level of healthcare that encompasses all other levels is often referred to as the tertiary healt...

Final review 2024 by fatimah alenezi HCM520 final review answer 1. Know which level of healthcare represents the system that encompasses all other levels The level of healthcare that encompasses all other levels is often referred to as the tertiary healthcare level or the comprehensive healthcare system in certain contexts. Here's why: Comprehensive System with All Levels Primary Care: This is the first point of contact for individuals (e.g., general practitioners, clinics), focused on preventive care, health promotion, and managing common illnesses. Secondary Care: Involves specialist care provided by hospitals or clinics upon referral from primary care (e.g., cardiologists, dermatologists). Tertiary Care: Provides highly specialized care (e.g., organ transplants, advanced surgeries, oncology treatment) and often includes services offered by specialized hospitals. 2. Know about metrics and its role Metrics are defined as standardized measurements used to evaluate the effectiveness, efficiency, quality, and outcomes of processes, services, or interventions. They provide a systematic way to collect, analyze, and interpret data to support decision-making. Role of Metrics 1. Performance Evaluation 2. Quality Improvement 3. Decision-Making 4. Accountability and Transparency 5. Benchmarking 6. Monitoring Progress Types of Metrics 1. Process Metrics: o Measure the efficiency of a process. o Example: Average wait time for patients in an emergency department. 2. Outcome Metrics: o Focus on the results or impact of an intervention. 3. Financial Metrics: o Assess the cost-effectiveness or financial health of an organization. 4. Structural Metrics: o Evaluate the resources, infrastructure, and systems in place. 5. Satisfaction Metrics: Final review 2024 by fatimah alenezi o Assess stakeholder satisfaction (e.g., patients, employees, customers). 3. Know the stages of PDSA and when to use them Stages of the PDSA Cycle 1. Plan o Objective: Identify an area for improvement, develop a plan, and predict outcomes. o Key Steps: ▪ Define the problem or goal. ▪ Identify the team and resources needed. ▪ Develop an actionable plan detailing what will be done, by whom, and when. ▪ Predict the potential results or outcomes of the intervention. ▪ Establish metrics to measure success. 2. Do o Objective: Implement the planned change on a small scale to test its feasibility. o Key Steps: ▪ Carry out the plan in a controlled setting (pilot test). ▪ Document observations and unexpected challenges during implementation. ▪ Collect data as per the defined metrics. 3. Study o Objective: Analyze the collected data to evaluate the effectiveness of the change. o Key Steps: ▪ Compare actual outcomes to the predicted outcomes. ▪ Identify successes, failures, and areas for improvement. ▪ Discuss findings with stakeholders and team members. 4. Act o Objective: Decide whether to adopt, adapt, or abandon the change based on the results. o Key Steps: ▪ If successful, implement the change on a broader scale and integrate it into standard practice. ▪ If partially successful, revise the plan and repeat the cycle. ▪ If unsuccessful, document learnings and consider alternative approaches. When to Use the PDSA Cycle 1. Quality Improvement Initiatives 2. New Process Implementation 3. Problem-Solving 4. Testing Innovations 5. Adapting to Policy or Regulatory Changes 4. Know importance of process in the delivery of care 1. Ensures Patient Safety 2. Enhances Quality of Care Final review 2024 by fatimah alenezi 3. Improves Efficiency 4. Promotes Patient-Centered Care 5. Facilitates Coordination and Integration 6. Drives Accountability and Transparency 7. Supports Regulatory Compliance 8. Enhances Provider Satisfaction 5. Be able to compare/contrast structure, process, outcome measurement as it relates to quality improvement initiatives 1. Definitions Aspect Definition Refers to the physical, organizational, and human resources available for delivering Structure healthcare. Process Encompasses the activities, workflows, and practices involved in delivering healthcare. Outcome Measures the results of healthcare interventions on patient health and well-being. 2. Comparison and Contrast 2.1 Focus and Purpose Aspect Focus Purpose in QI Initiatives Ensure resources and infrastructure support quality Structure Inputs/resources (e.g., facilities, staff). care. Actions taken (e.g., adherence to Optimize care delivery through evidence-based Process guidelines). practices. Results (e.g., patient health, Evaluate the effectiveness and impact of care Outcome satisfaction). interventions. 2.3 Relation to Quality Improvement Aspect Role in Quality Improvement Initiatives Identifies gaps in infrastructure and resources (e.g., outdated equipment or insufficient Structure staffing) that may impede care quality. Evaluates adherence to care protocols and identifies inefficiencies or deviations from Process evidence-based practices. Final review 2024 by fatimah alenezi Aspect Role in Quality Improvement Initiatives Tracks the effectiveness of interventions in improving health outcomes, patient experience, Outcome and overall system performance. 6. Know "Near Miss" in the context of patient safety A near miss in patient safety refers to an event or situation that could have resulted in harm to a patient but did not, either because of timely intervention or sheer luck. Although no harm occurs, near misses are critical opportunities for healthcare systems to identify and address vulnerabilities before they lead to actual adverse events. 7. Know the universal coverage Universal Health Coverage (UHC) ensures that all individuals and communities receive the health services they need without suffering financial hardship. It is a central goal of many healthcare reforms worldwide and is integral to achieving the United Nations Sustainable Development Goals (SDG 3), which focuses on ensuring healthy lives and promoting well-being for all.Reduces catastrophic health expenditures that can lead to poverty. 8. Know the difference between safety promotion, safety culture, safety learning, safety policy Comparison of Key Features Aspect Safety Promotion Safety Culture Safety Learning Safety Policy Learning from Activities to raise Organizational values and Formal guidelines Definition incidents to improve safety awareness. behaviors about safety. to ensure safety. safety. Awareness and Continuous Structured Focus Mindset and behavior. engagement. improvement. framework. Campaigns, Open reporting, leadership Root cause analysis, Written infection Examples workshops, posters. support. debriefings. control protocols. Inspires action and Embeds safety into Ensures learning from Sets the rules for Role engagement. organizational culture. errors. safety practices. 9. Know the role of leaders in terms of promoting high-reliability organizations 1. Setting a Clear Vision and Mission Final review 2024 by fatimah alenezi 2. Fostering a Culture of Safety 3. Modeling Leadership Commitment 4. Building Resilience 5. Driving Continuous Learning and Improvement 6. Establishing Robust Processes 7. Encouraging Team Collaboration 8. Adapting to External Changes 9. Monitoring and Evaluating Performance 10. How does Transparency contribute to effective leadership in healthcare organizations Key Ways Transparency Contributes to Effective Leadership 1. Builds Trust Among Stakeholders 2. Enhances Accountability 3. Improves Patient Safety 4. Fosters a Culture of Open Communication 5. Promotes Collaborative Decision-Making 6. Drives Organizational Performance 7. Enhances Patient Satisfaction 11. Know about safety management Key Components of Safety Management 1. Risk Identification and Assessment 2. Safety Policies and Procedures 3. Incident Reporting and Analysis 4. Training and Education 5. Monitoring and Evaluation 6. Continuous Improvement Final review 2024 by fatimah alenezi 7. Leadership and Accountability 8. Emergency Preparedness 12. Know about the contribution of safety management system implementation to patient safety in healthcare 1. Proactive Risk Identification and Mitigation 2. Systematic Incident Reporting and Learning 3. Standardization of Safety Practices 4. Enhancing Communication and Collaboration 5. Strengthening Leadership Commitment to Safety 6. Data-Driven Decision Making 7. Promoting Continuous Education and Training 8. Encouraging a Culture of Safety 9. Compliance with Regulatory Standards 10. Improved Patient Outcomes and Satisfaction 13. Know the following types of variations and which are quality concerns Types of Variations 1. Common Cause Variation Definition: o Variations inherent to a system due to routine or natural factors. 2. Special Cause Variation Definition: o Variations that arise due to specific, identifiable, and often unusual factors. 3. Clinical Variation Definition: o Differences in clinical practices, decisions, or treatments for similar patient conditions. Final review 2024 by fatimah alenezi 4. Procedural Variation Definition: o Differences in how processes or protocols are followed across departments or providers. 5. Operational Variation Definition: o Differences in administrative or operational processes affecting healthcare delivery. 6. Outcomes Variation Definition: o Differences in health outcomes for patients with similar conditions or treatments. 7. Demand Variation Definition: o Variations in healthcare demand due to external factors like demographics or patient preferences. 14. Know about Deming’s study Deming’s Study: Contributions to Quality Management W. Edwards Deming was a pioneer in quality management and organizational improvement. His work focused on systems thinking, continuous improvement, and statistical control methods, which transformed industries globally, particularly in manufacturing and healthcare. His principles are central to modern quality management theories and practices. The Deming Cycle (PDSA Cycle) Plan-Do-Study-Act (PDSA): o A framework for iterative problem-solving and continuous improvement. o Plan: Identify an issue, set goals, and plan interventions. o Do: Implement the plan on a small scale. o Study: Analyze the outcomes to assess effectiveness. o Act: Refine the plan and scale successful interventions. Final review 2024 by fatimah alenezi 15. Know difference between low-fidelity and high-fidelity simulation Key Differences Between Low-Fidelity and High-Fidelity Simulation Aspect Low-Fidelity Simulation High-Fidelity Simulation Simplistic simulations focusing on Realistic simulations replicating complex Definition fundamental skills or concepts. clinical scenarios. Limited realism, focusing on specific High level of realism, mimicking real-life Realism tasks or basic procedures. settings and patient responses. Technology Basic models or equipment (e.g., Advanced, computerized mannequins or Used mannequins, task trainers). virtual reality systems. Teach foundational skills, such as IV Train for advanced decision-making, Purpose insertion or CPR techniques. teamwork, and handling emergencies. Lower cost, requiring minimal High cost due to sophisticated technology and Cost technology. equipment. Limited; focuses on individual skill- High interactivity; involves dynamic Interactivity building. scenarios with team participation. Example Basic skills training (e.g., handwashing, Simulating cardiac arrest, trauma Scenarios vital sign measurement). resuscitation, or surgery. Suitable for beginner learners or Ideal for advanced learners or Use Case procedural training. interprofessional training. When to Use Low-Fidelity vs. High-Fidelity Simulation Learning Objective Low-Fidelity Simulation High-Fidelity Simulation Basic procedural skills (e.g., Advanced procedural skills requiring Skill Development injections, suturing). patient interaction. Critical Thinking and Ideal for complex, dynamic decision- Not suitable. Decision-Making making scenarios. Teamwork and Excellent for interprofessional and Limited application. Communication team-based training. Cost and Resource Preferred when budgets are tight. Used selectively due to higher costs. Constraints Final review 2024 by fatimah alenezi 16. Know the purposes of using Swiss cheese" model 1. Understanding Systemic Errors 2. Promoting a Systems Approach to Safety 3. Identifying and Addressing Vulnerabilities 4. Preventing Harm 5. Enhancing Communication and Teamwork 6. Educating Stakeholders 7. Encouraging a Culture of Safety 17. Know differences between Quality Control, Quality assurance, Quality Assessment, Quality Improvement Aspect Quality Control (QC) Quality Assurance (QA) Quality Assessment (QA) Quality Improvement (QI) The process of ensuring A systematic approach to The evaluation of A continuous, systematic that specific outputs meet ensuring processes are quality based on effort to enhance Definition established standards designed to produce specific metrics or processes, outcomes, and through inspections and quality outcomes criteria to identify gaps overall quality of testing. consistently. or variations. services. Detecting and correcting Preventing defects by Measuring the current state Making data-driven Focus defects or errors in a establishing robust of quality against changes to processes to product or service. processes and systems. benchmarks or standards. achieve better outcomes. Ensure outputs meet Ensure processes are designed Identify areas for Continuously enhance Goal defined quality to produce reliable and improvement through quality through iterative standards. consistent outcomes. evaluation. changes and innovation. Reactive: Focuses on Proactive: Focuses on Analytical: Measures Collaborative and iterative: Approach identifying and fixing preventing issues and evaluates the level Uses feedback and data to issues after they occur. before they occur. of quality. drive improvement. Final review 2024 by fatimah alenezi Policies, procedures, PDSA (Plan-Do-Study- Inspections, testing, Surveys, benchmarking, training, standard Act), Six Sigma, Lean, Methodology/Tools audits, statistical scorecards, compliance operating procedures Root Cause Analysis process control. reviews. (SOPs). (RCA). Limited to specific Focused on evaluating Encompasses all aspects of Broad, encompassing all Scope outputs or past or current processes, aiming for long-term processes in the system. products. performance. improvement. Typically handled by Managed by QA Often involves Involves multidisciplinary Responsibility specific QC teams or departments or external or internal teams across the inspectors. leadership teams. evaluators. organization. Checking medication Ensuring all staff are trained Assessing medication Implementing a new double- Example in Healthcare labels for errors on standard medication error rates in a check system for medication before dispensing. administration protocols. hospital over a year. administration to reduce errors. Types of Leadership Styles and Associated Behaviors 1. Transformational Leadership: o Inspiring and motivating team members to exceed expectations. o Focusing on innovation and organizational growth. 2. Transactional Leadership: o Emphasizing structure, rewards, and performance-based accountability. 3. Servant Leadership: o Prioritizing the needs of the team and fostering a supportive environment. 4. Democratic Leadership: o Encouraging collaboration and valuing team input in decision-making. 5. Autocratic Leadership: o Taking full control over decisions, often necessary in emergencies. 18. Know about high impact leaders Key Characteristics of High-Impact Leaders 1. Visionary Thinking 2. Emotional Intelligence (EQ) 3. Adaptability 4. Results-Oriented Approach 5. Strong Communication Skills 6. Inclusive and Collaborative Leadership 7. Accountability and Integrity 8. Focus on Developing Others 19. Know what scorecards reflect Final review 2024 by fatimah alenezi Scorecards are tools used to measure, monitor, and improve performance by providing a structured framework for tracking key metrics. In healthcare, scorecards reflect an organization's alignment with its strategic goals and highlight areas for improvement. They present data in an accessible format to facilitate decision-making and continuous improvement. 20. Know how to describe physician profiling and Provider Registries in a Changing Healthcare Landscape Physician Profiling Definition Physician profiling involves collecting, analyzing, and reporting data on physicians’ practices, outcomes, and performance. The goal is to assess and improve the quality, efficiency, and cost-effectiveness of care provided Differences Between Physician Profiling and Provider Registries Aspect Physician Profiling Provider Registries Evaluates individual physician Maintains comprehensive records of provider Focus performance and outcomes. credentials, specialties, and availability. Aimed at quality improvement, Facilitates network management, credentialing, Purpose benchmarking, and accountability. and patient access to providers. Primarily used by healthcare organizations, Used by patients, healthcare organizations, and Users insurers, and policymakers. regulatory bodies. Focused on performance and quality Broad database of all providers, regardless of Scope metrics for specific physicians. specialty or performance. 21. Know the importance of collaboration between traditional healthcare providers and public health agencies Key Reasons for Collaboration 1. Addressing Social Determinants of Health (SDOH) 2. Enhancing Disease Prevention and Management 3. Managing Health Crises and Emergencies 4. Reducing Healthcare Costs 5. Improving Health Equity 6. Data Sharing and Surveillance 7. Strengthening Community-Based Interventions Final review 2024 by fatimah alenezi 8. Coordinating Policy Advocacy Benefits of Collaboration Benefit How It’s Achieved Better Health Outcomes Combines clinical care with preventive and community-based strategies. Efficient Resource Reduces duplication of efforts and ensures targeted use of funds and Utilization services. Unified messaging and actions build public confidence in health Stronger Public Trust initiatives. Increased Preparedness Joint planning and response enhance readiness for health emergencies. Innovation in Care Delivery Diverse perspectives lead to innovative approaches to health challenges. 22. Know about sentinel events Sentinel events are unexpected occurrences involving serious physical or psychological injury, or the risk thereof, in healthcare settings. These events signal a need for immediate investigation and response because they highlight significant lapses in patient safety and the potential for harm. Definition According to The Joint Commission, a sentinel event is: Unexpected: It arises suddenly and is not anticipated as part of standard care. Serious: Involves death, permanent harm, or severe temporary harm requiring intervention. Significant Risk: Includes "near misses" or events that could have led to severe harm. Sentinel Events vs. Adverse Events Sentinel Events: Require immediate investigation and reporting due to their severe impact or potential risk. o Example: Wrong-site surgery. Adverse Events: Broader category that includes any harm caused by medical care, regardless of severity. o Example: Mild allergic reaction to a prescribed medication. Impact of Addressing Sentinel Events Benefit Impact Improved Patient Reduces the risk of harm through systemic improvements. Safety Final review 2024 by fatimah alenezi Benefit Impact Enhanced Quality of Focuses on evidence-based practices and process optimization. Care Regulatory Compliance Meets accreditation standards, ensuring organizational accountability. Demonstrates commitment to transparency and safety, building trust with Strengthened Trust patients and families. Cultural Promotes a culture of learning and improvement rather than blame. Transformation 23. Know the difference between soft- and hard-stop alerts Comparison of Soft-Stop and Hard-Stop Alerts Aspect Soft-Stop Alert Hard-Stop Alert Cannot be bypassed without taking Flexibility Can be overridden by the provider. corrective action. Enforcement Advisory in nature. Mandatory compliance required. Level Non-critical issues or where clinical Critical safety issues where deviation poses Use Cases judgment is crucial. significant risk. Impact on Minimal disruption; provides optional Potentially disruptive but ensures safety Workflow guidance. compliance. Risk of Alert Higher risk if alerts are frequent or Lower risk if used sparingly for critical Fatigue irrelevant. issues. Blocking contraindicated medication Examples Reminder for missing lab results. orders. 24. Know what simulation is used for Key Uses of Simulation in Healthcare 1. Skill Development and Training 2. Teamwork and Communication Training 3. Emergency Preparedness and Crisis Management 4. Diagnostic and Decision-Making Practice 5. Patient Safety and Error Reduction Final review 2024 by fatimah alenezi 6. Systems and Workflow Testing 7. Competency Assessment 8. Research and Innovation Types of Simulation in Healthcare Type Description Examples Low-Fidelity Focuses on basic skill development using Practice suturing on a training pad. Simulation simple models or mannequins. High-Fidelity Uses advanced, computerized mannequins Simulating cardiac arrest with Simulation or virtual reality for realistic scenarios. mannequins that respond dynamically. Virtual Involves computer-based or virtual reality VR training for laparoscopic surgery. Simulation platforms. Standardized Uses trained actors to replicate real patient Practicing breaking bad news to a Patients interactions. patient or family. 25. Know about Information Engineering approach Key Components of the Information Engineering Approach 1. Strategic Alignment 2. Data-Centric Design 3. Process Modeling 4. Modularity 5. Iterative Development 6. Top-Down Planning Phases of the Information Engineering Approach 1. Strategic Planning 2. Business Area Analysis 3. System Design 4. Implementation 5. Maintenance and Evolution 26. Know the Clinical Learning Environment Review Program (CLER) The Clinical Learning Environment Review (CLER) Program is an initiative by the Accreditation Council for Graduate Medical Education (ACGME) to improve the training environments of graduate medical education (GME) programs. It focuses on enhancing the quality and safety of care provided to patients while ensuring that residents and fellows receive comprehensive, high-quality education. Final review 2024 by fatimah alenezi 27. Know which outcomes are an important measure of quality improvement Outcome Type Examples Purpose Mortality rates, infection rates, treatment Measure health impact and care Clinical success effectiveness Patient Safety Adverse event rates, sentinel events Ensure harm prevention Patient-Centered Satisfaction scores, quality of life, access Reflect patient experiences Operational Length of stay, staff turnover, throughput Enhance efficiency and workflow Cost per case, avoidable costs, revenue Financial Balance cost and quality growth Population Vaccination rates, chronic disease Improve community-wide health Health management Maintain adherence to evidence-based Process Protocol compliance, timely screenings care 28. Know about measuring adverse outcomes and how to best improve quality 1. Types of Adverse Outcomes to Measure Patient Safety Events Hospital-Acquired Conditions (HACs Sentinel Events Readmissions Mortality Rates 2. Metrics and Tools for Measuring Adverse Outcomes Rate-Based Metrics: o Use denominators like "per 1,000 patient-days" to compare rates across time or facilities. Incident Reporting Systems: o Systems like voluntary error reporting platforms where staff can log adverse events or near misses. Surveillance and Data Analysis: Final review 2024 by fatimah alenezi o Continuous monitoring of clinical data to identify trends in adverse outcomes. Patient Safety Indicators (PSIs): o Developed by organizations like AHRQ to measure potential adverse events using administrative data. Root Cause Analysis (RCA): o A structured approach to identifying the underlying causes of adverse events. Strategies to Best Improve Quality 1. Implementing a Culture of Safety 2. Conducting Root Cause Analysis (RCA) 3. Using Evidence-Based Protocols 4. Adopting Technology Solutions 5. Engaging Patients and Families 6. Continuous Staff Training 7. Monitoring and Feedback 29. Know how an organization can promote cultural commitment to quality and safety 1. Leadership Commitment 2. Fostering a Culture of Transparency 3. Employee Empowerment and Engagement 4. Communication and Collaboration 5. Continuous Education and Training 6. Building Accountability at All Levels 7. Utilizing Data and Technology 8. Fostering Teamwork and Interdisciplinary Collaboration 30. Know about Governing for Quality Key Components of Governing for Quality 1. Leadership Commitment Final review 2024 by fatimah alenezi 2. Accountability 3. Quality Frameworks and Policies 4. Data-Driven Decision-Making 5. Continuous Improvement 6. Patient and Stakeholder Engagement 7. Risk Management and Compliance Key Areas of Focus in Governing for Quality 1. Patient Safety 2. Clinical Effectiveness 3. Efficiency 4. Equity 5. Patient-Centered Care Challenges in Governing for Quality 1. Balancing Competing Priorities 2. Data Overload 3. Cultural Resistance 4. Resource Constraints Impact of Governing for Quality Outcome Impact Improved Patient Safety Reduction in errors, adverse events, and harm. Enhanced Care Quality Better adherence to evidence-based practices and improved outcomes. Increased Accountability Clear roles and regular performance reviews build trust and transparency. Higher Patient Satisfaction Care that meets patient needs fosters loyalty and trust. Regulatory Compliance Meeting standards ensures accreditation and minimizes legal risks. 31. Know about Credentialing Credentialing is the process of verifying and evaluating the qualifications, experience, and professional competence of healthcare providers to ensure they meet the standards required to deliver safe, high- quality care. It is a critical component of healthcare governance, protecting patient safety and ensuring compliance with regulatory and accreditation requirements. Final review 2024 by fatimah alenezi Key Objectives of Credentialing 1. Patient Safety 2. Quality Assurance 3. Regulatory Compliance 4. Risk Mitigation Types of Credentials Verified 1. Educational Qualifications 2. Professional Licenses 3. Board Certifications 4. Work History 5. Malpractice Insurance 6. References 32. Be able to articulate 5 key performance indicators that you are managing quality and cost KPI Impact on Quality Impact on Cost Patient Safety Reduces harm and improves patient trust in Lowers costs associated with adverse Indicators care processes. events or penalties. Enhances continuity of care and outcomes Reduces penalties and unnecessary Readmission Rates post-discharge. resource use. Optimizes resource allocation without Identifies high-cost drivers for cost- Cost per Case compromising outcomes. saving opportunities. Ensures appropriate care delivery and Reduces overhead and maximizes bed Length of Stay reduces complication risks. utilization. Improves patient adherence, loyalty, and Increases patient retention and reduces Patient Satisfaction perception of value. litigation risks. 33. Be able to articulate an executive summary highlighting areas of improvement and key performance indicators, along with roles and responsibilities of team members 1. Areas of Improvement o Patient Safety o Readmission Rates o Operational Efficiency o Patient Satisfaction 2. Key Performance Indicators (KPIs) Final review 2024 by fatimah alenezi Area of Frequency of KPI Target Improvement Monitoring Reduce by Patient Safety Hospital-acquired infection (HAI) rates Monthly 30% 30-day readmission rates for chronic Reduce by Readmission Rates Quarterly conditions 15% Operational Reduce by Average Length of Stay (LOS) Monthly Efficiency 10% Improve by Patient Satisfaction HCAHPS communication-related scores Quarterly 20% Financial Efficiency Cost per case Reduce by 5% Monthly 34. Know what Total Quality Management is Key Principles of TQM 1. Customer Focus 2. Continuous Improvement 3. Employee Involvement 4. Process-Centric Approach 5. Integrated System 6. Data-Driven Decision-Making 7. Leadership Commitment Key Elements of TQM in Healthcare 1. Patient-Centered Care 2. Standardization 3. Quality Measurement 4. Error Reduction 5. Interdisciplinary Collaboration TQM Tools and Techniques 1. Plan-Do-Study-Act (PDSA) Cycles 2. Six Sigma 3. Benchmarking 4. Root Cause Analysis (RCA) 5. Pareto Charts 35. Know what continuous quality improvement depends on Key Elements that CQI Depends On 1. Leadership Commitment Final review 2024 by fatimah alenezi 2. Organizational Culture 3. Data-Driven Decision-Making 4. Employee Engagement and Participation 5. Training and Education 6. Patient and Stakeholder Involvement 7. Standardized Processes 8. Continuous Monitoring and Feedback 9. Use of Quality Improvement Tools and Methodologies 10. Alignment with Strategic Goals Dependencies in Action Dependency Practical Application Leadership Leaders allocate resources for a new patient safety initiative. Commitment Data-Driven Decision Analyzing trends in medication errors to implement targeted training. Nurses design a workflow to improve discharge planning for heart failure Employee Engagement patients. Standardized Processes Creating uniform protocols for hand hygiene compliance across departments. 36. Know the goals of physician profiling Key Benefits of Physician Profiling Goal Benefit Improved Quality Encourages consistency and better adherence to clinical guidelines. Increased Safety Reduces adverse events by addressing patterns of risk. Cost Control Identifies wasteful practices, ensuring more efficient resource utilization. Benchmarking Establishes a culture of continuous improvement through data comparison. Accountability Provides transparency, building trust among patients, peers, and administrators. 37. Key Considerations for Creating Physician Profiles Final review 2024 by fatimah alenezi 1. Timeliness 2. Data Sources 3. Stakeholder Involvement 4. Confidentiality 5. Actionability 38. now Know how technological advances impact quality measurement 1. Enhanced Data Collection and Integration 2. Real-Time Monitoring and Reporting 3. Advanced Analytics and Predictive Modeling 4. Standardization of Metrics 5. Patient Engagement and Feedback 6. Automation and Efficiency 7. Transparency and Accountability Technological Tools Supporting Quality Measurement Technology Function Example Electronic Health Records Captures clinical and administrative data Epic, Cerner, or Allscripts EHR (EHRs) for metrics tracking. systems. Visualizes quality metrics and trends in Tableau, Power BI, or custom Dashboards and BI Tools real-time. hospital dashboards. Tracks patient vitals and activities for Fitbit, Apple Watch, or remote Wearable Devices continuous monitoring. monitors. Analyzes data to identify patterns and Predictive tools for sepsis Artificial Intelligence (AI) predict outcomes. management. Facilitates patient feedback and MyChart or similar systems for Patient Portals engagement. online surveys. Interoperability Enables data sharing across systems and HL7, FHIR, or other data Standards organizations. exchange protocols. 39. Know the key drivers of the safety culture in the KSA Final review 2024 by fatimah alenezi 1. Leadership Commitment 2. Communication Openness 3. Non-Punitive Response to Errors 4. Staffing and Workload Management 5. Training and Education 6. Teamwork and Collaboration 7. Organizational Learning 8. Patient Involvement 40. Know the advantages of HER Category Key Benefit Patient Care Accurate, up-to-date data improves outcomes. Efficiency Automation reduces administrative burden. Coordination Facilitates teamwork and cross-facility communication. Patient Engagement Portals empower patients to participate in their care. Security Digital safeguards protect sensitive information. Error Reduction Medication alerts and legible records minimize errors. Cost Management Reduces duplication and optimizes resource use. Research and Public Health Aggregates data for insights and population management. 41. Know contributory factors to diagnostic errors 1. Cognitive Factors 2. Communication Failures 3. Systemic and Organizational Factors 4. Diagnostic Testing Errors 5. Technological and Data Issues 6. Patient Factors 7. Environmental Factors 8. Education and Training Deficiencies Final review 2024 by fatimah alenezi 9. Cultural and Psychological Factors - Know about Safety Science safety Science is an interdisciplinary field aimed at minimizing risks and preventing harm through the study of systems, processes, and human behavior. It emphasizes proactive risk identification, designing resilient systems, fostering a culture of safety, and learning from incidents to improve safety outcomes. Key Elements: 1. Risk Identification: Spotting hazards and assessing potential impacts. 2. Human Factors: Designing systems to reduce human error (e.g., user-friendly medical records). 3. System Design: Building processes that ensure reliability and safety (e.g., automated drug alerts). 4. Culture of Safety: Encouraging open communication and non-punitive reporting of errors. 5. Incident Analysis: Using root cause analysis to learn from mistakes. 6. Proactive Risk Management: Anticipating and addressing safety issues (e.g., using FMEA). Example in Healthcare: To reduce surgical site infections: Identify risks like poor hand hygiene. Implement protocols (e.g., checklists). Monitor infection rates and adjust practices based on data. - Know about debriefing Debriefing is a structured process of reflection and discussion conducted after an event or activity to review what happened, analyze performance, and identify areas for improvement. It is widely used in healthcare, education, military, and crisis management to enhance learning and performance. Key Elements: 1. Purpose: To foster learning, improve outcomes, and enhance teamwork. 2. Structure: A systematic approach often involves discussing: Final review 2024 by fatimah alenezi o What went well. o What could be improved. o Lessons learned. 3. Facilitation: Guided by a skilled leader who promotes open, non-judgmental communication. 4. Timing: Conducted immediately or shortly after the event to ensure accurate recollection. 5. Feedback: Focuses on constructive feedback rather than blame. Examples in Healthcare: Clinical Debriefing: After a critical patient event (e.g., cardiac arrest), teams discuss the response to identify strengths and gaps. Simulation Debriefing: After training scenarios, participants reflect on their actions to improve skills and confidence. Benefits: Enhances learning from real-life and simulated experiences. Improves communication, teamwork, and decision-making. Contributes to patient safety and quality improvement.