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Quality and Regulatory Compliance in Health Care

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Theera-Ampornpunt N. Quality and regulatory compliance in health care. Presented at: Faculty of ICT, Mahidol University; 2012 Mar 13; Bangkok, Thailand.

Theera-Ampornpunt N. Quality and regulatory compliance in health care. Presented at: Faculty of ICT, Mahidol University; 2012 Mar 13; Bangkok, Thailand.

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  • 1. Nawanan Theera-Ampornpunt, MD, PhD Health Informatics Division Faculty of Medicine Ramathibodi Hospital Mahidol University, Thailand Modified from slides of Assoc.Prof. Artit Ungkanont Parts of this material were based on materials developed by Johns Hopkins University, funded by the Office of theNational Coordinator for Health Information Technology, U.S. Department of Health and Human Services under Award Number IU24OC000013 (Health IT Workforce Curriculum v.3.0, Component 12/Units 1-12).
  • 2.  Introduction to Quality Improvement & Health IT Principles of Quality and Safety for HIT The Culture of Safety Learning From Mistakes: Error Reporting and Analysis and HIT
  • 3. Introduction to Quality Improvement and Health Information Technology: Part 1 This material (Comp12_Unit1a) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013.
  • 4. First, Do No HarmPrimum non nocere
  • 5. 2011 2009 2004 ONCHIT 2000-2001 HITECH Act “Meaningful Use”1991
  • 6. (IOM, 2000) (IOM, 2001) (IOM, 2011)
  • 7.  Humans are not perfect and are bound to make errors Highlight problems in the U.S. health care system that systematically contributes to medical errors and poor quality Recommends reform that would change how health care works and how technology innovations can help improve quality/safety Health IT plays a role in improving patient safety (but it may also carry risks to safety in certain ways)
  • 8. “Healthcare reform without attention to the nature and nurture of healthcare as a system is doomed …It will at best simply feed the beast, pouring precious resources into the overdevelopment of parts and never attending to the whole — that is care as our patients, their families and their communities experience it.” (Berwick, 2009)“The performance of a system — its achievement of its aims — depends as much on the interactions among elements as on the elements themselves. (Berwick, 2009)“The improvement of health and healthcare depends on systems thinking and systems redesign… ‘Reform’ without systems thinking isn’t reform at all.” (Berwick, 2009)Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 8 Lecture a
  • 9. MEANINGFUL USE Providers show theyre using certified EHR technology in ways that can be measured significantly in quality and in quantity. PATIENT-CENTERED MEDICAL HOME Providers organize care around patients, working in teams, coordinating care, and tracking over time. ACCOUNTABLE CARE ORGANIZATION Provider reimbursements are tied to quality metrics and reductions in the total cost of care for assigned population of patients.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 9 Lecture a
  • 10. “MeaningfulPumpkin Use” of a Pumpkin Image Source & Idea Courtesy of Pat Wise at HIMSS, Oct. 2009
  • 11. “Even hospitals with fully functioning EMRs still make extensive use of digitized scans of manually completed forms and textual checklists. With no forms or screens to capture data in a structured way, hospitals fail to report quality measures as a routine byproduct of the practices, relying instead on a retrospective chart abstracting process.” (Holland, 2010)Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 11 Lecture a
  • 12.  The American Recovery and Reinvestment Act of 2009 “…authorizes the Centers for Medicare & Medicaid Services (CMS) to provide reimbursement incentives for eligible professionals and hospitals who are successful in becoming ‘meaningful users’ of certified electronic health record technology …” (The American Reinvestment and Recovery Act of 2009)• The HITECH (Health Information Technology for Economic and Clinical Health) Act establishes programs under CMS in coordination with the Office of the National Coordinator to accomplish this charge.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 12 Lecture a
  • 13.  Improve quality, safety, & efficiency Engage patients & their families Improve care coordination Improve population & public health; reduce disparities Ensure privacy & security protectionsHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 13 Lecture a
  • 14. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 14 Lecture a
  • 15.  The quality of care received needs improvement. In the current healthcare environment there are a number of initiatives that aim to improve the care in the U.S. context through the use of HIT. • Meaningful Use • Patient Centered Medical Home • Accountable Care OrganizationHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 15 Lecture a
  • 16. References• Affordable Care Act. Available from: www.healthcare.gov/law/index.html• Berwick, D. October 30, 2009, speech, Harvard School of Public Health • Center for Medicaid Services. Shared Services Program. Available from: https://www.cms.gov/sharedsavingsprogram/ • Endorsing national consensus standards for measuring and publicly reporting on performance; California Academy of Family Physicians Diabetes Initiative Care Model Change Package originally developed by Lumetra • Holland, Marc. In Health Information Exchange: From Meaningful Use to Healthcare Transformation. Available from: http://www.himss.org/content/files/Carefx%20_HIE_meaningful-use2.pdf • The National Coalition on Health Care (NCHC, 2007). Available from: http://nchc.org/ Patient-Centered Primary Care Collaborative. What We Do (PCMH). Available from: http://www.pcpcc.net/what-we-do• Patient Protection and Affordable Care Act (PPACA). Available from: http://www.healthcare.gov/law/index.html • President Barack Obama. Barack Obama, speech at George Mason University, January 12, 2009 • U.S. Department of Health and Human Services. (June 22, 2011). Up to $500 million in Affordable Care Act funding will help health providers improve care. Retrieved from: http://www.hhs.gov/news/press/2011pres/06/20110622a.html Images Slide 14: Meaningful Use Stages. Courtesy of Dr. Anna Maria Izquierdo-PorreraHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 16 Lecture a
  • 17. Introduction to Quality Improvement and Health Information Technology: Part 2 This material (Comp12_Unit1b) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013.
  • 18.  Explainhealthcare quality and quality improvement (QI). Describe quality improvement as a goal of meaningful use.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 18 Lecture b
  • 19. “Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired outcomes and are consistent with current professional knowledge.” (IOM, 2001)Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 19 Lecture b
  • 20. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 20 Lecture b
  • 21.  National Quality Forum (NQF) www.qualityforum.org National Committee for Quality Assurance (NCQA) www.ncqa.org Provider organizations • AMA’s Physician Consortium for Performance Improvement (PCPI) www.ama-assn.org/ama/pub/physician- resources/clinical-practice-improvement/clinical- quality/physician-consortium-performance-improvement Joint Commission (JC) www.jointcommission.org Institute for Healthcare Improvement (IHI)Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 21 Lecture b
  • 22.  The Healthcare Accreditation Institute (Public Organization) www.ha.or.th Joint Commission (JC) www.jointcommission.org International Organization for Standardization (ISO) www.iso.org Provider & professional organizations • University Hospital Network (UHOSNET) www.uhosnet.com • The Medical Council of Thailand www.tmc.or.th • Thai Medical Informatics Association (TMI) www.tmi.or.th • Other professional councils and organizations Regulatory organizations • Ministry of Public Health • Ministry of Education  Thai Qualifications Framework for Higher Education (TQF:HEd) Payer organizations • National Health Security Office (NHSO) www.nhso.go.th • Social Security Office (SSO) • Comptroller-General Department Other quality frameworks • Thai Quality Award (TQA) www.tqa.or.th 22
  • 23.  Needs to be improved, especially for the uninsured  Patient safety & healthcare-associated infections warrant urgent attention  Quality is improving, but pace is slow, especially in preventive care & chronic disease management  Disparities are common and lack of insurance is a contributor  Many disparities are not decreasing; those that warrant increased attention include care for cancer, heart failure, and pneumoniaHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 23 Lecture b
  • 24.  National study of physician performance for 30 medical conditions plus preventive care: physicians provided only 55% of recommended care. (McGlynn et al. NEJM 2003; 348:2635) 66% of people with hypertension are inadequately treated. (JNC 7, JAMA 2003;289: 2560) 63% of people with diabetes have HbA1c levels greater than 7.0%. (Saydah, et al. JAMA 2004;291:335) 62% of people with elevated LDL cholesterol have not reached lipid goals. (Afonso, Am J Man Care 2006;12:589) 50-70% of healthcare-associated infections are preventable. (Umscheid et al. Infect Control Hosp Epidemiol. 2011 Feb;32(2):101-14.) 24.7% of Medicare patients admitted to the hospital for heart failure are readmitted within 30 days. (CMS, 2009)Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 24 Lecture b
  • 25.  Only 27% of adults with a regular primary care physician (PCP) could easily contact their physician over the telephone, obtain care or medical advice after hours, or experience timely office visits. Only 57% of adults rate the information they get about their health issues as very good; only 43% find it easy to get an appointment; and only 56% find the physician’s office to be well-organized and feel their time is not wasted.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 25 Lecture b
  • 26.  Given the current sub-optimal quality of care received by patients, the introduction of QI initiatives is imperative. HIT has an important role to play in QI initiatives.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 26 Lecture b
  • 27. “Every system is perfectly designed to achieve the results it achieves.” (Paul Batalden, M.D, 2008)So, the answer must lay in the system redesign.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 27 Lecture b
  • 28. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 28 Lecture b
  • 29.  Make it specific • Assign it a number if possible Assign it a timeline Make it measurable Make sure it is challenging but doableHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 29 Lecture b
  • 30.  PROCESS MEASURE: Are we doing what we must to get the improvement we seek?  OUTCOME MEASURE: Are we getting what we expect?  BALANCING MEASURE: Are we causing new problems in other parts of the system?Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 30 Lecture b
  • 31. Hospital Ambulatory • AIM: we will reduce the number of • AIM: we will reduce the amount ventilator-associated pneumonias of time it takes our patients to get (VAP) in the ICU from the current an appointment (request to 23% to under 10% in 4 months appointment) from 23 days to 0 • MEASURES: days in 6 months  Process measure: • MEASURES:  Ventilator days  Process measure:  Over-sedation hours  Supply  Oral care performed  Demand  Outcome measure: Number of VAP  No-show rate  Balancing Measure:  Outcome measure: third next available appointment  Cost of care  Re-intubation rates  Balancing Measure: Patient satisfactionHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 31 Lecture b
  • 32.  Concepts and strategies: decide on the overall changes that will lead to the desired improvement. Specific changes: • Make them small • Make them fast • Make them frequent You may need to include additional measures specifically to decide if a change you have tested is worth keeping or did not lead to improvement. Consider using pre-existing change packages.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 32 Lecture b
  • 33. • One of the most important aspects of QI is to understand how your systems actually perform, under a range of conditions.• Deming’s theory of profound knowledge is based on the principle that each organization is composed of a system of interrelated processes and people.• The improvement of the system depends on the capability to organize the balance of each component to enhance the entire system.• Understanding and learning about your system is essential to improve it.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 33 Lecture b
  • 34. • PDCA (Deming Cycle) Plan Act Do Checkhttp://en.wikipedia.org/wiki/Shewhart_cycle 34
  • 35. • Continuous Quality Improvement (CQI)http://en.wikipedia.org/wiki/Continual_improvement_process Quality improvement is an ongoing, continuous effort• Total Quality Management (TQM)http://en.wikipedia.org/wiki/Total_quality_management Quality of products and processes is the responsibility ofeveryone involved in the products or services• Six Sigmahttp://en.wikipedia.org/wiki/Six_Sigma Seeks to improve quality by removing causes of defects and minimizing variability in manufacturing and business processes 35
  • 36. • Leanhttp://en.wikipedia.org/wiki/Lean_manufacturing Considers expenditure of resources that does not create value awaste -> “Preserving value with less work” Including tools such as Value Stream Mapping, 5S, Kanban (pullsystems), Just in time (JIT), etc.• Routine to Research (R2R)http://home.kku.ac.th/kitsir/research/html/download/news/r2r.pdf Improves the routine work processes through research• Risk Managementhttp://en.wikipedia.org/wiki/Risk_management Identification, assessment, prioritization , prevention, mitigation,monitoring, and control of risks 36
  • 37. Nonaka SECI ModelImage source: Senoo et al. (2007) http://dx.doi.org/10.1108/14601060710776725
  • 38.  The quality of care received needs improvement. Quality improvement is an ongoing process that includes the setting of an aim and a progressive measurement, change test, and understanding of the system. There are various complementary approaches to quality improvementHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 38 Lecture b
  • 39. References• Agency for Healthcare Research and Quality (AHRQ). Available from: http://www.ahrq.gov/• Batalden, Paul M.D in The Improvement Collaborative: An Approach to Rapidly Improve Health Care and Scale Up Quality Services. June 2008. Available from: http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&ved=0CCQQFjAB&url=http%3A%2F%2Fw ww.ovcsupport.net%2Flibsys%2FAdmin%2Fd%2FDocumentHandler.ashx%3Fid%3D790&ei=g2nWTtbdFoHn0QH 8uP39AQ&usg=AFQjCNEnga43Tn8Y_Mmf0uUbcRUzhevA0w&sig2=RG7ZXVjV_eKlghcJarz_1A• Beal et al. Closing the Divide: How Medical Homes Promote Equity in Health Care. Commonwealth Fund, 2007• Centers for Medicare and Medicaid Services. http://www.cms.gov/• IOM—International Institute of Medicine. Available from: http://iom.edu/• Institute for Healthcare Improvement (IHI) Available from: http://www.ihi.org/Pages/default.aspx• Joint Commission. Available from: http://www.jointcommission.org/• National Committee for Quality Assurance. Available from: http://www.ncqa.org/• National Quality Forum (NQF). Available from: http://www.qualityforum.org/Home.aspx• Physician Consortium for Performance Improvement (PCPI)- American Medial Association. Available from: http://www.ama-assn.org/ama/pub/physician-resources/clinical-practice-improvement/clinical-quality/physician- consortium-performance-improvement.page• Wasson, J. & Benjamin, R. How is your health: what you can do to make your health and healthcare better, 2009. Available from: http://www.howsyourhealth.org/html/HowsYourHealth_4thEd.pdfHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 39 Lecture b
  • 40. Images Slide 20: Quality Health Care: Who Defines It? Courtesy of Dr. Anna Maria Izquierdo-Porrera Slide 23: Cover of the 2009 National Quality Healthcare Report and the 2009 National Healthcare Disparities Report. Available from: http://www.ahrq.gov/qual/qrdr09.htm Slide 28: Basics of Quality Improvement. Courtesy of Dr. Anna Maria Izquierdo-Porrera Health IT Workforce Curriculum Quality Improvement Version 3.0/Spring 2012 Introduction to QI and HIT 40 Lecture b
  • 41. Introduction to Quality Improvement and Health Information Technology: Part 3 This material (Comp12_Unit1c) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013.
  • 42. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 42 Lecture c
  • 43. Has the potential to: improve health care quality prevent medical errors increase health care efficiency & reduce unnecessary costs increase administrative efficiencies decrease paperwork expand access to affordable care improve population healthHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 43 Lecture c
  • 44. CPOE e-MAR Computerized provider order entry  Computerized medication administration Can reduce errors in drug prescribing record and dosing  Can reduce errors in drug administrationMedical Device Interface e-Allergy List Automated vital sign capture  Computerized allergy list Can reduce errors in transcription  Can reduce errors in preventable adverseKnowledge Links drug events Reference information links Reminders Can reduce errors due to lack of  Prompts and flags knowledge  Can reduce errors in omissionMonitoring Structured Notes Quality metric reporting  Standardized observations Can identify opportunities for  Can reduce errors related to failure to improvement detect subtle changes in statusHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 44 Lecture c
  • 45. System change: A medical logic module (MLM) was created that provides the following functionality: When selected drugs are ordered at a frequency of every 24 hours or longer, the prescriber is automatically presented with the last administration time if the drug had been ordered previously.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 45 Lecture c
  • 46. Early detection and effective treatment are the cornerstones of treatment for pneumonia. Adults aged 65 and older should receive the influenza and pneumococcal immunization to prevent pneumonia and its complications.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 46 Lecture c
  • 47. Knowledge access Patient portal Patient-friendly websites  Patient access and manage Can provide medical own health record information and access to  Can enable self- support groups managementTailor to Patient Needs Disease management Clinical decision support  Customized health Can tailor information education and disease according to patient management messaging characteristics and  Can enable self- condition managementHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 47 Lecture c
  • 48. Event: A standard protocol (document specifying best practices for care) and electronic prescriber order sets are used for all adult patients receiving intravenous blood thinners. There are new changes to the protocol due to a switch to new laboratory tests for monitoring drug activity.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 48 Lecture c
  • 49. System Change: The current protocol and electronic order sets were revised to include orders for the new laboratory tests. The new order sets include changes to the therapeutic goals of nurse-managed therapy.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 49 Lecture c
  • 50. Knowledge access Patient portal Patient-friendly websites  Patient access and manage Can provide medical own health record information and access to  Can enable self- support groups managementTailor to Patient Needs Disease management Clinical decision support  Customized health Can tailor information education and disease according to patient management messaging characteristics and  Can enable self- condition managementHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 50 Lecture c
  • 51. Event: Mr. Jackson took his mother to a pre-operative evaluation center in preparation for her impending surgery. He was asked to help her complete an information form that included her home medications. Mr. Jackson’s sister manages these medications and he had forgotten to bring the list. He was unable to contact her on her cell phone and became increasingly frustrated since, after all, his mother’s doctors should know what medicines she is taking!Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 51 Lecture c
  • 52. System Change: The ambulatory care center implemented a web- based patient portal that would allow patients or caregivers to enter much of the history information in advance, from home. Satisfaction scores for patients improved with this active role in their care.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 52 Lecture c
  • 53. A medical office practice is considering the use of a web-based secure messaging system to improve patient-provider communication and enhance patient satisfaction.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 53 Lecture c
  • 54. Telemedicine Clinicians Reminders• Internet-based access  Task list schedules• Can provide immediate  Can remind nurses when access to medical treatments are due informationTime-sensitive Prompts Patient Reminders  Appointment scheduling Timed draw alerts  Can remind patients Can remind nurses when when they need to to draw blood based on return for follow-up a medication intervention visitsHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 54 Lecture c
  • 55. Event: Medication patches are small, flesh-colored, and are usually placed in discreet locations, e.g. the upper shoulder area or on the back of the upper arm. Some patches are appropriately left on for 2-3 days or longer. It is difficult to track the placement and removal of these patches over time, leading to errors in which medication patches were not removed and the patient received too much medicine.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 55 Lecture c
  • 56. System Change: A change was made to the electronic medication record (eMAR). After the nurse documents the application of the patch in the eMAR, a follow-up task to remove the patch at the ordered date and time is automatically generated. If the follow-up task is still active during a transfer in care, the receiving nurse will see this task on the eMAR.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 56 Lecture c
  • 57. A healthcare system saw increases in adverse events in its home care company due to inadequate transfer of clinical information at hospital discharge. An electronic hospital discharge summary with auto-faxing was developed to increase availability of discharge information at the time of follow-up care.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 57 Lecture c
  • 58. Wireless mobile Character expansion technology • Ability to translate a few• Vital Sign Capture characters into phrases,• Can eliminate need to sentences or paragraphs • Can decrease typing write or type vital signs timeSystem integration Clinical decision• Pull forward historical support information • Prompt for duplicate• Can reduce data labs collection time • Can reduce redundant laboratory testingHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 58 Lecture c
  • 59. Event: The emergency department (ED) staff at a community hospital used a large whiteboard mounted on the wall that could be quickly updated with felt-tip markers to track patients and treatments. The problem was that staff could not obtain information from the board unless they were physically standing in front of it. In addition, information on the board only reflected what was already known by the ED staff.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 59 Lecture c
  • 60. System Change: The hospital implemented an automated ED patient tracking system that used business intelligence technology. This technology enabled more efficient patient flow using real- time data.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 60 Lecture c
  • 61. Hope Memorial Hospital implemented an electronic picture archiving and communication system (PACS) for requesting radiological examinations and displaying images. They saw a reduction in repeat chest X-ray films at outpatient appointments.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 61 Lecture c
  • 62. Data capture Multi-Modal functionality Monitoring by population  Various ways for patients to characteristics get health information Can uncover health care  Can decrease health care disparities disparityTailor to Patient Needs Decision support Competency-based patient  Drug cost information education  Can assist providers in Can tailor information to selecting alternatives for low educational background and income patients development statusHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 62 Lecture c
  • 63.  All healthcare settings can benefit from the assistance of HIT professionals in identifying electronic solutions to quality concerns.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 63 Lecture c
  • 64. References• Institute of Medicine. Crossing the quality chasm. Washington DC: National Academy Press, p. 232. 2001.ImagesSlide 42: What is Health Care Quality? Courtesy Dr.Anna Maria Izquierdo-PorreraHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 64 Lecture c
  • 65. Introduction to Quality Improvement and Health Information Technology: Part 4 This material (Comp12_Unit1d) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013.
  • 66.  Analyze the ways that HIT can either help or hinder quality improvement.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 66 Lecture d
  • 67.  Work-arounds and artifacts can lead to unintended consequencesHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 67 Lecture d
  • 68. Defined Example Alternative processes that help workers avoid  Nurses taking verbal demands placed on orders rather than them that they perceive prescribers entering to be unrealistic or harmful the order into POE Unanticipated due to workflow behaviors directly or timing of event indirectly caused by the EHR when the system impedes one’s workHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 68 Lecture d
  • 69.  When a bar-coding medication system interfered with their workflow, nurses devised work-arounds, such as removing the armband from the patient and attaching it to the bed because the barcode reader failed to interpret bar codes when the bracelet curved tightly around a small arm.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 69 Lecture d
  • 70.  Investigators found increased mortality among children admitted to Children’s Hospital in Pittsburgh after CPOE implementation.  Three reasons were cited for this unexpected outcome: • CPOE changed the workflow • Order entry required as many as 10 clicks & took as long as 2 minutes • When the team changed its workflow to accommodate CPOE, face-to- face contact among team members diminished.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 70 Lecture d
  • 71.  Well-crafted HIT solutions can: • Improve safety, effectiveness, efficiency, equity, timeliness, and patient-centeredness of care • Work to accomplish the best care for the whole population at the lowest cost Poorly designed HIT solutions can: • Lead to work-arounds and unintended consequences that may lead to patient risks or bad outcomesHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 71 Lecture d
  • 72. References • Connolly, C. (2005, March 21). Cedars-Sinai doctors cling to pen and paper. Washington Post, p. A01. Available from: http://gunston.gmu.edu/.../cedars-sinai%20cpoe%20washpost%203-21-05 • Doyle, M. Impact of the Bar Code Medication Administration (BCMA) system on medication administration errors. Unpublished doctoral dissertation, University of Arizona, Tucson in Nursing Informatics and the Foundation of Knowledge. Jones and Bartlett Publishers Sudbury, Massachusetts. 2005. • Han, Y.Y., Carcillo, J.A., Venkataraman, S.T., et al. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics. 116;1506-1512. 2005 Images Slide 69: Patient Armbands. Department of Defense. Available from: http://www.defense.gov/HomePagePhotos/LeadPhotoImage.aspx?id=74561 Slide 70: Childrens Hospital, Pittsburgh, PA. Available from: http://www.chp.edu/CHP/Community+Preview+Photo+GalleryHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Introduction to QI and HIT 72 Lecture d
  • 73. Principles of Quality and Safety for HIT Part 1This material (Comp12_Unit2a) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013.
  • 74. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Principles of Quality and Safety for HIT 74 Lecture a
  • 75. In U.S. Healthcare system 7% of patients suffer a medication error 44,000- 98,000 deaths 100,0000 death from hospital-acquired infections Patients receive half of recommend therapies $50 billion in total costs Similar results in UK and AustraliaHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Principles of Quality and Safety for HIT 75 Lecture a
  • 76.  How can this happen?  We need to view the delivery of health care as a scienceHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Principles of Quality and Safety for HIT 76 Lecture a
  • 77. 1. Accept we are fallible—assume things will go wrong rather than right.2. Every system is perfectly designed to achieve the results it gets.3. Understand principles of safe design. • Standardize • Create checklists • Learn when things go wrong4. Recognize these principles apply to technical and team work.5. Teams make wise decision when there is diverse and independent input. Caregivers are not to blameHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Principles of Quality and Safety for HIT 77 Lecture a
  • 78. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Principles of Quality and Safety for HIT 78 Lecture a
  • 79. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Principles of Quality and Safety for HIT 79 Lecture a
  • 80. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Principles of Quality and Safety for HIT 80 Lecture a
  • 81. References• Boeing. 2001 Statistical Summary of Commercial Jet Airplane Accidents. June 2002• Johns Hopkins Hospital. Josie King. Available: http://www.hopkinsmedicine.org/hmn/s04/feature1.cfm• Reason, J. BMJ 2000;320:768-770ImagesSlide 74: Sponge Left in Stomach. Image courtesy Dr. Peter Pronovost. Slide Presentation from the AHRQ 2008 Annual Conference: September 9, 2008 Available from: http://www.ahrq.gov/about/annualmtg08/090908slides/Pronovost.htmSlide 78: The Swiss Cheese Model. Adapted by Dr. Peter Pronovost from original in Reason, J. BMJ 2000;320:768-770. Slide Presentation from the AHRQ 2008 Annual Conference: September 9, 2008Slide 79: System Factors. Slide Presentation from the AHRQ 2008 Annual Conference: September 9, 2008 Image courtesy Dr. Peter Pronovost.Slide 80: A Dosage Error? Creative Commons by MBBradford. Available from: http://en.wikipedia.org/wiki/File:Glucagon_vials_and_syringe.JPGHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Principles of Quality and Safety for HIT 81 Lecture a
  • 82. Principles of Quality and Safety for HIT Part 2This material (Comp12_Unit2b) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013.
  • 83.  Standardize. • Eliminate steps if possible. Create independent checks. Learn when things go wrong. • What happened? • Why did it happen? • What did you do to reduce risk? • How do you know it worked?Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Principles of Quality and Safety for HIT 83 Lecture b
  • 84. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Principles of Quality and Safety for HIT 84 Lecture b
  • 85. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Principles of Quality and Safety for HIT 85 Lecture b
  • 86. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Principles of Quality and Safety for HIT 86 Lecture b
  • 87. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Principles of Quality and Safety for HIT 87 Lecture b
  • 88.  Assume things will go wrong Develop lenses to see systems Work to Mitigate Technical and Teamwork Hazards • Standardize work • Create independent checks • Learn from mistakes Make wise decisions by getting input from others Keep the patient the north starHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Principles of Quality and Safety for HIT 88 Lecture b
  • 89. In this unit we’ve learned about the ways that teams make wise decisions with diverse and independent input. We’ve also explored the importance of communication and especially the place of critical listening.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Principles of Quality and Safety for HIT 89 Lecture b
  • 90. References• Dayton, E. Joint Commission Journal, Jan. 2007• Johns Hopkins Hospital. Josie King. Available: http://www.hopkinsmedicine.org/hmn/s04/feature1.cfm• Reason, J. BMJ 2000;320:768-770ImagesSlide 85: A Bank of ATMs. Creative Commons: Piotrus. Available from: http://commons.wikimedia.org/wiki/File:PNC_bank_ATMs.JPGSlide 86. A Three-Point Seat Belt in a Lincoln Town Car. Courtesy Creative Commons Gerdbrendel. Available from: http://en.wikipedia.org/wiki/File:Seatbelt.jpgSlide 87. Jelly Beans. Creative Commons Brandon D Available from: http://3.bp.blogspot.com/-oxxwjc9sQp8/TbCxyVKPtWI/AAAAAAAAAcA/NkPtINLsFjw/s1600/jelly- beans.jpgHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Principles of Quality and Safety for HIT 90 Lecture b
  • 91. The Culture of SafetyThis material (Comp12_Unit4) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013.
  • 92. Video 1Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Reliability, Culture of Safety, & HIT 92
  • 93. Pointing the finger at people rather than systems.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Reliability, Culture of Safety, & HIT 93
  • 94. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Reliability, Culture of Safety, & HIT 94
  • 95.  Limitslearning Increases likelihood of repeat errors Drives self-reporting undergroundHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Reliability, Culture of Safety, & HIT 95
  • 96. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Reliability, Culture of Safety, & HIT 96
  • 97. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Reliability, Culture of Safety, & HIT 97
  • 98. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Reliability, Culture of Safety, & HIT 98
  • 99. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Reliability, Culture of Safety, & HIT 99
  • 100. Video 2Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Reliability, Culture of Safety, & HIT 100
  • 101. In this unit we explored the characteristics of high reliability organizations and learned more about establishing an organizational culture of safety.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Reliability, Culture of Safety, & HIT 101
  • 102. References• AHRQ Patient Safety Primers. Safety Culture. Available from: http://psnet.ahrq.gov/primer.aspx?primerID=5• Becoming a High Reliability Organization: Operational Advice for Hospital Leaders. Rockville, MD. AHRQ Publication No. 08-0022, 2008 April. Agency for Healthcare Research and Quality. Available from: http://www.ahrq.gov/qual/hroadvice/• Riley, W., Davis, S.E., Miller, K.K., & McCullough, M. A model for developing high reliability teams. J Nurs Manag. 2010 Jul18(5):556-563. Charts, Tables, Figures Table 4_1. The five specific concepts that help create the state of mindfulness that is needed for reliability, which in turn is a prerequisite for safety. Available from: http://www.ahrq.gov/qual/hroadvice/hroadvicefig1-6.htm Images Slide 92: Aircraft Carrier USS Enterprise. Courtesy U.S. Navy, photo by Photographers Mate Airman Rob Gaston. Available from: http://www.navy.mil/view_single.asp?id=15089 Slide 94: Blame. Created by Dr. Stephanie Poe. Slide 95: Blame Arrows. Created by Dr. Stephanie Poe. Slide 96: How to Promote a Culture of Learning 1. Courtesy: Dr. Anna Maria Izquierdo-Porrera Slide 97: How to Promote a Culture of Learning 2 Courtesy: Dr. Anna Maria Izquierdo-Porrera Slide 98:How to Promote a Culture of Learning 3 Courtesy: Dr. Anna Maria Izquierdo-Porrera Slide 99: Culture of Safety Characteristics. Courtesy: Dr. Anna Maria Izquierdo-Porrera Slide 100: Honey Bee. Creative Commons by William Warby. Available from: http://www.flickr.com/photos/wwarby/ Health IT Workforce Curriculum Quality Improvement Version 3.0/Spring 2012 Reliability, Culture of Safety, & HIT 102
  • 103. Learning From Mistakes: Error Reporting and Analysis and HIT: Part 1This material (Comp12_Unit12a) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013.
  • 104. “A new delivery system must be built to achieve substantial improvements in patient safety – a system that is capable of preventing errors from occurring in the first place, while at the same time incorporating lessons learned from any errors that do occur.” (IOM,2004)Health IT Workforce Curriculum Quality Improvement 104Version 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and HIT─Lecture a
  • 105. Health IT Workforce Curriculum Quality Improvement 105Version 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and HIT─Lecture a
  • 106. Health IT Workforce Curriculum Quality Improvement 106Version 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and HIT─Lecture a
  • 107.  Admit that providing health care is potentially hazardous  Take responsibility for reducing risks  Encourage error reporting without blame  Learn from mistakes  Communicate across traditional hierarchies and boundaries; encourage open discussion of errors  Use a systems (not individual) approach to analyze errors  Advocate for multidisciplinary teamwork  Establish structures for accountability to patient safetyHealth IT Workforce Curriculum Quality Improvement 107Version 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and HIT─Lecture a
  • 108.  Near Miss  HarmHealth IT Workforce Curriculum Quality Improvement 108Version 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and HIT─Lecture a
  • 109.  Swiss cheese model of error  A culture of safety  Three HIT mechanisms to help control error • surveillance systems, on-line event reporting, and predictive analytics/data modeling  Risk assessment model (near-miss VS harm)Health IT Workforce Curriculum Quality Improvement 109Version 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and HIT─Lecture a
  • 110. References • AHRQ Patient Safety Network. Glossary. Available from: http://psnet.ahrq.gov/glossary.aspx • AHRQ. Glossary: Failure Mode Effects Analysis. Available from: http://webmm.ahrq.gov/popup_glossary.aspx?name=failuremodeandeffectanalysis • Kilbridge PM, & Classen DC. The informatics opportunities at the intersection of patient safety and clinical informatics. J Am Med Inform Assoc. 2008 Jul-Aug;15(4):397-407. Epub 2008 Apr 24. • Reason J. Human error: models and management. BMJ. 320:768-770. 2000. Images Slide 105: Adapted from Reason J. Human Error: Models and Management. BMJ 320:768 2000. by Dr. Peter Pronovost. Available from: http://www.bmj.com/content/320/7237/768.long Slide 106: Adapted from Reason J. Human Error: Models and Management. BMJ 320:768 2000. by Dr. Peter Pronovost. Available from: http://www.bmj.com/content/320/7237/768.long Slide 108: Types of Outcomes. Dr. Anna Maria Izquierdo-PorreraHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis 110 and HIT─Lecture a
  • 111. Learning From Mistakes: Error Reporting and Analysis and HIT: Part 2This material (Comp12_Unit12b) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013.
  • 112. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 112 HIT─Lecture b
  • 113. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 113 HIT─Lecture b
  • 114. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 114 HIT─Lecture b
  • 115.  Alert fatigue
  • 116.  Classification of error • AHRQ • James Reason • Slips & mistakes • Latent conditions & active failures • Sharp end & blunt endHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 116 HIT─Lecture b
  • 117. References • AHRQ Patient Safety Network. Glossary. Available from: http://psnet.ahrq.gov/glossary.aspx • AHRQ. Glossary: Failure Mode Effects Analysis. Available from: http://webmm.ahrq.gov/popup_glossary.aspx?name=failuremodeandeffectanalysis • Ash JS, Sittig DF, Poon EG, Guappone K, Campbell E, Dykstra RH. The extent and importance of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc. 2007;14(4):415-423. • Reason J. Human error: models and management. BMJ. 320:768-770. 2000. • Siegler EL, Adelman R. Copy and paste. A remediable hazard of electronic health records. Am J Med. 2009 Jun;122(6):495-6. Images Slide 112: Types of Error –Commission/Ommission. Dr. Anna Maria Izquierdo-Porrera Slide 113: Types of Error. Dr. Anna Maria Izquierdo-Porrera Slide 114: Types of Error II. Dr. Anna Maria Izquierdo-PorreraHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 117 HIT─Lecture b
  • 118. Learning From Mistakes: Error Reporting and Analysis and HIT: Part 3This material (Comp12_Unit12c) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013.
  • 119. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 119 HIT─Lecture c
  • 120.  Structured problem-solving process Considers all potential causal or contributing factors  Human factors  System factors Detailed chronological list of events surrounding incident Premise: one can learn from one’s mistakesHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 120 HIT─Lecture c
  • 121. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 121 HIT─Lecture c
  • 122. Healthcare Example: Mrs. A. received blood inthe Emergency Department. Within 15 minutes,she experienced a bad reaction. Her nurserealized that she had received blood intended foranother patient. She was transferred to theintensive care unit to be stabilized. The ED staffwanted to know how this could have happenedso they assembled a team to identify possiblecauses.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 122 HIT─Lecture c
  • 123.  Briefly describe event Identify affected areas/services Assemble a team Diagram the process (flow chart) Identify potential root causes Prioritize root causes Develop action plan Evaluate results!Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 123 HIT─Lecture c
  • 124. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 124 HIT─Lecture c
  • 125. Story: Before I had children, I invited one of myhigh school friends and her family, including atoddler, to dinner. I was worried that her toddlerwould somehow manage to hurt himself in myhouse, which was designed for a childlesscouple.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 125 HIT─Lecture c
  • 126. Select a high risk process, one that isknown to have problems, and assemble ateam.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 126 HIT─Lecture c
  • 127. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 127 HIT─Lecture c
  • 128. The higher the number, the more urgent the need to prevent a failure.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 128 HIT─Lecture c
  • 129. Event: After reading several articles aboutlaboratory specimen errors that result in lab testsbeing done on the wrong patients, doctors at acommunity office practice decide to examine thepotential for this problem to happen in theiroffice laboratory.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 129 HIT─Lecture c
  • 130.  Select a high risk process (patient identification): • Affects a large number of patients • Carries a high risk for patients • Has known process problems identified by other organizations (e.g., Joint Commission Sentinel Event Alert!) Assemble a team • People closest to issue involved • People critical to implementation of potential changes • Respected, credible team leader • Someone with decision-making authority • People with diverse knowledge basesHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 130 HIT─Lecture c
  • 131. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 131 HIT─Lecture c
  • 132. The higher the number, the more urgent the need to prevent a failure.Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 132 HIT─Lecture c
  • 133. Health IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 133 HIT─Lecture c
  • 134.  Tools • Root Cause Analysis (RCA) • Failure Mode Effect Analysis (FMEA) • Hazard Analysis • Flow ChartingHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 134 HIT─Lecture c
  • 135. References• AHRQ Patient Safety Network. Glossary. Available from: http://psnet.ahrq.gov/glossary.aspx• AHRQ. Glossary: Failure Mode Effects Analysis. Available from: http://webmm.ahrq.gov/popup_glossary.aspx?name=failuremodeandeffectanalysisCharts, Tables, FiguresTable12.1 Conduct a Hazard Analysis. Dr. Stephanie PoeTable12.2 Conduct a Hazard Analysis II. Dr. Stephanie PoeImagesSlide 119: Quality Improvement Tools. Dr. Stephanie PoeSlide 121: Root Cause Analysis. Dr. Stephanie PoeSlide 124: Failure Mode Effects Analysis. Dr. Stephanie PoeSlide 127: FMEA: Steps. Dr. Stephanie PoeSlide 128: FMEA Diagram. Dr. Stephanie PoeSlide 133: Quality Improvement Tools. Dr. Stephanie PoeHealth IT Workforce Curriculum Quality ImprovementVersion 3.0/Spring 2012 Learning From Mistakes: Error Reporting and Analysis and 135 HIT─Lecture c
  • 136. The End

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