Association for Hospital
Medical Education (AHME)
April 13, 2011
Christiana Care Health System
Newark Delaware
Resources Developed by
Christiana Care Health System
Lee Ann Riesenberg, PhD, RN
Loretta Consiglio-Ward, RN, MSN
Carol K. Moore, MS, RN, NP
Thea Eckman, RN, BSN, CCRN
Teri Foy, MEd, RT
Theresa Fields
Donna Mahoney, BS, CPHQ
Omar Khan, MD, MHS
Contact Information
Lee Ann Riesenberg, PhD, RN
Director Medical Education Research & Outcomes, Christiana Care Health System, Newark DE
Research Assistant Professor, Jefferson School of Population Health, Thomas Jefferson
University, Philadelphia PA
Lriesenberg@christianacare.org
Brian W. Little, MD, PhD
Chief Academic Officer, Christiana Care Health System, Newark DE
BWL@christianacare.org
TABLE OF CONTENTS
IMPROVEMENT PROJECT WORK BOOK .................................................................................................................. 1
ACHIEVING COMPETENCY TODAY (ACT): ISSUES IN HEALTH CARE QUALITY, COST, SYSTEMS, AND SAFETY COURSE
............................................................................................................................................................................ 10
COURSE SYLLABUS .......................................................................................................................................................11
COURSE MEETING DETAILS ............................................................................................................................................12
COURSE OVERALL GOALS ..............................................................................................................................................12
COURSE OVERALL OBJECTIVES ........................................................................................................................................12
COURSE SUMMARY AT A GLANCE ....................................................................................................................................13
ACT BACKGROUND INFORMATION ..................................................................................................................................16
COURSE FACILITATOR TRAINING PROGRAM .......................................................................................................................18
FACILITATOR TEXTBOOKS ...............................................................................................................................................18
DECISION TOOLS FOR PERFORMANCE IMPROVEMENT ........................................................................................ 19
SIX DECISION MAKING OPTIONS .....................................................................................................................................20
RISK REDUCTION STRATEGIES: RECOMMENDED HIERARCHY OF ACTIONS..................................................................................21
EFFORT/BENEFIT MATRIX..............................................................................................................................................23
DIAGNOSTIC TOOLS ............................................................................................................................................. 24
WHAT IS A FISHBONE DIAGRAM? ...................................................................................................................................25
SAMPLE FISHBONE DIAGRAM .........................................................................................................................................28
FLOW CHART INSTRUCTIONS ..........................................................................................................................................29
SAMPLE FLOW CHARTS .................................................................................................................................................32
ESTIMATE THE COST OF IMPLEMENTING YOUR PLAN ...........................................................................................................34
MEASUREMENT RESOURCES................................................................................................................................ 35
DATA PRESENTATION....................................................................................................................................................36
CONTROL CHARTS ........................................................................................................................................................38
PERFORMANCE IMPROVEMENT CHECKLIST / ACTION STEPS..................................................................................................40
CHECK SHEET ..............................................................................................................................................................42
PARETO CHART ...........................................................................................................................................................43
SCIENTIFIC WRITING AND PUBLICATION RESOURCES .......................................................................................... 45
SQUIRE GUIDELINES .....................................................................................................................................................46
QUALITY SCORING SYSTEM ............................................................................................................................................49
ACRONYMS AND OTHER RELEVANT RESOURCES ................................................................................................. 51
QUALITY IMPROVEMENT & PATIENT SAFETY ACRONYMS, DEFINITIONS, AND WEB SITES ...........................................................52
QUALITY JOURNALS ......................................................................................................................................................64
IMPROVEMENT PROJECT
WORK BOOK
PLAN
 Clearly define the
process opportunity
(opportunity
statement).
What are you trying to
accomplish?
Specific population that
will be affected?
Is it measurable?
Opportunity statement
is a single sentence that
is specific, measurable,
and addresses these
points:
How good?
By when?
For whom (or for
what system)?
PLAN
[Insert your
institutions’ logo or
quality symbol
here.]
PLAN THE IMPROVEMENT
Define the opportunity statement.
Example statement: Reduce the incidence of pressure ulcers in the
critical care unit by 50 percent by June of 2012.
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
Examples of Measurable Words to Use for Opportunity Statement
Reduce
Improve
Decrease
Increase
Transfer every patient
Achieve >95% compliance
Eliminate
Grow
Insert your institution’s Mission/Quality Focus below and describe
how your project links to that focus.
[Insert institution Focus] (describe your project linkage):
__________________________________________________________
[Insert institution Focus] (describe your project linkage):
__________________________________________________________
[Insert institution Focus] (describe your project linkage):
__________________________________________________________
[Insert institution Focus] (describe your project linkage):
__________________________________________________________
1
PLAN
 Identify key
stakeholders and
bring them into the
process (i.e.,
interdisciplinary,
key stakeholders
and content
experts).
Identify potential resource individuals (anyone who might be able to
help you obtain needed information).
Resource Individual
Team Member Who Will Contact
Identify individuals involved in the current process (individuals or
groups currently affected by the process).
Individuals or Groups
Team Member Who Will Contact
Currently Affected
to Gather More Insight
Identify all departments/units that your project might affect. This
goes beyond those currently affected, as your project may bring other
departments/units into the process.
Departments/Units
How Might They be Affected?
that Might be Affected
Is there a team or individual at your institution who is already
working on this issue? If yes, how will you work with them?
__________________________________________________________
__________________________________________________________
2
PLAN
Schedule meetings with key stakeholders
Stakeholder: ______________________________________________
Team member(s) assigned:__________________________________
Meeting date: _____________________________________________
Members attending: _______________________________________
Stakeholder: ______________________________________________
Team member(s) assigned:__________________________________
Meeting date: _____________________________________________
Members attending: _______________________________________
Stakeholder: ______________________________________________
Team member(s) assigned:__________________________________
Meeting date: _____________________________________________
Members attending: _______________________________________
Stakeholder: ______________________________________________
Team member(s) assigned:__________________________________
Meeting date: _____________________________________________
Members attending: _______________________________________
3
PLAN
 Gather background
data about the
current process
 Conduct a literature
review
How did you identify
the opportunity?
o A strategic goal for
the year?
o Practice change
recommendation?
o System/
departmental data?
o Satisfaction results?
o An event that
happened?
o Personal
experience?
PLAN
 Identify potential
causes of the
problem or identify
gaps in the process.
Clarify current knowledge of the process or practice.
 Review best practices/ conduct a literature review (Potential
databases: Medline/PubMed, ERIC, CINAHL, PsychInfo).
 Provide data/information from your own institution
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
What information is already known about the current practice or
process?
 Fishbone diagram (cause and effect diagram)
(pages 25-28)
 Flow chart current state of the process and/or practice if appropriate
(pages 29-33).
PLAN
 Analyze baseline
data related to the
process, if
available.
Use appropriate Performance Improvement tool(s) to identify gaps or
potential causes of the problem; i.e., brainstorming, Fishbone diagram,
flow chart, etc. [list or attach PI tool(s)].
Collect baseline data about causes of the problem or gaps in the
process. Select potential baseline measures to use and describe how
you will obtain the data.
Measures
How will you obtain the data?
4
DO
 Generate
potential action
plans /strategies.
DO THE IMPROVEMENT
Develop a list of potential solutions/action plans for your project.
For every solution listed, identify the data needed to determine if the
change led to an improvement.
Potential Solutions “What”
DO
 Plan the action
plans/strategies.
Measure/Data Source
Consider the feasibility of the potential solutions above. Things to
consider include cost, time to implement, steps to achieve, and barriers.
List potential barriers and feasibility considerations below.
Feasibility Notes: _____________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
5
Use the “Estimate the Cost of Implementing your Plan” (page 34) to guide your
 Identify discussion of the following:
potential 1. Identify start-up costs: _____________________________________________
DO
costs.
____________________________________________________________________
____________________________________________________________________
2. Identify operating costs: ___________________________________________
____________________________________________________________________
____________________________________________________________________
3. List possible savings: ______________________________________________
____________________________________________________________________
____________________________________________________________________
4. Would your plan create any billable services? _________________________
____________________________________________________________________
____________________________________________________________________
5. Would your plan create non-financial benefits? ________________________
____________________________________________________________________
____________________________________________________________________
6. Categorize your Plan
 An ongoing financial expense (but worth it in terms of gaining desired outcomes)?
 Cost neutral?
 A moneymaker for the hospital or group (increased performance may streamline
processes, make them more efficient and effective, and still deliver improved care
for your selected patient)?
What does your team need to do to get better answers to the cost questions above?
Assign team members to find the answers.
Team Member Name
Assignment From Above
________________________
________________________________
________________________
________________________________
________________________
________________________________
________________________
________________________________
________________________
________________________________
6
DO
 Plan the action
plans/strategies.
 Implement the
selected action
plans/strategies,
asking who,
what, when,
where, & how.
 Develop
Education plan,
if appropriate.
 Do Rapid Cycle
Improvements
(small test of
change) – one
resident, one
nurse, one unit,
one patient.
Develop and implement recommended action plans/strategies (i.e.,
rapid cycle PDSA).
Action Plans/Strategies
(What)
Responsible
Person(s) (Who)
Location
(Where)
Target Date
(When)
1.
2.
3.
4.
Meet with key stakeholders prior to testing.
Date(s) scheduled:____________________________________________
____________________________________________________________
____________________________________________________________
GO LIVE!
Rapid Cycle Test Implementation Date(s): ________________________
____________________________________________________________
____________________________________________________________
7
CHECK
CHECK THE RESULTS
 Gather data to Display outcome measures/data demonstrating baseline and post
evaluate
measurement, if appropriate. Provide new flow chart of processes, if
process and
appropriate. Put notes on results in this section.
effectiveness
of action
plans
/strategies.
 Analyze the
data to
determine if
the process
has improved.
If no
improvement,
identify the
opportunity or
process to be
improved.
 Identify and
evaluate
results of
measures to
determine if
the process
improved
(include cost
savings /
avoidance).
 Identify if
there are
other unmet
customer
needs that
need to be
revisited.
Action Plan/
Strategy Number
Measure
NOTES (about your results):
8
Data
Source
Responsible
person(s)
ACT
 Adopt the
action plans/
strategies.
 Identify areas
where
processes can
be
standardized
or reduce
variation.
 Identify any
lessons
learned.
 Identify
systemic
implications,
barriers or
changes that
may be
beyond the
scope of the
team.
 Identify
ongoing
measures/data
of the process
to sustain
improvement.
ACT
Describe the path forward to implement plan, for next rapid cycle PDCA,
or to sustain improvement:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
List lessons learned
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Communicate Results and CELEBRATE SUCCESS / STORYTELLING!
9
ACHIEVING COMPETENCY
TODAY (ACT): ISSUES IN
HEALTH CARE QUALITY,
COST, SYSTEMS, AND SAFETY
COURSE
10
COURSE SYLLABUS
Course Director
Lee Ann Riesenberg, PhD, RN
Director Medical Education Research and Outcomes
(302) 623-4488
TEAM FACILITATORS Loretta Consiglio-Ward, RN, MSN
Carol Kerrigan Moore, MS, RN, NP
Christine Chastain-Warheit, MLS, AHIP
Thea Eckman, MSN, RN-BC, CCRN
Teri Foy, MEd, RT
Carmen Pal, RN, BSN, PCCN
Leslie Konizer, MS, CPHQ
Dean A. Bennett, RPh
Susan Coffey Zern, MD
LaRay Fox, CNMT, MEd
COURSE FACULTY
Brian Aboff, MD, FACP
Sharon Anderson, RN, BSN, MS, FACHE
Michele Campbell, RN, MSM, CPHQ
Jerry Castellano, PharmD, CIP
Loretta Consiglio-Ward, RN, MSN
William Conway
Neil Jasani, MD
Omar Khan, MD, MHS
Robert Laskowski, MD, MBA
Linda Laskowski-Jones, RN, MS, ACNS-BC,
CCRN, CEN
Brian W. Little, MD, PhD
Donna Mahoney, BS, CPHQ
Carol Kerrigan Moore, RN,MS APN
Terri Lynn Palmer, MPA
Patty Resnik, RRT, MBA, CPUR
Lee Ann Riesenberg, PhD, RN
Glen Stryjewski, MD, MPH
Maureen Seckel, RN, MSN, APRN-BC
Course Administrative Support
Theresa Fields
11
COURSE MEETING DETAILS
Course Attendance:
Learners must arrive promptly at 4 PM and attend at least 10 of the 12 sessions to receive credit (no
exceptions). Successful completion of the ACT program and ability to engage in the required
teamwork requires consistent attendance. Recognizing that there are occasions that might require your
presence elsewhere, we have elected to accept a maximum of two class session absences. Anticipated
absences need to be communicated to course facilitators and team members prior to the class session.
In the event of up to two absences, it is expected that you will collaborate with members of your team
to ensure that you have received all materials distributed in class, and that your contribution to the
teamwork component is disseminated to your team. Any additional absences compromise both learner
objectives and teamwork in designing a performance improvement project plan. Therefore, a third
absence will require immediate withdrawal from the course. Absences and withdrawals from the ACT
course class sessions will be communicated to program directors for residents; to immediate
supervisors, managers, or directors for nurses and allied health participants; to the chief academic
officer for medical students. This is to ensure a shared knowledge and understanding of any barriers to
full participation in the course. Admission into the course will not be granted if it is determined that
you are not able to attend the first and last session of the course.
COURSE OVERALL GOALS



Increase learner’s competence in systems and practice improvement while stimulating interprofessional learning and collaboration.
Increase learner’s awareness of how national and local systems, rules, and regulations contribute to
systems-based issues in the practice environment.
Promote learner’s role as advocates for quality and safety in patient care.
COURSE OVERALL OBJECTIVES
By the completion of this course, learners will be able to:





Identify system problems that compromise the quality and safety of care.
Analyze system problems and the effect they have on patient care.
Synthesize findings from the research literature as it applies to the problem being investigated.
Utilize systematic methodology for practice-based improvement activities.
Develop an evidence-based, performance improvement project plan with preceptor support as part
of an inter-professional team.
12
COURSE SUMMARY AT A GLANCE
Week
1
Date/Location
Topic(s)
Quality, Safety,
and Performance
(Insert Date)
Improvement
Ammon Med. Educ.
Overview
Building, Back of
Auditorium
Between Session Work
PDCA, RCA,
High Reliability
2
(Insert Date)
CCHS Main
Hospital Conference
Room 1100
Pre-session Assignments: Readings, IHI Modules, & Other Assignments (to be completed prior to session)
Readings
Berwick DM. Escape fire: Lessons for the future of health care. The Commonwealth Fund. 2002.
Annual Operating Plan
IHI Lessons (Instructions to access the IHI Lessons are on pages 9-11)
 Patient Safety 101: Lesson 1—To Err is Human
 Quality Improvement 101: Lesson 3—The Institute of Medicine’s Aims for Improvement
Using what was learned during this session, identify 1-2 possible improvement ideas and write the ideas on the “ACT
Course Work Sheet # 1”
Readings
McKeon LM, Oswaks JD, Cunningham PD. Safeguarding patients: Complexity science, reliability organizations, and
implications for team training in healthcare. Clinical Nurse Specialist 2006;20(6):298-304.
Shortell SM, Singer SJ. Improving patient safety by taking systems seriously. JAMA 2008;299(4):445-447.
IHI Lessons
 Quality Improvement 101: Lesson 1— Errors can happen anywhere and to anyone
 Quality Improvement 102: Lesson 1— An overview of the model for improvement
 Quality Improvement 102: Lesson 2—Setting an aim
Between Session Work
Complete “ACT Course PDCA Worksheet # 2” for each of the team’s top 2-4 project ideas.
Teams and
IHI Lessons
(Insert Date)
 Patient Safety 103: Lesson 1—Why are teamwork and communication important
Ammon Med. Educ. Opportunity
3
Building, Back of Statement
 Leadership 101: Lesson 1—Taking the leadership stance
Auditorium
 Leadership 101: Lesson 2—The leadership stance is not a pose
Between Session Work
Complete “ACT Course PDCA Worksheet # 3” to middle of page 3
Measurement and IHI Lessons
Outcomes
 Quality Improvement 101: Lesson 4—How to get from here to there: Changing Systems
(Insert Date)
CCHS Main
 Quality Improvement 102: Lesson 3—Measuring
4
Hospital Conference Health Care
 Quality Improvement 103: Lesson 1—Measurement fundamentals
Economics: Part
Room 1100
1
Between Session Work
Finalize fishbone, start flowchart (if appropriate), continue with background research
13
Week
5
Date/Location
Topic(s)
Previous ACT
Team
Presentation
(Insert Date)
Ammon Med. Educ.
Building, Back of AND
Auditorium
IRB
Between Session Work
Change Theory
6
(Insert Date)
Ammon Med. Educ.
Building, Back of
Auditorium
Pre-session Assignments: Readings, IHI Modules, & Other Assignments (to be completed prior to session)
Readings
Gawande A. The checklist: If something so simple can transform intensive care, what else can it do? The New Yorker
December 10, 2007. Available at: http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande.
Accessed June 4, 2008.
Newhouse RP, Pettit JC, Poe S, Rocco L. The slippery slope: Differentiating between quality improvement and research.
JONA 2006;36(4):211-219
IHI Lessons
 Patient Safety 103: Lesson 4—Developing and executing effective plans
Complete “ACT Course PDCA Worksheet # 3” pages 4 & 5
Readings
VanHoy SN, Laskowski-Jones L. Early intervention for the pneumonia patient: An emergency department triage protocol.
Journal of Emergency Medicine 2006;32(2): 154-158. Additional readings may be assigned.
Weed J. Factory efficiency comes to the hospital. The New York Times July 11, 2010.
IHI Lessons
 Quality Improvement 102: Lesson 4—Developing change
 Quality Improvement 102: Lesson 5—Testing change
 Leadership 101: Lesson 3—Influence, persuasion, and leadership
Between Session Work
Plan meeting with key stakeholders
Workforce Issues Workforce Readings
The Adequacy of Pharmacist Supply: 2004 to 2030, Executive Summary
Cooper RA. New directions for nurse practitioners and physician assistants in the era of physician shortages. Acad Med
AND
2007;82:827-828.
Kirch DG. Vernon DJ. Confronting the complexity of the physician workforce equation. JAMA 2008;299(22):2680-2682.
(Insert Date)
Variations in
Ammon Med. Educ.
Care
Variations in Care
7
Building, Back of
Gawande A. The cost conundrum. The New Yorker June 1, 2009.
Auditorium
Davis K, Schoen C, Stremikis K. Mirror, mirror on the wall: How the performance of the U.S. health care system
compares internationally. Commonwealth Fund; June 2010.
Between Session Work
(Insert Date)
Ammon Med. Educ.
8
Building, Back of
Auditorium
Between Session Work
IHI Open School Module:
 Quality Improvement 101: Lesson 2—Health care today
Complete “ACT Course PDCA Worksheet # 3” pages 6 & 7
The Evolution of
the US Health
Care System
(History)
Continue work on Performance Improvement Project
Complete self and team member evaluations
14
Week
9
Date/Location
(Insert Date)
Ammon Med. Educ.
Building, Back of
Auditorium
Topic(s)
Health Care
Economics: Part
2
Pre-session Assignments: Readings, IHI Modules, & Other Assignments (to be completed prior to session)
Readings
Review the previously assigned article: Gawande A. The cost conundrum. The New Yorker June 1, 2009.
IHI Open School Module:

 Quality Improvement 105: Lesson 1—Overcoming resistance to change
Assignment: Each participant needs to bring their print-out from IHI Web Site of the Completed IHI modules.
Complete “ACT Course PDCA Worksheet # 3” pages 8 & 9
Between Session Work
(Insert Date)
Teamwork Time
Ammon Med. Educ.
10
Building, Back of
Auditorium
Between Session Work
Focus on finalizing implementation and post-data collection; Finish first draft of presentation for practice.
Practice
Presentations
(Insert Date)
Ammon Med. Educ.
11
Complete
Building, Back of
confidence
Auditorium
survey during
this session
12
No class, unless needed for weather make-up
Deadline for submitting final PowerPoint to your Facilitator
Formal
Performance
(Insert Date)
Improvement
13
Ammon Med. Educ.
Project Plan
Building, Auditorium
Presentations and
Reception
Note: All course requirements must be met prior to receiving Certificates of Completion.
15
ACT BACKGROUND INFORMATION
ACT is a graduate level interdisciplinary curriculum for systems-based practice and practicebased learning and improvement. The original ACT curriculum was developed by Harvard’s
Partnerships for Quality Education (PQE) (www.pqe.org), a national initiative of the Robert
Wood Johnson Foundation. It has been piloted over the past five years. Christiana Care Health
System is one of “six of the top performing ACT sites” and as a result we received an extension
grant from Robert Wood Johnson Foundation, which will be used to continue our work on:
curriculum development, evaluation and improvement, and outcomes research. This two-year
extension grant started in January 2007 and concluded December 2008.
The course brings learners together with faculty and health system leaders to learn about
systems and practice improvement. Learners work together in teams to identify a health care
system-based performance improvement opportunity, review best practices and relevant
literature, and design and present an evidence-based performance improvement project plan.
Past participants have had opportunities to present at the ACT national conference, and at
least one team has published their results. ACT learners include nursing staff, graduate nursing
students, advanced practice nurses, resident physicians, pharmacy residents, allied health
professionals, and others. All sessions will include team work time to develop the final project
plan.
The original course content was designed as a four-week intensive curriculum with online as
well as traditional face-to-face lectures/discussions. The current curriculum has been modified to
be completed in 12 weeks, allowing participants to increase retention; practice and improve
interdisciplinary team skills; and enhance opportunities to synthesize and apply the course
content.
The ACT model, which is preparing health care professionals to address the performance
challenges of the future, has three essential elements:
1. An intensive, action-based learning curriculum that teaches learners about systems and
practice improvement.
2. Interdisciplinary learning through collaboration on a performance improvement project.
3. Connecting the learners with the organization’s senior quality leadership.
16
Institute for Healthcare Improvement (IHI) Open School Modules
What is the IHI Open School?
The IHI Open School for Health Professions was developed to advance quality improvement and
patient safety competencies in the next generation of health professionals worldwide. It is an
important goal, one not currently fulfilled by the curriculum at most health professions schools.
The IHI Open School aims to fill this gap.
Online Courses
There are three free online modules: Quality Improvement, Patient Safety, and Leadership. Each
module contains courses (e.g., 101, 102, & 103). Each course has 3-5 lessons (about 15 minutes
each). You may stop at any time and you may start back at that point. The software tracks your
progress. There are pre-tests and post-tests for each lesson. You must achieve a 75% on the
post-test to successfully complete the lesson.
Basic Certification
Basic certification is designed to provide a solid foundation in quality improvement, patient
safety, and patient-centered care. Completion of all modules is required to obtain IHI
certification. IHI will track completion and provide credit for all modules completed.
IHI Lessons for ACT Course
During the ACT course you will be completing 18 of the lessons. (Reminder: Completion of
these 18 lessons will not complete the IHI certification requirements).
Step-by-Step Instructions for IHI Logon and Getting Started
You will be required to register with IHI (free) and register to take the courses. We suggest that
you use the same login information for the IHI lessons as your membership login so that it is
easier to remember.) Access web page (http://www.ihi.org/ihi) to become a member.
How to Start Taking Courses
Welcome to the IHI Open School for Health Professions online courses! This is a tutorial to help
you get started. The whole setup process should take just a couple of minutes.
17
COURSE FACILITATOR TRAINING PROGRAM
In 2008/09, we developed an intensive experiential facilitator training program that has led to
each team having a trained, skilled facilitator. The training involves facilitator, team, and quality
content instruction; co-facilitation with an experienced facilitator for one course; post session
debriefs; reading two textbooks (one on QI content1 and the other on facilitator skills2); and
every other week 90-minute meetings to discuss readings and application to course teams. In
addition, these efforts resulted in the development of a Facilitator Guide, with resources and
helpful tools for the facilitators.
FACILITATOR TEXTBOOKS
1. Langley GJ, Moen RD, Nolan KM, Nolan TW, Norman CL, Provost LP. The
Improvement Guide: A Practical Approach to Enhancing Organizational Performance.
(2nd Ed.). San Francisco: Jossey-Bass, 2009.
2. Schwarz R, Davidson A, Carlson P, McKinney S, and Contributors. The Skilled
Facilitator Fieldbook: Tips, Tools, and Tested Methods for Consultants, Facilitators,
Managers, Trainers, and Coaches. San Francisco: Jossey-Bass, 2005.
18
DECISION TOOLS FOR
PERFORMANCE IMPROVEMENT
19
SIX DECISION M AKING OPTIONS
Option
Description
Spontaneous
Agreement
Solution is favored by everyone,
agreement seems to happen
automatically
Happens occasionally, often with
simple issues
Decision that the group decides to
refer to one person to make on behalf
of the group
 Fast
 Easy
 Unites group
 Too fast
 Lacks
discussion
 When full discussion
isn’t critical
 Trivial issues
 Fast
 Clear
accountability
 When one person is the
expert
 Individual willing to take
sole responsibility
Compromise
Process of negotiation-when there are
several distinct options and members
are strongly polarized, a middle
position is then created that
incorporates ideas from both sides
 Generates
discussion
 Creates a
solution
Multi-voting
Priority setting tool when group has
long set of options, rank ordering
based on set criteria




Majority
Voting
Choosing the option that is favored
by show of hand or ballot
 Fast
 High quality with
dialogue
 Clear outcome
Consensus
Building
Involves everyone clearly
understanding the problem to be
decided, analyzing facts, and jointly
developing solutions
Characterized by listening, healthy
debate, testing of options
 Collaborative
 Unites group
 High
involvement
 Systematic
 Fact driven
 Lack of group
input
 Can divide
group
 Low buy-in
 No synergy
 Negotiating
process tends to
be adversarialwin/lose
 Divides the
group
 Limited
discussion
 Influenced
choices if
voting is done
openly
 Real priorities
may not surface
 May be too fast
 Low in quality
if people vote
based on their
feelings
 Show of hands
may pressure
people to
conform
 Takes time
 Requires data
and member
skills
One Person
Decides
Pros
Systematic
Objective
Democratic
Participative
Cons
Uses
 When two opposing
solutions are proposed
and consensus is
improbable
 To sort or prioritize a
long list of options
 When decision needs to
be made quickly
 When there are clear
options
 When consensus
attempted but couldn’t be
reached
 If division of group is
okay
 Important issues
 When total buy-in
matters
Source: Bens I. Facilitation at a Glance! The Association of Quality and Participation (ACP)/Goal/QPC; 1999.
20
RISK REDUCTION STRATEGIES: RECOMMENDED HIERARCHY OF ACTIONS
Risk reduction strategies are interventions that will treat (fix) the identified vulnerability in the system and prevent a recurrence and/or
protect the patient from harm. Strong and well-crafted actions have a clear link to the vulnerabilities and are readily understood. The
table below presents some categories and types of actions that might be considered. Stronger actions are viewed as those that are more
likely to be successful in accomplishing the desired changes, rendering greater utility for the effort expended. Note: you may need
multiple actions (stronger, intermediate or weaker) to address a single root cause/contributing factor.
Stronger actions
Recommended hierarchy of actions:
Intermediate actions

Physical plant changes (room, work
area layout, people flow, tools)


New device with usability testing before 
purchasing

Engineering control or interlock
(forcing functions)

Weaker actions
Increase in staffing/decrease in
workload

Double checks

Warnings and labels
Software enhancements or
modifications

New procedure, memorandum or policy

Eliminate/reduce distractions

Training

Checklist/cognitive aid

Additional study/analysis
Simplify the process and remove
unnecessary steps

Eliminate look and sound alikes

Standardize on equipment or process or
care maps

Read back


Tangible involvement and action by
leadership in support of patient safety
Enhanced documentation and
communication

Redundancy
Adapted from: United States Department of Veterans Affairs: NCPS Root Cause Analysis Tools, Actions and Outcomes. Available at:
http://www.patientsafety.gov/CogAids/RCA/index.html#page=page-14. Accessed December 3, 2010.
21
Field
Risk Reduction Strategy
Stronger Actions




Physical plant changes/redesign
New device with usability testing
Engineering control or interlock
Simplify/standardize
 Tangible involvement and action by
leadership
Intermediate Actions


Increase in staffing/decrease in workload
Software enhancements or modifications





Eliminate/reduce distractions
Checklist/cognitive aid
Eliminate look and sound alikes
Read back
Enhanced documentation and
communication
Redundancy

Weaker Actions
Dictionary
An action designed to reduce the likelihood of an adverse event. The action has a clear link to the root
cause/contributing factor. Actions can be thought of as stronger or weaker based upon their likelihood of
reducing vulnerability.
A Stronger Action is more likely to eliminate or greatly reduce the likelihood of an event; uses physical plant
or systemic fixes; applies human factors principles.
Redesign of room, work area layout, people flow, tool location
Having end-users test new device to identify hidden vulnerabilities associated with device before they occur.
Forcing functions
Simplification of the process/ removal of unnecessary steps. Standardization of protocol/process/equipment
Action by leadership in support of patient safety
An Intermediate Action is likely to control the root cause or vulnerability; applies human factors principles,
but also relies upon individual action, e.g. checklist or cognitive aid.
Adding more staff/ decreasing or realigning workload
Automatic calculations, reminders, decision making assistance, safety mechanisms
Elimination or reduction of the things that draw the mind away from the task at hand.
Reminders. Provide access to knowledge in the world instead of requiring memorization.
Removing or separating items with similarities, i.e., similar labels, packaging, names, colors, caps.
Verbal verification and confirmation of communicated information by writing down and reading back order
Example: “Do not use unacceptable abbreviations,” Structured communication tools
Use of redundancy to heighten awareness of safe practice/behavior
Weaker Actions provide staff with additional information or new procedures to follow, but not a “hard fix”
that can eliminate the vulnerability. The action relies on policies, procedures, and additional training.


Double checks
Warnings and labels
Independent check of accuracy by a second staff member, redundancy, inspections
Verbal and/or visual information/reminders about safety



New procedure, memorandum or policy
Training
Additional study/analysis
Writing new policy, procedure and/or memo
Orientation/Education
Further investigation
Adapted from: United States Department of Veterans Affairs: NCPS Root Cause Analysis Tools, Actions and Outcomes. Available at:
http://www.patientsafety.gov/CogAids/RCA/index.html#page=page-14. Accessed December 3, 2010.
22
EFFORT/BENEFIT M ATRIX
Benefit
High
Low
High Priority
Solution
Further
Consideration
Needed
Further
Consideration
Needed
Low
Priority/Rejected
Solution
Effort
High
Adapted from http://www.asq.org/img/qp/qp_200702_15_figure1.gif
23
DIAGNOSTIC TOOLS
24
What Is A Fishbone Diagram?
Dr. Kaoru Ishikawa, a Japanese quality control statistician, invented the Fishbone diagram.
Therefore, it may be referred to as the Ishikawa diagram. The Fishbone diagram is an analysis
tool that provides a systematic way of looking at effects and the causes that create or contribute
to those effects. Because of the function of the Fishbone diagram, it may be referred to as a
cause-and-effect diagram. The design of the diagram looks much like the skeleton of a fish.
Therefore, it is often referred to as the Fishbone diagram.
Whatever name you choose, remember that the value of the Fishbone diagram is to assist teams
in categorizing the many potential causes of problems or issues in an orderly way and in
identifying root causes.
When should a Fishbone diagram be used?
Does the team . . .




Need to study a problem/issue to determine the root cause?
Want to study all the possible reasons why a process is beginning to have difficulties,
problems, or breakdowns?
Need to identify areas for data collection?
Want to study why a process is not performing properly or producing the desired results?
How is a Fishbone diagram constructed?
Basic Steps:
1. Draw the fishbone diagram....
2. List the problem/issue to be studied in the “head of the fish.”
3. Label each “bone” of the “fish.” The major categories typically utilized are:



The 4 M’s:
o Methods, Machines, Materials, Manpower
The 4 P’s:
o Place, Procedure, People, Policies
The 4 S’s:
o Surroundings, Suppliers, Systems, Skills
Note: You may use one of the four categories suggested, combine them in any fashion or make
up your own. The categories are to help you organize your ideas.
4. Use an idea-generating technique (e.g., brainstorming) to identify the factors within each
category that may be affecting the problem/issue and/or effect being studied. The team
should ask... “What are the machine issues affecting/causing...”
5. Repeat this procedure with each factor under the category to produce sub-factors. Continue
asking, “Why is this happening?” and put additional segments each factor and subsequently
under each sub-factor.
6. Continue until you no longer get useful information as you ask, “Why is that happening?”
25
7. Analyze the results of the Fishbone after team members agree that an adequate amount of
detail has been provided under each major category. Do this by looking for those items that
appear in more than one category. These become the most likely causes.
8. For those items identified as the most likely causes, the team should reach consensus on
listing those items in priority order with the first item being the most probable cause.
26
(Insert Opportunity Statement)
Insert
Problem
27
SAMPLE FISHBONE DIAGRAM
Opportunity: Increase near-miss reporting
(Note: to make this a complete opportunity statement you need to add “by how much,” “by
when,” and “where—in what unit or area will this change occur?”)
Causes
Effect
People
Fear of being alienated if others
find out that you reported
Process
Extra work when no harm was
done/no harm, no foul
Online reporting lacks
confidentiality assurance
Reporting
System
Don’t know about
reporting system
Don’t believe it
is confidential
No time mentality
Lack clarity on procedures
after reporting
Additional workload for
staff/time consuming
Don’t know who will
get the report
Lack of
Knowledge
Attitudes/
Beliefs
Online system
not very clear
Don’t know how to
report (phone & online)
Perception that near
misses are not important
Fear of punitive
actions/punishment
Privacy: PC/Phone
Availability
Manpower
Don’t know what a near miss
is or that it should be reported
Almost No
Near-Miss
Reporting
Materials
Causes
28
FLOW CHART INSTRUCTIONS
Flowchart
Also called: process flowchart, process flow diagram
Description
A flowchart is a picture of the separate steps of a process in sequential order.
Elements that may be included are: sequence of actions, materials or services entering or leaving
the process (inputs and outputs), decisions that must be made, people who become involved,
time involved at each step and/or process measurements.
The process described can be anything: a health care process, an administrative or service
process, a project plan. This is a generic tool that can be adapted for a wide variety of purposes.
When to Use a Flowchart?
 To develop understanding of how a process is done
 To study a process for improvement
 To communicate to others how a process is done
 To improve communication between people involved with the same process
 To document a process
 To plan a project
 The team needs to develop an understanding of how a process works in order to improve
it. Why?
o All work is part of a process
o Most problems are related to processes rather than people
Flowchart Basic Procedure
 Materials needed: sticky notes or cards, a large piece of flipchart paper, and marking
pens.
 Define the process to be diagrammed: Write its title at the top of the work surface.
 Identify beginning and ending: Discuss and decide on the boundaries of your process.
At the outset, you must decided where or when the process starts and where or when it
ends. Discuss and decide on the level of detail to be included in the diagram.
 Brainstorm the activities that take place: Write each on a sticky note. Sequence is not
important at this point, although thinking in sequence may help people remember all the
steps.
 Arrange the activities in proper sequence: When all activities are included and
everyone agrees that the sequence is correct, draw arrows to show the flow of the
process.
 Review the flowchart: Review the flowchart with others involved in the process
(workers, supervisors, suppliers, customers) to see if they agree that the process is drawn
accurately.
29
Flowchart Considerations
 Don’t worry too much about drawing the flowchart the “right way.” The right way is the
way that helps those involved understand the process.
 Identify and involve in the flowcharting process all key people involved with the process.
This includes those who do the work in the process: physicians, resident physicians,
nurses, pharmacists, other health care staff, patients, customers, suppliers, and
supervisors. Involve them in the actual flowcharting sessions by interviewing them before
the sessions and/or by showing them the developing flowchart between work sessions
and obtain their feedback.
 Do not assign a “technical expert” to draw the flowchart. People who actually perform
the process should create the flowchart.
Adapted from Tague NR. The Quality Toolbox, (2nd ed), ASQ Quality Press; 2004, 255-257.
Analyze the flowchart looking for:
 What is it that is flowing along – information? documents? people?
 Unnecessary complexity
 Difficulty in handoffs
 Delays
 Redundancy
 Unnecessary or non-value added tasks
 Opportunities for error
30
Commonly Used Symbols in Detailed Flowcharts
One step in the process; the step is written inside the box. Usually,
only one arrow goes out of the box.
Direction of flow from one step or decision to another.
Decision based on a question. The question is written in the
diamond. More than one arrow goes out of the diamond, each one
showing the direction the process takes for a given answer to the
question. (Often the answers are “ yes” and “ no.”)
Delay or wait
Unclear or unknown steps
Link to another page or another flowchart. The same symbol on
the other page indicates that the flow continues there.
Input or output
Document
Alternate symbols for start and end points
Flowchart Template:
http://www.asq.org/sixsigma/2009/04/flow-chart-template.xls
31
SAMPLE FLOW CHARTS
Simple Example
Patient asks about Advance
Directive (AD) in the
Emergency Department
Does
patient want
an AD?
No
Yes
Pastoral Care assists
patient in completing AD
Nurse puts AD on
patient’s chart
Care plan
developed
32
More Complex Example
Flow Chart: Reporting Critical Test Results for Discharged Patients
DRAFT_4 Saturday, June 20, 2009
Specimen collected
and sent to lab
Information about
patient & sample
entered into Lab
computer system
Test completed &
resulted
Results are reported in
appropriate clinical
system for physician
retrieval
No
Provider is
reached within
15 minutes?
Is result
critical?
Yes
No
Determine patient
location
Yes
2nd attempt to
contact provider
with result
Provider takes
result?
Yes
Provider to follow up
on lab/test sequellae
Yes
Inpatient
Results are called to
inpatient units in which
patient is located
Emergency
department
Discharged/
Outpatient
Results are called to ED
clerk; followed up by ED
resident on Admin rotation,
or DFES
Identify provider to
whom result will be
called
(Ordering physician
or designee)
Make attempt to
contact provider
with result
Provider is
reached within
45 minutes?
No
No
Follow “Chain of
Command” 1) Med Director of Lab
2) Chair of Pathology
3) on-call pathologist
Contact Physician
Communicator, X####, to
initiate process of
identifying patient’s PCP
and contacting PCP if
known
Monitor process of
reaching provider,
report feedback to Vice
Chairman of the Dept
of Medicine
33
ESTIMATE THE COST OF IMPLEMENTING YOUR PLAN
The Cost Estimate: In order to make an effective proposal for any system improvement, you must
have a good sense of implementation costs. In this exercise, your task will be to identify the
categories of costs and savings that your plan would generate (e.g., increased data analysis costs, cost
of educating staff, savings in number of staff needed, savings from reducing use).
The basic architecture of a financial analysis is relatively straightforward. In any project, there are
essentially two types of costs: (1) start-up (development and implementation) costs and (2) operating
costs (ongoing costs). In a typical project, the start-up costs are “borrowed” and paid back from the
savings generated by the project over time. Every project must, in some way, pay back start-up costs
and initial operating losses. Even if a specific project is justified by improvements in quality or in
service, its costs must be covered by a surplus from somewhere in the delivery system. You will
need to develop accurate, detailed estimates of start-up and operating costs, any savings or new
income that would be generated, and the net effect on the bottom line.
Step One is to identify the start-up costs that would be associated with your plan. Would it require
purchasing new equipment? Would it require staff time to do the planning needed for
implementation? Would staff training be needed?
Step Two is to identify the types of operating costs that would be associated with your proposed
change. Think about any resources that would be needed and make a list. Don’t worry about their
actual cost. Common expenses are personnel, space, equipment, and purchased services.
Step Three is to list the types of savings you think would result from implementing your idea. These
commonly include efficiencies in staff work and savings in staff time, reductions in purchased
supplies or services, and better use of space and equipment.
Step Four is to think about whether your intervention would create any billable services that might
generate additional income for the hospital. For example, would it generate, or decrease visits,
testing, referrals, or hospitalizations? These might be additional revenues if your hospital receives
payment for such services; conversely income might decrease if you reduce revenue-producing
services.
In Step Five, think about the nonfinancial benefits of your proposed plan (e.g., improvements in
quality, patient service or satisfaction, or enhancements in staff satisfaction). Remember, although
each of these benefits may have a long-term yield in financial performance, they do not usually
create short-term savings. That said, it may still be worth spending money on them. It will be your
job to make the case.
At this point, take a stab at categorizing your project. Do you think the project will be:
 An ongoing financial expense (but worth it in terms of gaining desired outcomes)?
 Cost neutral? or
 A moneymaker for the hospital or group (increased performance may streamline processes, make
them more efficient and effective, and still deliver improved care for your selected patient)?
Adapted from Module 3, Activity 4, “Estimate the cost of implementing your QIP and get initial
local administrative feedback.” From the original ACT curriculum developed by Harvard’s
Partnerships for Quality Education (PQE) (www.pqe.org).
34
MEASUREMENT RESOURCES
35
DATA PRESENTATION
Appropriate data presentation can help in analyzing changes in measures, monitoring progress toward goals and sharing
information with others. Graphic displays may provide insight into trends, comparisons, progress and controls that are
not evident with numbers displayed in a table.
It is important to select the correct type of graph for the measure you are monitoring, and to know your audience.
Often, many team members will want to see the numbers that make up a graph in a table format along with the graph.
Pie Chart
Bar
Graphs
Displays values for measures for
each category and/or time period.
Useful for showing the actual value,
but may be difficult for monitoring
trends or comparing across
categories.
Often used as the data source for
creating graphs in Excel.
Pie Charts are circle graphs that
display 100% of the data. They are
useful in showing the relationship
of various parts to a whole. They
show the percentage of contribution
of each group to the whole. A
convenient way of representing
percentages or relative frequencies.
Bar Graphs are columns of data that
compare the frequency of different
groups of data. They compare
quantity of data between and among
categories and against a measurable
scale (y axis). Bar Graphs are useful
when displaying many categories
and multiple figures.
The shape shows the nature of the
distribution of the data. The central
tendency (average) and the
variability are easily seen
5.6
5.5
5.2
5.0
4.9
Hospice
Other
2%
3%
Expired
Rehab 2%
2%
SNF
10%
Home
Health
20%
Home
61%
Acute Care Length of Stay
6
5.61
5.5
5.59
5.61
5.51
5.36
5.34
5.18
5.16
4.95 4.99
5
5.16
4.98
4.95 4.98
4.92
4.5
Hospital A
FY 2004
FY 2005
Hospital B
FY 2006
System
FY 2007
Length of Stay Distribution
10000
# discharges
A Histogram is a bar graph that is
used to show the distribution of
data points related to some
measurable characteristics such as
time, weight, size, or temperature.
System
5.6
5.4
5.2
5.0
5.0
Discharge Disposition
FY 2003
Histogram
Hospital B
Hospital A
5.6
5.3
5.2
4.9
5.0
FY 2003
FY 2004
FY 2005
FY 2006
FY 2007
ALOS (days)
Table
8000
6000
4000
2000
0
1
2
3
4
5
6
7
8
LOS (days)
9
10 11- 16- >20
15 20
36
Run
Charts
A Pareto Diagram helps you
quickly see the order or ranking
among many different factors. The
bars are arranged in descending
order of height from left to right.
This means the factors (causes)
represented by the tall bars on the
left are higher contributors to the
problem, thus prioritizing
opportunities.
80%
600
60%
400
40%
200
20%
0%
# Delays
Delay in
Transfer
Other
0
% of Delays
100%
800
# Delay Days
1000
Placement:
SNF
Placement:
Other
Physician
Delay
Placement:
Rehab
Pt/Family
Related
Execution
of D/C
Placement:
Financial
The name of the diagram derives
from the Pareto Principle: 80% of
the problems are due to 20% of the
factors (vital few).
Run Charts display a sequence of
data points over a specified time
period. They identify meaningful
trends or shifts in the average, and
provide a visual perspective of a
process over time.
Discharge Delays
% of Delays
Average Length of Stay
6.0
5.63
5.5
ALOS (days)
Pareto
5.37
5.17
5.0
5.37
5.34
5.16
5.09
5.02
4.93 4.97
5.26 5.28
5.20
5.22
5.11
5.01
4.89
4.96
4.92 4.94
4.84
4.73
4.64
5.02
4.93 5.03
5.09
5.11
5.11
5.05
4.99
5.03
5.03
5.07
5.01
4.98
4.89
4.85
4.81
4.90
4.85
4.80
4.5
Mar-04
Apr-04
May-04
Jun-04
Jul-04
Aug-04
Sep-04
Oct-04
Nov-04
Dec-04
Jan-05
Feb-05
Mar-05
Apr-05
May-05
Jun-05
Jul-05
Aug-05
Sep-05
Oct-05
Nov-05
Dec-05
Jan-06
Feb-06
Mar-06
Apr-06
May-06
Jun-06
Jul-06
Aug-06
Sep-06
Oct-06
Nov-06
Dec-06
Jan-07
Feb-07
Mar-07
Apr-07
May-07
Jun-07
4.0
Discharge Month
Acute Care Average Length of Stay
6.0
5.5
UCL
5.0
Mean
4.5
LCL
Scatter Diagrams require a large
number of data points. Scatter
Diagrams often indicate what type
of relationship may be occurring
between two variables. They
indicate possible cause & effect
relationships.
Oct-06
Dec-06
Aug-06
Jun-06
Apr-06
Feb-06
Oct-05
Dec-05
Jun-05
Aug-05
Apr-05
Feb-05
Oct-04
Dec-04
Jun-04
Aug-04
Apr-04
Patient Severity & Length of Stay
35
30
LOS (days)
Scatter
Diagram
Feb-04
4.0
Dec-03
Control Charts are a specialized
form of run charts on which
statistically determined upper and
lower control limit lines are added.
The purpose of a control chart is to
help you better focus resources on
identifying and eliminating special
(assignable) causes (see attached
definitions).
Oct-03
Control
Chart
25
20
15
10
5
0
0
5
10
15
Severity (CMI)
20
25
37
CONTROL CHARTS
Control charts provide a dynamic display that can assist in depicting variation over time. Run
charts allow users to monitor trends, but may be misleading in that they do not support
identification of “common-cause” versus “special cause” variation:
Common Cause (Random)
Common cause variation is inherent in every process. It is random and due to natural, irregular,
or ordinary causes. This type of variation produces processes that are “in control” or stable, and
allows team members to make predictions about a process.
 A process that is in control will not change unless the process is changed
 Actions should not be taken to address changes or “blips” in the data that are part of the
natural rhythm of process
Special Cause (Assignable)
Special cause variation is due to irregular or unnatural causes that are not inherent in the process,
such as implementation of an improvement. If special causes are present, the process will be
“out of control” and unpredictable.
 Special causes indicate that something has occurred to change the process
 Action should be taken to address the issue:
o If the special cause is desirable, verify its cause (Did an action plan lead to this
result?) and identify ways to maintain the change
o If the special cause is undesirable, ascertain its cause (What was different?) and
identify ways to keep the cause from recurring.
Control Chart Elements
Acute Care Average Length of Stay
6.0
UCL
A
B
5.5
C
C
5.0
Mean
B
A
LCL
4.5
Oct-06
Dec-06
Aug-06
Jun-06
Apr-06
Feb-06
Dec-05
Oct-05
Jun-05
Aug-05
Apr-05
Feb-05
Oct-04
Dec-04
Jun-04
Aug-04
Apr-04
Feb-04
Oct-03
Dec-03
4.0
The center line of a control chart is the Mean (average). The Upper Control Limit (UCL) and
Lower Control Limit (LCL) are used to monitor process variation and identify common or
special causes. The UCL & LCL are generally set at 3 standard deviations (3 sigmas) above and
below the mean. Thus, assuming a normal distribution, we can expect 99.73% of the data to fall
within the limits. Tighter limits indicate less variation in a process.
38
Control charts are divided into zones (A, B, C above), with each zone equal to 1 sigma or
standard deviation. The following rules may be applied to identify special cause variation:
1. Each side of the center line (Mean):
A. 1 point outside the 3-sigma limit
B. 2 of 3 successive points in Zone A or beyond
C. 4 of 5 successive points in Zone B or beyond
D. 8 successive points in Zone C or beyond (on the same side of the center line)
2. Based on the chart as a whole:
A. 7 successive points steadily increasing or decreasing (if you have 21 or more data
points); 6 points if there are less than 21 data points.
B. 14 successive points alternating up & down in a sawtooth pattern
C. 15 consecutive points in Zone C.
In the example above, special cause variation is identified by the green circle (per rule 1D). At
this point, control limits may be re-set. In our example, the tighter control limits indicate less
variation in the process, and it is now in control at the lower mean.
Acute Care Average Length of Stay
6.0
A
B
5.5
UCL
C
C
Mean
5.0
B
A
LCL
4.5
Dec-06
Oct-06
Aug-06
Jun-06
Apr-06
Feb-06
Oct-05
Dec-05
Jun-05
Aug-05
Apr-05
Feb-05
Dec-04
Oct-04
Aug-04
Jun-04
Apr-04
Feb-04
Oct-03
Dec-03
4.0
Handout created by Donna Mahoney, BS, CPHQ, Director, Data Acquisition & Measurement
Christiana Care Health System
May 2008
39
Performance Improvement Checklist / Action Steps
Questions to Answer for Project Goals
1. What is the goal or end result of your project or planned improvement?
 Describe a clear goal. It should not be too detailed, but should be a broad overview.
2. Did you quantify the goal?
 Assign actual numbers to your goal (i.e., educate 50 nurses, save $10,000, vaccinate
100 people). Specifically quantifying a goal, or element of a goal, improves clarity
and leads to increased precision.
3. Did you translate comparative terms into actual goals?
 Comparative terms – increase, decrease, more, fewer – have no meaning on their own
(e.g., decrease length of stay, improve patient satisfaction). Instead, describe &
quantify the specific result you want (e.g. decrease length of stay by 0.5 days to create
additional capacity of 20 beds).
4. Are you creating results or solving problems?
 Problem-solving is taking action to make something go away, and is difficult to
sustain. Creating results is taking action to fully meet your goals.
 Describe what you want to create or build instead of what you want to eliminate
“Implement mechanism to assure vaccination” rather than “Eliminate missed
vaccinations through nurse education.”
5. Do your goals describe an actual result or a process for achieving that result?
 Process describes the “how”; end results describe the “what.” “What will the project
accomplish?” versus “How will it be accomplished?”
 Whenever possible, the goal (end result) should describe outcomes rather than
process, such as “Reduce unplanned readmissions by 10% through vaccination.”
6. Are your goals specific or vague?
 Specific goals allow for improved organization around the goals. If goals cannot be
quantified, they should be stated as specifically as possible.
40
Checklist for Baseline
 Did you use your goals as a reference point for describing the baseline (i.e., Length of
stay is currently 5.0 days.)?
 Have you described the relevant picture?
 Have you included the whole picture?
 Avoid assumptions, exaggerations & editorials – be objective

Example: “30% of flu vaccines were given on day of discharge” rather than
“Vaccinations are always missed on day of discharge”
 Did you state what reality is, or how it got to be that way?
 Have you included all the facts you need?

Consider patient demographics, satisfaction, and other relevant information.
Checklist for Action Steps
 Do you have action steps for each goal?
 If you took these steps, will your goal be reached?

If your answer is No, identify additional action steps until you can answer “Yes.”
 Are the action steps accurate, brief, and concise?
 Does every action step have a due date?

Setting reasonable due dates for each action step establishes a project time frame and
an increased sense of reality.
 Is there one person assigned to each action step?

One person should be responsible for (and held accountable for) each action step.
This will help to ensure that the action is completed, and divides the labor among the
team members.
Adapted from Fritz R. The Path of Least Resistance for Managers: Designing Organizations to
Succeed. San Francisco, CA: Berrett-Koehler Publishers; 1999.
Handout created by Donna Mahoney, BS, CPHQ, Director, Data Acquisition & Measurement
Christiana Care Health System
September 2007
41
CHECK SHEET
Also called: defect concentration diagram
Description
A check sheet is a structured, prepared form for collecting and analyzing data. This is a generic
tool that can be adapted for a wide variety of purposes.
When to Use a Check Sheet
 When data can be observed and collected repeatedly by the same person or at the same
location.
 When collecting data on the frequency or patterns of events, problems, defects, defect
location, defect causes, etc.
 When collecting data from a production process.
Check Sheet Procedure
1. Decide what event or problem will be observed. Develop operational definitions.
2. Decide when data will be collected and for how long.
3. Design the form. Set it up so that data can be recorded simply by making check marks or Xs
or similar symbols and so that data do not have to be recopied for analysis.
4. Label all spaces on the form.
5. Test the check sheet for a short trial period to be sure it collects the appropriate data and is
easy to use.
6. Each time the targeted event or problem occurs, record data on the check sheet.
Check Sheet Example
The figure below shows a check sheet used to collect data on telephone interruptions. The tick
marks were added as data was collected over several weeks.
Excerpted from Tague NR. The Quality Toolbox, (2nd ed). ASQ Quality Press; 2004, pages 141142.
Important Note: When gathering performance improvement data, do not include patient
identifiers in your database.
Create a Check Sheet
This tool also creates a histogram, bar chart, and Pareto chart using the check-sheet data.
Start using the check sheet tool (Excel-Windows, 85 KB).
42
PARETO CHART
Also called: Pareto diagram, Pareto analysis
Variations: weighted Pareto chart, comparative Pareto charts
Description
A Pareto chart is a bar graph. The lengths of the bars represent frequency or cost (time or
money), and are arranged with longest bars on the left and the shortest to the right. In this way
the chart visually depicts which situations are more significant.
When to Use a Pareto Chart
When analyzing data about the frequency of problems or causes in a process.
 When there are many problems or causes and you want to focus on the most significant.
 When analyzing broad causes by looking at their specific components.
 When communicating with others about your data.
Pareto Chart Procedure
1. Decide what categories you will use to group items.
2. Decide what measurement is appropriate. Common measurements are frequency, quantity,
cost and time.
3. Decide what period of time the Pareto chart will cover: One work cycle? One full day? A
week?
4. Collect the data, recording the category each time. (Or assemble data that already exist.)
5. Subtotal the measurements for each category.
6. Determine the appropriate scale for the measurements you have collected. The maximum
value will be the largest subtotal from step 5. (If you will do optional steps 8 and 9 below, the
maximum value will be the sum of all subtotals from step 5.) Mark the scale on the left side
of the chart.
7. Construct and label bars for each category. Place the tallest at the far left, then the next tallest
to its right and so on. If there are many categories with small measurements, they can be
grouped as “other.”
Steps 8 and 9 are optional but are useful for analysis and communication.
8. Calculate the percentage for each category: the subtotal for that category divided by the total
for all categories. Draw a right vertical axis and label it with percentages. Be sure the two
scales match: For example, the left measurement that corresponds to one-half should be
exactly opposite 50% on the right scale.
9. Calculate and draw cumulative sums: Add the subtotals for the first and second categories,
and place a dot above the second bar indicating that sum. To that sum add the subtotal for the
third category, and place a dot above the third bar for that new sum. Continue the process for
all the bars. Connect the dots, starting at the top of the first bar. The last dot should reach 100
percent on the right scale.
43
Pareto Chart Examples
Example #1 shows how many customer complaints were received in each of five categories.
Example #2 takes the largest category, “documents,” from Example #1, breaks it down into six
categories of document-related complaints, and shows cumulative values.
If all complaints cause equal distress to the customer, working on eliminating document-related
complaints would have the most impact, and of those, working on quality certificates should be
most fruitful.
Example #1
Example #2
Excerpted from Tague NR. The Quality Toolbox, (2nd ed). ASQ Quality Press; 2004, pages 376378.
Create a Pareto Chart
Analyze the occurrences of up to 10 defects. Start by entering the defects on the check sheet.
This tool creates a Pareto chart using the data you enter. Start using the Pareto chart tool
(Excel-Windows, 85 KB).
44
SCIENTIFIC WRITING AND
PUBLICATION RESOURCES
45
SQUIRE GUIDELINES
The SQUIRE guidelines provide a checklist designed to guide authors of health care
improvement studies in writing more useful and consistent reports of their studies.
•
•
•
SQUIRE Guidelines
(Standards for QUality Improvement Reporting Excellence)
Final revision – 4-29-08
These guidelines provide a framework for reporting formal, planned studies designed to assess the nature and
effectiveness of interventions to improve the quality and safety of care.
It may not be possible to include information about every numbered guideline item in reports of original formal
studies, but authors should at least consider every item in writing their reports.
Although each major section (i.e., Introduction, Methods, Results, and Discussion) of a published original study
generally contains some information about the numbered items within that section, information about items
from one section (for example, the Introduction) is often also needed in other sections (for example, the
Discussion).
Text section; Item
number and name
Title and Abstract
1. Title
2. Abstract
Introduction
3. Background
Knowledge
4. Local problem
5. Intended
Improvement
6. Study question
Methods
7. Ethical issues
8. Setting
9. Planning the
intervention
Section or Item description
Did you provide clear and accurate information for finding, indexing, and scanning
your paper?
a. Indicates the article concerns the improvement of quality (broadly defined to
include the safety, effectiveness, patient-centeredness, timeliness, efficiency,
and equity of care)
b. States the specific aim of the intervention
c. Specifies the study method used (for example, “A qualitative study,” or “A
randomized cluster trial”)
Summarizes precisely all key information from various sections of the text using
the abstract format of the intended publication
Why did you start?
Provides a brief, non-selective summary of current knowledge of the care problem
being addressed, and characteristics of organizations in which it occurs
Describes the nature and severity of the specific local problem or system
dysfunction that was addressed
a. Describes the specific aim (changes/improvements in care processes and
patient outcomes) of the proposed intervention
b. Specifies who (champions, supporters) and what (events, observations)
triggered the decision to make changes, and why now (timing)
States precisely the primary improvement-related question and any
secondary questions that the study of the intervention was designed to
answer
What did you do?
Describes ethical aspects of implementing and studying the improvement, such as
privacy concerns, protection of participants’ physical well-being, and potential
author conflicts of interest, and how ethical concerns were addressed
Specifies how elements of the local care environment considered most likely to
influence change/improvement in the involved site or sites were identified and
characterized
a. Describes the intervention and its component parts in sufficient detail that
others could reproduce it
b. Indicates main factors that contributed to choice of the specific intervention
(for example, analysis of causes of dysfunction; matching relevant
46
Text section; Item
number and name
Section or Item description
improvement experience of others with the local situation)
Outlines initial plans for how the intervention was to be implemented: e.g.,
what was to be done (initial steps; functions to be accomplished by those steps;
how tests of change would be used to modify intervention), and by whom
(intended roles, qualifications, and training of staff)
a. Outlines plans for assessing how well the intervention was implemented (dose
or intensity of exposure)
b. Describes mechanisms by which intervention components were expected to
cause changes, and plans for testing whether those mechanisms were effective
c. Identifies the study design (for example, observational, quasi-experimental,
experimental) chosen for measuring impact of the intervention on primary and
secondary outcomes, if applicable
d. Explains plans for implementing essential aspects of the chosen study design,
as described in publication guidelines for specific designs, if applicable (see,
for example, www.equator-network.org)
e. Describes aspects of the study design that specifically concerned internal
validity (integrity of the data) and external validity (generalizability)
a. Describes instruments and procedures (qualitative, quantitative, or mixed) used
to assess a) the effectiveness of implementation, b) the contributions of
intervention components and context factors to effectiveness of the
intervention, and c) primary and secondary outcomes
b. Reports efforts to validate and test reliability of assessment instruments
c. Explains methods used to assure data quality and adequacy (for example,
blinding; repeating measurements and data extraction; training in data
collection; collection of sufficient baseline measurements)
a. Provides details of qualitative and quantitative (statistical) methods used to
draw inferences from the data
b. Aligns unit of analysis with level at which the intervention was implemented, if
applicable
c. Specifies degree of variability expected in implementation, change expected in
primary outcome (effect size), and ability of study design (including size) to
detect such effects
d. Describes analytic methods used to demonstrate effects of time as a variable
(for example, statistical process control)
What did you find?
a) Nature of setting and improvement intervention
i. Characterizes relevant elements of setting or settings (for example, geography,
physical resources, organizational culture, history of change efforts), and
structures and patterns of care (for example, staffing, leadership) that provided
context for the intervention
ii. Explains the actual course of the intervention (for example, sequence of steps,
events or phases; type and number of participants at key points), preferably
using a time-line diagram or flow chart
iii. Documents degree of success in implementing intervention components
iv. Describes how and why the initial plan evolved, and the most important lessons
learned from that evolution, particularly the effects of internal feedback from
tests of change (reflexiveness)
b) Changes in processes of care and patient outcomes associated with the intervention
i. Presents data on changes observed in the care delivery process
ii. Presents data on changes observed in measures of patient outcome (for example,
morbidity, mortality, function, patient/staff satisfaction, service utilization, cost,
care disparities)
iii. Considers benefits, harms, unexpected results, problems, failures
iv. Presents evidence regarding the strength of association between observed
c.
10. Planning the
study of the
intervention
11. Methods of
evaluation
12. Analysis
Results
13. Outcomes
47
Text section; Item
number and name
Discussion
14. Summary
15. Relation to
other evidence
16. Limitations
17. Interpretation
18. Conclusions
Other information
19. Funding
Section or Item description
changes/improvements and intervention components/context factors
v. Includes summary of missing data for intervention and outcomes
What do the findings mean?
a. Summarizes the most important successes and difficulties in implementing
intervention components, and main changes observed in care delivery and
clinical outcomes
b. Highlights the study’s particular strengths
Compares and contrasts study results with relevant findings of others, drawing on
broad review of the literature; use of a summary table may be helpful in building on
existing evidence
a. Considers possible sources of confounding, bias, or imprecision in design,
measurement, and analysis that might have affected study outcomes (internal
validity)
b. Explores factors that could affect generalizability (external validity), for
example: representativeness of participants; effectiveness of implementation;
dose-response effects; features of local care setting
c. Addresses likelihood that observed gains may weaken over time, and describes
plans, if any, for monitoring and maintaining improvement; explicitly states if
such planning was not done
d. Reviews efforts made to minimize and adjust for study limitations
e. Assesses the effect of study limitations on interpretation and application of
results
a. Explores possible reasons for differences between observed and expected
outcomes
b. Draws inferences consistent with the strength of the data about causal
mechanisms and size of observed changes, paying particular attention to
components of the intervention and context factors that helped determine the
intervention’s effectiveness (or lack thereof), and types of settings in which this
intervention is most likely to be effective
c. Suggests steps that might be modified to improve future performance
d. Reviews issues of opportunity cost and actual financial cost of the intervention
a. Considers overall practical usefulness of the intervention
b. Suggests implications of this report for further studies of improvement
interventions
Were other factors relevant to conduct and interpretation of the study?
Describes funding sources, if any, and role of funding organization in design,
implementation, interpretation, and publication of study
SQUIRE Guidelines. Available at: http://www.squirestatement.org/assets/pdfs/SQUIRE_guidelines_table.pdf. Accessed September 20, 2009.
Also visit the Squire home page at http://www.squire-statement.org/. There you will find many
resources, including a link to an article that provides more detail and examples for each item in
the SQUIRE checklist: http://qshc.bmj.com/cgi/reprint/17/Suppl_1/i13.
48
QUALITY SCORING SYSTEM*
Study quality indicator
Study type
Single group cross-sectional, or single group post-test only, or qualitative study
Single group pre- and post-test, or cohort
Non-randomized trial (includes control or comparison group)
Randomized controlled trial
Total sample size
Unclear
≤ 10
11-50
51-100
101-150
151-200
201 or more
Reporting
Points
1
1.5
2
3
0.0
0.5
1.0
1.5
2.0
2.5
3.0
Yes
No
1
0
1
0
1
0
1
0
1
0
1
0
1
0
1
0
Did they report obtaining Institutional Review Board (IRB) approval?
1
0
Did the reported conclusions follow from the reported results?
1
0
Is the hypothesis/aim/objective/purpose of the study clearly described?
Are the participants clearly described? Number, rotation or clerkship name (e.g., pediatrics,
medicine), and stage of training, if medical students; Number, residency type (e.g., internal
medicine, surgery), and stage of training, if residents; number and discipline (e.g., internists,
hospitalists, surgeons) if attending physicians.
Are the main outcomes to be measured clearly described in the Introduction or Methods section? (If
the main outcomes were first mentioned in the Results section, this question was answered no. If
the article does not have clearly marked sections for Introduction, Methods, Results, this question
was answered no.)
Are the methods described with enough details to replicate the study (e.g., intervention, interview
process, quality improvement process, measurement process and instrument) – given you had the
resources, training, etc needed?
Are the main outcomes of the study clearly described in the Results? (Simple outcome data—
including denominators and numerators—should be reported for all major findings so that the reader
can check the major analyses and conclusions.)
Internal validity
Did they use a previously validated or published instrument, questionnaire, interview script?
Did they conduct any validity assessment (e.g., analyze reliability, validity, inter-rater reliability)?
Did they use any method designed to enhance the quality of measurement (e.g., multiple
observations; training of observers/interviewers; iterative process used to develop a tool, assessment
instrument, or to conduct analysis for qualitative analysis or quality improvement process; pilot
study; focus group; or Delphi process used to develop measurement tool)?
*The quality scoring system in this chart was designed to assess both experimental and
observational studies and was adapted from the Downs and Black1 quality scoring system. This
quality scoring system was developed by Lee Ann Riesenberg, PhD, RN; Jessica Leitzsch; Jaime
49
L. Massucci, MD; Joseph Jaeger, MPH; and Jamie S. Padmore. It was used in the following
manuscripts:
Riesenberg L, Leitzsch J, Cunningham JM. Nursing handoffs: A systematic review of the literature.
American Journal of Nursing 2010;110(4):24-34.
Riesenberg L, Leitzsch J, Massucci JL, Jaeger J, Rosenfeld JC, Patow C, Padmore JS, Karpovich KP.
Residents’ and attending physicians’ handoffs: A systematic review of the literature. Acad Med
2009;84(12):1775-1787.
Padmore JS, Jaeger J, Riesenberg L, Karpovich KP, Rosenfeld JC, Patow CA. “Renters” or
“Owners”? residents’ perceptions and behaviors regarding error reduction in teaching hospitals:
A literature review. Acad Med 2009;84(12):1765-1774.
Reference
1. Downs SH, Black N. The feasibility of creating a checklist for the assessment of the
methodological quality both of randomised and non-randomised studies of health care
interventions. J Epidemiol Community Health 1998;52:377-384.
50
ACRONYMS AND OTHER
RELEVANT RESOURCES
51
QUALITY IMPROVEMENT & P ATIENT S AFETY ACRONYMS,
DEFINITIONS, AND WEB SITES
Listed below are brief explanations of common health care acronyms, definitions, and
organizations in the areas of quality improvement and patient safety, as well as relevant
Web sites and Journals.
Active Error: An error that occurs at the level of the practitioner and that has almost immediate
effects.
Adverse Drug Reaction (ADR): An adverse effect produced by the use of a medication in the
recommended manner. These effects range from “nuisance effects” (e.g., dry mouth with
anticholinergic medications) to severe reactions, such as anaphylaxis to penicillin. An ADR is an
adverse drug event.
Adverse Event (AE): Any injury caused by medical care. Identifying something as an adverse
event does not imply error, negligence, or poor quality care. It simply indicates that an
undesirable clinical outcome resulted from some aspect of diagnosis or therapy, not an
underlying disease process. Examples: pneumothorax from central venous catheter placement;
anaphylaxis from penicillin allergy; postoperative wound infection; hospital-acquired delirium
(or “sun downing”) in elderly patients.
Affinity Diagram: A method to summarize qualitative data into groups with a common theme.
Agency for Healthcare Research and Quality (AHRQ): http://www.ahrq.gov
The Agency for Healthcare Research and Quality (AHRQ) is a public Health Service agency in
the Department of Health and Human Services (HHS). Reporting to the HHS Secretary, AHRQ
sponsors and conducts research that provides evidence-based information on health care
outcomes; quality; and cost, use, and access. The information helps health care decision
makers—patients and clinicians, health system leaders, purchasers, and policy makers—make
more informed decisions and improve the quality of health care services. The mission of AHRQ
is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans.
Information from AHRQ’s research helps people make more informed decisions and improve the
quality of health care services. AHRQ was formerly known as the Agency for Health Care Policy
and Research.
AHRQ–Health Care Innovations Exchange (http://www.innovations.ahrq.gov) that includes
innovations and tools to improve quality and reduce disparities. AHRQ–Web M&M (Morbidity
& Mortality Rounds on the Web) (http://www.webmm.ahrq.gov) includes patient safety resources and
journals that showcases patient safety lessons drawn from actual cases of medical errors.
Aim: A written, measurable, and time-sensitive statement of the expected results of an
improvement project.
American College of Medical Quality (ACMQ): http://www.acmq.org
The American College of Medical Quality (ACMQ) is a physician membership specialty society
that welcomes all health care professionals. They also offer membership to institutions,
organizations and corporations. The mission of the American College of Medical Quality is to
provide leadership and education in health care quality management.
52
American Congress of Obstetricians and Gynecologists (ACOG) Patient Safety and
Quality Improvement: www.acog.org/departments/dept_web.cfm?recno=28
The American Congress of Obstetricians and Gynecologists (ACOG) Patient Safety and Quality
department makes recommendations on methods to improve patient safety, from the surgical
environment through medication.
American Hospital Association (AHA) Quality Center: http://www.aha.org/aha_app/issues/Qualityand-Patient-Safety/index.jsp
The American Hospital Association (AHA) Quality Center is a resource of the AHA to help
hospitals accelerate their quality and performance improvement processes. It features tools,
articles and other resources to support hospitals to achieve better patient outcomes, enhanced
safety, increased satisfaction and improved operational and financial performance.
American Society for Quality: http://www.asq.org
The American Society for Quality is a membership organization devoted to health care quality.
Annotated Time Series: A line chart showing results of improvement efforts plotted over time.
The changes made are also noted on the line chart at the time they occur. This allows the viewer
to connect changes made with specific results.
Barrier Analysis: Study of the safeguards that can prevent or mitigate an unwanted event.
Benchmarking: The process of measuring products, services, and practices against the best
performers or those companies recognized as industry leaders.
Best Practice: A service, function, or process that produces superior outcomes. A “best
practice” entails whatever a health care team does to give patients what they need when they
need it, and creates the best odds of achieving a desired clinical outcome. In this context, best
practices for patient safety are those system elements and processes that reduce medical errors.
Briefing: A conversation and two-way dialogue of concise and relevant information shared prior
to a procedure or activity. Surgical “time-out” may be a briefing. Elements include: Get the
person’s attention; make eye contact; introduce yourself; use names; use SBAR; supply
explicitly asked for information; talk about next steps; encourage ongoing monitoring and
cross‐ monitoring.
Cause and Effect Diagram: A tool for organizing a group’s current knowledge regarding a
problem or issue. Useful for recording ideas in a brainstorming session (also called a fishbone
diagram or an Ishikawa diagram).
Center for Continuous Quality Improvement (CCQI): http://www.ccqi.com/pages/Opening.htm
Center for Continuous Quality Improvement provides the knowledge and expertise to effect
organizational improvement, focuses on the structure and dynamics of the entire organization to
equip it with the tools and skills to meet existing and emergent challenges, provides education
workshops at CCQI’s headquarters and on site, and was founded in 1991 by Dr. Robert Gelina.
Since then, CCQI has advised and assisted over 95 organizations.
Centers for Medicare and Medicaid Services (CMS): http://www.cms.hhs.gov
The Centers for Medicare and Medicaid Services (CMS) was formerly known as the Health Care
Financing Administration (HCFA). The agency of the US Department of Health and Humans
Services that administers Medicare, Medicaid, and the State Children’s Health Insurance
Program (SCHIP). The current mission of CMS is “to ensure effective, up-to-date health care
coverage and to promote quality care for beneficiaries.”
53
Certified Professional in Healthcare Quality (CPHQ)
Professionals working in quality improvement can become a Certified Professional in Health
Care Quality (CPHQ). Certifying body is the Healthcare Quality Certification Board, at
http://www.cphq.org
Change Concept: A general idea for changing a process. Change concepts are usually at a high
level of abstraction, but evoke multiple ideas for specific processes. “Standardize,” “simplify,”
“reduce handoffs,” and “consider all parties as part of the same system” are all examples of
change concepts.
Christiana Care Health Care System, Issues in Health Care Quality, Cost, Systems, and
Safety Course Materials: http://www.christianacare.org/ACT
Clinical Governance: The process of training and engaging accountable leadership.
Close Call: A close call is an event or situation that could have resulted in an accident, injury, or
illness, but did not, either by chance or through timely intervention. Such events have also been
referred to as “near miss” incidents. An example of Close Calls would be: Surgical or other
procedure almost performed on the wrong patient due to lapses in verification of patient
identification but caught at the last minute by chance. Close calls are opportunities for learning
and afford the chance to develop preventive strategies and actions. Close calls will receive the
same level of scrutiny as adverse events that result in actual injury.
Close-loop Communication: When a request is made of team members, someone specifically
affirms aloud that they will complete the task and states aloud when the task has been completed.
Common Cause Variation: Variation due to factors inherent in a process itself; can be reduced
only through system redesign.
Complex, Adaptive Systems: Macrosystems (e.g., a community health care network) involved
in intrinsically hazardous activities and consisting of numerous, specialized Microsystems (e.g.,
individual physicians’ offices, hospitals, retail pharmacies) that are highly interdependent and
respond to stimuli in different, dynamic, and fundamentally unpredictable ways.
Computerized Physician Order Entry (CPOE): A computer‐ based system for physicians and
other prescribers to enter orders for medications and diagnostic tests. These orders are
communicated over a computer network to the members of the health care staff (nurses,
therapists, pharmacists, or other physicians) or to the departments (pharmacy, laboratory, or
radiology) responsible for fulfilling the order.
Continuous Quality Improvement (CQI): Continuous Quality Improvement (CQI) is an
approach to quality improvement in which past trials of change are used as the basis of future
trials and something is always being tested for its effects on improvement.
Control Chart: A method used to distinguish between variation in a process due to common
causes and variation due to special causes. It is constructed by obtaining measurements of some
characteristic of a process, summarizing with an appropriate statistic, and grouping the data by
time period, location, or other process variables. There are many different types of control charts,
depending on the statistic analyzed on the chart.
Crew Resource Management (CRM): Safety team training borrowing principles from the
aviation industry now applied to health care. Vanderbilt and Johns Hopkins were early adopters.
54
Critical Language: Use of key phrases understood by all team members to mean “stop and
listen, we have a potential problem.” Specific phrases may differ from one institution or work
unit to another.
Cross-monitoring: A method for acknowledging the concerns of others—watch team members,
have awareness of their actions, verbally state concerns, share work load, verbally update others
in a manner less formal than briefing, respond to the concerns of team members.
Debriefing: A conversation and two‐ way dialogue of concise and relevant information shared
after the procedure or activity is completed. Debriefing identifies what went well, what could
have been done differently, and what was learned.
Define, Measure, Analyze, Improve, Control (DMAIC): DMAIC is a rapid cycle quality
improvement toll used by six sigma.
Dot Plot: A tool to display data that presents basic information about the location, shape, and
spread of a set of data (also called a histogram or frequency chart).
Early Adopter: In the improvement process, the opinion leader within the organization who
brings in new ideas from the outside, tests them, and uses positive results to persuade others in
the organization to adopt the successful changes. Source: Diffusion of Innovation (Everett
Rogers, 1995).
Early Majority/Late Majority: The individuals in the organization who will adopt a change only
after it is tested by an early adopter (early majority) or after the majority of the organization are
already using the change (late majority). Source: Diffusion of Innovation (Everett Rogers, 1995).
Emergency Care Research Institute (ECRI) Patient Safety Organization (PSO):
https://www.ecri.org/PatientSafetyOrganization/Pages/default.aspx
The Emergency Care Research Institute (ECRI) PSO has been officially listed (effective 11/5/08)
by the U.S. Department of Health and Human Services as a federal Patient Safety Organization
under the Patient Safety and Quality Improvement Act of 2005. ECRI Institute Patient Safety
Organization will serve nationwide as a PSO directly for providers, hospitals, and health
systems as well as provide support services to state and ECRI Institute is an independent
nonprofit organization whose mission is to benefit patient care by promoting the highest
standards of safety, quality, and cost-effectiveness in health care. We accomplish this through
our research, publishing, education, and consultation.
Error: Failure of a planned action to be completed as intended, or the use of a wrong plan to
achieve an aim.
Evidence-Based Medicine (EBM): The deliberate and well-informed use of specific, reliable,
and measurable evidence in making decisions about the care of individual patients.
Evidence-Based Hospital Referral (EHR):
http://www.leapfroggroup.org/for_hospitals/leapfrog_hospital_survey_copy/leapfrog_safety_practices/evidencebased_hospital_referral
Evidence-based Hospital Referral (EHR) under the advisement of national experts in quality
improvement, the Leapfrog Group has adopted EHR as one of its initial Safety Standards.
Conditions and volume criteria were selected after review of published research in the field and
consultation with leading experts in surgery and neonatal intensive care.
Failure Mode: Operation of a system element in an unintended or undesirable manner.
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Failure Mode and Effects Analysis (FMEA): FMEA is a procedure for analysis of potential
failure modes within a system for classification by severity or determination of the effect of
failures on the system. Failure modes are any errors or defects in a process, design, or item,
especially those that affect the customer, and can be potential or actual. Effects analysis refers to
studying the consequences of those failures.
Failure to Rescue: “Failure to rescue” is shorthand for failure to respond to (i.e., prevent a
clinically important deterioration, such as death or permanent disability) for a complication of an
underlying illness (e.g., cardiac arrest in a patient with acute myocardial infarction) or a
complication of medical care (e.g., major hemorrhage after thrombolysis for acute myocardial
infarction). The failure may reflect the quality of monitoring, the effectiveness of actions taken
once early complications are recognized, or both. For a more detailed definition, please go to
http://www.webmm.ahrq.gov/popup_glossary.aspx?name=failuretorescue.
Fishbone Diagram: A tool for organizing a group’s current knowledge regarding a problem or
issue. Useful for recording ideas in a brainstorming session (also called a cause and effect
diagram or an Ishikawa diagram).
First-look Analysis Tool for Hospital Outlier Monitoring (FATHOM): First-look Analysis
Tool for Hospital Outlier Monitoring (FATHOM) helps Quality Improvement Organizations
(QIOs) compare short inpatient hospital stays and areas at risk for payment error using Medicare
discharge data at http://www.cms.hhs.gov.
Food and Drug Administration (FDA) Patient Safety News:
http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/psn/index.cfm
The Food and Drug Administration (FDA) Patient Safety News is a televised series for health
care personnel, carried on satellite broadcast networks aimed at hospitals and other medical
facilities across the country. It features information on new drugs, biologics and medical devices,
on FDA safety notifications and product recalls, and on ways to protect patients when using
medical products.
Forcing Function: An aspect of a design that prevents a target action from being performed or
allows its performance only if another specific action is performed first. For example,
automobiles are now designed so that the driver cannot shift into reverse without first putting a
foot on the brake pedal. An example of a forcing function in health care is the design of enteral
tubing to prevent connections with IV ports.
Frequency Chart: A tool to display data that presents basic information about the location,
shape, and spread of a set of data (also called histogram or dot plot).
Health Care Financing Administration (HCFA) is now known as Centers for Medicare and
Medicaid Services (CMS): http://www.cms.hhs.gov
The Medicare and Medicaid programs were signed into law on July 30, 1965. Since 1965, a
number of changes have been made to CMS programs. The current mission of CMS is “to ensure
effective, up-to-date health care coverage and to promote quality care for beneficiaries.”
Health and Human Services (HHS): http://www.hhs.gov
The Department of Health and Human Services (HHS) is the United States government’s
principal agency for protecting the health of all Americans and providing essential human
services, especially for those who are least able to help themselves. The work of HHS is
conducted by the Office of the Secretary and 11 agencies. The agencies perform a wide variety
of tasks and services, including research, public health, food and drug safety, grants and other
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funding, health insurance, and many others.
Health Insurance Portability and Accountability Act (HIPAA):
http://www.hhs.gov/ocr/privacy/hipaa/understanding/index.html
HIPAA, which stands for the American Health Insurance Portability and Accountability Act of
1996, is a set of rules to be followed by doctors, hospitals and other health care providers.
HIPAA took effect on April 14, 2003. The HIPAA Privacy Rule provides federal protections for
personal health information held by covered entities and gives patients an array of rights with
respect to that information. At the same time, the Privacy Rule is balanced so that it permits the
disclosure of personal health information needed for patient care and other important
purposes. The Security Rule specifies a series of administrative, physical, and technical
safeguards for covered entities to use to assure the confidentiality, integrity, and availability of
electronic protected health information. HIPAA helps ensure that all medical records, medical
billing, and patient accounts meet certain consistent standards with regard to documentation,
handling, and privacy. In addition, HIPAA requires that all patients be able access their own
medical records, correct errors or omissions, and be informed how personal information is shared
used. Other provisions involve notification of privacy procedures to the patient. In sum, HIPAA
is a body of national standards for electronic medical records and transactions for health care
providers, health plans, and employers. It also addresses the security and privacy of electronic
health records.
Health Literacy: Individuals’ ability to find, process, and comprehend the basic health
information necessary to act on medical instructions and make decisions about their health.
Health Plan Employer Data and Information Set (HEDIS):
http://www.ncqa.org/tabid/59/Default.aspx
A set of standardized measures of health plan performance. HEDIS permits comparisons
between plans on quality, access and patient satisfaction, membership and utilization, financial
information, and health plan management.
Health Resources and Services Administration (HRSA): http://www.hrsa.gov
HRSA is an agency of the US Department of Health and Human Services, which is the Nation’s
Access Agency. HRSA focuses on uninsured, underserved, and special needs populations in its
goals and program activities. HRSA provides national leadership, program resources and
services needed to improve access to culturally competent, quality health care.
High Reliability Organizations (HROs): High reliability organizations refer to organizations or
systems that operate in hazardous conditions but have fewer than their fair share of adverse
events. Commonly discussed examples include air traffic control systems, nuclear power plants,
and naval aircraft carriers. Weick and Sutcliffe identified the following characteristics in high
reliability organizations.



Preoccupation with failure—the acknowledgment of the high-risk, error-prone nature of an
organization’s activities and the determination to achieve consistently safe operations.
Commitment to resilience—the development of capacities to detect unexpected threats and
contain them before they cause harm, or to recover from them when they do occur.
Sensitivity to operations—an attentiveness to the issues facing workers at the front line. This
feature comes into play when conducting analyses of specific events (e.g., front‐line workers
play a crucial role in root cause analyses by identifying unrecognized latent threats in current
operating procedures), and also in connection with organizational decision making that is
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
somewhat decentralized. Management units at the front line are given some autonomy in
identifying and responding to threats, rather than adopting a rigid top‐down approach.
A culture of safety, in which individuals feel comfortable drawing attention to potential
hazards or actual failures without fear of censure from management.
Hindsight Bias: This expression captures the tendency for people to regard past events as
expected or obvious, even when, in real time, the events perplexed those involved. More
formally, one might say that after learning the outcome of a series of events—whether the
outcome of the World Series or the steps leading to a war—people tend to exaggerate the extent
to which they had foreseen the likelihood of its occurrence. For a more detailed definition, please
go to http://www.webmm.ahrq.gov/popup_glossary.aspx?name=hindsightbias.
Histogram: A tool to display data that presents basic information about the location, shape, and
spread of a set of data (also called a frequency chart or dot plot).
Hospital Compare:
http://www.hospitalcompare.hhs.gov/Hospital/Search/Welcome.asp?version=default&browser=IE%7C7%7CWindo
ws+Vista&language=English&defaultstatus=0&MBPProviderID=&TargetPage=&ComingFromMBP=&CookiesEn
abledStatus=&TID=&StateAbbr=&ZIP=&State=&pagelist=Home
Hospital Compare is a Web site created through the efforts of the Centers for Medicare &
Medicaid Services (CMS), the Department of Health and Human Services, and other members of
the Hospital Quality Alliance: Improving Care Through Information (HQA). The information on
the Web site comes from hospitals that have agreed to submit quality information for Hospital
Compare to make public. Using this tool, you can find information on how well hospitals care
for patients with certain medical conditions and surgical procedures, as well as results from a
survey of patients about the quality of care they received during a recent hospital stay.
Hospital Payment Monitoring Program (HPMP): Hospital Payment Monitoring Program –
performed by Quality Improvement Organizations (QIOs) and acts along with a HINN.
Hospital Standardized Mortality Ratio (HSMR): Hospital death rates, a key quality indicator
and baseline measure for hospitals engaged in improvement work. A new statistical methodology
to standardize hospital mortality rates in order to fairly compare them, developed by Institute for
Healthcare Improvement partner, Sir Brian Jarman.
Human Factors: Refers to the study of human behavior, abilities, limitations, and other
characteristics as they affect the design and smooth operation of equipment, systems, and jobs.
And work environments
Iatrogenic: An adverse effect of medical care, rather than of the underlying disease (literally
“brought forth by healer,” from the Greek iatros, for healer, and gennan, to bring forth).
Implementation: Making a change to a process a permanent part of the system. A change may
be tested first and then implemented throughout the organization. Implementation involves
engaging the infrastructure of the organization such as staff training, documentation,
compensation, supply or equipment requirements, hiring, policy, procedures, measurement, etc.
Implementation takes longer than testing and typically involves more resistance to change.
Developing strategies to mitigate resistance to change is part of implementation.
Informed Consent: Refers to the process whereby a physician informs a patient about the risks
and benefits of a proposed therapy or test. Informed consent aims to provide sufficient
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information about the proposed treatment and any reasonable alternatives so that the patient can
exercise autonomy in deciding how to proceed. For a more detailed definition, please go to
http://www.webmm.ahrq.gov/popup_glossary.aspx?name=informedconsent.
Institute for Healthcare Improvement (IHI): http://www.ihi.org
The Institute for Healthcare Improvement (IHI) is a not-for-profit organization driving the
improvement of health by advancing the quality and value of health care. Founded in 1991 and
based in Cambridge, Massachusetts, IHI offers comprehensive products and services. IHI is a
reliable source of energy, knowledge, and support for a never-ending campaign to improve
health care worldwide. The Institute helps accelerate change in health care by cultivating
promising concepts for improving patient care and turning those ideas into action.
Institute for Healthcare Improvement (IHI) Open School:
http://www.ihi.org/IHI/Programs/IHIOpenSchool/
The IHI Open School for Health Professions is an inter-professional educational community that
gives students the skills to become change agents in health care improvement. The IHI Open
School — including all of our online tools and resources, and our online courses — is open and
free for students of all health care professions.
Institute of Medicine (IOM): http://www.iom.edu
The Institute of Medicine (IOM) is an independent, nonprofit organization that works outside of
government to provide unbiased and authoritative advice to decision makers and the public.
Established in 1970, the IOM is the health arm of the National Academy of Sciences, which was
chartered under President Abraham Lincoln in 1863. Nearly 150 years later, the National
Academy of Sciences has expanded into what is collectively known as the National Academies,
which comprises the National Academy of Sciences, the National Academy of Engineering, the
National Research Council, and the IOM. The Institute of Medicine serves as adviser to the
nation to improve health.
Institute of Medicine (IOM) “Aims for Improvement”—STEEEP:
http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/ImprovementStories/Across+the+Chasm+Six+A
ims+for+Changing+the+Health+Care+System.htm
In 1999, the Institute of Medicine (IOM) in Washington, DC, USA, released To Err Is Human:
Building a Safer Health System, an alarming report that brought tremendous public attention to
the crisis of patient safety in the United States. In 2001, IOM followed up with Crossing the
Quality Chasm: A New Health System for the 21st Century, a more detailed examination of the
immense divide between what we know to be good health care and the health care that people
actually receive. This second report called for six “aims for improvement”: safe, effective,
efficient, equitable, patient centered, and timely. The acronym STEEEP may be used to help
remember these aims
Institute for Safe Medication Practices (ISMP): http://www.ismp.org
Institute for safe medication practices is a non-profit health care agency comprised of
pharmacists, nurses, and physicians. Founded in 1994, the organization is dedicated to learning
about medication errors, understanding their system-based causes, and disseminating practical
use.
Intentional Unsafe Acts: Intentional unsafe acts, as they pertain to patients, are any events that
result from: a criminal act; a purposefully unsafe act; an act related to alcohol or substance
abuse, impaired provider/staff; or events involving alleged or suspected patient abuse of any
kind.
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International Center for Patient Safety (ICPS):
http://www.jointcommission.org/NR/rdonlyres/CED69A23-4B51-41D7-B11B4AC3D945F248/0/Corporate_Brochure.pdf
International Center for Patient Safety (ICPS) – The Center was established in 2005 by the Joint
Commission and Joint Commission Resources (JCR). The Center’s missions is to continuously
improve patient safety by providing solutions, processes and procedures that help eliminate preventable
adverse events in all health care settings worldwide.
International Society of Six Sigma Professionals (ISSSP): http://www.isssp.com
International Society of Six Sigma Professionals committed to promoting the adoption,
advancement and integration of Six Sigma in business. Our community supports this mission
through advocacy and awareness efforts; professional recognition and development; and by
serving as an information and referral source.
Ishikawa Diagram: A tool for organizing a group’s current knowledge regarding a problem or
issue. Useful for recording ideas in a brainstorming session (also called a cause and effect
diagram or a fishbone diagram).
Joint Commission (used to be JACHO): http://www.jointcommission.org
The Joint Commission evaluates the quality and safety of care for nearly 15,000 health care
organizations and programs in the United States. An independent, not-for-profit organization, the
Joint Commission is the nation’s predominant standards-setting and accrediting body in health
care. Since 1951, the Joint Commission has developed state-of-the-art, professionally based
standards and evaluated the compliance of health care organizations against these benchmarks.
Its mission is to improve continuously the safety and quality of care provided to the public
through the provision of health care accreditation and related services that support performance
improvement in health care organizations.
Measure: An indicator of change. Key measures should be focused, clarify your team’s aim, and
be reportable. A measure is used to track the delivery of proven interventions to patients and to
monitor progress over time.
Medical Error: An adverse event or near miss that is preventable with the current state of
medical knowledge.
Medication Error: Any preventable event that may cause or lead to unintended and incorrect
medication use or patient harm, while the medication is in the control of the health care
professional or patient.
Medication Reconciliation: The process by which health care providers collect a list of the
medications that a patient is taking, using that information to make treatment decisions, and
ensuring that all other caregivers who need to know are informed of changes to those
medications. Applies in all health care settings where medication regimens may be modified.
Microsystem: A small, organized patient care unit with a specific clinical purpose, set of
patients, technologies, and practitioners who work directly with these patients.
Model for Improvement: An approach to process improvement, developed by Associates in
Process Improvement, that helps teams accelerate the adoption of proven and effective changes.
National Association for Healthcare Quality (NAHQ): http://www.nahq.org/certify
The mission of the National Association for Healthcare Quality (NAHQ) is to empower health
care quality professionals from every specialty by providing vital research, education,
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networking, certification and professional practice resources, and a strong voice for health care
quality.
National Center for Patient Safety: http://www.patientsafety.gov
The National Center for Patient Safety (NCPS) was established in 1999 to develop and nurture a
culture of safety throughout the Veterans Health Administration. Their goal is the nationwide
reduction and prevention of inadvertent harm to patients as a result of their care. Patient safety
managers at 153 VA hospitals and patient safety officers at 21 VA regional headquarters
participate in the program.
National Institutes of Health (NIH): http://www.nih.gov
The National Institutes of Health (NIH), is a part of the US Department of Health and Human
Services. The NIH is the primary Federal agency for conducting and supporting medical
research. National Institute for Nursing Research (NINR), founded in 1993, is part of NIH along
with many other subspecialty research organizations.
National Patient Safety Foundation (NPSF): http://www.npsf.org
National Patient Safety Foundation (NPSF) is an independent, non-profit research and education
organization dedicated to the measurable improvement of patient safety in the delivery of health
care.
National Quality Forum (NQF): http://www.qualityforum.org
National Quality Forum (NQF) is a private, non-profit, open membership, public benefit
corporation with participation from 170 organizations that represent all sectors of the health care
industry. NQF was created to develop and implement a national strategy for health care quality
measurement and reporting. The National Quality Forum (NQF) has a three-part mission: 1.
Setting national priorities and goals for performance improvement; 2. Endorsing national
consensus standards for measuring and publicly reporting on performance; and 3. Promoting the
attainment of national goals through education and outreach programs.
Near Miss: An event or situation that could have resulted in an adverse event, but did not, either
by chance or through timely intervention.
Operational Definition: A definition that gives communicable meaning to a concept by
specifying how the concept is applied within a particular set of circumstances.
Outcome Measure: Outcome measures evaluate how a system is performing. For example, in a
project to improve some aspect of clinical care, an outcome measure will evaluate the degree of
change in the well‐ being of a defined population. Improvement in the outcome measure will
reflect results related directly to the patient and will have an effect on mortality and morbidity.
Pareto Chart: A tool for helping focus improvement efforts by identifying how frequently
categories of events occur.
Performance Improvement (PI): Performance improvement is the concept of measuring the
output of a particular process or procedure, then modifying the process or procedure to increase
the output, increase efficiency, or increase the effectiveness of the process or procedure.
Physician Order Entry (POE): See Computerized Physician Order Entry (CPOE)
Plan, Do, Check, ACT (PDCA): The PDCA Cycle is one quality improvement methodology.
The four letters “PDSA” stand for Plan, Do, Study, and Act. At Christiana Care Health System
we use the Plan, Do, Check, Act (PDCA) cycle. Other institutions may use Plan, Do, Study, Act
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(PDSA).
Process: A series of actions or operations definitely conducting to an end.
Process Change: A specific change in a process in the organization. More focused and detailed
than a change concept, a process change describes what specific changes should occur. “Institute
a pain management protocol for patients with moderate to severe pain” is an example of a
process change.
Proximal (proximate) Cause: An observable system failure that leads directly to an error.
Process Measure: Process measures evaluate whether the system is functioning as
planned. For example, in a project to improve some aspect of clinical care, a process
measure will evaluate care delivery to the patient, that is, what is done to, for, with, or by
defined individuals or groups as part of the delivery of services.
Quality-Adjusted Life Years (QALYs): Quality-adjusted life years, or QALYs, are a measure of
the benefit of a medical intervention. QALYs are based on the number of years of life that would
be added by the intervention. Each year in perfect health is assigned the value of 1.0 down to a
value of 0 for death. If the extra years would not be lived in full health, for example if the patient
would lose a limb, or be blind or be confined to a wheelchair, then the extra life-years are given a
value between 0 and 1 to account for this. The “weight” values between 0 and 1 are usually
determined by methods such as:



Time-trade-off (TTO)—In this method, respondents are asked to choose between remaining
in a state of ill health for a period of time, or being restored to perfect health but having a
shorter life expectancy.
Standard gamble—In this method, respondents are asked to choose between remaining in a
state of ill health for a period of time, or choosing a medical intervention which has a chance
of either restoring them to perfect health, or killing them.
Another way of determining the weight associated with a particular health state is to use
standard descriptive systems such as the EuroQol EQ-5D questionnaire.
However, the weight assigned to a particular condition can vary greatly, depending on the
population being surveyed. Those who do not suffer from the affliction in question will, on
average, overestimate the detrimental effect on quality of life, while those who are afflicted have
come to live with their condition. QALYs are controversial as the measurement is used to
calculate the allocation of health care resources based upon a ratio of cost per QALY. As a result
some people will not receive treatment as it is calculated that cost of the intervention is not
warranted by the benefit to their quality of life.
Quality Assurance/Quality Improvement (QA/QI): Involves efforts to improve health care
services and increase desired health care outcomes.
Quality Improvement Organization (QIO): http://www.cms.hhs.gov/QualityImprovementOrgs
Quality Improvement Organization (QIO) contract with Centers for Medicare and Medicaid
Services (CMS) to collaborate with providers, administrators, and others to improve quality
health care.
Reliability: The extent of failure‐free operation over time (Source: David Garvin)
Return on Investment (ROI): Return on Investment is a performance measure used to help
make capital investment decisions. ROI is calculated by considering the annual benefit divided
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by the investment amount. To calculate ROI, the benefit (return) of an investment is divided by
the cost of the investment; the result is expressed as a percentage or a ratio.
Robert Wood Johnson Foundation (RWJF): http://www.rwjf.org
The Robert Wood Johnson Foundation (RWJF) is a funding source for health initiatives. The
mission of the Robert Wood Johnson Foundation is to improve the health and health care of all
Americans. Their goal is to help Americans lead healthier lives and get the care they need. They
support training, education, research and projects that demonstrate effective ways to deliver
health services, especially for the most vulnerable populations.
Root Cause Analysis (RCA): A structured process for identifying the causal or contributing
factors underlying adverse events or other critical incidents. For a more detailed definition,
please go to http://www.webmm.ahrq.gov/popup_glossary.aspx?name=rootcauseanalysis .
Run Chart: A graphical record of a quality characteristic measured over time. For a more
detailed definition, please go to http://www.webmm.ahrq.gov/popup_glossary.aspx?name=runcharts.
Sampling Methods: The selection of units for study. Different sampling methods include
judgment sampling, simple random sampling, proportionate random sampling, systematic
sampling, and stratified sampling.
Sampling Plan: A specific description of the data to be collected, the interval of data collection,
and the subjects from whom the data will be collected. The plan emphasizes the importance of
gathering samples of data and how to obtain “just enough” information.
Sentinel Event (SE): http://www.jointcommission.org/SentinelEvents
A sentinel event is an unexpected occurrence involving death or serious physical or
psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or
function. The phrase, “or the risk thereof” includes any process variation for which a recurrence
would carry a significant chance of a serious adverse outcome. Such events are called “sentinel”
because they signal the need for immediate investigation and response. In support of its mission
to improve the quality of health care provided to the public, The Joint Commission includes the
review of organizations’ activities in response to sentinel events in its accreditation process,
including all full accreditation surveys and random unannounced surveys.
Severity of illness (SOI): Severity of Illness (SOI) is a mechanism to determine the complexity
of a patient’s illness. SOI systems are a clinical tool for measuring the physical effects of disease
on the patient, planning treatment, and predicting outcomes. SOI allows for grouping of like
patients for comparison purposes (e.g., expected length of stay.) In addition, SOI is especially
useful at large tertiary care hospitals that tend to treat more severely ill patients, where the SOI
can be used as a management tool to help explain and justify above average treatment costs.
Spread: The intentional and methodical expansion of the number and type of people, units, or
organizations using the improvements. The theory and application comes from the literature on
Diffusion of Innovation (Everett Rogers, 1995).
Statistical Methods: Use of more advanced statistical methods such as correlation analysis,
regression analysis, confidence intervals, analysis of variance, statistical tests, and power
analysis.
Systems Thinking/Analysis: A view of the organization as comprising interdependent
processes and products, and as dynamic and adaptive to the needs of the customer.
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Test: A small-scale trial of a new approach or a new process. A test is designed to learn if the
change results in improvement and to fine-tune the change to fit the organization and patients.
Tests are carried out using one or more PDCA/PDSA cycles.
Total Quality Improvement (TQI): Total Quality Improvement (TQI) is a collection of methods
and practices used in an attempt to achieve total quality. TQI represents a theory for
transformation that requires continuous quality improvement (CQI).
Total Quality Management (TQM): Total Quality Management is a comprehensive and
structured approach to organizational management that seeks to improve the quality of products
and services through ongoing refinements in response to continuous feedback.
Tree Diagram: A tool used to visualize the structure of a problem, plan, or any other opportunity
of interest. It helps in thinking systematically about each aspect of the problem or plan. It also
has been called a “systematic diagram.” The tree diagram presents a graphical view of different
level of details about a problem or plan.
Utilization Review (UR): Utilization review is a review of services delivered by a health care
provider to evaluate the appropriateness, necessity, and quality of the prescribed services. The
review can be performed on a prospective, concurrent, or retrospective basis.
QUALITY JOURNALS
American Journal of Medical Quality: http://ajm.sagepub.com
BMC Health Services Research: http://www.biomedcentral.com/bmchealthservres
Health and Quality of Life Outcomes: http://www.hqlo.com
Health Services Research: http://www.hsr.org
International Journal for Quality in Health Care: http://intqhc.oxfordjournals.org
Medical Decision Making: http://mdm.sagepub.com
Patient Safety & Quality Healthcare: http://www.psqh.com/
Quality and Safety in Healthcare: http://qshc.bmj.com/
Quality of Life Research: http://www.springer.com/medicine/journal/11136
The Joint Commission Journal on Quality and Patient Safety: http://www.jcrinc.com/The-JointCommission-Journal-on-Quality-and-Patient-Safety
Value in Health: http://www.wiley.com/bw/journal.asp?ref=1098-3015
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