Improving Outcomes
through
Patient Safety Initiatives
Patricia A. Patrician, PhD, RN, FAAN
Associate Professor and Donna Brown Banton
Endowed Professor
University of Alabama at Birmingham
Birmingham, AL
Acknowledgement: Many slides came from American Association of Colleges of Nursing and Quality and
Safety Education for Nurses Project, funded by the Robert Wood Johnson Foundation,
PI: Linda Cronenwett, PhD, RN
Dallas, TX • November 2–4, 2012
Improving Outcomes through Patient
Safety Initiatives
Session Code: 105 Contact Hours: 0.8 CRNI Units: 2
Please use session code shown above when completing
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Return the evaluation to the registration desk or receptacles located
outside meeting rooms at the end of the day.
Handouts for this session are available online at www.ins1.org.
Session recordings will also be available post-meeting courtesy of
B.Braun Medical/Aesculap Academy.
As a courtesy to both presenters and attendees, please turn off all cell phones and refrain
from talking during the session.
Tonight’s Event:
Industrial Exhibition and Networking Reception
3:30-5:30pm
Dallas, TX • November 2–4, 2012
Outline
• Overview: Patient safety and quality
improvement
• National initiatives
• Infusion safety
• Additional resources
Dallas, TX • November 2–4, 2012
“First Do No Harm”
http://bcove.me/stbtnf90
(1:37 min.)
(CATHLEEN F. CROWLEY and
ERIC NALDER,
HEARST NEWSPAPERS)
Dallas, TX • November 2–4, 2012
Betsy Lehman (1995)
• Received 4X Cytoxan dose for four days
• “If this can happen at a place like DanaFarber, a nationally respected institute, what
is happening in other places?” –Dr. Michael
Colvin, Duke U. Comprehensive Cancer
Center
Dallas, TX • November 2–4, 2012
Lewis Blackman (2000)
• http://www.qsen.org/video/blackman/vid
eo.php?qsen_a_Lewis_Blackman_Story
.f4v
(6.44 minutes)
Dallas, TX • November 2–4, 2012
Dallas, TX • November 2–4, 2012
Josie King (2001)
• http://www.qsen.org/video/josieking/
(13.33 minutes)
Dallas, TX • November 2–4, 2012
To Err is Human
Beginning in 2000, the Institute of Medicine
released a series of reports that brought
attention to the issues of quality. The first, To Err is
Human brought startling statistics to light about the
number of needless deaths and injuries caused by
medical errors.
Annual deaths
• AIDS---------------------------- 16,516
• Breast cancer----------------- 42,297
• Motor vehicle accidents---- 43,458
• Medical Errors--------------- 98,000
Dallas, TX • November 2–4, 2012
Crossing the Quality
Chasm
•
The second report, Crossing the
Quality Chasm, provided a definition
and aimed to improve quality of care. In
this report, the Institute of Medicine
defined quality as:
The degree to which health services for individuals
and populations increase the likelihood of desired
health outcomes and are consistent with current
professional knowledge.
Dallas, TX • November 2–4, 2012
Crossing the Quality
Chasm
Crossing the Quality Chasm established six aims that have formed
a framework for moving forward with improving quality. The aims
are that care should be:
Safe
Care should be as safe for patients in healthcare facilities as in their
homes.
Timely
Patients should experience no waits or delays in receiving care and
service.
Effective
The sciences and evidence behind healthcare should be applied and
serve as the standard in the delivery of care.
Efficient
Care and service should be cost-effective, and waste should be removed
from the system.
Equitable
Unequal treatment should be a fact of the past; disparities in care should
be eradicated
Patient
centered
The system of care should revolve around the patient, respect patient
preferences, and put the patient in control.
Dallas, TX • November 2–4, 2012
Subsequent IOM Reports
http://www.iom.edu/Reports.aspx
Reports are free electronically – at
least read the executive
summaries!
Dallas, TX • November 2–4, 2012
Patient Safety
• Minimize risk of harm to patients and
providers through both system effectiveness
and individual performance.
• Requires understanding of the complexity of
care delivery, the limits of human factors,
safety design principles, characteristics of
high reliability organizations, and patient
safety resources.
- QSEN/American Association of Colleges of Nursing, 2009
Dallas, TX • November 2–4, 2012
Human Factors
Engineering
•Science of the interrelationship between humans, their tools and the
environment in which they live and work
•So that systems and products can be built to enhance performance.
•Can be used to reduce adverse events and errors by identifying how
and why systems break down and how and why human beings miscommunicate.
•Goal is to provide better designed systems and processes by:
–Simplifying processes
–Standardizing procedures
–Providing backup when humans fail
–Improving communication
–Redesigning equipment
–Understanding behavioral, organizational and technological limitations that
lead to error. (WHO, 2009).
Dallas, TX • November 2–4, 2012
Why Human Factors
• Health care services are provided within a
complex and technological setting that is prone
to accidents.
• When systems fail, it is due to multiple faults
that occur together.
• Human error is one of the greatest contributors
to accidents (active error); however…
• Latent errors or system failures pose the
greatest threat to safety in a complex system.
• Need to shift from emphasis on active errors to
one on latent errors and fix the system, not the
person.
Dallas, TX • November 2–4, 2012
Latent Condition Pathways
• Organizational factors
– Poorly designed equipment
– Lack of appropriate communication
– Fearful environment
Defense
s
• Work setting factors
– Unworkable procedures
– Inadequate or inaccessible
equipment
– Storage of supplies
Hazards
Accident
• Unsafe acts
– Not following procedural guidelines
– Hurried, stressed staff
– Work-arounds for work setting and
organizational factors
Dallas, TX • November 2–4, 2012
Anatomy of a Near Miss
Failed
defenses
Intact
defenses
Dallas, TX • November 2–4, 2012
Anatomy of an Error
Organizational
influences
Latent failure
Unsafe
supervision
Latent failure
Preconditions
for unsafe acts
Latent failure
Unsafe acts
Active
failure
Failed or
absent
defenses
Latent failures conditions that lead
to failures – hidden;
not readily apparent;
an accident waiting
to happen.
Active failures –
the “last straw”; the
apparent error.
Mishap
Dallas, TX • November 2–4, 2012
Nurses and Patient Safety
While delivery of healthcare is extremely
complex and there are tremendous systems
challenges, nurses often have been held
accountable for harm to patients . . .
. . . even while they have not had input
into system designs and have little
understanding of how complex
systems leave them vulnerable to
making errors.
-QSEN/American Association of Colleges of Nursing, 2009
Dallas, TX • November 2–4, 2012
Culture of Safety vs.
Culture of Blame
•Within a culture of safety, when an adverse
event occurs, the focus is on what went
wrong, not who is the problem.
•A culture of blame has been pervasive in
healthcare. The focus has often been to try
to determine who has been at fault and, all
too often, to mete out discipline.
– This approach leads to hiding rather than
reporting errors and is the antithesis of a
culture of safety.
Dallas, TX • November 2–4, 2012
Culture of Safety
•Elements of a culture of safety in an
organization are establishment of safety as
an organizational priority, teamwork, patient
involvement, openness/transparency and
accountability (Lamb, 2003).
•There are shared core values and goals,
non-punitive responses to adverse events
and errors, and promotion of safety through
education and training.
Dallas, TX • November 2–4, 2012
Culture of Safety
• A safety culture requires strong,
committed leadership, and engagement
and empowerment of all employees. It
entails periodic assessment of the
culture and relationship between the
organization culture and the quality and
safety within the organization.
Dallas, TX • November 2–4, 2012
IOM Recommendations
The IOM described 9 categories that
provide opportunities to improve patient
safety.
Dallas, TX • November 2–4, 2012
1. User-centered design
• Approaches include
making things visible
so the user is able to
see actions possible
at any time.
• Use constraints and
forcing-functions
(makes it hard to do
the wrong thing and
easier to do the right
thing).
Dallas, TX • November 2–4, 2012
2. Avoid reliance on memory
•
Standardizing and simplifying procedures
and tasks decreases the demand on
memory, planning, and problem-solving.
•
The use of protocols and checklists
reduces reliance on memory and serves as
a reminder for the steps to be followed.
•
Simplifying processes minimizes problemsolving.
•
Having the usual dose of a medication as
the default in an electronic order entry.
•
Purchasing equipment that is easy to use
and maintain are examples of simplification
of processes.
Dallas, TX • November 2–4, 2012
3. Attend to work safety
Work hours, workloads, staffing
ratios, distractions,
and
counterclockwise
shift changes all
affect patient
safety.
Dallas, TX • November 2–4, 2012
4. Avoid reliance on vigilance
• Checklists, welldesigned alarms,
rotating staff and
breaks decrease the
need for remaining
vigilant for long periods.
• Look-alike medications
should be stored far
apart.
Dallas, TX • November 2–4, 2012
5. Train for teamwork
• Training programs for
effective interprofessional
communication and
collaboration include
transitions in care and handoffs.
• Introduction of new
processes and technologies
depends on a chain of
involvement of frontline users
and the need for pilot testing
before widespread
implementation.
Dallas, TX • November 2–4, 2012
6. Involve patients in their care
• Patients and
families should be
in the center of
the care process.
Dallas, TX • November 2–4, 2012
7. Anticipate the unexpected
Reorganization and
organization-wide
changes result in
new patterns and
processes of care.
Dallas, TX • November 2–4, 2012
8. Plan for service recovery
• Errors will occur despite the
best of planning.
• Designing and planning for
recovery will allow reversal or
make it hard to carry out
irreversible critical functions.
Dallas, TX • November 2–4, 2012
9. Improve access to timely,
accurate information
•Information for decision making needs to
be available at the point of care.
•This includes easy access to drug
formularies, evidence-based practice
protocols, patient records, laboratory
reports, and medication administration
records.
Dallas, TX • November 2–4, 2012
Quality Improvement
Quality and Safety Education for Nurses
(QSEN) defines quality improvement as:
Use of data to monitor the outcomes
of care processes and use of
improvement methods to design and test
changes to continuously improve the
quality and safety of healthcare systems
(Cronenwett et al., 2007).
Dallas, TX • November 2–4, 2012
Quality Improvement:
Another Definition
". . .the combined and unceasing efforts of everyone –
health care professionals, patients and their families,
researchers, payers, planners, educators – to make
changes that will lead to better patient outcomes
(health), better system performance (care), and better
professional development (learning)."
– Batalden, P. & Davidoff, F. (2007).
What is "quality improvement" and how
can it inform health care? Quality and
Safety in Health Care, 16(1), 2-3.
Dallas, TX • November 2–4, 2012
Improving Care
•Requires problem identification:
–systematic process of defining problems
–to identify potential causes of those
problems
–and develop strategies to improve care.
•Requires measurement
Dallas, TX • November 2–4, 2012
Institute for Healthcare
Improvement (IHI)
AIM
MEASUREMENT
CHANGES
Dallas, TX • November 2–4, 2012
Problem Identification
• Routine monitoring
• Sentinel event or observation
• To better understand the problem:
– Cause and effect diagrams (“fishbone” or
“Ishikawa”)
– Process flow maps
– Root cause analysis
– Failure Mode and Effect Analysis
Dallas, TX • November 2–4, 2012
Root Cause Analysis (RCA)
From
thinkreliability.
com
Dallas, TX • November 2–4, 2012
RCA
• Identify the underlying causes of why an incident
occurred
• So that the most effective solutions can be
identified and implemented.
• It's typically used when something goes wrong
(sentinel events)
• What's the problem? Why did it happen? Series of
WHY’s
• What will be done to prevent it?
• Uses process maps, fishbones, and others
• See TapRoot®: http://www.taproot.com/index.php
Dallas, TX • November 2–4, 2012
Failure Mode and Effect
Analysis (FMEA)
• Documents current knowledge and actions
about the risks of failures, for use in
continuous improvement.
• Used during design to prevent failures.
• Later it’s used for control, before and
during ongoing operation of the process.
• Ideally, FMEA begins during the earliest
conceptual stages of design and continues
throughout the life of the product or
service.
Dallas, TX • November 2–4, 2012
Selecting Measures
• Measure things that matter to patients, providers
• Measure things you can change (actionable): what do you (or
your team) “own”?
• Measure close to what you are after
– Temporally (time-wise): close to patient encounter
– Operationally (content-wise): close to your theoretical
definition. If nursing sensitive outcome is your concept,
and patient adverse events are your theoretical terms, is
mortality a good measure?
• Measure at the correct level – hospital, unit, day, shift
• Measure as objectively as possible – self-reports versus pill
counts
Dallas, TX • November 2–4, 2012
Selecting Measures
• Measure things for which you have (or can get) comparisons
• Select a balanced set of measures (structure-processoutcomes)
• Measure things for which you already collect data
• Select standardized and tested measures if possible (e.g.,
National Quality Forum (NQF); National Database of Nursing
Quality Indicators (NDNQI); Collaborative Alliance for Nursing
Outcomes; CALNOC); Agency for Healthcare Research and
Quality (AHRQ) Patient Safety Indicators:
http://www.qualitymeasures.ahrq.gov/browse/by-topic.aspx
• Consider ease of data collection, especially if you are not
actually collecting the data.
Dallas, TX • November 2–4, 2012
Instituting Change
1.
2.
3.
4.
5.
6.
7.
8.
Establish sense of urgency
Create guiding coalition
Develop vision and strategy
Communicate change vision
Empower broad based action
Generate short term wins
Consolidating gains and producing more change
Anchoring new approaches in the culture
Kotter, J. (1996). Leading Change.
Dallas, TX • November 2–4, 2012
National Initiatives
• Agency for Healthcare Research & Quality
(AHRQ)
• National Quality Forum (NQF)
• Centers for Medicare and Medicaid Services
(CMS)
• Institute for Healthcare Improvement (IHI)
• Quality and Safety Education for Nurses
(QSEN)
Dallas, TX • November 2–4, 2012
Agency for Health care
Quality & Research (AHRQ)
• Lead Federal agency charged with improving the
quality, safety, efficiency, and effectiveness of health
care for all Americans
• As 1 of 12 agencies within the Department of Health
and Human Services, AHRQ supports research that
helps people make more informed decisions and
improves the quality of health care services
• Research funding opportunities, data collection and
reporting, data sources for research, clinical practice
guidelines, consumer healthcare information
Dallas, TX • November 2–4, 2012
AHRQ Focus
• Safety and quality: Reduce the risk of harm by
promoting delivery of the best possible health
care.
• Effectiveness: Improve health care outcomes by
encouraging the use of evidence to make
informed health care decisions.
• Efficiency: Transform research into practice to
facilitate wider access to effective health care
services and reduce unnecessary costs.
• Great collection of useful tools and other
resources on web site
Dallas, TX • November 2–4, 2012
National Quality Forum
(NQF)
Promotes change through development
and implementation of a national
strategy for health care quality
measurement and reporting.
Dallas, TX • November 2–4, 2012
Nursing Sensitive
Measures – NQF Definition
•
Nursing-sensitive performance measures are processes and outcomes and structural proxies for these processes and outcomes (e.g., skill mix,
nurse staffing hours) - that are affected, provided, and/or influenced by
nursing personnel, but for which nursing is not exclusively responsible.
Nursing-sensitive measures must be quantifiably influenced by nursing
personnel, but the relationship is not necessarily causal.
•
The NQF Report details 12 voluntary, NQF-endorsed consensus standards
for nursing-sensitive care, including evidence-based nursing-sensitive
performance measures, a framework for measuring nursing-sensitive care,
and related research recommendations.
•
This is the first-ever set of national standardized performance measures to
assess the extent to which nurses in acute care hospitals contribute to
patient safety, healthcare quality, and a professional work environment
(NQF, 2012).
Dallas, TX • November 2–4, 2012
NQF - 12
•
•
•
•
•
•
•
•
•
•
•
•
NSC-1 Death Among Surgical Inpatients with Treatable Serious
Complications
NSC-2 Pressure Ulcer Prevalence (Hospital-Acquired)
NSC-3 Restraint Prevalence
NSC-4 Patient Falls
NSC-5 Falls with Injury
NSC-6 Catheter-Associated Urinary Tract Infections (UTI) for Intensive
Care Unit (ICU) Patients
NSC-7 Central Line Catheter-Associated Blood Stream Infections for ICU
and Neonatal Intensive Care Unit (NICU) Patients
NSC-8 Ventilator-Associated Pneumonia for ICU and NICU Patients
NSC-9 Skill Mix
NSC-10 Nursing Care Hours per Patient Day
NSC-11 Voluntary Turnover
NSC-12 Practice Environment Scale-Nursing Work Index (PES-NWI)
Appendices
Dallas, TX • November 2–4, 2012
Centers for Medicare and
Medicaid Services (CMS)
• In order to receive Medicare and
Medicaid reimbursement, hospitals and
other health care organizations must
meet certain standards or “conditions of
participation”
• Health Care Financing Administration
(HCFA)
• Increasing requirements for
reimbursement in hospitals
Dallas, TX • November 2–4, 2012
Creating a Sense of Urgency:
“Never Events”
Recent rules established by CMS have
identified “never events,” which are serious and
costly events that should never occur in a
hospital if appropriate care is provided.
All nurses should be aware of information
available from regularly collected data. For
instance, all hospitals collect data related to
infections, 30-day readmissions, pressure
ulcers, and others.
Dallas, TX • November 2–4, 2012
“Never Events” and
Hospital Reimbursement
Hospitals no longer get
paid for the costs of
certain Never Events,
because they are
preventable and should
never happen to patients.
Dallas, TX • November 2–4, 2012
Institute for Healthcare
Improvement (IHI)
• Motivating and building the will for change;
• Identifying and testing new models of care
in partnership with both patients and
health care professionals; and
• Ensuring the broadest possible adoption of
best practices and effective innovations
• Great educational resource: IHI Open
School
Dallas, TX • November 2–4, 2012
IHI Open School for Health
Professionals
• Interprofessional educational community that gives students
the skills to become change agents in health care
improvement.
• Skills like quality improvement, patient safety, teamwork,
leadership, and patient-centered care. Employers are
looking for these skills, and patients expect providers to have
them. But most schools barely touch on these topics.
• Health professionals and students in nursing, health
administration, medicine, pharmacy, dentistry, policy, and
other health professions can join.
• There are no applications, no admissions requirements, and
no due dates.
Dallas, TX • November 2–4, 2012
Quality and Safety Education
for Nurses (QSEN)
• Program to increase knowledge, skills, and attitudes of
nurses about quality and safety.
• The overall goal for the Quality and Safety Education for
Nurses (QSEN) project is to meet the challenge of
preparing future nurses who will have the knowledge, skills
and attitudes (KSAs) necessary to continuously improve the
quality and safety of the healthcare systems within which
they work.
• Provide tools for faculty (staff development personnel) to
teach these competencies.
Dallas, TX • November 2–4, 2012
QSEN Competencies
1.
2.
3.
4.
5.
6.
Patient-centered care
Teamwork and collaboration
Evidence-based practice
Quality improvement
Safety
Informatics
Dallas, TX • November 2–4, 2012
Has Health Care Improved?
• Wachter:
– Modest improvement
– Grade: B -
• Bielaszka-DuVernay:
– Cites McGlynn et al (2003): US adults receive 55% of
recommended care
– Key issues – measuring improvement, incentives for
better quality, disparities in care, patient involvement,
health care complexity
• Nembhard et al.,:
– Significant barriers to improvement: Many are
organizational/cultural
– Innovation implementation failures
Dallas, TX • November 2–4, 2012
Infusion Safety:
What can YOU do?
• Learn about patient safety and quality
improvement (QI)
• Report potential and actual problems,
concerns, errors
• Monitor your practice – processes and
outcomes
• You job is not only to do your work, but to
continuously improve your work (P. Batalden)
Dallas, TX • November 2–4, 2012
Infusion Safety
• Med errors: account for 20% of medical
injuries
• IV medications associated with 54% of
potential adverse drug events
– 40% of deaths from adverse drug events
due to wrong dose
– 16% deaths from adverse drug events due
to wrong drug
Dallas, TX • November 2–4, 2012
IV Infusion Safety Initiative
• Standardized medication delivery mechanism – identical
IV smart pumps
• Decision-support drug library
– Dose-error Reduction Software
– Customized for different unit types
– Provides alerts
• Capnography monitors for all patients on PCA
• Expanded role for RTs: rounds; first responders
• Wireless networking system – connectivity to pharmacy for
monitoring, trending data
• Ongoing monitoring and analysis . . . and improvement
Maddox, R. R., Danello, S., Williams, C. K., & Fields, M. (2008). Intravenous infusion safety initiative: Collaboration,
evidence-based practices, and “smart” technology help avert high-risk adverse drug events and improve patient
ouitcomes. In Advances in Patient Safety: New Directionsand Alternative Approaches. Vol 1-4, available at
http://www.ahrq.gov/downloads/pub/advances2/vol4/Advances-Maddox_38.pdf
Dallas, TX • November 2–4, 2012
IV Infusion Safety Initiative
Results
• Med errors averted: January-June 2006, 967
errors prevented, including 328 overdoses
• Decreased programming errors during PCA
administration: 52 in first 4 months
• Cost savings: $2 million between Jan-Jun 2006
• Improved nurse satisfaction with IV system
• Nurses felt more comfortable with aggressive
pain management
– St. Joseph’s/Candler Health System
– Read more at AHRQ Innovations Exchange:
http://www.innovations.ahrq.gov/content.aspx?id=2375
Dallas, TX • November 2–4, 2012
Conclusion
• It is not enough for a nurse to be welleducated in the technical aspects of nursing
and be well-intentioned in providing good care.
• Unless there are consistent efforts to measure
and improve care, our health system will
continue to provide great care in some places
and situations, and mediocre or poor care in
others.
• Nurses can make the difference.
Dallas, TX • November 2–4, 2012
Questions?
ppatrici@uab.edu
205-996-5211
Dallas, TX • November 2–4, 2012
Quality and Safety Resources
• Agency for Healthcare Research & Quality, www.ahrq.gov
• AHRQ Patient Safety Indicators (PSIs) – helpful in
defining/standardizing measures:
http://www.qualityindicators.ahrq.gov/Default.aspx
• Centers for Medicare & Medicaid Services, www.cms.gov
• Hospital Compare, www.hospitalcompare.hhs.gov
• Institute for Healthcare Improvement, www.ihi.org
• Institute of Medicine, www.iom.edu
• Institute for Safe Medical Practices, www.ismp.org
• National Quality Forum, www.qualityforum.org
• Quality and Safety Education for Nurses, www.qsen.org
• The Joint Commission, www.jointcommission.org
• US Pharmacopeia, www.usp.org
Dallas, TX • November 2–4, 2012
Other Resources
Bielaszka-DuVernay, C. (2011). Health policy brief. Improving quality and safety. Health
Affairs. www.healthaffairs.org
Institute of Medicine. (2001). Crossing the quality chasm. Report brief. Available at
http://www.iom.edu/~/media/Files/Report%20Files/2001/Crossing-the-QualityChasm/Quality%20Chasm%202001%20%20report%20brief.pdf
Institute of Medicine. (1999). To err is human: Report brief. Available at
http://www.iom.edu/~/media/Files/Report%20Files/1999/To-Err-isHuman/To%20Err%20is%20Human%201999%20%20report%20brief.pdf
Nembhard, I. M., Alexander, J. A., Hoff, T. J., & Ramanujam, R. (2009). Why does quality
of health care continue to lag? Insights from management research. Academy of
Management Perspectives, 23(1), 24-42.
Wachter, R. (2010). Patient safety at ten: Unmistakable progress, troubling gaps. Health
Affairs, 29(1),165-173.
Dallas, TX • November 2–4, 2012
Professional Organizations
• American Society for Quality www.asq.org
Global community of people passionate about quality
who use the tools and their ideas to make our world
work better. The global voice of quality.
• AcademyHealth http://academyhealth.org/
Seeks to improve health and health care by generating
new knowledge and moving knowledge into action.
Dallas, TX • November 2–4, 2012
Professional Organizations
• The Dartmouth Institute
www.tdi.dartmouth.edu/
Dedicated to improving health care through
education, research, policy reform, leadership
improvement, and communication with patients and
the public.
• Microsystem Academy
http://clinicalmicrosystem.org/
The Place That Works: patients, families, and care
teams.
Dallas, TX • November 2–4, 2012
Professional Organizations
• Healthcare.gov:
http://www.healthcare.gov/law/resources/r
eports/quality03212011a.html#na
“Take health care into your own hands.” Consumerfocused web site.
• Institute For Safe Medication Practices
www.ismp.org/
Devoted entirely to medication error prevention and
safe medication use.
Dallas, TX • November 2–4, 2012
Professional Organizations
• Institute for Healthcare Improvement:
http://www.ihi.org/
Focuses on motivating and building the will for change;
identifying and testing new models of care in
partnership with both patients and health care
professionals; and ensuring the broadest possible
adoption of best practices and effective innovations.
• Academy for Healthcare Improvement:
http://www.a4hi.org/
Aim is to foster an interprofessional community that
advances quality improvement in health care through
scholarly and educational activities.
Dallas, TX • November 2–4, 2012
Professional Organizations
• National Quality Forum: www.qualityforum.org/
Promotes change through development and implementation of a
national strategy for health care quality measurement and
reporting.
• National Priorities Partnership
http://www.nationalprioritiespartnership.org/
Convened by the National Quality Forum, The National Priorities
Partnership (NPP) offers consultative support to the Department
of Health and Human Services on setting national priorities and
goals for the HHS National Quality Strategy. The 48 member
organizations also play a key role in identifying strategies for
achieving the aims of better care, affordable care, and healthy
people and communities; and facilitating coordinated, multistakeholder action.
Dallas, TX • November 2–4, 2012
List of QI/Safety Journals
• http://www.sgim.org/userfiles/file/SGIM
%20August%202011%20Web(1).pdf
Dallas, TX • November 2–4, 2012
RCA
• The Joint Commission has a nice framework for
conducting a Root Cause Analysis:
http://www.jointcommission.org/Framework_for_
Conducting_a_Root_Cause_Analysis_and_Acti
on_Plan/
• Great example of RCA: Smetzer, J., Baker, C.,
Byrne, F. D., & Cohen, M. R. (2010). Shaping
systems for better behavioral choices: Lessons
learned from a fatal medication error. The Joint
Commission Journal of Quality and Safety,
36(4), 152-163.
Dallas, TX • November 2–4, 2012
FMEA
• For more information on FMEAs, go to
http://asq.org/learn-about-quality/processanalysis-tools/overview/fmea.html
• Click on flowcharts or go to:
http://asq.org/learn-about-quality/processanalysis-tools/overview/flowchart.html
Dallas, TX • November 2–4, 2012