HCA 333 1st Edition Exam 1 Study Guide Lecture 1 1 28 Chapter 1 What does the industry want Industry wants safer patients and less errors What are examples of different opinions on how to attain the goal Different opinions include stronger laws more data collection more mandated reporting complete redesign of the delivery system and others What are Key Indicators of success Indicators of success include buy in from leadership buy in from staff What are some obstacles to strengthening patient care through more reporting and data collection Obstacles litigation disciplinary action etc The Institutes of Medicine recommendations Why create a Center for Patient Safety within the Agency for health Care Policy Research Set national goals track progress and issue annual report to the President and Congress Develop knowledge and understanding of errors and evaluate methods of identifying and improving patient safety What are the benefits of a national mandatory reporting system Identify and designate an entity that is held responsible for promulgating and maintaining a core set of standards to be used by states Health care organizations would be required to report standardized information Provide funding technical support expertise How should Congress use the reported information Congress should only use it for improving safety and quality What should health care providers do to demonstrate a greater focus on safety and quality Providers should be mandated to implement meaningful patient safety programs with defined executive responsibility What should public and private purchasers do to improve safety and quality Purchasers should provide incentives What should professional societies and licensing bodies do to improve safety and quality Societies and licensing bodies should incorporate safety and quality into credentialing processes Also develop curriculum and classes promoting safety etc What should the FDA do FDA should focus on drugs labeling packaging naming post marketing surveillance to protect safety of patients How can health care organizations professionals demonstrate their commitment to patient safety HC orgs should have established formal programs clear vision and attention Nonpunative systems for reporting incorporate well understood principles establish interdisciplinary team trainings that incorporate the previous What else could orgs do Implement proven medication safety programs Chapter 2 What is Crossing the Chasm A report b the IOM where a committee created on the behalf of Health Care quality d escribes problems in healthcare and changes needed What are the 15 priority conditions 1 Cancer 2 Diabetes 3 Emphysema 4 High Cholesterol 5 HIV AIDS 6 Hypertension 7 Ischemic heart disease 8 Stroke 9 Arthritis 10 Asthma 11 Gallbladder disease 12 Stomach ulcers 13 Back problems 14 Alzheimer s and other dementia 15 Depression Anxiety What are the priority conditions based on 1 Volume 2 Cost 3 Risk Chapter 6 Why are we interested in Patient Safety Now Errors causing harm to patient safety go back almost 100 00 years Why is accurate counting extremely difficult Costs There are legal cultural and administrative barriers to reporting How should these errors be addressed Systemic Inclusion based on self collected data Finding the Root Cause of the Error When punitive measures don t appear to work Lecture 2 2 4 Chapter 14 Cancer Patient Story Goeltz took it upon herself ot be creative and informed regarding the treatment options Chapter 15 Functional Illiteracy definition Illiterate but able to survive in society What is the connection between low health literacy utilization of health care services Lover the Literacy the higher the utilization How does one assess literacy TOFHLA Test of functional health literacy How is literacy addressed by legislation Title VI Civil rights act then accreditation Chapter 27 What contributes to suboptimal performance Lack of knowledge Lack of skill Results of health related issues mental physical Why is it difficult for organizations people to respond to poor performance Difficulty of detection Organizational barriers Supervisory barriers Economic barriers Lecture 3 2 11 Chapter 4 What is Organizational Development Planned Approach to implementing organizational change that emphasizes the need to integrate individual needs with organizational goals What is The Burke Litwin model of Organizational Development OD A coordinated application of top down bottom up interventions which allows participants to see changes quickly What are the attributes of the Burke Litwin Model External environment examples Organizational Culture of communication Managerial Practices to reduce complexity Individual and organizational performances align incentives Attributes of Leadership Scanning environment Creating a culture Aligning staff around safety Accept accountability Chapter 11 Attributes of High reliability Organizations Flexibly structured Reliability over efficiency Rewards Acknowledgement of risk Valid and reliable sense making Heedfulness of individual players Migrating decision making Big Picture sense of what is going on Redundancy multiple parties can catch mistakes Formal rules and procedures Lots of training Chapter 18 Skills required to be effective Leadership Management of multi disciplinary groups Knowledge Regulation Financing Information systems Organizational culture Process knowledge purpose root cause analysis What is success Every member is of an organization is involved in CQI Chapter 20 What is driving the changes in measuring quality in medicine Complexity Treatments Drugs Organizations of patients What was the historical role of the physician and what is it today Was Absolute leader Today Less direct control and part of a complex team What are the systemic changes Credentialing Privileging processes Assessment of clinical performance Peer review Electronics Catching impaired physicians Ways to deal with disasters Keys to systemic redesign Early involvement of stakeholders Clear and compelling incentives for stakeholders Mitigating the negative effects of electronic systems Clear understanding of how information collection use will affect workflow Training training training Evidence based medicine state of the industry Best practices are not uniformly applied How long does it take for new knowledge to be incorporated into everyday practice i e common sense 17 years Chapter 21 Historically what has been the perceived role of counsel lawyers