Statements of expectation set by a competent authority concerning a degree or level of requirement, excellence, or attainment in quality or performance.
Use of performance information to determine the degree to which an acceptable level of quality has been achieved.
System in which individuals in an organization look for ways to do things better, usually based on understanding and control of performance variation.
Individuals, groups, or agency with ultimate legal authority and responsibility for overall operation of an organization; sometimes called board of trustees
Degree to which health services for individuals and population increase like the likelihood of desired health outcomes and are consistent with current professional knowledge.
Planning and making changes to current practices so performance will be better in the future.
Collection of information for the purpose of understanding current performance and seeing how performance changes over time.
Medical staff executive committee
Leadership group of a hospital’s organized medical staff that exercises primary authority over activities of the medical staff and over performance of individuals with hospital clinical privileges
Health services misuse includes incorrect diagnoses as well as medical errors and other sources of avoidable complications
Overuse occurs when a health service is provided even though its risk of harm exceeds its likely benefit.
Actions taken to reduce the risk of patients being unintentionally harmed by effects of healthcare services.
Collections of actions following prescribed procedures for bringing about a result
Way of doing business which continuously improves products and services to achieve even better levels of performance.
Quality management plan
Written description of the organizational structure, responsibilities, procedures, processes and resources supporting an organization’s quality management system
Quality Management System
Organizational structure, responsibilities, procedures, processes and resources supporting the design, measurment, assessment and improvement of key functions and key processes, sometimes referred to as the quality program or performance improvement program
Person, group, organization, or entity with a direct or indirect stake in an organization because it can affect or be affected by that organization’s actions, objectives and performance
Occurs when a health service is not provided though it would have been medically beneficial
Any organization or individual that is licensed or trained to give healthcare.
Any organization or individual that pays for healthcare services either directly or indirectly.
Any recipient of healthcare services.
Key Dimensions of Healthcare Quality Identified by the Institute of Medicine
Three Primary Activities of Quality Management
Quality is the responsibility of
everyone working in healthcare
this individual often a nurse or social worker, helps coordinate patient services among and between caregivers and provider sites.
This individual helps assure the organization adheres to external regulations and accreditation requirements related to quality management
Health Data Analyst
this individual gathers, evaluates and reports information in support of various quality management activities–may have clinical, health information management or informatics expertise
Infection control practitioner
this individual collects and analyzes health data related to patient infections and disseminates information on prevention of infections–typically filled by nurse, physician, epidemiologist or medical technologist
this individual serves as a liaison and primary customer service contact for patients and family members–often gather patient and family complaint data for performance measurment purposes
Patient safety officer
this individual oversees patient safety improvement activities which may include evaluation of patient incident data, facilitation of safety improvement projects and coordination of information flow about patient safety among relevant administrative and medical staff committees
this individual serves as a full or part-time quality management advisor– works closely with the quality department and medical staff president to ensure appropriate physician participation in, and communication of, quality management activities–may serve as advisor for UM activities
this individual serves as the administrative head of the quality department and performs or coordinates functions assigned to that department– assists senior leadership in facilitating compliance with quality-related accreditation standards, government regulations and purchaser requirements
this individual provides guidance and assistance in support of liability control programs including reporting and analysis of patient and employee incidents and identification and control of liability risks throughout the organization
this individual is involved in resource management activiites to prevent underuse and overuse of services–determine appropriateness of care–collect utilization-related data for quality management purposes
CMS and NCQA requires a quality management plan but
TJC does not but is implied that it is desirable
Quality management is the means by which high quality patient care is maintained and improved in all levels of the system —
individual, departmental and organizational
What involves gathering information to determine current levels of performance?
What involves finding the cause of performance gaps and implementing interventions to correct cause of undesirable performance?
What involves evaluating current levels of performance to determine if there are gaps between expected and actual quality?
What are the Core Elements of a quality management system?
–leadership oversight and accounability
–quality infrastructure, including routine meetings with cross-departmental representation
–performance measurement of key clinical and service areas
–activities aimed at improving performance in clinical and service areas
–involvement of stakeholders and transparency of performance data
What is the range of groups involved in the quality management system of a healthcare organization?
Second Tier Groups
Third Tier Groups
Quality Management Support Services
Who is responsible for ensuring continuous quality improvement and for establishing and cultivating a culture of safety?
The Senior Leaders (president, chief operating officer, vice presidents, medical director)
Quality management oversight committees or councils: coordinates quality management activities, evaluate the performance of physicians involving credentialling, privileging, and PPEs
Second Tier Groups (Medical staff executive committee in hospital)
Any number multi-disciplinary committee or group formed to support various areas of quality management:
3rd tier groups (cancer committee) Medical staff and administrative committees
Quality Management Support Services: vary considerably among organizations:
Health Data Analyst
Infection control practitioner
Patient safety officer
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