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Risk Management / CQI. Nutr 564: Management Summer 2005. Risk Management / CQI. Risk Management / CQI. Objectives: Review issues on patient safety Identify components of quality assurance processes Describe a ‘culture of safety’ Characterize ‘risk’ situations in health care.

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Risk management cqi

Risk Management / CQI

Nutr 564: Management

Summer 2005

Risk management cqi2

Risk Management / CQI


Review issues on patient safety

Identify components of quality assurance processes

Describe a ‘culture of safety’

Characterize ‘risk’ situations in health care


Shaping the Future for Health

November 1999



Health care in the United States is not as safe as it should be--and can

be At least 44,000 people, and perhaps as many as 98,000 people, die

in hospitals each year as a result of medical errors that could have

been prevented, according to estimates from two major studies

Patient safety
Patient Safety

  • 2005 proposed budget for patient safety is $84 million.

  • The Centers for Medicare & Medicaid Services (CMS) has made it clear that patient safety is indistinguishable from quality of care.

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Risk Management / CQI

  • What are Medical Errors?

  • Medical errors happen when something that was planned as a part of medical care doesn't work out, or when the wrong plan was used in the first place

  • Where do they happen:

    • Medical errors can occur anywhere in the health care system:

      Hospitals Clinics

      Outpatient Surgery Centers Doctors' Offices

      Nursing Homes Pharmacies

      Patients' Homes

  • http://www ahrq gov/consumer/20tips htm

    Concept discussion
    Concept Discussion

    • What is an SOC?

    • Review the table on P. 5 of the “Docs Need SOCs”. Can you add any additional activities where a health center’s quality counts?

    • What type of teams might best support the quality improvement process outlined in this document?

    Risk management cqi4

    Risk Management / CQI

    Quality Assurance

    is a dynamic, systematic process that assures the delivery of high-quality care to clients

    Risk management cqi5

    Risk Management / CQI

    QA Process

    Identify or define the problem

    Establish a method to evaluate the problem

    Set a timeline for data collection

    Collect the data

    Analyze the results

    Discuss the findings and make conclusions

    Suggest alternatives to rectify the problem

    Try a solution – evaluate

    Develop a system to monitor the success

    Implement a system to reevaluate the plan with set time criteria

    Risk management cqi6

    Risk Management / CQI

    Clinical Indicators:

    Measurement tool used to monitor and evaluate quality

    Process indictor

    Outcome indicator

    Rate-based indicator

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    Risk Management / CQI

    Process Indicator - measures an activity

    Easy to Measure

    May not directly impact safety

    Process Indicators - Examples

    Volume Indicators / Service Trends


    Patient Satisfaction

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    Risk Management / CQI

    Outcome Indicator

    Measures what happens after an activity

    Outcome Indicator

    Examples: Weight loss


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    Risk Management / CQI

    Rate-based indicator:

    Assesses an event for which a certain proportion of the events that occur are expected

    Rate-based indicator:

    Example: Proportion of patients NPO 24 hours after surgery

    Prevention quality indicators

    Prevention Quality Indicators:

    The PQIs are a set of measures that can be used with hospital inpatient discharge data to identify "ambulatory care sensitive conditions" (ACSCs).

    ACSCs are conditions for which good outpatient care can potentially prevent the need for hospitalization, or for which early intervention can prevent complications or more severe disease.

    Prevention quality indicators1

    Prevention Quality Indicators:

    Prevention Quality Indicators: developed by Stanford University under a contract with the (AHRQ)

    Diabetes short-term complication AR Perforated appendix AR

    Diabetes long-term complication AR Pediatric asthma AR

    Chronic obstructive pulmonary disease Pediatric gastroenteritis

    Low birth weight rate Hypertension AR

    Congestive heart failure AR Dehydration AR

    Bacterial pneumonia AR Urinary tract infection AR

    Angina admission without procedure Uncontrolled diabetes AR

    Adult asthma AR

    Rate of lower-extremity amputation among patients with diabetes

    AR = admission rate

    In patient quality indicators

    In-Patient Quality Indicators

    Complications of Anesthesia Death in Low-Mortality DRGs

    Decubitus Ulcer Failure to Rescue

    Foreign Body Left During Procedure Iatrogenic Pneumothorax

    Selected Infections due to Medical Care Postoperative Hip Fracture

    Postoperative Respiratory Failure Birth Trauma – Injury to Neonate

    Postoperative Sepsis Postoperative Wound Dehiscence

    Accidental Puncture or Laceration Transfusion Reaction

    Postoperative Physiologic and Metabolic Derangements

    Postoperative Pulmonary Embolism or Deep Vein Thrombosis

    Postoperative Hemorrhage or Hematoma

    Obstetric Trauma with or without 3rd Degree Lacerations– Vaginal with

    Instrument; Vaginal without Instrument; Cesarean Delivery

    Risk management cqi10

    Risk Management / CQI

    Elements of successful CQI projects

    Team effort in design

    Employee involvement at all levels

    Quality is part of job description

    Safety in participation

    Continuous effort

    Culture of safety

    Culture of Safety


    People would report error

    System would assess error

    Take corrective action

    Monitor for additional sources of error

    without fear of punishment

    Liang BA, MD, PhD, JD

    Concept discussion1
    Concept Discussion:

    • Review the questionnaire “Hospital Survey on Patient Safety Culture”. What is your reaction to this questionnaire?

    • How do you envision using such a questionnaire in a facility?

    • Does the document ‘Docs Need SOCs” convey a culture of safety?

    Culture of safety1

    Culture of Safety

    A safety culture can be defined as:

    a set of values, beliefs, and norms about

    what's important,

    how to behave, and

    what attitudes are appropriate when it comes to patient safety in a workgroup.

    The safety culture is the product of

    individual and group values,



    competencies, and

    patterns of behavior that determine the commitment to, and the style and proficiency of, an organization's health and safety management.

    Culture of safety2

    Culture of Safety

    A safety culture

    A positive safety culture is characterized by

    communications founded on mutual trust,

    by shared perceptions of the importance of safety, and

    by confidence in the efficacy of preventive measures.

    Culture of safety3

    Culture of Safety

    The ten dimensions of patient safety culture

    Supervisor/manager expectations and actions promoting patient safety

    Organizational learning—Continuous improvement

    Teamwork within units

    Communication openness

    Feedback and communication about error

    Nonpunitive response to error (no shame and blame)


    Hospital management support for patient safety

    Teamwork across hospital units

    Hospital handoffs and transitions

    Culture of safety4

    Culture of Safety

    Dr. David Hunt (CMS)

    Intent: An organization must intentionally look for adverse events and the systems that may need attention. The intention is for improvement of systems, not malpractice avoidance.

    2. Relevance: “What” is being looked at is important. There are several relevant topics from which to choose.

    3. Transparency: If the problem is hidden under shame and blame, it will not be transparent; only by bringing it out in the sunlight can problems be addressed.

    Concept discussion2
    Concept Discussion:

    • Does the document ‘Docs Need SOCs” convey a culture of safety?

    Risk management cqi12

    Risk Management / CQI

    Risk Management

    Clinical and administrative activities undertaken to identify, evaluate, and reduce the risk of injury to patients, staff, and visitors and the risk of loss to the organization itself

    Concept discussion3
    Concept Discussion:

    Seattle Times article

    • Picture this same scenario 20 years ago. Describe what you envision would be a traditional management approach to such an event? Do you agree with the approach described in this article?

    • What factors might influence a family’s decision to take legal action?

    Concept discussion4
    Concept Discussion:

    Other safety issues in a health care facility.

    • What are high risk areas in food service?

    • How can a culture of a safety be applied to staff training

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    Risk Management / CQI

    Clinical Nutrition and Food Service Systems

    High risk areas





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    Risk Management / CQI

    Clinical Nutrition and Food Service Systems

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    Risk Management / CQI

    Clinical Nutrition and Food Service Systems

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    Risk Management / CQI

    Clinical Nutrition and Food Service Systems

    High risk areas

    * Equipment - knives / blades

    * Wet floors

    * Cleaning solutions

    * High turnover in personnel