Topics of this game:
- This is an error that is due to a product of the system designed.
- The single greatest impediment to error prevention in the medical industry is “that we punish people for making mistakes.”
- You’re making a questionable choice but it’s in a way that the risk isn’t recognized or it feels justified
- At risk behavior is managed through these processes
- Reckless behavior is managed through these processes.
- Your employee has been having trouble getting to work on time. She has a 3-month old child and has found the early morning routine to be quite difficult. She has been counseled about her repetitive tardy arrivals at work. She has been put on notice that per policy, one more tardy day will result in disciplinary action. Today she arrived late again. She claims she was stuck behind an accident. How would you classify this behavior?
- A near-term pregnant patient is told by her PCP she needs to return to the clinic within one week for her next prenatal check-up. The scheduler is new and made a mistake within the system booking the patient for an apt in 2 weeks. Before the next apt the patient goes into labor and the baby is stillborn. The PCP tells the clinic manager that the baby might have lived if the apt had been scheduled correct. This is the employee's first error in scheduling. How would you classify this behavior?
- Housekeeping was waxing floors at 10 pm and couldn't find a wet floor sign. The housekeeper went to another building to find one believing he was alone in the building. The CNO slipped on the wet floor, damaging their knee. Housekeepers have made managers aware of lack of signs requiring them to go search for signs making them behind in work. The manager did not take any action to purchase more. How would you classify the housekeepers behavior?
- Housekeeping was waxing floors at 10 pm and couldn't find a wet floor sign. The housekeeper went to another building to find one beliving he was alone in the building. The CNO slipped on the wet floor, damaging their knee. Housekeepers have made managers aware of lack of signs requiring them to go search for signs making them behind in work. The manager did not take any action to purchase more. How would you classify the managers behavior?
- If the problem is system based what should the focus be on?
- If the problem is due to a human performance issue., how do you correctly diagnosis human errors?
- If the problem is due to a human performance issue., how do you correctly diagnosis at risk behaviors?
- If the problem is due to a human performance issue., how do you correctly diagnosis reckless behaviors?
- You are asked to lead a CAUTI initiative. After reviewing evidence and evaluating adherence, you decide on two interventions. CY22Q1 performance baseline: CAUTI rate - 2.34 per 1,000 catheter days CAUTI SIR (95% CI) = 1.34 (1.09-1.53) CY22Q2 1st initiative: CAUTI rate = 1.15 per 1,000 catheter days; CAUTI SIR (95% CI) = 0.91 (0.81 -1.05) CY22Q3 2nd initiativ: CAUTI rate = 1.56; CAUTI SIR = 0.85 (0.73-0.94) What does this data tell you about performance for CY22Q3?
- You are asked to lead a CAUTI initiative. After reviewing evidence and evaluating adherence, you decide on two interventions. CY22Q1 performance baseline: CAUTI rate - 2.34 per 1,000 catheter days CAUTI SIR (95% CI) = 1.34 (1.09-1.53) CY22Q2 1st initiative: CAUTI rate = 1.15 per 1,000 catheter days; CAUTI SIR (95% CI) = 0.91 (0.81 -1.05) CY22Q3 2nd initiativ: CAUTI rate = 1.56; CAUTI SIR = 0.85 (0.73-0.94) Do you expect a performance change?
- You are asked to lead a CAUTI initiative. After reviewing evidence and evaluating adherence, you decide on two interventions. CY22Q1 performance baseline: CAUTI rate - 2.34 per 1,000 catheter days CAUTI SIR (95% CI) = 1.34 (1.09-1.53) CY22Q2 1st initiative: CAUTI rate = 1.15 per 1,000 catheter days; CAUTI SIR (95% CI) = 0.91 (0.81 -1.05) What does the data tell you about baseline performance?
- You are asked to lead a CAUTI initiative. After reviewing evidence and evaluating adherence, you decide on two interventions. CY22Q1 performance baseline: CAUTI rate - 2.34 per 1,000 catheter days CAUTI SIR (95% CI) = 1.34 (1.09-1.53) CY22Q2 1st initiative: CAUTI rate = 1.15 per 1,000 catheter days; CAUTI SIR (95% CI) = 0.91 (0.81 -1.05) What does the data tell you about the 1st initiative? Do you expect a performance change?
- The following measure hospital performance using sophisticated risk adjustment models to accommodate differences in severity of illness of patients across hospitals.
- These type of programs use a variety of risk adjustment methods to evaluate outcomes.
- The programs use sophisticated multivariate regression models (logistic regression, linear regression) to evaluate mortality and other outcomes (ex: sepsis, PE/DVT, complications, etc.)
- The CDC uses this to evaluate performance (a form of risk adjustment)
- This outcome accounts for different numbers of devices used over a time period, but doesn't account for illness severity. The outcome is good to track performance over a time period, but not great to compare quality. It is not acceptable for financial reward/penalty.
- This measure takes into account risk factors associated with infection incidence. The CDC/NHSN uses sophisticated regression models based on all US hospital data Adjusts for various facility and patient-level factors that contribute to HAI risk within each facility
- When is SIR not calculated?
- In the three components of the Donabedian Model (structure, process, outcomes), structure makes up the following:
- In the three components of the Donabedian Model (structure, process, outcomes), process makes up the following:
- In the three components of the Donabedian Model (structure, process, outcomes), outcomes makes up the following:
- A composite measure that includes things like sepsis, DVT/PE, or other hospital acquired conditions (can feel like you’re being “double-dinged” for this measure)
- Conditions that are related to the care provided and are considered preventable.
- This makes up 15% of overall QBR and includes all cause in-hospital mortality and THA/TKA complications
- This makes up 35% of overall QBR and includes CLASBI, CAUTI, SSI, MRSA, Cdiff, and PSI-90
- This makes up 50% of overall QBR and includes communication, staff response, discharge care, overall hospital rating, and environment rating
- Maryland QBR differs from National VBP as the National VBP components consist of the following:
- CMS payment makes up the following:
- Maryland (HSCRC) payment makes up the following:
- Maryland QBR differs from National VBP as the Maryland QBR components consist of the following:
- The following are causes of quality gaps:
- Key findings from the Rand Study include....
- Doing the right thing for the right patient at the right time in the right way to achieve the best possible results
- Prevention of harm to patients, absence of preventable harm, reducing unnecessary risk
- The following is an example of a Level I nurse performing in the caring practices competency
- The following is an example of a Level 3 nurse performing in the caring practices competency
- The following is an example of a Level 5 nurse performing in the caring practices competency
- Characteristics of HROs: treat any lapse as a symptom that something is wrong. HROs focus on actual as well as near misses for investigation
- Analysis and representation of clinical work processes from the perspective of the staff member(s)
- Assessment of the strengths and weaknesses in the ability of an organization to manage risk
- A prospective assessment that identifies and improves steps in a process, thereby reasonably ensuring a safe and clinically desirable outcome. A systematic approach to identify and prevent product and process problems before they occur
- The analysis of large amounts of data for relationships that have not previously been discovered and increase understanding of work complexities
- Uses graphical symbols to depict the nature and flow of events leading up to an adverse/near-miss event
- A process for identifying the basic or contributing causal factors that underlie variations in performance associated with adverse events or near misses
- Characteristics of HROs: Take deliberate steps to create more complete and nuanced pictures of details surrounding a failed process
- Characteristics of HROs: Maintain an ongoing concern with unexpected. Look for and dealing quickly with latent failures before event occurs
- Characteristics of HROs: focus on detecting, containing, and bouncing back from adverse events.
- Characteristics of HROs: push decision making down to front line and authority moves to people with most expertise regardless of rank
- In the 6 AIMS of fundamental change in HC. The aim of safe is described as the following:
- In the 6 AIMS of fundamental change in HC. The aim of effective is described as the following:
- In the 6 AIMS of fundamental change in HC. The aim of patient centered is described as the following:
- In the 6 AIMS of fundamental change in HC. The aim of timely is described as the following:
- In the 6 AIMS of fundamental change in HC. The aim of efficient is described as the following:
- In the 6 AIMS of fundamental change in HC. The aim of equitable is described as the following:
- What are the 6 AIMS of fundamental change in HC?
- This type of error is a result of an action not taken
- This type of error is due to the result of an action taken
- Results from acceptable diagnosis or therapy (deliberate) that results in complications such as death or arrest. Name an example.
- Errors that should have never occurred.
- Any event that could of had an adverse consequence but didn't. Provide opportunities for developing preventative strategies
- Deviations from process of care that results in harm. Act of commision or omission.
- This error is due to an error in the system or process design. It occurs in combination with XXX. Name an example. It often goes unnoticed for a long period of time.
- This is usually due to an error that is medical or surgical rather than an underlying condition. It is preventable when XXXX. Name an example
- This error takes place between a person and the larger aspect of the system. Name an example.
- Injury causes by substandard medical care. XXX events that satisfy legal criteria.
- Any unexpected occurrence involving death, serious physical, or psychological injury, or 'risk there of'
