When a crisis situation is identified in which the health and safety of individuals is at risk
(does not apply to CLIA-lab, but applies to all other types of surveys and investigations)
Defined as: the provider's non-compliance with one or more CoP caused or is likely to
cause, past, present or future serious injury, harm, impairment or death. Also includes
potential for undesired outcome.
Triggers:
Failure to prevent abuse
Failure to prevent neglect
,Failure to protect from psychological harm
Failure to protect from undue adverse med consequences or failure to provide meds as
prescribed
Failure to provide adequate nutrition and hydration
Failure to protect from widespread infection
Failure to correctly identify patients
Failure to safely administer blood products/monitor organ transplantation
Failure to provide safety from fire, smoke and environmental hazards
Failure to train staff in emergency situations
Failure to provide initial screening for OB
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Immediate jeopardy
"Next Monday get RN to use the form for 3 patients"
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Do
Unintended consequence
Example: reduction in C-section rates=balancing measure is mom and baby
morbidity/mortslity
Give this one a try later!
Balancing Measures
,Throughput is the rate at which money is generated, and can be calculated as selling
price minus the price of raw materials.
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Throughput
Created authorized PSOs to improve quality through the collection and analysis of data
on patient events
1. Efforts to improve safety and quality of hc delivery
2. Collect and analyze patient safety work product
3. Develop and disseminate information re: best practices
4. Use patient safety work product to encourage a COS
5. Preserve confidentiality
6. Provision of security measures
7. Use of qualified staff
8. Activities related to the operation of a patient safety evaluation system and feedback
Give this one a try later!
The Patient Safety Act and the Patient Safety Rule
1. All privileges for new practitioners and all new privileges for existing practitioners
(other than board cert.)
2. Peer Review (corrective actions should avoid disciplinary actions, a meeting with a
physician = training, needs focused consultations)
Give this one a try later!
, FPPE when?
Is designed to generate and apply the best evidence for the collaborative healthcare
choices of each patient and provider; to drive the process of discovery as a natural
outgrowth of patient care; and to ensure innovation, quality, safety and value in
healthcare.
Give this one a try later!
A learning healthcare system
80% of observed variations are caused by 20%of process input.
Give this one a try later!
Pareto Principle
Abuse is not one of the types of quality problems identified by the Institute of Medicine's
National Roundtable on Health Care Quality. Misuse, overuse, and underuse are the
three most common problems; they also represent three sources of waste in health care.
The National Roundtable on Health Care Quality was significant because it asserted that
the provision of health care services can be assessed with scientific precision. This was a
major step towards incorporating business and manufacturing productivity systems in
health care.
Give this one a try later!
(does not apply to CLIA-lab, but applies to all other types of surveys and investigations)
Defined as: the provider's non-compliance with one or more CoP caused or is likely to
cause, past, present or future serious injury, harm, impairment or death. Also includes
potential for undesired outcome.
Triggers:
Failure to prevent abuse
Failure to prevent neglect
,Failure to protect from psychological harm
Failure to protect from undue adverse med consequences or failure to provide meds as
prescribed
Failure to provide adequate nutrition and hydration
Failure to protect from widespread infection
Failure to correctly identify patients
Failure to safely administer blood products/monitor organ transplantation
Failure to provide safety from fire, smoke and environmental hazards
Failure to train staff in emergency situations
Failure to provide initial screening for OB
Give this one a try later!
Immediate jeopardy
"Next Monday get RN to use the form for 3 patients"
Give this one a try later!
Do
Unintended consequence
Example: reduction in C-section rates=balancing measure is mom and baby
morbidity/mortslity
Give this one a try later!
Balancing Measures
,Throughput is the rate at which money is generated, and can be calculated as selling
price minus the price of raw materials.
Give this one a try later!
Throughput
Created authorized PSOs to improve quality through the collection and analysis of data
on patient events
1. Efforts to improve safety and quality of hc delivery
2. Collect and analyze patient safety work product
3. Develop and disseminate information re: best practices
4. Use patient safety work product to encourage a COS
5. Preserve confidentiality
6. Provision of security measures
7. Use of qualified staff
8. Activities related to the operation of a patient safety evaluation system and feedback
Give this one a try later!
The Patient Safety Act and the Patient Safety Rule
1. All privileges for new practitioners and all new privileges for existing practitioners
(other than board cert.)
2. Peer Review (corrective actions should avoid disciplinary actions, a meeting with a
physician = training, needs focused consultations)
Give this one a try later!
, FPPE when?
Is designed to generate and apply the best evidence for the collaborative healthcare
choices of each patient and provider; to drive the process of discovery as a natural
outgrowth of patient care; and to ensure innovation, quality, safety and value in
healthcare.
Give this one a try later!
A learning healthcare system
80% of observed variations are caused by 20%of process input.
Give this one a try later!
Pareto Principle
Abuse is not one of the types of quality problems identified by the Institute of Medicine's
National Roundtable on Health Care Quality. Misuse, overuse, and underuse are the
three most common problems; they also represent three sources of waste in health care.
The National Roundtable on Health Care Quality was significant because it asserted that
the provision of health care services can be assessed with scientific precision. This was a
major step towards incorporating business and manufacturing productivity systems in
health care.
Give this one a try later!
