Patient Safety and Quality Improvement: Developing a Systems View (Patient Safety I)

Start Date: 07/05/2020

Course Type: Common Course

Course Link:

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About Course

In this course, you will be able develop a systems view for patient safety and quality improvement in healthcare. By then end of this course, you will be able to: 1) Describe a minimum of four key events in the history of patient safety and quality improvement, 2) define the key characteristics of high reliability organizations, and 3) explain the benefits of having strategies for both proactive and reactive systems thinking.

Course Syllabus

In this module, you will review the history of patient safety and quality improvement in healthcare. You will start with defining the scope of the problem of preventable harm in healthcare which leads into the history of the work that has been done to date that has helped to define, measure and improve preventable harm. You review three landmark reports to ensure you have a deep understanding of this work. At the end of this module, you will be able to: 1) identify a minimum of four key events in the history of patient safety an quality improvement, 2) describe the key characteristics of each of the three landmark patient safety publications and 3) summarize the impact of preventable harm on patients, communities and society.

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Course Introduction

Patient Safety and Quality Improvement: Developing a Systems View (Patient Safety I) Patient safety and quality improvement are at the heart of good patient safety. In this course you will learn best practices for designing and implementing a systems view for quality improvement in healthcare. You will start by learning why patient safety and quality are core considerations for improving patient safety in healthcare. You will learn how to design systems reviews and quality improvement programs to effectively identify problems and evaluate solutions. You will then learn patient safety evaluation criteria and standardized quality measures developed by organizations engaged in quality improvement. You will then learn an evidence-based, data-driven approach to quality improvement that integrates patient safety and quality. You will learn best practices for data collection and analysis, processes for quality improvement, and processes for quality improvement. As a result, you will be able to collect data from patients, data analysts, and improve quality processes. You will also learn how to use best practices in systems use and quality improvement management.Module 1: Patient Safety and Quality Management Module 2: Quality Measures and Criteria Module 3: Data Collection and Analysis Module 4: Systems View and Quality Improvement Management Patient Safety and Quality Improvement: Implementing a Systems View (Patient Safety II) Safety is at the heart of patient safety. In this course you will learn how to design systems reviews and quality improvement programs to effectively identify problems and evaluate solutions. You will learn how to design quality measures and quality improvement processes. You will then learn how

Course Tag

Patient Care Systems Thinking Quality Improvement

Related Wiki Topic

Article Example
Patient safety Quality improvement and patient safety is a major concern in the pediatric world of health care. This next section will focus on quality improvement and patient safety initiatives in inpatient settings.
Patient safety organization On November 5, 2008, ECRI Institute PSO was officially listed as a federal Patient Safety Organization under the Patient Safety and Quality Improvement Act of 2005. ECRI Institute Patient Safety Organization serves nationwide as a PSO directly for providers, hospitals, and health systems as well as provide support services to state and regional PSOs.
Patient safety Patient safety is a discipline that emphasizes safety in health care through the prevention, reduction, reporting, and analysis of medical error that often leads to adverse effects. The frequency and magnitude of avoidable adverse events experienced by patients was not well known until the 1990s, when multiple countries reported staggering numbers of patients harmed and killed by medical errors. Recognizing that healthcare errors impact 1 in every 10 patients around the world, the World Health Organization calls patient safety an endemic concern. Indeed, patient safety has emerged as a distinct healthcare discipline supported by an immature yet developing scientific framework. There is a significant transdisciplinary body of theoretical and research literature that informs the science of patient safety. The resulting patient safety knowledge continually informs improvement efforts such as: applying lessons learned from business and industry, adopting innovative technologies, educating providers and consumers, enhancing error reporting systems, and developing new economic incentives.
Patient Safety and Quality Improvement Act The Patient Safety and Quality Improvement Act of 2005 (PSQIA): , 42 U.S.C. ch. 6A subch. VII part C, established a system of patient safety organizations and a national patient safety database. To encourage reporting and broad discussion of adverse events, near misses, and dangerous conditions, it also established privilege and confidentiality protections for Patient Safety Work Product (as defined in the act). The PSQIA was introduced by Sen. Jim Jeffords [I-VT]. It passed in the Senate July 21, 2005 by unanimous consent, and passed the House of Representatives on July 27, 2005 with 428 Ayes, 3 Nays, and 2 Present/Not Voting.
Patient Safety and Quality Improvement Act The definition of "Patient Safety Work Product" (PSWP) is quite broad. Patient safety work product includes any data, reports, records, memoranda, analyses (such as root cause analyses), or written or oral statements (or copies of any of this material), which could improve patient safety, health care quality, or health care outcomes, that are assembled or developed by a provider for reporting to a PSO and are reported to a PSO. It also includes information that is documented as within a patient safety evaluation system that will be sent to a PSO and information developed by a PSO for the conduct of patient safety activities.
Patient safety organization Patients for Patient Safety is part of the World Alliance for Patient Safety launched in 2004 by the WHO. The project emphasizes the central role patients and consumers can play in efforts to improve the quality and safety of healthcare around the world. PFPS works with a global network of patients, consumers, caregivers, and consumer organizations to support patient involvement in patient safety programmes, both within countries and in the global programmes of the World Alliance for Patient Safety.
Patient safety organization Based in Berlin, the German Agency for Quality in Medicine is a not-profit organisation, which co-ordinates healthcare quality programmes. In the field of patient safety AQUMED was one of the first German organisations calling for effective patient safety programs. The agency was co-founder of the German Coalition for Patient Safety. AQUMED established a national network of Critical Incident Reporting Systems. The institution is partner of the international High 5 Project.
Patient safety organization The Commission engages in collaborative work in patient safety and healthcare quality that benefits from national coordination. This includes the development of the Australian Charter of Healthcare Rights and the National Safety and Quality Health Service Standards, improving areas such as patient identification, medication safety, clinical handover and open disclosure, and reducing healthcare associated infection. The Commission has also developed the National Safety and Quality Framework to improve the safety and quality of the Australian health system.
National Patient Safety Foundation Educating health professionals about patient safety best practices is a key area of focus for NPSF. Since the annual NPSF Patient Safety Congress has brought together health leaders, patient safety professionals, and patient advocates. In recent years, the meeting has touched on some of the most pressing concerns in health care, such as the move toward patient satisfaction as a measure of quality, engaging patients and families in their care, and the use of simulation to teach and promote safe practices.
National Patient Safety Foundation NPSF was instrumental in creating the Certification Board for Professionals in Patient Safety. Established in 2012, the CBPPS is an independent body charged with developing and overseeing a credentialing exam for the patient safety field.
Patient safety Several authors of the 1999 Institute of Medicine report revisited the status of their recommendations and the state of patient safety, five years after "To Err is Human". Discovering that patient safety had become a frequent topic for journalists, health care experts, and the public, it was harder to see overall improvements on a national level. What was noteworthy was the impact on attitudes and organizations. Few health care professionals now doubted that preventable medical injuries were a serious problem. The central concept of the report—that bad systems and not bad people lead to most errors—became established in patient safety efforts. A broad array of organizations now advance the cause of patient safety. For instance, in 2010 the principal European anaesthesiology organisations launched The Helsinki Declaration for Patient Safety in Anaesthesiology, which incorporates many of the principles described above.
Patient Safety and Quality Improvement Act "Patient Safety Organization" (PSO) must certify that it lists the requirements in the PSQIA and be listed on the Agency for Healthcare Research and Quality (AHRQ) web site.
Patient Safety and Quality Improvement Act However, patient safety work product does not include a patient’s medical record, billing and discharge information, or any other original patient or provider information; nor does it include information that is collected, maintained, or developed separately, or exists separately, from a patient safety evaluation system.
Patient safety organization On July 29, 2005, the United States Congress established guidelines for Patient Safety Organizations under the Patient Safety Quality Act of 2005. The focus of the legislation is to provide incentives for clinicians to participate in voluntary initiatives to improve the outcomes of patient care, provide information about the underlying causes of errors in the delivery of health care, and to disseminate this information in order to speed the pace of improvement.
Patient safety Handwritten reports or notes, manual order entry, non-standard abbreviations and poor legibility lead to substantial errors and injuries, according to the IOM (2000) report. The follow-up IOM report, "Crossing the Quality Chasm: A New Health System for the 21st Century", advised rapid adoption of electronic patient records, electronic medication ordering, with computer- and internet-based information systems to support clinical decisions. This section contains only the patient safety related aspects of HIT.
Pennsylvania Patient Safety Authority The Authority is charged to take steps to reduce and eliminate such events through identification of problems evident in the collected data and recommendation of solutions that promote patient safety. As such, the Authority’s tagline is analyzing, educating and collaborating for patient safety. Efforts to improve patient safety in Pennsylvania include patient safety liaisons providing education on a facility-by-facility basis, in-depth education programs, collaborative improvement projects with Pennsylvania healthcare facilities, and the "Pennsylvania Patient Safety Advisory". The "Advisory", a quarterly publication, chronicles events reported to the Authority, “especially those associated with a high combination of frequency, severity, and possibility of solution; novel problems and solutions; and problems in which urgent communication of information could have a significant impact on patient outcomes.”
Patient safety organization The Missouri Center for Patient Safety (MOCPS) is a private, not-for-profit corporation fostering change throughout Missouri’s health care delivery systems and across the continuum of care. It was established by the Missouri Hospital Association (MHA), the Missouri State Medical Association (MSMA) and Primaris in response to recommendations from the Governor’s Commission for Patient Safety. The Center’s vision is “a health care environment safe for all patients, in all processes, all the time." The Center’s mission is “to be a leader in providing solutions and resources to improve patient safety and the quality of health care delivery by conducting activities in collaboration with health care providers, physicians, purchasers, consumers and government."
Patient safety The goal of a healthcare professional is to aid a patient in achieving their optimal health outcome, which entails that the patient's safety is not at risk. Practice of effective communication plays a large role in promoting and protecting patient safety.
Scottish Patient Safety Programme The Scottish Patient Safety Programme (SPSP) is national initiative to improve the reliability of healthcare and reduce the different types of harm that can be associated. The programme is co-ordinated by Healthcare Improvement Scotland and is the first example of a country introducing a national patient safety programme across the whole healthcare system.
Patient safety In public surveys, a significant majority of those surveyed believe that health care providers should be required to report all serious medical errors publicly. However, reviews of the medical literature show little effect of publicly reported performance data on patient safety or the quality of care. Public reporting on the quality of individual providers or hospitals does not seem to affect selection of hospitals and individual providers. Some studies have shown that reporting performance data stimulates quality improvement activity in hospitals.