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CPPS EXAM STUDY GUIDE
executive sponsor - Answers - "Barrier Buster" The person or group who provides the financial resources for the project Regulator - Answers - Provide public oversight of healthcare entities and providers Name the 6 Major Regulators of Healthcare - Answers - CMS: Sets minimum standard for $$$ Joint Commission: Accreditation NAM: Objective health information NQF: Endorses national standard for science IHI: Improvement science to advance better health outcomes Sentinel event - Answers - unexpected occurrence involving death or serious injury (temporary or permanent) Senior Executive Adopt-a-Work Unit - Answers - pair a hospital executive with a work unit to help them with safety issues Situational Awareness - Answers - Knowledge and understanding of your surroundings and situation and the risk they potentially pose to your safety ROI equation - Answers - savings/investment x 100 RPN equation - Answers - severity x likelihood of UNdetectability x likelihood to happen what makes an RCA credible? - Answers - varied participants internally consistent explains "N/A" or "No problem" when to use the 5 why's - Answers - to get to the root cause Hierarchy of Improvement Strategies - Answers - Education < Rules/Policies < Checklists < Standardization < Automation < Forcing Function RCA Steps and Phases - Answers - Initiation Phase ID event Select team Screening Phase Describe what happened Analysis Phase
ID contributing factors ID root causes Design and implement plan Monitoring Phase Measure success of plan biggest pitfall of RCA - Answers - skipping chronology FMEA Steps - Answers - 1. Select team
- ID process
- Diagram process
- ID failure modes and rank them
- Determine an action plan Latent failure - Answers - a flaw in a system that does not immediately lead to an accident but establishes a situation in which a triggering event may lead to an error. i.e sleep deprivation active failure - Answers - errors at the sharp end (error that occurs at the point of contact) i.e. pushing the wrong button or ignoring a call light bundle - Answers - 3 - 5 evidence based processes that improve pt outcomes meaningful use - Answers - CMS gives $$$ to hospitals with certified EHRs to improve pt care medwatch - Answers - Program that collects data about any undesirable experience with a medical product (dietary supplements, cosmetics, infant formulas, medical foods) Patient Safety Organizations - Answers - - collect, aggregate, and analyze confidential information reported by health care providers ECRI - Answers - Emergency Care Research Institute products and services help the healthcare community to improve quality, reduce cost, and achieve better outcomes across all care settings. OSHA - Answers - Occupational Safety and Health Administration a government agency in the Department of Labor to maintain a safe and healthy work environment
balanced measures - Answers - are these changes causing new problems in other areas of the system? leading cause of sentinel events - Answers - communication failure NIOSH - Answers - Federal agency that recommends ways to prevent work-related injury safe design 3 step strategy - Answers - 1. simplify workflow and standardize equipment
- controls to minimize drift (make desired action the default action)
- ID errors before they can cause harm using redundancy tools qualitative data - Answers - data expressed in NATURAL LANGUAGE central line for control charts - Answers - the mean central line for run charts - Answers - the median (can be the mean) run charts or control charts for patient safety improvement projects? - Answers - run charts shift - Answers - 6+ points above or below the central line stewhart chart - Answers - another name for control chart clinical rounds - Answers - 1 on 1 pt safety rounds - Answers - risk identification Juran's Trilogy of Quality - Answers - Quality Planning Quality Control Quality Improvement Deming's System of Profound Knowledge - Answers - - Appreciation for a system
- Understanding variation
- Theory of knowledge
- Psychology why are runs counted? - Answers - to see if we have enough data points to stop when to use a control chart - Answers - if you have >15 data points the 4 E's - Answers - establish trust encourage reporting eliminate fear of punishment
examine reports measures of central tendency - Answers - mean, median, mode measures of variability - Answers - range, variance, standard deviation model for improvement - Answers - 1. what is your aim?
- how to know change is improvement?
- what change can cause improvement? Who releases Sentinel Event Alerts? - Answers - Joint Commission What does the AHRQ spend most of its money on? - Answers - patient safety HCAHPS - Answers - Survey: Hospital Consumer Assessment of Healthcare Providers and Systems Elicits pt's perspective on healthcare. Carried out by CMS. Rapid cycles of change - Answers - PDSA Parallel Systems - Answers - redundant systems failover - Answers - A technique that ensures a redundant component, device, or application can quickly and efficiently take over the functionality of an asset that has failed. PSO - Answers - Patient Safety Organization Analyzes reported events, purpose is to reduce risk in patient care Do PSO's ever share information publically? - Answers - no Are sentinel events and never events required to be reported to the board of medicine?
- Answers - No. What to do if a patient commits suicide on the unit - Answers - This is a Never Event --
Report
Patient protection events - Answers - • DC of pt wo decision making capacity wo an authorized person
- Infant discharged to wrong person,
- Patient death or serious disability associated with patient elopement,
- Patient suicide or attempted suicide resulting in serious disability during care in a health care facility.
devoted to preventing medication errors shared mental model - Answers - Knowledge, expectations, conceptualizations, and other cognitive representations that members of a group have in common pertaining to the group and its members, tasks, procedures, and resources. human factors science - Answers - Study of the interrelationships between humans, the tools they use, and the environment in which they work and live human factors - Answers - environmental, organizational, and job factors, along with human individual characteristics, that influence behaviors and actions at work human factors analysis - Answers - examines all aspects of a work system and its influence on human performance human factors engineering - Answers - modification of system design to better aid people systems thinking - Answers - focuses on how the system's individual parts affect one another within a whole how does Reason describe safety? - Answers - dynamic non-event 2 types of human error - Answers - Skill based error -- slips of action, memory lapse Mistakes-- rule based or knowledge based IMSAFE - Answers - Illness Medication Stress Alcohol Fatigue Eating/Elimination NCC MERP - Answers - Index for categorizing medication errors AIDET - Answers - acknowledge, introduce, duration, explanation, thank you IDC - Answers - indwelling catheter universal protocol - Answers - conduct pre-op verification, mark procedure site, and perform a time out. premature closure - Answers - stop inquiry once a possible answer is found recall bias - Answers - the error associated with remembering
situational bias - Answers - attributing a behavior more to external circumstances rather than person's inner characteristics availability bias - Answers - a mental shortcut that relies on immediate examples that come to a given person's mind when evaluating a specific topic, concept, method or decision.
