Quality Improvement & Safety
Quality Improvement Strategy
- System Priority Over Individual Blame: Historically, healthcare has placed blame on individuals for errors. Our QI efforts focus on improving working conditions and processes to prevent errors from occurring in the first place.
- Data-Driven Analysis: We utilize medical data to identify areas for improvement and to track the effectiveness of implemented changes. This allows us to make informed decisions that enhance patient outcomes, efficiency, and cost-effectiveness.
- Technological Integration: By leveraging modern technology, we can manage and interpret vast amounts of data efficiently, facilitating quicker and more accurate quality improvements.
The Six Areas of Quality Improvement:
- Safety: Preventing harm to patients during treatment
- Effectiveness: Providing beneficial services while avoiding ineffective ones
- Timeliness: Reducing delays in care
- Efficiency: Minimizing resource waste
- Equitability: Ensuring consistent quality of care across diverse patient groups
- Patient-Centeredness: Valuing and involving patients in their care decisions
Examples of Quality Improvement Initiatives:
- Reducing medication administration errors
- Decreasing urinary catheter infections
- Improving inter-departmental care coordination
- Enhancing electronic medical record documentation
- Optimizing sepsis care
- Reducing hospital readmissions
- Minimizing medication-related adverse events
Importance of Quality Improvement
Quality improvement is crucial as it leads to significant changes within healthcare institutions, resulting in financial savings and, most importantly, saving lives. For instance, during the COVID-19 pandemic, QI processes were vital in adjusting care methods, reducing deaths, and managing hospital resources effectively.
According to the National Academy of Medicine, quality is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.
Our North Star
We aim to develop a framework that standardizes our processes and structures to reduce variation, achieve predictable results, and improve outcomes for patients, and healthcare systems in collaboration with the M Health Fairview partners in the surgical clinical services line. This involves:
- Structure: Technology, culture, leadership, and physical capital
- Process: Knowledge capital (e.g., standard operating procedures) and human capital (e.g., education and training)
Insight through Quality Measurement
By benchmarking quality measures, we identify best practices in care, recognize research opportunities to advance professional knowledge, and track our quality improvement progress accurately. Currently, we focus on the following metrics:
- Bispectral Index (BIS) Monitoring Use and prevention of burst suppression
- Temperature Management
- Exposure Keratopathy
- Neuromuscular Blockade Management and Reversal
- Perioperative normoglycemia
Below are our active quality improvement projects.
Additional Information
Resident Course in Quality & Safety
Goals
- Promote a culture of safety to maintain a safe and professional work environment for anesthesiology residents.
- Teach key principles of quality improvement methodologies and facilitate efforts to optimize the quality of care for patients and families.
- Disseminate quality improvement and patient safety indicators relevant to anesthesiology practice and raise awareness of individual and departmental practice relative to national performance and standards.
Objectives
After completing the Department of Anesthesiology’s Quality Improvement and Patient Safety Residency Curriculum, residents will be able to:
- Identify patient safety concerns and opportunities for improvement in healthcare systems.
- Understand the adverse event reporting and review processes used by the Department of Anesthesiology and the NewYork-Presbyterian Hospital.
- Apply quality improvement (QI) methods and work in interdisciplinary teams aimed to improve the efficiency and effectiveness of patient care systems.
- Identify challenges and barriers associated with performance improvement initiatives.
- Understand anesthesiology-related quality improvement and patient safety indicators and how to improve individual clinical practice to meet departmental and national standards.
- Execute an A3 project
Glossary of QI Terminology
Action plan: A set of initiatives that are to be undertaken to achieve a performance improvement goal.
Agenda: A list of the task to be accomplished during a meeting.
Balanced scorecard: A model that groups multidimensional performance metrics into perspectives. This typically includes quadrants such as financial, customer, internal processes and learning and growth metrics. It is a measurement system of carefully selected measures derived from the organizations strategy.
Benchmarking: The systematic comparison of the products services, and outcomes of one organization with those of a similar organization; or the systematic comparison of one organization’s outcomes with regional or national standards.
Brainstorming: An idea generation technique in which a team leader solicits creative input from team members.
Cause and effect diagram: An investigation technique that facilitates the identification of the various factors that contribute to a problem; also called a fishbone diagram.
Check sheet: A data collection tool used to identify patterns in sample observations.
Clinical guidelines: The descriptions of medical interventions for specific diagnoses in which treatment regimens and the patient’s progress are evaluated based on nationally accepted standards for each diagnosis.
Clinical practice standards: The established criteria against which the decisions and actions of healthcare practitioners and other representatives of healthcare organizations are assessed in accordance with state and federal laws, regulations, and guidelines; the codes of ethics published by professional associations or societies; the criteria for accreditation published by accreditation agencies; or the usual and common practice of similar clinicians or organizations in a geographical region.
Closed record review: The examination of patient records assumed to be complete with respect to all necessary and appropriate documentation by surveyors from accreditation organizations.
Compliance: The process of meeting a prescribed set of standards or regulations in order to maintain active accreditation, licensure, or certification status.
Continuous Quality Improvement (CQI): A term used in the healthcare industry to describe a constant cycle of improvement. It is usually patient and employee focused.
Control chart: A data display tool used to show variation in key processes over time.
Credential: A formal agreement granting an individual permission to practice in a profession, usually conferred by a national professional organization dedicated to a specific area of healthcare practice; or the accordance of permission by a healthcare organization to a licensed, independent practitioner (physician, nurse, practitioner, and another professional) to practice in a specific area of specialty within that organization.
Credentialing process: The examination of an independent healthcare practitioner’s licenses, specialty credentials, and professional performance upon which a healthcare organization bases its decision to confer or withhold permission to practice (privileges) in the organization.
Cross-functional: refers to a metric, measure or indicator that spans several departments.
Dashboard report: A tabulation of factors, indicators and statistics that are pertinent to a specific organization.
Evidence-based medicine: The care processes or treatment interventions that researchers performing large, population-based studies have found to achieve the best outcomes in various types of medical practice.
FMEA: Failure mode and effect analysis; a tool to support identifying where a system might fail, what the results of the failure are likely and identification of steps that may reduce the chance of system failure. Used proactively to prevent system failure and/or harm.
Flowchart: An analytical tool used to illustrate the sequence of activities in a complex process.
Gantt chart: A type of data display tool used to schedule a process and track its progress over time.
Histogram: A type of bar graph used to display data proportionally.
Key performance factors: Variables especially critical in achieving a desired set of outcomes. Key performance factors are normally linked to core products and services and associated customer expectations. For example, for healthcare, timeliness, quality and cost represent three key performance factors.
Line chart: A type of data display tool used to plot information on the progress of a process over time.
Mean: The average value in a range of values that is calculated by summing the values and dividing the total by the number of values in the range.
Median: A measure of central tendency that shows the midpoint of a frequency distribution when the observations have been arranged in order from lowest to highest.
Measure: A way to describe a specific observation characterizing performance related to an outcome or process. Measure, indicator, metric and criteria are used interchangeably.
Open record review: The examination of health records to determine all necessary and appropriate documentation prior to the patient’s discharge from the health care site. A required element in the CAH State Operation Manual (SOM).
Opportunity for improvement: A healthcare structure, product, service, process, or outcome that does not meet its customers’ expectations and, therefore, could be improved.
Outcomes: The end results of healthcare services in terms of the patient’s expectations, needs, and quality of life; may be positive and appropriate or negative and diminishing.
Pareto chart: A type of bar graph used to determine priorities in problem solving.
Peer review committee: A group of like professionals, or peers, established according to an organization’s medical staff bylaws, organizational policy and procedure, or the requirements of state law; the peer review system allows medical professionals to candidly critique and criticize the work of their colleagues without fear of reprisal.
Performance improvement (PI): An organization wide process that includes clinical care and all other work processes within the organization. Quality improvement and performance improvement are frequently used interchangeably.
Performance Improvement Committee: Members of the healthcare organization who have formed a cross-functional group to examine a performance issue and make recommendations with respect to improvement.
Performance measures: Those outputs by which the quality of the organization and its work units are assessed by patients, clients, visitors, and community leaders.
Pie chart: A data display tool used to show the relationship of individual parts to the whole.
Process: The interrelated activities of healthcare organizations that include governance, managerial support, and clinical services—that affect patient outcomes across departments and disciplines with in an integrated environment.
Quality assurance (QA): A term commonly used in healthcare to refer to quality-monitoring activities during the 1970’s and 1980’s, at which time it was connoted a retrospective review of care provided with admonishment of providers for substandard care.
Quality Improvement (QI): The philosophy that processes, management, and workers all can benefit from learning how to provide better service, products, and ideas. Quality improvement and performance improvement are frequently used interchangeably although quality improvement typically relates to clinical care and services. Improvement always requires change but change is not always improvement.
Root-cause analysis: Analysis of a sentinel event from all aspects (human, procedural, machinery, materials) to identify how each contributed to the occurrence of the event and to develop new systems that will prevent recurrence.
Sentinel event: An unexpected occurrence involving death or serious injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase “or risk thereof” includes any process variation for which a recurrence would carry a significant chance of serious adverse outcome. Such events are called “sentinel” because they signal the need for immediate investigation and response.
Stakeholder: A person or group with an interest in your performance.
Standards of care: An established set of clinical decisions and actions taken by clinicians and other representatives of healthcare organizations in accordance with state and federal laws, regulations, and guidelines; codes of ethics published by professional associations or societies; regulations for accreditation published by accreditation agencies; or usual and common practice of similar clinicians or organizations in a geographical region.
Strategy: A planned approach to gaining advantage, a plan for how the organization will prevail over competitors and obstacles. In practice, considerable variation exists in what organizations consider “strategy”.
Strategic plan: The document in which the leadership of a healthcare organization identifies the organization’s overall mission, vision, and values to help set the long term direction of the organization as a business entity.
Survey: A written or verbal evaluation of a department or organization by its internal and external customers.
Vision: A description of the ideal end state or a description of the best way or process.