quality improvement principles of quality and safety for hit lecture b this material (comp12_unit2b)...
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Quality Improvement
Principles of Quality and Safety for HIT
Lecture b
This material (Comp12_Unit2b) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013.
Principles of Quality and Safety for HIT
Learning Objectives─Lecture b• Investigate the fallibility of people and systems.• Describe the ways that every system is designed
to achieve the results it gets.• Apply the basic principles of safe design. • Explain the ways that teams make wise
decisions with diverse and independent input.
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Quality Improvement Principles of Quality and
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Principles of Safe Design
• Standardize. – Eliminate steps if possible.
• Create independent checks.
• Learn when things go wrong.– What happened?– Why did it happen?– What did you do to reduce risk?– How do you know it worked?
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Quality Improvement Principles of Quality and
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Standardize
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Quality Improvement Principles of Quality and
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Eliminate Steps
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Quality Improvement Principles of Quality and
Safety for HIT Lecture b
Create Independent Checks
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Quality Improvement Principles of Quality and
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Basic Components and Processes of Communication
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Quality Improvement Principles of Quality and
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The Jelly Bean Test
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Quality Improvement Principles of Quality and
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When you feel something say something!
Don’t Play Man Down
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Safety for HIT Lecture b
Your Role
• Assume things will go wrong• Develop lenses to see systems• Work to Mitigate Technical and Teamwork
Hazards– Standardize work– Create independent checks– Learn from mistakes
• Make wise decisions by getting input from others• Keep the patient the north star
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Quality Improvement Principles of Quality and
Safety for HIT Lecture b
Principles of Quality and Safety for HIT
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Quality Improvement Principles of Quality and
Safety for HIT Lecture b
Principles of Quality and Safety for HITSummary─Lecture b
In this unit we’ve learned about the ways that teams make wise decisions with diverse and independent input. We’ve also explored the importance of communication and especially the place of critical listening.
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Quality Improvement Principles of Quality and
Safety for HIT Lecture b
Principles of Quality and Safety for HITReferences
References• Dayton, E. Joint Commission Journal, Jan. 2007• Johns Hopkins Hospital. Josie King. Available: http://www.hopkinsmedicine.org/hmn/s04/feature1.cfm• Reason, J. BMJ 2000;320:768-770
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Images
Slide 4: A Woman Peers into a Microscope to Examine a Circuit Board. Courtesy National Science Foundation. Available from http://nsf.gov
Slide 5: A Bank of ATMs. Creative Commons: Piotrus. Available from: http://commons.wikimedia.org/wiki/File:PNC_bank_ATMs.JPG
Slide 6. A Three-Point Seat Belt in a Lincoln Town Car. Courtesy Creative Commons Gerdbrendel. Available from: http://en.wikipedia.org/wiki/File:Seatbelt.jpg
Slide 7: Basic Components of Communication. Courtesy Elizabeth Dayton, Joint Commission Journal, Jan. 2007
Slide 8. Jelly Beans. Creative Commons Brandon D
Available from: http://3.bp.blogspot.com/-oxxwjc9sQp8/TbCxyVKPtWI/AAAAAAAAAcA/NkPtINLsFjw/s1600/jelly-beans.jpg
Slide 9: Johns Hopkins lacrosse team . Courtesy Johns Hopkins University.
Slide 11. Josie King. Courtesy Dr. Peter Pronovost. Slide Presentation from the AHRQ 2008 Annual Conference: September 9, 2008 Available from: http://www.ahrq.gov/about/annualmtg08/090908slides/Pronovost.htm