James Reason (2000) described two approaches to viewing and managing human errors – the person and the system. The person approaches errors as a result of deficient mental processing or lack of morals. This may include a lack of attention to detail or motivation, forgetfulness, or general careless behavior. Errors are typically managed with discipline, …
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Change is difficult for most people. It often requires moving outside of one’s comfort zone, doing something different, or acquiring new skills. Understanding the dynamics of change management is another necessary leadership skill when implementing quality and safety initiatives. Though there are many different models of change, this article will be focusing on Kurt Lewin’s …
The United States has one of the highest rates of healthcare costs in comparison to countries of similar economic development. Unfortunately, this does not equate to a better quality of care. Despite high costs, the U.S. ranks poorly in the areas of life expectancy and other quality areas (Burke & Ryan, 2014). According to Dr. …
Successful project planning involves starting with the end in mind, meaning planning for sustainability from the onset. Too often as new projects come in, attention shifts, and backsliding can occur. In the Institute for Healthcare Improvement’s white paper titled “Sustaining Improvement” (2016) key lessons are summarized from high-performing healthcare organizations known for their clinical excellence. …
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When integrating change into practice, it’s important to understand the threats to integrating quality and safety work and planning for success. This is the third article in a series describing challenges encountered in this area, and it highlights backsliding, knowledge degradation, and large-scale implementation without testing. Backsliding Backsliding occurs when there is initial improvement noted …
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When integrating change into practice, it’s important to understand the challenges involved with quality and safety implementation and sustainability. This will allow for adequate planning and preparation. This is the second article in a series describing challenges encountered in this area, and it highlights lack of upper-level support, project fatigue, inadequate personnel, and competing priorities. …
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When integrating change into practice, it’s important to understand the common barriers encountered in quality and safety implementation. This will allow for adequate planning and preparation. Some of the challenges include a lack of team integrity and disruptive and hierarchical behavior. Unfortunately, these factors can contribute to medical errors and patient harm. Historically disruptive and …
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In order to continuously improve quality and safety within healthcare, processes must be monitored before and after changes are implemented to determine if improvement has been made. There are various ways to track progress with data including run charts and control charts. Run charts are useful in providing a quick analysis and visual review of …
As part of the quality improvement process, data is needed to identify a baseline current state, determine gaps, and track progress towards a target rate. Dashboards are one way to display these components and enable a picture of current performance. Think of dashboards as performance monitoring systems, similar to an automobile dashboard that provides real-time …
Tracking change with quality improvement efforts requires establishing clear data definitions, using a standardized method of data collection, and displaying the data in a manner that generates meaningful information. To begin, in order to determine if improvement has been made, one must establish that a change has occurred and that it has led to improvement. …
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