Quality Management Systems, Tools, and Patient Safety

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Quality Management Systems, Tools, and Patient Safety

Healthcare Organization and Management · Chapter 12: Quality Improvement and Process Excellence in HealthcareSection 12.4 · lesson 72 of 10510 min · free with a free account

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Earn 3 college credits for Healthcare Organization and ManagementRecommended for credit by NCCRS · Health 302 · self-paced · one payment, lifetime access
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In this lesson

Building connected quality systems and using tools to improve patient safety.

  • Describe the six parts of a quality management system and the governance line for quality
  • Choose a quality tool such as a Pareto chart, run chart, control chart, or fishbone diagram by the question it answers
  • Compare retrospective root cause analysis with proactive failure mode and effects analysis
  • Classify safety events and explain why near-miss reporting and high reliability habits matter

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Transcript

Everything said in the video, section by section (1,388 words). Read along, or search it.

Opening Case

Good People Working in Bad Systems

In nineteen ninety-nine, the Institute of Medicine's report, To Err Is Human, estimated that forty-four thousand to ninety-eight thousand Americans die each year from medical errors in hospitals. The exact numbers are still debated. The report's central message isn't: most errors come from good people working in bad systems. So what does a system that catches problems actually look like, at a hospital like Larkfield? And why can a hospital have every safety program, and still not be safe?

Quality System

Six Parts That Must Connect

The answer starts with a quality management system: the connected arrangements through which an organization defines, monitors, improves and assures its quality. It has six parts. Policy: what it commits to. Structure: who owns quality at each level. Measurement: the indicators. Improvement activity. Review by people with authority to act. And documentation. The connections are what fail. Measurement that reaches no review produces unread reports. Review without improvement capability produces concern and no change. And documentation without the other five is the classic failure: a quality department, and no quality system.

Governance

An Unbroken Line of Accountability

Quality is a governance job, with an unbroken line of accountability. The board answers for quality of care with the same standing as for finance. A quality committee reviews performance and holds executives to account. Executives own the systems that deliver quality. Department managers own the quality of their departments' work. Two failures recur. A board pack of indicators with no story invites the board to stare at whichever number is red, usually not the most important one. And a committee that reviews performance, without ever asking who can run an improvement project, keeps commissioning work nobody can deliver.

Quality Tools

Pick the Tool by the Question

The quality toolset is small, and each tool answers one kind of question. Pick the tool by the question, not by familiarity. A check sheet: how often, and when? A Pareto chart: where is the problem concentrated? A run chart: is it changing, signal or noise? A cause-and-effect diagram: what might be causing it? A process map: what steps and handovers are there? An impact-and-effort matrix: what should we try first? The order that works is collect, display, explore, prioritize. Teams that jump straight to a cause diagram explore their assumptions, not their data.

Pareto Chart

Three Circumstances Behind Most Falls

Here's a Pareto chart of the two hundred falls on Larkfield's medical units last year, by circumstance, largest first. Unassisted trips to the toilet, ninety-two. Getting out of bed at night, forty-six. Medication side effects, twenty-eight. Then footwear, equipment, and other: sixteen, ten, eight. The top three make up a hundred sixty-six of two hundred: eighty-three percent. Work on those, and you're working on most of the problem. Two cautions. It ranks by frequency, not harm, so a rare but severe category needs separate handling. And a big other bar means the categories were wrong.

Cause and Change

Fishbone Diagrams and Control Charts

To explore causes, a cause-and-effect diagram, also called a fishbone or Ishikawa diagram, groups candidate causes by type: people, process, equipment, environment. It lists what might be operating. It can't tell you which causes actually do, or how much each contributes. For change over time, there's the control chart, which goes back to Walter Shewhart in the nineteen twenties. It's a run chart with statistical control limits drawn above and below the center line. A point outside the limits, or an unusual pattern, signals special cause variation. Points wandering inside them are the process's ordinary noise.

Quick Check

Is Hourly Rounding Working

Quick check. 4 South started hourly rounding in March. Since then, its monthly falls rate has bounced up and down. The manager wants to know if the rounding is working, or if this is noise. Which tool answers that? Pause, and decide. A run chart. Plot the monthly rate in time order with its median, and look for a shift, like six points in a row below the median since March. A Pareto chart is tempting, because it's about falls. But it shows where falls concentrate, not whether the rate changed over time.

Retrospective Analysis

Ask What Conditions Made It Possible

Patient safety analysis comes in two kinds. Retrospective analysis examines events that already happened: incident reports and near misses, structured reviews, and for serious events, a root cause analysis. What matters is the question asked. An analysis aimed at who was involved produces a name and no change. One aimed at what conditions made it possible produces fixes for everyone. Stopping at individual error stops at the last link. The screen design, the store room layout, the shift's staffing, the vague protocol all stay in place for the next person. And its built-in limit: it only studies what already went wrong. A hospital relying on it alone improves at the rate it harms people.

Proactive Analysis

Severity, Occurrence, and Detection in FMEA

Proactive analysis asks what could go wrong, before it does. The main method is failure mode and effects analysis, or FMEA. The team walks a process step by step. For each step, it lists the ways it could fail, and rates each failure on three things. Severity: how serious would it be? Occurrence: how likely is it? And detection: how likely is it to be caught before it reaches the patient? Detection is the least intuitive. A failure that's sure to be noticed at once is less dangerous than a rarer one, one that would pass unseen. Run it before a change: a new process, a system setting, a move to a new location. Afterward, the failures get discovered the other way.

Event Types

Why Near Misses Are Valuable

Safety events come in three kinds. A near miss could have caused harm, but didn't, by interception or luck. A no-harm event reached the patient without injury. A harm event caused injury. Near misses are the most valuable safety data a hospital has. They're far more numerous, so patterns show early. They carry the same information about system weakness, since the difference is often just whether someone noticed. And they can be studied without the defensiveness that surrounds harm. So a rising near-miss count is usually a good sign: staff are noticing and reporting. A falling count, with harm unchanged, usually means a hospital is becoming less visible to itself.

Reporting Culture

Conditions That Make Staff Report

Reporting depends on conditions, not instructions. Staff report when it's quick, when they aren't blamed, when reports visibly lead to change, and when they hear back that their report was read. Each of those is within a manager's influence. The last, telling the reporter what happened, is the cheapest and the most neglected. The opposite is just as specific: a twenty-minute form, silence afterward, and the last reporter getting spoken to. That produces a low reporting rate, which leaders misread as safety.

Quick Check

A Wrong-Strength Vial Caught in Time

Quick check. A nurse notices a wrong-strength vial on the medication tray. She swaps it before the dose is drawn up, so it never reaches the patient. How is the event classified? Pause, and decide. A near miss. The vial was swapped before the dose was drawn up, so nothing reached the patient. A no-harm event is tempting, since nobody was hurt. But that label is for an error that reached the patient and caused no injury.

High Reliability

Five Habits of Reliable Organizations

Some industries run hazardous processes with very few catastrophes. Karl Weick and Kathleen Sutcliffe described five habits of these high reliability organizations. Preoccupation with failure: small signals are information, not noise. Reluctance to simplify: resist easy explanations. Sensitivity to operations: leaders know what's happening at the front line. Commitment to resilience: build the ability to recover, not only to prevent. And deference to expertise: in a problem, decisions go to whoever knows most, not whoever ranks highest. They're dispositions, easy to endorse and hard to live. The test is observable: does a small anomaly get discussed, or explained away?

Being Safe

What Happens to Information

That's the difference between having a safety program and being a safe organization. A hospital can have a reporting system, a committee, policies, training and a dashboard, and still be unsafe. It shows in what happens to information. In a safe organization, a problem noticed at the front line reaches someone who can act, gets acted on, and the person who raised it finds out. Every part of a quality management system exists to make that sequence happen reliably. A part that doesn't contribute to it is just documentation.

Key Takeaways

Quality System and Safety Essentials

To recap. A quality system's six parts only work when they're connected. Choose the tool by the question: collect, display, explore, prioritize. Look back with root cause analysis, and ahead with FMEA. Treasure near misses, and tell reporters what happened. And judge safety by what happens to information.

About Healthcare Organization and Management at UPI Study

Healthcare Organization and Management (Health 302) is a self-paced online course of 105 video lessons in 18 chapters, from health systems and the law to ethics, leadership, teams, strategy, informatics, finance, quality, human resources, marketing and evidence-based practice. It carries a NCCRS credit recommendation for 3 semester credits.

Every lesson transcript is free on pages like this one, and the videos are free with a free UPI Study account. Enrolling adds a practice quiz after each lesson, the graded work and final exam that earn the credit, lifetime access, and an official transcript on completion. UPI Study has helped over 130,000 students with college credits. ACE and NCCRS have over 2,100 cooperating colleges that will consider accepting credits; the final decision is with the universities.

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Why take it here

Why students take Healthcare Organization and Management with UPI Study

How hospitals and clinics are runHealthcare Organization and Management covers how care organizations are led and run: health law and ethics, leadership and teams, strategic planning, health informatics, budgets, quality improvement, staffing and marketing. It is a core course in healthcare administration and health management degrees.
Credit at a fraction of the priceThe same 3 credits can cost $750 or more at a US college. Here it is one payment, self-paced, with lifetime access.
Finish your degree soonerTransfer credits reduce the courses you still owe, so you can graduate earlier or lighten a heavy semester.
Strengthen an applicationA completed college-level course on an official transcript shows admissions and scholarship committees you can do the work.
Study on your own scheduleNo start dates, no deadlines. Watch the lessons, practice, and take the final when you are ready.
130,000+students helped with college creditsACE and NCCRS have over 2,100 cooperating colleges that will consider accepting credits; the final decision is with the universities.

Where the credit goes

Universities that work with NCCRS

Healthcare Organization and Management carries a NCCRS credit recommendation. These universities work with NCCRS; some are UPI Study's signed partners. ACE and NCCRS have over 2,100 cooperating colleges that will consider accepting credits; the final decision is with the universities.

Thomas Edison State UniversityThomas Edison State UniversitySigned partnerUniversity of the PeopleUniversity of the PeopleSigned partnerCharter Oak State CollegeCharter Oak State CollegeSigned partnerStrayer UniversityStrayer UniversitySigned partnerColumbia Southern UniversityColumbia Southern UniversitySigned partnerIndiana TechIndiana TechSigned partnerPenn StatePenn StateWorks with NCCRSSouthern New Hampshire UniversitySouthern New Hampshire UniversityWorks with NCCRSSUNYSUNYWorks with NCCRS +many more cooperating universitiesFind my college →

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FAQ

Questions students ask us

About Quality Management Systems, Tools, and Patient Safety

What is a Pareto chart and how is it used in healthcare quality improvement?
A Pareto chart ranks the categories of a problem by frequency, largest first, to show where the problem is concentrated. If 166 of 200 patient falls come from three circumstances, working on those addresses 83 percent of the falls. It ranks by frequency rather than harm, so a rare but severe category needs separate attention, and a large other bar suggests the categories were poorly chosen.
What is FMEA in patient safety?
Failure mode and effects analysis, or FMEA, is a proactive method that asks what could go wrong before it does. A team walks a process step by step, lists the ways each step could fail, and rates each failure for severity, occurrence, and detection. It is best run before a change, such as a new process, a new system setting, or a move to a new location.
What is the difference between a near miss, a no-harm event, and a harm event?
A near miss could have caused harm but did not reach the patient, because it was intercepted or by luck. A no-harm event reached the patient without causing injury, and a harm event caused injury. Near misses are especially valuable safety data because they are more numerous, reveal the same system weaknesses, and can be studied without the defensiveness that surrounds harm.
What are the five principles of a high reliability organization?
Karl Weick and Kathleen Sutcliffe described five habits: preoccupation with failure, reluctance to simplify, sensitivity to operations, commitment to resilience, and deference to expertise. In practice they mean treating small signals as information, resisting easy explanations, knowing what happens at the front line, building the ability to recover, and letting whoever knows most decide during a problem. A useful test is whether small anomalies get discussed or explained away.

About the Healthcare Organization and Management course

How many college credits is Healthcare Organization and Management?
Healthcare Organization and Management (Health 302) carries a NCCRS credit recommendation for 3 semester credits. ACE and NCCRS have over 2,100 cooperating colleges that will consider accepting credits; the final decision is with the universities.
How much does Healthcare Organization and Management cost and what is included?
$250, paid once, with lifetime access: all 105 video lessons, a practice quiz after each, the graded work and final exam, and an official transcript when you finish. Students who want several courses choose UPI Study PRO instead.
Which universities accept UPI Study credits?
UPI Study has signed partner agreements with universities such as Thomas Edison State University, University of the People and Charter Oak State College, and works with universities such as Penn State, SNHU and SUNY. ACE and NCCRS have over 2,100 cooperating colleges that will consider accepting credits; the final decision is with the universities. Use "Find my college" on this page to check yours.
How long does Healthcare Organization and Management take?
It is self-paced with no deadlines. The 105 lessons total about 17 hours of video; most students add reading and practice time and finish in a few weeks to a few months, on their own schedule.
How are the exams done?
Quizzes and assignments are online in the course. The final exam is taken online with proctoring; a person on the UPI Study team checks assignments, usually within two days.
How do my credits reach my college?
When the course shows 100% complete, request the official transcript from your dashboard. It is sent to the college you name, and you can send it to more than one. Check your college first with "Find my college" on this page, or ask Athena.

Ready for the full course? Earn 3 credits in Healthcare Organization and Management.

105 video lessons, a quiz after each one, and the graded work that earns the credit. Recommended for credit by NCCRS.

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