A3
the size of paper that used to create a visual map of an improvement plan
What is A3?
reason that some might not want to disclose an error
What is fear?
information is gathered about the best way to solve a problem
What is the plan cycle of the PDSA/PDCA?
a standard set within an industry or discipline that is used to set a target for everyone to compare to or use; expectation
What is a benchmark?
important nursing responsibilities related to keeping patients safe
What are vigilance and surveillance?
the side of the A3 dedicated to finding the root cause of the problem to be solved
What is the left side?
how errors, accidents, or unsafe conditions are reported
What is an event reporting system?
a small test of change using info from the problem analysis
What is the "do" part of the PDSA/PDCA cycle?
a goal or aim
What is a target?
the steps taken after a change is deemed successful
What is embed and sustain?
another word for interventions or actions used to reach the target future state
What are countermeasures?
possible causes of an error are carefully explored by a team
What is Root Cause Analysis (RCA)?
data from during and after the change is implemented is reviewed and compared to a baseline
What is the "study or check" portion of the PDSA/PDCA cycle?
possible, implement, challenge, kill
What is a PICK chart?
processes have clear steps that everyone knows and that happen every single time
What is standardization?
the side of the A3 associated with how the problem is solved over time
What is the right side of the A3?
a philosophy that looks at errors as opportunities for improving processes and systems
What is Just Culture?
based on data analysis, a change is adopted, adapted or aborted
What is the "act" in the PDSA/PDCA cycle?
a diagram looking at causal factors named after QI pioneer, Ishikawa
What is a fishbone diagram?
because patients should not be injured by avoidable mistakes
Why is quality improvement important?
Specific, Measurable, Attainable, Relevant, Timebound
What is a SMART goal?
term for trauma experienced by healthcare staff involved in a safety event
What is second victim?
the term for PDSA/PDCA building on each other, one informing the next
What is iterative?
a tracking tool for everyone impacted by a change, their role, and how to get them involved
What is a stakeholder engagement plan (SEP)?
bears a responsibility to perform their best and report any safety risks, near misses, or errors
Who is every member of the healthcare team?