A3
Just Culture
PDSA
Vocab
Themes
100

the size of paper that used to create a visual map of an improvement plan

What is A3?

100

reason that some might not want to disclose an error

What is fear?

100

information is gathered about the best way to solve a problem

What is the plan cycle of the PDSA/PDCA?

100

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?

100

important nursing responsibilities related to keeping patients safe

What are vigilance and surveillance?

200

the side of the A3 dedicated to finding the root cause of the problem to be solved

What is the left side?

200

how errors, accidents, or unsafe conditions are reported

What is an event reporting system?

200

a small test of change using info from the problem analysis

What is the "do" part of the PDSA/PDCA cycle?

200

a goal or aim

What is a target?

200

the steps taken after a change is deemed successful

What is embed and sustain?

300

another word for interventions or actions used to reach the target future state

What are countermeasures?

300

possible causes of an error are carefully explored by a team

What is Root Cause Analysis (RCA)?

300

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?

300

possible, implement, challenge, kill

What is a PICK chart?

300

processes have clear steps that everyone knows and that happen every single time

What is standardization?

400

the side of the A3 associated with how the problem is solved over time

What is the right side of the A3?

400

a philosophy that looks at errors as opportunities for improving processes and systems

What is Just Culture?

400

based on data analysis, a change is adopted, adapted or aborted

What is the "act" in the PDSA/PDCA cycle?

400

a diagram looking at causal factors named after QI pioneer, Ishikawa

What is a fishbone diagram?

400

because patients should not be injured by avoidable mistakes

Why is quality improvement important?

500

Specific, Measurable, Attainable, Relevant, Timebound 

What is a SMART goal?

500

term for trauma experienced by healthcare staff involved in a safety event

What is second victim?

500

the term for PDSA/PDCA building on each other, one informing the next

What is iterative?

500

a tracking tool for everyone impacted by a change, their role, and how to get them involved

What is a stakeholder engagement plan (SEP)?

500

bears a responsibility to perform their best and report any safety risks, near misses, or errors

Who is every member of the healthcare team?