Index

Structural Approaches to Address Issues in Patient Safety

ISBN: 978-1-83867-085-6, eISBN: 978-1-83867-084-9

ISSN: 1474-8231

Publication date: 24 October 2019

This content is currently only available as a PDF

Citation

(2019), "Index", Structural Approaches to Address Issues in Patient Safety (Advances in Health Care Management, Vol. 18), Emerald Publishing Limited, Leeds, pp. 263-269. https://doi.org/10.1108/S1474-823120190000018014

Publisher

:

Emerald Publishing Limited

Copyright © 2019 Emerald Publishing Limited


INDEX

Abstraction hierarchy
, 176–177, 181–185

for case cart preparation
, 186

for sterilization
, 184

Alarm

desensitization
, 137–138

suppression
, 169

“Alert, verbal, pain, unresponsive” scale (AVPU scale)
, 236–237

Algorithm-based patient assessment approaches

algorithm development approaches
, 235–236

considerations
, 236–237

intensive care illness severity scores
, 234–235

literature review of
, 230–237, 231–233

pre-operative and post-anesthesia care level risk assessment scores
, 230–234

“track and trigger” algorithms
, 235

See also System-based approaches for hospitals

American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP)
, 230–234

calculator
, 238

American Heart Association (AHA)
, 161

American Society of Anesthesiologists (ASA)
, 230

Bartlett’s Test of Sphericity
, 105

Beryl Institute
, 256

“Best Care at Lower Cost” report
, 198–199

Blood-stream infections (BSIs)
, 38

Burnout
, 100–101, 102

professionals
, 104

structural equation model
, 109

Cardiac monitoring days (CMD)
, 161, 163–164

Care coordination
, 239, 240–241

Case cart preparation
, 174, 176–177, 179–180, 193–194

Centers for Disease Control and Prevention (CDC)
, 62–63

Fluview
, 63–64

Clinical

decision support tools
, 77

environment
, 104–105

patient-safe working environments
, 101

quality
, 259–260

reasoning skills
, 243

space design
, 77

Computer-based GIS applications
, 62–63

Conservation of Resources Theory
, 104

Continuous cardiac monitoring (CCM)
, 160–161

guidelines for effective
, 161

interventions
, 161–162

methods
, 162–164

orders
, 162

patient classification
, 163

policy
, 169

results
, 164–165

Continuous learning health care system
, 198–199

case setting
, 201–202

cultural catalyst and deterrent themes and sub-themes
, 216–218

cultural enabler and motivator themes and sub-themes
, 207–215

cultural evolution
, 204–214

data analysis and interpretation
, 202–204

practice implications
, 223

procedures and data sources
, 202

study design overview
, 200–201

theory
, 200

See also Health care

Cultural/culture
, 200

catalysts
, 206, 216–218, 221

deterrents
, 206, 216–218, 221

evolution model
, 204–214

Data

consumers
, 245–246

data-driven approaches
, 235–236

producers
, 245–246

source review and open coding
, 202–204

E-prescribing system
, 12–13

Early warning scores (EWS)
, 235

Electronic health record (EHR)
, 63–64, 67, 161

Electronic medical record (EMR)
, 136–137, 237

Emergency department (ED)
, 160–161

boarding rate
, 163–164, 166–169

Ethnography
, 199, 200–201, 203

Exploratory factor analysis (EFA)
, 105

Extended Control Model (ECOM)
, 130, 131, 140

Failure Modes and Effects Analysis (FMEA)
, 194

Failure to rescue events (FTR events)
, 228–229

analysis goals and assessment approach
, 122–124

case example
, 121–122

improvement investigation
, 229

leverage point analysis
, 134–144

macro-level systems analysis
, 124–134

mitigation system analysis
, 121, 147

opportunity for systems analysis of patient safety programs
, 120–121

system requirements development and intervention selection
, 144–146

Foley catheters
, 45, 46

General Surgical Care
, 129–130

Geographic information systems (GIS)
, 62–63

analysis of research gaps
, 66–67

challenges to implementation of Hospital GIS
, 70, 71

complexity assessment using NASSS framework
, 67–69

design/methodology/approach
, 64–65

future directions
, 72

GIS for infection prevention
, 65–66

hospital GIS for outbreak investigation
, 66

limitations
, 71–72

originality/value
, 72

targeted literature review
, 65–66

Glasgow Coma Scale (GCS)
, 236–237

Goodness of fit index (GFI)
, 107–109, 111

Health care

delivery in modern hospitals
, 146

delivery units
, 37–38

design
, 20–21

environment
, 20–21, 40

landscape
, 20

process model development to guide change
, 22–23

PRODUCE
, 23–31

professionals
, 12, 104

services
, 199

systems approach in
, 38–39, 120, 198–199

Health information technology (HIT)
, 38, 75–76, 92–93

Healthcare-associated infections (HAIs)
, 36

central venous catheter
, 48

complex system risk of infection model
, 39–41

fractional factorial experimental design
, 58–59

mixture design and contour plot development
, 53–57

model validation and optimization
, 42

risk
, 47

systems approach in health care and infection control
, 38–39

systems model to simulate and identify effective interventions
, 43–47

See also Hospital-acquired infection (HAI)

Hospital design
, 3, 5, 10

Hospital GIS
, 63–64, 65, 67, 72

challenges to implementation of
, 67–69, 71

for outbreak investigation
, 66

See also Geographic information systems (GIS)

Hospital-acquired infection (HAI)
, 62

See also Healthcare-associated infections (HAIs)

Human factors
, 75–77

analysis to derive design requirements
, 84–85

application to physical space design
, 78

approach
, 101

data collection
, 79–85

evaluating candidate design plan against design requirements
, 85

expert evaluation
, 85–87

findings
, 87–91

identifying vulnerabilities in proposed design
, 85–87

implications
, 92–94

in-depth individual interviews
, 80–83

Interim Build design concept assessment
, 91

methods
, 79–87

metrics development
, 87

NICU redesign effort
, 78–79

observations
, 83–84

recommendations
, 91

revisions to design plan
, 91

stakeholder meeting
, 79–80

Illness-severity scores
, 230

Individuals and Moving Range charts (I-MR charts)
, 164

Infection prevention, GIS for
, 65–66

Institute for Healthcare Improvement’s Framework for Spread
, 200

Institute of Medicine (IOM)
, 75–76

Integrated system approach to design
, 239–248

clinical workflow design
, 241–245

control model of patient care
, 242

flowchart of notification process
, 245

general information flow concept
, 243

information systems infrastructure model
, 245–246

initial stakeholder preferences
, 240

modeling
, 130–132

observations from current state data and algorithm literature review
, 239–240

pilot implementation planning
, 246–248

scope and objectives
, 240–241

Intensive care unit (ICU)
, 126, 162, 230

See also Neonatal Intensive Care Unit (NNICU); Surgical critical care unit (SICU)

Interim Build design
, 79–80, 81–83

Intraorganizational Model for Developing and Spreading Quality Improvement Innovations
, 200

Intravenous medication (IV medication)
, 48

Job Demands-Resources Model (JD-R Model)
, 101–102, 104, 112

Latent safety threat (LST)
, 21–22

Law of Stretched Systems
, 166–169

Lean Six Sigma-based competency development program
, 123, 238

Leverage point analysis
, 134–144

current state analysis
, 138–140

driver diagram
, 145

dynamic system modeling
, 140–141

evidence review
, 134–138

excerpt of requirements document
, 146

inpatient rescue data analysis
, 139

integrated fishbone diagram
, 143

people and teams
, 134–136

simulation of patient deterioration
, 141

stakeholder feedback and analysis integration
, 142–144

technology and socio-technical issues
, 136–138

See also Macro-level systems analysis

Licensed nursing assistants (LNAs)
, 129–130

Life Safety Program
, 127

Light(ing)
, 7–8

optimization
, 7–8

Machine learning approaches
, 235

Macro-level systems analysis
, 124–134

current state analysis
, 127–130

evidence review
, 126–127

institutional-level baseline data for general and FTR specific metrics
, 128

integrated system modeling
, 130–132

process and resource mapping
, 129

stakeholder knowledge elicitation and identification of key system leverage points
, 132–134

See also Leverage point analysis

Macro-system

enablers
, 206–215, 220–221

motivators
, 206–215, 221

Maslach’s burnout measure
, 113–114

Medical error(s)
, 2, 3, 75–76

in obstetric departments
, 100–101

Methicillin-resistant Staphylococcus aureus (MRSA)
, 38–39

Model for Understanding Success in Quality (MUSIQ) model
, 200

Modified Early Warning Score (MEWS)
, 238

Multi-drug resistant organisms (MDROs)
, 62

National Early Warning Score (NEWS)
, 235

Neonatal Intensive Care Unit (NNICU)
, 29–31, 77

redesign effort
, 78–79

Noise reduction
, 8–9

Nonadoption, abandonment, scale-up, spread, and sustainability framework (NASSS framework)
, 64–65

complexity assessment using
, 67–69

Nudging

to raise compliance
, 12–13

solutions
, 4–5

Nurses
, 243–244

Obstetric care, study of
, 99

hypothesized model of study
, 105

item statements
, 106

limitations
, 113–114

method
, 105–106

model fit indices
, 111

one-way analysis of variance
, 110

results
, 107–111

theoretical framework
, 103–105

Ohio State University Wexner Medical Center (OSUWMC)
, 162

Patient assessment
, 239

integrated systems approach to design
, 239–248

literature review of algorithm-based patient assessment approaches
, 230–237

score calculations
, 236

study hospital current state system information
, 238–239

tools
, 229

Patient experience
, 256

analysis
, 258

data collection
, 257

demographics
, 258

metrics of success
, 258

multidimensional definition
, 256–257

performance measures beyond satisfaction scores
, 259

satisfaction
, 256

sharing of data
, 259

survey instrument
, 257

Patient safety
, 93, 100, 228, 259–260

good practices for improving
, 7–13

opportunity for systems analysis of
, 120–121

Patient Safety Indicator 4 (PSI4)
, 127

Pediatric Index of Mortality (PIM2)
, 39–40

Performance improvement (PI)
, 257

Performance measurement
, 247–248

Portsmouth Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (P-POSSUM)
, 234, 237

Post Anesthesia Recovery (PAR)
, 234, 237

Post-anesthesia care unit (PACU)
, 30–31, 129–130, 234

Process for design of user-centered environments (PRODUCE)
, 23–31

assessing outcomes
, 28

construction
, 25–26

design
, 23–25

post go-live
, 27

pre-opening
, 26–27

putting PRODUCE into practice
, 31

scaling model
, 28–29

women’s services and neonatal intensive care
, 29–31

Quality of patient experience
, 259–260

Quick Sequential Organ Failure Assessment Score for Sepsis (qSOFA)
, 235

Registered nurses (RNs)
, 80–81

Rescue

activation
, 239

system
, 127

Risk

algorithms
, 237

analysis model
, 40

model
, 40–41, 42

risk-based index
, 40

scoring mechanisms
, 47

Safety, Communication, Operational Reliability and Engagement survey (SCORE survey)
, 129–130

Salmonella enteritidis
, 66

Sequential Organ Failure Assessment Score (SOFA Score)
, 235

Sexton’s tool version
, 113–114

Simplified Acute Physiology Score 3 (SAPS 3)
, 234

Stakeholder

knowledge elicitation
, 132–134

meeting
, 79–80

Steam sterilizers
, 179

Sterile processing

abstraction hierarchies
, 181–185

approach
, 176

basic system description
, 177–180

case cart interruptions
, 189–191

department (SPD)
, 174, 175

design and setting
, 175–176

general observations
, 189

generalizability
, 192

HTA
, 181

limitations
, 194–195

modeling
, 176–177

performance sampling
, 177, 189–192

tray defect data
, 192

variance matrix
, 185–189

Structural Equation Modeling (SEM)
, 105–106

of burnout
, 109

Structural model of burnout (SMOB)
, 104

Subjective, Objective, Assessment, Plan (SOAP)
, 244

Supporting services
, 23–24

for patient experience
, 256–257

Surgical critical care unit (SICU)
, 129–130

Surgical site infections (SSIs)
, 62

System-based approaches for hospitals
, 6–7

conceptual framework
, 3–6

creating health-promoting environment
, 5–6

directly reducing risks
, 4

encouraging intuitive, safety-promoting behavior
, 4–5

good practices for improving patient safety by design
, 7–13

in health care
, 229

noise reduction
, 8–9

nudging to raise compliance
, 12–13

optimizing latent conditions, supporting staff performance levels
, 4

optimizing lighting
, 7–8

reduction of interruptions
, 9–11

standardization
, 11–12

See also Algorithm-based patient assessment approaches

Systemic inflammatory response syndrome (SIRS)
, 234

Systems engineering
, 229, 242

approaches
, 121

Systems Engineering Initiative for Patient Safety (SEIPS) model
, 23–24, 38, 101, 176–177

SEIPS 2.0 model
, 20–21, 22, 77

“Track and trigger” algorithms
, 230, 235–236

Unit support assistants (USAs)
, 129–130

University Health System Consortium
, 163–164

Urinary tract infections (UTIs)
, 38

User-centered design
, 21–22, 23, 25

User-centered health care environment
, 22

Vancomycin-resistant Enterococcus (VRE)
, 39

Variance matrix
, 176–177, 185–189

for case cart preparation
, 190–191

for sterilization and case cart preparation
, 187–188

Ventilator-associated pneumonia (VAP)
, 38, 45

Visibility
, 80, 87

effective
, 85–87

Welch’s two group t-test
, 164

Women’s services and neonatal intensive care
, 29–31

World Health Organization (WHO)
, 8