1. Survey of Medical Informatics CS 493 – Fall 2004 November 8, 2004 V. “Juggy” Jagannathan

2. Quality Improvement and Proactive Hazard Analysis Models: Deciphering a New Tower of Babel Appendix F: Patient Safety - Achieving a New Standard of Care. IOM Report

3. Quality improvement Two category of tools – page 473 table  Continuous quality improvement, six sigma and Toyota production system  Proactive hazard analysis tools – healthcare failure mode and effect analysis Shewhart and Deming analytical approaches

4. Tools brief Table D-1 pg 474 Table D-2 pg 476

5. Commonalities between the approaches Each tool is a scientific and statistical analytical approach to analyzing a process  Scientific  Decision driven by data  Process focus  Improvement focus  Prevention focus  Team approach

6. Common elements for QI tools Customer focus Waste reduction Empowerment Reducing errors to near zero Focus on control Organizational

7. Features of PHA tools Hazard score matrix Regulatory oversight – FDA Identification of critical process steps International standard Attempts to look broadly to identify hazards Attempts to identify rare multi-failure cases Fault trees and risk assessment Assignment of specific probabilities

8. IOM recommendation – establish a clearinghouse for process and methodological related information for healthcare

9. Hazard Analysis approach Identify high-risk process Create a process flowchart Assess implementation of process Assess variability of implementation and failure modes Assess effects of failures Root cause analysis of critical possible failures Redesign process to eliminate/reduce failures Recursive analysis of the overall redesigned process Evaluate process using simulation Evaluate process using pilots Identify and collect performance measures Monitor and implement a process of continuous improvement

10. Data requirements Error taxonomy  Impact  Type  Domain  cause

11. Case Studies