John Hopkins Quality Improvement Report

Johns Hopkins Health System employs more than 20,000 people annually. It is a diverse organization that is dedicated to its employees, patients, their families, and the community it serves. John Hopkins has spent substantial amount of time, energy, and resources to address and improve patient safety understanding that, like any other area of medicine, science must guide the way to improvement. With a need to train physicians, nurses, medical students and administrators in this evolving area of the science of safety, it found that the best approach is to have that training led by employees that are in the trenches. John Hopkins developed a program that helped better understand how to identify and learn from mistakes. The goal was to establish …show more content…
Because errors are caused by system and process failures, it is important to establish a protocol to control changes associated with these systems. Each of these techniques involve assessing performance and using findings to inform change. Some of the well-known strategies and tools for quality improvement that have been used to improve the quality and safety of health care include: Root-Cause Analysis, Six Sigma, Plan-Do-Study-Act, and Lean. For all of these techniques, the goal is for an organization to establish a measurable outcome system so an organization can determine the effects of health care on desired outcomes and to assess the degree to which health care adheres to processes based on best …show more content…
It also can help to identify need for changes to policies and procedures, and to serve as a basis to suggest system changes, including improving communication of risk. It is one of the most widely used retrospective methods for detecting safety hazards. The goal of RCA, is to prevent future harm by eliminating the latent errors that so often underlie adverse events. The primary aim of RCA is to identify the factors that resulted in the nature, the magnitude, the location, and the timing of the harmful outcomes of one or more past events. It then can determine what behaviors, actions, inactions, or conditions need to be changed. Finally, RCA can prevent recurrence of similar harmful outcomes by identifying lessons that may promote the achievement of better consequences. To be effective, root cause analysis must be performed systematically, usually as part of an investigation, with conclusions and root causes that are identified backed up by documented evidence. A team effort is required for RCA to be successful. RCA can help transform a reactive culture into a forward-looking culture. More importantly, RCA reduces the frequency of problems occurring over time within the environment where the process is