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IOM (1990)

Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.

SPO- Donabedian

(Safety)

(Effectiveness)-

(Patient Centeredness)

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A Diagram of Cost of Quality over Time

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Safety Culture

Sorra et al. AHRQ, 2004

1. A reporting culture

2. A just culture

3. A flexible culture

4. A learning culture

James Reason,managing the risks of organizational accidents

(no(no(no(no----blame)blame)blame)blame)

(high (high (high (high reliability organization HRO)reliability organization HRO)reliability organization HRO)reliability organization HRO)

(Observing)(Observing)(Observing)(Observing)(Reflecting) (Reflecting) (Reflecting) (Reflecting) (Creating) (Creating) (Creating) (Creating) (Acting) (Acting) (Acting) (Acting)

Institute of Medicine Institute of Medicine Institute of Medicine Institute of Medicine To Error is HumanTo Error is HumanTo Error is HumanTo Error is HumanNational Health Service National Health Service National Health Service National Health Service Organization with a Organization with a Organization with a Organization with a MemoryMemoryMemoryMemory

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JCAHO (JCAHO (JCAHO (JCAHO (2007200720072007))))

American Hospital AssociationAmerican Hospital AssociationAmerican Hospital AssociationAmerican Hospital Association

To err is human.

To cover up is unforgivable.

To fail to learn is inexcusable.

-Sir Liam Donaldson, Chief Medical Officer, England

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listen to patient

patient and family

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