Internal Assessment vs. Quality Indicator

Are these one and the same? While both Internal Assessment and Quality Indicators provide methods that a facility can use to evaluate their operations, they are separate and distinct activities.

Internal Assessment:

The planned inspection and examination of a process or quality system to ensure compliance with requirements. These requirements may be those of a regulatory agency or the facilities own policies and procedures.

An Internal Assessment provides the facility with opportunities to find and correct gaps in what the SOP says and what may actually be occurring. It is also the facilities opportunity to identify where a gap might exist between a particular standard or a requirement and what is actual practice.

Internal Audit Examples include:

Obtaining the CAP checklist or AABB assessment tool and performing an audit verifying that all requirements are met.

Tracing a patient specimen from collection to transfusion and ensuring that all the procedures were followed as written and appropriately documented.

Quality Indicator:

An agreed-upon process or outcome measure that is used to determine the level of quality achieved. A measurable variable (or characteristic) that can be used to determine the degree of adherence to a standard or achievement of quality goals.

Ongoing monitoring of selected indicators provides the facility with important information that assists in identifying and resolving problem issues before they become adverse findings on an audit report. For each quality indicator a level of achievement that determines the difference between what is deemed to be acceptable quality (threshold) or not. For example, "the minimal acceptable level of FDA reportable deviations is 0 % percent,”. This means that even one FDA reportable error requires action to be taken and that it is indication of a quality problem. When choosing quality indicators evaluate critical processes in terms of:

High Risk: Poor performance that can cause harm to patients

High Cost: Requires repeat expenses of time and materials

Problematic areas: Problem recurring leading to dissatisfied staff and/or customers

Transfusion services should also consider TJC (The Joint Commission) and CAP defined Patient Safety Goals.

Examples of Quality Indicators include: Mislabeled Specimens Missed Panic Value Calls Reportable and Non-Reportable Events - Other Turn around time

So what do you think? Are they the same?