Chapter 20

Chapter 20Chapter 20
Managing Quality and RiskManaging Quality and Risk
Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

22Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
ObjectivesObjectives
 Apply quality management principles andApply quality management principles and
strategies.strategies.
 Use the six steps of the quality improvementUse the six steps of the quality improvement
process.process.

ObjectivesObjectives (cont’d)(cont’d)
 Incorporate roles of leaders, managers, andIncorporate roles of leaders, managers, and
followers to create a quality managementfollowers to create a quality management
culture of continuous readiness.culture of continuous readiness.
 Apply risk management strategies to anApply risk management strategies to an
agency’s quality management program.agency’s quality management program.

Case StudyCase Study
A significant increase in patient falls resultingA significant increase in patient falls resulting
in injury has been reported on your unit. Inin injury has been reported on your unit. In
accordance with the National Patient Safetyaccordance with the National Patient Safety
Goals, you are assigned to a multidisciplinaryGoals, you are assigned to a multidisciplinary
Quality Improvement/Risk Management teamQuality Improvement/Risk Management team
to address the problem.to address the problem.

Steps in the Risk ManagementSteps in the Risk Management
ProcessProcess
 Define high-risk situation.Define high-risk situation.
 Patient fallsPatient falls
 Determine frequency of falls.Determine frequency of falls.

Steps in the Risk ManagementSteps in the Risk Management
ProcessProcess (cont’d)(cont’d)
 Intervene and investigate.Intervene and investigate.
 Identify opportunities to improve care.Identify opportunities to improve care.
 Use steps of the QI process.Use steps of the QI process.

Evolution of Quality ManagementEvolution of Quality Management
 DDefine opportunities.efine opportunities.
 MMeasure performance.easure performance.
 AAnalyze opportunity.nalyze opportunity.
 IImprove performance.mprove performance.
 CControl performance.ontrol performance.

Principles of QM and QIPrinciples of QM and QI
 QM most effective in a flat, democratic,QM most effective in a flat, democratic,
organizationorganization
 Managers and workers must be committed toManagers and workers must be committed to
QI.QI.
 Goal of QM is to improve systems andGoal of QM is to improve systems and
processes, not to assign blame.processes, not to assign blame.

Principles of QM and QIPrinciples of QM and QI (cont’d)(cont’d)
 Customers define quality.Customers define quality.
 QI focuses on outcomes.QI focuses on outcomes.
 Decisions must be based on data.Decisions must be based on data.

Comparison of QA and QIComparison of QA and QI
QA ProcessQA Process QI ProcessQI Process
GoalGoal Improve qualityImprove quality Improve qualityImprove quality
FocusFocus Discover/correctDiscover/correct
errorserrors
Prevent errorsPrevent errors
Major tasksMajor tasks Inspection of nurseInspection of nurse
activities;activities;
Chart auditsChart audits
Review nurse activities;Review nurse activities;
Innovation;Innovation;
Staff developmentStaff development
Quality teamQuality team QA or departmentQA or department
personnelpersonnel
Multidisciplinary teamMultidisciplinary team
OutcomesOutcomes Set by QA team withSet by QA team with
input from staffinput from staff
Set by QI team with inputSet by QI team with input
from staff and patientsfrom staff and patients

Steps in the QI ProcessSteps in the QI Process
 Identify needs.Identify needs.
 Assemble multidisciplinary team.Assemble multidisciplinary team.
 Collect data.Collect data.
 Establish outcomes and quality indicators.Establish outcomes and quality indicators.
 Select and implement plan.Select and implement plan.
 Evaluate.Evaluate.

Identify NeedIdentify Need
 Compliance with National Safety GoalsCompliance with National Safety Goals
 Reduction of hospital risk/financial lossReduction of hospital risk/financial loss
 Reduction in LOS after an adverse fall eventReduction in LOS after an adverse fall event
 Improved patient outcomesImproved patient outcomes

Assemble TeamAssemble Team
 NursesNurses
 PhysiciansPhysicians
 Unlicensed assistive personnelUnlicensed assistive personnel
 PharmacistsPharmacists
 Facility/environmental managementFacility/environmental management
representativesrepresentatives
 QI/risk management expertsQI/risk management experts

Collect DataCollect Data
 Define incidence of falls.Define incidence of falls.
 Determine high-risk patients.Determine high-risk patients.
 AgeAge
 Mental statusMental status
 History of fallsHistory of falls
 MedicationMedication
 Physical environmentPhysical environment

Outcomes and IndicatorsOutcomes and Indicators
 Education of 100% of all direct care providersEducation of 100% of all direct care providers
 Completion of Fall Risk Assessment on 100%Completion of Fall Risk Assessment on 100%
of patientsof patients
 Reduction in patient falls by 25% within 3Reduction in patient falls by 25% within 3
months of programmonths of program
 Medical record demonstrating 100%Medical record demonstrating 100%
compliance with Fall Prevention Programcompliance with Fall Prevention Program

Establish Fall Prevention PlanEstablish Fall Prevention Plan
 Consistent use of ID bracelets based on FallConsistent use of ID bracelets based on Fall
Risk Assessment scoreRisk Assessment score
 Implementation of bed alarmsImplementation of bed alarms
 Staff education (e.g., toileting at-risk patientsStaff education (e.g., toileting at-risk patients
routinely)routinely)
 Change of environment (e.g., vertical grabChange of environment (e.g., vertical grab
bars)bars)

EvaluateEvaluate
 Change in incidence of falls (e.g., throughChange in incidence of falls (e.g., through
incident reports, sentinel event monitoring)incident reports, sentinel event monitoring)
 Root cause analysisRoot cause analysis
 Staff compliance with Fall Prevention PlanStaff compliance with Fall Prevention Plan
 Patient/family satisfaction with planPatient/family satisfaction with plan
 Reliability and validity of Fall RiskReliability and validity of Fall Risk
Assessment toolAssessment tool

Standards of Care: FallStandards of Care: Fall
PreventionPrevention
 Nurse practice actsNurse practice acts
 Professional organization guidelinesProfessional organization guidelines
 Institutional guidelines (e.g., policies andInstitutional guidelines (e.g., policies and
procedures, structure/process standards)procedures, structure/process standards)

Standards of Care: Fall PreventionStandards of Care: Fall Prevention
(cont’d)(cont’d)
 Research/evidence-based practice guidelinesResearch/evidence-based practice guidelines
 Accreditation standards (e.g., JCAHOAccreditation standards (e.g., JCAHO
National Patient Safety Goals)National Patient Safety Goals)

National Patient Safety GoalsNational Patient Safety Goals
 Patient identificationPatient identification
 Communication among caregiversCommunication among caregivers
 High-risk medicationsHigh-risk medications
 Infusion pumpsInfusion pumps

National Patient Safety GoalsNational Patient Safety Goals
(cont’d)(cont’d)
 Risk of health care–associated infectionsRisk of health care–associated infections
 Accurate medication across continuumAccurate medication across continuum
 Patient fallsPatient falls

Risk Management: MalpracticeRisk Management: Malpractice
 Duty: Nurse has responsibility to patient.Duty: Nurse has responsibility to patient.
 Dereliction: Nurse did not carry out duty.Dereliction: Nurse did not carry out duty.
 Damage: Patient was injured.Damage: Patient was injured.
 Direct cause: Injury secondary to the nurse’sDirect cause: Injury secondary to the nurse’s
failure to carry out dutiesfailure to carry out duties

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