Nursing plays a key role in improving patient safety, quality of care, timely access, and patient-centered care. Nurses should lead quality improvement efforts through leadership, appropriate staffing, education, research, and use of informatics. Ensuring timely access to appropriate, patient-centered care delivered safely and with high quality is essential to achieving health as a human right.

1. ACCESS TO HEALTH CARE:
Safe, quality care
Timeliness to access
People centered care
Geetanjli Kalyan
Tutor
National Institute of Nursing
Education, PGIMER, Chandigarh
The content is prepared for the symposium organized as a part of International Nurses Day 2018.
Theme- Nurses: A voice to lead- Health is a Human Right

2. Error
“To err is Humane ”
• Commission:
• doing the wrong thing
• Omission
• failing to do the right thing

3. ERROR, DEATH AND SAFTEY
Globally
• Out of 421 million hospitalisations, 42.7 million are due to adverse events
ICN
• 1adverse event : 10 hospital admissions
• 1death :300 admissions
WHO
• Medical errors are the14th leading cause of the disease burden.
According to Organisation for Economic Co-operation and Development
(OECD) 2017

4. ERROR, DEATH AND SAFTEY
• Medical errors in top 10 killers
WHO
• 44,000 to 98,000 Americans die each year as a result of medical errors.
Institute of medicine

5. Developed vs Developing nations.
• Developed nation
• Three million people lose their
lives annually due to medical
mistakes and hospital-acquired
infection
• 100 hospitalisations: 7 HAI
• Developing nation
• It's 16 million
Joe Kiani, founder of US headquartered
Global Patient Safety Movement Foundation
(PSMF). Times of India
• 100 hospitalisations: 10 HAI

6. ERROR, DEATH AND SAFTEY
Health world. The economic times. 2016

7. Why human make errors
Doctors
• Fatigue due to long duty hours
85(65%),
• inadequate experience 66(52%),
• inadequate supervision 58(48%)
• complex case 58(45%)
• lack of knowledge (p=0.001),
• missing warning signs (p=<0.001),
• not seeking advice (p=0.003)
• procedural complications
(p=0.001).
Nurses
• Lack of knowledge
• Workload
• Inappropriate nurse patient ratio
• Lack of motivation
• Lack of accountability
• Lack of cross check by supervisors
Patel, Nrupal et al. “A Study of Medication Errors in a Tertiary Care
Hospital.” Perspectives in Clinical Research. 2016

8. As Per ICN (staffing level matters)
• Each 1 patient increase in nurses’ workloads is associated with 7% increase in
mortality
• Each 1 patient increase in patient to nurse work load increases readmissions by:
• 9% for heart failure, pneumonia, AMI
• 11% for children
• 3% for general surgery
• 8% hip and knee replacements
• Hospitals with good nurses staffing levels have 30% fewer hospital acquired
infections
• Each 1 patient increase to nursing workloads increases missed care.

9. Common types of adverse errors/ events
• Medication error: inappropriate selection, inaccurate dose/ interval/
route and wrong patient
• Healthcare-associated infections
• Patient falls
• Pressure ulcers
• Venous thromboembolism (VTE)/ deep vein thrombosis (DVT)
• pulmonary embolism
• Diagnostic error
• Death during interventions with typically low mortality rates.
OECD/ WHO/ Patel, Nrupal et al. “A Study of Medication Errors in a Tertiary Care Hospital.” Perspectives in
Clinical Research. 2016

10. Errors increase cost and length of stay
• Globally US$42 billion annually which is 1% of total global health
expenditure
ICN, 2018
• India PICU
• Cost of patient with HAI 2,04,787 and Non HAI 56,587 respectively
and the mean difference in the total cost between cases and controls was
1,48,200 (p<0.01) and PICU stay by 14.6 days
Sodhi Jitender etal. Healthcare associated infections in Paediatric Intensive Care Unit of a tertiary care
hospital in India: Hospital stay and extra costs. IJMR. 2016

11. Safety

12. Solution is : Quality Improvement
• Quality is related to
• level of improved health services and the desired health outcomes
• Quality improvement (QI):
• Is systematic and continuous actions that lead to measurable
improvement in health care services and the health status of targeted
patient groups.
Institute of Medicine (IOM)

13. “Crossing the Quality
Chasm”
• In 2001 IOM published a report “Crossing the Quality Chasm”
• This report was an urgent call for fundamental change to close
the quality gap
• It was mentioned that though providers have more research
findings and more technology available to them than ever before
still quality is in doubt.

14. Crossing the Quality Chasm: Six dimensions
of high-quality
• Safe
• Timely
• Effective
• Efficient
• Equitable
• Patient centered
Special emphasis to
• Value (ratio of cost, quality care and equity)
• Access
• Prevention

15. Quality improvement through nursing ( as per ICN)
QI by nursing:
Setting the
Standards
LEADERSHIP
STAFFING
LEVELS
CULTURE
SKILL MIX
INTER-
DISCIPLINARY
CARE
RESEARCH
INFORMATICS
EDUCATION

16. LEADERSHIP
• When nurses participate in health service decision making and policy
development it lead to Improved:
• hospital experience for patients
• patient involvement in care
• health literacy
• patient safety
• quality measures and satisfaction among staff members
• quality care at lower cost
• financial performance of an organisation
ICN, 2018

17. Quality improvement through nursing (as per ICN)
QI by nursing:
Setting the
Standards
LEADERSHIP
STAFFING
LEVELS
CULTURE
SKILL MIX
10% decrease:
25% increase
death
INTER-
DISCIPLINARY
CARE
RESEARCH
INFORMATICS
EDUCATION
10% BSc : 7% dec
mortality

18. Timeliness of access
• Timeliness of access is also critical in preventing potentially
harmful delays in the delivery of health care.
• Delays in treatment increase the likelihood of
• Worsening of symptoms and clinical outcomes
• preoperative death
• unplanned emergency admission
• lead to poorer outcomes in terms of physical and social functioning
• Deterioration of the patient’s condition
ICN, 2018

19. In resource limited setting
• Major Problem
• Access
• No means of carrying a labouring women living in an
oversea territory where mainland is separated by a river
(Sodzi Sodzi-Tettey, MD, MPH; IHI Senior Technical Director for
the Africa Region)
• True Indian Story: Dashrath Manjhi living in Gehlaur village,
near Gaya in Bihar, India who spent 22 years chiselling this
massive gap through a mountain out of love for his dead wife,
who died because the 34-mile route round to the nearest town
was too far to take her for urgent medical care The Mountain Man

20. Timeliness of access
• Equitable access to health care of appropriate quality.
• Equitable access is about ensuring that no one is denied access. It is also
matter of scale and timing.
• Appropriate quality: also implies that services will be delivered at the right
time. Timing is an aspect of appropriateness and is closely correlated with
the effectiveness of an intervention
• Solution: RNs triage emergency services, coordinate care and
navigate patients through the system; they reduce length of stays and
expedite patient discharge
ICN, 2018

22. People Centered Care (ICN, 2018)
• People–centred approach : to care delivery is where patient and
family is engaged in care, decision making and treatment
decisions.
• Pattern–centred care : refers to completing numerous tasks within
a specific amount of time with the risk that these tasks take
precedent over engaging and meeting the holistic needs of the
client.

23. Nurses reporting missed care during their
last shift (ICN, 2018)

24. People Centered Care
• In Article 12 of the International Covenant on Economic, Social
and Cultural Rights, persons requiring care have rights to free,
informed, active and meaningful participation in decisions that
affect their lives.
• The right to participation extends further than receiving care, it
also involves the organisation and implementation of health care
services.
• ICN

25. People Centered Care
• “Access to optimal care ultimately requires the person to be fully
engaged in care and this is seen as interacting with the nature of
the service actually offered and provided.”
• ICN, 2018

26. Conclusion
• Patient safety, quality care timely access to care and patient centered care
are the core component of nursing care
• To improve these practice nurse should take lead in quality improvement
and conduct improvement projects in their area of practice on regular
basis.
• Leadership, education, research, appropriate staffing level, good work
culture and informatics can improve care.