Chapter 21

Chapter 21
Quality Improvement and Patient
Safety
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Urgent Case for Quality
Improvement in the U.S. Health
Care System
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 2

 Between 44,000 and 98,000 Americans die from
medical errors annually (IOM, 2000)
 Medication-related errors for hospitalized
patients cost $2 billion annually (IOM, 2000)
 49 million uninsured Americans exhibit
consistently worse clinical outcomes than the
insured and are at increased risk for dying
prematurely (Kaiser Family Foundation, 2011)
Selected Indicators from
Recent IOM Reports

 Lag between discovery of more effective forms
of treatment and their incorporation into routine
patient care is 17 years (IOM, 2003)
 25% of patients are not receiving care that is
recommended (AHRQ, 2010)
 The 2008 National Healthcare Quality report
notes that U.S. health care quality is suboptimal
and continues to improve at a slow pace (AHRQ,
2010)
Selected Indicators from
Recent IOM Reports (cont'd)

 Safe: avoiding injuries to patients caused by the
care that is intended to help them
 Timely: reducing waits and sometimes harmful
delays for those who receive and give care
 Effective: providing services based on scientific
knowledge to all who could benefit, and
refraining from providing services to those not
likely to benefit
IOM’s Six Aims to Guide
Improvements

 Efficient: avoiding waste of equipment, supplies,
ideas, and energy
 Equitable: providing care that does not vary in
quality because of personal characteristics such
as gender, ethnicity, geographic location,
socioeconomic status
 Patient-centered: providing care that is
respectful of and responsive to individual patient
preferences, needs, and values, and ensuring
that patient values guide all clinical decisions
IOM’s Six Aims to Guide
Improvements (cont'd)

 Care based on continuous healing relationships
 Care customized to patient needs and values
 The patient is the source of control
 Knowledge is shared, and information flows freely
 Decision making is evidence based
 Safety is a system property
 Transparency is necessary
 Needs are anticipated
 Waste is continually decreased
 Cooperation among clinicians is a priority
Ten Simple Rules to Guide
Improvements

 Total quality management (TQM)
 Continuous quality improvement (CQI)
 Continuous process improvement
 Statistical process control
 Performance improvement (PI)
Quality Buzzwords

 Quality: customer defines quality
 Scientific approach: organizational support for all
employees to develop knowledge and skills in
the science of QI
 “All one team”: belief in the people who are
working to serve the customer
Cornerstones of Quality
Management

 Customers pay attention to both personal
interactions and products or services
 If the “bundle” of products or services provided
is seen as a good value, then customer loyalty is
enhanced
Quality

 Improvement decisions based on sound, valid
data
 Variation in processes must be understood
 Common cause variation: stable, predictable, and in
statistical control
 Special cause variation: unstable, unpredictable, and
not in statistical control
Scientific Approach

 Believe in people and treat everyone in the
workplace with dignity, trust, and respect
 Everyone in the organization works together to
continually enhance customer satisfaction
All One Team

Quality Management in
Health Care

 W. Edwards Deming
 American pioneer in quality management movement
 Introduced U.S. to quality management principles
 Worked with the Japanese in post–World War II
reconstruction efforts
 Hospitals the first health-related organizations to
explore quality efforts beginning in the 1980s
History

 Quality assurance
 Inspection oriented
 Reactive to problems
 Corrected special problems and did not address
overall process improvement
 Responsibility belonged to only a few people
Quality Assurance to Quality
Improvement

 Quality improvement
 Planning and prevention oriented
 Problem solving by employees at all levels
 Correction of common cause problems and
improvement in work processes
Quality Assurance to Quality
Improvement (cont'd)

 Drive quality improvement efforts in health care
facilities
 Almost all regulatory and voluntary accrediting
agencies require quality management in some
form
Regulatory and Accreditation
Agencies
17

 Regulatory organizations
 Centers for Medicare & Medicaid Services (CMS)
• Administers the Medicare program
• Requires quality management in “Conditions of Participation”
 State licensing authorities require quality
management activities and set quality standards
Regulatory and Accreditation
Agencies (cont'd)

 2002: TJC required accredited hospitals to collect data on
standardized “core” performance measures
 2004: TJC and CMS aligned their current and future measures
common to both organizations
 Standardized core measures are referred to as National Hospital
Quality Measures
 2009 reporting requirements allow hospitals to collect and
submit data on a minimum of four core measure sets or a
combination
 Core measures address acute myocardial infarction, heart
failure, pneumonia, pregnancy and related conditions, surgical
care improvement project (SCIP), children’s asthma care,
hospital outpatient department, and hospital-based inpatient
psychiatric services
The Joint Commission Core
Measures

1. A patient understands that the hospital where he
is currently having a procedure done is “Joint
Commission” accredited. The patient asks the
nurse how accreditation ensures that patients
receive the best care possible. The nurse informs
the patient that there are several quality initiatives
required by The Joint Commission in order for the
hospital to be accredited. One of these quality
initiatives is known as:
A. Pareto charts
B. Never events
C. Core measures
D. PDSA cycle

Clinical Indicators and Process
Improvement Tools

 Foundation for quality monitoring and evaluation
 Measurable aspects of care that show the
degree to which clinical care is carried out (e.g.,
administer correct IV solution at prescribed rate)
 Used as an assessment of clinical care to
identify areas in which quality improvement
issues may be present
 Help to identify the goals of quality improvement
Clinical Indicators

 Lean methodology
 Six Sigma
 Failure mode and effects analysis
 All support the understanding of key work processes:
 Analyzing and clearly understanding the work process
 Selecting the key aspects of the process to improve
 Establishing “trial” targets to guide improvement
 Collecting and plotting data
 Interpreting results
 Implementing improvement actions and evaluating effectiveness
Process Improvement
Strategies/Models

 Flowchart
 Maps out what actually occurs in a work process
 Includes steps and substeps, and who does the work
 (see Figures 21-1 and 21-2 in the text)
Process Improvement Tools

 Pareto chart
 Bar chart
 Reflects frequency at which events occur, or the effect
events have on a process
 (see Figure 21-3 in the text)
(cont'd)

 Cause-and-effect diagram
 Lists potential causes arranged by category to show
their effect on a problem
 Helps determine potential causes of a problem
(cont'd)

 Run chart
 Graph of data points as they occur over time
 Sometimes referred to as time plots
 A control chart is a more sophisticated run chart that
helps to distinguish between “common” cause and
“special” cause
(cont'd)

2. A quality improvement team was collecting data to
determine how nurses use their time and to identify areas
to improve nurses’ efficiency. The team found that 60% of
nurses’ time was spent charting, 30% was spent in direct
patient care activities, and 10% was spent on patient and
family teaching. Which type of chart would best support the
data collected by the quality improvement team?
A.Cause and effect
B.Flowchart
C.Pareto
D.Time plot

Understanding, Improving, and
Standardizing Care Processes

 Referred to as best known methods or best
practices
 Care carried out in uniform, systematic method
 Employees trained to perform procedures
according to standards rather than learning by
watching others
 Avoids haphazard changes to procedures
 Standardized practices should be based on
scientific evidence and research
Definition and Purpose of
Standardization

 Clinical guidelines or pathways
 Outline the optimal sequencing and timing of clinical
interventions for a particular diagnosis or procedure
 Benefits
 Reduction in variation of care provided
 Facilitation and achievement of expected outcomes
 Reduction in care delays and lengths of stay
 Improvements in cost-effectiveness
 Increase in patient and family satisfaction with care
Methods of Standardization

 Clinical algorithms or protocols: outline decision
paths that a practitioner might take during a
particular care episode or need (e.g., ACLS
algorithms)
Methods of Standardization (cont'd)

Breakthrough Thinking

 Knowledge about how to achieve better
performance in health care has been attained,
although it is not always used
 Strong examples reveal organizations that have
applied the knowledge and “broken through” to
achieve substantial results
Premises of Breakthrough Thinking

 Voluntary organization formed to assist health
care leaders to improve quality
 Led development of change concepts for
specific areas
 Reducing patient delays
 Reducing cesarean deliveries
 Reducing adverse drug events
Institute for Healthcare
Improvement (IHI)

 Three fundamental questions
 What are we trying to accomplish?
 How will we know that a change is an improvement?
 What changes can we make that will result in
improvement?
Two-Part Model for Improving
Health Care (IHI)

 Plan–do–check–act (PDCA) cycle
 Plan: develop action plan based on the three
questions
 Do: take action to test the action plan
 Check: make refinements as needed
 Act: implement resultant changes in real work settings
Two-Part Model for Improving
Health Care (IHI) (cont'd)

Patient Safety

 Identifies five practices that improve nurses’ work
environments and are linked to quality and safety
 Balance the tension between efficiency (productivity) and
reliability (safety)
 Support the development and maintenance of trusting
relationships throughout work areas
 Actively manage the process of change
 Involve workers in decision making pertaining to work design
and workflow
 Use knowledge management practices to establish a “learning
organization”
Keeping Patients Safe: Transforming
the Work Environment of Nurses (IOM,
2004)

 Nonprofit organization known as an education resource
for the prevention of medication errors
 Provides independent, multidisciplinary, expert review of
reported errors
 Health care professionals across the nation voluntarily
and confidentially report medication errors and
hazardous conditions that could lead to errors
 Offer Medication Safety Self Assessments to allow
nurses and other health care professionals to assess the
medication safety practices in their work setting
 www.ismp.org
Institute for Safe Medication
Practices

 TJC sentinel event standard
 Requires organizations to carry out designated steps
to fully understand the factors and systems
associated with adverse patient events
 Root cause analysis: conducted to understand the
systems at fault within the organization so that
improvements can be determined and implemented to
prevent future occurrences
Programs Initiated in Response to
Imperative to Improve Patient
Safety

 TJC National Patient Safety Goals
 Purpose: promote specific improvements in patient
safety with the goals highlighting problematic areas
and evidence-based solutions to the problems with
system-wide solutions wherever possible
Imperative to Improve Patient Safety
(cont'd)
42

 TJC 2010 National Patient Safety Goals
 Improve the accuracy of patient identification
 Improve the effectiveness of communication among caregivers
 Improve the safety of using medications
 Reduce the risk of health care–associated infection
 Reduce the risk of patient harm resulting from falls
 Prevent health care–associated pressure ulcers
 The organization identifies safety risks inherent in its patient
population
 Universal Protocol—the organization fulfills the expectations set
forth for eliminating wrong site, wrong procedure, wrong person
surgery
(cont'd)
43

 CMS “never events”
 Serious, costly errors that should never happen
 Examples: wrong site surgery, mismatched blood
transfusions, patient falls, hospital-acquired infections
 CMS will no longer pay the additional cost of
hospitalization of such conditions as an incentive to
hospitals to prevent the events
(cont'd)

 Answers for improved patient safety require all
care providers to pull together to review critical
circumstances and learn from key events
 Nurses’ challenge is to make patient safety a
personal priority
The Professional Nurse and
Patient Safety

 Two significant nursing functions closely
influence patient safety and quality
 Monitoring for early recognition of adverse events,
complications, and errors
 Initiating deployment of appropriate care providers for
timely intervention and response/rescue of patients in
these situations
Patient Safety (cont'd)

 National Database of Nursing Quality Indicators
(NDNQI)
 Indicators that strongly affect clinical outcomes
 Two major purposes
• Provide comparative data to health care organizations to
support quality improvement activities
• Acquire national data for better understanding of link
between nurse staffing and patient outcomes

 Quality indicators
 Nursing hours per patient day
 Staff mix (RNs, LPNs/LVNs, UAP)
 Hospital-acquired pressure ulcers
 Falls/injury resulting from falls
 Nurse staff satisfaction/RN survey
 Pediatric/neonatal only: pain assessment and peripheral IV
infiltration
 Psychiatric only: physical/sexual assault
 RN education and certification
 Nurse turnover
 Nosocomial infections

 Work environment that supports effective
communication of nurses with other health care
professionals is critical to patient safety
 Patient care dependent on effective
communication to support coordination of
activities to promote efficiency and safety
Interprofessional Teamwork

 Enter practice with the knowledge and skills to
make quality improvement part of their regular
work
 Quality improvement should not be considered a
separate function within the nursing role but
rather an ongoing part of the professional role
Nurses’ Role in Quality
Improvement

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