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WHERE TO BEGIN:At the beginning, of course!What is the relationship between Research and Quality Improvement (QI)?The Institute of Medicine has strongly emphasized the need for evidence-based practice to improve quality health care. Unfortunately, the evidence base needed to support effective care is in many cases lacking. It becomes very important that nurses become educated consumers of research and learn how to apply research findings to specific patient situations.To help you understand the research process, we will be going through the process step by step in class using the Great American Cookie Experiment. You will be given a scenario, asked to sign a consent for participation and then participate in the experiment. We will then do some simple statistics and come to some conclusions based on the data we gather. And then we will discuss how this data can be used in a Quality Improvement project.Become one with research – it is now a part of your world as a nurse.Be sure to read the article on Bb:Hudson-Barr, D. (2004). How to read a research article. Journal of Specialists in Pediatric Nursing, (9)2, 70-72.
TERMINOLOGYQuality“The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (IOM, 2001)Quality Management (QM)A preventative approach to address problems before they happen. THIS IS AN IMPORTANT CONCEPT!Quality Improvement (QI)The systematic processes used to measure outcomes, identify hazards and errors, and improve care.Blame-free“In 1997, President Clinton established a short-term commission called the Advisory Commission on Consumer Protection and Quality in the Healthcare Industry. The purpose of this commission was to advise President Clinton about healthcare delivery system changes related to quality, consumer protection, and the availability of needed services. This initiative produced numerous healthcare quality recommendations. The Institute of Medicine, a nonprofit organization established in 1970, was asked to further examine healthcare quality, respond to issues identified in the Presidential Commission’s report, and identify strategies to improve healthcare quality over the next 10 years. The IOM produced numerous reports referred to at the Quality Chasm series. The recommendations of this series of reports will be discussed on slide 5.
WHY IS THERE A NEED TO IMPROVE CARE?The 2000 report by the Institute of Medicine (IOM) “To Err is Human: Building a Safer Health System” revealed ~98,000 deaths in hospitals each year are PREVENTABLE!!!! ~Current system is fragmented and poorly organizedOut of the “To Err is Human” report came far reaching recommendations. Some of these are:Congress should create a Center of Patient Safety with the Agency for Healthcare Policy and Research2. Establish a nationwide mandatory reporting system to collect information about adverse events that result in death or serious harm.3. Performance standards and expectations for healthcare organizations and health professionals should focus greater attention on patient safety. Professional societies should make a visible commitment to patient safety by establishing a permanent committee dedicated to safety improvement.The FDA should increase attention to the safe use of drugs in both pre- and post-marketing processes Healthcare organizations and health professionals should make improved patient safety a serious goal byProviding strong, clear, and visible attention to safetyImplement non-punitive systems for reporting and analyzing errorsIncorporate well-understood safety principlesEstablish interdisciplinary team training programs for providersHealthcare organizations should implement proven medication safety practices
The Six Aims for improving the health care system are based on recommendations from the report Crossing the Quality Chasm. Accomplishing these six aims will require an interprofessional solution to a multifaceted problem. And this collaboration will need to also include the healthcare consumer.The aims are pretty self-explanatory.We need to keep our patients safe from the care we provide. This seems intuitive on so many levels, but it is one of the reasons we need to continuously ask ourselves, “Is what I am doing going to cause harm to the patient? Do the benefits of my care outweigh the risks to the patient?”Is our care effective and based on the most recent evidence? Is it benefitting those who need the care and withheld from those who do not?By now, you should all understand that all the care we provide must be patient-centered. All patients are to be respected, which means we are responsive to our pts based on their preferences, needs, and values – respect must guide all patient interactions.Responding to patient needs in a timely manner is part of patient-centered care. Delays in care can result in serious injury to a patient or an increase in their symptoms. For example, delaying pain assessment and management is not being responsive to a pts needs.Being efficient in the care of pts reduces medical costs. Being disorganized in the care of a patient in isolation results in overuse/disposal of multiple sets of isolation garb, driving up healthcare costs. The care we provide to our patients is the same or equitable, whether that patient is the President of the United States or a homeless person in off the streets for care. There is no room in nursing or medicine for discrimination.
There are several NATIONAL INITIATIVES to address quality in healthcare.The National Database of Nursing Quality Indicators was created by the American Nurses Association in 1998 to collect and evaluate nursing-sensitive indicators. The goal of the NDNQI, as stated on their website, is “to aid the registered nurse in patient safety and quality improvement efforts by providing national comparative data to participating hospitals and conducting research on the relationship of nursing care and patient outcomes.” The primary focus of the NDNQI is to collect data at the Unit level, where nursing occurs. Reports are generated by Unit Type (ICU/CCU, med/surg, OB, Peds, etc). Data is reported on a quarterly basis and specifically addresses nurse staffing and patient outcomes. Reporting is not mandatory and hospitals may choose the specific indicators to meet their needs. These indicators are: Nursing staff skill mix (LPN/RN/ADN/BSN/MSN) Nursing hours per pt day Assault/Injury assault rates Catheter associated urinary tract infections Central line associated blood stream infections Fall rates Injury fall rates Hospital/Unit acquired pressure ulcer prevalence Peripheral IV infiltrations Pain assessment/intervention/reassessment cycle Restraint prevalence RN education/certification RN Education/Certification RN Survey: Practice environment and job satisfaction Ventilator associated pneumonia Voluntary nurse turnoverIn 1999, less than 50 hospitals reported data. By 2011, almost 1700 hospitals were voluntarily reporting data.For pleasure reading, you might consider the book: Patient Safety and Quality: An Evidence-Based Handbook for Nurses. This handbook was developed by the Agency for Healthcare Research and Quality (AHRQ), whose mission is to improve the quality, safety, efficiency, and effectiveness of healthcare for all Americans. Perhaps you are beginning to see a trend here.National Patient Safety Goals (NPSGs) are goals developed by the Joint Commission for every are in which patient care occurs – ambulatory health care, behavioral health care, Home care, hospitals, etc. The JC is the hospital accrediting body so any hospital wishing to be accredited, must meet the National Patient Safety Goals standards. A copy of the 2013 NPSGs are located on Bb
Implementing QI requires that we move from failed standards and develop proactive approaches to solving the problems that have been identified. And it must involve everyone in the organization – especially nurses! All nurses are part of unit-based quality improvement initiatives. In fact, we are the ones who often identify issues that need to be addressed. Perhaps a nurse notes that there is an increase in unit based nosocomial infections. The reasons for this need to be assessed and a plan implemented to decrease the infection rate.
SENTINEL EVENTS – those events that that signal the need for immediate investigation and response. “Unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.” Joint CommissionSpecifically includes loss of limb or functionThe joint commission has identified events that are reviewable by them if the event occurs within an accredited hospital. These events include:Any patient death, paralysis, coma, or other major permanent loss of function associated with a medication errorA patient commits suicide within 72 hours of being discharged from a hospital setting that provides staffed around-the-clock careAny elopement, that is, unauthorized departure, of a patient from an around-the-clock care setting resulting in a temporally related death (suicide, accidental death, or homicide) or major permanent loss of functionA hospital performing the wrong invasive procedure or operating on the wrong side of the patient’s body, on the wrong site on the patient’s body, or on the wrong patientAny intrapartum (related to the birth process) maternal deathAny perinatal death unrelated to a congenital condition in an infant having a birth weight greater than 2,500 gramsA patient is abducted from the hospital where he or she receives care, treatment, or servicesAssault, homicide, or other crime resulting in patient death or major permanent loss of functionA patient fall that results in death or major permanent loss of function as a direct result of the injuries sustained in the fallHemolytic transfusion reaction involving major blood group incompatibilitiesA foreign body, such as a sponge or forceps, that was left in a patient after surgery
ROOT CAUSE ANALYSISIdentifies factors that led to sentinel eventFocus on systems, processesGoal determine which organizational improvements are needed to decrease likelihood of such events reoccurringRCA may also be done for non-sentinel events – as in the case of a QI initiative
A root cause analysis is often done using a fishbone diagram. The fishbone diagram describes all possible causes by category that led to the problem.So, let’s say we have identified that there are an increased number of falls on a unit. (Advance slide)Now we need to identify the potential causes. This means we need to take a hard look at the unit processes and everyone and everything that may contribute to the problem. In each of the boxes on the fishbone, we would list a broad category in as many of those boxes as needed. It may be that you don’t use one of those boxes and that is okay.For our identified problem of increased falls, perhaps one of the boxes is labeled “people.”Under this box we might write a possible cause as (Advance slide) “Not enough nurses.” We would continue to list causes under various broad categories. Often there is a need to explain a cause further – this is known as a “secondary” cause. So if we go back to the cause of “not enough nurses” we need to list the secondary cause, if there is one. (Advance slide) Perhaps in this case we don’t have enough nurses because our secondary cause is “budget cuts.” (Advance slide) We would list that secondary cause on the secondary line.As you might suspect, this fish will get really full really fast with complex clinical problems.A completed fishbone diagram allows us to evaluate all the potential causes for, in this case, an increased number of falls on a unit. This, then, directs our research, which in turn, helps us develop a plan to fix the problem.
A BREACH OF CARE, also known as a breach of duty, occurs when a nurse deviates from the standard of care. It is very important that a nurse is current in his/her practice in both skills and knowledge base, unit policy and procedures, and that we use every step of the nursing process when caring for patients.For example, the standard of care at a hospital is that all medications must be given within an hour of the scheduled time. So a medication due at 0900 may be given between 0800 and 1000. If the patient is on the unit, it is expected that the medications due at 0900 are given within the 0800-1000 window of time. If it is not, and there are no extenuating circumstances, then a breach of care was committed.If this is a common problem on a unit – nurses just cannot administer meds routinely during the prescribed time frame, then it is a system problem and it needs to be addressed as a system-wide problem.If it is a problem for an individual nurse, then it needs to be handled one-on-one with that nurse.Either way, a root cause analysis will need to be done. In the case of the individual nurse, we don’t need a fishbone diagram, just his or her perceptions of why medication administration is a problem and then a joint discussion on how to fix it.Nurses are required to report problems in care delivery – this is part of being a patient advocate. We are charged with doing what is right for the patient, and it may mean that we report our own errors. As an example, several years ago I was working as a staff nurse and questioned the sobriety of the nurse from whom I was receiving report. She was dazed, confused, and glassy eyed. I was concerned first for the patients for whom she was caring and then about her. She may have been under the influence of drugs or alcohol or she may have been diabetic or having a stroke. I didn’t know. But I did immediately follow my chain of command and spoke with the charge nurse, who made an independent assessment of the nurse in question. The charge nurse then immediately called our unit manager, who arrived on the unit shortly thereafter, assessed the nurse and called the shift supervisor. Unbeknownst to me, this nurse had a history of substance abuse. As a nurse, with patient advocacy and safety as my guide, I did the right thing in reporting this nurse. I had to write an objective account of my experiences with this nurse, including the care she neglected to do during her shift – which was significant. Patients were at risk. My report was added to the reports of others and this nurse was fired by the end of the week.
Every health care facility has a comprehensive quality management plan by which they design, measure, assess and improve their organizational processes. By nature, they have to multidisciplinary. One way health care facilities address and standardize patient care is through the use of Critical paths. Critical paths identify patient outcomes to be addressed within a certain time frame. Going back to an earlier example of medications being administered within one hour of the scheduled time. This is a critical path – all meds must be given between one hour before the scheduled time and within one hour after the scheduled time. This is a standard critical path/outcome for this facility. These critical paths are continuously evaluated. Think about your clinical setting right now – what critical paths have you noted.Clinical pathways are also used by many facilities to standardize hospital stays for various medical diagnoses. For example, the critical pathway for a patient with an uncomplicated appendicitis may have an outcome of undergoing laparoscopic appendectomy on Day 1 of admission and a discharge date on Day 2 after receiving the 3rd dose of prophylactic antibiotics. If the patient does not meet these outcomes, it is noted as a variant and evaluation of the variant is conducted to ask the question “Why did the care of this particular patient not follow the defined clinical pathway?” Again, this is something that is continuously evaluated.The team charged with evaluating the data and designing a plan for improvement maintains a focus on patient outcomes, expectations, and satisfaction.All facilities, if they care about their quality management plans, will seek the opinions of their biggest stakeholders – the health care consumer. They do this by randomly mailing out patient satisfaction surveys. Those results are reported routinely – monthly, bimonthly, or quarterly – to the units so that they may use the data to determine if they are meeting their benchmarks. Which we will discuss next.
BENCHMARKING is a method of comparing standards to actual performance.This nursing program has benchmarks for each semester that we want our students to achieve. We measure these in a variety of ways. Three dimensions of quality care:Structure standards – relates to the physical environment, organization and management of the organization. For example, the structure of your formal nursing education is the Concept Based CurriculumProcess standards – using the above example, this describes those connected to the delivery of the concept based curriculum – your faculty – and the methods we use to teach you what you need to know to be safe, competent, entry level practitionersOutcome standards – are the end results. Again, using the above example, we might say that we want 80% of students who begin the nursing program to graduate within 5 semesters.So how do we know if our nursing program is successful? Well, we have many indicators to tell us how we are doing. An Indicator is a tool used to measure the performance of structure, process, and outcome standards. The easiest indicator to explain to you is the NCLEX pass rate. Our benchmark (or goal) has always been that 90% of our graduates pass NCLEX on their first attempt. Every 6 months we receive a report from the board of nursing about our pass rate, as well as the pass rates of all schools of nursing in Maryland. You will be happy to know that we always surpass our benchmark with >90% of our graduates passing the NCLEX exam on their first attempt. AND….we rank among the highest pass rates in the state. The data from this particular indicator is very useful in helping us evaluate our program.Hospitals and other healthcare facilities use the same process to evaluate the care they provide to patients.
Quality improvement involves both intradisciplinary and interdisciplinary evaluation. INTRADISCIPLINARY ASSESSMENT AND IMPROVEMENT means “within” the discipline of nursing. We accomplish this through several methods.Peer review – nurses assessing and judging nursing care. This is a very important process because, really, who better to assess and judge nurses and nursing, than other nurses!? WE understand our practice better than anyone else. So if we are concerned about increasing unit-based infections on our unit, it is quite possible that the unit management will bring in the infection control nurse to review the processes in place, conduct observational assessments , and create a plan to improve the infection rate.Outcomes management – measures and evaluates costs and quality in order to improve clinical practice. Outcomes are measured against the benchmarks set by the unit or hospital.Audits are examinations of the medical records and may either be retrospective or concurrent.Retrospective audits are done after the fact. We may audit a random group of charts of patients discharged in the previous month to determine the time it takes between a physician writing an order and the time the order is transcribed. Concurrent audits are reviews of the medical or nursing records done while the patient is still receiving care. These audits allow us to examine the care being given to achieve a desired outcome in the client’s health and to evaluate the nursing care activities being provided. For example, we may look at the computerized documentation to see how often nurses are documenting IV fluids to determine if this is this consistent with the standards set by the unit. Or we may look at whether or not nurses are rounding hourly on their patients and that they are documenting this care.
INTERDISCIPLINARY ASSESSMENT AND IMPROVEMENT involves evaluation of care across disciplines – nursing, medicine, respiratory therapy, physical therapy, pharmacy, etc. It is focused on team work and collaboration between disciplines. Audits and peer reviews may be used for interdisciplinary evaluation. But if a hospital is accredited by the Joint Commission, the hospital must have a Utilization Review (UR) department established. This department reviews hospital care for appropriateness – is the care necessary, was it carried out appropriately, and by whom? This is not just directed at nursing, but at the entire system in which a patient interacts. Often, UR departments make the determination of whether or not a hospitalization or specific treatment recommended by a physician will be approved.
MEASURING QITotal Quality Management, or TQM, emphasizes a commitment to excellence throughout an organization.TQM involves 4 core characteristics – which are pretty self-explanatory:Customer or client focus – this includes all health care consumers, whether or not they are in the hospital. It also includes employees, physicians, insurance companies, and the Joint Commission2. Total organizational involvement – All employees are accountable when it comes to quality improvement. It is important that, as an employee and nurse, that you know what the overall goals and mission of the health care facility where you work in regards to total quality management. This is often a criteria on annual evaluations.3. Using quality tools and statistics for measurement – This involves the use of tools to help develop quality improvement plans and the use of the statistics to improve overall care. A common tool is the PDSA – Plan-Do-Study-Act. We will discuss this in more detail in a moment.The final core characteristic of TQM is the 4. Identification of key processes for improvement . These processes may be systems related, clinically based, or managerial. They often involve a multidisciplinary approach.
PDSA CYCLEOnce a problem has been identified and we have identified all possible causes (go back to the fishbone diagram), we need to determine what changes need to take place to fix the problem. These changes must be evidence-based – this is where research comes in to play. What does the research say should be done to fix the problem identified. So we do our research and decide on a change intervention – we are going to implement something that will help solve the problem. Now, we need a plan to test the new intervention. We put our plan into action and do or implement the change intervention. As the change intervention is put into practice, we collect data to study the effect of the change intervention – what are the consequence of the change? Is it working to solve the problem? Finally, we analyze the findings of our stud and determine what modifications to our change intervention need to happen and act on those revised plans.There is a very nice example on page 2427 of your text that takes you through this process. We will practice this in class, as well. So be familiar with the process.
CONTINUOUS QUALITY IMPROVEMENT, OR CQI, is exactly that – a continuous, never-ending process to improve quality care. Every hospital unit has its own CQI team as every unit has specific needs. However, the CQI team is also aware of the bigger picture and the goals of the hospital as explained in the TQM plan.A CQI team continuously strives for clinical excellence through evaluation and action. Your book lists 4 major players on the CQI team:Resource group – includes senior management (CEO, VP). This group establishes the overall CQI policy and vision.Coordinator – often appointed by the CEO to provide day-to-day management of the CQI process and related activities (training programs) throughout the hospitalTeam leader – Each CQI team has a team leader who is familiar with the CQI process. On the hospital unit, the unit manager may take on this role, although often it is a senior nurse familiar with the process.Team – depending on the unit, all nurses may be part of the team or their may be representatives across all shifts. Regardless of formal committee membership, however, all nurses are responsible for being involved in CQI projects and data collection.
IMPROVING THE QUALITY OF CARE involves many factors.Costs – many QI projects are aimed at containing healthcare costs and preventing the wasting of resources – both supply and staff resources.Nurse staffing – through QI initiatives, it has been proven that appropriate staffing ratios decrease medical and nursing errors!Medication errors – Med errors have been a big problem in all settings and the source of many QI projects. The IOM has looked at this issue in depth and made many recommendations for decreasing the rate of med errors. Including education of patients and the use of computerized medication administration systems.
RISK MANAGEMENT is a component of a QI program but it is Problem focused.PurposeIdentify, analyze, evaluate risks, and develop plan for reducing frequency and severity of accidents and injuriesFunctionsIdentifies potential risks for accidents and injuriesReviews current monitoring systems: audits, QI data collection results, pt satisfaction survey resultsAnalyzes frequency, severity and causes of incidents causing injury or deathReviews safety and risk aspects of pt care proceduresMonitors laws and codes related to pt safety, consent, and careReduces as much risk in the hospital environment as possibleReview the work of other committees to determine liability and recommend prevention or corrective actionIdentifies needs for client, family, and employee educationEvaluates the results of the risk management programProvides reports to administration, medical and nursing administration and board of directors.
SUCCESSFUL RISK MANAGEMENTNurses can reduce risk to patients by looking at health and illness from the client’s perspective. Patient and family satisfaction is very important in assessing risk. Pts who are satisfied with their care present a low risk to the hospital. Pts who complain and are distraught, and do not have their needs met, present a potential liability to the hospital.Important factors once incident has occurredRecognition of the incident – don’t try to sweep it under the rug or deny that it happened.Quick follow-up and action – Attempt to resolve the issue – communicate with the patient/family and the healthcare provider is important. Personal contact – If there was a bad outcome, a hospital representative should contact the family to clarify misconceptions and answer questions.Immediate restitution – when appropriate.You will be studying risk management next term, so this is just a brief overview.
BLAME-FREE ENVIRONMENTWhen errors happen, the goals are to correct system failures, prevent future mistakes and ensure patient safety. As nurses we need to remember this. Is it easy reporting a mistake we make – of course not! But we are bound by moral, ethical, and legal obligations to do so. Administrators need to have processes in place that prevent blame form being assigned to a person or group of people for an error. If the hospital culture is such that blame is assigned when there is an error, reporting of the errors will not happen. This prevents the hospital from addressing the reasons for the errors and putting processes in place to protect both the pts and the staff.That being said, there are always exceptions to the rules. While we don’t want to blame people for errors, there are times when disciplinary action is necessary. These include failure to report an adverse event or error, criminal acts (stealing narcotics), false reporting, or refusing to participate in a system designed to prevent errors (known as “work-arounds”).
If it hasn’t been made clear up to this point, all nurses must be involved in quality improvement. It is our job to protect our patients. Be accountable and admit to errors, if they occur.This is the end of the powerpoint. Please bring one question that you have about its content to class and we will discuss them at the beginning of class.See you soon!
Where to Begin… At the beginning, of course! What is the relationship between Research and Quality Improvement (QI)? To really understand the Quality Improvement process, you need to understand the research process and how research results are used in the QI process Become one with research – it is now a part of your world as a nurse. Be sure to read the article on Bb: Hudson-Barr, D. (2004). How to read a research article. Journal of Specialists in Pediatric Nursing, (9)2, 70-72.
Terminology Quality “The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (IOM, 2001) Quality Management (QM) A preventative approach to address problems before they happen Quality Improvement (QI) The systematic processes used to measure outcomes, identify hazards and errors, and improve care. Blame-free
Why is there a need toimprove care? The2000 report by the Institute of Medicine (IOM) “To Err is Human: Building a Safer Health System” revealed 98,000 deaths in hospitals each year are PREVENTABLE!!!! Current system is fragmented and poorly organized
National Initiatives National Database of Nursing Quality Indicators (NDNQI) https://www.nursingquality.org Patient Safety and Quality: An Evidence- Based Handbook for Nurses http://www.ahrq.gov National Patient Safety Goals http://www.jointcommission.org/standards_i nformation/npsgs.aspx
Implementing QualityImprovement Quality improvement Moves from failed standards to proactive approach Involves everyone in organization
Sentinel Events “Unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.” Joint Commission Specifically includes loss of limb or function Reviewable events http://www.jointcommission.org/sentinel_ event.aspx
Root Cause Analysis (RCA) Identifiesfactors that led to sentinel event Focus on systems, processes Goal determine which organizational improvements are needed to decrease likelihood of such events reoccurring RCA may also be done for non-sentinel events
Cause EffectEquipment Process People Not enough nurses Increased Problem Falls Materials Environment Management
Breach of Care aka - Breach of duty Occurs when nurse deviates from standard of care Report problems in care delivery Chain of command
Components of QualityManagement Programs Basedon integrated system information and accountability Comprehensive quality management plan Multidisciplinary Critical paths Clinical pathways Focus on client outcomes Implementation continually evaluated
Benchmarking Method of comparing standards to actual performance Three dimensions of quality care: Structure Process Outcome Indicator
Measuring QI Total Quality Management (TQM) Four core characteristics Customer or client focus Total organizational involvement Using quality tools and statistics for measurement Identification of key processes for improvement
PDSA CycleSource: Adapted from Schroeder, P. (1994). Improving quality performance. St. Louis, MO: Mosby.
Continuous QualityImprovement (CQI) Processto improve quality, performance Four major players Resource group Coordinator Team leader Team
Improving the Quality of Care Costs Nursestaffing Medication errors
Risk Management Focus on problem Purpose Identify, analyze, evaluate risks, and develop plan for reducing frequency and severity of accidents and injuries Functions
Successful Risk Management Nurses play key role Patient perceptions Important factors once incident has occurred Recognition of the incident Quick follow-up and action Personal contact Immediate restitution
Nursing Practice All nurses must be involved in quality improvement Nursing students Commitment never to perform an act if student uncertain how to perform Show accountability for actions Admit to errors if they occur