Chapter 20 Quality Improvement & Patient Safety

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Chapter 20Quality Improvement & Patient

Safety


Urgent Case for Quality Improvement in the U.S. Health

Care System


Between 44,000 and 98,000 Americans die from medical errors annually (Institute of Medicine [IOM], 2000; Thomas et al, 2000; Thomas et al, 1999)

Medication-related errors for hospitalized patients cost roughly $2 billion annually (IOM, 2000; Bates et al, 1997).

Selected Indicators From Recent IOM Reports



41 million uninsured Americans exhibit consistently worse clinical outcomes than the insured and are at increased risk for dying prematurely (IOM, 2002; IOM, 2003a)

The lag between the discovery of more effective forms of treatment and their incorporation into routine patient care averages 17 years (Balas, 2001; IOM, 2003b)



Only 55% of patients in a recent random sample of adults received recommended care, with little difference found between care recommended for prevention, to address acute episodes, or to treat chronic conditions (McGlynn et al, 2003)

18,000 Americans die each year from heart attacks because they did not receive preventive medications, although they were eligible for them (Chassin, 1997; IOM, 2003a)



Medical errors kill more people per year than does breast cancer, AIDS, or motor vehicle accidents (IOM, 2000; Centers for Disease Control and Prevention, National Center for Health Statistics: Preliminary Data for 1998, 1999)



More than 50% of patients with diabetes, hypertension, tobacco addiction, hyperlipidemia, congestive heart failure, asthma, depression, and chronic atrial fibrillation are currently treated inadequately (IOM, 2003c; Clark et al, 2000; Legorreta et al, 2000; McBride et al, 1998; Ni et al, 1998; Perez-Stable and Fuentes-Afflick, 1998; Samsa et al, 2000; Young et al, 2001)


IOM’s Six Aims to Guide Improvements

Safe: avoiding injuries to patients caused by the care that is intended to help them

Timely: reducing waits and sometimes harmful delays for both those who receive and those who 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, including 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, and 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


Ten Simple Rules to Guide Improvements

Care is based on continuous healing relationships Care is customized according 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 continuously decreased Cooperation among clinicians is a priority


Quality Buzzwords

Total quality management (TQM) Continuous quality improvement (CQI) Continuous process improvement (CPI) Statistical process control (SPC) Performance improvement (PI)


Cornerstones of Quality Management

Customer defines quality Organizational support for all employees to develop quality

knowledge and skills Belief in the people who are working to serve the customer


“Joiner Triangle”

Quality• 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



Scientific approach• Improvement decisions are 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



All one team• 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


Quality Management in Health Care


History

W. Edwards Deming• American pioneer in the quality management movement• Introduced the United States to quality management

principles• Worked with the Japanese in post–World War II (WWII)

reconstruction efforts Hospitals were the first health-related organizations to explore

quality efforts beginning in the 1980s


Quality Assurance to Quality Improvement

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


Drive quality improvement efforts in health care facilities Almost all regulatory and voluntary accrediting agencies now

require quality management in some form

Regulatory and Accreditation Agencies


Regulatory organizations• Centers for Medicare and Medicaid Services

Administers the Medicare program Requires quality management in “Conditions of Participation”

• State licensing authorities require quality management activities and set quality standards




Voluntary accrediting organizations • Commission on Accreditation of Rehabilitation Facilities

(CARF)—promotes quality management requirements and standards

• Accreditation Council of Developmental Disabilities (ACDD)—promotes quality management requirements and standards



• National Committee for Quality Assurance (NCQA)—primary voluntary accreditation agency for managed care organizations

• The Joint Commission—first regulatory agency to embrace quality improvement principles in hospital-based settings



Nursing’s role in regulatory and accreditation standards• Enables health care organizations to successfully

meet regulatory standards• Supports the overall management of patient care

and working collaboratively with other professionals to do the following:

Identify process improvements needs Initiate change Monitor ongoing effectiveness of patient care


Clinical Indicators and Process Improvement

Tools


Clinical Indicators

Serve as a basic foundation for quality monitoring and evaluation

Measurable aspects of care that show the degree to which clinical care is or is not 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


Process Improvement Tools

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



Flowchart• Maps out what actually occurs in a work process• Includes steps and substeps, and who does the work



Pareto chart• Bar chart• Reflects frequency at which events occur, or the impact

events have on a process



Cause-and-effect diagram• Lists potential causes arranged by category to show their

potential impact on a problem• Helps determine potential causes of a problem



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


Understanding, Improving, and Standardizing Care Processes


Definition and Purpose of Standardization

Referred to as best methods or best practices Care practices carried out in a uniform, systematic method Employees are trained to perform procedures according to

standards rather than learning by watching others


Definition and Purpose of Standardization

Avoids haphazard changes to procedures Standardized practices should be based on scientific

evidence and research.


Methods of Standardization

Clinical guidelines or pathways • Outline the optimal sequencing and timing of clinical

interventions for a particular diagnosis or procedure• Effectiveness monitored through the following:

Patient health outcomes Patient satisfaction outcomes Financial outcomes



Benefits• Reduction in variation of care provided• Facilitation and achievement of expected clinical

outcomes• Reduction in care delays and lengths of stay• Improvements in cost-effectiveness• Increase in patient and family satisfaction with care



Clinical algorithms or protocols: Outline decision paths that a practitioner might take during a particular care episode or need (e.g., ACLS algorithms)

Case management: Appropriate health care services are matched to care needs in an efficient manner


Breakthrough Thinking


Premises of Breakthrough Thinking

Substantial 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


Institute for Healthcare Improvement (IHI)

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


Two-Part Model for Improving Health Care (IHI)

Ask 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)

Action steps: Plan–Do–Check–Act cycle (“PDCA”)• PLAN: Develop an action plan that is 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


Process Improvement and Patient Safety


IOM Report: To Err Is Human: Building a Safer Health System

Focused national attention on medical mistakes and patient safety

Concluded that up to 98,000 patients are killed each year as a result of medical errors


IOM Recommendations

National center for patient safety Nationwide, mandatory, state-based error-reporting system Systems that do not blame individuals but look at processes Safety performance standards for health care organizations Proven medication safety systems and practices


IOM Report: Keeping Patients Safe: Transforming the Work Environment of

Nurses Recognized the critical role of nurses in patient safety Identified five practices that are repeatedly linked with

achieving safety targets in spite of high risks for errors• Balance the tension between production efficiency 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 as it pertains to work design

and work flow• Use knowledge management practices to establish a “learning

organization”


The Institute for Safe Medication Practices (ISMP)

Education resources for the prevention of medication errors • Provides independent, multidisciplinary, expert review of

errors reported through the U.S. Pharmacopoeia: ISMP Medication Errors Reporting Program (MERP)


The Institute for Safe Medication Practices (ISMP)

• Through the MERP, health care professionals voluntarily and confidentially report medication errors and hazardous conditions that could lead to errors

• Offer a self-assessment tool that is designed to heighten hospital awareness of safe hospital medication systems


Roles of Accrediting and Regulatory Agencies

Developing new accountability models Sentinel event standard established by The Joint Commission

requires organizations to carry out designated steps to fully understand factors and systems associated with adverse patient events



National patient safety goals established by The Joint Commission:• Improve the accuracy of patient identification• Improve the effectiveness of communication among

caregivers• Improve the safety of medication use• Reduce the risk of health care–associated infections• Accurately and completely reconcile medications across the

continuum of care



National patient safety goals established by The Joint Commission (continued):• Reduce the risk of patient harm resulting from falls• Encourage patients’ active involvement in their own care

as a patient safety strategy• The organization identifies safety risks inherent in its

patient population• Universal Protocol: The organization fulfills the

expectations set forth in the Universal Protocol (for eliminating wrong site, wrong procedure, wrong person surgery)


The Professional Nurse and Patient Safety

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



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



National Database of Nursing Quality Indicators (NDNQI)• Collects designated indicators that strongly affect clinical

outcomes • Two major purposes

Provide comparative data to health care organizations to help support quality improvement activities.

Acquire national data to gain a better understanding of the link between nurse staffing and patient outcomes



Quality indicators • Nursing Hours per Patient Day• Staff Mix (RNs, LPNs/LVNs, Unlicensed Assistive

Personnel)• 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


Nurses’ Role in Quality Improvement

Nurses should 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

Chapter 20 Quality Improvement & Patient Safety

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