Quality Improvement and Patient Safety (QPS) 6-the-tqci/8-june-2017/2... · Quality Improvement and...

Quality Improvement and

Patient Safety

(QPS)

Ratchada Prakongsai Senior Manager

Overview Comprehensive approach to quality

improvement and patient safety that

impacts all aspects of the facility’s

operation.

department-level input and

participation into the quality

improvement and patient safety

program;

use of objective, validated data to

measure how well processes work;

effectively using data and

benchmarks to focus the program;

implementing and sustaining changes

that result in improvement

Both quality improvement and patient

safety programs

are leadership driven;

seek to change the culture of an

organization;

proactively identify and reduce

variation;

use data to focus on priority issues;

and

seek to demonstrate sustainable

improvements

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Management of Quality and Patient Safety Activities

(QPS.1)

Measure Selection and Data Collection

(QPS.2, 3)

Analysis and Validation of Measurement Data

(QPS 4, 4.1, 5, 6, 7, 8, 9

Gaining and Sustaining Improvement

(QPS 10, 11)

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Overview 12 Standards

53 Measurable Elements

5 Required Policies

MANAGEMENT OF QUALITY AND

PATIENT SAFETY

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Management of Quality and Patient Safety

• The overall program for quality and

patient safety in a hospital is

approved by the governing entity

(GLD.2),

• with the hospital’s leadership defining

the structure and allocating resources

required to implement the program

(GLD.4).

• Leadership also identifies the

hospital’s overall priorities for

measurement and improvement

(GLD.5),

• with the department/service leaders

identifying the priorities for

measurement and improvement within

their department/service (GLD.11 and

GLD.11.1).

• This QPS chapter identify the structure,

leadership, and activities to support the

data collection, data analysis, and

quality improvement for the identified

priorities hospitalwide, as well as

department- and service-specific.

• This includes the collection and analysis

on, and the response to, hospitalwide

sentinel events, adverse events, and

near-miss events.

• The standards also describe the central

role of coordinating all the quality

improvement and patient safety

initiatives in the hospital and providing

guidance and direction for staff training

and communication of quality and

patient safety information.

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QPS.1 - A qualified individual guides the implementation of the hospital’s

program for quality improvement and patient safety and manages the activities

needed to carry out an effective program of continuous quality improvement

and patient safety within the hospital.

Require well-implement program

Approve and support resources form governance

knowledge and experience staff in data collection, data validation,

and data analysis

Coordinate and organize throughout the organization

Understand how to take the hospital wide priorities and the

department/service–level priorities

Training and communication

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P


QPS.1 Measurable Elements

1.An individual who is experienced is selected to guide the implementation

of the quality and patient safety program

2.The individual with oversight for the quality program selects and supports

qualified staff for the program

3.Support and coordination to department/ service leader across the hospital

4.Implement a training program for all staff

5.Regular communication of quality issues to all staff

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MEASURE SELECTION AND

DATA COLLECTION

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QPS.2 Quality and patient safety program staff support the measure selection

process throughout the hospital and provide coordination and integration of

measurement activities throughout the hospital.

Measure selection is a leadership responsibility.

The leadership of the hospital decides the priority areas to measure

for the entire hospital (GLD.5)

The measure selection process for each department/service. (GLD.11 and GLD.11.1)

All departments and services—clinical and managerial—select

measures related to their priorities.

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Indicator Selection

Standard

Indicator Guideline USA : The Joint Commission

Library of Measures (LOM) : Joint Commission International

Agency for Healthcare Research and Quality (AHRQ)

The healthcare accreditation institute (Thailand)

Best practice

Core service

Risk Assessment

Occurrence / Complaint

Medical record Audit

Tracer result

11


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1. Quality program supports the selection of measures.

2. Quality program coordinate and integration of measurement activities

throughout the hospital.

3. Quality program provides for the integration of event reporting systems,

safety culture measures and others to facilitate integrated solution and

improvement.

4. Tracks progress on the planned collection of measure data.

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QPS.3 The quality and patient safety program uses current scientific and other

information to support patient care, health professional education, clinical

research, and management.

Health care practitioners, researchers, educators, and managers often need

information to assist with their responsibilities.

Such information may include scientific and management literature, clinical

practice guidelines, research findings, and educational methodologies.

The Internet, print materials in a library, online search sources, and personal

materials are all valuable sources of current information.

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1. Current scientific and other information supports patient care.

2. Current scientific and other information support clinical education.

3. Current scientific and other information support research.

4. Current scientific and other information support management.

5. Information is provided in a time frame that meets user expectations.

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ANALYSIS AND VALIDATION OF

MEASUREMENT DATA

QPS.4 The quality and patient safety program includes the aggregation and

analysis of data to support patient care, hospital management, and the quality

management program and participation in external databases.

Aggregate data provide a profile of the hospital over time and allow the

comparison of the hospital’s performance with other organizations, particularly

on the hospitalwide measures selected by leadership.

In particular, aggregate data from risk management, utility system management,

infection prevention and control, and utilization review can help the hospital

understand its current performance and identify opportunities for improvement.

External databases also are valuable in the ongoing monitoring of professional

practice as described in SQE.11.

A hospital can compare itself to that of other similar hospitals locally,

nationally, and internationally.

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1. Process to aggregate data.

2. Support patient care, hospital management, professional practice review,

and the overall quality and patient safety program

3. Provided to agencies outside when required by laws or regulations.

4. Contribute and learn from external databases for comparison purposes.

5. Security and confidentiality are maintained when using external databases

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Compared with itself over time

Compared with standard / best practices

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Compared with other similar organizations


QPS.4.1 Individuals with appropriate experience, knowledge, and skills

systematically aggregate and analyze data in the hospital.

Data analysis involves individuals who understand information

management, have skills in data aggregation methods, and know how

to use various statistical tools.

Results of data analysis need to be reported to those individuals

responsible for the process or outcome being measured and who can

take action on the results. Thus, data analysis provides continuous

feedback of quality management information to help those individuals

make decisions and continuously improve clinical and managerial

processes.

The frequency of aggregated and analyzed process depends on the

activity or area being measured and the frequency of the measurement.

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The goal of data analysis is to be able to compare a hospital in four ways:

1. With itself over time : month to month, or one year to the next

2. With other similar organizations :reference databases

3. With standards : accrediting and professional bodies , laws or regulations

4. With recognized desirable practices : best or better practices or practice

guidelines

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1. Data are aggregated, analyzed, and transformed into useful information to identify opportunities for improvement.

2. Individuals with appropriate clinical or managerial experience, knowledge, and skills participate in the process.

3. Statistical tools and techniques are used

4. The frequency of data analysis is appropriate to the process or outcome being studied.

5. Results of analysis are reported to those accountable for taking action. (GLD.1.2, ME 2)

6. Data analysis supports comparisons internally over time, including comparisons with databases of like organizations, with best practices, and with objective scientific professional sources.

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QPS.5 The data analysis process includes at least one determination per year

of the impact of hospitalwide priority improvements on cost and efficiency.

The quality and patient safety program includes an analysis of the

impact of priority improvements as supported by leadership (GLD.5).

There is evidence to support that the use of clinical practice guidelines

to standardize care has a significant impact on efficiency of care and a

reduction in the length of stay, which ultimately reduces costs.

The quality and patient safety program staff develop tools to evaluate

the use of resources for the existing process and then reevaluate the use

of resources for the improved process.

The analysis will provide useful information on which improvements

impact efficiency and therefore cost.

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1. At least one impact analysis of cost efficiency per year of an improvement project

2. Evaluate and re-evaluate the use of resources for the current and improved process and Coordination with other departments: HR, IT, Finance

3. Report result to leadership

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28


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QPS.6 The hospital uses an internal process to validate data.

Data validation is most important when…..

a) evaluate and improve an important clinical process or outcome;

b) data will be made public on the hospital’s website or in other ways;

c) a change has been made to an existing measure ; the data collection

tools changed etc.

d) the data resulting from an existing measure have changed in an

unexplainable way;

e) the data source has changed ; part of the patient record turned into an

electronic format

f) the subject of the data collection has changed ; research protocol

alterations, new practice guidelines implemented, or new technologies and

treatment methodologies introduced etc.

P

• Data validation is an important tool for understanding the quality of the

data and for establishing the level of confidence decision makers can have

in the data.

• Data validation becomes one of the steps in the process of setting priorities

for measurement, selecting what is to be measured, extracting or collecting

the data, analyzing the data, and using the findings for improvement.

• When a hospital publishes data on clinical outcomes, patient safety, or

other areas, or in other ways makes data public, such as on the hospital’s

website, the hospital has an ethical obligation to provide the public with

accurate information. Hospital leadership is accountable for ensuring that

the data are valid.

• Reliability and validity of measurement and quality of data can be

established through the hospital’s internal data validation process or,

alternatively, can be judged by an independent third party, such as an

external company contracted by the hospital. (GLD.6)

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31


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Sample of Data validation

1st abstractor 2nd abstractor


1. Data validation is used as a component of the improvement process

selected by leadership.

2. Data are validated when any of the conditions noted in a) through f) in

the intent are met.

3. An established methodology for data validation is used.

4. Hospital leadership assumes accountability for the validity of the quality

and outcome data made public

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QPS.7 The hospital uses a defined process for identifying and managing

sentinel events.

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P

A sentinel event is an

unanticipated occurrence

involving death or serious

physical or psychological

injury. Serious physical

injury specifically includes

loss of limb or function.

Such events are called

sentinel because

they signal the need for

immediate investigation and response.

Establishes an operational definition of a sentinel

event that includes at least

a) an unanticipated death,

b) major permanent loss of function unrelated to

the patient’s natural course of illness or

underlying condition;

c) wrong-site, wrong-procedure, wrong-patient

surgery;

d) transmission of a chronic or fatal disease or

illness as a result of infusing blood or blood

products or transplanting contaminated organs

or tissues;

e) infant abduction or an infant sent home with

the wrong parents; and

f) rape, workplace violence ; assault, homicide

(willful killing) of a patient

• Accurate details of the

event are essential to a

credible root cause

analysis, thus the root

cause analysis needs to be

performed as soon after

the event as possible.

• The analysis and action

plan is completed within

45 days of the event or

becoming aware of the

event.

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prevent or reduce the risk of such sentinel events recurring,

the hospital redesigns the processes and takes whatever other actions

QPS. 7 Measurable Elements

1. Hospital leadership has established a definition of a sentinel event that at

least includes a) through f ) found in the intent.

2. The hospital completes a root cause analysis of all sentinel events and in

a time period specified by hospital leadership that does not exceed 45 days

from the date of the event or when made aware of the event.

3. The root cause analysis identifies the origins of the event that may lead

to improvements and/or actions to prevent or reduce the risk of the sentinel

event recurring.

4. Hospital leadership takes action on the results of the root cause analysis

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Sentinel event and medical error are not synonymous. An incident as a sentinel event is not an indicator of legal liability.

Survey Tip QPS.7 • Will look for you to have done a credible RCA down

to the origin of the event

• Then, how did you use/apply that key information

• In fact, this could be used prospectively towards a possible new process and in the form of FMEA

• Some RCAs are too superficial; watch policy definitions

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QPS.8 Data are always analyzed when undesirable trends and variation are

evident from the data.

The hospital collects data on diverse and different areas of patient care

services periodically.

In order to do so there must be reliable mechanisms of reporting outcomes

to ensure quality services.

Those that pose patient safety risk are identified and monitored.

Data collection should be sufficient to detect trends and patterns and will

vary depending on the service frequency and/or the risk for patients.

P

Data gathering and analysis are conducted for at least the following:

a) All confirmed transfusion reactions, if applicable to the hospital (COP.3.3)

b) All serious adverse drug events, if applicable and as defined by the hospital

(MMU.7, ME 3)

c) All significant medication errors, if applicable and as defined by the hospital

(MMU.7.1, ME 2)

d) All major discrepancies between preoperative and postoperative diagnoses;

for example, a preoperative diagnosis of intestinal obstruction and a postoperative

diagnosis of ruptured abdominal aortic aneurysm (AAA)

e) Adverse events or patterns of adverse events during procedural sedation

regardless of administration site (ASC.3.2 and ASC.5)

f ) Adverse events or patterns during anesthesia regardless of administration site

g) Other adverse events; for example, health care–associated infections and

infectious disease outbreaks (PCI.7.1, ME 6)

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Intense analysis & Improvement

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QPS.8 Measurable Elements of

1. Defined data gathering processes are developed and implemented to ensure

accurate data gathering, analysis, and reporting.

2. Intense analysis of data takes place when adverse levels, patterns, or trends

occur.

3. Data gathering and analysis are performed on items a) through g) of the intent.

4. Results of analyses are used to implement actions to improve the quality and

safety of the service, treatment, or function. (PCI.10, ME 3)

5. Outcome data are reported to the governing entity as part of the quality

improvement and patient safety program. (GLD.4.1, ME 1)

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Surveyor Tips: QPS.8 • What are your sources of data? Think more than just closed record reviews: occurrence reports (On-line to Quality Program?); open record reviews; daily rounds related to KPIs • Make your data results work for you; try something • Keep a track record of all that goes to Governance

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QPS.9 The organization uses a defined process for the

identification and analysis of near-miss events.

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• First, the hospital establishes a

definition of a near miss and what

types of events are to be reported.

• Near miss applies to more than

potential medication errors. Near

misses also include other types of

adverse events.

• Second, a reporting mechanism is put

into place, and finally there is a

process to aggregate and analyze the

data to learn where proactive process

changes will reduce or eliminate the

related event or near miss. (MMU.7.1

and QPS.11)

Near miss = Any process variation that did not

affect an outcome but for which a recurrence

carries a significant chance of a serious adverse

outcome. Such a “near miss” falls within the scope of the definition of an adverse event.

Adverse event = An unanticipated,

undesirable, or potentially dangerous occurrence in a health care organization.


Reporting System Work Flow


1. Establishes a definition of a near miss

2. Defines types of events are to be reported.

3. Establishes the process for the reporting of near misses

4. The data are analyzed and actions taken to reduce near-miss events

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GAINING AND SUSTAINING

IMPROVEMENT

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QPS.10 Improvement in quality and safety is achieved and sustained.

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• The information from data analysis is used to identify potential

improvements or to reduce (or prevent) adverse events.

• After an improvement(s) is planned, data are collected during a

test period to demonstrate that the planned change was actually an

improvement.

• To ensure that the improvement is sustained, measurement data

are then collected for ongoing analysis.

• Effective changes are incorporated into standard operating

procedure, and any necessary staff education is carried out.

• The hospital documents those improvements achieved and

sustained as part of its quality management and improvement

program. ( GLD.11, ME 4)

A

Risk Profile / Risk Assessment

Unit Performance Measurement

B

Prioritization CQI

Unit Performance Measurement flow 47


1. Improvements in quality and patient safety are planned, tested, and

implemented

2. Data demonstrates that improvements are effective and sustained

3. Policy changes necessary to plan, to carry out, and to sustain the

improvement are made.

4. Successful improvements are documented.

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Categories of risks include

1. strategic (those associated with

organizational goals);

2. operational (plans developed to

achieve organizational goals);

3. financial (safeguarding assets);

4. compliance (adherence to laws

and regulations); and

5. reputational (the image

perceived by the public).

Formalized risk management

program

a) risk identification;

b) risk prioritization;

c) risk reporting;

d) risk management, to include risk

analysis (MMU.7.1, QPS.7, QPS.8,

and QPS.9); and

e) management of related claims

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QPS.11 Risk management program is used to identify and to proactively reduce unanticipated adverse events and other safety risks to patients and staff.

P



1. Risk management framework includes a) through e) in the intent.

2.Leadership identifies and prioritizes potential risks associated with at least

the strategic, financial, and operational functions of the hospital.

3. At least annually, a proactive risk-reduction is conducted on one of the

priority risk processes. (FMEA , HVA or Similar tools)

4. High-risk processes are redesigned based on the analysis of the test results.

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Surveyor Tips: QPS.11 • Remember that proactive means not looking back at a past occurrence • Six categories of risks that can impact • Be prepared to show/explain in the Quality Program Interview • Ensure formal documentation

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