Ch. 18: Quality and Safety

A framework for understanding health care improvement has been proposed by the IOM Committee on Quality of Health Care in America. The aims for health care quality improvement propose that health care systems ensure that care is: (Select all that apply.) a. safe. b. timely. c. efficient. d. cost-controlled. e. patient-centered.

ANS: A, B, C, E A framework for understanding health care improvement has been proposed by the IOM Committee on Quality of Health Care in America. These six aims for health care quality improvement propose that health care systems ensure that care is safe, effective, patient-centered, timely, efficient, and equitable.

TJC requires accredited organizations to participate in their core measure initiative. The current core measure sets include: (Select all that apply.) a. stroke. b. tobacco treatment. c. pneumonia measures. d. iatrogenic pneumothorax. e. venous thromboembolism. f. acute myocardial infarction.

ANS: A, B, C, E, F The current core measure sets include perinatal care, stroke, venous thromboembolism, substance use, tobacco treatment, hospital outpatient department, pneumonia measures, heart failure, acute myocardial infarction, surgical care improvement project, hospital-based inpatient psychiatric services, emergency department, children's asthma care, and immunization (TJC, 2016d).

The Baldrige National Quality Award (BNQA) establishes a set of performance standards that define a total quality organization. The standards in areas of excellence include: (Select all that apply.) a. leadership. b. strategic planning. c. environment of care. d. human resource focus. e. medication management.

ANS: A, B, D The standards in seven areas of excellence established by the BNQA are: (1) leadership, (2) strategic planning, (3) customer and market focus (focus on patients, other customers, and markets), (4) information and analysis, (5) human resource focus, (6) process management, and (7) business results (organizational performance results).

Quality planning establishes the design of a product, service, or process that will meet customer, business, and operational needs to produce the product before it is produced. Quality planning follows a universal sequence of steps. List the universal sequence of steps in order. a. Identify customers and target markets. b. Discover hidden and unmet customer needs. c. Develop a service or product that exceeds customer's needs. d. Transfer these designs to the organization and the operating forces to be carried out. e. Translate these needs into product or service requirements: a means to meet their needs. f. Develop the processes that will provide the service, or create the product, in the most efficient way.

ANS: A, B, E, C, F, D Quality planning follows a universal sequence of steps, as follows: Identify customers and target markets. Discover hidden and unmet customer needs. Translate these needs into product or service requirements: a means to meet their needs (new standards, specifications, etc.). Develop a service or product that exceeds customer's needs. Develop the processes that will provide the service or create the product in the most efficient way. Transfer these designs to the organization and the operating forces to be carried out (Juran Institute, 2009, pp. 1-2).

A successful enterprise risk management (ERM) program will: (Select all that apply) a. identify risks. b. improve quality. c. prevent damage. d. control occurrences. e. control legal liability.

ANS: A, C, D, E ERM program is defined as an organization-wide program to identify risks, control occurrences, prevent damage, and control legal liability; it is a process whereby risks to the institution are evaluated and controlled.

Principles of a fair and just culture include: (Select all that apply.) a. zero-tolerance for reckless behavior. b. reduction of personal accountability and discipline. c. recognition that competent professionals make mistakes. d. errors and unintended events being reported unless no patient harm occurs. e. acknowledgment that even competent professionals develop unhealthy norms.

ANS: A, C, E A fair and just culture "is an approach to medical event reporting that emphasizes learning and accountability over blame and punishment" (CAPSAC, 2016, p. 1). Everyone throughout the organization is aware that medical errors are inevitable, but all errors and unintended events are reported—even when the events may not cause patient injury. This culture can make the system safer as it recognizes that competent professionals make mistakes and acknowledges that even competent professionals develop unhealthy norms (shortcuts or routine rule violations), but it has zero-tolerance for reckless behavior.

A nursing quality improvement supervisor is proposing to enhance the current quality improvement program. One of the most important themes that a nursing quality improvement supervisor should consider is: a. budgetary considerations. b. collaboration between health care teams. c. regular staff training programs. d. suggestions from patients.

ANS: B Collaborative partnerships are part of this imperative and shape the way professional nurses act clinically and how they participate in performance and quality improvement efforts. As the complexity of care increases, multidisciplinary and inter-professional teamwork is used to solve complex problems in practice

Hospitals must submit specific quality performance data regarding Medicare patients or risk: a. an increase in federal tax. b. decreased payments. c. fewer physician referrals. d. sanctions by The Joint Commission (TJC).

ANS: B In 2011, CMS developed the Hospital Value-Based Purchasing Program, which applied to payments beginning in fiscal year 2013 for discharges occurring on or after October 1, 2012. Under the program, CMS makes value-based incentive payments to 3500 acute care hospitals based either on how well the hospitals perform on certain quality measures or how much the hospitals' performance improves on certain quality measures from their performance during a baseline period. Reimbursement is based on quality of care, not quantity. The higher a hospital's performance or improvement during the performance period for a fiscal year, the higher the hospital's value-based incentive payment for the fiscal year would be

Which of the following is an example of a nurse-sensitive indicator? a. Cardiac patient mortality b. Hospital-acquired pressure ulcers c. Pulmonary embolus after knee surgery d. Iatrogenic pneumothorax after central line placement

ANS: B Nurse-sensitive indicators refer to the structure, process, and outcomes of professional nursing care. These include falls and falls with injury, hospital-acquired pressure ulcers, health care-associated infections, nursing care hours per patient day, nursing care hours, nursing turnover, physical restraints, RN survey, and skill mix.

To provide the best care to every patient every day through integrated clinical practice, education, and research is an example of a(n): a. accountability agreement. b. mission statement. c. organizational standard. d. vision and value proposal.

ANS: B The mission statement of an organization is a concise statement that answers the question: What business are we in today?

1. Which of the following are never events? (Select all that apply.) a. A minor medication error b. A foreign object left in the body during surgery c. Surgery on the wrong body part d. A mismatched blood transfusion e. Hip fracture acquired in the hospital f. Pressure ulcer acquired in the home g. Catheter-associated urinary tract infection h. Surgical site infection

ANS: B, C, D, E, G, H A never event is an event that should never happen. The insurer will never pay. Insurers will no longer pay for never events. A pressure ulcer will be covered if it was not acquired in the hospital facility. A minor medication error that causes no harm to the patient will not cause an insurer to withhold payment.

Tenets embraced by health care professionals and promoted by health care leaders and organizations such as TJC and the IOM include which of the following? (Select all that apply.) a. People and systems are the problems, not processes. b. Quality measurement and monitoring is everyone's job. c. Quality cannot be enhanced by non-punitive work cultures. d. Standardization of processes is key to managing work and people. e. The impetus for quality monitoring is not primarily for accreditation or regulatory compliance.

ANS: B, D, E Tenets embraced by health care professionals and promoted by health care leaders and organizations such as TJC and the IOM include the following: processes and systems are the problems, not people; standardization of processes is key to managing work and people; quality can be enhanced only in safe, non-punitive work cultures; quality measurement and monitoring is everyone's job; the impetus for quality monitoring is not primarily for accreditation or regulatory compliance, but rather as a planned part of an organization's culture to continuously enhance and improve its services; based on continuous feedback from employees and customers, consumers and stakeholders must be included in all phases of quality improvement planning; consensus among all stakeholders must be gained to have an impact on quality and safety; and health policy should include a focus on continuous enhancement of quality and safety

Which comment by the nurse manager would indicate that the hospital places a high value on patient safety? a. We have safety posters throughout the hospital that encourage people to report problems. b. We have monthly safety in-services. c. We encourage patients and families to participate in their care. d. All employees are required to update their knowledge of safety practices each year.

ANS: C Nurse leaders will continue to play an important role in designing care delivery systems that promote patient and family engagement (Pelletier & Stichler, 2014a). Various toolkits have been developed to assist staff nurses and managers who desire to engage patients and their families in hospitals (AHRQ, 2013c; Pelletier & Stichler, 2014b) and ambulatory and primary care

The industry-based model for quality management and measurement whose premise is that operational waste needs to be eliminated is: a. Six Sigma. b. ISO 9000. c. Lean Enterprise. d. Baldrige National Quality Award Program.

ANS: C Lean Enterprise is a model of quality measurement that was originally associated with Deming but reintroduced to the United States by Womack in the mid-1990s (Jones & Womack, 2003). The premise of this model is that operational waste in an organization needs to be eliminated.

A clearly recognizable process of providing care that has an evidence base demonstrating that it reduces the likelihood of harm is: a. risk adjustment. b. a sentinel event. c. a patient safety practice. d. a performance measure.

ANS: C Patient safety practices are "discrete and clearly recognizable processes or manners of providing care that have an evidence base demonstrating that they reduce the likelihood of harm due to the systems, processes, or environments of care"

The degree to which health services for individuals and populations increases the likelihood of desired health outcomes that are consistent with current professional knowledge is known as the: a. care delivery quotient. b. excellence index. c. quality of health care. d. standard of care.

ANS: C Quality of health care is defined as the degree to which health services for individuals and populations increases the likelihood of desired health outcomes that are consistent with current professional knowledge

The risk manager wants to illustrate the causes that have been leading to an increase in patient misidentification. The most appropriate tool to use is a: a. pareto chart. b. control chart. c. fishbone diagram. d. detailed flowchart.

ANS: C The fishbone diagram resembles diagramming sentences. The effect is illustrated in a box at the end of a midline (or head of the fish). The causes are generally four or five categories of elements that might contribute to the effect (e.g., machines, methods, people, materials, and measurements) and the specific activities. Under each of these category headings, individual items that might lead to the effect are listed. By diagramming all of the possible contributors, the predominant or root causes may be found more readily.

Nurse managers can create an environment that is devoted to health care safety by doing which of the following? (Select all that apply.) a. Adopting and embracing the concept of disciplining staff who commit errors b. Learning the concepts and tools related to quality improvement and quality assurance c. Becoming a role model for staff and peers in practicing health care safety concepts d. Encouraging staff to be constantly vigilant in identifying potential risks in the care environment e. Creating a sense of partnership with patients and families to promote communication about safety concerns and soliciting their suggestions to correct and prevent potential risks

ANS: C, D, E Nurse managers can personally create an environment that is devoted to health care safety by doing the following: learning the concepts and tools related to risk identification, analysis, and error reduction; adopting and embracing the concept of non-punitive error reporting; advocating for the establishment of a non-punitive culture if it is not currently a strong ideal within the organization; encouraging staff to be constantly vigilant in identifying potential risks in the care environment; creating a sense of partnership with patients and families to promote communication about safety concerns and soliciting their suggestions to correct and prevent potential risks; and becoming a role model for staff and peers in practicing health care safety concepts.

Attributes of a total quality organization according to BNQA include: (Select all that apply.) a. accreditation by TJC. b. a commitment to obtaining Magnet designation. c. strategic planning. d. focus on patients, other customers, and markets. e. organizational performance results.

ANS: C, D, E The Baldrige National Quality Award (BNQA) establishes a set of performance standards that define a total quality organization. Named after the Secretary of Commerce, the BNQA "was established by Congress in 1987 to enhance the competitiveness and performance of U.S. businesses" (National Institute of Standards and Technology, 2007, p. 1). The standards in seven areas of excellence are: (1) leadership, (2) strategic planning, (3) customer and market focus (focus on patients, other customers, and markets), (4) information and analysis, (5) human resource focus, (6) process management, and (7) business results (organizational performance results). Organizations committed to quality improvement choose to adopt the BNQA approach as another means of defining and improving their organizational processes to achieve quality outcomes.

Which of the following responses from the nurse manager is consistent with a culture that promotes patient safety? a. We make sure that we don't have any errors on this unit. b. We identify who made the error and take corrective action. c. We provide remedial training for all staff on the unit when there is an error. d. We report any medical error or near-miss to help us find the root cause of the problem.

ANS: D Health care organizations that embrace a fair and just culture identify and correct the systems or processes of care that contributed to the medical error or near-miss. Managers believe that more health care professionals will report more errors and near-misses when they are protected by a non-punitive culture of medical error reporting, and this will further improve patient safety through opportunities for improvement and lessons learned (CAPSAC, 2016). The American Nurses Association has endorsed just culture as a means of ensuring safe care

Responding to a code called in the psychiatric unit where she works, a staff nurse finds that a patient has committed suicide. The staff nurse correctly identifies this as a: a. benchmark incident. b. quality improvement issue. c. performance breach. d. sentinel event

ANS: D Specific sentinel event outcomes are considered "reviewable" by TJC. Reviewable sentinel events are events that have resulted in an unanticipated death, permanent harm, or severe temporary harm and include suicide of any patient receiving care, treatment, and services in a staffed around-the-clock care setting.

Mercy Hospital compares its surgical site infection rate to General Heart Hospital, which is known as a best-in-class hospital for its surgical site infection rates. Mercy Hospital studies General Heart Hospital's methods for reducing surgical site infection rates and uses that information to improve its own performance. This quality performance method is called: a. benchmarking. b. evidence-based practice. c. enterprise risk management. d. continuous quality improvement

ANS: A In ambulatory care (and other settings), benchmarking "is the process of comparing a practice's performance with an external standard. Benchmarking is an important tool that facilitators can use to motivate a practice to engage in improvement work and to help members of a practice understand where their performance falls in comparison to others"

Sentinel Event Alerts are published by TJC to do which of the following? a. Allow facilities to learn from sentinel events that have occurred in other facilities and incorporate recommendations for prevention into their policies. b. Notify hospitals that if a sentinel event occurs during an alert, the hospital will be subject to withdrawal of Medicare and Medicaid certification and reimbursement. c. Prevent a near-miss from occurring. d. Assist hospitals to find national standardized performance measures to benchmark themselves against other similar hospitals.

ANS: A Sentinel Event Alerts are published by TJC to review the lessons learned from those facilities that had experienced these sentinel events. The hope is that other hospitals will incorporate the recommendations into their policy to avoid making similar errors.

The purpose of a root cause analysis (RCA) is to: a. discipline the staff involved in the patient safety event. b. disclose the medical error to the patient/patient s family. c. identify the person(s) responsible for committing the error. d. identify the systems issues that led to a sentinel event.

ANS: D The purpose of the RCA is to drill down to the most common cause(s) for the event and determine what process improvements can be made to prevent the sentinel event from occurring in the future.

A Healthcare Failure Modes and Effects Analysis (HFMEA) for a new bar-coding system is being conducted by an interdisciplinary team. List the steps of the HFMEA in the correct order. a. Identifying prevention strategies b. Endorsing action plans for implementation c. Assessing risk points within the process steps d. Flowcharting the steps of the process being studied e. Designing out the most critical of the potential failures f. Recommending process improvements for prevention of the failures g. Ranking key risk points in terms of their impact on the potential failure of the system h. Reporting action plans for implementing prevention strategies to the enterprise leaders

ANS: D, C, G, E, F, A, H, B The HFMEA is conducted by an interdisciplinary team of professionals who own the process being studied and is facilitated by someone with knowledge and skills in quality improvement tools. The HFMEA begins with flowcharting the steps of the process being studied. The team assesses risk points within the process steps, and these key risk points are ranked in terms of their impact on the potential failure of the system. Scores for severity and probability are calculated to give a hazard score to the identified breakdown, and detectability of the failure mode is factored into the analysis of its impact on the overall process. The team then designs out the most critical of the potential failures and recommends process improvements for prevention of the failures. Once these prevention strategies are identified, action plans for implementing them are reported to the enterprise leaders and endorsed for implementation

_____ is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.

ANS: Evidence-based practice Evidence-based practice is defined by Sackett and colleagues (1996) as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.

The improvement process in which an organization measures its strategies, operations, or internal process performance against that of best-in-class organizations within or outside its industry determines how those organizations achieved their performance levels, and uses that information to improve its own performance is known as _____.

ANS: benchmarking Benchmarking "is the process of comparing a practice's performance with an external standard. Benchmarking is an important tool that facilitators can use to motivate a practice to engage in improvement work and to help members of a practice understand where their performance falls in comparison to others" (Agency for Healthcare Research and Quality [AHRQ], 2013a, p. 11).