NUR 101 Health Care Quality (Giddens)

Regulatory Agencies

-Centers for Medicare & Medicaid Services (CMS), The Joint Commission (TJC), and the Occupational Safety and Health Administration (OSHA) -Department of Health and Safety of the U.S. Food and Drug Administration (FDA), the Department of Justice (DOJ), the Office of the Inspector General (OIG), and the Drug Enforcement Administration (DEA), which is part of the DOJ

Attributes

**you cannot improve what you cannot or do not measure -nursing students track their grade point averages to determine how well they are doing in school, the health care system uses measures to gauge progress and improve results -provides valuable information for patients choosing high-quality providers, purchasers and insurers shaping payment policies based on rewarding quality and efficiency, physicians making referral decisions, and patients recommending a specific health care system to their friends and family

medical error or adverse event

*error of execution*-the failure of a planned intervention or action to be completed as intended and includes a variation from the standard of care -using the wrong plan to achieve an outcome which is an error in diagnosis, planning, or delivery of care

quality

- focus should be on providing patients excellent services via competent health care, comprehensive communication, interprofessional teamwork, and cultural sensitivity -also both tangible and intangible (perception, a feeling, or an impression, it can also be something measured) -*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-institute of medicine)

complex adaptive systems (CAS) (Plsek and Greenhalgh)

-a collection of individuals who have freedom to act in ways that are not always predictable and who are interconnected so that small changes can affect other individuals in the CAS ex) health care system

The National Center for Nursing Quality (NCNQ) (created by ANA)

-addresses patient safety and quality in nursing care and nurses' work lives -nursing workforce shortages and impact on patient outcomes are tackled through innovative initiatives

Root Cause Analysis (RCT)

-define the problem, identify risks and protective factors, develop and test prevention strategies, and ensure widespread adoption of system improvements -used when a patient has been seriously harmed or has died as a result of a medical error

Centers for Disease Control and Prevention (CDC)

-defined a culture of safety as the shared commitment of management and employees to ensure the safety of the work environment -seven subcultures of patient safety: (a) leadership, (b) teamwork, (c) evidence-based, (d) communication, (e) learning, (f) just, and (g) patient-centered

Plan-Do-Study-Act (PDSA)

-determine if changes they are making will lead to quality improvement -developing a plan to test the change (plan), trying out the change (do), analyzing what happened from the change (study), and determining what was learned (act)

Health Information Technology (HIT)

-enables organizations to mine the data collected in the delivery of patient care and track performance against established benchmarks more quickly and economically than with manual systems ex) electronic health record (EHR), computerized physician order entry, and medication administration systems

The Joint Commission

-leader in developing the highest standards for quality and safety in the delivery of health care, and evaluating organization performance based on these standards -only accrediting organization with the capability and experience to evaluate health care organizations across the continuum of care -standards similar to CMS -National Patient Safety Goals (NPSGs) program - accredited organizations address specific areas of concern in regards to patient safety

Leapfrog Group

-make health care safer -works with medical experts throughout the United States to identify and propose solutions designed to reduce medical errors ex) computer physician order entry (CPOE), evidence-based hospital referral, and ICU physician staffing standards - "never events" policy (events are categorized as events that should never occur in the delivery of health care): •Apologize to the patient and/or family affected by the event. •Report the event to at least one of the following agencies: The Joint Commission; state reporting program for medical errors; or a patient safety organization. •Agree to perform a root cause analysis, consistent with instructions from the chosen reporting agency. •Waive all costs directly related to a serious reportable adverse event. •Make a copy of the organization's policy available to patients and payers upon request.

The National Quality Forum (NQF)

-multistakeholder organization that has been instrumental in advancing efforts to improve quality through performance measurement and public reporting -"gold standard" for health care performance measures

The Institute of Medicine

-nonprofit organization that conducts studies and provides unbiased and authoritative advice to improve the nation's health - "To Err Is Human: Building a Safer Health System" & "Crossing the Quality Chasm: A New Health System for the 21st Century"

Transparency

-powerful catalyst for change and serves as a continual feedback loop for improving outcomes in patient care -not in conflict with confidentiality nor does it involve open disclosure of errors, but fear of discipline and malpractice suits can impede this goal (IOM) -goal of transparency is to have information flow freely for the purpose of mitigating potential errors and allowing patients to make decisions based on all the available information

Failure Mode Effective Analysis (FMEA)

-prevent the occurrence of errors or system failures ex) an FMEA strategy can assist in producing positive results when the goal is decreasing the number of catheter-related bloodstream infections -first step is to define the critical problem: maintaining sterile technique with both central line insertion and line maintenance • Potential failure modes include inappropriate skin preparation, compromised equipment, and outdated procedures and nursing protocols • Analyze causes of the system failure, such as a break in sterile technique, inadequate size of the sterile field, or lack of standardized catheter insertion kits and/or equipment • Solutions to the problem can include designing custom catheter insertion kits, providing catheter insertion carts, developing central line insertion checklists, informing nurses to stop the insertion procedure when there is a break in sterile technique, avoiding the femoral site, standardizing maintenance supplies, requiring daily documentation of need for central line, implementing a central line team, and providing extensive education • Evaluate the results. Examples include utilizing a central line team review procedure for catheter insertion and maintenance documentation and communicating results of central line infections per 1000 central line days

Avedis Donabedian

-quality as values and goals present in the medical system and defined outcomes as a validator of the quality and effectiveness of medical care -examining care processes instead of focusing on outcomes provided a more reliable indicator of the quality of medical care -*model identifies ways to define, categorize, and measure quality* -*three-part procedure: structure, process, and outcomes* -*Structure* is defined as the attributes of settings where care is delivered ex) facilities, equipment, supplies, staff training, provider knowledge and attitudes, and supervision -*Context* (structure) in which care is delivered affects processes and outcomes. ex) if the facility is lacking in amenities, wait times are too long, or the providers and staff are not adequately prepared, people will prefer to avoid the facility. -Service *process* dimensions include the services offered, the technical quality of the services (i.e., the staff and providers perform the technical aspects of the task or job), the quality of interpersonal relations, and the adequacy of patient education, access, safety, and promotion of continuity of care (i.e., appropriate referral, follow-up) -*Outcomes* are the impact of structure and process on the patient's satisfaction; perceptions of quality, knowledge, attitudes, and behavior; and health outcomes. For example, if a provider or facility is unavailable or if patients do not have accessibility, then the outcome will be a direct result of inadequate access.

Centers for Medicare & Medicaid Services (CMS)

-quality oversight for Medicare and Medicaid reimbursements - eliminate additional Medicare payments for eight preventable hospital-acquired conditions

The National Database for Nursing Quality Indicators (NDNQI)

-to aid the registered nurse in patient safety and quality improvement efforts by providing research-based national comparative data on nursing care and its relationship to patient outcomes -only national nursing database that collects and evaluates unit-specific nurse-sensitive indicators and provides quarterly and annual reporting of structure, process, and outcome indicators to evaluate nursing care at the unit level NDNQI quality indicators: falls, pressure ulcers, skill mix, nursing hours per patient day, RN Surveys/Job Satisfaction, practice environment scale, RN education and certification, peds pain assessments, intervention, reassessment cycle, health care-associated infections, peds IV infiltration rate, psych patient assault rate, nurse turnover

bedside nurse (quality)

the delivery of safe, caring, and competent care

Meade (quality)

the patient's perception of whether he or she received extraordinary service

minor attributes

timely, patient centered, and equitable (providing care that does not vary in quality because of gender, ethnicity, geographic location, and socioeconomic status)

Review of Advisory Bodies

• Association for Healthcare Research and Quality (AHRQ) • Institute of Medicine (IOM) • National Center for Nursing Quality (NCNQ) • National Quality Forum (NQF)

Review of Quality Plans and Philosophies

• Baldrige • Culture of safety • Magnet designation • Plan-do-study-act (PDSA) • Six sigma • Total quality improvement

Review of Regulatory Agencies

• Centers for Medicare & Medicaid Services (CMS) • The Joint Commission (TJC)

Review of Health Information Technology

• Computerized physician order entry (CPOE) • Electronic health records (EHRs) • Medication administration systems

SAFE

• Demonstrates knowledge base on health/illness status of individual/groups • Provides sound decision making in care of individuals/groups • Avoids injuries from care that is intended to help your patient • Acts within scope of practice of license or certification • Conforms to standards of practice for both self and patients

EFFICIENT

• Ensures that transitions between providers, departments, and health care settings are respectful, coordinated, and efficient • Routinely uses information for decision making • Same work is performed with fewer resources • Reduces length of hospital stays (result of increased safety and better scheduling and coordination) • Monitors costs and delivers most effective, cost-effective interventions

Review of Error Prevention Management

• Failure mode effective analysis (FMEA) • Root cause analysis (RCA)

EFFECTIVE

• Offers services that address most important • Addresses health problems of most vulnerable groups • Integrates curative and preventive services • Attains high population coverage

scope

consistently poor quality and poor outcomes, to perfection—that is, always delivering error-free, high-quality care, resulting in optimal outcomes for every patient

Context to nursing

identify unsafe practices and respond appropriately to ensure a safe outcome for patients, clients, oneself, and others

high-reliability organizations (HROs)

operate in hazardous conditions but have fewer than their fair share of adverse events ex) aviation, air traffic control, nuclear power plants, petrochemical processing, and naval aircraft carriers

U.S. Department of Health and Human Services National Healthcare Quality Report (2009)

quality health care as a delivery of services that diagnose, treat, and result in improvement of physical and mental well-being of patients of all ages in a way that is safe, timely, patient-centered, efficient, and equitable

quality health care

safe, effective, and efficient care (IOM) see chart

Florence Nightingale (quality)

she assessed for quality by measuring patient outcomes

Errors

•*Near miss*: A near miss is an error that could have caused harm to a patient, but did not, as a result of chance, prevention, or some intervention that mitigated the impact. Fortunately, the majority of adverse events that occur are considered near misses ex)Mild variation in standard of care,• Caused by human or system error, Does not reach the patient, Does not cause harm, Use FMEA to analyze causes •*Adverse event*: Some errors result in moderate to severe harm to a patient. One of the most common adverse events familiar to nurses involves medication administration and these are called adverse drug events (ADEs) ex) Moderate variation in standard of care, Caused by human or system error, Reaches the patient, Minimal or no harm, Use FEMA to analyze causes •*Sentinel event*: A serious adverse event is called a sentinel event when a patient dies or has a serious, undesirable, and largely avoidable outcome as a result of the error ex) Severe variation in standard of care, Caused by human or system error, Reaches the patient, Death or major harm, Use RCA to analyze causes

culture of safety

•Acknowledgment of the high-risk, error-prone nature of an organization's activities •A blame-free environment where individuals are able to report errors or close calls without fear of reprimand or punishment •An expectation of collaboration across ranks to seek solutions to vulnerabilities •A willingness on the part of the organization to direct resources for addressing safety concerns

Crossing the Quality Chasm (Institute of Medicine) importance of using HIT:

•Design care processes based on best practices. •Translate new clinical knowledge and skills into practice. •Support the work of multidisciplinary teams. •Enable the coordination of care across patient conditions, services, and settings. •Measure and improve performance.

Other organizations (some have power to implement Medicare & Medicaid reimbursement)

•Healthcare Facilities Accreditation Program (HFAP) •The Joint Commission (TJC) •National Committee for Quality Assurance (NCQA) •Community Health Accreditation Program (CHAP) •Accreditation Commission for Health Care (ACHC) •The Compliance Team, "Exemplary Provider Programs" •Healthcare Quality Association on Accreditation (HQAA) •Accreditation Association for Ambulatory Health Care (AAAHC)

Variables that impact quality

•Patient care outcomes •Patient satisfaction •Delivery of care based on latest evidence •Delivery of care that is safe •Delivery of care that is patient centered •Effective resource utilization