Chapter 21 intro

6) Prevent health care associated pressure ulcers National Patient Safety Goals 2012

-Assess and periodically reassess each patient's risk for developing a pressure ulcer, and take action to address any identified risk

4) Reduce the risk of health care associated infections National Patient Safety Goals 2012

-Comply with either the current CDC hand hygiene guidelines or the current WHO hand hygiene guidelines -Implement evidence based practices to prevent central line associated blood stream infections -Implement evidence based practices for preventing surgical site infections -Implement evidence based practices to prevent indwelling catheter associated urinary tract infections

8) Universal protocol for preventing wrong site, wrong procedure, wrong person surgery National Patient Safety Goals 2012

-Conduct a preprocedure verification process -Mark the procedure site -Perform a time out before the procedure

Examples of never events

-Foreign body retained after surgery -air embolism -blood incompatibility -pressure ulcers stages III and IV -falls and trauma: fracture, dislocation, intracranial injury, crushing injury, burn, other injuries -catheter associated urinary tract infections -vascular catheter associated infection -manifestations of poor glycemic control -surgical site infection, mediastinitus, following coronary bypass surgery -surgical site infection following certain orthopedic surgeries -surgical site infection following bariatric surgery for obesity -deep vein thrombosis and pulmonary embolism following certain orthopedic procedures

7) The organization identifies safety risks inherent in its patient population National Patient Safety Goals 2012

-Identify patients at risk for suicide -Identify risks associated with home oxygen therapy, such as home fires

Quality Assurance

-Inspection oriented (detection) -Reactive -Correction of special causes -Responsibility of few people -Narrow focus -Leadership may not be vested -Problem solving by authority

3) Improve the safety of using medications National Patient Safety Goals 2012

-Label all medications, medications containers, and other solutions on and off the sterile field in perioperative and other settings. -Reduce the likelihood of patient harm associated with the use of anticoagulant therapy -Maintain and communicate accurate patient medication information

Following are selected indicators from recent reports that indicate just how wide the quality chasm is between what we know is good care and what is current practice

-On average, patient's are subjected to at least one medication error each day with extremely high costs to patients, families, health care professionals, hospitals, and insurance -49 million nonelderly americans do not have health insurance and experience gaps in healthcare -The lag between the discovery of more effective forms of treatment and their incorporation into routine patient care averages 17 years. -Twenty five percent of patients are not receiving care that is recommended, racial and ethnic minorities generally receive worse care than white, and poor people receive worse care than rich -The quality of health care in the United States is suboptimal.

Quality Improvement

-Planning oriented (prevention) -Proactive -Correction of common causes -Responsibility of all involved with the work -Cross functional -Leadership actively leading -Problem solving by all employees at all levels

5) Reduce the risk of patient harm resulting from falls National Patient Safety Goals 2012

-Reduce the risk of falls

2) Improve the effectiveness of communication among caregivers National Patient Safety Goals 2012

-Report critical results of tests and diagnostic procedures on a timely basis

1) Improve the accuracy of patient identification National Patient Safety Goals 2012

-Use at least two patient identifiers when providing care, treatment, and services -Eliminate transfusion errors related to patient misidentification

National Patient Safety Goals 2012

1-Improve the accuracy of patient identification 2-Improve the effectiveness of communication among caregivers 3-Improve the safety of using medications 4-Reduce the risk of health care associated infections 5-Reduce the risk os patient harm resulting from falls 6-Prevent health care associated pressure ulcers 7-The organization identifies safety risks inherent in tis patient population 9-Universal protocol for preventing wrong site injury, wrong procedure, wrong person surgery

The Joint Commission

A national agency that conducts surveys of inpatient and ambulatory facilities and certifies their compliance with established quality standards. It was one of the first accreditation agencies to embrace quality improvement principles in hospital based settings. Today organizations seek TJC accreditation to demonstrate they have a gold seal of approval. Accredits more than 19,000 hospitals. Address performance in areas such as patient safety, patient rights, patient treatment, and infection control. Requires evidence of actual performance and continued improvement.

Run Charts

Also known as time plots, are graphs of data points as they occur over time. Measuring data over time to evaluate patterns in process variation typically is suited for tools such as run charts. Valuable information can be obtained regarding process variation by studying the trends in the run chart. PAGE 385 Graph of data in time order that help identify changes that occur over time, also called a time plot. A run chart that has a centerline and statistical control limits is known as a control chart.

Never Events

CMS investigated ways that Medicare could help decrease or eliminate the occurrence of never events-which are serious and costly errors in health care delivery that should never happen. Medicare will no longer make additional payments for these treatments

What is the quality chasm report?

Details a number of factors that have contributed to this chasm, including the unprecedented advancement of science and technology, growing complexity of healthcare, changing public health care needs, and a poorly organized and uncoordinated health care delivery system. Details significant issues in quality and safety

Cause and Effect Diagrams

Help determine the potential sources of a problem. These diagrams essentially are lists of potential causes, arranged by categories to show their potential effect on a problem. Categories usually are broad with subsequent levels of detail pursued under each as the might cause question is asked of each subsequent level of detail. Referred to as the fish bone diagram. Useful when the major problem areas have been localized using the pareto chart. PAGE 384

Deployment flowchart

Maps out the steps of a process under headings designating people or departments who actually carry out each step. This is especially helpful when there is a need for common understanding of what the process is doing as a whole. PG 383

The quality chasm report details six guiding aims for improvement that should be adopted by every individual and group involved in the provision of health care, including healthcare professionals, public and private health care organizations, purchasers of health care, regulatory agencies and state and federal policy makers.STEEP

Safe: Preventing injuries to patients from 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 Efficient: Preventing 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

Top down flowchart

Simple lists the main steps and substeps of a process in a linear fashion. PG382

Sentinel Events

TJC established its sentinel events standard in 2000. this standard, which continues today, requires organizations to carry out designated steps to fully understand the factors and systems associated with adverse patient events, given that certain defining characteristics have been confirmed. The steps revolve around a root cause analysis. Which is a direct application of the quality improvement principles and methods defined earlier in this chapter. The intention behind the root cause analysis is to understand the systems at fault within the organization so that improvements can be determined and implemented to prevent any further occurrences. Defined by TJC as an unexpected occurence involving patient death or serious physical or psychological injury or the risk thereof. Serious injury specifically involves the loss of a limb or function. Risk thereof includes any process variation for which recurrence would carry a significant chance of serious adverse outcome. Called sentinel because they signal the need for immediate investigation and response.

Flowchart

The analysis of a work process usually is initiated through construction of some sort of flowchart or flow diagram. Picture of the sequence of steps in a process. Different steps or actions are represented by boxes or other symbols. A top down flow chart shows the sequence of steps in a job or process. It can have different levels of detail. A deployment flowchart shows the detailed steps in a process and the people or departments that are involved in each step.

Clinical protocols or algorithms

These are different from clinical pathways because they represent more of a decision path that a practitioner might take during a particular episode or need. For example, common algorithms exist for treatment of hypertension, provision of both basic and advanced life support, and general diagnostic screening.

What is the purpose of TJC's national patient safety goals?

To help accredited organizations address specific areas of concern in regards to patient safety. The goals are based on an ongoing analysis of reported sentinel events and the identified root cause

Pareto Chart

With this chart by collecting data on presumed or known problems in a given process, areas of focus or concentration can be achieved. It is a type of bar graph, with the height of bars reflecting the frequency with which events occur or the effect events have on a process problem. The bars are arranged in descending order so that the most commonly occurring problems are readily visible. PAGE 384 A graphic tool that helps break down a big problem into its parts and then identifies which parts are the most important.