Quality management

Innovation

coming up with new ideas for change

Role of professional nurses in quality improvement

here are lessons for all nurses from one of the original patient safety and quality improvement mentors, Florence Nightingale. Nightingale used data to support her efforts to reduce the incidence and spread of infections in the patient wards she was accountable for during the Crimean War. What resulted from her work was a broader shift in the culture of health care at that time. What can result from the current emphasis on quality and patient safety is a new cultural shift in health care with "building health care systems that do no harm" increasingly being the shared value and goal of all those involved in patient care delivery. Nurses are in the perfect position to lead this cultural change. Quality improvement should not be considered a separate function within the role of care provider, but rather an ongoing part of the professional role for all health care professionals.

aim statement defines

how much, by when, and for whom,"

Spread

implementating the change in several settings

quality assurance

inspection -oriented (detection), correction od special causes , Reactive

process

is a series of linked steps necessary to accomplish work. For example, the steps necessary to complete a new medication order, from the time the order is received until the medication is administered to a patient, is a process. Understanding variation—the differences in how the steps in the process might be accomplished and/or the variables that may affect each step in the process—is necessary to identify the direction that improvement efforts must take. Two types of variation in processes can occur: common cause variation and special cause variation. Processes that demonstrate common cause variation are stable, predictable, and statistically in control. Processes that demonstrate both common cause and special cause variation are unstable, unpredictable, and not in statistical control. The actions that should be taken to implement improvements under each type of variation are significantly different.

Implementation

making the change the new process in a defined setting

clinical indicators,

measurable items that reflect the quality of care. Just like the National Hospital Quality Measures previously referenced, clinical indicators are aspects of clinical care that can be measured to show the degree to which care is or is not implemented as it should be. Indicators focus on clinical actions or outcomes of clinical care; indicators should not focus on procedures that support clinical care

Never events

n 2006, CMS began to investigate ways that Medicare could help decrease or eliminate the occurrence of never events—serious and costly errors in health care delivery that should never happen. Examples of such events include wrong site surgery or mismatched blood transfusions, which can cause serious injury or death to the patient and result in increased costs to Medicare. CMS worked with the National Quality Forum (NQF) to identify hospital-acquired conditions that were determined to be reasonably preventable and for which the additional cost of hospitalization for treating these conditions should not be paid. Box 22-2 presents the most current list of hospital-acquired conditions for which Medicare will no longer make additional payments for treatment.

Standardized processes

otherwise referred to as best known methods or best practices, when effectively managed, have shown to be the foundation for improvements in all areas of business today, but especially in the clinical care setting. There is a typical resistance to standardizing practices, especially when they involve providing patient care and services, but the realistic effect of care without standardization must be considered in the following context as described by Joiner (1994): • Most employees receive little training on how to do their jobs. Instead the majority are left to learn by watching a more experienced employee. • Most employees have developed their own unique versions of any general procedures they witnessed or were taught. They think, "My way is the best way." • Changes to procedures happen haphazardly; individuals constantly change details to counteract problems that arise or in hopes of discovering a better method. Tampering is rampant. Each of the quality improvement cornerstone

Improvement Stories

select and read one story. How might you do something similar to make a difference?

data collection plan

specifies how you will track outcome, process, and balancing measures.

Pilot

testing a change on a small scale

Ten Rules to Improve Health System Quality one

1. Care is based on continuous healing relationships. 2. Care is customized according to patient needs and values. 3. The patient is the source of control. Patients should be given the necessary information and opportunity to exercise the degree of control they choose over health care decisions that affect them. 4. Knowledge is shared and information flows freely. Patients should have unfettered access to their own medical information and to clinical knowledge with clinicians communicating effectively and sharing information. 5. Decision making is evidence-based. Patients should receive care based on the best available scientific knowledge and care should not vary illogically from cl

The Joint Commission (TJC):

A national agency that conducts surveys of inpatient and ambulatory facilities and certifies their compliance with established quality standard

What is a process?

A process is a series of linked steps necessary to accomplish work. A process turns inputs, such as information or raw materials, into outputs, such as: Products Services Reports Clinical processes are a series of linked steps necessary for the provision of patient care. An organization improves its work and sustains itself by improving its processes.

What is root cause analysis?

A root cause analysis is defined by The Joint Commission as "a process for identifying the basic or causal factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event". A root cause analysis focuses primarily on systems and processes rather than individual performance. The analysis progresses from special causes in clinical processes to common causes in organizational processes. In addition, it identifies potential improvements in processes or systems that would tend to decrease the likelihood of such events in the future or, after analysis, it determines that no such improvement opportunities exist.

Run Charts

A run chart is a plotting of occurrences over time. The patterns that result demonstrate trends that allow the nurse to see improvements or setbacks. Trending may also allow for correlation between occurrence data and other events. For example, an increase in medication errors during a certain shift would prompt an evaluation of process variations that may occur on one shift and not others.

What is a sentinel event?

A sentinel event is defined by The Joint Commission as "an unexpected occurrence involving patient death or serious physical or psychologic injury or the risk thereof". According to The Joint Commission, "serious injury" specifically includes loss of limb or function. The phrase "or the risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called "sentinel" because they signal the need for immediate investigation and response.

Process:

A series of linked steps necessary to accomplish work. A process turns inputs, such as information or raw materials, into outputs, such as products, services, and reports. Clinical processes are a series of linked steps necessary for the provision of patient care.

The Institute for Safe Medication Practices

the Institute for Safe Medication Practices (ISMP) works through the U.S. Pharmacopeia's Medication Errors Reporting Program (MERP). This effort is instrumental in the development of strategies to prevent medication errors. Reporting these errors is confidential and may be done online without identifying the institution or even the name of the person reporting the error. The impact of this program has been vital to patient safety. Examples of significant actions taken to prevent errors include the following: Early warning systems Opportunities for learning Changes in devices, packaging, labeling, and drug names Development of standards and guidelines Advocate for policy changes

pt as customers, what do they expect?

to be knowledgeable, responsive, reliable, courteous, they assume that care will be cpnsistent, accurate, and provided on time

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 future occurrences. TJC allows organizations some latitude in determining the policy for disclosure of these events to the commission

Standardization:

Approach to process improvement that involves developing and adhering to best-known methods and repeating key tasks in the same way, time and time again, until a better way is found, thereby creating exceptional service with maximal efficiency.

What does CMS do?

By now, you are familiar with the Medicare program. However, you may not know that, in order for organizations to receive Medicare funds, they must meet certain conditions for participation. Among these conditions is a requirement for quality management. Further, states have varying requirements for what constitutes "quality" as a component of Medicaid services.

What are clinical indicators?

Clinical indicators are measurable aspects of care that reflect the quality of care provided and demonstrate the degree to which desired clinical outcomes are accomplished. Clinical indicators help identify the goals of quality improvement and measure whether desired quality

How do process improvement skills and tools fit with clinical indicators?

Clinical indicators help to identify the goals of quality improvement, whereas process improvement skills and tools support the quantitative understanding of key work processes. There are several different methods used by healthcare facilities for quality improvement and process improvement, including Lean methodology, Lean Six Sigma, and failure mode and effects analysis (Frankel et al, 2009). The tools described within this section (e.g., flow charts, Pareto charts) are all used in each of these various methods of quality improvement. It is not within the scope of this chapter to address these specific improvement strategies, but it is important to note that all improvement models generally have the following in common: • Analyzing and clearly understanding the process • Selecting key aspects of the process to improve • Establishing "trial" targets to guide improvement measures • Collecting and plotting data • Interpreting results • Implementing improvement actions and evaluati

Clinical Pathways

Clinical pathways (also known as critical pathways) promote standardization by requiring day-to-day timing of sequenced events. These pathways are developed by interdisciplinary teams who have specialized knowledge and intimate familiarity with the organizational culture. They apply this insight to create "best practice" guidelines to develop an individualized plan designed specifically for their institution.

Clinical protocols or algorithms

Clinical protocols or algorithms 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 (Figure 22-6).

Clinical Protocols or Algorithms

Clinical protocols or algorithms are similar to clinical pathways in that both provide a roadmap of sequenced events to be considered in providing patient care. The primary difference between them is that clinical algorithms are designed for practitioners, such as advanced practice nurses and physicians, who manage illnesses. As a result, these tools are developed by specialists in a medical discipline.

Quality Improvement

Correction of common causes, Planning -oriented (prevention), Proactive

Sentinel event:

Defined by TJC (2013) as an "unexpected occurrence involving patient death or serious physical or psychological injury or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase 'or the risk thereof' includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called sentinel because they signal the need for immediate investigation and response" (p. SE-1).

All one team

Effective team functioning is the third QI cornerstone, which embodies the principles of believing in people; treating everyone in the workplace with dignity, trust, and respect; and working toward win-win situations for all customers, employees, shareholders, suppliers, and perhaps even the broader community as a whole. For people to work this way, they must believe it is in their best interest to cooperate; they need to be more concerned with how the system as a whole operates rather than optimizing their own contributing area. In other words, all team members must rely more on cooperation and less on competition.

Interprofessional teamwork

Equally critical in its effect on patient safety is the work environment that supports the interdependence and effective communication among nurses and other health care professionals. Most nurses and other clinical staff assume they already work in teams; however, teamwork concepts are infrequently taught in health professional educational programs. Patient care is dependent on effective interprofessional communication to support the coordination of activities that promote efficiency and safety. One strategy to improve interprofessional teamwork is TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety). TeamSTEPPS was developed by the AHRQ and the U.S. Department of Defense as an evidence-based teamwork system aimed at optimizing patient outcomes by improving communication and teamwork skills among health care professionals. Comprehensive information about TeamSTEPPS, including readiness assessments and training materials, is available online at http://teamst

Clinical indicators:

Measurable items that reflect the quality of care provided and demonstrate the degree to which desired clinical outcomes are accomplished

Root cause analysis (RCA):

Method of problem solving that helps to identify how and why an event occurred. RCA is defined by TJC (2013) as a "process for identifying the factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event. A root cause analysis focuses primarily on systems and processes, not individual performance" (p. SE-2).

IOM:

National Academy of Sciences Institute of Medicine; a nonprofit organization with a mission of advancing and disseminating scientific knowledge to improve human health. The institute provides objective, timely, authoritative information and advice concerning health and science policy to the government, the corporate sector, the professions, and the public.

Case Management

Nurse case managers use a different kind of standardization to improve quality. Rather than using a sequence of events as guidance, they use standards of intervention. For example, interventions and services are identified based on what is appropriate for the patient's problem so that patients receive care with the following qualities: Coordinated Effective Cost-efficient

Nursing Implications

Nurses have an obligation to assure that patient care is safe and of high quality. Fortunately, current perspectives on quality improvement processes provide a sound framework for achieving these goals. Furthermore, guidelines, standards, and tools provide support and direction for improving processes and outcomes. This module has introduced you to many of those resources and provided a foundation for you to apply quality improvement principles and goals in your nursing practice.

The Need for Standardization

Research-based processes of providing patient care, commonly known as "best practices," have been shown to increase quality. Standardization of nursing practices, although important or even essential, typically meets with resistance when presented to nursing staff. To circumvent this resistance, a number of tools and methods have been identified to improve compliance with recommended practice guidelines or clinical pathways. This list includes three tools that are commonly used: Clinical pathways or critical pathways Clinical protocols or algorithms Case management We'll look at each of these tools.

How to Improve

Review the Quality Improvement Model. How could this be applied to a quality issue that you have noticed in the clinical setting?

STEEEP Principles

Safe Timely Effective Efficient Equitable Patient-Centered

What does NCQA do?

The National Committee for Quality Assurance (NCQA) is an accreditation body that has become the primary group that accredits health maintenance organizations.

flowcharts

The analysis of a work process usually is initiated through construction of some sort of flowchart or flow diagram. These are indispensable tools in mapping out what actually occurs during the process versus what is intended.

Process variation:

The differences in how the steps in a work process might be accomplished and/or the variables that may affect each step in the process. Variation results from the lack of perfect uniformity in the performance of any process. Understanding variation in a process is necessary to determine the direction that improvement efforts must take

process variation

The failure to document the catheter discontinuation order under these circumstances was considered to be special cause process variation, one of extreme impact, but related to a clearly identified single source. If the team had modified the overall documentation process based solely on the special cause factor, the underlying problem most likely would not have been improved for the long term.

Nursing quality indicators

The governing body of the American Nurses Association (ANA) established the National Database of Nursing Quality Indicators (NDNQI) in 1998 as part of the ANA's safety and quality initiative. This national database program collects designated indicators (Box 22-3) that strongly affect patient clinical outcomes for two major purposes: (1) to provide comparative data to 393health care organizations to support QI activities and (2) to develop national data to better understand the link between nurse staffing and patient outcomes. The NDNQI is unique in that it is the only national nursing quality measurement program that allows comparison measures of nursing quality among national, regional, and state hospitals of similar type and size, from the unit level perspective. As of 2014, 2000 hospitals have joined the database with quarterly reports now being provided to these organizations for analysis of their own care processes and support systems as related to nurse staffing (ANA, 2014).

National patient safety goals

The purpose of TJC's national patient safety goals is to help accredited organizations address specific areas of concern in regards to patient safety. These goals are based on ongoing analyses of reported sentinel events and the identified root causes of these events. An annual review of these goals generally results in modification of existing goals and the creation of new ones, as evidenced in the published list for 2014, which now includes a goal for improving the safety of clinical alarm systems (Box 22-1).

Scientific Approach as a Quality Management Principle

The scientific approach is data driven. In quality management, the scientific approach is focused on process. Through assessing, analyzing, evaluating, and understanding the interrelationship of processes across and within departments, you can improve processes for an overall improvement in quality services. Process variation is an important and inherent factor of established work processes. There are two types of variations: Common cause variations Special cause variations

cause-and-effect diagrams

are other worthy tools that can help determine potential sources of a problem. These diagrams are lists of potential causes arranged by categories to show their potential effect on a problem. The categories usually are broad, with subsequent levels of detail to illustrate what "might cause" the effect in question. This diagram sometimes is referred to as a fishbone diagram because it resembles a fish skeleton when complete. Cause-and-effect diagrams (Figure 22-4) are useful when the major problem areas have been localized using the Pareto chart.

Pareto chart:

A graphic tool that helps break down a big problem into its parts and then identifies which parts are the most important

Ten Rules to Improve Health System Quality 2

6. Safety is a system property. Patients should be safe; reducing risk and ensuring safety require greater attention to systems that help prevent and mitigate errors. 7. Transparency is necessary. The system should make available to patients and families information that allows them to make informed decisions, including information describing the system's performance on safety, evidence-based practice, and patient satisfaction. 8. Needs are anticipated. The system should anticipate patient needs rather than simply react to events. 9. Waste is continuously decreased. The system should not waste resources or patient time. 10. Cooperation among clinicians is a priority. Actively engage in collaboration and communication to ensure an appropriate exchange of information and coordination of care.

What is a Pareto chart?

A Pareto chart is a graphic tool that helps break a big problem down into its parts and then identifies which parts are the most important. This Pareto chart shows the reasons for administration of incorrect intravenous solutions.

What is a cause-and-effect diagram?

A cause-and-effect diagram is a tool for identifying and organizing possible causes of a problem in a structured format. It is sometimes called a "fishbone" diagram because it resembles the skeleton of a fish when complete. This cause-and-effect diagram shows the causes of mislabeled intravenous solutions.

Clinical pathways or critical pathways

A clinical pathway or critical pathway typically defines the optimal sequencing and timing of interventions by physicians, nurses, and other interprofessional team members when providing care for a patient with a particular diagnosis or procedure, such as a patient who is hospitalized for a coronary artery bypass graft. These pathways typically are developed through collaborative efforts of the interprofessional team that includes physicians, nurses, pharmacists, and others to improve the quality and value of the patient care provided. Among the most obvious benefits of using clinical pathways are (1) reduction in variation of the care provided, (2) facilitation and achievement of expected clinical outcomes, (3) reduction in care delays and ultimately lengths of stay in the inpatient setting, and (4) improvements in cost-effectiveness of the care delivered while maintaining or increasing patient and family satisfaction.

What is a flowchart?

A flowchart is a picture of the sequence of steps in a process. Different steps or actions are represented by boxes or other symbols. A top-down flowchart 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. This deployment flowchart shows the process for administering intravenous solutions.

Failure mode and effects analysis (FMEA):

A systematic process for identifying potential design and process failures before they occur, with the intent to eliminate them or minimize the risk associated with them.

Regulation of Quality Management

Although there is no doubt that many organizations would likely have instituted some manner of quality management without a push from regulatory and accrediting agencies, the agencies' requirement to address some aspect of quality helped formalize many programs. Three regulatory agencies, in particular, have had major effects on the quality management movement: The National Committee for Quality Assurance (NCQA) The Centers for Medicare and Medicaid Services (CMS) The Joint Commission

The professional nurse and patient safety

For nurses, the challenge starts with making patient safety improvement and error reduction not just an organizational priority, but a personal one as well. This means adopting a state of mind that recognizes the complexity and high-risk nature of modern health care, implementing standardized best practices, and working to eliminate never events. Two significant nursing functions that most closely effect patient safety, quality of care, and resulting outcomes are as follows: 1. Monitoring for early recognition of adverse events, complications, and errors 2. Initiating deployment of appropriate care providers for timely intervention and response and rescue of patients in these situations A critical factor in supporting a nurse's ability to carry out these two functions is nurse staffing. Although defining the appropriate level of staffing is a matter of debate, there is widespread recognition that a strong linkage exists between patient outcomes and nurse staffing (Aiken et al, 2008;

Summary

For today's graduating nurses, the challenge is to find whatever means are available to refine the knowledge and skills fundamentally necessary to enter a partnership with all other interprofessional team members in the ongoing improvement of health care. Just as essential to professional nursing practice as knowing, for instance, the symptoms of diabetic ketoacidosis or how to give an injection, is understanding the basic principles of QI, process improvement, and variation; using clinical indicators, process improvement tools, and standardized care processes; and addressing patient safety in every aspect of care. Every nurse should enter practice accepting accountability for the quality of care provided by the health care organization and taking a leadership role to implement improvements to achieve health care that is safe, timely, effective, efficient, equitable, and patient centered.

Never Events: The Centers for Medicare and Medicaid Services Listing of Hospital-Acquired Conditions for 2014

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, mediastinitis, following coronary artery bypass graft • Surgical site infection following certain orthopedic procedures • Surgical site infection following bariatric surgery for obesity • Surgical site infection following cardiac implantable electronic device • Deep vein thrombosis and pulmonary embolism following certain orthopedic procedures • Iatrogenic pneumothorax with venous catheterization

Quality improvement (QI):

Framework for taking action to systematically make changes that lead to measurable improvements in health care services for patients, staff and organizations; quality is determined by the needs, expectations, and desired health outcomes of individuals and populations.

Run chart:

Graph of data in time order that helps identify any changes that occur over time; also called a time plot. A run chart that has a centerline and statistical control limits added is known as a control chart.

HAC:

Hospital-acquired condition. A term used to indicate an unintended and typically adverse patient-acquired condition occurring as a result of being cared for in a hospital.

Process Improvement

If measurement of a clinical indicator reveals that quality outcomes have not been met, action must be taken to improve outcomes. As you have learned, the focus of quality management is the improvement of processes that affect quality of care. The examination of current processes requires a comprehensive and thoughtful approach. It is all too easy to make assumptions or miss important elements of processes that contribute to poor outcomes. Fortunately, a number of tools, which are listed here, have been developed to guide the examination and evaluation of processes: Flowcharts Pareto charts Cause-and-effect diagrams Run charts We'll look at each of these.

Customer:

Individual or group who relies on an organization to provide a product or service to meet some need or expectation. It is these customer needs and expectations that determine quality.

The Four Phases of an Improvement Project

Innovation, Pilot, Implementation, Spread

Breakthrough thinking to improve quality

Just as standardization is critical to the foundation of health care improvement, so is the notion of breakthrough thinking and swift application of best-known methods for practice. The premise behind breakthrough thinking and its resulting action is threefold: (1) substantial knowledge exists about how to achieve better performance than currently prevails; (2) strong examples already exist of organizations that have applied that knowledge and broken through to substantial improvements; and (3) the stakes are high and relevant to the most crucial strategic needs of health care (Berwick, 1997). The Institute for Healthcare Improvement (IHI), a voluntary organization formed to assist leaders in all health care settings actively involved in improving quality, recommends a QI model developed by Langley and colleagues (2009) and composed of two parts. Part one asks three fundamental questions: 1. What are we trying to accomplish? 2. How will we know that a change is an improvement? 3. W

The National Database of Nursing Quality Indicators (NDNQI)

Nursing Staff Skill Mix: Registered Nurses (RNs) Licensed Practical/Vocational Nurses (LPN/LVNs) Unlicensed Assistive Personnel (UAP) Nursing Hours per Patient Day RN Education/Certification Nurse Turnover RN Survey: Practice Environment Scale Job Satisfaction Scales Patient Falls/Injury Falls Hospital/Unit-Acquired Pressure Ulcers Physical/Sexual Assault Pain Assessment/Intervention/Reassessment Cycles Peripheral IV Infiltration Physical Restraints Healthcare-Associated Infections: Catheter-Associated Urinary Tract Infection Central Line-Associated Bloodstream Infection Ventilator-Associated Pneumonia Ventilator-Associated Events New clinical measures in 2014 Falls in Ambulatory Settings (now available) Pressure Ulcer Incidence Rates from Electronic Health Records (now available) Nursing Care Hours in Emergency Departments, PeriOperative Units, and Perinatal Units Skill Mix in Emergency Departm

Other Factors Affecting Complexity

Other factors affecting the complexity of a flowchart include the following: The number of steps The number of departments involved in the steps The addition of subcategories The more complex a flowchart is, the more important it becomes to look closely at all of its aspects. In that way, you gain a full understanding of the situation and do not overlook problem areas.

QSEN Competencies

PATIENT-CENTERED CARE Definition: Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient's preferences, values, and needs Knowledge Skills Attitudes Integrate understanding of multiple dimensions of patient-centered care Elicit patient values, preferences, and expressed needs as part of clinical interview Value seeing health care situations "through patients' eyes" Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values Communicate patient values, preferences, and expressed to other members of health care team Respect and encourage individual expression of patient values, preferences, and expressed needs TEAMWORK AND COLLABORATION Definition: Function effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision making to achieve quality patient care Knowledge Skil

Improvement Tools

Peruse the list of tools. Which ones do you recognize from your readings and the content of this module? Because you have registered, you will be able to download any or all of these tools that you would like to practice.

Flowchart:

Picture of the sequence of steps in a process. Different steps or actions are represented by boxes or other symbols.

What is process variation?

Process variation is the differences in how the steps in a work process might be accomplished and/or the variables that might affect each step in the process. Variation results from the lack of perfect uniformity in the performance of any process. Understanding variation in a process is necessary to determine the direction that improvement efforts must take.

What is quality management?

Quality management (QM) is a philosophic framework for managing organizations that recognizes that quality is determined by customer needs and expectations. Attention is paid to how the work is done, with an emphasis on involving the people who best understand the detail of the work processes with which they are involved. Health care QM is specifically related to the quality of health care services provided.

The Role of Nursing

Regulation and policy alone will not ensure patient safety. The registered nurse (RN) must take an active role in assuring the care provided is safe. Errors, when they occur, must be faced and analyzed so that knowledge can be gained to prevent further errors. Now let's suppose that at the end of a long busy day on your unit, you are approached by an LPN who is obviously shaken. She reports that she accidentally administered the wrong drug to a patient.

STEEEP. Individually, these aims are for health care to be (IOM, 2001)

Safe: Preventing injuries to patients from the care that is intended to help them 382 • 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

The Shift from Assurance to Improvement

Screen 12 of 33 Evolution of the Quality Movement A nurse administering medication. The Shift from Assurance to Improvement The focus on quality in health care did not begin with the IOM report; rather, the IOM report supported a shift in perspectives and approaches to quality. One of these shifts was a move from quality assurance to quality improvement. In examining the differences between these two concepts, you can see how the transition from assuring quality to improving quality is a step toward the quality management model. To look at quality improvement and quality assurance in more detail, work on these two activities (see tabs numbered 1and 2). When you have completed each activity under a tab, select the next tab.

Clinical Indicators

Screen 15 of 33 Clinical Indicators and Tools A nurse administering medication to a child. Clinical Indicators Clinical indicators are measurable aspects of care that can be used to determine if the desired quality of care is attained and maintained. Because they are measurable, these indicators provide a quantitative basis for comparison of quality improvement over time. Examples of common clinical indicators include: Development of decubitus Unplanned readmissions Postoperative infections Falls Injuries secondary to falls Medication errors Medication errors can include: Wrong drug Wrong patient Wrong amount Wrong time Wrong route

Pareto Charts

Screen 18 of 33 Clinical Indicators and Tools A nurse reading a document. Pareto Charts A Pareto chart is used to identify the causes of problems. The name comes from the "Pareto principle" or the "80-20 rule" proposed by the economist Vilfredo Pareto. According to this principle, 80% of problems come from 20% of causes. Therefore, by identifying and correcting the small number of causes contributing to most of the problems, a large majority of problems can be eliminated. Although the 80-20 rule does not always hold true, the tendency for a small number of causes to be responsible for most of the problems holds fast. The Pareto chart is a simple bar graph that highlights the frequency with which events causing problems occur. This allows the nurse to identify the most significant cause(s) and scrutinize processes that may contribute to the cause.

Never events:

Serious adverse events during an inpatient stay that should never occur or are reasonably preventable through adherence to evidence-based guidelines. The Centers for Medicare and Medicaid Services, through revisions in coverage and payment policies, provide hospitals with financial incentives to reduce the occurrence of never events.

All One Team" as a Quality Management Principle

The "all-one-team" perspective values all members as integral to the whole. This all-encompassing holistic perspective, which values "all" over "each" and the whole rather than the parts, is inherently value-laden toward promoting the following attitudes in the organizational environment and perhaps even the broader community: Appreciation Trust Confidence Respect

The Institute for Healthcare Improvement

The Institute for Healthcare Improvement (IHI) has emerged as a prominent leading organization for quality improvement. First visit the IHI website and register. (Registration is free.) Then go to the three sections listed in the table and complete the assignments.

What is the Institute for Safe Medication Practices (ISMP)?

The Institute for Safe Medication Practices (ISMP) is a nonprofit organization that is well known as an education resource that provides impartial, timely, and accurate medication safety information. The ISMP is devoted entirely to medication error prevention and safe medication use.

What does The Joint Commission do?

The Joint Commission, formerly called the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), is a national agency that conducts surveys of inpatient and ambulatory facilities and certifies their compliance with established quality-standards. Accreditation by The Joint Commission is voluntary.

QSEN (quality and safety education in nursing) competencies

This chapter has examined the vital need to transform today's health care systems to improve quality and safety for patients. Nurses are emerging as leaders in this transformation and as such, need to incorporate into their nursing practice the six competencies recommended by the IOM (2003) as essential for all health professionals: • Patient-centered care • Teamwork and collaboration • Evidence-based practice • Quality improvement • Safety • Informatics To support nursing education around these six competencies, the national Quality and Safety Education for Nurses (QSEN) project was created through support from the Robert Wood Johnson Foundation (Cronenwett et al, 2009). In support for the importance of these six 394competencies to nursing practice, they have been incorporated into nursing education standards and the nurse licensure examination (American Association of Colleges of Nursing, 2008; Smith et al, 2007) so that all nurses will be held accountable for being competent

Cause-and-effect diagram:

Tool that is used for identifying and organizing possible causes of a problem in a structured format. It is sometimes called a fishbone diagram because it looks like the skeleton of a fish.

How would the quality assurance approach handle a lack of documentation?

Under the quality assurance model, the nurse manager would do the following: Examine charts and schedules to determine who was failing to document. Remind staff that if it wasn't charted, it wasn't done. Warn staff of repercussions for failure to document. Place a note in the personnel files of individuals who failed to document. Staff also might have been required to attend an in-service on charting or complete some other kind of remedial program. Charting would likely improve in the short term but return to pre-intervention status unless a knowledge deficit related to charting was the real reason for the individual's failure to chart.

How would the quality improvement approach handle a lack of documentation?

Under the quality improvement module, the nurse manager would investigate processes to determine if common or special variations contributed to the failure to document. Generally, processes involved in charting require the following: The chart is available for charting. The proper forms are available in the chart. Adequate time is allotted for charting. Any variation affecting any part of the process (for example, charts being sequestered in a physician's work area for a prolonged period of time) potentially affect the ability of the nurse to document an aspect of care. In the event that this sequestering of charts is the problem, the remedy would target this issue (or a way around this issue), not the nurse.