4520 Concepts Exam 1
Components of high quality care (4 exam questions)
Access to care: -Outcomes are better bc they have access to needed care Adequate scientific knowledge: -Organizations stay updated in changes to healthcare Competent health care providers: -Up to date with new advances -Want to avoid negligence (failure to meet standard of practice) Separation of financial & clincal decisions: -Comprehensive system, not deciding on clincial decisions based on financial issues Organization of health care institiutions to maximize quality: -Big thing here is COMMUNICATION
Accountability measures (HCAHPS) (Questions on exam)
Accountability Measures on Consumer Assessment of Healthcare Providers and Systems (HCAHPS): -Heart Attack Care -Heart Failure Care -Pneumonia Care -Surgical Care -Children with Asthma Care -Inpatient Psychiatric Services -VTE (Venous Thromboembolism) care -Stroke Care -Perinatal Care -Immunizations -These standare measures help to compare say UNMH to another hospital
Culture of healthcare in the USA
Consumer driven: -Demands placed on they system by patients who are more informed than every before. Power Relations with the Actors in our system are shifting: -Professional Model migration to Corporate Model -High number of Underinsured and Uninsured -Access to Care is challenging -Increased % of income going to health costs.
What is quality health care?
Bodenheimer & Grumbach Defenition: -It is care that assists healthy people to stay healthy, cures acute illnesses, and allows chronically ill people to live as long and fulfilling a life as possible. US Health Care: Pockets of Excellence- Variable Performance -Low Quality --Low performing institutions -High Quality --Places like Mayo Clinic, colorado childrens, etc.
VS of the health system PPT
-I believe 0 questions on the exam
Magic bullet philosophy
-No one solution is going to improve and solve everyone healthcare crisis at any level -Interventions & policy canges have significant impacts but in the end, when a solution has been put in place there are unconditional consequences
Nursing Special Report PPT (4 questions on exam)
-
Quality Health Care PPT
-
Quality Management Process PPT
-
Regulatory Agencies PPT (6 Questions on exam)
-
Accountability Measures HCAHPS (Questions on Exam)
-Accountability measures that help CMS & joint commision look at these to compare hospitals to one another Consumer Assessment of Healthcare Providers and Systems (HCAHPS): -Heart Attack Care -Heart Failure Care -Pneumonia Care -Surgical Care -Children with Asthma Care -Inpatient Psychiatric Services -VTE (Venous Thromboembolism) care -Stroke Care -Perinatal Care -Immunizations
Regulation & health outcomes: with all this regulation why not better outcomes?
-Big thing is behavior patterns, changes to begavior come about with long term interventions and strong primary care -Significant portion of mortality & morbidity attribute to begavior patterns in people (40%) -95% of investments go to short term medical interventions that only fix 10-15% causes of mortality -5% is invested in programs that help modify begaviors -We need to put money wehre the people actually need it, no amount of regulation can help until funds are reallocated -Regulation is about making hospitals safer and maintaining a standared, however big improvements in quality are not likely to come inthe way regulation is done in the moment
Quality, economica, organization, policy
-Falls example Quality: -Poor care arises, resulting in falls Economics: -Federal gov insurance program for elderly (medicare), CMS is in charge of this, hospitals rely on reimbursement for care -CMS decides no payment to organizations for fall insuries while under care of the organization Organization: -Hospitals realize falls are costing them a ton as medicare wont pay for poor care Policy: -New policy is rolled out to fix this -Changing nursing care at the bedside
Nursing special report recomendations
-Institute of Medicine The Future of Nursing Leading Change 2020 -Magnet Models (certification of high quality care and quality nursing environment -Kaiser Permanente Nursing Vision, Values and Professional Practice Model (nursing driving a big part of their business model for patinet care
High quality nursing care
-It is not just about the nurse, for nursing to be successful they must have a heathcare system to support them -These pieces should be focused on by organizations to create a supportive environemnt for the nurses -Often times organizations will only invest in staffing rations (nurse-pt. ratio) and that is not the silver bullet. Each of these is important Dependent on Structure and Process Factors: -Staffing Ratios (nurse pt. ratio) -Nursing Skills Set/Education -Availability of Sufficient Supplies and Equipment -Staff Training (continuous training) -Facilities (physical environment up to par) -Reliable Use and Demonstration of EBP -Interprofessional Relationships (job satisfaction goes way up) -Nurse Engagement (self governance, TCAB, etc.) -Job Satisfaction
Perspectives on regulation (pros & cons)
-Large number of insurance companies in the US result in increased amount of regulation Postive: -Establish Standards -Provides For safe patient care -Rewards good quality care and not poor quality care -A platform for insuring best practice is followed -Certifies minimum competency for providers Negative: -Very Time Consuming -Very Little value added to delivery of care. -Red Tape/bureaucratic -Expensive and Many are unable to comply -Too many regulations to keep up with
Suggestions for improving care
-Licensure, accreditation, peer review -Measuring practice patterns -Clinical practice guidlines -Continuous Quality Improvement (KEY) -Computerized information systems (standard now) -Public reporting of quality -Pay for performance: No longer paying for poor quality outcomes for patinets, reimbursing based off good performance -Financially neutral clinical decision making (really important)
Magnet Recognition program
-Magnet is nursing centric with interprofessional components Transformational Leadership: -Quality of Nursing Leadership -Management Style -Analyzing their management styles, nurse leadership has a lot of support Structural Empowerment: -Organizational Structure -Personnel Policies and Programs -Policies supportive of nursing, based on nursing Community and Health Organization: -Image of Nursing (to the community) -Professional Development Exemplary Professional Practice: -Professional models of care -Consultation and resources -Autonomy -Nurse as a teacher -Interdisplinary relationships. New Knowledge, Innovation & Improvements: -Quality Improvement Empirical Quality Results: -Quality of Care -NURSE QUALITY INDICATORS
Quality assurance (QA)
-Monitoring Health Care: Inspecting the Quality Care that is already in place.. -RETROSPECTIVE Quality Control: -Focus on the Process standards -"Did the nurse document response to pain management?" -"Did the patient receive adequate pain relief post operatively? Chart Audits: -Retrospective -EX: looking to see if nurse charted a pain response after pain management
National Data Base of Nursing Quality Indicators
-National Data Base of Nursing Quality Indicators NDI -Nursing Sensitive Indicators: Structure, Process, Outcomes (3 audits) -This is what should be important to nursing and are major components of nursing quality Nursing Hours per Hospital Stay: -Registered nurses hours per patient day -Unlicensed assistive per patient day Nursing Turnover Rate: Nosocomial Infections: -Patient Falls -Patient Falls/ Injury Pressure Ulcer Rate: -Community- acquired -Hospital- acquired -Unit- acquired- Pediatric Pain Assessment Pediatric Peripheral Infiltration RN/Education/Certification RN Survey: -Job Satisfaction -Proactive Environment Restraints Staff Mix: -RN, LPN, UAP, Percentage of Agency Staff
Standards of quality care
-Nurse practice act (understanding what we can & cant do_ -Accreditation Standards (e.g., TJC National Patient Safety Goals) -Governmental bodies (e.g., Agency for Healthcare Research and Quality [AHRQ], National Quality Forum [NQF]; the National Institute for Occupational Safety and Health [NIOSH]) -Healthcare advisory groups (e.g., Institute of Medicine [IOM]) -Internal or external performance measurements (e.g., patient satisfaction surveys, employee opinion surveys, safety assessment surveys, patient rounds) -Institutional Guidelines (e.g., Policies and Procedures, Structure/Process Standards) Research/Evidence -based practice guidelines
Data collection: 3 types of audits
-Often combining these different audits will make exploration of that poor care more meaningful Structure: -The resources and organizational arrangements are in place to deliver care -Facilities, equipment, staff, finances, latent errors, things that support the nursing staff -Example: number of patients per nurse Process: -Appropriate health care provider activities are carried out to deliver care -Nurses role/EBP -Example: percentage of patients with asthma for whom appropriate medications are ordered. -Evaluating the process: Nursing process, Q2 turns have been done, etc. Outcomes: -The results of health care delivery -Example: number of avoidable complications and deaths, pressure ulcer occurence, CAUTI, patient falls, etc. -Experience with health care or the level of satisfaction with care
Quality and Safety Education for Nurses (QSEN)
-Patient centered Care -Team Work/ COllaboration (Interprofessional) -Evidence Based Practice -Quality Improvement -Safety -Informatics (how we use data to inform our care
Transforming Cate at the Bedside (TCAB) (CHECK ON THIS)
-Rapid Cycle Change (you as the nurse starting change) -The longer it takes to make change the more likely it is for someone to get hurt -Box 13-2 Goal is to Improve Practice Patterns In Specific Units -Patient Centered Work Design -Effective Care Teams -System Design -Impacts Work Environment -Appropriate staffing -Elimination of Inefficiencies Goals of TCAB: -Reliability -Vitality -Patient-Centerdness -Increased Value
Plan-Do-Study-Act (PDSA)
-Similar to 6 steps in quality improvement cycle, 6 steps sometimes too formal, and not utilized as much as PDSA & easier for use at the bedside -Quality tool used to help foster TCAB -Meant to be cyclical & simpler, faster turn around in terms of quality improvement and one nurses at the bedside can participate in Plan: -Developing a plan to test a change -Root Cause Analysis -Fishbone -SMART Goals Do: -Carrying Out the Test -Doing intervention, implementing changes Study: -Observing and Learning From Consequences -Decide whether your interventions work or not Act: -What Modifications Should Be Made to the test? -If it worked out, move on to number 2 issue, if not, change the plan and do again
Why is regulation so complex in the US?
-So many conflicting parties with competing interests Demands of the opposing interests that shape the U.S. health system -Providers RN, MD, NP, -Hospitals -Community Providers -Insurances Consumers - Government (State and Local) -Private Survey Companies
Why focus on improving healthcare quality?
-The quality of healthcare that Americans receive varies greatly across social, economic, and geographical boundaries. -Recent studies have indicated that American adults receive recommended care only about 55 percent of the time. (largely wasteful) -Disparities exist in the way care is delivered to racial and ethnic minorities. -Significant portions of healthcare spending is wasteful and produces no value to the patient. -Medical errors third leading cause of death in the U.S.
Nursing Quality Indicators (3 questions on exam possibly)
-These numbers help judge quality of nursing -These numbers can be linked to nursing but also linked to systems in the organization -Nursing Hours per Patient Day -Patient Falls -Patient Falls with Injury -Pediatric Pain Assessment, -Intervention, Reassessment Pediatric -Peripheral IV Infiltration Rate -Pressure Ulcer Prevalence -Psychiatric Physical/Sexual Assault rate -Restrain Prevalence RN -Education/Certification -Percentage of total nursing hours provided -RN Satisfaction Survey -Nurse Vacancy Rate -Voluntary Nurse Turnover Nosocomial Infections UTI, CABSI, VAP
Principles of Quality Management
Box 20-1 -Works best with Flat, democratic Organization structures -Managers and workers must be committed to quality improvement -The goal of quality management is to improve systems and process, not to assign blame. -Customers Define Quality -Quality improvement focuses on outcomes -Decision must be based on data. -Support from managment, listening to customers, and everyone being on the same page, MUST BE INFORMED CHANGES
Continuous Quality Improvement (CQI)
CQI - Organizations constant reflection of practice and patient outcomes -Systematic data collection (use data collection to inform changes) Formalized Standards of Care: Process Measures: one of our 3 audits -Types of services delivered: turning patient every 2 hours, nursing assessments completed, medication reconciliation. Outcomes Measures: one of our 3 audits -Death, Symptom Control, Physical Functioning -Risk Adjusted can be difficult to risk adjust, so process measures used more often. Other examples of tools utilized in CQI: -Six-Sigma, TeamSteps, PDSA, Transforming Care at the Bedside, Rapid Cycle Change
Center for medicaid & medicare
Center For Medicaid and Medicare Services (CMS): -Largest Insurer in the Nation -Organizations must meet the Conditions of Participation to receive Accreditation -Without Accreditation the Organization will not receive Medicare or Medicaid reimbursement. -Sets Standards that tend to trickle down to other insurance companies Medicare: -Gov insurance for people over age of 65 Medicaid: -Insurance for people that fall below a particular poverty level -State & federally funded, meaning medicaid is differrent between states Safety and Quality is a big concern and assuring that what the tax payers are funding is truly quality care.: -Require Hospital Consumer Assessment of Healthcare Providers HCAHPS -CMS Hospital Quality Initiative: Outcome Measures, Process of care measures creates the ratings seen on hospital compare site and the Leap Frog foundation Accrediting Bodies: "Deeming Authority": -Table 7-3 -Main accrediting bodies that hospital nurses will encounter are Joint Commission and American Osteopathic Association's (AOA), Healthcare Facilities Accreditation Program AOA/HFAP
3 big regulatory agencies
Center for Medicare and Medicaid Services (CMS): -Federal organization overseeing all medicare & medicaid services -Medicaid also regulated at state level -Can withold reimbursments if organization doesn't fall in line with policy/standards State Department of Health: -Engaged in oversight of long term care facilities & regulating the delivery of care at state levels Health and Human Services: -3rd big agency Where does the joint commision & AOA fall in this?: -These are accredidation programs -Independent deeming authority gratned to them by CMS but arent part of federal gov. -These independent groups certifies quality and safe care for patients -Deeming authority: CMS requires hospital organizations to seek out approval from entities like joint ocmmision, which essentially is considered being in line with CMS standards -EX: Medicare will approve medicare patients to go in to your hospital if you've had joint commision certification. IF you dont have an accreditation recognized by CMS you cant get reimbursed for care provided to you medicare or medicaid patients
Variability in high quality care:
Contributors of Variability: Patients: -Acuity level, socioeconomic status Technology: -Rural areas with inadequate technology, or can even be pockets with dispraportionate numbers of specialists (EX: lots of cardiothoracic surgeons in one area may have increased utilization for these services then actually necessary) Workflow: -Differences in the ways we work as a team New treatment developments: -Not every organization may be up to date Complexity of care: -Shift to more interdisciplinary approaches to caring for patients
Swiss Cheese Diagram
Diagram: -Each slice represents barriers to patient harm -Holes represent potential areas of weakness in that barrier -When holes line up end result is patient harm Goal: -Add additional layers (slices) & eliminating weaknesses (holes) Latent: -Things hidden within the system -EX: Wrong meds were entered into MAR, pharmacy didn't;t stock Pyxis with right med, etc. Active: -At the point of care -Individual actively contributing to that error -EX: Nurse giving insulin and drew up wrong dose -Important to evaluate the system (latent), analyze more than just individuals commiting the problem at the bedside (active)
Quality management tools (13 questions on exam)
Examples: -RCA (fishbone, swiss cheese) -PDSA -3 types of audits (structure, outcomes & process) -Six Sigma -TCAB
Nursing special report
High - Value Care & Nursing/Nursing Work Environments Really only important part of this slide: -Focusing on nursing work environments will cause nursing quality indicators, HCAHPS, pay for permanence, etc. to go up Standards for High Value Care: --Key Performance Measures (KPM's) Standardized Outcome, Structure and Process Audits --National Database of Nursing Quality Indicators http://www.pressganey.com/solutions/clinical-excellence/nursing-quality --Hospital Consumer Assessment of Healthcare Providers Systems (HCAHPS) https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalHCAHPS.html --Pay-for-Performance ~ Hospital Value Based Purchasing Program https://www.cms.gov/newsroom/fact-sheets/cms-hospital-value-based-purchasing-program-results-fiscal-year-2019 --Value Based Purchasing https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reduction-program.html --Press Ganey Employee Engagement Surveys -Standardized Outcome, Structure and Process Audits
Steps in Quality Imporvement Process (questions on exam)
Identify needs of consumer: -Needs of patient Assemble interprofessional team: -Need more than just a nursing team Collect data: -So important, need data to improve system Establish outcomes and quality indicators: -Look at quality indicators Develop and implement plan: Evaluate change: -After you evaluate and see it was good, dont just forget about it -This process is cyclical, continue improvement
Lean Six Sigma (CHECK ON THIS)
Improve Capability Of Business Process: -Very Process and Data Driven -Like PDSA but uses a lot of metrics, and more complicated requiring formal training DMAIC: -Define -Measure -Analyze -Improve -Control
Epidemiologist Realization
Infectious Disease Prevention: Chronic Disease Prevention: -Increasing rates of chronic disease these days compared to infectious disease -Prevention of these is much more complicated Strategies for prevention: -Measures to Address social determinants of Illness -Public Health Interventions -Individual Providers Providing Preventive Services. -Prevention of all illness is not necessarily a cost savings to the USA health system, but it does help to maximize years of life without illness
Risk management
Legal & Data Crunchers Do Not Necessarily Need Health Care Background -Prevents errors before they occur (e.g. Enterprise Risk Management) -Identifies and corrects errors -Adverse events are decreased -Safety and quality outcomes are maximized -Optimizes patient outcomes -Prevents patient care problems -Mitigates adverse events
Malpractice impact (1 question on exam)
Malpractice goals: -To financially compensate people who in the course of seeking medical care have suffered medical injuries -To prevent physicians and other health care personnel from negligently causing harm to patients Reality: -Aren't really accomplishing this goal in current malpractice situation -Havent seen significant change in healthcare delivery on the account of malpractice other than it being more expensive to deliver healthcare -Settlements often made outside of court, resulting in lack of change in healthcare systems Communication-and-resolution programs -Disclose adverse events ot pts -Apologize -Rare cases offer compensation -EX: allowing families to be present for code, patients see whats going on and malpractice lawsuits go down drastically
Evaluation of quality
Overuse: -In pockets of low performing areas may have overuse of the system -EX: patient that had a back surgery, has a lot of pain, sought care from an ED and they did a CT, gave pain meds and sent them on their wat. They went to another ED, they did a CT, gave pain meds, then sent them on their way -Issue is there was no communication between these organizations and the patient got unnecessary care due to this overuse -Another example is as a country we overuse c-sections Underuse: -Don't have access so you underutilize the system -Dont have access to right provider for whatever the issue is -Some people dont go to the doctor because you would have to pay the copay which is another example Misuse: -Malicious, leads to really poor quality -EX: Provider that gets incentive for ordering MRIs bc they have a stake in the company. THey have high rates of referral for MRI. Misuse that harms patinets, malicious intent -Usually tied to financial incentive -EX: Going to ER instead of primary care bc there is no primary care available to you (also kind of undeuse and no malicious intent in this case)
Other items CMS surveys: Pay-for performance, Value based purchasing
Pay for performance & value based purchasing: -CMS regulation for how they pat hospitals -No longer blankely writing checks -Checking for quality outcomes then reimbursing based off that -Making hospitals more accountable for care they are providing -HCAHPS: nursing practice changed bc of regulation
Healthcare work force
Physicians: -1/3 in primary care -2/3 in specialty areas -Lacking PCPs alow people to fall through the cracks and only being caught in tertiary care -Interventions: Make med school either free or affordable thorugh gov requiring them to work in underserved areas and also limit specialties. RN: -Largest workforce in USA health system -Over half of all jobs in tertiary hospitals, quarter in ambulatory/longterm care stting NP: -Half of all NP's work in primary care settings -NPs often have never worked in primary care setting -Problem here is early in their career hospital work encultures the medical model of curative medicine early Supply & demand -Rely on market demand -Job openings in hospital is one way to look at this -Focusing too much on what the market says is important and less on what the population actually needs
Fishbone diagram
Premises of Fishbone: -Helpful in determining RCA, also in what needs to change to stop the error from occuring again or prevent the error from occuring in the first place -Team agrees on the problem statement -Team agrees on major categories of problems -Brainstorm possible causes of the problem -Identify sub branches of the problem -Open nonjudgmental brainstorming Diagram: -Head of the fish on the right is the identified problem -Branches are slices of swiss cheese that should catch the problem before fruition -Individual problems written under each branch can help determine your interventions
Linking performance measurement data to quality imporvement
Public reporting and transparency: -A healthcare institution (e.g., a hospital) reports the results of a standard to an external body, such as a state or federal agency. The state or federal agency then shares the data with the public so that consumers can compare results across institutions and over time. - Example: Centers for Medicare & Medicaid Services (CMS) Hospital Compare website Pay for performance: -Healthcare institutions are judged by their performance on certain standards and are rewarded financially based on the quality of care that they provide. (e.g. CMS stops reimbursing hospitals for certain preventable conditions, or something like falls)
Quality programs
Quality Assurance vs. Continuous Quality Improvement -Retrospective vs. prospective Peer Review that is systematic (monitor practice patterns): -Systematic in that you look at data that provides trends to monitor practice patterns and adjust the system accordingly Clinical Practice Guidelines: Public Reporting Big Data * Hospital Compare: -Accountability Measures (allow us to compare hospitals based off this data) -"Not everything that can be counted counts, and not everything that counts can be counted" Communication and Resolution Programs: -Want facilities to have strong communication
Improving quality
Quality Management about creating a philosophy of quality for the health system. Goals of QM: -Comprehensive -Systematic Approach -Decrease Adverse Events -Improve on Quality Outcomes Total Quality Management, (TQM) focus on shaping the culture of the health care organization. -Continuous Quality Improvement -Customer focus -Teamwork
Hosptial quality structure
Quality Management/Total Quality management: -First tier -Over arching management support, improving healthcare Quality assurance: -One of 3 under management -Comprised of quality nurses (specific staff) Approach: -Retrospective approach (looking back) Tools: -RCA -PDSA -Outcomes audits Continuous Quality improvement: -One of 3 under management -High performance hosptials have this -Includes engaging the interprofessional team Approach: -Prospective approach (looking ahead) Tools: -RCA -PDSA -Six Sigma -All 3 audits (structure, process, outcome) -TCB Risk management: -One of 3 under management -Legal department, reviews errors to mitigate future occurrences Approach: -Restrospective & prospective approach
Root Cause Analysis (RCA)
RCA: -Structured method for analyzing errors or potential errors -Goal is to identify underlying problems that contribute to the increased likelihood of error or poor patient outcomes. -Utilize a cause and effect diagram -Step by step process that helps us understand contributing factors to the poor outcomes or improvement you want to make Examples of data collection methods: -Fish Bone -Flow Charts -Diagrams -Spider Charting Graphs -Swiss Cheese Philosophy
Nursing special report interventions
Robust Shared Governance: -Have nurses actively engaging, takes extra time & work Support for Interprofessional Relationships: -Growing extensively -Improves job satisfaction Consistent Adequate Staffing Mix: -Right amount of new nurses to veteran nurses Development of Highly Education Workforce: -Facilities pushing nurses to further their educaiton even if that is in the form of certifications -Keeping up to date with best practices, as well as policy issues Appropriate & Consistent Leadership Support: -Most important part in all of this is making sure an organization has appropriate & consistent leadership & that they provide support -Invest heavily in leaders so they are advocating for their employees
Major tensions in healthcare
Table 17-1 Point of Equilibrium: -Improve Health not Costs of Healthcare -Prioritize resources and distribute fairly -We seek out as a society, want to improve health but not explode healthcare costs while distributing fairly Brighter future: -Accessible -Affordable -High Quality -Debate openly about viable solutions and RN's must be at the table...
Long term care (2 questions on exam)
Why do we need this?: -Growing # of elderly -Increase in chronic conditions earlier in life What is long term care?: -SNF, unskilled, care in the home -Some covered by insurance, many are not -Super vulnerable patients (1/3 of all COVID deaths) How do we improve LTC?: -Difficult to impove bc cost of care is very high and reibursment is low -Investment in staff -PACE models of care -Policy changes altering reimbursment can help, investment in staff