Chapter 23 quality control
Patient Satisfaction Surveys
- Required by CMS - Standardized survey instrument - Bonuses - Compares • Overall satisfaction with care • Pain management • Involvement in care decisions • Trust/confidence in care providers • Quality of meals • Satisfaction with roommate • Noise on the unit • Wait time for call lights
total quality management principles
1. Create a constancy of purpose for the improvement of products and services 2. Adopt a philosophy of continual improvement 3. Focus on improving processes not inspection of product 4. And the practice of awarding businesses on price alone instead minimize total cost by working with a single supplier 5. Constantly improve every process for planning production and service 6. Institute job training and retraining. 7. Develop the leadership in the organization. 8. Drive out fear by encouraging employees to participate actively in the process. 9. Foster interdepartmental cooperation, and break down barriers between departments. 10. Eliminate slogans, exhortations, and targets for the workplace. 11. Focus on quality and not just quantity; eliminate quarter systems if they are in place. 12. Promote teamwork rather than individual accomplishments. Eliminate the annual rating or merit systems. 13. Educate/train employees to maximize personal development. 14. Tart all employees with carrying out the total quality management principles
hallmarks of effective quality control programs
1. Support from top-level administration 2. Commitments by the organization in terms of fiscal and human resources 3. Quality goals reflect the search for excellence rather than minimums 4. Process is ongoing or continuous
three steps of the quality control process
1. The criteria are standard is determined. 2. Information is collected to determine if the standard has been met. 3. Educational or corrective action is taken if the criterion has not been met. 4. Reevaluation
Stetson auditing quality control
1. establish control criteria 2. identify the information relevant to the criteria 3. determine ways to collect information 4. collect and analyze information 5. compare collected information with the established criteria 6. make a judgment about quality 7.Provide information and, if necessary, take corrective action regarding findings 8. reevaluation
Workplace Violence
: Incidents that lead one to believe that he/she has been harmed by the experience • Epidemic • Goes beyond simple rudeness & civility o Favoritism o Verbal abuse o Abusive correspondence o Bullying, pranks
Quality Control Process
Activities that evaluate, monitor, or regulate services rendered to customers o Determine standards (objective, measurable, achievable) ANA Develops Standards (i.e., assessment, diagnosis, outcome identification, planning, implementation, evaluation) Joint Commission • Action taken to correct discrepancies (i.e., education, Root Cause Analysis [RCA], corrective action).
Medical Errors:
An Ongoing Threat to Quality • "To Err is Human" 1999 IOM Report • 8th leading cause of death (44,000-98,000) • Medication errors especially high risk • Most errors are due to system errors, NOT individual recklessness 2008-2010 • 254,200 potentially preventable patient safety events among Medicare patients • 56,367 deaths among Medicare patients who experienced one or more of these events (healthgrades.com) 2008 : Cost of Medical Error • Cost of Medical Errors $19.5 billion- r/t lost productivity, medical costs, and mortality • 1.5 million measurable errors • 10 million lost work days • > 2500 avoidable deaths (Society of Actuaries, 2008) Costs: 2008 • Pressure Ulcers: $3.9 billion • Post-op infections: $3.7 billion • Device complications: $1.1 billion • Failed spinal surgery: $1.1 billion • Hemorrhage: $960 million
Quality Control vs. Risk Management
Moved health care from a model of identifying failed standards, problems, and "problem people" TO Proactive organizations where problems are prevented and care improvements are continuously made
examples of standardize nursing language approved by the American nurses Association
NANDA, NIC, NOC, CCC, the Omaha system, perioperative nursing datasets, international classification of nursing practices, systemized nomenclature of medicine clinical terms, logical observation identifier names and codes, nursing minimum data sets, nursing management minimum datasets, and ABC codes
COLLECT INFORMATION : Audits
Systematic exam of a record, process, structure, environment or account to evaluate performance When can Audits be done? - Retrospective - After patient discharged - Concurrent - While patient inpatient - Prospective - How future performance will be affected by current interventions
The FDA has suggested that a drug barcode system coupled with a computerized order entry system would greatly decrease the risk of medication errors.
True
as directed caregivers, staff nurses are in an excellent position to monitor nursing practice by identifying problems and implementing corrective actions that have the greatest impact on patient care.
True
historically, the healthcare industry has been comfortable with striving for three Sigma processes (all data points fall within three standard deviations) in terms of healthcare quality instead of the six (that are adopted by the highest performing organizations in terms of quality).
True
the 27 item HCAPS Survey is the first national, standardize, publicly reported survey of patients perspectives of health perspectives of hospital care. It measures recently discharged patients perceptions of their hospital experience.
True
true or false clinical practice guidelines reflect evidence-based practice; that is, they should be based on cutting edge research and best practices.
True
Concurrent -
While patient inpatient
ORYX the joint commission instituted its agenda for change
a multiphase, multidimensional set of initiatives directed at modernizing the accreditation process by shifting the focus of accreditation from organizational structure to organizational performance or outcomes. This required that the development of clinical indicators to measure the quality of care provided to further this goal the joint commission approved a milestone initiative known as ORYX
a standard is
a predetermined level of excellence that serves as a guide for practice. Standards have distinguishing characteristic; they are predetermined, established by an authority, and communicated to and accepted by people affected by them.
quality control
a specific type of controlling Systematic refers to activities that are used to evaluate, monitor, or regulate services rendered customers.
organizational standards
all my levels of acceptable practice within the institution. For example, each organization develops a policy and procedures manual outlines its specific standards.
structure audit
assumes that a relationship exists between quality care and appropriate structure. A structure audit includes resource inputs such as the environment in which healthcare is delivered. It also includes all those elements that exist prior to and separate from the interaction between the patient and healthcare worker.
prospective audits
attemp to identify how future performance will be affect by current intervetions
total quality management TQM
based on the premise that the individual is the focal element on which production and service depend and that the quest for quality is an ongoing process. True false
Toyota production system TPS
built on the complete elimination of waste and focus on the pursuit of the most efficient production model possible
Outcome audits
defined as the end result of care
the roles of leadership in quality control
encourage active involvement in the quality control process clear communication of standards of care setting of high standards to maximize quality embrace and champion quality improvement use control is a method of determining what by goals were not met X is a role model for followers in accepting responsibility and accountability distinguishes between Coco Sanders and resource utilization standards sports actively participates in research efforts to identify and measure nursing sensitive patient outcomes creates a work culture the empty emphasizes blame for errors encourage the use of six Sigma as the benchmark for quality improvement goals establishes benchmarks that mirror those of best-performing organizations
The American nurses Association (ANA)
has been instrumental in developing professional standards for almost 80 years. In 1973 the a in a Congress first establish standards for nursing practice, thereby providing a means of determining quality of nursing the patient receives, regardless of whether such services are provided by a professional nurse alone or in conjunction with nonprofessional assistance
quality measurement and outcomes accountability
have been buzzwords in healthcare since the 1980s and continued to be at the forefront of almost every healthcare agenda today
management functions of quality control
in conjunction with other personnel in the organization establishes clear-cut measurable standards of care and determines the most appropriate method for measuring those standards selects and uses process outcome and structure audit appropriately assesses appropriate sources of information determines discrepancies between care provided in unit standards uses quality control findings in determining need areas of Educational coaching keep abreast of current government accrediting body or licensing regulations actively participates in state and national benchmark practices continually assesses the unit or organizational environment to identify and categorize errors establishes an environment where research evidence in clinical guidelines based on best practices drive critical decision-making is accountable to ensure his patients providers and legislative and regulatory bodies establishes six Sigma methodology as a goal for every aspect of quality improvement
diagnosis related groups DRGs
in the early 1980s added to the ever increasing need for organizations to monitor cost-containment yet guarantee a minimum level of quality as a result of DRGs hospitals became part of the prospect of payment system PPS whereby providers are paid a fixed amount per patient admission regardless of the actual costs provide care. The system has been criticized as promoting abbreviated hospital stay and services leading to a reduced quality of care
what is the national guideline clearinghouse
is a free publicly available comprehensive database of evidence-based critical practice guidelines and related documents in one easy-to-use location, AHRQ
professional standards review organization
mandate certification of need for the patient admission and continued review of care evaluation of medical care and analysis of the patient profile the hospital and the practitioners
Process audit
measure how nursing care is provided
• Recommendations
o No more than three 12 hour shifts in a row o Discuss expectations with preceptor o Take your time/Focus o Know policy/Report to Preceptor/Manager/Instructor o Complete the form, "Injury/Illness Reporting Form for students & visitors" per UTACON policy
controlling phase of management process
performance is measured against predetermined standards and action is taken to correct discrepancies between the standards and actual performance.
Organizations the control over
productivity, innovation, and quality outcomes.
Standardized nursing language
provide a consistent terminology for nurses to describe and document their assessments, interventions, and outcomes of their actions
Standardized clinical practice guidelines or CPG's
provide diagnosis based, step by step interventions for providers to follow in an effort to promote high-quality care while controlling resource utilization and cost
quality assurance model
seek to ensure that quality currently exist
healthcare quality defined by the Institute of medicine
the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge
quality gap
the difference in performance between top-performing healthcare organizations and the national average is called the quality gap. It is significant healthcare
quality improvement models
the process is ongoing and quality can always be improved true or false
Outcome reflect the end result of care or how the patient's health status changed as a result of an intervention
true
Process audits are used to measure the process of care or how the care was carried out and assume that a relatioship exists between the process used by the nurse and the quality of care provided. true or false
true
True false controlling and should not be viewed as a means of determining success or failure but as a way to learn and grow, both personally and professionally
true
True or false benchmarking is a process of measuring products, practices, and services against best-performing organizations
true
a plethora of studies across the past two decades suggest that medical errors continue to be rampant in the health care system
true
ideally, everyone in an organization's should participate in quality control activities
true
in response to the demand for objective measures of quality a number of health plans healthcare providers employer purchasing groups consumer information organizations and state governments have began to formulate healthcare quality report cards
true
joint commission is a major accrediting body for healthcare organizations and programs the United States it also administers the ORYX initiative and collects data on core measures in an effort to better standardize data collection across acute-care hospitals
true
quality assurance model seek to ensure that quality currently exist, where as quality improvement models assume that the process is ongoing and that quality can always be improved
true
quality control and healthcare organizations has evolved primarily from external forces and not as a voluntary effort to monitor the quality of services provided
true
the NCQA, a private nonprofit organization that accredits managed-care organization, also developed the HEDIS to compare quality of care and managed-care organizations
true
the leapfrog group identified for evidence-based standards that they believe will provide the greatest impact on reducing medical errors: CPOE, EHR, IPS and the use of the leapfrog safe practices scores
true
the patient safety and quality improvement act, signed into law in 2005, protects medical error information that is voluntarily submitted to a new private organizations (patient safety organizations) from being subpoenaed or use in legal discovery and generally requires that the information is treated as confidential
true
to understand quality control manager must be familiar with the process and terminology used in quality measurement and improvement activities
true
true false critics of the PPS argue that although DRGs may have held to contain rising healthcare costs the associated rapid declines in length of hospital stay and services provided have resulted in the client the quality of care
true
true or false patient satisfaction often has little to do with whether a patient's health improved during a hospital stay
true
true or false quality control efforts must be proactive, not solely as a reaction to a problem
true
true or false while outcomes are an important measure of quality care, it is dangerous to use them as the only criteria for quality measurement
true
continuous quality improvement CQI and total quality management
which is one of the hallmarks of Japanese management systems assumes that production and service focus on the individual in the quality can always be better
Successful Organizations
• "Culture" of quality • Data Driven • A "Just Culture" of accountability
Handling Patient Complaints
• A satisfied patient/family is low risk • View illness from patient's perspective • 5 steps: 1. Acknowledge the incident 2. Quick follow-up 3. Personal contact 4. Immediate restitution 5. Document facts
Incident Reports (AKA Occurrence Reports)
• Accurate and comprehensive report on unplanned or unexpected occurrence that could potentially affect a patient, family member, or staff • Could be actual error or "near miss" o Why are nurses reluctant to report incidents?
Communicating with Patients and Families
• Communicate openly, honestly, and with respect • Use language appropriate to level of understanding • Maintain privacy and a neutral location for difficult interactions • Make effort to find interpreters • Recognize cultural differences
Causes of Medical Errors
• Complexity of work • High workload demands • Distractions • Poor coordination across departments or job functions • Lack of adequate handoffs • Missed side effects • Poor communication is the number one cause of Sentinel Events
Reducing Risk: Clinical Nurse Perspective
• Consistently provide competent care within scope of practice and according to policies and procedures • Anticipate patient care needs • Exceed client expectations • Thorough, objective documentation as care is provided
Examples of Joint Commission Standards
• Core Measures • National Patient Safety Goals
Culture of Safety
• Emphasis on "why" an error occurred rather than "who" made the error • Interdisciplinary analysis of incidents • Emphasis on continual improvement • Adequate resources o Financial o Technology o Staffing (including RNs) • "Best practices" from other industries
2014 National Patient Safety Goals
• Get important test results to the right staff person on time. • Find out which patients are most likely to try to commit suicide. • Use the hand cleaning guidelines from the CDC or the WHO • Use proven guidelines to prevent infections that are difficult to treat. • Use proven guidelines to prevent infection of the blood from central lines. • Use proven guidelines to prevent infection after surg.
Documentation
• Know hospital policy • Report the error!! • Document facts and patient's response • NO reference to incident report being filed • NO use of words "error", "accidentally" or "inappropriate" • Never use chart as disciplinary tool
Structure Audit
• Looking at the patient care "environment" o Structures (i.e., lighting, beds, flooring, etc.) o Environment of care (staffing ratios, staffing mix, ED wait times)
The Joint Commission (TJC)
• Major external force impacting Quality and Patient Safety • Independent, not-for-profit agency • Evaluates and accredits the quality and safety of care for over 17,000 health care organizations • Purpose: evaluate organization's performance in areas that affect client care • Hospital must be accredited to receive reimbursement!
Process Audit
• Measures how nursing care was provided • Task oriented
High Risk Areas for Nurses
• Medication errors (major problem area) • Complications from procedures • Patient falls • Refusal of treatment • Refusal to sign consent for treatment • Patient or family dissatisfaction
Patient Dissatisfiers
• Not being included in decision-making • Lack of information • Waiting for caregiver response • Quality of food • Disorganized, dirty unit
Joint Commission Survey
• On-site review by a Joint Commission team at least once every 3 years • Site visits are unannounced • Looks at organizational performance (outcomes) and how hospital meets Joint Commission standards
Patient Satisfaction Surveys
• Overall satisfaction with care • Pain management • Involvement in care decisions • Trust/confidence in care providers • Quality of meals • Satisfaction with roommate • Noise on the unit • Wait time for call lights
Risk Management
• Planned program of loss prevention and liability control • Daily program of detection, education, and intervention • Responsible for error tracking • Problem-focused
Quality Improvement models
• QI: Target ongoing and continually improving quality • QA: Target currently existing quality • TQM never ending process, everyone can improve • Benchmarking is used
Healthcare Quality Report Cards
• Report cards for all hospitals licensed in the state • Quality performance data of healthcare institutions made available to the public • Information may not be easily understood by the average consumer • Leapfrog Group - CPOE - Evidence based hospital referral (EHR) - More acute go to a hospital with better outcomes - ICU Physician staffing - Examines MD training in ICUs - Leapfrog safe practice scores - reduces risk of harm
Needle Sticks
• Risk Factors o Fatigue o Hurrying o Multi-tasking o Conflicting personal responsibilities during capstone o Student's perceptions of preceptor's expectations
Patient Satisfiers
• Staff concerns for privacy • Staff sensitivity to inconvenience of hospitalization • Adequacy of family briefings • Overall cheerfulness of hospital • Nurses' attitudes toward calls from patients
Outcome Audit
• What results occurred as a result of specific interventions? (Nursing - i.e., patient falls, nosocomial infections, pressure ulcers, restraints, patient satisfaction) • Traditionally measure morbidity/mortality
