Chapter 23 Quality Control

Total Quality Management

- Also referred to as continuous quality improvement (CQI) - Developed by Dr. W. Edward Deming - Based on the premise that the individual is the focal element on which production and service depend - Focus is on doing the right things, the right way, the first time, and problem-prevention planning, not inspective and reactive problem solving.

*Centers for Medicare and Medicaid Services* - Plays an active role in setting standards for and measuring quality in health care - With the introduction of the Medicare Quality Initiative (MQI) in November 2001 (now called the Hospital Quality Initiative [HQI]), health outcomes were targeted as the data source.

- As part of the HQI, easy-to-understand data on health-care quality from nursing homes, home health agencies, hospitals, and kidney dialysis facilities are made available to all consumers via a variety of media.

Strategies to Prevent Medication Errors

- Better reporting of the errors that do occur - The Leapfrog initiatives - Reform of the medical liability system - Other point-of-care strategies * Bar coding * Smart IV pumps * Medication reconciliation

Leapfrog Group

- Computerized physician-provider order entry - Evidence-based hospital referral - ICU physician staffing - The use of Leapfrog Safe Practices scores http://leapfroggroup.org/

Six Sigma Approach - Sigma is a statistical measurement that reflects how well a product or process is performing. - Higher sigma values indicate better performance.

- Historically, the health-care industry has been comfortable striving for three sigma processes in terms of health-care quality, instead of six. - Organizations should aim for less errors by carefully applying the Six Sigma methodology to every aspect of QI.

CMS: Setting Standards and Measuring Quality in Health Care - Pay-for-performance/quality-based pricing - Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS surveys)

- National Committee for Quality Assurance (NCQA) - Maryland Hospital Association Quality Indicator Project (QI Project) - Multistate Nursing Home Case Mix and Quality Demonstration - Report cards

Audits Frequently Used in Quality Control

- Outcome—determine what results, if any, followed from specific nursing interventions for patients - Process—measure the process of care or how the care was carried out - Structure—monitor the structure or setting in which patient care occurs

Clinical Practice Guidelines

- Provide diagnosis-based step-by-step interventions for providers to follow in an effort to promote quality care - Also called standardized clinical guidelines - Should reflect evidence-based practice (EBP); that is, they should be based on cutting-edge research and best practices

Hallmarks of Effective Quality Control Programs

1. Support from top-level administration 2. Commitment by the organization in terms of fiscal and human resources 3. Quality goals reflect search for excellence rather than minimums 4. Process is ongoing (continuous)

Three Steps of the Quality Control Process

1. The criterion or standard is determined. 2. Information is collected to determine whether the standard has been met. 3. Educational or corrective action is taken if the criterion has not been met.

Standard

Predetermined baseline condition or level of excellence that constitutes a model to be followed and practiced Each organization and profession must set standards and objectives to guide individual practitioners in performing safe and effective care.

Quality Assurance

Quality assurance models seek to ensure that quality currently exists, whereas quality improvement models assume that the process is ongoing and that quality can always be improved. Quality control in health-care organizations has evolved primarily from outside forces and not as a voluntary effort to monitor the quality of services provided.

Medication Errors

Studies across the past two decades suggests that medical errors are rampant in the health-care system. Ignoring the problem of medical errors, denying their existence, or blaming the individuals involved in the processes does nothing to eliminate the underlying problems.

Reminder

The ANA has played a key role in developing standards for the profession.

Quality Measurement as an Organizational Mandate - External impacts on quality control - Professional Edward Deming - Prospective Payment System (PPS) - The Joint Commission

The Joint Commission - Sentinel event reporting - ORYX http://www.jointcommission.org/accreditation/performance_measurementoryx.aspx - Core measures - National Patient Safety Goals - Medication reconciliation

Quality Improvement Models The American health-care system has moved from a quality assurance (QA) model to one focused on quality improvement (QI).

The difference between the two concepts is that QA models target currently existing quality; QI models target ongoing and continually improving quality. - Two models that emphasize the ongoing nature of QI include: * total quality management (TQM) * Toyota Production System (TPS).

Benchmarking

The process of measuring products, practices, or services against best-performing organizations Organizations can determine how and why their organization differs from these exemplars and then use the exemplars as role models for standard development and performance improvement.

Outcomes

There is growing recognition that it is possible to separate out the contribution of nursing to the patient's outcome. This recognition of outcomes that are nursing sensitive creates accountability for nurses as professionals and is important in developing nursing as a profession.