EFSC Leadership: Chapter 10 Issues of Quality and Safety

Medical Error: (2)

"Failure to complete a planned action as intended, or the use of a wrong plan to achieve an aim"-IOM "An unintended act, either of omission or commission, or an act that does not achieve its intended outcome"-Joint Commission

How to build your impact: (6)

(1) Write a letter to your representative (2) Attend a meeting where your topic will be addressed in a public forum or at a professional gathering. (3) Vote for candidates and officers in your professional organizations and within the government. (4) Visit your representative (local, state, federal) or ANA leadership or state-level delegate to share your ideas. (5) Volunteer. Ask what you can do to help. (6) Testify before decision-making bodies.

Characteristics of QI: (5)

-A link to key elements of the organization's strategic plan -Training programs for all levels of personnel -Mechanisms for selecting improvement opportunities -Staff support for process analysis and redesign -Personnel policies that motivate and support staff participation in process improvement

The Institute of Medicine (IOM): (3)

-A private, nonprofit organization chartered in 1970 by the U.S government. -The IOM's role is to provide unbiased, expert health and scientific advice for the purpose of improving health. -The result of the IOM's work supports government policy making, the health-care system, health-care professionals, and consumers.

Risk Management:

-A process of identifying, analyzing, treating, and evaluating real and potential hazards.

Crossing the Quality Chasm by IOM:

-Addressed broad quality issues in the U.S healthcare system.

Evidenced-Based Care: (2)

-An approach to making quality decisions and providing nursing care based upon personal clinical expertise in combination with the most current, relevant research available on the topic. -Implements the most up to date methods of providing care, which have been proven through appraisal of high quality studies and statistically significant research findings.

"Near Miss":

-An error that results in no harm or very minimal patient harm. -Near misses are useful in identifying and remedying vulnerabilities in a system before harm can occur.

Accident:

-An event that involves damage to a defined system that disrupts the ongoing or future output of that system. -Accidents occur when multiple systems fail and tend to be unplanned or unforeseen

Risk Management: Service Occurrence

-An unexpected occurrence that does not result in a clinically significant interruption of services and that is without apparent patient or employee injury. Example: Minor equipment damage.

Guidelines:

-Based on current research strategies and are often developed by experts in the field. -The use of guidelines is seen as a way to decrease variations in practice.

QI: (3)

-Began with Florence Nightingale -Structured organizational process. -Included evidence-based methods for gathering data and achieving goals.

Post-Acute Care Reform Plan.

-CMS is examining post-acute transfers with the aim of reducing care fragmentation and unsafe transitions.

Core Areas of Nursing Informatics: (4)

-Concept representation and standards to support evidence-based practice, research, and education -Research methodologies to disseminate new knowledge into practice -Information presentation and retrieval approaches to support safe patient centered care -Vision and management for the development, design, and implementation of communication and information technology.

How to achieve a "Culture of Safety":

-Create a blame free environment. -Promote reporting of errors.

What causes Medication Errors: (6)

-Deficient drug knowledge -Patient knowledge -Ordering/prescribing -Dispensing -Administration -Poor labeling (SALAD)

Types of Medical Errors: (5)

-Diagnostic errors -Equipment failure -Infections -Transfusion errors -Transcription errors

Regulation/Legislation in Quality and Safety in Healthcare:

-Diverse interests of: Consumers Insurance Companies and Government affect health care legislation. -Legislation regulates the practice of healthcare.

How do we use informatics in healthcare? (7)

-Documentation-use and implementation -Research -Local and National Data bases -Quality Improvement -Clinical pathways -Tele-health -Simulation

Treatment Error:

-Error in the performance of an operation, procedure, or test -Error in administering the treatment -Error in the dose or method of using a drug -Avoidable delay in treatment or in responding to an abnormal test -Inappropriate (not indicated) care

Diagnostic Error:

-Error or delay in diagnosis -Failure to employ indicated tests -Use of outmoded tests or therapy -Failure to act on results of monitoring or testing

Quality improvement (QI):

-Evidenced based methods for gathering data and achieving desired results.

What agencies are reported to with errors:

-FDA (About drug related adverse effects) -Joint Commission (About Sentinel Events)

Preventable Error: (2)

-Failure to provide prophylactic treatment -Inadequate monitoring or follow-up of treatment

QI Structured Organizational Process: (2)

-Focus, Analyze, Develop, Execute (FADE) or -Plan, Do, Study, Act (PSDA)

What was the Goal of the "To err is human" recommendations?

-For the external environment to create sufficient pressure to make errors costly to health-care organizations and providers, so they are compelled to take action to improve safety.

CQI works?: (3)

-Goal: Monitor and evaluate. -Process: Identify, collect data, analyze, evaluate, change -When goal is met, a new project is started.

Organizations and Initiatives in the Healthcare field: (4)

-Governmental Agencies -Health-Care Provider Professional Organizations -Nonprofit Organizations, Foundations and Research -Quality Organizations

SCM's include: (5)

-Guidelines -Protocols -Algorhythms -Standards of Care -Critical Pathways

Factors Contributing to the Nursing Shortage: (3)

-Increased Demand -Reduction in and Shortage of Nursing Faculty -Job Dissatisfaction

Demographics/Diversity in Quality and Safety Healthcare: (3)

-Increased number of elderly -Longer lifespans and -Limited access to healthcare traditionally by ethnic minorities and elderly affect care.

MedQIC:

-Initiative aims to ensure each Medicare recipient receives the appropriate level of care.

Adverse Event:

-Injury to a patient caused by medical management rather than an underlying condition of the patient.

Nursing informatics (NI):

-Integrates nursing science with multiple information management and analytical sciences to identify, define, manage, and communicate data, information, knowledge, and wisdom in nursing practice.

Healthcare Practice+ Quality and Safety in Healthcare:

-Integration of evidenced based practice improves quality and safety for patients.

What does "To Err is Human" address?

-It quantified unnecessary death in the U.S. healthcare system and placed emphasis on system failures as the foundation for errors and mistakes. -According the report, it is the flawed systems in patient care that often leave the door open for human error.

Areas of Risk Managment programs: Prevention (5)

-Latex allergies -Repetitive stress injuries -Barrier protection for tuberculosis -Back injuries -The rise of antibiotic resistant organisms

Economics in Quality and Safety Healthcare: (3)

-Media Criticism of Healthcare Costs (Compared with other developed nations.) -Rising cost of research and development of technology. -Initial costs may rise but improvements in quality and safety will lower costs in the long term.

Causes of Errors: (5)

-Medication errors -Falls -Hand-off errors -Diagnostic and surgical errors -Health-care acquired infections.

Delay in treatment: (7)

-Misdiagnosis -Test results -Admin of care -Incomplete treatment -Delayed initial assessment -Unattended patient -Unable to locate entrance

Continuous Quality Improvement (CQI):

-Monitors and evaluates quality of care. (Over time).

The Nursing Shortage and Patient Safety (3)

-More acutely ill patients are in the hospital setting. -Decreased number of qualified nurses increases the chance of errors. -Short staffing and increased workload contribute to errors.

IOM Evidenced Based Care is Focused on: (6)

-Nursing -Education -Research -Leadership -Interdisciplinary approach -Improve Patient Safety

Standards of Care:

-Often discipline-related and help to operationalize patient care processes and provide a baseline for quality care. -Lawyers often refer to a discipline's standards of care in evaluating whether a patient has received appropriate services.

Critical Pathways:

-Outlines the expected course of treatment for patients with similar diagnoses. -Involve all disciplines. -Designed for tracking a planned clinical course for patients based on average and expected lengths of stay. -Provide a framework for communication and documentation of care.

Outcome standards address indicators such as: (5)

-Physical Function -Mental Health -Social function -Utilization of Services -Customer Satisfaction

Evidenced-Based Care Core Competencies: (5)

-Provide patient centered care -Work in interprofessional teams -Employ evidenced-based practice -Apply quality improvement -Utilize informatics

Process variables include: (2)

-Psychosocial interventions: Teaching, counseling and physical care measures. -Leadership measures: Interdisciplinary team meetings.

QA: (3)

-Quality Assurance. -Used before the 1980's. -Focused on meeting minim standards.

High Risk Areas for Medical Errors: (2)

-Radiation Department -Operating Room

Aspects of Care Process:

-Refers to the activities carried out by the health-care providers and all the decisions made while a patient is interacting with the organization.

Aspects of Care: Structure

-Refers to the setting in which the care is given and to the resources (human, financial, and material) that are available.

Risk Management: Serious Incident

-Results in a clinically significant interruption of therapy or service, minor injury to a patient or employee or significant lose or damage or equipment or property.

Process: Examples (7)

-Setting an appointment. -Conducting a physical assessment -Ordering a radiograph and magnetic resonance imaging scan. -Administering a blood transfusion -Completing a home environment assessment -Preparing the patient for discharge -Telephoning the patient post discharge

Protocols:

-Specific, formal documents that outline how a procedure or intervention should be conducted. Example: Chest Pain Protocol

Algorithms:

-Systematic procedures that follow a logical progression based on additional information or patient responses to treatment. -Advanced cardiac life support algorithms are now widely used in health-care agencies.

Technology in Quality and Safety in Healthcare:

-Technology and Electronic Record keeping is projected to reduce costs, improve outcomes and improve quality and safety. -Tech also produces advancements in medical treatments.

Quality: IOM Definition

-The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current and professional knowledge.

Environment/Globalization+Quality and Safety in Healthcare: (3)

-The ease of travel and advances of technology have made the movement of disease, money and people more effective. -Climate change is linked to drug resistant organisms, and vector borne issues. -Migration may lead to disease spread.

What sentinel events are reviewed by the Joint Comission: (6)

-The event has resulted in an unanticipated death or major permanent loss of function. -Suicide of a patient in a setting where the patient receives around-the-clock care. -Infant abduction or discharge to the wrong family. -Rape -Hemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibilities. -Surgery on the wrong patient or wrong body part.

What does Crossing the Quality Chasm Address? (3)

-The gaps between actual care and high-quality care could be attributed to key interrelated areas in the health-care system. (Such as): 1. The growing complexity of science and technology 2. An increase in chronic conditions. 3. A poorly organized delivery system of care and constraints on exploiting the revolution in information technology

Joint Commission Root Cause Analysis on Sentinel Events:

-The process of learning from consequences. Principals: 1. Determine what influenced the consequences, i.e., determine the necessary and sufficient influences that explain the nature and the magnitude of the consequences. 2. Establish tightly linked chains of influence. 3. At every level of analysis, determine the necessary and sufficient influences. 4.Whenever feasible, drill down to root causes. 5. Know that there are always multiple root causes.

Aspects of Care: Outcome

-The result of all the health care providers' activities. -Outcome measures evaluate the effectiveness of nursing activities by answering such questions as: Did the patient recover? Is the family more independent now?

Hospital Quality Initiative: (2)

-This is a major initiative aimed at improving quality of care at the provider and organization level. -This initiative creates a uniform set of quality measurement by which consumers can compare organizations and by which organizations can benchmark progress toward achieving goals in specified areas of care.

How is Process Evaluated: (4)

-Timeliness -Appropriateness -Accuracy -Completeness

Structured Care Methodologies:

-Tools for tracking outcomes. -Used to identify best practices, facilitate standards of care and outcome measurement.

Culture of Safety Promotes:

-Trust -Honesty -Transparency.

What government agencies provide for safety: (2)

-U.S. Department of Health and Human Services. -Center for Medicare and Medicaid (CMS).

What are the two reports that the IOM's Committee on Quality have to serve as the foundation of health system reform?

1. "To Err is Human: Building a Safer Health System." 2. "Crossing the Quality Chasm: A New Health System for the 21st Century."

How do Nurses stay involved in shaping Health Care Reform:

1. Become informed. 2. Plan: Gather facts and figures that will support your ideas and position 3. Take action. Shape public opinion by the method of your choice. Start small, and build your impact.

Ten Rules to Govern Health-Care Reform for the 21st Century:

1. Care is based on a continuous healing relationship. 2. Care is provided based on patient needs and values. 3. The patient is the source of control of care. 4. Knowledge is shared and free-flowing. 5. Decisions are evidence-based. 6. Safety as a system property. 7. Transparency is necessary; secrecy is harmful. 8. Anticipate patient needs. 9. Waste is continually decreased. 10. Cooperation between health-care providers.

What issues affect quality and safety in healthcare? (6)

1. Economics 2. Demographics/Diversity 3. Regulation/Legislation 4. Technology 5. Healthcare Practice 6. Environment/Globalization

What are the 4 focus areas of recommendations made by "To Err is Human" to decrease Human errors by 50% in 5 years:

1. Enhance knowledge and leadership regarding safety. 2. Identify and learn from errors. 3. Set performance standards and expectations for safety. 4. Implement safety systems within health-care organizations.

In Healthcare Structure can be evaluated in 4 aspects:

1. Facilities: Comfort, convenience of layout, accessibility of support services, and safety 2. Equipment: Adequate supplies, state-of-the-art equipment, and staff ability to use equipment 3. Staff: Credentials, experience, absenteeism, turnover rate, staff-patient ratios. 4. Finances: Salaries, adequacy, sources.

How to Prevent Errors in Prodecures: (3)

1. Informed Consent 2. Time Out 3. Universal Protocol

Universal Protocol Includes: (3)

1. Pre-procedure verification 2. Site marking 3. Time-out

IOM 5 Core Competencies for Health Professionals:

1. Provide patient-centered care 2. Work in interdisciplinary teams. 3. Employ evidence-based practice. 4. Apply quality improvement. 5. Utilize informatics.

The IOM's 1998 Roundtable on Health Care Quality stated what 4 things on Quality in American Healthcare:

1. Quality can be defined and measured; 2. Quality problems are serious and extensive; 3. Current approaches to QI are inadequate; and 4. There is an urgent need for rapid change.

Quality Healthcare should be: (6)

1. Safe: Avoiding injuries to patients from the care that is intended to help them. 2. Effective: Services based on scientific knowledge. 3. Patient-centered. 4. Timely. 5. Efficient: Avoiding waste, in particular that of equipment, supplies, ideas, and energy. 6. Equitable: Providing care that does not vary in quality because of characteristics such as gender, ethnicity, geographic location, and socioeconomic status.

What does the Joint Commission do? (6)

1. Sets patient safety standards 2. Implements and oversees sentinel event policy and advisory group 3. Developed the universal protocol related to surgical procedures 4. Evaluates organizations' monitoring of quality of care issues. 5. Conducts patient safety research 6. Involved with patient safety coalitions and legislative efforts.

A CQI program can evaluate three aspects of health care:

1. The structure within which the care is given. 2. The process of giving care. 3. The outcome of that care.

QI: Strategic Plan (5)

A short, visionary conceptual document that: -Serves as a framework for decisions or for securing support/approval. -Provides a basis for more detailed planning. -Explains the business to others in order to inform, motivate, and involve. -Assists benchmarking and performance monitoring. - Stimulates change and becomes the building block for the next plan.

Risk Management: Sentinel Event

A unexpected occurrence involving death or serious/permanent physical or psychological injury or the risk thereof.

Medication Error:

Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient or consumer.

Skill based errors:

Lapses when actions taken by the provider were not what was intended.

Health IT:

Multifaceted initiative that includes: (a) research support of $260 million in grants and contracts to support and stimulate investment in health information technology (IT); (b) the newly created AHRQ National Resource Center, which provides technical assistance and research funding to aid technology implementation within communities; and (c) learning laboratories at more than 100 hospitals nationwide

Minor Injury:

Needing medical intervention outside a hospital admission.

Rule Based Error:

Not following policies.

If the diagnosis is the hypothesis the treatment is the _____.

Test.

Goal of Agencies:

To: monitor, evaluate, accredit, influence, research, finance, advocate for the healthcare field.

Common areas of Risk for Nurses: (5)

■ Medication errors ■ Documentation errors and/or omissions ■ Failure to perform nursing care or treatments correctly ■ Errors in patient safety that result in falls ■ Failure to communicate significant data to patients and other providers

Outcome Specific Indications by Patient Family and Team

■ Patient: Wound healed; blood pressure within normal limits; infection absent. ■ Family: Increased time between visits to the emergency department; applied for food stamps. ■ Team: Decisions reached by consensus; attendance at meetings by all team members.