Quality Care
Control Criteria or Standards of Care
A Predetermined level of excellence that serves as a guide for practice
Sentinel Event
A patient safety event that results in death, permanent harm, or severe temporary harm Debilitating to both patients and health care providers involved in the event Patient safety event (not primarily related to the natural course of the patient's illness or underlying condition)
Pay for Performance
Align payment and quality incentives and to reduce costs through improved quality and efficiency
Who Determines Standards of Care?
American Nurse's Association American Medical Association American Association of Critical Care Nurses The Joint Commission - National Safety Goals OSHA DHEC Others
Audit as a quality control tool
An audit is a systematic and official examination of a record, process, structure, environment, or account to evaluate performance. a performance improvement process
Never Events
Are errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients Indicate a real problem in the safety and credibility of a health care facility.
Preventable Medical Errors
Are the 3rd highest cause of death in the United States following Heart Disease & Cancer.
Structure Audit
Assume that a relationship exists between quality care and appropriate structure. Includes resource inputs such as the environment in which health care is delivered.
Patient Surveys
Data collected include how well nurses and doctors communicate with patients How responsive hospital staff are to patients' needs. How well hospital staff help patients manage pain How well the staff communicates with patients about medicines Whether key information is provided at discharge
Outcome Audit
Determine what results, if any, occurred because of specific nursing interventions for patients. These audits assume that the outcome accurately demonstrates the quality of care that was provided.
Sentinel Event Examples
Fall related events Suicide events Wrong patient, wrong site, wrong procedure events Delay in treatment events
ANA
Has played a key tole in developing standards for the profession.
Never Event Examples
Hospital acquired pneumonia Severe "pressure ulcer" acquired in the hospital (i.e. stage 3 and 4 pressure ulcers) Surgery on the wrong body part Foreign body left in a patient after surgery
2020 Hospital Safety Goals
Identify patients correctly Improve staff communication Use medicines safely Use alarms safely Prevent infection Identify patient safety risks Prevent mistakes in surgery
Joint Commission
Independent, not-for-profit organization that accredits more than 21,000 health care organizations and programs in the United States. Has had a tremendous impact on planning for quality control in acute care hospitals.
Best Practices Program
Invites healthcare institutions to submit a description of a program or protocol relating to improvements in quality of life, quality of care, staff development, or cost effectiveness practices. Experts review the submissions, examine outcomes, and then designate a best practice.
Process Auditq
Measure how nursing care is provided. The audit assumes a connection between the process and quality of care. Process audits tend to be task oriented and focus on whether practice standards are being fulfilled. May be documented in a patient care plan, procedure manual or protocol statement.
Preventing Medical Errors
Medical error research Strategies created to include better reporting of the errors that do occur
Never Event Examples Cont.
Mismatched blood transfusion Major medication error Preventable post-operative deaths Central line-associated bloodstream infection (CLABSI) Catheter-associated urinary tract infection (CAUTI)
Never Event vs. Sentinel Event
Never Event Rare Usually not reimbursable Some Never Events are considered Sentinel Events Sentinel Event Unexpected May be reimbursable Some Sentinel Events are considered Never Events
Sentinel Event Examples Cont.
Operation/post-operation complication events Perinatal events Medication error events Fire related events
Is Quality Defined by Outcomes?
Other factors that must be considered include the following: What is a positive outcome? Who decides? What if you have poor care but good outcomes? Is that OK? What if the care is stellar and the outcome is bad? Does patient satisfaction play a role? Can the patient be satisfied whether or not the patient's health improved during a hospital stay?
ORYX
Part of Agenda for Change; a multi-phase, multidimensional set of initiatives directed at modernizing the accreditation process by shifting the focus of accreditation from organizational structure to organizational performance or outcomes. o Clinical indicators to measure the quality of care provided o The initiative integrated outcomes and other performance measures into the accreditation process with data being publicly reported at a website o All organizations accredited by JC were required to select at least one of the 60 acceptable performance measurement systems and to begin data collection on specific clinical measures.
Controlling Phase
Performance is measured against predetermined standards, and action is taken to correct discrepancies between these standards and actual performance.
Control Criteria or Standards of Care Cont.
Policies & procedures Facilities will often benchmark their performance against best performing organizations.
Control Criteria or Standards of Care Cont.
Predetermined level of excellence that serves as a guide for practice Established by an authority Communicated & accepted by those affected by them Must be objective, measurable & achievable Evidence based
Never Events Cont.
Preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers.
Root Cause Analysis
Process designed to investigate and categorize the root causes of events that occur Can help identify all of the factors leading up to the error ...getting to the bottom of the problem
Risk Management
Process that is initiated when incidents or events occur that may pose a financial risk or pose the risk of a lawsuit to the institution Evaluates how to prevent a re-occurrence by changing systems or processes that have allowed the incident to occur
Standard Clinical Guidelines
Provide diagnosis-based step-by-step interventions for providers to follow to promote high-quality care while controlling resource utilization and costs.
Prospective Payment System
Providers are paid a fixed amount per patient admission regardless of the actual cost to provide the care.
Standardized Nursing Language
Provides a consistent terminology for nurses to describe and document their assessments, interventions, and the outcomes of their actions. (I.e. NANDA)
QA vs. QI
QA target currently existing quality QI models target ongoing and continually improving quality
Quality of Care based on patient satisfaction
Quality of care is more encompassing and must always include an examination of whether the patient received the most appropriate treatment from the most appropriate provider in a timely manner.
Quality Control
Refers to activities that are used to evaluate, monitor, or regulate services rendered to clients. Must be ongoing; it must reflect a belief that the search for improvement in quality outcomes is continuous and that care can always be improved. o There must be support from top level administration. o There must be commitment by the organization in terms of fiscal and human resources. o Quality goals reflect search for excellence rather than minimums. o Process is ongoing.
Total Quality Management
TQM is based on the premise that the individual is the focal element on which production and service depend (i.e., it must be a customer-responsive environment) and that the quest for quality is an ongoing process.
QA vs. QI
The Quality Assurance (QA)model seeks to ensure that quality currently exists. The Quality Improvement (QI) model assumes that the process is ongoing and quality can always be improved.
Health Care Quality
The degree to which health services for individuals and populations increase the likelihood of desired health outcomes are consistent with current professional knowledge
Benchmarking
The process of measuring products, practices, and services against best performing organizations- as a tool for identifying desired standards of organizational performance.
Sentinel Event
Unexpected events that result in a patient's death or a serious physical or psychological injury
JC Core Measures
o Acute myocardial infection o Children's asthma care o Emergency department o Hospital outpatient department o Hospital based inpatient psychiatric services o Immunization o Perinatal care o Stroke o Venous thromboembolism
ANA Standards of Care
o Assessment o Diagnosis o Outcomes Identification o Planning o Implementation o Evaluation
TQM Principles
o Create a constancy of purpose for the improvement of products and service o Adopt a philosophy of continual improvement o Focus on improving processes not on inspection of product o End the practice of awarding business on price alone; instead, minimize total cost by working with a single supplier. o Improve constantly every process for planning, production, and service. o Institute job training and retraining. o Develop the leadership in the organization. o Drive out fear by encouraging employees to participate actively in the process o Foster interdepartmental cooperation and break down barriers between departments. o Eliminate slogans, exhortations, and targets for the workforce. o Focus on quality and not just quantity; eliminate quota systems if they are in place. o Promote teamwork rather than individual accomplishments. Eliminate the annual rating or merit system. o Educate/train employees to maximize personal development. Charge all employees with carrying out the TQM package
Leadership Roles- Quality Control
o Encourages followers to be actively involved in quality control process. o Communicate expected standards of care to subordinates clearly. o Encourages the setting of high standards to maximize quality instead of setting minimum safety standards. o Embraces and champions quality improvement as an ongoing process. o Uses control as a method of determining why goals were not met. o Is active in communicating quality control findings and their implications to other health professionals and consumers.
Management Functions - Quality Control
o Establishes clear-cut, measurable standards of care and determines the most appropriate method for measuring if those standards have been met, in conjunction with other personnel in the organization. o Selects and uses process, outcome, and structure audits appropriately as quality control tools. o Collects and accesses appropriate sources of information in data gathering for quality control activities. o Determines discrepancies between care provided and unit standards and uses critical event analysis to determine why standards were not met. o Uses quality control findings in determining needed areas of staff education or coaching. Keeps abreast of current government, accrediting body, and licensing regulations that affect quality control.
Patient Safety Officer
o Individual nurse assigned o As many staff as possible should be included in determining criteria or standards, reviewing standards, collecting data or reporting. o Can create impression that responsibility for quality of care is not shared.
Three Basic Steps of Quality Control as a Process
o The criterion or standard is determined. o Information is collected to determine if the standard has been met. o Educational or corrective action is taken if the criterion has not been met.
