Exam 3 Jacob
Automatic reminders about preventive practices • Drug alerts for dosing and interactions • Electronic resources for data interpretation and clinical decision making
Clinical Decision Support
Measurable items that reflect quality of care - Focus on clinical actions or outcomes of clinical care, should not focus on procedures - Meant not to define quality but rather to point the way to assess areas in which quality issues may be present - Help identify goals of QI - Process improvement skills and tools support quantitative understanding of key work processes
Clinical indicators
Implicit standards and values for the profession First introduced late 19th century International Council of Nurses Code for Nurses American Nurses Association Code of Ethics
Codes of ethics
Clinician with order writing authority sits at a computer to directly enter patient care orders • Eliminates lost orders and illegible handwriting • monitoring for duplicate or contradictory orders • Generates related orders automatically • reducing time to fill orders • Prevents medical error
Computerized Provider Order Entry (CPOE)
the act of limiting disclosure of private matters
Confidentiality
less intense, still problematic
Contempt
Quality Scientific approach All one team
Cornerstones of Quality Management
Sustains cooperative relationships
Coworkers
Cultural self-assessment Cultural client assessment Cultural client nutrition assessment Cultural beliefs about sickness and cures
Cultural assessment
Lead to culturally relevant nursing diagnoses and give direction to nursing intervention • Identify patterns that may assist/interfere with nursing intervention or treatment regiment because of clients beliefs
Cultural client assessment
Nurse's culture often differs from client's • Culturally incompetent care is more costly • Culturally incompetent care is ineffective • Meet specific objectives for persons in different cultures as outlined by Healthy People 2020 • Disparities in health and health care • Nursing is committed to social justice • Global infectious disease epidemics
Reasons for cultural competence
Widely accepted theory on moral development: Lawrence Kohlberg, cognitive developmental process that states:
Understanding moral development theory
QSEN (Quality and Safety Education in Nursing)
QSEN project created to support development of six competencies for nursing students and nurses • Six QSEN competencies Patient-centered care Teamwork and collaboration Evidence-based practice Quality improvement Safety Informatics
customer defines quality. Included in personal interactions and products/services they receive
Quality
assessment and improvement of work processes while focusing on what customers need and want
Quality Improvement (QI)
Use information and technology to communicate • Manage knowledge, mitigate error, support decision making • Navigate the electronic health record • Respond to clinical decision-making supports and alerts
informatics
interoperability of systems and linkages for exchange of data across systems
information and communication
Hardware and software that enable information to be stored, retrieved, communicated, and managed
information technology
access provided only to those who are authorized and have a legitimate purpose for its use
security
the means to control access and protect information from accidental or intentional disclosure to unauthorized persons and from alteration, destruction, or loss
security
Do good
Beneficence
Technology advancements • Influenced all populations including developing countries that have limited access to health care • Widespread use of health information technology (HIT) • Reduce costs • Improve patient care quality and safety • Expansion of internet is responsible for promoting health resources • Accrediting bodies are requiring/strongly recommending the integration of technology
Health Information Technology (HIT)
Decisions are made with the patient, family, other nurses, and other health care providers
Health care decisions
Dilemmas created by technology
Illnesses that once led to mortality are now manageable and are classified as chronic illnesses
how data is view by health care providers, can be presented in summary or detail
Information presentation
Provide ethics education
Institutional Ethics Committees
Dilemmas for health professionals - no right or wrong answers
Life and death
Measures data over time to evaluate patterns o Graphs of data points as they occur overtime
Run chart (Clinical indicators)
Take a step back to look at the situation and reflect ethical theory
Select one alternative
Is the site well designed, stable, and easy to use? • Content should be error-free and readable by the intended audience
Usability
concern for the welfare of others
altruism
right to self-determination
autonomy
respect for inherent worth and uniqueness of individuals and populations
human dignity
o Some minority populations less knowledgeable about specific health problems o Programs to increase public awareness o Education programs have the greatest effect on diseases developed by lifestyle (obesity, diabetes, etc)
- Health information and education
1. Care is based on continuous healing relationships 2. Care is customized according to patient needs and values. 3. The patient is the source of control. Patients should be given 4. Knowledge is shared and information flows freely. 5. Decision making is evidence based. 6. Safety is a system priority. 7. Transparency is necessary. 8. Needs are anticipated. 9. Waste is continually decreased. 10. Cooperation among clinicians is a priority.
10 Rules Guiding Improvement Initiatives by IOM
Look for documentation and referencing • Compare information on the website with other sources
Accuracy
Scheduling systems, billing and claims, insurance, inventory
Administrative processes
Regulatory Organizations ● Centers for Medicare and Medicaid Services (CMS) ● U.S. Medicare program ● Requires quality management in "Conditions of Participation" ● State licensing authorities require quality management activities and set quality standards • Accreditation [voluntary] ● The Joint Commission (TJC)
Advancing Quality through Regulation & Accreditation
belief in the people who are working to serve the customer, in their best interest to cooperate, concerned with how the system as a whole operates
All one team
What is safe care?
Answering difficult questions
Self governance
Autonomy
Meeting guidelines is strenuous and costly • Lack of interoperability • Corporate competition • EHR implementation cost • Continued resistance from providers and nurses
Barriers to EHR
Study of ethical issues and what decision making associated with the use of living organisms.
Bio + ethics
Dilemmas that pose a choice between perplexing alternatives in the delivery of health care because of the lack of a clear sense of right or wrong
Bioethical Dilemmas
Interdisciplinary field within health care that has evolved within the past 50 years with modern medicine to address questions that arise as science and technology produce new ways of knowing
Bioethics
Can help determine potential sources of a problem o Potential causes arranged by category
Cause and effect diagram (Clinical indicators)
affirmation of positive merits of cultural differences
Celebration
Value-Based Purchasing ● Hospital inpatient Medicare payments are reduced annually by 1-2% ● Hospitals can be reimbursed based on performance results
Centers for Medicare and Medicaid Services [CMS]
Health information and education Education and certification International marketplace Nursing literature
Practice issues related to cultural competence
Nursing schools including culturally diverse concepts is Mandatory for accreditation • RWJF new careers in nursing scholarship program Minority Nurse Faculty Scholars Program • Doctoral Advancement in Nursing (DAN) project - enhance number of minority nurses completing doctoral degrees • Nursing Workforce Diversity Grants - funding for projects to increase nursing education opportunities for people from disadvantaged backgrounds • The Essentials of Baccalaureate Education for Professional Nursing Practice Cultural Competencies • Mandates the inclusion of culturally diverse nursing care concepts in the curriculum with attention to cultural, spiritual, ethnic, gender, and sexual orientation diversity. • The AACN five competencies to serve as a framework for integrating cultural content into existing curricula: • Apply knowledge of social and cultural factors that affect nursing and health care across multiple contexts • Use relevant data sources and best evidence in providing culturally competent care • Promote achievement of safe and quality outcomes of care for diverse populations • Advocate for social justice • Participate in continuous cultural competence development
Cultural competence in nursing education
- Vary among cultural groups and affect health care - Environmental control o Ability of members of a particular culture to control nature or other environmental factors o Some groups believe humans have mastery over nature, some believe humans are dominated by nature, and some believe we have a harmonious relationship - Biologic variations o Body build and structure, genetic variations, skin characteristics, susceptibility to disease, nutritional variations o Skin color, eye color, hair texture, etc - Social organization o Family unit and the religious or ethnic groups in which these families identify Family is defined differently among cultures - Communication o Language differences, verbal and nonverbal behaviors, and silence o Language can be greatest obstacle to providing multicultural care (interpreter needed, some want strangers and some want family/friends) o Eye contact varies among cultures o Cultural differences surrounding women and children - Space o Comfort level regarding personal space between nurse and patient, varies among cultures - Time orientation o View of time in the present, past, or future o Many cultures do not view time in the same way (ex. Western culture is v rushed)
Cultural phenomena
Identifies individual culturally based attitudes • requires self-honesty and sincerity
Cultural self-assessment
Look for dates • Compare the last update with current literature
Currency
collection and entry of data into an EHR
Data capture
Quality of life and definition of death issues: with advances in health care, what is usual and what is heroic care has become unclear
Death
Derived from the Greek word "deon" meaning "duty"
Deontology
Questions of existence, reality, individual rights, responsibility, informed consent, cultural competence, equality, justice, ability to pay, fairness
Dilemmas in Between:
Members of cultural groups want culturally relevant health care that incorporates their beliefs and values - Lack of diversity and ethic representation among health care professionals, as well as limited knowledge about values and beliefs - Changing health care system must reflect community, so minority representation in all health professions is essential
Diversity in the health care work force
Functional ehr's are very complex, they capture info, process it, communicate it to others, and present it, the complexity explains why adoption of ehr's has been slow
EHR Data Management
Populations of minority groups growing faster than population as a whole • Asian American • Black or African American • Hispanic or Latino • Native Hawaiian and other Pacific Islander • American Indian and Alaska Native
Federally Defined minority groups
Defined as a complex set of capabilities and standards to be met by EHR use in a series of stages over several years • For providers (hospitals and physician practices) to qualify for EHR incentive payments, their EHR must be certified as a meaningful ageuse EHR by an independent agency • Goals of meaningful use: 1. Improve quality safety and efficiency 2. Engage family and patients into their health care 3. Improve care coordination 4. Improve public and population health 5. Ensure privacy and security • Stage 1: capture of info, access, exchange, and reports for quality improvement Stage 2: continuous quality improvement Stage 3: use of certified ehr technology
EHRs and "Meaningful Use"
Changing Economics and Downsizing • Joblessness • Homelessness • Depression • These conditions are associated with stress related symptoms, substance abuse, violence, crime • Poverty • Changes in technology and specialization made health care costs skyrocket • Limited access to health care insurance and health care • High cost of insurance and lower wages make it difficult for minority groups to rise out of poverty and access health care • Higher costs and lower wages for minority groups • More minorities lack health care and live in higher percentage poverty • Opportunities for education, occupation, income earning, and property ownership more available to upper and middle class • Residential segregation • Substandard housing • Unemployment • Poor physical and mental health • Poor self-image • US has poor history of providing better care to highest socioeconomic status, and worst care to lowest socioeconomic status
Economic and Social Changes
o Transcultural nursing is the study of differences and similarities of various cultural health values and beliefs among different ethic and minority groups o Not introduced in most basic education programs o Certification has increased recognition as legit nursing specialty
Education and certification
Increased opportunity to develop chronic illness • Social isolation & depression resulting from loss of family & friends • Primary care providers faced with promoting maximum functional status and identifying risks to health & independence • Health care providers must guard against issues of ageism
Effect of people living longer
Must be interoperable with the ability to exchange info across systems and settings to protect the confidentiality of the info • 2 major influences on adoption of EHR: federal government and health insurance plans • Center for medicare/Medicaid offers incentives for providers that adopt EHR • System that captures, processes, communicates, secures, and presents data about a patient • Also includes clinical rules, patient education materials, evidence based practice guidelines, payer rules related to reimbursement • More than a patient record, a knowledge tool • Integration of information from multiple sources • Serves as a primary source of information for patient care and quality
Electronic Health Record (EHR)
A system of principles by which a person can determine what ought and ought not to be done
Ethical Theory
Animal experimentation? Human experimentation? Imprisoned subjects? Research on fetus?
Ethical challenges
science or study of moral values
Ethics
Chemical impairment
Examples Whistle Blowing
o Analysis of a work process initiated by construction of flow chart o Tools in mapping out what actually occurs during the process vs what is intended
Flowchart (Clinical indicators)
Smart watches will continue to expand their features and become as ubiquitous as smartphones • Mobile technologies that promote health (mHealth) will continue to advance allowing patients and providers to communicate routinely • Sensors and wearable technologies that monitor will continue to expand offering more options to continuously assess individuals • Biometric technology-more biometric technology for authentication and security
Future health information technology trends
Current technologies that offer insight to possibilities • Social media will develop into social platforms with more legitimate data sources • Cloud computing, applications accessed through the Internet, will dominate the computing world • Patient-centered care driven by rapid change and unlimited opportunity • Gaming will expand health technologies by promoting health maintenance, physical activity, and cognitive skills for improved health behavior
Future technology trends
extreme negative prejudice
Hate
Life expectancy is shorter for African American • Causes of death for minority groups • Cancer • Heart disease and stroke • Chemical dependency • Diabetes • Homicides and accidents • Infant mortality
Health disparities
Determines/implements desirable nursing practice standards & nursing education
Profession
Health information and data Results/data management Order entry and order management Clinical decision support Patient support Administrative processes Reporting and population health management
IOM Core Functionalities
30% of Americans failed to receive recommended care in 2010 ● On average, patients are subjected to at least one medication error each day with high costs to patients, families, health care professionals, hospitals, and insurance companies ● Unprecedented advancement of science and technology, ● Growing complexity of health care, ● Changing public health care needs, and a ● Poorly organized and uncoordinated health care delivery system
IOM Crossing the Quality Chasm: A New Health System for the 21st Century
List all possible actions for a certain situation, even unlikely ones
Identify and analyze available alternatives for action
Attempt to find out scientific and technical facts and human dimension of situation (feelings, attitudes)
Identify the ethical issues and problems
Set of skills needed to find, retrieve, analyze, and use information • Skills to equip the nurse in the timely retrieval of information necessary to plan, deliver, and evaluate evidence-based care • Many organizations promote use of technology • Great discrepancy in the levels of IL skills for nurses, many nurses turn to less reliable sources (coworkers) • Information Literacy Competency Standards for Nursing • Defines and articulates the need for information • Accesses needed information effectively and efficiently • Critically evaluates the procured information and its sources • Uses information effectively to accomplish a specific purpose • Understands many of the economic, legal, and social issues surrounding the use of information and Accesses and uses information ethically and legally
Information Literacy (IL) for Nurses
effective retrieval and processing of data into useful info, decision support tools, reminders, access to guidelines
Information processing
Nonprofit organization • Education resource for the prevention of medication errors • Provides independent, multidisciplinary, expert review of reported errors • Health care professionals across the nation voluntarily and confidentially report medication errors and hazardous conditions that could lead to errors • Offers Medication Safety Self Assessments® to allow nurses and other healthcare professionals to assess the medication safety practices in their work setting
Institute for Safe Medication Practices [ISMP]
To Err Is Human: Building a Safer Health System [2000report] 98,000 patients die each year from preventable medical errors ● poor quality of care is a major problem in the United States ● updated estimate validated these original IOM statistics • Contributing factors ● Overuse of expensive invasive technology ● Underuse of inexpensive care services ● Error-prone implementation of care that could harm patients and waste money • Crossing the Quality Chasm: A New Health System for the 21st Century ● Defines vision for improving quality of health care • "The U.S. health care delivery system does not provide consistent, high quality medical care to all people. Americans should be able to count on receiving care that meets their needs and is based on the best scientific knowledge—yet this frequently is not the case. Health care harms too frequently and routinely fails to deliver its potential benefits. Indeed, between the health care that we now have and the health care that we could have lies not just a gap, but a chasm" (p. 1).
Institute of Medicine (IOM
acting in accordance with an appropriate coded of ethics
Integrity
The fundamental responsibility of the nurse People Practice Profession Coworkers
International Council of Nurses Code of Ethics for Nurses
Nurses trained in US work internationally, most valuable assets of the healthcare system o Technology has enhanced global communication and travel o Nurses need to understand intercultural issues related to our global society
International marketplace
Effective and efficient Internet searching is a must in today's information overloaded society • Professional association and societies are a good starting point for professional information • Scientific and research information usually requires literature resources that can only be found in scholarly databases such as CINAHL • Quick and dirty searching: unfamiliar info • Advanced searching: edu, gov, org Brute force: type in URL • Link searching: using links provided from reliable source
Internet Search
Ethics of care
Involves the nurse fulfilling the caring task by seeking the best way to care for each patient, one patient at a time, to alleviate suffering by taking action
Decision must be justified by explaining how the decision was made
Justify the selection
Infants have no concept of right and wrong, but moral development starts in infancy
Learning right and wrong
Total Quality Management (TQM) ● Continuous Quality Improvement (CQI) ● Continuous Process Improvement ● Statistical Process Control ● Performance Improvement (PI)
Many buzzwords describe activities associated with quality management (QM). The most prevalent are
A subgroup of the population that tends to be hidden, overlooked, or on the outer edge. • Lesbian • Gay • Bisexual • Transgender • Older adults • Recent immigrants from countries such as Russia, Rwanda, and Afghanistan (their lives and health care needs are often kept secret, and they are often voiceless)
Marginalized Populations
Rightness/wrongness of health care depends on the moral development of health care professionals
Moving toward moral maturity
Maintain competence/continual learning
Practice
Assault/Injury Assault Rates • Catheter-Associated Urinary Tract Infection Rates • Central Line-Associated Blood Stream Infection Rates • Fall/Injury Fall Rates • Hospital/Unit Acquired Pressure Ulcer Rates • Pain Assessment/Intervention/Reassessment Cycles Completed • Peripheral IV Infiltration Rate • Physical Restraint Prevalence • Ventilator-Associated Pneumonia Rates • Falls in Ambulatory Settings • Pressure Ulcer Incidence Rates from Electronic Health Records • Hospital Readmission Rates • Nursing Staff Skill Mix • Nursing Hours per Patient Day • Nurse Turnover Rate • RN Education/Certification • Nursing Care Hours in Emergency Departments, PeriOperative Units and Perinatal Units Skill Mix in Emergency Departments, PeriOperative Units and Perinatal Units • Interprofessional Teamwork • Team Strategies and Tools to Enhance Performance and Patient Safety [TeamSTEPPS]
NDNQI® Safety benchmarks
-voluntary database, collects national data -link between nurse staffing and patient outcomes measurement program that allows comparison -measures of nursing quality among national, regional, and state hospitals of similar type and size
National Database of Nursing Quality Indicators (NDNQI)
Measures are being used along with patient satisfaction scores and other select clinical measures "pay for performance" ● Based on the quality of care ● Offers incentive to deliver services designed to improve patient outcomes ● health plans pay physicians and hospitals more if they meet certain quality targets. ● Hospitals may earn back the reduced payments or even exceed the original payment amount based on their performance results • Nurses Awareness ● Support overall management of patient care throughout length of stay ● Collaborate with other healthcare professionals to initiate changes ● Monitor ongoing effectiveness of care provided
National Hospital Quality Measures
abstain from injuring others
Nonmaleficence
Cultural beliefs about sickness and cures
Nontraditional cures • Determine how culturally diverse clients define health and illness
Examining value systems
Nurses must examine their own value systems; values clarification Ethics acculturation Nurses must commit to a virtuous value system Worldview Provides a cohesive model for life Encourages personal responsibility for living life Prepares one for making ethical choices
examine life and its origins, as well as its worth, usefulness, and importance
Nurses must:
system of principles concerning the actions of the nurse in relation to patients, families, other health care providers, policymakers, and society
Nursing Ethics
The Department of Nursing adheres to the provisions of the HIPAA Act of 1996 which was designed to ensure the privacy and security of protected individually identifiable information. Students and faculty must comply with HIPAA-related policies of the department and of the clinical agencies with which the Department is affiliated to safeguard patient/client/recipient of care protected health information. Nursing students and faculty must complete mandatory HIPAA-related training sessions as deemed necessary by the Department of Nursing and/or the clinical agencies with which the Department is affiliated. • Nursing students have the ultimate responsibility for their own actions and may be liable for their own negligence if they violate patient/client/recipient of care protected individually identifiable information. Students must not remove ANY identifiable information from clinical agencies. Violation of the Department of Nursing policy related to HIPAA compliance will lead to the dismissal of the student from the nursing program of studies at UL Lafayette.
Nursing Student Handbook - HIPAA
Number of journal articles related to culture and nursing has increased since 50s o Still a need for additional research regarding individual behavior responses to life processes (pregnancy, birth, death, development) and differences among culture groups (biologic, psychologic, sociologic, spiritual)
Nursing literature
Continues to recognize the effect of cultural diversity on outcomes of health care. • Understanding the client's perspective, the nurse can be a better advocate for the client
Nursing profession
performance measurement and improvement initiative
ORYX
Is the purpose of the website clear? • Is the information factual or opinion? • Is the information primary or secondary in origin? • Who is sponsoring the site?
Objectivity
Financial incentives from the federal government to promote adoption • Quality care, safety, and efficiency Continuity of care • Ability to predict outcomes across data
Opportunities to EHR
CPOE • Clinical decision support • **see below • Electronic communication and connectivity among providers, the health care team, and patients • Electronic communication between health care team
Order entry and order management
Type of bar graph used to select key aspects on which to focus within the process o Arranged in descending order, most commonly occurring issues most visible
Pareto chart (Clinical indicators)
Patient is source of control • Patient values • Patient preferences • Diverse cultures, ethnic, & social backgrounds • Respect & encourage individual expression
Patient Centered Care
Quality Improvement is essential to improve safety and reduce health care errors
Patient Safety
Core nursing value since the beginning of professional nursing • "Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions" • Nurses, physicians, and other health professionals' partner with patients and families to ensure that health care decisions respect patients' wants, needs, and preferences • Patients have the education and support they need to make decisions and participate in their own care, support patients to live their best lives • Philosophy of care • Not a nursing care delivery model but a philosophy of care • Should be incorporated as an essential component of any nursing care delivery model. Include patients and family in: • Developing care plans/discharge plans • Participating in shift change reports • Receiving education to make informed decisions • Many organizations Establishing "family advisory councils" to engage decision making • Incorporating user friendly technology to support patient education
Patient centered care
for patient education and home monitoring, when applicable • Computer based patient education and home monitoring
Patient support
Primary responsibility is those needing nursing care
People
Federal regulations, standardized protocols, clinical practice guidelines • Personal health information [PHI] • Hipaa focuses on Privacy and security • HIPAA compliance and the student nurse
Personal Health Information [PHI] And Health Insurance Portability And Accountability Act [HIPAA]
HIT directly at the bedside or within close proximity to where services are delivered • Handheld computers, laptops, tablets, smartphones, and PDAs • Essential to deliver safe, efficient, and quality patient care • Easy access to patient data (past and present), references, policies, procedures, evidence-based literature, supported by mobile technology • Moves from practice that relies on memory to continuous use of resources as they are needed
Point-of-care technology
• Becoming more racially and ethnically diverse • Minority groups have grown faster than the population as a whole • Minority populations will become the majority population in 2044 • Growth in the number and proportion of older adults is increasing at an unprecedented rates • Longer lifespans and aging Baby Boomers • Double the population of Americans aged 65 years or older during the next 25 years to about 72 million. • By 2030, old people will be 20% of population
Population Trends
• Promote and support attitudes, behaviors, knowledge, and skills necessary for staff to work in a culturally diverse environment • Comprehensive management strategy to address culturally and linguistically appropriate services • Utilize community and consumer involvement in planning, policymaking, evaluation, etc • Recruit, retain, promote culturally competent staff • Require and arrange ongoing cultural education • Provide clients access to bilingual staff/ interpretation services • Inform of rights to interpreter service • Translate and make available patient education material and signage for members of dominant language to use • Ensure appropriate interpreter services • Ensure that clients primary language and race/ethnicity are incorporated into the organization's management information system • Collect and use appropriate demographic/cultural data and assess needs and resources of the community • Ongoing self-assessment of cultural competence • Develop procedures to address cross-cultural ethical and legal conflicts • Prepare an annual progress report related to CLAS
Recommended Standards for Culturally and Linguistically Appropriate Health Care Services (CLAS)
Addressing internal quality improvement, private/public sectors reporting to federal/state/local
Reporting and population health management
integrate differences into positive interactions/relationships
Respect
Nursing policies should openly include extended family members and folk healers, client may consult before making medical decisions, nurses should respect clients right to privacy when interacting with healers as well as clients beliefs Provide resources for education and practice to assist with culture specific needs of clients • Be careful with translators: gender, birth origin, and socioeconomic status matters • Employ or consult transcultural clinical specialists to be a role model to staff in culturally sensitive and competent care • Offer continuing education programs about cultural issues
Responsibility for Cultural Care by Health Care Facilities
Electronic reports of lab results, electronic consultation reports
Results/data management
Issue of justice/injustice
Right to health care
conducted to understand the systems at fault within the organization so that improvements can be determined and implemented to prevent future occurrences
Root cause analysis
Safe- preventing injuries, care is intended to help them • Timely- reducing waits and delays • Effective- services to those who benefit, no service to those who wont • Efficient- preventing waste: supplies, ideas, energy • Equitable- providing unvaried care based on personal characteristics • Patient centered- individual patient needs, values, preferences
STEEEP
Minimizes the risk of harm to patients and providers through system effectiveness and individual performance • Use national patient safety resources • Effective use of technology and standardization practices • Examine human factors and basic safety design • Values standardization practices that support safety Informatics
Safety
decisions must be based of data, understand process variation (differences in how the steps of the process may be accomplished) common cause variation (stable predictable) special cause variation (unstable and unpredictable), organizational support for all employees to develop knowledge and skills in the science of QI
Scientific approach:
patient safety event that results in death, permanent harm, or severe temporary harm
Sentinel event
Identify the ethical issues and problems Identify and analyze available alternatives for action Select one alternative Justify the selection
Situation assessment procedure
Authority • Authority with regard to the topic, author, and author's credentials • Affiliation of the website is important • .edu = educational institutions • .org = nonprofit organization • .com = commercial enterprise • .net = Internet service provider • .gov = governmental body • .mil = military
Specific Criteria Useful In Evaluating A Website
TJC and CMS worked together→
Standardized Measures (aka national hospital inpatient quality measures) • Publicly reported performance data
Social Justice • Critical reflection • Knowledge of cultures • Culturally competent practice • Cultural competence in health care systems and organizations • Patient advocacy and empowerment • Multicultural workforce • Education and training in culturally competent care • Cross-cultural communication • Cross-cultural leadership • Policy development • Evidence-based practice and research • **** further explained in book • Essential that nurses: be sensitive and show respect of beliefs, take responsibility to learn about beliefs, try to change prejudice
Standards of Practice for Culturally Competent Nursing Care:
the physical location of data • Access protocol permits
Storage
STEPPS
Strategies and Tools to Enhance Performance and Patient Safety
Requires organizations to carry out designated steps to fully understand the factors and systems associated with adverse patient events
TJC sentinel event standard
Foster open communication • Mutual respect • Shared decision making • Awareness of strengths and limitations as a team member • Minimize risks associated with hand-off among providers
Teamwork and collaboration
Telecommunications technology to assess, diagnose, treat persons who are located some distance from the health care provider via telephone, computers, interactive videos, and teleconferencing • Home care arena has seen significant changes as a result of telehealth • Effective for those that may have difficulty accessing necessary services such as rural communities, older adults, or prisoners • Telehome care devices: automated blood pressure monitors, glucometers, peak flowmeters, pulse oximeters, weight scales, video monitors, etc. • Real-time data capturing improves management of chronic diseases • Patients must possess the skills to evaluate and critique info
Telehealth
Health care organizations voluntarily seek TJC accreditation to demonstrate that they have achieved a "gold seal of approval" in quality and safety standards • TJC one of the first accreditation agencies to embrace QI principles as an accreditation requirement in hospitals • Organizations accredited by TJC receive deemed status to automatically meet foundational approval from CMS • Not only focuses on ability to provide high quality care, but requires evidence of performance and continued improvement • Accredits more than 21,000 health care organizations • Address the organizations level of performance in key areas ● Patient safety ● Patient rights ● Patient treatment ● Infection control
The Joint Commission (TJC)
Answers for improved patient safety require all care providers to pull together to review critical circumstances and learn from key events • Nurses' challenge is to make patient safety a personal priority • Two significant nursing functions closely influence patient safety and quality • Monitoring for early recognition of adverse events, complications, and errors • Initiating deployment of appropriate care providers for timely intervention and response/rescue of patients in these situations
The Professional Nurse and Patient Safety
Nurse needs sense of responsibility and personal integrity
The challenge of accountability
Patient clearly understands choices offered, form of consent/ refusal of treatment
The challenge of autonomy
Concepts of alternative treatment and acknowledging uncertainty
The challenge of veracity
Rights of conscience
The civil right that protects conscientious health care providers against discrimination, allowing them the right to act according to the dictates of their conscience
To promote health
The fundamental responsibility of the nurse
more neutral attitude
Tolerance
Aka "best methods" or "best practices" are foundation for improvements especially In clinical care setting - Come care practices only exist because that's how the practitioner was taught. Using this method instead of research based methods is lack of standardization - Used to support standardization of care processes: - Clinical pathways or critical pathways o o Optimal sequencing and timing of interventions by health care professionals when providing care for patient Benefits: reduction in variation of care, achievement of expected clinical outcomes, reduction in care delays/length of stay, more cost effective - Clinical protocols or algorithms o They represent more of a decision path that a practitioner might take
Understanding, improving, and standardizing care processes
An approach that is rooted in the assumption that an action or practice is right if it leads to the greatest possible balance of good consequences or to the least possible balance of bad consequences
Utilitarianism
Truth telling
Veracity
Businesses, churches, and schools have become sites for random acts of violence • Unemployment is associated with violence • Homicide is the second leading cause of death among Americans 15-24 years of age Culturally vulnerable groups especially at risk for violence • Unemployment rates among young minority men are high, this group also has highest rate of violence • Intimate partner violence (IPV) formerly domestic violence • Greatest cause of injury in women 15-24 years of age, across all ethnic, racial, socioeconomic, & educational groups • Crosses all ethnic, racial, socioeconomic, and educational lines
Violence
the use of various forms of technology to improve the quality of health services to individuals and communities
What is health information technology (HIT)
The obligation to denounce a harmful action or potentially threatening situation committed by a colleague
Whistle Blowing
Essential Nursing Values and Behaviors
altruism, autonomy, human dignity, integrity, social justice
shared values, beliefs, and practices of a particular group of people that are transmitted from one generation to the next and are identified as patterns that guide thinking and action
culture
Integrate best current evidence with clinical expertise and patient/family preferences and values • Knowledge of basic scientific methods and processes • Participate in data collection and other research activities • Consult with clinical experts
evidence based practice
forming a worldview and value system through an evolving, continuous, dynamic process that moves along a continuum of development
moral development
the right of a person to keep information about himself/herself from being disclosed to anyone else
privacy
Use data to monitor the outcomes of care processes • Use improvement methods to design and test changes • Continually improve the quality and safety in healthcare • Describe approaches for changing processes of care
quality improvement
hate, contempt, tolerance, respect, celebration
range of attitudes
acting in accordance with fair treatment regardless of economic status, race, ethnicity, age, citizenship, disability, or sexual orientation
social justice
personal belief about worth that acts as a guide to behavior
value
entire framework on which actions are based
value system
a process by which people attempt to examine the values they hold and how those values function as a part of the whole
values clarification
Cultural client nutrition assessment
• For clients who are minorities • Ex. Certain cultures don't consider greens to be food • Frequency and number of meals, amount and type of food eaten, regularity of food consumption are all factors to consider • Nurses should avoid food stereotypes (Asians like rice)
Info to make sound clinical decisions ex. Past medical history, lab reports, etc
• Health information and data
serious reportable events (SREs)
• Never Events
Guiding aims for improvement that should be adopted by every individual in health care
• Quality Chasm Report
Purpose: promote specific improvements in patient safety with the goals highlighting problematic areas and evidence-based solutions to the problems with system-wide solutions wherever possible 1. Identify patients correctly 2. Improve staff communication 3. Use medicines safely 4. Use alarms safely 5. Prevent infection 6. Identify patient safety risks 7. Prevent mistakes in surgery CMS "Never Events" • Serious, costly errors in health care that should NEVER happen • Can cause serious injury or death to the patient • CMS Hospital-Acquired Conditions • Reasonably preventable
• TJC National Patient Safety Goals