NURSE 3040 M&H CHP 23

American Nurses Association Scope and Standards of Practice

-Assessment—The registered nurse (RN) collects comprehensive data pertinent to the health-care consumer's health or the situation. -Diagnosis—The RN analyzes the assessment data to determine the diagnoses or issues. Outcomes identification—The RN identifies expected outcomes for a plan individualized to the health-care consumer or the situation. -Planning—The RN develops a plan that prescribes strategies and alternatives to attain expected outcomes. -Implementation—The RN implements the identified plan.Standard 5A. Coordination of Care—The RN coordinates care delivery.Standard 5B. Health Teaching and Health Promotion—The RN employs strategies to promote health and a safe environment. -Evaluation—The RN evaluates progress toward the attainment of outcomes.

Total Quality Management Principles

-Create a constancy of purpose for the improvement of products and service. -Adopt a philosophy of continual improvement. -Focus on improving processes, not on inspection of product. -End the practice of awarding business on price alone; instead, minimize total cost by working with a single supplier. -Improve constantly every process for planning, production, and service. -Institute job training and retraining. -Develop the leadership in the organization. -Drive out fear by encouraging employees to participate actively in the process. -Foster interdepartmental cooperation, and break down barriers between departments. -Eliminate slogans, exhortations, and targets for the workforce. -Focus on quality and not just quantity; eliminate quota systems if they are in place. -Promote teamwork rather than individual accomplishments. Eliminate the annual rating or merit system. -Educate/train employees to maximize personal development. -Charge all employees with carrying out the TQM package.

medical 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 health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use.

The Five Steps of Medication Reconciliation

Develop a list of current medications. Develop a list of medications to be prescribed. Compare the medications on the two lists. Make clinical decisions based on the comparison. Communicate the new list to appropriate caregivers and to the patient.

Leadership roles associated with quality care

Encourages followers to be actively involved in the quality control process Communicates expected standards of care to subordinates clearly Encourages the setting of high standards to maximize quality instead of setting minimum safety standards Embraces and champions quality improvement (QI) as an ongoing process Uses control as a method of determining why goals were not met Is active in communicating quality control findings and their implications to other health professionals and consumers Acts as a role model for followers in accepting responsibility and accountability for nursing actions Uses established professional standards and ethical codes as a guide for practice excellence Distinguishes between clinical standards and resource utilization standards, ensuring that patients receive at least minimally acceptable levels of quality care Supports/actively participates in research efforts to identify and measure nursing-sensitive patient outcomes Creates a work culture that deemphasizes blame for errors and focuses instead on addressing factors that lead to and cause near misses, medical errors, and adverse events Encourages the use of Six Sigma as the benchmark for QI goals Establishes benchmarks that mirror those of best performing organizations and that drive a goal of continuous quality improvement (CQI) Seeks transparency in sharing and translating quality data with consumers

Management Functions Associated With Quality Control

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 Selects and uses process, outcome, and structure audits appropriately as quality control tools Collects and accesses appropriate sources of information in data gathering for quality control activities Determines discrepancies between care provided and unit standards and uses critical event analysis or root cause analysis(RCA) to determine why standards were not met. 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 Participates actively in state and national benchmarking and "best practices" initiatives Assesses continually the unit or organizational environment to identify and categorize errors that are occurring and proactively reworks the processes that led to the errors Establishes an environment where research evidence and clinical guidelines based on best practices drive clinical decision making and patient care Is accountable to insurers, patients, providers, and legislative and regulatory bodies for quality outcomes Establishes Lean Six Sigma methodology as a goal for every aspect of QI Complies with external regulatory requirements and data collection related to QI efforts Coordinates efforts to become a high-reliability organization

Report cards

Most states have laws requiring providers to report some type of data. AHRQ has also been exploring the development of a this for the nation's health-care delivery system. However, many current ones do not contain information about the quality of care rendered by specific clinics, group practices, or physicians in a health plan's network. In addition, some critics of health-care report cards point out that health plans may receive conflicting ratings on different ones. This is a result of using different performance measures and how each report card chooses to pool and evaluate individual factors. In addition, report cards may not be readily accessible or may be difficult for the average consumer to understand.

Standardized Nursing Languages Approved by the American Nurses Association

NANDA International (NANDA-I) Nursing Interventions Classification (NIC) Nursing Outcomes Classification (NOC) Clinical Care Classification System (CCC) The Omaha System Perioperative Nursing Data Set (PNDS) International Classification for Nursing Practice (ICNP) Systematized Nomenclature of Medicine-Clinical Terms (SNOMED-CT) Logical Observation Identifiers Names and Codes (LOINC) Nursing Minimum Data Sets (NMDS) Nursing Management Minimum Data Sets (NMMDS) ABC Codes Patient Care Data Set (Retired)

sentinel event

Patient Safety Event (an event, incident, or condition that could have resulted or did result in harm to a patient) that reaches a patient and results in death, permanent harm, or severe temporary harm and intervention required to sustain life (JC, 2016d, 2016e). Such events are called "sentinel" because they signal the need for immediate investigation and response

PDSA cycle

Plan: Plan a change and develop a test or observation, including a plan for data collection. Do: Try out the change on a small scale. Study: Review and analyze the data, study the results, and identify what has been learned. Act: Refine the change and take action based on the lessons learned from the test.

Hallmarks of Effective Quality Control Programs

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

First step in quality control process

The criterion or standard is determined. ---the establishment of control criteria or standards. Measuring performance is impossible if this have not been clearly established. Not only must these exist, leader-managers must also see that subordinates know and understand them. Because these vary among institutions, employees must know the standard expected of them at their organization. Employees must be aware that their performance will be measured in terms of their ability to meet the established standard. For example, hospital nurses should provide postoperative patient care that meets standards specific to their institution. A nurse's performance can be measured only when it can be compared with a preexisting standard.

Patient Safety and Quality Improvement Act

This bill protects medical error information voluntarily submitted to private organizations (patient safety organizations) from being subpoenaed or used in legal discovery and generally requires that the information is treated as confidential. Federal legislation has also been proposed to protect the voluntary reporting of ordinary injuries and "near misses"—errors that did not cause harm this time but easily could the next time. This would be like what is done in aviation, in which near misses are confidentially reported and can be analyzed by anyone.

Centers for Medicare & Medicaid Services Pay for Performance Programs

Value-Based Purchasing (VBP) Readmissions Reduction ---penalizes hospitals for high readmission rates with lower Medicare reimbursement overall. For purposes of the program, CMS defines readmission as an admission to a hospital within 30 days of discharge from the same or another hospital Hospital-Acquired Conditions (HACs) ---Any hospital scoring in the top quartile, in other words those demonstrating the highest incidence of HACs, experience a 1% reduction in base operating payments Electronic Health Record (EHR) Incentive Program-incentive was intended to expedite the adoption of meaningful EHR technology to improve patient care

International Classification for Nursing Practice

a compositional terminology for nursing practice that is applicable globally. The ICNP represents the domain of nursing practice as an essential and complementary part of professional health services, necessary for decision making and policy development aimed at improving health status and health care

National Guideline Clearinghouse (NGC)

a free, publicly available comprehensive database of evidence-based CPGs and related documents in one easy-to-access location ---however, that many currently endorsed guidelines are largely based on expert opinion rather than research evidence

Nursing Interventions Classification (NIC)

a research-based classification system that provides a common, standardized language for nurses; it consists of independent and collaborative interventions of nurses in all specialty areas and in all settings. With 30 diverse classes of care, such as drug management, child bearing, community health promotion, physical comfort promotion, and perfusion management and multiple domains of interventions

Quality control

a specific type of controlling—refers to activities that are used to evaluate, monitor, or regulate services rendered to consumers.

Six Sigma approach

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

audit

a systematic and official examination of a record, process, structure, environment, or account to evaluate performance. Auditing in health-care organizations provides managers with a means of applying the control process to determine the quality of services rendered. -Retrospective audits are performed after the patient receives the service. -Concurrent audits are performed while the patient is receiving the service. -Prospective audits attempt to identify how future performance will be affected by current interventions. ---The audits most frequently used in quality control include the outcome, process, and structure audits.

adverse events

adverse changes in health that occur as a result of treatment. When medications are involved, these are known as adverse drug events (ADEs).

Total Quality Management

assumes that production and service focus on the individual and that quality can always be better. Thus, identifying and doing the right things, the right way, the first time, and problem-prevention planning—not inspection and reactive problem solving—lead to quality outcomes.

the Leapfrog Group has identified four evidence-based standards that they believe will provide the greatest impact on reducing medical errors:

computerized physician-provider order entry (CPOE), evidence-based hospital referral (EHR) intensive care unit (ICU) physician staffing (IPS) the use of National Quality Forum (NQF)-endorsed Safe Practices

National Patient Safety Goals

for hospitals for 2016 included such things as identifying patients correctly, improving staff communication, using medicines safely, using alarms safely, preventing infection, identifying patient safety risks, and preventing mistakes in surgery

Second Step in quality control process

identifying information relevant to the criteria. ---What information is needed to measure the criteria? In the example of postoperative patient care, this information might include the frequency of vital signs, dressing checks, and neurologic or sensory checks. Often, such information is determined by reviewing current research or existing evidence.

best practices program

invites health-care 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. The difference in performance between top-performing health-care organizations and the national average is called the quality gap. Although the quality gap is typically small in many industries, it is often significant in health care.

nursing-sensitive outcome

measures for the acute care setting include patient fall rates, nosocomial infection rates, the prevalence of pressure sores, physical restraint use, and patient satisfaction rates.

high-reliability organizations (HROs)

organizations that perform well (minimal catastrophic error) despite high levels of complexity and the existence of multiple risk factors that encourage error.

Organizational standards

outline levels of acceptable practice within the institution. For example, each organization develops a policy and procedures manual that outlines its specific standards. These standards may minimize or maximize in terms of the quality of service expected. Such standards of practice allow the organization to measure unit and individual performance more objectively.

standardized clinical guidelines

provide diagnosis-based, step-by-step interventions for providers to follow in an effort to promote high-quality care while controlling resource utilization and costs. ---developed following an extensive review of the literature and suggest what interventions, in what order, will likely lead to the best possible patient outcomes. In other words, should reflect current research findings and best practices.

standardized nursing language

provides a consistent terminology for nurses to describe and document their assessments, interventions, and the outcomes of their actions.

Multistate Nursing Home Case Mix and Quality Demonstration

seeks to develop and implement both a case mix classification system to serve as the basis for Medicare and Medicaid payment and a quality-monitoring system to assess the impact of case mix payment on quality and to provide better information to the nursing home survey process

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)

survey is the first national, standardized, publicly reported survey of patients' perspectives of hospital care. asks medical, surgical, and maternity care patients who have been recently discharged (between 48 hours and 6 weeks) about aspects of their hospital experience including "how often" or whether patients experienced a critical aspect of hospital care rather than whether they were "satisfied" with the care. 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, and whether key information is provided at discharge. In addition, the survey addresses the cleanliness and quietness of patients' rooms, the patients' overall rating of the hospital, and whether they would recommend the hospital to family and friends.

"five rights" of medication administration

that the right person receives the right drug in the right dose via the right route at the right administration time.

health-care quality (Defined by IOM)

the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and 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. In doing so, organizations can determine how and why their performance differs from exemplar organizations and use the exemplar organizations as role models for standard development and performance improvement.

Health Plan Employer Data and Information Set

to compare the quality of care in managed care organizations. consists of 81 measures across five domains of care, which provide numerical and descriptive information about the quality of care, patient outcomes, access and availability of services, utilization, premiums, and the plan's financial stability and operating policies

Methodologic studies

which focus on the development, validation, and assessment of methodologic tools or strategies (e.g., the psychometric testing of a new scale).

criticism of IOM definition of health-care quality

-quality does not exist unless desired health outcomes are attained. Outcomes are only one indicator of quality. Sometimes, patients receive the best possible care with the information available and poor outcomes occur. At other times, poor care may still result in good outcomes. Using outcomes alone as a way to measure quality care then is flawed. -for care to be considered high quality, it must be consistent with current professional knowledge. Staying current in terms of professional knowledge in today's information firestorm is difficult for even the most dedicated providers. -how quality of care is defined and measured often differs between providers and patients.

The committee outlined eight goals to reduce diagnostic error and improve diagnosis:

Facilitate more effective teamwork in the diagnostic process among health-care professionals, patients, and their families. Enhance health-care professional education and training in the diagnostic process. Ensure that health IT support patients and health-care professionals in the diagnostic process. Develop and deploy approaches to identify, learn from, and reduce diagnostic errors and near misses in clinical practice. Establish a work system and culture that supports the diagnostic process and improvements in diagnostic performance. Develop a reporting environment and medical liability system that facilitates improved diagnosis through learning from diagnostic errors and near misses. Design a payment and care delivery environment that supports the diagnostic process. Provide dedicated funding for research on the diagnostic process and diagnostic errors.

standard

a predetermined level of excellence that serves as a guide for practice. These have distinguishing characteristics: -predetermined -established by an authority -communicated to and accepted by the people affected by them. Because these are used as measurement tools, they must be objective, measurable, and achievable. There is no one set of these. Each organization and profession must set these and objectives to guide individual practitioners in performing safe and effective care. They for practice define the scope and dimensions of professional nursing.

Core Measures program

an effort to better standardize its valid, reliable, and evidence-based data sets. Hospitals that choose not to participate in the Core Measures initiative receive a reduction of 2% in their Medicare Annual Payment. Stroke Venous thromboembolism Perinatal care Substance use Tobacco treatment Hospital outpatient department Pneumonia measures Heart failure Acute myocardial infarction Surgical care improvement project Hospital-based inpatient psychiatric services Emergency department Children's asthma care Immunization

The Joint Commission

an independent, not-for-profit organization that accredits more than 21,000 health-care organizations and programs in the United States (JC, 2016c)—has historically had a tremendous impact on planning for quality control in acute-care hospitals. JC was the first to mandate that all hospitals have a QA program in place by 1981. These QA programs were to include a review of the care provided by all clinical departments, disciplines, and practitioners; the coordination and integration of the findings of quality control activities; and the development of specific plans for known or suspected patient problems. Again, in 1982, JC began to require quarterly evaluations of standards for nursing care as measured against written criteria.

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. It also includes all those elements that exist prior to and separate from the interaction between the patient and the health-care worker. For example, staffing ratios, staffing mix, emergency department wait times, and the availability of fire extinguishers in patient care areas are all structural measures of quality of care. ---often set by licensing and accrediting bodies, ensure a safe and effective environment, but they do not address the actual care provided. An example might include checking to see if patient call lights are in place or if patients can reach their water pitchers. It also might examine staffing patterns to ensure that adequate resources are available to meet changing patient needs.

fourth step in quality control process

collecting and analyzing information if the standards specify that postoperative vital signs are to be checked every 30 minutes for 2 hours and every hour thereafter for 8 hours, it is necessary to look at how often vital signs were taken during the first 10 hours after surgery. The frequency with which vital signs are assessed is listed on the postoperative flow sheet and then is compared with the standard set by the unit. The resulting discrepancy or congruency gives managers information with which they can make a judgment about the quality or appropriateness of the nursing care. If vital signs were not taken frequently enough to satisfy the standard, the manager would need to obtain further information regarding why the standard was not met and counsel employees as needed. This is often done using computer-aided error analysis (CEA) or through RCA. In addition to evaluating individual employee performance, quality control provides a tool for evaluating unit goals. If unit goals are consistently unmet, the leader must reexamine those goals and determine if they are inappropriate or unrealistic. There is danger here that the leader, who feels pressured to meet unit goals, may lower standards to the point where quality is meaningless. This reinforces the need to determine standards first and then evaluate goals accordingly.

Outcome Audit

determine what results, if any, occurred as a result of specific nursing interventions for patients. These audits assume that the outcome accurately demonstrates the quality of care that was provided. Many experts consider outcome measures to be the most valid indicators of quality care, but until the past decade, most evaluations of hospital care focused on structure and process.

Third step in quality control process

determining ways to collect information ---the manager must be sure to use all appropriate sources. When assessing quality control of the postoperative patient, the manager could find much of the information in the patient chart. Postoperative flow sheets, the physician orders, and the nursing notes would probably be most helpful. Talking to the patient or nurse could also yield information.

Delphi surveys

developed as a tool for short-term forecasting. The technique involves a panel of experts who are asked to complete several rounds of questionnaires focusing on their judgments about a topic of interest. Multiple iterations are used to achieve consensus.

Transforming Care at the Bedside

engaged leaders at all levels of the organization, empowered frontline staff to improve care processes, and engaged family members and patients in decision making about their care. Ideas that came out of TCAB were the use of Rapid Response Teams to "rescue" patients before a crisis occurred; specific communication models that supported consistent and clear communication among caregivers; liberalized diet plans and meal schedules for patients; and redesigned workspaces that enhanced efficiency and reduced waste

smart pumps

have safety software inside an advanced infusion therapy system that prevents IV medication errors through minimum and maximum dose limits as well as preset limits that cannot be overridden at a clinician's discretion.

Secondary analysis.

involve the use of existing data from a previous or ongoing study to test new hypotheses or answer questions that were not initially envisioned. Secondary analyses are often based on quantitative data from a large data set (e.g., from national surveys), but secondary analyses of data from qualitative studies have also been undertaken.

Professional standards review organizations

mandated certification of need for the patient's admission and continued review of care; evaluation of medical care; and analysis of the patient profile, the hospital, and the practitioners. ---This new kind of surveillance and the existence of external controls had a huge effect on the industry. Health-care organizations began to question basic values and were forced to establish new methods for collecting data, keeping records, providing services, and accounting in general. Because government programs, such as Medicare and Medicaid, represent such a large group of today's patients, organizations that were unwilling or unable to meet these changing needs did not survive financially.

Process Audit

measure how nursing care is provided. assumes a connection between the process and the quality of care. Critical pathways and standardized clinical guidelines are examples of efforts to standardize the process of care. They also provide a tool to measure deviations from accepted best practice process standards. tend to be task oriented and focus on whether practice standards are being fulfilled. Process standards may be documented in patient care plans, procedure manuals, or nursing protocol statements. might be used to establish whether fetal heart tones or blood pressures were checked according to an established policy. In a community health agency, a process audit could be used to determine if a parent received instruction about a newborn during the first postpartum visit.

controlling phase of the management process

performance is measured against predetermined standards, and action is taken to correct discrepancies between these standards and actual performance. Employees who feel that they can influence the quality of outcomes in their work environment experience higher levels of motivation and job satisfaction. Organizations also need some control over productivity, innovation, and quality outcomes. Should not be viewed as a means of determining success or failure but as a way to learn and grow, both personally and professionally. the fifth and final step in the management process. Because the management process—like the nursing process—is cyclic, this is not an end in itself; it is implemented throughout all phases of management. Examples of these functions include the periodic evaluation of unit philosophy, mission, goals, and objectives; the measurement of individual and group performance against preestablished standards; and the auditing of patient goals and outcomes.

prospective payment system

providers are paid a fixed amount per patient admission regardless of the actual cost to provide the care. This system has been criticized as promoting abbreviated hospital stays and services leading to a reduced quality of care.

fifth step in quality control process

reevaluation If quality control is measured on 20 postoperative charts and a high rate of compliance with established standards is found, the need for short-term reevaluation is low. If standards are consistently unmet or met only partially, frequent reevaluation is indicated. However, quality control measures need to be ongoing, not put forth simply in response to a problem. Effective leaders ensure that quality control is proactive by pushing standards to maximal levels and by eliminating problems in the early stages before productivity or quality is compromised.

Medication reconciliation

the process of comparing the medications a patient is taking (or should be taking) with newly ordered medications (JC, 2015b). This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten. Transitions in care include changes in setting, service, practitioner, or level of care

Lean Manufacturing

the removal of waste from a value stream, with waste defined as anything that consumes resources but does not add value for the customer (Gill, n.d.). By removing the waste in a value stream, it becomes possible to only produce the right material, in the quantity desired by the customer, at exactly the right time

QA,QI

these models seek to ensure that quality currently exists, whereas these models assume that the process is ongoing and quality can always be improved.

Leapfrog group

to help minimize risks to patients, the standards and expectations of oversight groups, insurers, and professional groups have been raised. a growing conglomeration of non-health-care Fortune 500 company leaders who are committed to modernizing the current health-care system.

quality improvement (QI)

to improve practices and processes within a specific organization—not to generate knowledge that can be generalized beyond the specific context of the study.

The National Database of Nursing Quality Indicators

was founded by the ANA in 2001 to examine the relationships between nursing and patient outcomes (tracks up to 19 nursing-sensitive quality measures, providing actionable insights based on structure, process, and outcome data focused surveys to measure nursing quality, improve nurse satisfaction, strengthen the nursing work environment, assess staffing levels, and improve reimbursement