Managing and Improving Quality Flashcards
Institute of Medicine (IOM)
An independent, non profit organization that works outside the government that provides unbiased and authoritative advice to decision makers and the public
est. 1970
over 2000 members from disciplines beyond just healthcare like management, law, engineering, business, etc
75 members chosen each year to serve on the committee
To Err is Human
1999 IOM report on how safe you are in the hospital
found that 44-98000 deaths each year occurring in the hospital is due to preventable medical errors
ID’ed the pitfalls of hospital safety
To Err is Human Report found that what thing is the number 1 cause of death in hospitals
Medication Administration Errors are #1
Lessons Learned from To Err is Human
It is not necessarily the people of the healthcare system that are causing the issues, but the system itself since employees do not necessarily have the tools to do their job safely or a safety net to prevent errors
Errors are contributed by flawed systems, lack of proper training, perverse incentives
“Crossing the Quality Chasm”
IOM report in 2001 after To Err is Human
States that “the healthcare system is in need of improvement”
What were the 6 goals of healthcare improvement stated in Crossing the Quality Chasm by the IOM
Safe
Effective
Patient-Centered
Timely
Efficient
Equitable
SEPTEE
IOM’s 5 Core Competencies Report
IOM report outlining 5 core competencies needed in healthcare to improve the system
What are the IOM’s 5 Core Competencies
- Provide patient centered care - ID, respect, and care about patient’s differences
- Work in interdisciplinary teams - cooperate, collaborate, communicate and integrate care in teams
- Employ EBP
- Apply QI
- Utilize informatics
What are some of the IOM’s recommendations for improving hospital safety
Create a culture of safety
Create a blame free work environment
Improve staff safety - needle sticks, infections, violence
TCTB - transforming care at the bedside
Employing IHI and JC annual safety goals
What are some of the ways of TCTB (Transforming Care at the Bedside)
Provide safe and reliable care
Vitality and teamwork
patient centered care
value added care processes
___-___% of patient, even today, suffer 1 or more serious adverse events
6-10%
What are some examples of serious adverse events
Adverse drug events
Surgical site infections
needle stick infections
wrong side/site surgery
device associated infection
ventilator associated pneumonia
catheter and central line infections
What are some things the healthcare system has done to improve quality in hospitals
QI has emerged
surveillance for hospital acquired infections
looking at the donning PPE issues which cause spreading of infection rates
computerized medication distribution and bar coding use
patient safety standards implemented by many organization have been made a top priority
national safety standards created policies and practices in 2005
CMS will not reimburse hospitals if a condition is acquired in hospital
diagnostic errors followed more closely
focus on communication and collaboration among systems and services increase
research needed and done to measure and validate quality standards
National Safety Standards and the Center for Medicare Services (CMS) - 2005
Standards were made where Medicate/Medicaid would no longer reimburse hospitals for certain hospital acquired conditions like pressure injuries, falls with injury, and infections an makes hospitals report conditions
How does the USA’s health expenditures compare to other countries
While the US has nearly 2x the spending the outcomes and qualities are not better than other countries still
Quality Improvement (QI)
a FORMAL approach to the analysis of performance and systematic efforts to improve it
What is the old model used before QI
Quality Assurance - QI
TQM/CQI Stands For
Total or Continuous Quality Improvement
PI Stands For
Performance Improvement
High Reliability Organizations
Hospitals Strive to be this
It is an organization focusing and functioning well with minimal patient/system errors in outcomes
Health services end up improving outcomes, but organizations can provide this while still having poor outcomes so this can be hard to define
What is the challenge of high reliability organizations
it is challenged by the definition of quality and reliability
organizations can provide being high reliability organizations and still have poor outcomes
Edwards Deming
Father of Quality Evolution
Philosophy
Involved in TQM
Total Quality Management (TQM)
1940s
Emphasize the commitment to excellence throughout the organization and created by Edwards Deming
Post WWII it was adopted by the Japanese industrial industry and then adopted by the US to improve quality of health care
It looks at how to make organizations thrive in quality management
What are some of the tenet/ideas involved in TQM
Quality does not happen by accident
thee individual is the focal element on which production and service depend and the quest for quality IS AN ONGOING PROCESS
Doing the right things, the right way, the first time
Problem PREVENTION planning
How does Quality Assurance differ from Quality Improvement
QA is an older term - 1970s
It is a retrospective process that targets currently existing quality and often involves determining who is at fault through policing and is often punitive
Does not see the bigger picture and points fingers
How does Quality Improvement differ from Quality Assurance
new term - 1980s
involves prospective and retrospective views - target ongoing and continually improving quality
the goal is IMPROVEMENT
attempts to avoid blame and create a system to prevent errors while looking at the larger picture
Quality Improvement = Opportunities to…
look at things differently
think outside the box or do not be defined by “the box”
develop new options and solutions
eliminate things that make you crazy
What are some of the Root Causes of Errors
Patient ID
Care planning Process
Continuum of care - following up
Staffing levels - not safe
Orientation and training of staff - not sufficient
Competency assessment/credentialing
Supervision / Management / Leaders
Communication
Availability of information
Adequacy of technology support
Equipment maintenance
Physical Environment
Joint Commission
Governing body that regulates the healthcare industry with goals and safety measures
National Patient Safety Goals of the Joint Commission in 2018
improve accuracy of patient ID
Improve effectiveness of communication between caregivers
Improve safety of using medications
Reduce harm associated with clinical alarm systems
Reduce the risk of health care associated infections
Reduce the risk of patient harm resulting from falls
Prevent health care associated pressure ulcers
ID safety risks for patient population
prevent mistakes in surgery
Why do healthcare providers need to meet the National Patient Safety Goals of the Joint Commission
They need to meet goals for reimbursement
Who should be involved in quality improvement
Everybody working in healthcare should be playing a role
What are the 2 ways to identify what is best to use for quality improvement
- Benchmarking
- Best Practices
Benchmarking
Measure products, practices, and services against best performing organizations
Allows organizations to compare performance within the organization and with others
Data then drives improvement
Best Practices
A program or protocol relating to improvements to quality of life, quality of care, staff development, or cost effectiveness practices
Institutions submit outcomes related to quality improvement initiatives; and may be designated a “best practice”
What are the 3 measures of quality
Structure
Process
Outcome
Structure of Quality
Assumes a relationship exists between quality care and appropriate structure
The physical environment in which healthcare is delivered
ex: Staffing ratios, staffing mix, emergency department wait times, availability of fire extinguishers in patient care areas
Process of Quality
Used to measure the process of care or how the care was carried out
Assumes that a relationship between the process used by the nurse and the quality of care delivered
ex: Policies, procedures, protocols, critical pathways, standards of care tools used to measure deviations from best practice standards
Outcome of Quality
What results occur for the patients, what things to help ongoing, morbidity, and mortality, infections, etc
End result of care or patients health status changed as a result of an intervention
ex: Non nursing sensitive outcomes - mortality, morbidity, LOS
ex: Nursing sensitive outcomes - falls, nosocomial infections, pressure injuries, restraint use, patient satisfaction scores
NDNQI - National Database of Nursing Quality Indicators
Reporting body founding by the ANA in 2001 that hospital systems need to report standards too
It is used by over 2000 hospitals in the country
The gold standard for nursing quality data
Tracks up to 19 nursing sensitive quality measures based on structure, outcome, and process
Hospitals can use this to compare their nursing quality against national, regional, and state norms for hospitals of the same type and down to the unit level
What is the gold standard for nursing quality data
National Database of Nursing Quality Indicators (NDNQI)
What are some of the NDNQI Indicators
Nursing hours per patient day - by RN, LPN, UAP
Nursing turnover
Nosocomial infections
patient falls (with and without injury)
Pressure Injury Rate (HAP, CAP, Unit Acquired)
Pediatric pain assessment and reassessment
RN certification
RN surveys (job satisfaction and work environment)
Restraints
Staff mix
Other than NDNQI what are some other measures looked at for quality data
P4P
Hospital and physician report cards
Hospital consumer assessment of healthcare providers and systems survey (HCAHPS)
Pay for Performance (P4P)
incentive program from CMS for preventing complications and hospitalizations
Groups of providers are given incentives to get the patients out and kept out of hospitals through high quality care - make money keeping them out
HCAHPs
27 item survey that measures patients perceptions of their hospital experience including how well nurses and docs communicate with patients, how responsive hospital staff are, pain management, medication information, discharge information, cleanliness of room, quietness
Commonly Studied QI Topics
patient falls
adverse drug rxns
surgical site infections
nosocomial infections
VAP
hospital acquired pressure injuries
central line infections
What are the 3 common quality models
- PDSA (PDCA) - Plan Do Study Act
- Six Sigma
- FADE
PDSA (PDCA) Model of Quality
Plan Do Study Act
Plan - Set goals, predict, plan data collection
Do - Test the plan, document problems, reassess and revise
Study - Complete data analysis, review lessons, decide actions
Act - Implement, evaluate, decide next cycle
REPEAT
Six Sigma Model of Quality
Define, Measure, Analyze, Improve, Control - DMAIC
Define - the problem (outcome) to work on and the customer and definition of value
Measure - determine which processes and inputs have the greatest impact on variation in the outcome and develop a data collection plan and gather data
Analyze - analyze data gathered with stat methods to determine the part of the process causing the most (unwanted) variation in the outcome
Improve - decide on a solution or a solution set and develop implementation and monitoring plans for the solution
Control - sustain gains achieved during the previous phase and transition solutions (new process) to person responsible
FADEE Model of Quality
Focus, Analyze, Develop, Execute, Evaluate
Focus - define and verify the process to be improved
Analyze - collect and analyze data to establish baselines, identify root causes and point toward possible solutions
Develop - based on the data, develop action plans for improvement including implementation, communication, and measuring/monitoring
Execute - implement the action plans, on a pilot basis as indicated, and …
Evaluate - install an ongoing system measuring/monitoring (process control) to ensure success
QI Process uses results of QI to do what things
recommend practice changes
implement revised practice
revise policies and procedures
provide education
and go back through the cycle again (continuous quality improvement = CQI)
IOM Future of Nursing Report from 2010 States What things to improve quality
Nurses should practice to the full extent of education
Nurses should achieve higher education
Nurses should be full partners with physicians
Nurses should be involved more with health quality decisions
Nurses should play a fundamental role in health care transformation
IOM Future of nursing Report for 2020-2030 States what things should be done to improve quality
Address diversity, improve health equity
Understand social determinants of health
Public and community health references should be known
Respond to health emergencies, pandemics, and disaster response better
Improve quality in nursing education
Simulation based learning in nursing
Addresses substance abuse disorders among nursing
Evidence Based Practice (EBP)
The conscientious use of current best practice in making decisions about patient care
A problem solving approach to clinical practice integrating various things
More than just research
EBP is a problem solving approach to clinical practice that integrates what things?
a systematic search for and critical appraisal of the most relevant answer to a clinical question
Clinical expertise
patient preferences and values
assessment of the patients history and physical exam
availability of healthcare resources
How does QI differ from EBP
NO theoretical underpinnings
Evaluates a work process to improve practice
Data collected and reported internally!!!
How does EBP differ from QI
Uses theory
Seeks to generate new knowledge or test interventions
Results add to the body of knowledge!!!
Hierarchy of EBP Tools (Reviews and Studies)
Level I: Cochrane Systematic Reviews - Systematic review of RCTs
Level II: Systematic Reviews and Meta Analyses - RCT
Level IV: Evidence Summaries - case control and cohort studies
Level V: RCTs Case Cohorts, Control Studies - reviews of qualitative studies
Level VI: Clinical Research Critiques - single descriptive study
Level VII: Other reviews of the literature - opinions of authorities and or/reports of expert committees
Bottom: Case reports, case series, practice guidelines, etc
Hallmarks of Effective Quality Control Programs
There must be support from a top level administration
There must be a commitment by the organization in terms of fiscal and human resources
Quality goals reflect search for excellence rather than minimums
Process is ongoing (continuous)
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
High Care Quality
degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge
Quality has properties/domains of
effectiveness
efficiency
equity
patient centeredness
safety
timeliness
Benchmarking
the process of measuring products, practices, and services against best performing organizations
Quality Gap
the difference in performance between top performing health care organizations and the national average
Steps of Quality Control
- Establish control criteria or standards
- ID information relevant to the criteria
- Determine ways to collect information
- Collecting and analyzing information
- Re-evaluation
Nursing Process Standard of Practice Process (Nursing Process)
Assessment
diagnosis
Outcomes ID
Planning
Implementation
Evaluation
CPGs
Standardized clinical guidelines
provide diagnosis based, step by step intervention for providers to follow to promote high quality care while controlling resource utilization and costs
Audit
Systematic and official examination of a record, process, structure, environment, or account to evaluate performance
Retrospective Audits
audit done after service is received by the patient
Concurrent Audit
performed audit while patient is receiving service
Prospective Audit
audit attempting to ID how future performance will be affected by current interventions
Outcome Audot
Audit to determine what results, if any, occurred as a result of a specific nursing intervention for patients
Outcomes reflect …
the result of care or how the patients health status changed as a result of an intervention
Process Audit
measure how nursing care is provided
audit assumes a connection between the process and the quality of care
They are used to measure the process of care or how the care was carried out and assume that a relationship exists between the process used by the nurse and the quality of care provided
Structure Audit
assumes 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
Standardized Nursing Language
provide a consistent terminology for nurses to describe and document their assessments, interventions, and outcomes of their actions
TQM is a…
never ending process, everything and everyone in the organization are subject to continuous improvement efforts (workers not QI dept do the data collection)
TQM 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 total quality management package.
Patient satisfaction often…
has little to do with whether a patients health improved during a hospital stay
an important component of patient comfort, and therefore quality of care, quality 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.
Prospective Payment System
providers are paid a fixed amount per patient admission regardless of the actual cost to provide the care - could reduce quality or abbreviate care
Leapfrog Group
conglomerate of non health care fortune 500 company leaders who are committed to modernizing the current health care system and ID 4 EBP standards they believe will have the biggest impact on reducing medical errors
What are the 4 major initiatives of the Leapfrog Group
- Computerized Physician Provider Order Entry (CPOE)
- Evidence based hospital referral
- intensive care unit physician staffing (IPS)
- National Quality Forum Endorse Safe Practice
