Managing and Improving Quality

Question 1

Institute of Medicine (IOM)

Answer 1

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

Question 2

To Err is Human

Answer 2

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

Question 3

To Err is Human Report found that what thing is the number 1 cause of death in hospitals

Answer 3

Medication Administration Errors are #1

Question 4

Lessons Learned from To Err is Human

Answer 4

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

Question 5

“Crossing the Quality Chasm”

Answer 5

IOM report in 2001 after To Err is Human

States that “the healthcare system is in need of improvement”

Question 6

What were the 6 goals of healthcare improvement stated in Crossing the Quality Chasm by the IOM

Answer 6

Safe

Effective

Patient-Centered

Timely

Efficient

Equitable

SEPTEE

Question 7

IOM’s 5 Core Competencies Report

Answer 7

IOM report outlining 5 core competencies needed in healthcare to improve the system

Question 8

What are the IOM’s 5 Core Competencies

Answer 8

1. Provide patient centered care - ID, respect, and care about patient’s differences
2. Work in interdisciplinary teams - cooperate, collaborate, communicate and integrate care in teams
3. Employ EBP
4. Apply QI
5. Utilize informatics

Question 9

What are some of the IOM’s recommendations for improving hospital safety

Answer 9

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

Question 10

What are some of the ways of TCTB (Transforming Care at the Bedside)

Answer 10

Provide safe and reliable care

Vitality and teamwork

patient centered care

value added care processes

Question 11

___-___% of patient, even today, suffer 1 or more serious adverse events

Answer 11

6-10%

Question 12

What are some examples of serious adverse events

Answer 12

Adverse drug events

Surgical site infections

needle stick infections

wrong side/site surgery

device associated infection

ventilator associated pneumonia

catheter and central line infections

Question 13

What are some things the healthcare system has done to improve quality in hospitals

Answer 13

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

Question 14

National Safety Standards and the Center for Medicare Services (CMS) - 2005

Answer 14

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

Question 15

How does the USA’s health expenditures compare to other countries

Answer 15

While the US has nearly 2x the spending the outcomes and qualities are not better than other countries still

Question 16

Quality Improvement (QI)

Answer 16

a FORMAL approach to the analysis of performance and systematic efforts to improve it

Question 17

What is the old model used before QI

Answer 17

Quality Assurance - QI

Question 18

TQM/CQI Stands For

Answer 18

Total or Continuous Quality Improvement

Question 19

PI Stands For

Answer 19

Performance Improvement

Question 20

High Reliability Organizations

Answer 20

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

Question 21

What is the challenge of high reliability organizations

Answer 21

it is challenged by the definition of quality and reliability

organizations can provide being high reliability organizations and still have poor outcomes

Question 22

Edwards Deming

Answer 22

Father of Quality Evolution

Philosophy

Involved in TQM

Question 23

Total Quality Management (TQM)

Answer 23

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

Question 24

What are some of the tenet/ideas involved in TQM

Answer 24

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

Question 25

How does Quality Assurance differ from Quality Improvement

Answer 25

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

Question 26

How does Quality Improvement differ from Quality Assurance

Answer 26

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

Question 27

Quality Improvement = Opportunities to...

Answer 27

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

Question 28

What are some of the Root Causes of Errors

Answer 28

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

Question 29

Joint Commission

Answer 29

Governing body that regulates the healthcare industry with goals and safety measures

Question 30

National Patient Safety Goals of the Joint Commission in 2018

Answer 30

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

Question 31

Why do healthcare providers need to meet the National Patient Safety Goals of the Joint Commission

Answer 31

They need to meet goals for reimbursement

Question 32

Who should be involved in quality improvement

Answer 32

Everybody working in healthcare should be playing a role

Question 33

What are the 2 ways to identify what is best to use for quality improvement

Answer 33

1. Benchmarking 2. Best Practices

Question 34

Benchmarking

Answer 34

Measure products, practices, and services against best performing organizations Allows organizations to compare performance within the organization and with others Data then drives improvement

Question 35

Best Practices

Answer 35

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"

Question 36

What are the 3 measures of quality

Answer 36

Structure Process Outcome

Question 37

Structure of Quality

Answer 37

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

Question 38

Process of Quality

Answer 38

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

Question 39

Outcome of Quality

Answer 39

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

Question 40

NDNQI - National Database of Nursing Quality Indicators

Answer 40

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

Question 41

What is the gold standard for nursing quality data

Answer 41

National Database of Nursing Quality Indicators (NDNQI)

Question 42

What are some of the NDNQI Indicators

Answer 42

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

Question 43

Other than NDNQI what are some other measures looked at for quality data

Answer 43

P4P Hospital and physician report cards Hospital consumer assessment of healthcare providers and systems survey (HCAHPS)

Question 44

Pay for Performance (P4P)

Answer 44

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

Question 45

HCAHPs

Answer 45

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

Question 46

Commonly Studied QI Topics

Answer 46

patient falls adverse drug rxns surgical site infections nosocomial infections VAP hospital acquired pressure injuries central line infections

Question 47

What are the 3 common quality models

Answer 47

1. PDSA (PDCA) - Plan Do Study Act 2. Six Sigma 3. FADE

Question 48

PDSA (PDCA) Model of Quality

Answer 48

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

Question 49

Six Sigma Model of Quality

Answer 49

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

Question 50

FADEE Model of Quality

Answer 50

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

Question 51

QI Process uses results of QI to do what things

Answer 51

recommend practice changes implement revised practice revise policies and procedures provide education and go back through the cycle again (continuous quality improvement = CQI)

Question 52

IOM Future of Nursing Report from 2010 States What things to improve quality

Answer 52

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

Question 53

IOM Future of nursing Report for 2020-2030 States what things should be done to improve quality

Answer 53

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

Question 54

Evidence Based Practice (EBP)

Answer 54

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

Question 55

EBP is a problem solving approach to clinical practice that integrates what things?

Answer 55

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

Question 56

How does QI differ from EBP

Answer 56

NO theoretical underpinnings Evaluates a work process to improve practice Data collected and reported internally!!!

Question 57

How does EBP differ from QI

Answer 57

Uses theory Seeks to generate new knowledge or test interventions Results add to the body of knowledge!!!

Question 58

Hierarchy of EBP Tools (Reviews and Studies)

Answer 58

Level I: Cochrane Systematic Reviews - Systematic review of RCTs Level II: Systematic Reviews and Meta Analyses - RCT Level III: Evidence Guidelines - controlled trial no randomization --------------------------------------------------------------------------------- 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

Question 59

Hallmarks of Effective Quality Control Programs

Answer 59

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)

Question 60

High Reliability Organizations (HROs)

Answer 60

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

Question 61

High Care Quality

Answer 61

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

Question 62

Quality has properties/domains of

Answer 62

effectiveness efficiency equity patient centeredness safety timeliness

Question 63

Benchmarking

Answer 63

the process of measuring products, practices, and services against best performing organizations

Question 64

Quality Gap

Answer 64

the difference in performance between top performing health care organizations and the national average

Question 65

Steps of Quality Control

Answer 65

1. Establish control criteria or standards 2. ID information relevant to the criteria 3. Determine ways to collect information 4. Collecting and analyzing information 5. Re-evaluation

Question 66

Nursing Process Standard of Practice Process (Nursing Process)

Answer 66

Assessment diagnosis Outcomes ID Planning Implementation Evaluation

Question 67

CPGs

Answer 67

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

Question 68

Audit

Answer 68

Systematic and official examination of a record, process, structure, environment, or account to evaluate performance

Question 69

Retrospective Audits

Answer 69

audit done after service is received by the patient

Question 70

Concurrent Audit

Answer 70

performed audit while patient is receiving service

Question 71

Prospective Audit

Answer 71

audit attempting to ID how future performance will be affected by current interventions

Question 72

Outcome Audot

Answer 72

Audit to determine what results, if any, occurred as a result of a specific nursing intervention for patients

Question 73

Outcomes reflect ...

Answer 73

the result of care or how the patients health status changed as a result of an intervention

Question 74

Process Audit

Answer 74

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

Question 75

Structure Audit

Answer 75

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

Question 76

Standardized Nursing Language

Answer 76

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

Question 77

TQM is a...

Answer 77

never ending process, everything and everyone in the organization are subject to continuous improvement efforts (workers not QI dept do the data collection)

Question 78

TQM Principles

Answer 78

1. Create a constancy of purpose for the improvement of products and service. 2. Adopt a philosophy of continual improvement. 3. Focus on improving processes not on inspection of product. 4. End the practice of awarding business on price alone; instead, minimize total cost by working with a single supplier. 5. Improve constantly every process for planning, production, and service. 6. Institute job training and retraining. 7. Develop the leadership in the organization. 8. Drive out fear by encouraging employees to participate actively in the process. 9. Foster interdepartmental cooperation and break down barriers between departments. 10. Eliminate slogans, exhortations, and targets for the workforce. 11. Focus on quality and not just quantity; eliminate quota systems if they are in place. 12. Promote teamwork rather than individual accomplishments. Eliminate the annual rating or merit system. 13. Educate/train employees to maximize personal development. 14. Charge all employees with carrying out the total quality management package.

Question 79

Patient satisfaction often...

Answer 79

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.

Question 80

Prospective Payment System

Answer 80

providers are paid a fixed amount per patient admission regardless of the actual cost to provide the care - could reduce quality or abbreviate care

Question 81

Leapfrog Group

Answer 81

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

Question 82

What are the 4 major initiatives of the Leapfrog Group

Answer 82

1. Computerized Physician Provider Order Entry (CPOE) 2. Evidence based hospital referral 3. intensive care unit physician staffing (IPS) 4. National Quality Forum Endorse Safe Practice