NU456 Quality Control (pt 2)

what is the kaiser family foundation (KFF)

-One-of-a-kind information organization

-Independent source of information on national health issues—one with the scope and reach to be a counter weight to health care's vested interests.

-Supported by an endowment that is supplemented by external funds primarily from foundations

what are the five major program areas of the KFF?

policy analysis, polling, journalism, public health information campaigns, and health misinformation and trust.

what is part of quality?

access

how to the centers for medicare and Medicaid (CMS) carry out quality reporting and VBP & Initiatives

-Manages quality programs across many areas of health care

-Programs encourage improvement of quality through payment incentives, payment reductions, reporting on healthcare quality on government websites.

-Consumers (Patients) can compare based on quality outcomes

how does CMS focus on health equity?

The attainment of the highest level of health for all people, where everyone has a fair and just opportunity to attain their optimal health regardless of race, ethnicity, sexual orientation, gender identity, socioeconomic status, geography, preferred language, or other factor that affect access to care and health outcomes.

what are Press Ganey Surveys?

-CMS approved vendor for Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys

-Survey developed by CMS (Centers for Medicare & Medicaid Services) AHRQ (Agency for Healthcare Research and Quality)

-Collects data on patient experience

-Triggered by discharge of patient discharge after inpatient stay

-CMS reports data on 12 month rolling basis, typically updated quarterly- posted on CMS Compare site

-Hospitals that participate in Hospital Inpatient Prospective Payment System (IPPS)subject to a possible reduction in Mcare reimbursement

give an example of hospital audits for the following topics:

-assessing skin for pressure injuries

-audit IV catheter sites

-transfusions

-restraints

-Ensure appropriate documentation including Braden score. If <18, note interventions taken to protect patients

-Dressing intact, tubing and fluid bag labelled and dates for changes noted; caps changed q 4 days; flowsheet documentation; IV SOI assessed q shift

-Verification of patient; Review flowsheets to ensure documentation of VS according to protocol

-Review documentation to ensure assessment of extremities, patient offered food and drink, toileting; S/Sof injury from restraint; indication for continued restraint; active order

YOU NOTICE AN UPTICK IN CL INFECTIONS ON YOUR UNIT-WHAT WOULD YOU DO? (3)

assess, implement, evaluate

what is the checklist manifesto? (4)

• Makes a distinction between categories of error

• Errors of ignorance (mistakes we make because we don't know enough)

• Errors of ineptitude (mistakes we made because we don't make proper use of what we know)

• Because healthcare is so complex, mistakes of one kind or another are virtually inevitable!!!

how is a root cause analysis performed? (7_

-Identify the problem/ issue

-Gather data- relevant information about the issue

-Determine possible causal factors :understand events that led to the incident

-Determine possible causal factors: what events led to the problem?

-Identify the root cause: pinpoint the underlying reason

-Recommend and implement solutions:propose and execute corrective actions

-RCA should NOT be disciplinary!!!

how must physicians go about apologizing?

The American Medical Association Code of Medical Ethics, which sets forth standards of professional conduct, states that when a patient suffers significant medical complications that may have resulted from the physician's mistake or judgment, the physician is ethically required to disclose to the patient all the facts necessary to ensure understanding of what has occurred [AMA].

how must nurses go about apologizing? (4)

-A complete apology expresses regret and acknowledges fault or shortcoming.

-Regret (saying sorry and accepting responsibility)

-Reason (providing a reason for the mistake)

-Remedy (trying to resolve the mistake as far as possible)