Quality Management and Patient Safety

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What is meant by throughput?

The things that pass through a system

Are transformed through processes and interactions

What was the call to action for developing the 6 aims for healthcare? Describe this.

1999 → “To Err is Human”

• 44000-98000 preventable deaths occur each year in hospitals due to medical errors and system failures

6 aims for Healthcare

• STEEEP

  • Safe, timely, effective, efficient, equitable, and PT/person centered care

6 Aims for Healthcare Quality

Developed in response to high number of preventable hospital deaths.

STEEEP

• Safe — Avoid injuries from care that is intended to help

• Timely — Reducing wants and delays from pts and providers

• Efficient — Provide appropriate level of services based on scientific knowledge (not giving too much but not too little)

• Effective — Avoiding waste of equipment, supplies, ideas, and energy

• Equitable — Care does not vary in quality due to personal characteristics

• Pt/Person centered — Respectful and Responsive

STEEEP

6 Aims for Healthcare quality

• Safe — Avoid injuries from care that is intended to help

• Timely — Reducing wants and delays from pts and providers

• Effective— Provide appropriate level of services based on scientific knowledge (not giving too much but not too little)

• Efficient — Avoiding waste of equipment, supplies, ideas, and energy

• Equitable — Care does not vary in quality due to personal characteristics

• Pt/Person centered — Respectful and Responsive

One of the National Patient Safety Goals is to Improve the Accuracy of Patient Identification. What elements of performance can ensure this goal is met?

1. Use at least two patient identifiers when (The patient's room number or physical location is not used as an identifier.):

   • administering medications, blood, or blood components

   • collecting blood samples and other specimens for clinical testing

   • providing treatments or procedures.

2. Label containers used for blood and other specimens in the presence of the patient.

3. Use distinct methods of identification for newborn patients. Examples:

   • Distinct naming systems

   • Standardized practices for identification banding

   • Establish communication tools among staff

One of the National Patient Safety Goals is to Improve the Effectiveness of Communication among Caregivers. What elements of performance can ensure this goal is met?

I.E — Report critical results of tests and diagnostic procedures in a timely manner

Examples:

• Written procedures for managing the critical results of tests and diagnostic procedures that address the following:

  • Definition of critical results of tests and diagnostic procedures

  • By and to who critical results of tests and diagnostic procedures are reported

  • Acceptable length of time between the availability and reporting of critical results of tests and diagnostic procedures

• Evaluation of the timeliness of previous reports

One of the National Patient Safety Goals is to Use Medicines Safely. What elements of performance can ensure this goal is met?

• Label all medications in an area where medicines and supplies are set up

• Take extra care with patients who take blood thinners

• Record and pass along correct information regarding a patient’s medications.

  • What meds are they taking?

  • Compare with new meds/prescriptions

  • Give pt written info regarding their meds

  • Tell the pt is important to give updated med info every time they visit a doctor

One of the National Patient Safety Goals is to Use Alarms Safely. What elements of performance can ensure this goal is met?

• Ensure that alarms on medical equipment are heard and responded to on time

• Determine which alarms are most important to manage immediately based on risk for patient harm if not responded to in a timely manner

• Identify clear policies for whether alarms can be disabled or parameters changed

One of the National Patient Safety Goals is to Prevent infections. What elements of performance can ensure this goal is met?

• Proper hand hygiene based on CDC and WHO guidelines

• Set goals for improving hand cleaning

One of the National Patient Safety Goals is to Identify Patient Safety Risks. What elements of performance can ensure this goal is met?

• Reduce the risk for suicide

  • Identify high risk patients with screening and assessment

  • Ensure environmental safety and safe discharges and counseling

One of the National Patient Safety Goals is to Improve Health Care Equity. What elements of performance can ensure this goal is met?

According to 2025 goals

• One individual may be only in charge of ensuring equity for patients

• Assess a patient’s health-related social needs

• Identify health care disparities that a specific population faces

• Written plan that describes how equity will be addressed

• Include stakeholders to improve equity

One of the National Patient Safety Goals is to Prevent Mistakes in Surgery. What elements of performance can ensure this goal is met?

• Ensure correct surgery on correct patient

• Mark correct area on body where surgery is to be done

• Have a “timeout” before surgery to ensure no mistake is being made

QSEN

• Quality and safety education for nurses

• Initiative to develop and implement competencies for safe and high-quality patient care

National quality strategy

• Part of affordable care act

• Goals:

  • Improve health of american public

  • Improve healthcare experiences

  • Make healthcare more affordable

Definition: Quality

• How much health services (on individual and population level) increase the likelihood of desired health outcomes

• Are they consistent with current professional knowledge (are they based on current evidence?)

True or false:

Total quality management is interchangeable with quality improvement

TRUE

Total Quality Management (TQM) = Quality Improvement (QI) = Process improvement (PI)

Definition: Quality improvement

• Systematic process to improve outcomes

• Uses data + scientific method to assess and problem solve

• Based on customer needs

• Proactive approach

• Everyone has a responsibility in QI

• Continuous process

Quality improvement:

• ______ process to improve outcomes

• Uses ____ and _______ to assess and problem solve

• Based on _______

• (Reactive or proactive) approach

• Who is responsible for quality improvement?

• Is quality improvement a continuous process or in response to acute problems?

• Systematic process to improve outcomes

• Uses data + scientific method to assess and problem solve

• Based on customer needs

• Proactive approach

• Everyone has a responsibility in QI

• Continuous process

Quality improvement vs Quality Assurance

Quality Improvement:

• Systematic process

• Determining ways/methods to improve future quality

• Continuous process

• Prospective approach — looking to future

• Everyone’s responsibility

Quality Assurance:

• Investigative approach

• Ensuring that current practices are compliant against standards

  • Is the quality produced good?

• Reactive process

• Retrospective — Looking at previous/current approaches, seeing if it’s good enough

  • Audits, incident reports, etc

• Responsibility of a few — People who overlook to reports, look at data, etc

A plan is developed in order to decrease the number of CAUTIs developed on a unit. Would this be quality improvement or quality assurance?

Quality improvement

The incident reports on a particular unit are reviewed in order to identify any consistent issues present. Is this quality improvement or quality assurance?

Quality assurance

Donabedian model of quality

3 domains

• Structure

  • Elements that make up health care system

• Process

  • Interaction between patients and providers

• Outcome

  • End results of health care practices/interventions

Domains of Donabedian Model of Quality

1. Structure

   • “How is care organized?”

   • Stable elements → Make up the healthcare system

2. Process

   • “What is done?”

   • Interactions between patients and providers

3. Outcome

   • “What happens to patient’s health?”

   • End results of healthcare practices/interventions

Structure domain of Donabedian Model of Quality

• Structure

  • “How is care organized?”

  • Stable elements → Make up the healthcare system

Process domain of Donabedian Model of Quality

1. Process

   • “What is done?”

   • Interactions between patients and providers

Outcome domain of Donabedian Model of Quality

1. Outcome

   • “What happens to patient’s health?”

   • End results of healthcare practices/interventions

What are examples of nursing indicators representing the Structure domain in Donabedian’s Model of Quality?

• Supply of nursing staff

• Skill levels

• Education/certification of staff

What are examples of nursing indicators representing the Process domain in Donabedian’s Model of Quality?

• Assessments

• Interventions (meds given, nursing actions, etc)

• RN job satisfaction (?)

Are nursing activities/care being done appropriately, effectively, and efficiently?

What are example of nursing indicators representing the Outcomes domain in Donabedian’s Model of Quality?

• Falls

• Pressure ulcers

• IV infiltrations

Did the services provided make a difference (good or bad)?

Patient safety indicators

Set of measures that screen for adverse events

• Pressure ulcers

• “Failure to rescue”

• Foreign body left during procedures

• Transfusion reactions

• Post-op sepsis

• Post-op wound dehiscence

What empowers the public to seek quality healthcare services?

Core measures — Methods of tracking the quality of healthcare provided from various hospitals

• Core measures —> Strokes, VTE, etc

• Quality measures

  • Efficiency of care

  • Structure of the care

  • Process of the care

  • Outcomes of care

  • The patient’s experience/perception of the care they received

Core measure: Efficiency of care

• Resources needed to provide quality care VS the actual quality of the healthcare

• Example: cost of care

Core measure: Structure of care

• The presence of a mechanism/system that supports the delivery of quality health care

• Example:

  • Electronic health records

  • Participation in quality measures databases

Core measure: Process of care

• Whether the patient received elements of care that are evidence-based

• Example:

  • Documentation that aspirin was given to pts with MI

Core measure: Intermediate outcomes

• Result of health care processes

• Example:

  • Mortality rates

  • Patient safety indicators

How is patient-centered care measured?

Surveys

Standards of care

• Minimum acceptable nursing care → Scope, function, and role of a nurse in practice

• Reflect the knowledge and skill possessed by active nurses

• Developed by the ANA (american nurses association)

• Used to determine the presence of malpractice

What organization develops the standards of care by which active nurses practice?

American nurses association (i think this is the main source?)

What outlines the scope, function, and role of actively practicing nurses?

Standards of care from ANA

What is compared to a nurse’s actions in order to determine the presence of malpractice?

ANA Standards of care

How is a nursing intervention evaluated according to the Standards of Care?

• 2 factors: appropriateness of the intervention + correct application of the intervention

• Standards of care —→ Determine whether the intervention was appropriate or whether additional interventions need to be taken

Basic steps in quality improvement (check lippincott, i think it’s organized better lmaoo)

1. Identify the problem

2. Identify the metric associated with the problem

3. Assemble evidence that the problem is legitimate

4. Align with Donabedian Model of quality (Structure, Process, or Outcome problem)

5. Assemble an improvement team

6. Determine extent of problem with analysis tools and data collection

7. Consider financial aspect

8. Determine evidence-based interventions

9. Testing of evidence-based interventions

10. Develop a plan to sustain the interventions

Put the steps of quality improvement in order

• Assemble an improvement team

• Determine evidence-based interventions

• Identify the problem

• Align with Donabedian Model of quality

• Assemble evidence that the problem is legitimate

• Identify the metric associated with the problem

• Develop a plan to sustain the interventions

• Determine extent of problem with data collection

• Consider financial aspect

• Testing of evidence-based interventions

1. Identify the problem

2. Identify the metric associated with the problem

3. Assemble evidence that the problem is legitimate

4. Align with Donabedian Model of quality (Structure, Process, or Outcome problem)

5. Assemble an improvement team

6. Determine extent of problem with analysis tools and data collection

7. Consider financial aspect

8. Determine evidence-based interventions

9. Testing of evidence-based interventions

10. Develop a plan to sustain the interventions

You notice that on your floor, there are a high amount of pressure ulcers.

What step in quality improvement would this be?

1. Identify the problem/opportunity for improvement

   • Noticing a gap between what organization desires vs actual performance

   • Is it possible to obtain data that proves the problem exists?

   • Is this issue important to patient care, goals, and/or team?

You identify that the frequency of pressure ulcers on your floor aligns with AHRQ Patient Safety Indicator #3: Pressure ulcer rates.

What step in the quality improvement process is this?

2. Identify metric associated with the problem

   • What measure/data and/or indicator is associated with the problem?

You gather information on the rate of pressure injuries on your floor from every month in the past year. You determine that your floor is not meeting current standards.

What step in quality improvement process is this?

3. Examine historical data to assemble evidence that the problem actually exists

You determine that the high frequency of pressure injuries on your floor is indicative of an issue with patient outcomes, according to the Model of Quality.

What step in quality improvement process is this?

4. Align the problem/indicator with Donabedian’s Framework

You speak to the manager on your floor regarding the high frequency of pressure injuries on your floor. You get permission to assemble a team to address this issue.

What step in the quality improvement process is this?

5. Notify the chain of command, assemble the improvement team

   • “Know your stakeholders”??

   • Seek support in addressing the problem

     • Time, money, supplies, personnel

   • Assemble the team

   • Project goals — SMART format

You compare the rates of pressure injuries on your floor with the rates of pressure injuries in the same unit at a neighboring hospital (that has overall better outcomes).

What step in the quality improvement process is this?

6. Determine the extent of the problem

   • Benchmarking: Comparison against other organizations that have better outcomes/results. Determine how those results are achieved, and use this info to improve our own operations.

   • Other methods of collecting/comparing data

     • Gap analysis, fishbone

     • Surveys, interviews

     • Qualtiy metrics

     • Etc

Benchmarking

• improvement process

• Comparison of results with those of another organization with better results

• Determine how this performance is achieved —→ Used to improve its own performance

• Internal vs external

  • Internal - using data from within the organization

  • External - comparing with other hospitals/organizations (nationwide or worldwide or whatever)

You determine that addressing the high frequency of pressure injuries on your unit would save your hospital a large amount of money and resources.

Which step in the quality improvement process is this?

7. Consider the financial aspect of the problem

   • Does the problem impact you financially?

   • Will there be a return on investment into fixing the problem?

You and your team research and determine based on previous research studies strategies that can reduce the frequency of pressure injuries on your floor.

What step in the quality improvement process is this?

8. Search the literature for interventions that are evidence-based

   • Create evidence table with interventions

     • Use this to determine the best intervention(s)

What are often components of a sustainment plan in the quality improvement process?

• Champions - encouraging staff to maintain gains, continue to improve

• Quality Assurance Monitoring

Error definition

• Error of execution: Failure to complete a planned action as intended

• Error in Planning: Use of the wrong plan to achieve an aim

• Directly related to outcomes

• Active (you messed up directly) vs latent (the system itself is effed up)

Active error vs Latent error

Active error

• “Incident that is non-compliant with procedure”

• The nurse makes a mistake on their own

Latent error

• The incident involves problems within the system

• “May lie dormant in a system”

When they both occur —→ They can bypass multiple safeguards

Definition: Misuse

• Avoidable event — prevents patient from receiving the full benefits of a service

• Examples:

  • Incorrect diagnoses

  • Medication errors

  • Avoidable complications

Definition: Overuse

• Occurs when the potential for harm from a service exceeds the possible benefits

• “Risks outweigh the benefits”

• Examples:

  • Overtesting, overdiagnoses, overtreatment → May increase risk for complications, errors, and healthcare costs

Definition: Adverse event

• Injury resulting from medical intervention

• Not due to the patient’s underlying conditions

• Example:

  • Falls, pressure injuries, cautis, etc

Definition: Never Event

• “particularly shocking medical errors—such as wrong-site surgery—that should never occur.”

• “adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable.”

• I’m pretty sure it’s the same as a never event. They literally have the same definitions.

Examples:

• Surgical

  • Wrong site, foreign body,wrong pt

• Devices

  • Contamination leading to death/impairment

  • Air embolisms

• Death from medication error

• Etc

Failure to Rescue

• Deterioration (death or permanent disability) that occurs from a complication from illness or medical care

• The degree to which providers responded to adverse occurrences that developed under their care that lead up to the deterioration

  • Not inherently due to negligence. It describes when a pt dies/is disabled due to a complication.

Work-around

• When one doesn’t follow the rules or works around the rules/correct actions of a process in order to save time

• “Cutting corners” (especially in an unsafe way)

• Can lead to error and/or adverse events!

Near-Miss

• Recognition that an event occurred that might have led to an adverse event

Sentinel event

• Event that had a negative patient outcome (unexpected death, serious physical/psychological injury, serious risk)

• I’m pretty sure it’s the same as a never event. They literally have the same definitions.

Root Cause Analysis

• In-depth analysis of an error to assess the event and identify causes and possible solutions

Incident/Variance Report

• Confidential document

• Describes any patient or staff accident/incident while on premises

What conditions might serve as a barrier to creating an incident report?

• Inability to recognize errors

• Documentation suckss

• Lack of anonymity

• Hesitancy

• Unclear reporting requirements for errors without an adverse outcome

• Fear of lawsuits

• Feeling like it won’t make a difference

What is a Root Cause Analysis?

• Interdisciplinary and full of experts - meant to be impartial

• Involves those who are most familiar with the situation

• “Why why why”

Trying to determine why an adverse event/near miss/error or whatever the frick occurred

• Identifies changes that need to be made

Goals:

• What happened, why did it happen, and how to prevent it from happening

A thorough Root Cause Analysis will include:

• Determination of contributing _____

• Determination of the related _____ and ______

• Analysis of underlying _____ and ______

• Identification of ____ and their potential contributions

• Determination of potential _______ in processes or systems

• Determination of contributing factors

• Determination of the related processes and systems

• Analysis of underlying causes and effects

• Identification of risks and their potential contributions

• Determination of potential improvement in processes or systems

Culture of Safety

• Blame-free environment in which staff can practice and openly discuss potential errors or near-misses and actual errors

• “Prevention, NOT punishment!”

• A culture of safety allows a just culture to exist

Just Culture

• Staff are willing to come forward with info about errors so people can learn from mistakes

• Recognition of need for accountability and at times, disciplinary actions

• “No shame, no blame”

• A happy medium between punishment for every mistake vs letting everybody get off scott free.

• People shouldn’t be afraid to speak up - However, accountability still needs to exist at some capacity

5 Characteristics of High-Reliability Organizations

• Preoccupation with failure

  • Be alert to near-misses, recognize weaknesses in systems early

  • Basically be like me — always prepare for and expect the worst

• Reluctance to simplify

  • Recognize the complexity of the work

  • Easy-fix causes may not be enough to prevent a failure

  • (note to self - don’t think of it as complicating things. think of it as not expecting an easy simple magic fix for a problem, and that it will likely require a lot of effort to address the causes of a failure")

• Sensitivity to operations

  • Recognize complexity of healthcare processes

  • Situational awareness of environment, distractions, resources, supplies, and relationships

• Resilience

  • Anticipate failure

  • Determine how to diminish risk of harm

  • Identify strategies to recover when an adverse event occurs

• Deference to expertise

  • Teamwork

  • Active participation from other professionals

  • Share information

  • Deemphasize hierarchys

  • Basically = bitch be humble

List the 5 characteristics of high-reliability organizations

1. Preoccupation with failure

2. Reluctance to simplify

3. Sensitivity to operations

4. Resilience

5. Deference to expertise

Safe Harbor

• protects a nurse from employer retaliation, suspension, termination, etc when a nurse makes a good faith request for peer review of an assignment

• Nurse must believe it could result in violation of NPA or board rules

• MUST be invoked PRIOR to engaging in the assignment in question

• May be invoked at anytime should the assignment change

A nurse has been given an assignment of 6 patients. Midway through her shift, she receives another patient with a relatively high acuity. She tries to continue caring for all 7 of her patients, however, she becomes overwhelmed due to the new pts acuity. She invokes safe harbor.

Is she allowed to do this?

If she had invoked it prior to starting patient care then maybe.

However, at this point, she may be unable to invoke it.

“Must be invoked prior to engaging in assignment in question”

Requirements for invoking safe harbor?

• “Good faith”

• Orally invoke safe harbor

• Invoke PRIOR to accepting an assignment

• Nurse supervisor must complete the Safe Harbor form