Overview of Patient Safety and Quality Improvement CH. 8

NR 201 Intro to Nursing week 8 Overview of Patient Safety and Quality Improvement CH. 8 Professor Panella

Safety:

•(QSEN) Refers to the minimization of risk of harm to patients and providers through both system effectiveness and individual performance

To Err is Human definition of patient safety

• freedom from accidental injury

Cause of the errors is defective system processes

leads people to make mistakes or fail to stop them from making a mistake, not the recklessness of individual providers

IOM report defines error as:

failure of a planned action to be completed as intended, or the use of a wrong plan to achieve an aim with the goal of preventing, recognizing, and mitigating harm

Comon errors include:

drug events and improper transfusions, surgical injuries and wrong-site surgeries, suicides, restraint-related injuries or death, falls, burns, pressure ulcers, and mistaken patient identities (IOM, 2000)

Person approach to errors

• creates a culture of blame on the person who comitted the error

• creates an environment where providers fear admitting to mistakes and hiding mistakes

• result is disciplinary action

Culture of Safety

• promotes trust and empowers staff to report risks, near misses, and errors

• Focuses on what went wrong rather than who did it

• 3 key attributes

  • trust of peers and management

  • reporting unsafe conditions

  • and improvement

System approach to error

• view the error in the context or prevention of future errors by looking at all the factors related ot the incident

• more likely to admit to errors or near misses because the identification of system issues will lead to patient safety.

Just culture

balance between not blaming individuals for errors and not tolerating careless or egregious behaviors

•Human Factor Errors

•Skill-based

•Knowledge-based

•Rule-based

Root cause analysis

one method to review error that has already occurred and along with actions to eliminate risks it is required by the Joint Commision for all sentinel events

• problem is clarified by completing and event flow digram (fish bone)

• problem = fish head

• bones of fish = related process or categories that are potential causes of the problem

TERCAP

ongoing root causes analysis to increase patient safety

• develops a data set to distinguish between human and system errors from negligence or misconduct while identifying areas of nursing practice breakdown in relation to standards of nursing practice (safe med admin, doc, attentiveness, prevention, etcc)

•Reason’s Adverse Event Trajectory or Swiss Cheese Model

identifies events or characterstics of a system that may allow potential errors

• explains how faults in the system align to result in adverse events, emphasizing the importance of multiple layers of safeguards to prevent patient harm.

Common errors

drug events and improper transfusions, surgical injuries and wrong-site surgeries, suicides, restraint-related injuries or death, falls, burns, pressure ulcers, and mistaken patient identities

•Types of error             

•Communication

•Patient management

•Clinical performance

Where the do error occurs

•Patient handoff: transfer of responsibility for a patient from on clinician to another

•Latent failure and active failure

•Organizational system failures and system process or technical failure

•Latent failure and active failure

• Latent failure

  • arising from decision affecting this such as organization policies or allocation of resources

• active failure

  • errors or harm at the share end or in direct contact with the patient

•Organizational system failures and system process or technical failure

errors related to management, organization culture and stem process; technical failure refers to indirect failure of facilities or external resources

what is a skill based error?

•Deviation in the pattern of a routine activity such as an interruption

knowledge based error

•Error arising from inadequate knowledge or information during decision-making processes.

what is a rule based error?

•Conscious decision by the nurse to “workaround” or take a shortcut, so the system defense mechanisms are bypassed, thereby increasing risk of harm to patient

•Recommendations from To Err Is Human

1. Development of user-centered designs

2. Avoidance of reliance on memory

3. Attending to work safety

4. Avoidance of reliance on vigilance

5. Training concepts for teams

6. Involving patients in their care

7. Anticipating the unexpected

8. Designing for recovery

9. Improving access to accurate, timely information

•STEEEP (expectations known as the six aims to improving healthcare quality for patients)

•Safe: avoiding harm to patients from that is supposed to help them

•Timely: includes reducing delays from those who receive care and for those who provide care

•Effective: prvision of services based on evidence to all who could benefit and refrain from providing services to those not

•Efficient

•Equitable

•Patient-centered

•10 rules for redesign

•Rule #6: Safety is a system property

•Recommendations from Keeping Patients Safe: Transforming the Work Environment of Nurses (report addressing link between work environment o f nurses and patient quality and safety)

•Chief nursing executive should have leadership role in the organization

•Creation of satisfying work environments for nurses

•Evidence-based nurse staffing and scheduling to control fatigue

•Giving nurses a voice in patient care delivery

•Designing work environments and cultures that promote patient safety

•Preventing medication errors

•Paradigm shift in the patient–provider relationship

• patient takes an active role in the healthcare process and the provider does a better job of educating the patient abt medications

•Using information technology to reduce medication errors

•Improving medication labeling and packaging

•Policy changes to encourage the adoption of practices that will reduce medication errors

•National Quality Forum Goals (safety initiative)

•Improving quality health care by setting national goals for performance improvement

•Endorsement of national consensus standards for measuring and public reporting on performance

•Promoting the attainment of national goals

•National Quality Forum Safe Practices

•Endorsed safe practices defined to be universally applied in all clinical settings in order to reduce the risk of error and harm for patients

•34 practices have been shown to decrease the occurrence of adverse health events

•Also endorses list of 29 preventable, serious adverse events for public reporting

•Never events (are not expected and medicare has eliminated reimbursement fro certain never events)

Sentinel events (unexpected occurence involving death or serious physical or psychological injury / not required to be reported)

Sentinel events (never events) EXAMPLES

•Wrong patient,

wrong site,

wrong procedure,

delay in treatment,

operative or post-operative complication,

retention of a foreign body,

patient suicide,

medication error,

perinatal death or injury,

and criminal events

•Progress of Healthcare organizations

have responded to incentive programs, accreditation standards, and public opinion

Progress of Professional organizations

have responded with revisions to standards that place more emphasis on healthcare quality and patient safety

Progress of Educators

have responded by infusing quality and safety concepts into student didactic and clinical experiences guided by initiatives such as the QSEN and Nurse of the Future

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 Improvement

the use of data to monitor the outcomes of care processes, and uses improvement methods to design and test changes to continuously improve the quality and safety of healthcare systems

CARE (Insights from the Crossing the Quality Chasm report)

•based on continuous healing relationships with patients receiving care whenever and wherever it is needed

•can be customized according to the patient’s needs and preferences even though the system is designed to meet the most common types of needs

CONTROL (Insights from the Crossing the Quality Chasm report)

The patient is the source of control and, as such, should be given enough information and opportunity to exercise the degree of control he or she chooses regarding decisions that affect him or her

KNOWLEDGE / INFO ACCESS (Insights from the Crossing the Quality Chasm report)

is shared and information flows freely so that patients have access to their own medical information

EVIDENCED BASED DECISION MAKING (Insights from the Crossing the Quality Chasm report)

that is, it is based on the best available scientific knowledge and should not vary illogically between clinicians or locations

SAFETY / SYSTEM PROPERTY (Insights from the Crossing the Quality Chasm report)

patients should be safe from harm caused by the healthcare system

TRANSPARENCY (Insights from the Crossing the Quality Chasm report)

is necessary where systems make information available to patients and families that enable them to make informed decisions when selecting a health plan, hospital, or clinic, or when choosing alternative treatments

PATIENT NEEDS (Insights from the Crossing the Quality Chasm report)

are anticipated rather than reacted to

WASTE OF RESOURCES & PT TIME IS…. (Insights from the Crossing the Quality Chasm report)

•continuously decreased

COOPERATION AMONG CLINICIANS (Insights from the Crossing the Quality Chasm report)

priority to ensure appropriate exchange of information and coordination of care

Patient Safety Goals (PRAISE)

Patient Safety Goals (2 forms of ID)

Report/Communicate (crucial reports/labs/tests)

Admin meds cautiously

Infection Prevention

Suicide Risk Detection

Eliminated surgery errors

Safe

avoid injuries to patients from the care that is intended to help them

Effective

providing services based on scientific knowledge to all who could benefit and refraining from providing services based on scientific knowledge to all who could benefit (avoiding underuse and overuse respectively)

patient centered

providing care that is respectful of and responsive to individual patient preferences, needs and values and ensuring the patient values guide all clinical decisions

Timely

reducing waits and sometimes harmful delays for both those who receive and those who give care

Efficient

avoid waste, including waste of equipment, supplies, ideas, and energy

Equitable

providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location etc…

Quality Improvement Measurement and Process

• Benchmarking

• Healthcare Transparency

• Core Measures

• Accountability Measures

• Composite Measures

Benchmark

seeking out and implementing best practices or seeking to attain an atribute or achievement that sources as a standard for other institutions to emulate

Healthcare Transparency

tends to improve care because the public availability of data allows patients to make informed choices about there they want to recieve health care services

• Core Measures

standardized peformance indicators, they allow for comparison of the measure across healthcare organization and over time

• Accountability Measures

evidence based care processes clinicly linked to positive patient outcomes

• Composite Measures

combine the results of related measure into a single percentage rating calculated by adding up the number of times recomended evidence based care was provided to patients and dividing this sum by the total number of opportunities to provide countability measures within the 10 sets of measures

Measures of Nursing Care

•Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospital Survey

•National Voluntary Consensus Standards for Nursing-Sensitive Care

•National Database of Nursing Quality Indicators (NDNQI)

Continuous quality improvement (CQI)

•Structured organizational process that involves personnel in planning and implementing the continuous flow of improvements in the provision of quality health care that meets or exceeds expectations

Quality Improvement Process FIRST

•process occurs as data that is regularly collected is monitored; if the data indicate that a problem exists, then an analysis is done to identify possible causes and a process is initiated to pilot a change

Quality Improvement Process & Tools SECOND

•involves the identification of a problem outside of the routine data monitoring system

Quality Improvement Methodologies

• Plan, Do, Study, Act

• Six Sigma

• Swiss Cheese Model

Plan do study Act

most used commonly used quality improvement methodology in health care

• encourages innovation by experimenting with a change, studying the results, and making refinements as necessary to achieve sustained desired outcomes

Six Sigma

goal: to decrease the defects or errors from the current level within an organization

• emphasize the use of information and statistical analysis to rigoursly and routinely measure and improve and organizations performance practices and systems

• 6 phases:

  • Define: stating the problem that is the focus for quality improvement

  • Measure : review all available data measure the extent of the quality problem and obtain baseline performance info

  • Analyze: use tools to study the root cause of the problem and develop potential solution alternatives

  • Improve: develop the alternative process to help achieve the desired outcome

  • Control: sustain improvement though ongoing measurement and by conducting ongoing communication review and training

ROLE OF THE NURSE in Quality Improvement

•The registered nurse contributes to quality nursing practice with competencies that include the nurse’s role in various quality improvement activities such as collecting data to monitor quality and collaboration to implement quality improvement plans and interventions

• Collecting and analyzing patient data

• Identification of problems

CHALLENGES of the role of the nurse in quality improvement

•Adequacy of resources

•Engaging nurses from management to the bedside in the process

•Increasing number of QI activities

•Administrative burden of QI initiatives

•Lack of preparation of nurses in traditional nursing education programs for role in QI

Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospital Survey

the only national survey that includes a measure of nursing quality. The survey asks a core set of questions set of questions with 4 sets of questions specifically relating to nursing

• How often did nurses communicate well with patients?

• how often did nurses treat your with courtesy and respect?

• how often did nurses listen carefully to you?

• how often did nurses explain things in way you could understand?

•National Voluntary Consensus Standards for Nursing-Sensitive Care

• nursing sensitive measure: identified as patient related process or outcomes that reflect the nurse quality relationship

• The following were endorsed by the NQF

  • Death among surgical inpatients with relatable serious complications

  • pressure uler prevalence

  • falls prevalence

  • falls with injury

  • restraint prevalence

  • urinary catheter associated UTI

  • central line catheter associated blood stream infection rate

  • ventilator associated pneumonia for ICU & high risk nursery patients

  • skill mix

  • nursing care hours per patient day

  • Practice environment scale of the nursing work index

  • Voluntary turnover of nursing staff

•National Database of Nursing Quality Indicators (NDNQI)

national nursing database developed by the American Nurses Association (ANA) that collects and analyzes data on nursing-sensitive quality indicators.

These indicators reflect the structure, process, and outcomes of nursing care and are directly impacted by the quality and quantity of nursing.

• To track nursing performance and patient outcomes over time

• To improve patient safety and care quality

• To benchmark nursing practices across hospitals and healthcare systems

• To support Magnet status and other quality initiatives

EXAMPLES:

• Patient falls

• Pressure injuries (ulcers)

• Hospital-acquired infections

• Nurse staffing levels

• Nurse job satisfaction

• Patient satisfaction with nursing care

plan:

begin with planning the changes to a process that are to be implemented and tested

Do:

carry out the plan and make the desired changes to the process

Study:

review the effect and outcomes of the implemented changes

Act:

determine if the changes can be implemented as is or if ifrther cycles are necessary for refinement