chapter 020 1
TRANSCRIPT
Chapter 20
Managing Quality and Risk
All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc.
Objectives
Apply quality management principles and strategies to clinical situations.
Use the six steps of the quality improvement process.
Practice using select quality improvement strategies.
All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 2
Objectives (Cont.)
Incorporate roles of leaders, managers, and followers to create a quality management culture of continuous readiness.
Apply risk management strategies to an agency’s quality management program.
All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 3
Managing Quality and Risk
Comprehensive systematic approach Prevents errors before they occur Identifies and corrects errors
• Adverse events are decreased • Safety and quality outcomes are maximized
Optimizes patient outcomes Prevents patient care problems Mitigates adverse events
All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 4
Standards of Quality Care
Nurse Practice Acts Accreditation Standards (e.g., TJC National
Patient Safety Goals) Governmental bodies (e.g., Agency for
Healthcare Research and Quality [AHRQ], National Quality Forum [NQF]; the National Institute for Occupational Safety and Health [NIOSH])
Healthcare advisory groups (e.g., Institute of Medicine [IOM])
All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 5
Standards of Quality Care (Cont.)
Internal or external performance measurements (e.g., patient satisfaction surveys, employee opinion surveys, safety assessment surveys, patient rounds)
Institutional Guidelines (e.g., Policies and Procedures, Structure/Process Standards)
Research/Evidence-based practice guidelines
All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 6
Quality Management Terms
Continuous Quality Improvement (CQI) Total Quality Management (TQM) Quality Improvement (QI) Quality Assurance (QA)
All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 7
Total Quality Management
Structure Facilities Equipment Staff Finances
Process Nurses’ role/EBP
Outcome
All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 8
Principles of QM and QI
QM most effective in a flat, democratic organization.
Leaders, managers, and followers must be committed to QI.
Goal of QM is to improve systems and processes, not to assign blame.
All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 9
Principles of QM and QI (Cont.)
Customers define quality. QI focuses on outcomes. Decisions must be based on data.
All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 10
Comparison of QA and QIQA Process QI Process
Goal Improve quality Improve quality
Focus Discover/correct errors
Prevent errors
Major tasks Inspect nurse activities; chart audits
Review nurse activities;innovation;staff development
Quality team QA or department personnel
Interprofessional team
Outcomes Set by QA team with input from staff
Set by QI team with input from staff and patients
All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 11
Steps in the QI Process
Identify needs. Assemble interprofessional team. Collect data. Establish outcomes and quality indicators. Select and implement plan. Evaluate.
All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 12
National Patient Safety Goals
Accuracy of Patient Identification Effectiveness of Interdisciplinary
Communication Safety of Medication Reduced Hospital-Acquired Infections Identification of specific safety risks
Suicide Falls
All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 13
Case Study
A significant increase in patient falls resulting in injury has been reported on your unit. In accordance with the National Patient Safety Goals, you are assigned to an interprofessional Quality Improvement/Risk Management team to address the problem.
All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 14
Case Study: Steps in the Risk Management Process
Define high-risk situation. Patient falls
Collect data, including frequency of falls. Intervene and investigate. Identify opportunities to improve care.
Use steps of the QI process.
All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 15
Case Study: Identify Needs
Compliance with National Safety Goals Reduction of hospital risk/financial loss Reduction in LOS after an adverse fall event Establish outcomes
Nursing-sensitive outcomes
All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 16
Case Study: Assemble Interprofessional Team
Nurses Physicians Unlicensed assistive personnel Pharmacists Facility/environmental management
representatives QI/risk management experts
All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 17
Case Study: Collect Data
Define incidence of falls. Benchmark using National Database of
Nursing Quality Indicators (NDNQI). Determine high-risk patients.
Age Mental status History of falls Medication Physical environment
All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 18
Case Study: Identify Outcomes and Indicators
Education of 100% of all direct care providers Completion of Fall Risk Assessment on 100%
of patients Reduction in patient falls by 25% within 3
months of program Medical record demonstrating 100%
compliance with Fall Prevention Program
All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 19
Case Study: Establish Fall Prevention Plan
Consistent use of ID bracelets based on Fall Risk Assessment score
Implementation of bed alarms Staff education (e.g., toileting at-risk patients
routinely) Change of environment (e.g., vertical grab
bars)
All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 20
Case Study: Evaluate Change
Change in incidence of falls (e.g., through incident reports, sentinel event monitoring) Root cause analysis
Staff compliance with Fall Prevention Plan Patient/family satisfaction with plan Reliability and validity of Fall Risk
Assessment tool
All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 21
Case Study: Ensuring Standards of Care for Fall Prevention
Nurse practice acts Professional organization guidelines Institutional guidelines (e.g., policies and
procedures, structure/process standards) Research/evidence-based practice guidelines Accreditation standards (e.g., TJC National
Patient Safety Goals)
All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 22
Questions to Consider
How can a staff nurse make effective suggestions to improve nursing practice?
How can a culture of assigning blame for errors be transformed into an environment invested in improving patient care?
How can patients’ expectations be used to improve nursing care and promote optimal outcomes?
All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 23