leadership
Enny123Chapter 23 Quality Control in Creating a Culture of Patient Safety
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Learning Objectives
1. Describe the complexity of defining and measuring quality health care (Text p 621-22)
2. Describe a systematic process (such as FOCUS PDCA) that could be used to initiate a quality improvement process (ATI p 12—Steps in the Quality Improvement Process) (ATI p 12—Quality Improvement) (Text 622-25)
3. Determine appropriate criteria or standards for measuring quality (Text p 625-26)
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Learning Objectives
4. Collect and analyze quality control data to determine whether established standards have been met (ATI p 13. Audits) )Text p 626-28)
5. Differentiate among outcome, structure, and process audits as well as concurrent, retrospective, and prospective audits (Text p 626-28)
6. Write nursing criteria for process, outcome, and structure audits (Text--Learning Exercise 23.2 p 628)
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Learning Objectives
7. Describe key components of total quality management (Continuous quality improvement) (Text p 630-31)
8. Debate the importance of articulating “nursing sensitive” outcome measured in measuring quality of health care (Text 638-39) (NDNQI website)
9. Describe the role of organizations such as The Joint Commission (TJC), the Centers for Medicare & Medicaid Services (CMS,) the American Nurses Association (ANA), and the Agency for Healthcare Research and Quality (AHRQ) in establishing standards of practice and clinical practice guidelines for healthcare organizations and healthcare professionals(Text p 633 & 633-638)
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Learning Objectives
10. Define and provide examples of sentinel events in healthcare as defined by TJC (Text p 633-34)
11. Describe the national efforts such as Health Plan Employer Data and Information Set, the National Database of Nursing Quality Indicators to standardize the collection of quality data and make that data more transparent to providers and consumers (Text 633-36)
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Learning Objectives
12. Identify the four evidence-based standards the Leapfrog Group believes will provide the greatest impact on reducing medical errors (Text p 640-42)
*ATI p 12—Nurse’s Role in Quality Improvement
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Quality Control: Fifth and Final Step of the Management Process
Activities that are used to evaluate, monitor, or regulate services rendered to consumers
Performance is measured against predetermined standards.
Action is taken to correct discrepancies between these standards and actual performance.
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Management Controlling Functions
Periodic evaluation of unit philosophy, mission, goals, and objectives
Measurement of individual and group performance against preestablished standards
Auditing of patient goals and outcomes
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Hallmarks of Effective Quality Control Programs
Support from top-level administration
Commitment by the organization in terms of fiscal and human resources
Quality goals reflect search for excellence rather than minimums.
Process is ongoing (continuous).
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Three Steps of the Quality Control Process
The criterion or standard is determined.
Information is collected to determine whether the standard has been met.
Educational or corrective action is taken if the criterion has not been met.
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Steps in Auditing Quality Control
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Standards #1
Predetermined baseline condition or level of excellence that constitutes a model to be followed and practiced
Each organization and profession must set standards and objectives to guide individual practitioners in performing safe and effective care.
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Standards #2
The American Nurses Association (ANA) has played a key role in developing standards for the nursing profession.
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Quality Gap
The difference in performance between top-performing health-care organizations and the national average is called the quality gap. Although the quality gap is typically small in industries such as manufacturing, aviation, and banking, variation is more common in health care.
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Benchmarking #1
The process of measuring products, practices, or services against best-performing organizations
Organizations can determine how and why their organization differs from these exemplars and then use the exemplars as role models for standard development and performance improvement.
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Benchmarking #2
Critical event analysis and root cause analysis help to identify not only what and how an event happened but also why it happened, with the end goal being to ensure that a preventable negative outcome does not recur.
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Audits Frequently Used in Quality Control
Structure—monitor the structure or setting in which patient care occurs
Process—measure the process of care or how the care was carried out
Outcome—determine what results, if any, followed from specific nursing interventions for patients
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Sample Standardized Nursing Languages and Measures #1
NANDA International (NANDA-I)
Nursing Interventions Classification (NIC)
Nursing Outcomes Classification (NOC)
Clinical Care Classification System (CCC)
The Omaha System
Perioperative Nursing Data Set (PNDS)
International Classification for Nursing Practice (ICNP)
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Sample Standardized Nursing Languages and Measures #2
Systemized Nomenclature of Medicine Clinical Terms (SNOMED CT)
Logical Observation Identifiers Names and Codes (LOINC)
Nursing Minimum Data Sets (NMDS)
Nursing Management Minimum Data Sets (NMMDS)
ABC Codes
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Nursing Sensitive Outcomes
There is growing recognition that it is possible to separate out the contribution of nursing to the patient’s outcome; this recognition of outcomes that are nursing sensitive creates accountability for nurses as professionals and is important in developing nursing as a profession.
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Clinical Practice Guidelines
Provide diagnosis-based step-by-step interventions for providers to follow in an effort to promote quality care
Also called standardized clinical guidelines
Should reflect evidence-based practice (EBP); that is, they should be based on cutting-edge research and best practices
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Quality Assurance and Quality Improvement #1
Over the past three decades, the American health-care system has moved from a quality assurance (QA) model to one focused on quality improvement (QI).
The difference between the two concepts is that QA models target currently existing quality; QI models target ongoing and continually improving quality.
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Quality Assurance and Quality Improvement #2
Two models that emphasize the ongoing nature of QI include total quality management (TQM) and the Toyota Production System (TPS).
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Total Quality Management (TQM)
Also referred to as continuous quality improvement (CQI)
Based on the premise that the individual is the focal element on which production and service depend
Focus is on doing the right things, the right way, the first time, and problem-prevention planning, not inspective and reactive problem solving.
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Toyota Production System (TPS) #1
Customer-focused quality improvement model
Production system built on the complete elimination of waste and focused on the pursuit of the most efficient production method possible
Adopting TPS in an organization requires a substantial commitment of leadership time and resources
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Toyota Production System (TPS) #2
Quality control in health-care organizations has evolved primarily from external forces and not as a voluntary effort to monitor the quality of services provided.
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Quality Measurement as an Organizational Mandate #1
The Joint Commission
ORYX
Core measures
National Patient Safety Goals
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Quality Measurement as an Organizational Mandate #2
The Joint Commission is the major accrediting body for healthcare organizations and programs in the United States. It also administers the ORYX initiative and collects data on core measures to better standardize data collection across acute care hospitals.
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Centers for Medicare & Medicaid Services (CMS) #1
CMS plays an active role in setting standards for and measuring quality in health care including pay for performance.
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Centers for Medicare & Medicaid Services (CMS) #2
The National Committee for Quality Assurance (NCQA), a private nonprofit organization that accredits managed care organizations, also developed the Health Plan Employer Data and Information Set (HEDIS) to compare quality of care in managed care organizations.
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Centers for Medicare & Medicaid Services (CMS) #3
The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is the first national, standardized, publicly reported survey of patients’ perspectives of hospital care. It measures recently discharged patients’ perceptions of their hospital experience.
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Medical Errors #1
A plethora of studies across the past two decades suggests that medical errors are rampant in the health-care system.
Ignoring the problem of medical errors, denying their existence, or blaming the individuals involved in the processes does nothing to eliminate the underlying problems.
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Medical Errors #2
A “just culture” deemphasizes blame for errors and focuses instead on addressing factors that lead to and cause near misses, medical errors, and adverse events.
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Strategies to Prevent Medical Errors
Better reporting of the errors that do occur
The Leapfrog initiatives
Reform of the medical liability system
Other point-of-care strategies
Bar coding
Smart IV pumps
Medication reconciliation
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Leapfrog Group Initiatives
Computerized physician–provider order entry
Evidence-based hospital referral
ICU physician staffing
The use of Leapfrog safe practices scores
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Six Sigma Approach
Sigma is a statistical measurement that reflects how well a product or process is performing.
Higher sigma values indicate better performance.
Historically, the health-care industry has been comfortable striving for three sigma processes in terms of health-care quality, instead of six.
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