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Quality and Safety in Nursing: Using quality as a tool to improve practice outcomes

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Title: Quality and Safety in Nursing: Using quality as a tool to improve practice outcomes


1
Quality and Safety in Nursing Using quality as a
tool to improve practice outcomes
  • Denise Hirst, MSN, RN
  • Fall 2008

2
Objectives
  • Identify emerging views of quality in health care
  • Describe the current safety crisis and key
    elements from the IOM report.
  • Discuss the four key questions that need to be
    considered when we explore safety.
  • Identify the types of errors and provide
    examples.
  • Discuss the impact of the blame culture and how
    to avoid it.
  • Examine leadership strategies for managing change
    in a culture focused on quality

3
Perspectives on quality
  • What are examples from recent media reports that
    reflect quality monitoring and/or lapses in
    various industries?
  • What are economic consequences?
  • What are ethical considerations?

4
How does the United States measure up?
5
The United States is worse on key measures
American College of Physicians, Ann Intern Med
200814855-75
6
Quality and Safety
  • Quality and safety are in a sense inseparable
  • Creating a culture of safety is part of building
    a system of continuous quality improvement

7
Quality carries a moral and ethical imperative
  • People become nurses in order to relieve
    suffering and contribute to the overall health of
    communities and individuals
  • Quality care is an essential value

8
There is also an economic imperative
  • As nurses work in systems where quality is
    eroded, satisfaction diminishes
  • Lower satisfaction contributes to work force
    shortages
  • Health professionals run our systems -- they can
    improve our systems if they possess the
    competencies required to make improvement a part
    of daily work

9
Quality Factors to consider
  • What is the role of technology and informatics
  • How do nurses acquire Interdisciplinary team
    skills to achieve goals of care
  • How do we include patients and families as
    partners in care
  • What are strategies for improving the way health
    professionals must work together to achieve
    quality outcomes

10
Raising the Bar the Framework
  • All health professionals should be educated to
    deliver patient-centered care as members of an
    interdisciplinary team, emphasizing
    evidence-based practice, quality improvement
    approaches, and informatics.
  • Committee on Health Professions Education
  • Institute of Medicine (2003)

11
Emphasis on improving quality of health care
  • Focus on quality improvement in healthcare
    organizations
  • Improves patient care outcomes
  • Helps improve the work environment people want
    to work in organizations that emphasize quality

12
Quality and Safety Education for Nurses (QSEN
www.qsen.org)
  • Principal Investigator Linda Cronenwett, PhD,
    RN, FAAN
  • Co-Investigator Gwen Sherwood, PhD, RN, FAAN
  • Project Manager Denise Hirst, MSN, RN
  • Librarian Jean Blackwell
  • National expert panel and pedagogical experts
  • Funded by the Robert Wood Johnson Foundation for
    the University of North Carolina at Chapel Hill
  • 2005-2007 Phase I Pre-licensure Education
  • 2007-2009 Phase II Graduate Education and Pilot
    School Collaborative
  • 2009-2012 Phase III Partnered with American
    Academy of Colleges of Nursing to disseminate
    information to faculty and educators
  • Reported in special issue Nursing Outlook, May
    2007

13
New challenges
  • To achieve the goals of care, health
    professionals must examine new views of quality
    and safety science for redesigning how care is
    delivered, monitored, and improved.

14
What are the leadership challenges for leading
this change?
15
Nurses Role Redefined
  • Continuous quality improvement
  • Encourages a culture of inquiry
  • Welcomes questions
  • Investigates outcomes and critical incidents from
    a system perspective
  • Workers who are engaged in their work ask
    critical questions to continually seek to improve
    outcomes of care.

16
Quality impacts the work environment
  • Nurses who work in hospitals recognized for
    quality report healthier work environments and
    higher levels of job satisfaction than those who
    work in non-recognized settings. (American
    Association of Critical-Care Nurses (AACN),
    reported in CQ HealthBeat )

Quality is a factor in nurse satisfaction and
retention.
17
6 competencies to transform systems are not
linear but are broad and overlapping
Teamwork And collaboration
Informatics
Patient centered care
Quality improvement
Safety
Evidence Based practice
18
Quality improvement
  • Using data to monitor the outcomes of care
    processes and using improvement methods to design
    and test changes to continuously improve the
    quality and safety of health care systems

19
Quality management is comparing the outcomes of
care in the local setting with evidence based
industry benchmarks.
What are the knowledge, skills, and attitudes
nurses need in clinical settings to work in
quality-focused settings?
  • Efforts are then focused on leading change to
    improve identified outcomes.

20
Quality Improvement
  • Knowledge
  • Describe strategies for learning about the
    outcomes of care in the setting in which one is
    engaged in practice
  • Skills
  • Seek information about outcomes of care for
    populations served in care setting
  • Seek information about quality improvement
    projects in the care setting
  • Attitudes
  • Appreciate that continuous improvement is an
    essential part of the daily work of all health
    professionals

21
Implications for nursing
  • Focus on quality and safety requires new
    knowledge, skills and attitudes about how care is
    delivered, monitored, and improved.
  • Preparing nurses to work to work in quality
    focused settings.
  • Staff development in quality improvement
    processes, safety and error prevention
    techniques, and informatics.

22
Developing Quality Improvement Skills
  • Knowing the specific steps to interpret
    integrative literature reviews to identify the
    evidence to support data based care protocols.
  • Learning new quality improvement terminology
    such as variance reports, benchmarks, dashboards,
    report cards, statistical control charts, and
    satisfaction measures.

23
Quality and Safety can they be separated?
  • Safety science is more than the 5 rights of
    medication administration, assessing risks for
    falls, and monitoring the environment.
  • It goes beyond individual actions to prevent
    errors through system re-design.
  • Health care is adapting innovations from the high
    performance industries to build cultures of
    safety by applying human factors and safety
    science concepts

24
The Institute of Medicine
  • To Err Is Human (1999)
  • Safety In Healthcare Delivery

Institute of Medicine. (1999). To Err Is Human.
Washington, DC National Academies Press.
25
A Safety Crisis
  • The IOM report on safety opened the door to
    acknowledge there is a healthcare safety crisis,
    for example data indicated in 1999Approximately
    44,000 to nearly 100,000 patients die annually in
    U.S. hospitals due to error.
  • What is your reaction to this?

Teaching IOM Instruction Materials sponsored by
the American Nurses Association, To Err is
Human (1999) Safety in Healthcare Delivery
26
Key Terms
  • Safety Freedom from accidental injury
  • Error Failure of a planned action to be
    completed as intended or the use of a wrong plan
    to achieve an aim

Teaching IOM Instruction Materials sponsored by
the American Nurses Association, To Err is
Human (1999) Safety in Healthcare Delivery
27
Some Elements of the IOM Safety Report
  • Two primary dimensions to consider
  • Safe care is consistent with current knowledge
    and customized/individualized to meet patient
    needs and requirements
  • Factors within external environment also have an
    impact on safety.

Teaching IOM Instruction Materials sponsored by
the American Nurses Association, To Err is
Human (1999) Safety in Healthcare Delivery
28
Safe CareQuality Care?
  • Just because care is considered safe does not
    mean that it is of a higher quality. BUT
  • There is a greater chance that the care is of
    higher quality.

Teaching IOM Instruction Materials sponsored by
the American Nurses Association, To Err is
Human (1999) Safety in Healthcare Delivery
29
Need for a Framework
  • To understand more about safety and how to
    respond we need a standard framework and
    terminology.
  • We need to know more about the safety issue.

Teaching IOM Instruction Materials sponsored by
the American Nurses Association, To Err is
Human (1999) Safety in Healthcare Delivery
30
Types of Errors
  • Diagnostic
  • Treatment
  • Preventive
  • Other
  • Many errors go undocumented or are not reported
    due to staff fear of reprisal, lack of adequate
    systems to report, limited staff education about
    safety and report process, and lack of
    computerized surveillance systems.

Teaching IOM Instruction Materials sponsored by
the American Nurses Association, To Err is
Human (1999) Safety in Healthcare Delivery
31
Other Types of Errors
  1. Active error
  2. Adverse error
  3. Error of commission
  4. Error of execution
  5. Error of planning
  6. Iatrogenic injury
  7. Latent error
  8. Near-miss
  9. Sentinel event

Teaching IOM Instruction Materials sponsored by
the American Nurses Association, To Err is
Human (1999) Safety in Healthcare Delivery
32
Errors
33
Patient Role in Errors
  • Patients make errors in their own care or during
    self-management.
  • Patient noncompliance may lead to errors
    (accidental or unintentional non-adherence to a
    therapeutic regimen)

Teaching IOM Instruction Materials sponsored by
the American Nurses Association, To Err is
Human (1999) Safety in Healthcare Delivery
34
Technology
  • How might medical technology and information
    technology have an impact on healthcare safety?
    What are positive and negative impacts?

Teaching IOM Instruction Materials sponsored by
the American Nurses Association, To Err is
Human (1999) Safety in Healthcare Delivery
35
The Blame Culture
  • What is the Blame Culture?
  • Why is this important in the IOM report and its
    recommendations for change?
  • How might this be applied to nursing?

Teaching IOM Instruction Materials sponsored by
the American Nurses Association, To Err is
Human (1999) Safety in Healthcare Delivery
36
Building safety into processes of care is a more
effective way to reduce errors than blaming
individuals.(IOM, 1999, p.4)
Teaching IOM Instruction Materials sponsored by
the American Nurses Association, To Err is
Human (1999) Safety in Healthcare Delivery
37
Mandatory Reporting System
  • The IOM recommends a mandatory reporting system.
  • What do you think about this?

Teaching IOM Instruction Materials sponsored by
the American Nurses Association, To Err is
Human (1999) Safety in Healthcare Delivery
38
Major Sources of Adverse Event Data
  1. Voluntary and mandatory reporting
  2. Document review
  3. Automated surveillance
  4. Monitoring patient progress to identify
    circumstances when adverse events might occur

Teaching IOM Instruction Materials sponsored by
the American Nurses Association, To Err is
Human (1999) Safety in Healthcare Delivery
39
Root Cause Analysis
  • Definition of Root causes
  • Specific underlying causes.
  • Causes that can reasonably be identified
  • Causes management or practitioners have control
    to fix.
  • Causes for which effective recommendations for
    preventing recurrences can be made.
  • Should include failed and successful defenses
    and recoveries for the patient outcomes for the
    patient and lessons learned and ways to improve
    patient safety (IOM, 2004, p. 160).

Teaching IOM Instruction Materials sponsored by
the American Nurses Association, To Err is
Human (1999) Safety in Healthcare Delivery
40
Near-Misses
  • Errors of commission or omission that could harm
    a patient but do not
  • Think about the times that you almost made an
    error. We all have these experiences. What do you
    do to learn from these experiences?

Teaching IOM Instruction Materials sponsored by
the American Nurses Association, To Err is
Human (1999) Safety in Healthcare Delivery
41
Common Care-Management Problems
  • Failure to monitor, observe, or act
  • Delay in diagnosis
  • Incorrect assessment of risk
  • Loss of information during transfer to other
    healthcare staff
  • Failure to note faulty equipment

Teaching IOM Instruction Materials sponsored by
the American Nurses Association, To Err is
Human (1999) Safety in Healthcare Delivery
42
More Common Care-Management Problems
  • Failure to carry out preoperative checks
  • Deviation from an agreed protocol without
    clinical justification
  • Failure to seek help when necessary
  • Use of incorrect protocol
  • Treatment given to wrong body site
  • Wrong treatment plan

Teaching IOM Instruction Materials sponsored by
the American Nurses Association, To Err is
Human (1999) Safety in Healthcare Delivery
43
Medication Administration Recommendations
  • Use standard processes for medication doses, dose
    timing, and dose scales in a given patient unit.
  • Standardize prescription writing and prescribing
    rules.
  • Limit the number of different kinds of common
    equipment
  • Implement physician order entry

Teaching IOM Instruction Materials sponsored by
the American Nurses Association, To Err is
Human (1999) Safety in Healthcare Delivery
44
Medication Administration Recommendations
  • Use pharmaceutical software
  • Implement unit dosing
  • Central pharmacy should supply high-risk
    intravenous medications
  • Use special procedures and written protocols for
    use of high-risk medications on patient units
  • Do not store concentrated solutions of hazardous
    medications on patient units

Teaching IOM Instruction Materials sponsored by
the American Nurses Association, To Err is
Human (1999) Safety in Healthcare Delivery
45
Medication Administration Recommendations
  • Ensure the availability of pharmaceutical
    decision support
  • Include pharmacist during rounds of patient care
    units
  • Make relevant patient information available at
    the point of patient care
  • Adopt a system-oriented approach to medication
    error reduction
  • Improve patients knowledge about their treatment
  • (IOM, 1999, pp. 160-164)

Teaching IOM Instruction Materials sponsored by
the American Nurses Association, To Err is
Human (1999) Safety in Healthcare Delivery
46
The call to leadership
  • To change practice calls for transformational
    leadership to achieve the collective purpose
  • Ordinary methods will not create behavior change
  • What is in your tool kit to create new work
    environments where quality is valued?

47
IOM, Keeping Patients Safe
  • Calls for relational styles of leadership
  • Latent working conditions are a major contributor
    to error
  • Poor working relationships and communication are
    at the core of many adverse events
  • What are ways to build a quality focused team?

48
5 Essential Management Strategies
  • Balancing the tension between efficiency and
    reliability
  • Creating and sustaining trust
  • Actively managing the process of change
  • Involving workers in work design and work flow
    decision making
  • Creating a learning organization

49
A positive approach to change
  • Appreciative Inquiry
  • A flexible process for engaging people in
    building the kind of organization they want to
    work in
  • Seeks a focus on what is right rather than
    focusing on gap analysis or what is wrong, what
    is missing

50
Appreciative Inquiry
  • Is about appreciating and valuing
  • Recognizes the best in people and the
    organization, affirms strengths
  • Is about inquiring
  • Explores, discovers, asks questions, sees new
    potential
  • Looks at root causes for success and designs ways
    to replicate
  • Root cause analysis looks for deficits and causes
    of failure

51
4-D cycle of Appreciative Inquiry
  • Discovery appreciating and valuing
  • Dream Envision what might be
  • Design Co-constructing the future, how can it
    be?
  • Destiny learning, empowering, and improvising to
    sustain an improved future

52
Appreciative Inquiry works from a collective
sense of purpose
  • Shared conversations about goals, ideals, and
    open-space planning
  • How each person can contribute to the
    organizational mission and unit goals
  • Uses a reflective process to think about ones
    practice with questions about why things are done
    the way they are, and is there evidence to
    change?

53
Making quality a win-win
  • Organizations with a quality focus are where
  • Improving outcomes is recognized
  • Teamwork is valued
  • A just culture is embraced
  • Questions are part of everyday practice
  • Evidence supports clinical decisions and pathways
  • No one tries to do it all alone

54
Guiding principle..
  • Achieving quality outcomes is a group process.
  • It will require all of us working together in
    commitment to improve quality and safety of
    patient care.

55
Case Study
  • Read the case study
  • Each group will answer one question about the
    case
  • Groups will choose a member to present your
    answer and recommendations
  • Each group will briefly present the groups
    answer and recommendations to the class
  • You have 20 minutes to discuss

56
EBP and Safety Issues
  • The AHRQ report, Making Healthcare Safer A
    Critical Analysis of Patient Safety Practices
    http//www.ahrq.gov/clinic/ptsafety/pdf/ptsafety.p
    df

Teaching IOM Instruction Materials sponsored by
the American Nurses Association, To Err is
Human (1999) Safety in Healthcare Delivery
57
JCAHO Annual Safety Goals
  • Current and past annual JCAHO goals are found
    at
  • http//www.jcipatientsafety.org/show.asp?dur
    ki9335

Teaching IOM Instruction Materials sponsored by
the American Nurses Association, To Err is
Human (1999) Safety in Healthcare Delivery
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