Quality Improvement & Patient Safety

Why the Focus on Patient Safety?

Between 44,000 and 98,000 Americans die from medical errors
annually (Institute of Medicine [IOM], 2000; Thomas et al, 2000;
Thomas et al, 1999)
Medication-related errors for hospitalized patients cost roughly $2
billion annually (IOM, 2000; Bates et al, 1997).
41 million uninsured Americans exhibit consistently worse clinical
outcomes than the insured and are at increased risk for dying
prematurely (IOM, 2002; IOM, 2003a)
The lag between the discovery of more effective forms of treatment
and their incorporation into routine patient care averages 17 years
(Balas, 2001; IOM, 2003b)

IOMs Six Aims to Guide

Improvements

Safe: avoiding injuries to patients caused by the care that is

intended to help them
Timely: reducing waits and sometimes harmful delays for both
those who receive and those who give care
Effective: providing services based on scientific knowledge to all
who could benefit, and refraining from providing services to
those not likely to benefit

IOMs Six Aims to Guide

Improvements

Efficient: avoiding 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, and socioeconomic status
Patient-centered: providing care that is respectful of and
responsive to individual patient preferences, needs, and values,
and ensuring that patient values guide all clinical decisions

Simple Rules to Guide Improvements

Care is customized according to patient needs and values

Knowledge is shared, and information flows freely
Decision making is evidence based
Safety is a system property
Transparency is necessary
Needs are anticipated
Waste is continuously decreased
Cooperation among clinicians is a priority

Cornerstones of Quality Management

Customer defines quality

Organizational support for all employees to develop quality
knowledge and skills
Belief in the people who are working to serve the customer

Quality Management in
Health Care

Quality Assurance

Inspection oriented
Reactive to problems
Corrected special problems and did not address

overall process improvement

Responsibility belonged to only a few people

Quality Improvement
Planning and prevention oriented
Problem solving by employees at all levels
Correction of common cause problems and

improvement in work processes

Regulatory and Accreditation Agencies

Regulatory organizations
Centers for Medicare and Medicaid Services
Administers the Medicare program
Requires quality management in Conditions of
Participation
State licensing authorities require quality management
activities and set quality standards

Regulatory and Accreditation Agencies

National Committee for Quality Assurance (NCQA)

primary voluntary accreditation agency for managed
care organizations
The Joint Commissionfirst regulatory agency to
embrace quality improvement principles in hospitalbased settings

Regulatory and Accreditation Agencies

Nursings role in regulatory and accreditation standards

Enables health care organizations to successfully meet
regulatory standards
Supports the overall management of patient care and
working collaboratively with other professionals to do
the following:
Identify process improvements needs
Initiate change
Monitor ongoing effectiveness of patient care

Clinical Indicators and

Process Improvement
Tools

Clinical Indicators

Serve as a basic foundation for quality monitoring and evaluation

Measurable aspects of care that show the degree to which clinical
care is or is not carried out (e.g., administer correct IV solution at
prescribed rate)
Used as an assessment of clinical care to identify areas in which
quality improvement issues may be present
Help to identify the goals of quality improvement

Process Improvement Tools

Support the understanding of key work processes:

Analyzing and clearly understanding the work process
Selecting the key aspects of the process to improve
Establishing trial targets to guide improvement
Collecting and plotting data
Interpreting results
Implementing improvement actions and evaluating
effectiveness

Process Improvement Tools

Flowchart

Bar chart

Reflects frequency at which events occur, or the impact events

have on a process

Cause-and-effect diagram

Maps out what actually occurs in a work process

Helps to identify potential causes of a problem

Run chart

Graph of data points as they occur over time

Institute for Healthcare

Improvement (IHI)

Voluntary organization formed to assist health care leaders to

improve quality
Led development of change concepts for specific areas
Reducing patient delays
Reducing cesarean deliveries
Reducing adverse drug events
Reducing ventilator-related pneumonia
Reducing hospital-acquired pressure ulcers

Two-Part Model for Improving

Health Care (IHI)

Ask three fundamental questions:

What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make that will result in improvement?

Two-Part Model for Improving

Health Care (IHI)

Action steps: PlanDoCheckAct cycle (PDCA)

PLAN: Develop an action plan that is based on the three
questions
DO: Take action to test the action plan
CHECK: Make refinements as needed
ACT: Implement resultant changes in real work settings

Process Improvement and

Patient Safety

Roles of Accrediting and

Regulatory Agencies

National patient safety goals established by The Joint

Commission:
Improve the accuracy of patient identification
Improve the effectiveness of communication among
caregivers
Improve the safety of medication use
Reduce the risk of health careassociated infections
Accurately and completely reconcile medications across the
continuum of care

Roles of Accrediting and

Regulatory Agencies

National patient safety goals established by The Joint

Commission (continued):
Reduce the risk of patient harm resulting from falls
Encourage patients active involvement in their own care as
a patient safety strategy
The organization identifies safety risks inherent in its patient
population
Universal Protocol: The organization fulfills the expectations
set forth in the Universal Protocol (for eliminating wrong
site, wrong procedure, wrong person surgery)

The Professional Nurse and Patient

Safety

National Database of Nursing Quality Indicators (NDNQI)

Collects designated indicators that strongly affect clinical
outcomes
Two major purposes
Provide comparative data to health care
organizations to help support quality
improvement activities.
Acquire national data to gain a better
understanding of the link between nurse staffing
and patient outcomes

The Professional Nurse and Patient

Safety

Quality indicators

Nursing Hours per Patient Day

Staff Mix (RNs, LPNs, Unlicensed Assistive Personnel)
Hospital-Acquired Pressure Ulcers
Falls/Injury Resulting From Falls
Nurse Staff Satisfaction/RN survey
Pediatric/Neonatal only: Pain Assessment and Peripheral IV
Infiltration
Psychiatric only: Physical/Sexual Assault

Nurses Role in Quality

Improvement

Nurses should enter practice with the knowledge and skills to

make quality improvement part of their regular work
Quality improvement should not be considered a separate
function within the nursing role but rather an ongoing part of
the professional role

Two significant nursing functions closely influence patient

safety and quality:

Monitoring for early recognition of adverse events,

complications, and errors
Initiating deployment of appropriate care providers for
timely intervention and response/rescue of patients in these
situations