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Quality and Safety

Chapter 10

History and Overview

Historical trends and issues
Political influences
The Institute of Medicine (IOM) and the Committee on the Quality of Health Care in America

Objectives:

Discuss the history of quality and safety within the U.S. health-care system.

Analyze historical, social, political, and economic trends affecting the nursing profession and the health-care delivery system.

OUTLINE:

HISTORY AND OVERVIEW

Historical Trends and Issues

The Institute of Medicine and the Committee on the Quality of Health Care in America

Trends and Issues

Economic
Societal demographics and diversity
Regulation and legislation
Technology
Health-care delivery and practice
Environmental and globalization

Statement of Quality of Care

The IOM concluded that

Quality can be defined and measured.

Quality problems are serious and extensive.

Current approaches to quality improvement are inadequate.

There is an urgent need for rapid change.

Focus Areas of To Err Is Human

The IOM recommended to

Enhance knowledge and leadership regarding safety.
Identify and learn from errors.
Set performance standards and expectations for safety.
Implement safety systems within health-care organizations.

Crossing the Quality Chasm Conclusions

The gaps between actual care and high-quality care could be attributed to key interrelated areas in the health-care system.
The growing complexity of science and technology
An increase in chronic conditions.
A poorly organized delivery system of care and constraints on exploiting the revolution in information technology

Ten Rules to Govern Health-Care Reform for the 21st Century

Care is based on a continuous healing relationship.

Care is provided based on patient needs and values.

The patient is the source of control of care.

Knowledge is shared and free-flowing.

Decisions are evidence-based.

Ten Rules to Govern Health-Care Reform for the 21st Century (cont’d)

Safety as a system property.
Transparency is necessary; secrecy is harmful.
Anticipate patient needs.
Waste is continually decreased.
Cooperation between health-care providers.

Quality in the Health-Care
System

Quality improvement
Using CQI to monitor and evaluate quality of care
Quality improvement at the organizational and unit levels
Aspects of health care to evaluate
Risk management

Objectives:

Discuss the history of quality and safety within the U.S. health-care system.

Analyze historical, social, political, and economic trends affecting the nursing profession and the health-care delivery system.

Explain the importance of quality improvement to the nurse, patient, organization, and health-care delivery system.

Discuss the role of the nurse in continuous quality improvement (CQI) and risk management.

OUTLINE:

QUALITY IN THE HEALTH-CARE SYSTEM

Quality Improvement

Using CQI to Monitor and Evaluate Quality of Care

Quality Improvement at the Organizational and Unit Levels

Strategic Planning

Structured Care Methodologies

Critical Pathways

Aspects of Health Care to Evaluate

Structure

Process

Outcome

Risk Management

Quality

The Institute of Medicine (IOM) defines quality as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current and professional knowledge”

(IOM, 2001, p. 232)

Six Aims for Improving Quality in Health Care

Health care should be
Safe
Effective
Patient-centered
Timely
Efficient
Equitable

Safe: avoiding 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 to those not likely to benefit (avoiding underuse and overuse).

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.

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

Efficient: avoiding waste, in particular 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.

QI vs. CQI

QI
Began with Florence Nightingale
Structured organizational process
Included evidence-based methods for gathering data and achieving goals
CQI
Purpose
Identify, collect data, analyze, evaluate, change
Responsibility

Evaluation of Health Care

Structure
Process
Outcomes

Risk Management

Service occurrence
Serious error
Sentinel event

The Economic Climate in the Health-Care System

Economic perspective
Regulation and competition
Nursing labor market

Objectives:

Analyze historical, social, political, and economic trends affecting the nursing profession and the health-care delivery system.

Explain the importance of quality improvement to the nurse, patient, organization, and health-care delivery system.

Promote the role of the nurse in the contemporary health-care environment.

OUTLINE:

THE ECONOMIC CLIMATE IN THE HEALTH-CARE SYSTEM

Economic Perspective

Regulation and Competition

Nursing Labor Market

Defining and Identifying the Nursing Shortage

Factors Contributing to the Nursing Shortage

Factors Influencing Economic Climate

Economic
Regulation
Competition
Nursing labor market

Safety in the U.S. Health-Care System

Types of errors
Error identification and reporting
Developing a culture of safety
Organizations, agencies, and initiatives supporting quality and safety in the health-care system

Objectives:

Discuss the history of quality and safety within the U.S. health-care system.

Analyze historical, social, political, and economic trends affecting the nursing profession and the health-care delivery system.

Examine factors contributing to medical errors and evidence-based methods for the prevention of medical errors.

Explain the use of technology to enhance and promote safe patient care, educate patients and consumers, evaluate health-care delivery, and enhance the nurse’s knowledge base.

Promote the role of the nurse in the contemporary health-care environment.

OUTLINE:

SAFETY IN THE U.S. HEALTH-CARE SYSTEM

Types of Errors

Error Identification and Reporting

Developing a Culture of Safety

Organizations, Agencies, and Initiatives Supporting Quality and Safety in the Health-Care System

Government Agencies

Health-Care Provider Professional Organizations

Non-Profit Organizations and Foundations

Quality Organizations

Integrating Initiatives and Evidenced-Based Practices into Client Care

Types of Errors

Diagnostic
Treatment
Preventive
Other

Diagnostic

Error or delay in diagnosis

Failure to employ indicated tests

Use of outmoded tests or therapy

Failure to act on results of monitoring or testing

Treatment

Error in the performance of an operation, procedure, or test

Error in administering the treatment

Error in the dose or method of using a drug

Avoidable delay in treatment or in responding to an abnormal test

Inappropriate (not indicated) care

Preventive

Failure to provide prophylactic treatment

Inadequate monitoring or follow-up of treatment

Other

Failure of communication

Equipment failure

Other system failure

Types of Events

Near miss
Adverse
Accident

Causes of Errors

Medication errors
Falls
Hand-off errors
Diagnostic and surgical errors
Health-care acquired infections

The Nursing Shortage and Patient Safety

More acutely ill patients are in the hospital setting.
Decreased number of qualified nurses increases the chance of errors.
Short staffing and increased workload contribute to errors.

Culture of Safety

Roles of leadership, individuals, and teams
Event reporting systems
Methods
Organizations, agencies, and initiatives

Root Cause Analysis

Determine what influenced the consequences.
Establish tightly linked chains of influence.
At every level of analysis determine the necessary and sufficient influences.
Whenever feasible drill down to root causes.
Know that there are always multiple root causes.

Health-Care System Reform

Role of nursing in system reform

The ANA’s Agenda

Influence of Nursing

Objectives:

Discuss the history of quality and safety within the U.S. health-care system.

Analyze historical, social, political, and economic trends affecting the nursing profession and the health-care delivery system.

Examine factors contributing to medical errors and evidence-based methods for the prevention of medical errors.

Explain the use of technology to enhance and promote safe patient care, educate patients and consumers, evaluate health-care delivery, and enhance the nurse’s knowledge base.

Describe the effects of communication on patient-centered care, interdisciplinary collaboration, and safety.

Promote the role of the nurse in the contemporary health-care environment.

OUTLINE:

HEALTH-CARE SYSTEM REFORM

Role of Nursing in System Reform

The ANA’s Agenda

Influence of Nursing

Role of Nursing in Health-Care Reform

American Nurse’s Association
Nursing’s agenda for health-care reform
ANA’s health-care agenda
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