How do best practices contribute to quality and safety?
Safety and Quality Improvement in Professional Nursing Practice
Chapter 8
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Patient Safety
Ensures that nursing practice is safe, effective, efficient, equitable, timely, and patient-centered (ANA)
Minimization of risk of harm to patients and providers through both system effectiveness and individual performance (QSEN & NOF)
To Err Is Human: Building a Safer Health System (IOM, 2000)
At least 44,000 and possibly up to 98,000 people die each year as the result of preventable harm.
Cause of the errors is defective system processes that either lead people to make mistakes or fail to stop them from making a mistake, not the recklessness of individual providers.
Error
Error is the failure of a planned action to be completed as intended, or the use of a wrong plan to achieve an aim with the goal of preventing, recognizing, and mitigating harm.
Common errors include drug events and improper transfusions, surgical injuries and wrong-site surgeries, suicides, restraint-related injuries or death, falls, burns, pressure ulcers, and mistaken patient identities (IOM, 2000).
Event Analysis
Individual approach or system approach
Culture of blame
Culture of safety
Just culture
Root-cause analysis
TERCAP
Reason’s Adverse Event Trajectory
Example Fishbone Diagram
Figure 8-2 Typical fishbone diagram.
Classification of Error
Type of error
Communication
Patient management
Clinical performance
Where the error occurs
Latent failure and active failure
Organizational system failures and system process or technical failure
Human Factor Errors
Skill-based
Deviation in the pattern of a routine activity such as an interruption
Knowledge-based
Rule-based
Conscious decision by the nurse to “workaround” or take a shortcut, so the system defense mechanisms are bypassed, thereby increasing risk of harm to patient
To Err Is Human: Building A Safer Health System (IOM, 2000) (1 of 2)
User-centered designs with functions that make it hard or impossible to do the wrong thing
Avoidance of reliance on memory by standardizing and simplifying procedures
Attending to work safety by addressing work hours, workloads, and staffing ratios
Avoidance of reliance on vigilance by using alarms and checklists
To Err Is Human: Building A Safer Health System (IOM, 2000) (2 of 2)
Training programs for interprofessional teams
Involving patients in their care; anticipation of the unexpected during organizational changes
Design for recovery from errors
Improvement of access to accurate, timely information such as the use of decision-making tools at the point of care
Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2000)
STEEEP
Safe
Timely
Effective
Efficient
Equitable
Patient-centered
10 rules for redesign
Rule #6: Safety is a system property.
Keeping Patients Safe: Transforming the Work Environment of Nurses (IOM, 2004)
Chief nursing executive should have leadership role in the organization.
Creation of satisfying work environments for nurses.
Evidence-based nurse staffing and scheduling to control fatigue.
Giving nurses a voice in patient care delivery.
Designing work environments and cultures that promote patient safety.
Preventing Medication Errors: Quality Chasm Series (IOM, 2006)
Paradigm shift in the patient–provider relationship
Using information technology to reduce medication errors
Improving medication labeling and packaging
Policy changes to encourage the adoption of practices that will reduce medication errors
Joint Commission National Patient Safety Goals
Reviewed and updated annually, focuses on system-wide solutions to problems
2015 goals: Identify patients correctly, use medications safely, improve staff communication, use alarms safely, prevent infection, identify patient safety risks, and prevent mistakes in surgery
National Quality Forum Goals
Improving quality health care by setting national goals for performance improvement
Endorsement of national consensus standards for measuring and public reporting on performance
Promoting the attainment of national goals
National Quality Forum Safe Practices
Endorsed safe practices defined to be universally applied in all clinical settings in order to reduce the risk of error and harm for patients.
34 practices have been shown to decrease the occurrence of adverse health events.
Also endorses list of 29 preventable, serious adverse events for public reporting.
Sentinel Events
An unexpected occurrence involving death or serious physical or psychological injury or the risk thereof.
Examples include wrong patient events, wrong site events, wrong procedures, delays in treatment, operative or postoperative complications, retention of foreign body, suicides, medication errors, perinatal death or injury, and criminal events.
Progress
Healthcare organizations have responded to incentive programs, accreditation standards, and public opinion.
Professional organizations have responded with revisions to standards that place more emphasis on healthcare quality and patient safety.
Educators have responded by infusing quality and safety concepts into student didactic and clinical experiences guided by initiatives such as the QSEN and Nurse of the Future.
Patient Narratives
A short video about The Betsy Lehman Center for Patient Safety and Medical Error Reduction is available at: https://youtu.be/wwB88zF4wvU
The Chasing Zero: Winning the War on Healthcare Harm video is available at: https://youtu.be/MtSbgUuXdaw
The Transparent Health−Lewis Blackman Story video is available at: https://youtu.be/Rp3fGp2fv88
Healthcare Quality (1 of 2)
Quality is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.
Healthcare Quality (2 of 2)
Quality improvement refers to the use of data to monitor the outcomes of care processes, and uses improvement methods to design and test changes to continuously improve the quality and safety of healthcare systems.
Crossing the Quality Chasm (IOM, 2001)
Safe, timely, effective, efficient, equitable, and patient-centered (STEEEP)
10 rules for redesign to move the healthcare system toward the identified performance expectations
10 Rules for Redesign (1 of 3)
Care is based on continuous healing relationships with patients receiving care whenever and wherever it is needed.
Care can be customized according to the patient’s needs and preferences even though the system is designed to meet the most common types of needs.
The patient is the source of control and, as such, should be given enough information and opportunity to exercise the degree of control he or she chooses regarding decisions that affect him or her.
10 Rules for Redesign (2 of 3)
Knowledge is shared and information flows freely so that patients have access to their own medical information.
Decision making is evidence based; that is, it is based on the best available scientific knowledge and should not vary illogically between clinicians or locations.
Safety is a system property and patients should be safe from harm caused by the healthcare system.
10 Rules for Redesign (3 of 3)
Transparency is necessary where systems make information available to patients and families that enable them to make informed decisions when selecting a health plan, hospital, or clinic, or when choosing alternative treatments.
Patient needs are anticipated rather reacted to.
Waste of resources and patient time is continuously decreased.
Cooperation among clinicians is a priority to ensure appropriate exchange of information and coordination of care.
Measures of Quality
Benchmarking
Core measures
Accountability
Composite measures
Measures of Nursing Care
Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospital Survey
National Voluntary Consensus Standards for Nursing-Sensitive Care
National Database of Nursing Quality Indicators (NDNQI)
Continuous Quality Improvement (CQI)
Structured organizational process that involves personnel in planning and implementing the continuous flow of improvements in the provision of quality health care that meets or exceeds expectations
Processes or Pathways for CQI
First process occurs as data that is regularly collected is monitored; if the data indicate that a problem exists, then an analysis is done to identify possible causes and a process is initiated to pilot a change.
Second process involves the identification of a problem outside of the routine data monitoring system.
Quality Improvement Methodologies
“Plan, Do, Study, Act”
Six Sigma
Define, Measure, Analyze, Improve, Control
Swiss Cheese Model
Figure 8-5 Plan, Do, Study, Act (PDSA) cycle.
American Nurses Association (ANA) Standard #14
ANA standard of professional performance: The registered nurse contributes to quality nursing practice with competencies that include the nurse’s role in various quality improvement activities such as collecting data to monitor quality and collaboration to implement quality improvement plans and interventions.
Challenges
Adequacy of resources
Engaging nurses from management to the bedside in the process
Increasing number of QI activities
Administrative burden of QI initiatives
Lack of preparation of nurses in traditional nursing education programs for role in QI
