Chapter 10: Quality And Safety

Question 0

Focus areas of to err is human

Answer 0

The IOM recommended (Box 10-3)
§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
They want to make errors costly enough that healthcare organizations are compelled to take action to improve safety.

Question 1

Statement of quality care

Answer 1

The IOM concluded that

1. Quality can be defined and measured
2. Quality problems are serious and extensive
3. Current approaches to quality improvement are inadequate
4. There is an urgent need for rapid change

Question 2

Crossing the quality chasm

Answer 2

IOM
The gaps between actual care and high-quality care could be attributed to key inter-related 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

Question 3

10 rules to govern health care

Answer 3

1. Care is based on a continuous healing relationship
2. Care is provided based on patient needs and values
3. Patient is source of control of care
4. Knowledge is shared and free-flowing
5. Decisions are evidence-based
6. Safety as a system property
7. Transparency is necessary; secrecy is harmful
8. Anticipate patient needs
9. Waste is continually decreased
10. Cooperation between health care providers

Question 4

Quality

Answer 4

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”

Question 5

6 aime’s to improve quality

Answer 5

Health care should be
§Safe
§Effective: based on science, refrain from services that don’t benefit.
§Patient-centered
§Timely
§Efficient
§Equitable: Providing care that does not vary in quality because of characteristics such as gender, ethnicity, location, or socioeconomic status

Question 6

QI vs CQI

Answer 6

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

Question 7

Evaluation of healthcare

Answer 7

§Structure
§Process
§Outcomes

Question 8

Risk management

Answer 8

The process of identifying, analyzing, treating, and evaluating real and potential hazards. It is the nurses responsibility to report adverse incidents to the risk manager.

§Service occurrence: Unexpected occurrence that does not result in clinically significant interruption of services and without injury. Most occurrences are patient complaints. Examples include minor property damage, unsatisfactory service, interruption of service
§Serious error: Results in interruption of therapy or service, minor injury to patient or employee, significant loss or damage of equipment or property. Minor injuries defined as needing intervention outside of hospital admission or physical or psychological damage
§Sentinel event: Unexpected occurrence involving death or serious and permanent physical or psychological injury or the rest of there of. See other card

Question 9

Economic climate

Answer 9

§ Economic perspective: Resources are scarce, resources have alternative uses, individuals want different services or have different preferences
§ Regulation and competition: attempts to control cost. Medicare prospective payment system. DRGs (how Medicare determines payment). Managed care. Cost-sharing. Medical savings accounts. Single-payer/national health coverage.
§ Nursing labor market:

Question 10

Factors influencing economic climate

Answer 10

§Economic
§Regulation
§Competition
§Nursing labor market

Question 11

Safety

Answer 11

§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

Question 12

Types of errors

Answer 12

§Diagnostic
§Treatment
§Preventive: Failure to provide prophylactic treatment, in adequate monitoring or follow-up treatment
§Other: Failure to communicate, equipment failure, other system failure

Question 13

Types of events

Answer 13

§Near miss: Results in no harm or very minimal harm.
§Adverse event: Injury to patient caused by medical management rather than an underlying condition.
§Accident: Event that involves damage to the defined system that disrupts ongoing or future output of the system.

Question 14

Culture of safety

Answer 14

Organization should have a blame free environment in which reporting of errors is promoted and rewarded. Culture of safety promotes trust, honesty, openness, and transparency.

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

Question 15

Role of nursing in health care reform

Answer 15

American Nurse’s Association
§Nursing’s agenda for health care reform
§ANA’s health care agenda: Healthcare is a basic human right. The development of health policies that incorporate the IOM six aims of healthcare will save money. The healthcare system must be reshaped and redirected away from the overuse of expensive technology driven, acute, hospital-based services in the model we now have to one in which a balance is struck between high tech treatment and community based and preventive. The ANAs supports a single-payer healthcare system.

You
§Become informed
§Plan
§Take action!

Question 32

Healthcare delivery systems outside influences

Answer 32

Economics. Societal demographics and diversity. Regulation and legislation. Technology. Healthcare delivery and practice. Environment and globalization.

Question 33

IOM. Institute of medicine

Answer 33

A private, nonprofit organization chartered in the 1970 by the US government. Their role is to provide unbiased, expert help and scientific advice for the purpose of improving health. Their work supports government policymaking, the healthcare system, healthcare professionals, and consumers.

Question 34

Structured care methodologies. SCMs

Answer 34

Interdisciplinary tools to identify best practices, facilitate standardization of care, and provide a mechanism for variance tracking, quality enhancement, outcomes measurement, and outcomes research. They include guidelines, protocols, algorithms, standard of care, critical pathways, and order sets

Question 35

Critical pathways

Answer 35

Clinical protocols involving all disciplines. They are designed for tracking a planned clinical course for patients based on average and expected length of stay. They provide a framework for communication and documentation of care. They are excellent teaching tools. They include discharge planning, patient education, consultations, activities, nutrition, medications, diagnostic tests, and treatment. The nurse is responsible for identifying any deviations

Question 36

Aspects of health care to evaluate

Answer 36

A CQI program evaluates three aspects of healthcare. The structure within which the care is given, the process of giving care, and the outcome of that care.

Structure refers to the setting and resources such as facilities, equipment, staff, and finances.

Process refers to the activities carried out by healthcare providers and all the desicions made. It includes setting an appointment, assessment, orders for x-rays, giving blood, completing a home assessment, preparing for discharge, telephoning the patient after discharge. These need to be evaluated for timeliness, appropriateness accuracy and completeness.

Outcome is the result of all the activities. Did the patient recover, is the family independent, did the team functioning improved. Outcome is harder to measure.

Question 37

Sentinel events

Answer 37

A serious or unexpected occurrence involving death or serious/permanent physical or psychological injury, or the risk in there of. They signal the need for immediate investigation and response.

Sentinel events that are subject to review by the joint commission include: an unanticipated death or major permanent loss of function not related to the natural course of the patient’s illness or underlying condition. Suicide of a patient where around-the-clock care was done. Infant abduction, discharge to the wrong family, rape, hemolytic transfusion reaction involving administration of blood or blood products having a major blood group incompatibilities, surgery on the wrong patient or the wrong body part.

Question 38

Common errors for Sentinel events

Answer 38

Medication errors
documentation errors and or omissions.
Failure to perform nursing care or treatments correctly.
Errors in patient safety that result in falls. Failure to communicate significant data to patients and other providers.

Question 39

Incident report

Answer 39

Once an incident occurs, a report must be completed immediately. It is used to collect and analyze data for further determination of risk. Should be accurate, objective, complete, and factual. If there is future litigation, the attorney can subpoena the report. Should be prepared in only a single copy and never placed in the medical record.

Question 40

Root cause analysis

Answer 40

The process of learning from consequences. One. Determine what influences the consequences.
Two. Establish tightly linked chains of influence.
Three. At every level of analysis, determine the necessary and sufficient influences.
Four. Whenever feasible, drill down to lot causes
Five. Know that there are always multiple root causes

Question 41

IOMs 5 core competencies.

Answer 41

Provide patient centered care.  
Work in interdisciplinary teams. 
Employee evidence-based practice. 
Apply quality improvement. 
Utilize informatics:  Communicate, manage knowledge, mitigate error, and support decision-making using information technology