Presentation on theme: "Quality, Safety and Performance Improvement"— Presentation transcript:
1 Quality, Safety and Performance Improvement Compiled byKaye Culberson Wilkie, RN, BSNAutopsy to Determine if Heparin Overdose Killed Texas NewbornMultiple cancer patients killed by improperly programmed chemotherapy pump
2 There are some patients whom we cannot help There are some patients whom we cannot help. There are none whom we cannot harm. -Bloomfield-
3 To Err is HumanTo Err Is Human: Building a Safer Health System (1999 IOM report)98,000 die each year from medical errorMedical error kills more Americans than breast cancer, MVA, or AIDS7% hospital patients experience serious medication errorCost = $8-29 billion/yearInstitute of Medicine (IOM) spearheaded initiative to improve quality careIOM – skilled and caring professionals can – and do – make mistakesNational agenda to reduce errors through design of safer delivery systems
4 Impact of the Institute of Medicine’s (IOM) Report Captured media, public, political and professional attentionShocking statisticsErrors caused by faulty systems/process focusCongressional hearings, President’s Task ForceImplementation of IOM’s recommendations…
5 IOM RecommendationsNational focus to enhance knowledge base about safetyIdentifying/learning from errorsRaising standards for improvements in safety (oversight/benchmarking)Creating safety systems by implementing safe practices (safety science) at the delivery level
6 Factors in Healthcare Errors WorkloadInterruptionsFatigueMulti-taskingFailure to follow upPoor handoffsIneffective communicationTask fixationExcessive professional courtesyHalo effectHidden agendaComplacencyHigh-riskNot following policy/procedure
7 Goal for quality and safety education for nurses is to prepare future nurses with: KnowledgeSkillsAttitudes
8 Six competencies: Patient centered care Teamwork and collaboration Evidence-based practiceInformaticsQuality improvementSafety
9 Example: Patient-centered care KnowledgeSkillsAttitudesExamine common barriers to active involvement of patients in their own health care processDescribe strategies to empower patients or families in all aspects of the health care processRemove barriers to presence of families and other designated surrogates based on patient preferencesEngage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care managementRespect patient preferences for degree of active engagement in care processRespect patient’s right to access to personal health records
10 IOM RecommendationsNational focus to enhance knowledge base about safetyIdentifying/learning from errorsRaising standards for improvements in safety (oversight/benchmarking)Creating safety systems by implementing safe practices (safety science) at the delivery level
11 Quality Measure for Patient Centered Care State variation: Adult ambulatory patients who reported good communication with health providers,* 2007
12 Example: Teamwork and Collaboration KnowledgeSkillsAttitudesDescribe own strengths, limitations, and values in functioning as a member of a teamAnalyze own strengths, limitations, and values as a member of a teamAnalyze impact of own advanced practice role and its contributions to team functioningClarify roles and accountabilities under conditions of potential overlap in team-member functioningGuide the team in managing areas of overlap in team member functioningInitiate and sustain effective health care teamsAcknowledge own potential to contribute to effective team functioningAcknowledge own contributions to effective or ineffective team functioningAppreciate the importance of inter-professional collaboration
13 Repeat as needed until the desired goal is achieved PDSAPLAN: Plan a change or test of how something works.DO: Carry out the plan.STUDY: Look at the results. What did you find out?ACT: Decide what actions should be taken to improve.Repeat as needed until the desired goal is achieved
14 Failure Mode Effects Analysis (FMEA) Failure modes are any errors or defects in a process, design, or item, especially those that affect the patient, and can be potential or actual.Effects analysis refers to studying the consequences of those failures.
15 Example: Evidence-based Practice KnowledgeSkillsAttitudesExplain the role of evidence in determining best clinical practiceAnalyze how the strength of available evidence influences the provision of care (assessment, dx, tx, and evaluation)Determine evidence gaps within the practice specialtyRead original research and evidence reports related to area of practiceCritically appraise original research and evidence summaries related to area of practiceExhibit contemporary knowledge of best evidence related to practice specialtyAppreciate the importance of regularly reading relevant professional journalsValue knowing the evidence base for practice areaValue public policies that support evidence-based practiceRecognize importance of search skills in locating best evidence
18 Quality Measure for Evidence Based Practice Adult surgery patients with postoperative catheter-associated urinary tract infection, overall and by selected comorbid conditions, 2006
19 Example: Quality Improvement KnowledgeSkillsAttitudesDescribe strategies for learning about the outcomes of care in the setting in which one is engaged in practiceDescribe strategies for improving outcomes of care in the setting in which one is engaged in practiceExplain common causes of variation in outcomes of care in the practice specialtySeek information about outcomes of care for populations served in care settingUse a variety of sources of information to review outcomes of care and identify potential areas for improvementAssert leadership in shaping the dialogue and providing leadership for the introduction of best practicesAppreciate how unwanted variation affects careAppreciate the importance of data that allows one to estimate the quality of local careAppreciate that all improvement is change but not all change is improvement
20 Sentinel EventUnexpected occurrence involving death or serious physical or psychological injury, or the risk thereofSerious injury specifically includes loss of limb or functionThe phrase “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.
22 Root Cause Analysis (RCA) Aiming performance improvement measures at root causes is more effective than merely treating the symptoms of a problem.To be effective, RCA must be performed systematically, with conclusions and causes backed up by documented evidence.There is usually more than one potential root cause for any given problem.To be effective the analysis must establish all known causal relationships between the root cause(s) and the defined problem.Root cause analysis transforms an old culture that reacts to problems to a new culture that solves problems before they escalate, creating a variability reduction and risk avoidance mindset.
24 Root Cause Analysis Define the problem. Gather data/evidence. Ask why and identify the causal relationships associated with the defined problem.Identify which causes if removed or changed will prevent recurrence.Identify effective solutions that prevent recurrence, are within your control, meet your goals and objectives and do not cause other problems.Implement the recommendations.Observe the recommended solutions to ensure effectiveness.Variability Reduction methodology for problem solving and problem avoidance.
25 Example: Safety Knowledge Skills Attitudes Discuss effective strategies for reducing reliance on memoryDescribe processes used in understanding causes of error and allocation of responsibility (such as, root cause analysis)Use appropriate strategies for reducing reliance on memory (such as, forcing functions and checklists)Use organizational error reporting systems for near miss and error reportingEngage in root cause analysis rather than blaming when errors or near misses occurAppreciate the cognitive and physical limits of human performanceValue own role in preventing errorsValue vigilance and monitoring (even of own performance of care activities) by patients, families, and other members of the health care team
26 Quality Measure for Safety Hospital patients with adverse drug events,
27 Hospital Survey on Patient Safety Culture 12 dimensions1. Communication openness2. Feedback & communication about error3. Frequency of event reporting4. Handoffs & transitions5. Management support for patient safety6. Nonpunitive response to error7. Organizational learning--continuous improvement8. Overall perceptions of patient safety9. Staffing10. Supv/mgr expectations & actions promoting patient safety11. Teamwork across units12. Teamwork within units
29 Is it QI or is it PI?Quality improvement (QI) and performance improvement are interchangeable termsQI/PI describe approaches to study and improvement of processes…rememberPrimary focus should be on systems/process rather than individual performance