1. Quality, Safety and Performance Improvement
Compiled by
Kaye Culberson Wilkie, RN, BSN
Autopsy to Determine if Heparin Overdose Killed Texas Newborn
Multiple 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 Human
To Err Is Human: Building a Safer Health System (1999 IOM report)
98,000 die each year from medical error
Medical error kills more Americans than breast cancer, MVA, or AIDS
7% hospital patients experience serious medication error
Cost = $8-29 billion/year
Institute of Medicine (IOM) spearheaded initiative to improve quality care
IOM – skilled and caring professionals can – and do – make mistakes
National 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 attention
Shocking statistics
Errors caused by faulty systems/process focus
Congressional hearings, President’s Task Force
Implementation of IOM’s recommendations…

5. IOM Recommendations
National focus to enhance knowledge base about safety
Identifying/learning from errors
Raising 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
Workload
Interruptions
Fatigue
Multi-tasking
Failure to follow up
Poor handoffs
Ineffective communication
Task fixation
Excessive professional courtesy
Halo effect
Hidden agenda
Complacency
High-risk
Not following policy/procedure

7. Goal for quality and safety education for nurses is to prepare future nurses with:
Knowledge
Skills
Attitudes

8. Six competencies: Patient centered care Teamwork and collaboration
Evidence-based practice
Informatics
Quality improvement
Safety

9. Example: Patient-centered care
Knowledge
Skills
Attitudes
Examine common barriers to active involvement of patients in their own health care process
Describe strategies to empower patients or families in all aspects of the health care process
Remove barriers to presence of families and other designated surrogates based on patient preferences
Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management
Respect patient preferences for degree of active engagement in care process
Respect patient’s right to access to personal health records

10. IOM Recommendations
National focus to enhance knowledge base about safety
Identifying/learning from errors
Raising 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
Knowledge
Skills
Attitudes
Describe own strengths, limitations, and values in functioning as a member of a team
Analyze own strengths, limitations, and values as a member of a team
Analyze impact of own advanced practice role and its contributions to team functioning
Clarify roles and accountabilities under conditions of potential overlap in team-member functioning
Guide the team in managing areas of overlap in team member functioning
Initiate and sustain effective health care teams
Acknowledge own potential to contribute to effective team functioning
Acknowledge own contributions to effective or ineffective team functioning
Appreciate the importance of inter-professional collaboration

13. Repeat as needed until the desired goal is achieved
PDSA
PLAN: 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
Knowledge
Skills
Attitudes
Explain the role of evidence in determining best clinical practice
Analyze how the strength of available evidence influences the provision of care (assessment, dx, tx, and evaluation)
Determine evidence gaps within the practice specialty
Read original research and evidence reports related to area of practice
Critically appraise original research and evidence summaries related to area of practice
Exhibit contemporary knowledge of best evidence related to practice specialty
Appreciate the importance of regularly reading relevant professional journals
Value knowing the evidence base for practice area
Value public policies that support evidence-based practice
Recognize importance of search skills in locating best evidence

16. Evidence-based Practice: what we know…

17. Evidence-based Practice: so…

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
Knowledge
Skills
Attitudes
Describe strategies for learning about the outcomes of care in the setting in which one is engaged in practice
Describe strategies for improving outcomes of care in the setting in which one is engaged in practice
Explain common causes of variation in outcomes of care in the practice specialty
Seek information about outcomes of care for populations served in care setting
Use a variety of sources of information to review outcomes of care and identify potential areas for improvement
Assert leadership in shaping the dialogue and providing leadership for the introduction of best practices
Appreciate how unwanted variation affects care
Appreciate the importance of data that allows one to estimate the quality of local care
Appreciate that all improvement is change but not all change is improvement

20. Sentinel Event
Unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof
Serious injury specifically includes loss of limb or function
The phrase “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.

21. Sentinel Events

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 memory
Describe 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 reporting
Engage in root cause analysis rather than blaming when errors or near misses occur
Appreciate the cognitive and physical limits of human performance
Value own role in preventing errors
Value 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 dimensions
1. Communication openness
2. Feedback & communication about error
3. Frequency of event reporting
4. Handoffs & transitions
5. Management support for patient safety
6. Nonpunitive response to error
7. Organizational learning--continuous improvement
8. Overall perceptions of patient safety
9. Staffing
10. Supv/mgr expectations & actions promoting patient safety
11. Teamwork across units
12. Teamwork within units

28. Hospital Strengths & Areas for Improvement

29. Is it QI or is it PI?
Quality improvement (QI) and performance improvement are interchangeable terms
QI/PI describe approaches to study and improvement of processes…remember
Primary focus should be on systems/process rather than individual performance