Supporting Quality Care Chapter 4

Standards for Evaluating Health Care Types of standards Structural standards Process standards Outcome standards

Structural Standards establish guidelines for the facility’s patterns and supports for providing client care i.e. The nurse patient ratio in ICU is 1:2 All home health nurses will have at least 1 year of acute care experience Can you think of an example of a structural standard???

Process Standards deal with the methods or the process used in providing client care or services i.e. The initial nursing care plan will be established within 24 hours of admission. The patient meal trays will be passed out within 30 minutes of arrival to the unit Can you think of an example of a process standard???

Outcome standards used to evaluate patient outcomes or the desired result of care i.e. Post op hip replacement patients will be ambulatory by Day 2. The incidence of nosocomial infections will be less than 10%. Can you think of an example of an outcome standard???

Question Each nursing unit will have a fire extinguisher on each side of the hallway. This is an example of a: a) structural standard b) process standard c) outcome standard

Answer Structural. Rationale- Structural standards include the physical plant and equipment.

Sources of Standards for Care Nursing specific standards Regulatory agency standards Accrediting agency standards Clinical practice guidelines as standards Health facility established standards

Question Is the following statement true or false? A type of standard to which a nurse is held accountable is called a process standard.

Answer True. Rationale: process standards describe methods of providing services. Process standards are also referred to as performance standards. Protocols and procedures are examples of process standards.

Benchmarking Benchmark – a specific quantitative standard (expressed as a number or percent) to which you compare to your own facility to a similar facility or standards established by JCAHO or another entity. i.e. 3 falls per 100 patient care days 8% nosocomial infection rate 75 medication errors per year 5% surgical site infection rate

Cost Standards Outcomes related to cost Cost-effectiveness Cost- benefit ratio Doesn’t take into consideration quality of life or satisfaction

Collecting Data for Evaluation- Key Indicators Selected data that reveal the need for more extensive data collection i.e. Number of Falls per year evaluates Safety Number of Nosocomial Infections per year evaluates Infection Control Number of Medication Errors per year evaluates Safety Length of stay for Hip Replacement evaluates Cost

Collecting Data for Evaluation- cont. Quality assurance reports- “Incident report” Audit- Retrospective-i.e. Going back to medical records for chart review to see if all medications were signed off. , concurrent- i.e. Looking at a chart which is currently in use to see if I.V. restarts were charted

Collecting Data for Evaluation- cont Direct Observation i.e. Going in patient rooms to see if I.V. tubing is labeled Interview i.e. Interviewing a patient to see if pain is less than 5 on a scale of 1-10

Question What is the term used for a systematic data collection process that commonly focuses on documentation? A. Cost-analysis report B. Benchmarking C. Audit D. Survey

Answer C. Audit Rationale: an audit is a systematic data collection process that commonly focuses on documentation.

Analyzing Data and Developing Action Plans Types of reports Simple descriptive reports Percentage and numerical reports Sophisticated statistics Analysis of data Identify discrepancies Opportunities for improvement

Analyzing Data and Developing Action Plans (cont'd) Detailed approaches to change Specific Identify responsible person Set time frame

Using Goals and Objectives in the Evaluation Process Broad statements of overall intent of an organization, department, unit, or individual Usually stated in general terms Objectives Specific accomplishments that help achieve a goal Usually have a related time deadline

Strengths of Using Goals and Objectives Everyone knows what is expected Facilitates change in individual behavior Evaluation is clear

Limitations of Using Goals and Objectives Cannot be done in isolation Related to standards of care Impossible to address all the areas of function Conflict over goals can occur

Quality Assurance and Improvement Refers to activities that are used to monitor, evaluate, and control services provided to consumers Goal is to identify areas where standards are not met and improve them

Quality Assurance and Improvement (cont'd) Sentinel events Defined by the Joint Commission (2007c) as “unexpected occurrences involving death or serious physical or psychological injury, or risk thereof.”

Quality Assurance and Improvement (cont'd) Both errors and near misses Death from medication error Suicide of a patient receiving 24/7 care Surgery on wrong patient or body part Hemolytic transfusion reaction Near miss

Quality Assurance and Improvement (cont'd) Root cause analysis Comprehensive, often complex, process that seeks to identify all the contributory factors to an error and identify their share of causation What happened Why it happened How do you keep it from happening again Tool for prevention strategies

Quality Assurance and Improvement (cont'd) Acting to prevent error Addressing system problems Patient safety goals

Question Is the following statement true or false? A medication error that results in the death of the patient is a sentinel event.

Answer True. Rationale: sentinel events include both errors and what are commonly referred to as near misses. An example of a sentinel event is a death resulting from a medication error or other treatment-related error.

Quality Improvement Movement Incorporates all aspects of quality assurance Aimed at improving quality of health care JCAHO: “Quality assessment and improvement” Efforts toward evidence-based practice

Continuous Quality Improvement A process in which ongoing analysis and improvement lay the foundation for change Includes: Collecting data Analyzing data Forming a task force Planning change Implementing change Collecting data again

Key Aspects of Quality Improvement Culture of empowerment Blame-free environment Effective data collection systems Use of teams for problem solving Focus on the customer Eliminating waste

Barriers to Quality Improvement Costs Staff time Computer programming Documentation Improvement may not defray costs

Risk Management Minimizing the risk to the institution or agency from an error or problem that could result in legal action or liability Think ahead about defense when a legal action is contemplated or actually occurs Attempts to be proactive in identifying and eliminating areas of risk for the institution Response of those in the health care system when an adverse event occurs

Question What is one purpose of risk management? A. Change in time when vital signs are done at night B. Improvement of quality of meals served to patients C. Defense when legal action occurs D. Planning of community emergency drills

Answer C. Defense when legal action occurs Rationale: another focus of risk management is to think ahead about defense when a legal action is contemplated or actually occurs.

Evaluating Nursing Care You Manage Identify specific standards of care that you will strive to meet and determine ways of improving care Goals and objectives may be established informally with a team even when the setting does not have a formal process in place A philosophy of continuous improvement