1. Chapter 15 Ensuring Quality Care
Viki Saidleman
Joseph T. Catalano

2. Quality of Care Definition of quality Institute of Medicine (IOM)
A level of excellence of care based upon pre-established criteria.
Institute of Medicine (IOM)
The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.

3. Quality of Care (cont’d)
IOM recommendations to improve error reduction and quality
Establish leadership, research, tools, and protocols to enhance the safety knowledge base.
Develop a public mandatory national reporting system and encourage participation in voluntary reporting systems.

4. Quality of Care (cont’d)
IOM recommendations to improve error reduction and quality (cont’d)
Use oversight organizations, health- care purchasers, and professional organizations to increase performance standards and expectations for safety improvements.
Implement safety systems at the point of care delivery in health-care organizations.

5. Quality of Care (cont’d)
IOM estimated that 98,000 people die per year due to adverse events and medical errors in hospitals.
Consumer demand for higher quality care has increased dramatically.
Nurses are in a pivotal position to positively influence quality and safety at local, state, and national levels.

6. Methods to Improve Quality of Care
Quality assurance (QA)
Continuous quality improvement (CQI)
Total quality management (TQM)
Benchmarking
Leapfrog group
Quality indicators (QIs)

7. Quality of Care (cont’d)
Case management protocols
Also known as clinical pathways
Streamline charting process
Encourage documentation across multidisciplinary teams
Systematically monitor variances from prescribed plans of care

8. Quality of Care (cont’d)
Case management protocols (cont’d)
Identify how client care and progress vary from a predetermined plan
Enable more accurate assessment of client-care costs
Maintain quality-control measures

9. Quality of Care (cont’d)
Risk management
Focuses on identifying, analyzing, evaluating risks
Reduces risk to decrease harm to clients
When an adverse event does occur, attempts are made to minimize losses.
Is interdisciplinary in nature

10. Quality of Care (cont’d)
Risk management (cont’d)
Includes aspects of detection, education, and intervention
Nursing staff is key to any risk management program
High risk areas include
Medication errors
Complications from tests and treatments
Falls
Refusal of treatment or refusal to sign treatment

11. National Client Safety Goals
Improve accuracy of client identification.
Improve effectiveness of communication among caregivers.
Improve safety of using medications.
Reduce risk of health-care-associated infections.
Identify client safety risks inherent in its patient population.

12. Sentinel Events
Sentinel event = an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.
Serious injury includes loss of limb or function.
Sentinel events are not the same as errors.
Indicate the need for immediate investigation and response.

13. Six Sigma Quality Improvements
Was first developed and used for the manufacturing industry in the early 1980s
Began being used in the health-care system in the mid- to late 1990s
Origins can be traced back to the 1920s and are based on the statistical model bell-shaped curve

14. Six Sigma Quality Improvements (cont’d)
In the perfect bell curve, there is a mean exactly in the center at the highest point of the curve.
Away from the mean, the curve slopes down at a predictable rate on both sides.
It is divided into standard deviations.
Each standard deviation is designated a sigma and given a number (e.g., plus or minus 1 sigma).
Six standard deviations (six sigmas) are so far out in the tails of the bell curve that they are generally considered a total lack of error; in other words, “perfection” (statistically, 3.4 defects per million).
Minus 6 Sigma
Plus 6 Sigma

15. Six Sigma Quality Improvements (cont’d)
Six Sigma process comprises five distinct phases
Define
Measure
Analyze
Improve
Control

16. Six Sigma Quality Improvements (cont’d)
Six Sigma in health care
It is difficult to find and define the specific cause of errors.
Six Sigma provides a wide-reaching and more pragmatic approach to identifying and measuring problems.

17. Six Sigma Quality Improvements (cont’d)
Six Sigma in health care (cont’d)
Adapting and modifying the traditional Six Sigma methodology, health-care providers can develop more inclusive objectives to increase reliability and quality.
The overriding goal of Six Sigma is to develop a fully reliable process or system of care.

18. Six Sigma Quality Improvements (cont’d)
Black belts
Specialized training is required to use Six Sigma.
Individuals can become certified as Six Sigma consultants through the Institute of Industrial Engineers or the American Society for Quality.

19. Six Sigma Quality Improvements (cont’d)
Black belts (cont’d)
Trained employees of Six Sigma are called black belts.
They are well-paid consultants for hospitals and other institutions that believe Six Sigma may be the answer to their problems.

20. Six Sigma Quality Improvements (cont’d)
Looking for problems.
Looks primarily for two types of statistical anomalies or variations.
Primary variation is called “special” or “assigned” variation.
Shows a pattern of activity outside the patterns expected to produce high-quality care.
Once detected, the five-step statistical process can be applied.
Second variation is called “common” or “chance” variation.
Usually attributed to environmental factors that cannot be controlled.
Chance variations can become so significant that they affect the process and have to be addressed.

21. Six Sigma Quality Improvements (cont’d)
Hybrid
Lean Six Sigma is a hybrid
Focuses on identifying and eliminating waste
Improves the flow of processes
Improves the quality of trauma care by reducing inappropriate hospital stays while reducing costs
Improves the collaborative efficiency of meal delivery, radiological testing, and timing of inpatient insulin administration

22. Competency Focus in Education
The focus on quality care needs to begin on the first day of a health-care professional’s education and continue through the whole education program.
Competency Outcomes Performance Assessment (COPA) Model
Used by medical schools and some schools of nursing
Validates the skills and knowledge of graduates
Designed to promote competency for clinical practice at all levels.

23. Quality and Safety Education for Nurses (QSEN)
Built on five competencies developed initially by the Institute of Medicine (IOM).
Using the QSEN model contributed to the adoption of quality and safety competencies as core practice values.
See Chapter 4 for more detail.

24. The Agency for Healthcare Research and Quality (AHRQ)
One of the Department of Health and Human Services agencies that supports research to improve the quality of health care.
Helps people make more informed health-care decisions.

25. The Agency for Healthcare Research and Quality (AHRQ) (cont’d)
Charged with developing partnerships that create long-term improvement in U.S. health care
The research goal is to measure those improvements in terms of client outcomes, decreased mortality, improved quality of life, and cost effective quality care.

26. The Agency for Healthcare Research and Quality (AHRQ) (cont’d)
Focus is in three areas
Safety and quality: risk reduction by promoting quality care
Effectiveness: improved health outcomes by using evidence to make informed health care decisions
Efficiency: translating research into practice to increase access and to decrease costs

27. Affordable Care Act Sect. 3501
Mandates that the Agency for Healthcare Research and Quality (AHRQ) work through a Center for Quality Improvement and Patient Safety to conduct research on best quality improvement practice innovations and strategies.

28. Affordable Care Act Sect. 3501 (cont’d)
The Center’s tasks also include identifying, creating, critiquing, sharing, and giving training in these best practices.

29. Quality Improvement Organization (QIO)
The mission of the QIO is to improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries.
The QIO is a federal program designed to review medical care, verify its necessity, and assist Medicare and Medicaid beneficiaries with complaints about quality of care.

30. Quality Improvement Organization (QIO) (cont’d)
Three core functions for QIO
Improving quality of care for beneficiaries.
Protecting the integrity of the Medicare Trust Fund by ensuring that Medicare pays only for services and goods that are reasonable and necessary and that are provided in the most appropriate setting.

31. Quality Improvement Organization (QIO) (cont’d)
Three core functions for QIO (cont’d)
Protecting beneficiaries by expeditiously addressing individual complaints, such as
Beneficiary complaints
Provider-based notice appeals
Violations of the Emergency Medical Treatment and Labor Act (EMTALA)
Other related responsibilities as articulated in QIO-related law

32. Never Events
These are reasonably preventable medical errors that occur in the hospital.
The Centers for Medicare & Medicaid Services (CMS) will no longer pay for Never Events.
Hospitals now have to cover costs themselves for Never Events.

33. Never Events (cont’d)
Purpose = to control Medicare costs and improve the quality care.
In light of the Affordable Care Act (ACA) passage, this will be revised.

34. Key Factors to High Quality Care
Evidence-based practice/research
Environment: a culture of quality care
Client-centered care
Teamwork and collaboration
Lifelong learning
Informatics