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Current mind-set influenced by

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- Evolving perspective on errors and causal factors - Specific high-profile cases - Psychology and human factors - Lessons learned from high-risk industries - Pressure from patients and consumer groups - Court cases - Governmental agencies

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Historical Context

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In the 1990s, Lucian Leape and colleagues released the Medical Practice Study - Adverse events occurred in 4% of 30,000 hospitalizations, 28% due to negligence - Challenged "perfectibility model"

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• IOM's report on medical errors in 1999: To Err Is Human

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- Launched modern-day patient safety movement - Thrust issue into public and political consciousness - Described nation's healthcare system as fractured, prone to errors, detrimental to safe patient care

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• IOM's report on medical errors in 1999 To Err Is Human primary recommendations

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- Congress should create Center for Patient Safety - Nationwide mandatory reporting system should be established - Development of voluntary reporting should be encouraged - Congress should pass legislation to extend peer review protection to patient safety data

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recommendations cont....

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- Performance standards and expectations for healthcare focus on patient safety - FDA should increase attention to safe use of drugs - Healthcare organizations should establish patient safety programs with defined responsibility - Healthcare organizations should implement proven medication safety practices

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Current Trends and Concepts

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• Quality and safety competencies recommended for nursing education • Specialized staff roles that focus primarily on safety and quality initiatives • Patient safety - Freedom from accidental injury or preventable injuries produced by medical care - Emphasizes system of care delivery that prevents errors, learns from errors, and is built on culture of safety

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Harm

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- Impact and severity of process of care failure - Includes temporary or permanent physical or psychological impairment

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• Risk

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- Reasoned judgment of likelihood of and/or effects of adverse events occurring - Nurses are responsible for assessing risk for specific adverse events

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• Adverse events/occurrences

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- Injuries that result from medical management rather than underlying disease - Classified as preventable or not

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• Error

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- Failure of planned action to be completed as intended or use of wrong plan to achieve aim - Classified as Latent Active Organizational system Technical

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• Never event

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- Serious, mostly preventable patient safety incidents that should not occur if available preventive measures are implemented

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Root cause analysis

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- Structured method used to analyze serious events - Focus on what, how, and why event occurred to understand and eliminate root causes and prevent recurrence

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• Quality of care

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- Degree to which health services increase likelihood of desired outcomes - Safety is the foundation

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- According to IOM, quality care is

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Safe Effective Patient-centered Timely Efficient Equitable

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• Always event

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- Positive behavior that helps to facilitate improved patient safety and better outcomes - Includes various strategies to ensure safety

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• Nursing work environment

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- Combination of factors including Organizational characteristics Leadership Teamwork Workload Opportunities for professional development Salary Autonomy in practice Participation in decision making Physical environment Innovation Clarity of responsibilities Recognition

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• Psychological safety

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- Shared belief that work environment is safe place to engage in discussions about care without fear of blame or punishments - Individuals not inhibited by prospect of disapproval or potential negative consequences

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• Culture of patient safety

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- Attitudes, shared core values, goals, and behaviors related to patient safety

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- Key features

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Recognition of high-risk nature of health care Environment where individuals can report errors or near misses without fear Collaborative interdisciplinary approach to developing solutions Organizational commitment of resources to address safety concerns

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• High reliability organizations (HROs)

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- Organizations that are able to sustain excellent safety records despite operating in complex and hazardous environments

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- Key concepts

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Sensitivity to operations Reluctance to simplify Preoccupation with failure Deference to expertise Resilience

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• Human factors science

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- Relates understanding of human strengths and limitations to interrelated systems of individuals, equipment, and environment - Provides a systems approach to understanding challenges to patient safety - Aligns with Reason's Swiss cheese model of causation Weaknesses within a system line up like holes in Swiss cheese Protective layers of defense that promote safety are penetrated and adverse events occur

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The Joint Commission

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, a federal agency, is to improve health care for public with goal of inspiring healthcare organizations to provide high-quality care

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The Joint Commission (JC)

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- Evaluates care delivery - Provides accreditation and certification to organizations and programs

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The Joint Commission • Established National Patient Safety Goals (NPSGs) program in 2002 to assist organizations in addressing specific patient safety issues

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- Patient Safety Advisory group (panel of nurses, physicians, pharmacists, other healthcare professionals) meets annually to guide JC on updating and developing new NPSGs - Healthcare organizations evaluated on performance in meeting NPSGs

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• 2014 National Patient Safety Goals

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- Improve accuracy of patient identification - Improve effectiveness of communication among caregivers - Improve the safety of using medications - Reduce harm associated with clinical alarm systems - Reduce risk of health-care-associated infections - Reduce risk of patient harm resulting from falls - Prevent health-care-associated pressure ulcers - Organization identifies safety risks inherent in its patient population

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• Sentinel event

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- Unexpected occurrence that results in death or serious physical or psychological injury

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• Organizations expected to conduct investigation

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- Root cause analysis - Implement improvements to reduce risk - Monitor effectiveness of improvements

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• Reviewable sentinel events

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- Suicide - Unanticipated death of full-term infant - Abduction - Discharge of infant to wrong family - Rape - Hemolytic transfusion reaction - Surgery on wrong individual or wrong body part - Unintended retention of foreign object in an individual - Severe neonatal hyperbilirubinemia - Delivery of radiotherapy to wrong body region

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• Centers for Medicare and Medicaid Services (CMS) issued ruling to deny reimbursement of federal funds to pay for services by physicians and hospitals for treatment of never events

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- Hospitals cannot pass on costs to patients for additional care required to address never event - Private insurers implemented similar policies shortly after - Sends message to healthcare organizations and public of commitment to improve quality, cut unnecessary costs, and prevent suffering

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State Regulatory Agencies

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• State departments of health provide protection for public through licensing of health professionals and care facilities based on minimum health and safety standards • Conduct inspections of facilities to determine standard compliance • Organizations required to report sentinel events to state health department • Facilitate public reporting of complaints

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• Agency for Healthcare Research and Quality (AHRQ)

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-primary governmental agency focused on designing research to improve safety and quality of care, control costs, increase access to essential services - Responsible for Consumer Assessment of Health Plans (CAHPS)

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National Quality Forum (NQF)

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a nonprofit organization focused on improving quality of American health care through - Consensus building on national priorities and goals - Working in partnership to achieve goals - Endorsing national consensus standards for measuring - Publicly reporting on performance - Promoting attainment of national goals through education and outreach

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• National Association for Healthcare Quality (NAHQ)

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the professional organization for healthcare quality professionals - Publishes Journal for Healthcare Quality (JHQ) - Provides only professional certification in healthcare quality (Certified Professional in Healthcare Quality, CPHQ)

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National Patient Safety Foundation (NPSF)

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- Provides resources for research, education, and campaigns to raise awareness

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Leapfrog Group

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includes private and public purchasers of healthcare benefits - Healthcare organizations voluntarily submit data related to quality and safety and receive comparison reports to assess their performance - Information made available to consumers to assist in making decisions about hospital care

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• Institute for Healthcare Improvement (IHI)

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an independent, nonprofit organization working to accelerate improvement in healthcare systems - Focus on facilitating collaboration among organizations through broad improvement campaigns - Provides education, seminars, and collaborative efforts to foster safety and quality

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Quality and Safety Education for Nurses (QSEN)

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spurred by IOM call to improve quality and safety in health care - Focus of initiative is to prepare future nurses with knowledge, skills, and attitudes necessary to improve quality and safety of healthcare systems

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Quality and Safety Education for Nurses (QSEN) competencies

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- Quality improvement - Safety - Teamwork and collaboration - Patient-centered care - Evidence-based practice - Informatics

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Quality Indicators: Measuring Performance

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- Focused measuring and reporting on top priority areas - Scientifically acceptable - Usable and relevant - Feasible to collect with readily available data

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AHRQ organizes quality indicators as

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- Patient Safety Indicators - Prevention Quality Indicators - Inpatient Quality Indicators - Pediatric Quality Indicators Measurement selection should be given thought based on purpose, focus, and timing of improvement project

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National Database of Nursing Quality Indicators (NDNQI)

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primary registry for nursing-sensitive indicators - Supported by ANA's National Center for Nursing Quality (NCNQ) - Provides evidence-based comparative data reflecting relationship of nursing care to patient outcomes at national level

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Continuous quality improvement (CQI)

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a broad, overarching philosophy with roots in management - Focuses on applying scientific methods to improve all aspects of care and service on ongoing basis

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Any CQI initiative should consider primary components of

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- Structure - Process - Outcomes

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Toyota Lean initiatives focus on

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- Improving flow to eliminate waste and decrease delays - Getting things right the first time - Empowering and motivating staff to sustain results - Applying evidence to make good decisions - Learning by doing to get results rapidly

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IHI Model for Improvement

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- Developed as strategy to accelerate quality improvement processes in healthcare organizations - Can be used as adjunct to other CQI models - Focuses on developing goals for improvement and team building - Strategies based on plan-do-study-act (PDSA) cycle

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Six Sigma is a QI

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approach that is data-driven and focuses on eliminating defects and minimizing variability - Focus on measurement-based methods of improvement and reduction of variation using multiple improvement projects - Improvement projects focus on five strategies, Define, Measure, Analyze, Improve, Control (DMAIC)

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Just Culture model

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- Developed as alternative to punitive system; considers system factors while still providing individual accountability - Three types of behavior related to error occurrence Human error At-risk behavior Reckless behavior

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Teamwork and collaboration

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- Can decrease potential for error and improve system resistance to errors - Effective teams characterized by Mutual respect Sharing common purpose Strong leadership and communication Commitment and sense of cohesion Measurable goals based on distinct purpose - Structured communication strategies are useful when communicating

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- Situation Background Assessment Recommendation (SBAR) technique

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Used in a number of healthcare settings Helpful when communicating information about a patient that requires attention and action Helpful at shift reports and handoffs

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Patient-centered care (PCC)

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- One of six key elements of quality care described by IOM - Care organized around the patient - Approach to health care (planning, delivery, and evaluation) grounded in partnering with patients and families - Involves transformation in organizational culture and requires buy-in and commitment from all levels

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Patient-centered care (PCC) focuses on

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- Effective communication with patients and families - Personalization of care - Continuity of care - Access to information - Family involvement - Environment of care - Spirituality - Caring for community - Caring for caregiver (staff)

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Current NDNQI list of nursing-sensitive indicators

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- Nursing hours per patient day - Nursing turnover - Nosocomial infections - Patient falls - Pressure ulcer rate - Pediatric pain assessment, intervention, reassessment (AIR) cycle - Pediatric peripheral intravenous infiltration - Psychiatric physical/sexual assault - RN education/certification - RN survey - Job satisfaction scales - Practice environment scale (PES) - Restraints - Staff mix NQF - Percentage agency staff - Additional data elements - Number of staffed beds

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National and state report cards

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- Web-based report cards to provide public and healthcare professionals information regarding quality of health care - Used to link care to financial incentives, facilitate quality improvement projects, direct public toward higher quality providers

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Research indicates that nursing care has influential effect on patient perceptions

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- Most direct effect is on overall ratings of quality of care and services - Negative experience with nursing care has disproportionately negative effect on perceptions of quality - Highlight priority to focus on high-quality nursing care

Chapter 11 The Nurse’s Role in Quality and Safety – Flashcards

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