Chapter 020 1

Chapter 20

Managing Quality and Risk

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc.

Objectives

Apply quality management principles and strategies to clinical situations.

Use the six steps of the quality improvement process.

Practice using select quality improvement strategies.

All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. 2

Objectives (Cont.)

Incorporate roles of leaders, managers, and followers to create a quality management culture of continuous readiness.

Apply risk management strategies to an agency’s quality management program.


Managing Quality and Risk

Comprehensive systematic approach Prevents errors before they occur Identifies and corrects errors

• Adverse events are decreased • Safety and quality outcomes are maximized

Optimizes patient outcomes Prevents patient care problems Mitigates adverse events


Standards of Quality Care

Nurse Practice Acts Accreditation Standards (e.g., TJC National

Patient Safety Goals) Governmental bodies (e.g., Agency for

Healthcare Research and Quality [AHRQ], National Quality Forum [NQF]; the National Institute for Occupational Safety and Health [NIOSH])

Healthcare advisory groups (e.g., Institute of Medicine [IOM])


Standards of Quality Care (Cont.)

Internal or external performance measurements (e.g., patient satisfaction surveys, employee opinion surveys, safety assessment surveys, patient rounds)

Institutional Guidelines (e.g., Policies and Procedures, Structure/Process Standards)

Research/Evidence-based practice guidelines


Quality Management Terms

Continuous Quality Improvement (CQI) Total Quality Management (TQM) Quality Improvement (QI) Quality Assurance (QA)


Total Quality Management

Structure Facilities Equipment Staff Finances

Process Nurses’ role/EBP

Outcome


Principles of QM and QI

QM most effective in a flat, democratic organization.

Leaders, managers, and followers must be committed to QI.

Goal of QM is to improve systems and processes, not to assign blame.


Principles of QM and QI (Cont.)

Customers define quality. QI focuses on outcomes. Decisions must be based on data.


Comparison of QA and QIQA Process QI Process

Goal Improve quality Improve quality

Focus Discover/correct errors

Prevent errors

Major tasks Inspect nurse activities; chart audits

Review nurse activities;innovation;staff development

Quality team QA or department personnel

Interprofessional team

Outcomes Set by QA team with input from staff

Set by QI team with input from staff and patients


Steps in the QI Process

Identify needs. Assemble interprofessional team. Collect data. Establish outcomes and quality indicators. Select and implement plan. Evaluate.


National Patient Safety Goals

Accuracy of Patient Identification Effectiveness of Interdisciplinary

Communication Safety of Medication Reduced Hospital-Acquired Infections Identification of specific safety risks

Suicide Falls


Case Study

A significant increase in patient falls resulting in injury has been reported on your unit. In accordance with the National Patient Safety Goals, you are assigned to an interprofessional Quality Improvement/Risk Management team to address the problem.


Case Study: Steps in the Risk Management Process

Define high-risk situation. Patient falls

Collect data, including frequency of falls. Intervene and investigate. Identify opportunities to improve care.

Use steps of the QI process.


Case Study: Identify Needs

Compliance with National Safety Goals Reduction of hospital risk/financial loss Reduction in LOS after an adverse fall event Establish outcomes

Nursing-sensitive outcomes


Case Study: Assemble Interprofessional Team

Nurses Physicians Unlicensed assistive personnel Pharmacists Facility/environmental management

representatives QI/risk management experts


Case Study: Collect Data

Define incidence of falls. Benchmark using National Database of

Nursing Quality Indicators (NDNQI). Determine high-risk patients.

Age Mental status History of falls Medication Physical environment


Case Study: Identify Outcomes and Indicators

Education of 100% of all direct care providers Completion of Fall Risk Assessment on 100%

of patients Reduction in patient falls by 25% within 3

months of program Medical record demonstrating 100%

compliance with Fall Prevention Program


Case Study: Establish Fall Prevention Plan

Consistent use of ID bracelets based on Fall Risk Assessment score

Implementation of bed alarms Staff education (e.g., toileting at-risk patients

routinely) Change of environment (e.g., vertical grab

bars)


Case Study: Evaluate Change

Change in incidence of falls (e.g., through incident reports, sentinel event monitoring) Root cause analysis

Staff compliance with Fall Prevention Plan Patient/family satisfaction with plan Reliability and validity of Fall Risk

Assessment tool


Case Study: Ensuring Standards of Care for Fall Prevention

Nurse practice acts Professional organization guidelines Institutional guidelines (e.g., policies and

procedures, structure/process standards) Research/evidence-based practice guidelines Accreditation standards (e.g., TJC National

Patient Safety Goals)


Questions to Consider

How can a staff nurse make effective suggestions to improve nursing practice?

How can a culture of assigning blame for errors be transformed into an environment invested in improving patient care?

How can patients’ expectations be used to improve nursing care and promote optimal outcomes?


Chapter 020 1

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