Nursing Quality Assurance Issues in CVVH

Timothy L. Kudelka, RN, BSN

Pediatric Dialysis Program

C.S. Mott Children’s Hospital

University of Michigan

What Is Quality?

The Institute of Medicine defines quality as the degree to which health services for individuals or populations achieve a desired outcome and is consistent with

current professional knowledge.

What is Quality Assurance?

A process for improvement. To prevent and correct identified problems. A multidisciplinary team working together to

provide the highest quality health care by meeting or exceeding the expectations of the customers we serve.

To assure that procedures, methods, and systems have an effective impact and are cost effective.

Existing Standards

• Acute Dialysis Quality Initiative (www.adqi.net)

• The Joint Commission on the Accreditation of Healthcare Organizations(JCAHO)

• The Food and Drug Administration.

Continuous Quality Improvement

Standards and guidelines are ways to improve quality on a large scale.

Continuous quality improvement (CQI) is a way to build standards and

guidelines into daily practice.

Continuous Quality Improvement

• CQI has three main parts:• Quality planning• Quality control• Quality improvement

• Tools used in CQI• (PDCA)Plan,Do,Check,Act• Priority rating scale

Quality Planning

• Involves planning processes and procedures to achieve desired outcomes, or goals for patients and staff.

• All problems are seen as a chance for improvement.

Quality Control

• Checks to see that the goals are met.

• In CRRT there are many aspects of care that are checked as part of quality control including:

•Monitoring electrolytes

•Fluid status

•Maintaining anticoagulation

•Blood loss

•Heat loss

•Immobility

•Accurate prescription

•Access

•Documentation

Quality Improvement

• If the desired goals are not met for each area, quality improvement is used to study how tasks are done and how to improve them.

• When a problem is identified, an on going cycle of improvement begins.

Method or Tool

• P - Plan

• D - Do

• C - Check

• A - Act

Plan

• Collection of information or data

• Design or redesign policies, procedures services or products

• Specify objectives or degree of improvement.

DO

• Deliver care, perform policy or procedure in limited trial run

• Do a pilot test of the plan to see how it works.

Check

• The third step is to

Check to see if the plan works.

• Obtain judgments of improvement and determine if solution or change has been successful.

Act• CQI is a continuous

full circle.• Implement solutions,

change, modify tests, revise standards.

• (develop standards) and incorporate revision in to day-to-day practices.

• Communicate.

A Powerful Quality Tool

The Opportunity

• The CQI approach is versatile and can be applied to any problem for which data can be collected.

• Nursing should be and usually is the lead in coordinating a CQI team.

• CQI is the perfect tool to address troubleshooting issues in CVVH.

Benefits

Benefits

• Prevent and correct identified problems.

• Assure patient care is of the highest quality, meeting community, national and international standards.

• Engage and organize individuals closest to the work process to improve.

Benefits

• To assure that procedures, methods, and systems are cost effective.

• Performance standards designated by regulatory and accrediting agencies are consistently met.

Benefits

• To assure that patient care, practice and professional performance are regularly, validly and reliably evaluated.

• Performance results are tracked by a valid measurement tool.

Performance Improvement Priority Rating Scale

Scoring Guidelines IMPACT: Any score of 4=Top priority; any score of 3=moderate priority; all scores of 2=low priority; all scores of 1 or less=no priority. APPLICABILITY: Any two score of 4=Top priority; any two score of 3 or one score of 4= moderate priority; no more than one score of 3=low priority; all scores 2 or less=not a priority. CUMULATIVE SCORE: Scores >20=top priority; score of15-20=moderate priority; score of 10-15=low priority; scores <10=not a priority. PRIORITY RATING: Top priority= DO NOW; moderate priority=do within 6 months; low priority= do as able; Not a priority=continue to monitor. Modified and reproduced from “Effective JCAHO Survey Preparation” © 1997 Opus Communications, Inc., PO Box 1168, Marblehead, MA, 01945,617-659-1872.

Selection Parameters 4 3 2 1 0

Applicability & Alignment

Relationship to Vision/Mission/Goal

Critical to achievement of the mission; key to

organization’s purpose.

Important to more than one of the

organization’s goals.

Important to at least one of the

organization’s goals

Related to one or more of the organization’s

goals No relationship

Relationship to Patient Population

(high volume)

100% of all patients affected.

75% of all patients affected.

50% of all patients affected.

25% of all patients affected.

Affects only the rare patient.

Relationship to Hospital Services

(high risk, problem-prone)

Both high risk and problem-prone.

High risk, but not problem-prone.

Problem-prone but not high risk.

Occasional problem, but low risk

Neither high risk nor problem-prone.

Quality Impact

Clinical/Technical (impact on patient

outcomes)

Potential to cause death or permanent disability

OR potential to significantly improve current standards of

care.

Potential to cause a temporary disability;

extends need for care OR greatly improves standards of care.

Potential to cause discomfort; minor

assed treatment OR moderately improves

standards of care

Potential to cause a mild discomfort; no

assed care needed OR minimally improves

care.

No effect on outcomes OR

negative effect on outcomes.

Resource Utilization (impact on cost; LOS;

staffing, supplies)

Significant and very positive impact.

High and positive impact.

Moderate and positive impact.

Minimal and positive impact.

No impact OR negative impact.

Service Quality (impact on customer

satisfaction)

Drives away patient/customers OR significantly improves

customers satisfaction.

Affects reputation and business OR greatly improves customers

satisfaction,

Source of frequent complaints OR

moderately improves customers satisfaction.

Source of rare complaints OR

minimally improves customers satisfaction.

No effect on customers

satisfaction OR negative impact.

Requirements Required Quality Control Activity

Required N/A N/A N/A Not required

One of the Important Functions of the

Hospital Yes N/A N/A N/A No

Relationship to Dimensions of Performance

Affects four or more dimensions.

Affects three or more dimensions.

Affects two or more dimensions.

Affects one or more dimensions.

No relationship.

History Past Opportunities for Improvement

Significant variation; no action yet.

Action taken; but still has significant variance

Improvement made, process not yet stable.

Action taken and process stabilized.

No opportunity for improvement.

In t e r n e t R e s o u r c e s

A m e r ic a n S o c ie ty fo r Q u a li ty – w w w .a s q .o r g

A s s o c ia tio n fo r Q u a li ty a n d P a r tic ip a tio n – w w w .a q p .o r g

A g e n c y fo r H e a l th c a r e R e s e a r c h a n d Q u a li ty -

w w w .a h c p r .g o v / fu n d /in d e x .h tm # g r a n ts

B e s t P r a c t ic e N e tw o r k – w w w . ih ig h p o in t .n e t /b p n /

In s t i tu te fo r S a fe M e d ic a tio n P ra c tic e s – w w w . is m p .o r g

In s t i tu te fo r H e a l th c a r e Im p r o v e m e n t – w w w . ih i .o r g

J o in t C o m m is s io n fo r A c c re d i ta tio n o f H e a l th c a r e O rg a n iz a tio n s ( J C A H O ) w w w . jc a h o .o r g

J u r a n In s ti tu te – w w w . ju r a n .c o m

N a t io n a l P a tie n t S a fe ty F o u n d a tio n – w w w .n p s f .o r g

N a t io n a l Q u a li ty P r o g r a m – w w w .q u a l i ty .n is t .g o v /

N a t io n a l A s s o c ia tio n fo r H e a l th c a r e Q u a li ty – w w w .n a h q .o r g

“ T o p 1 0 0 H o s p i ta ls - C lin ic a l B e n c h m a r k in g ” – w w w .s o lu c ie n t .c o m

Thanks to:

Dr. Timothy E. Bunchman MD

Dr. Patrick D. Brophy MD

University of Michigan Pediatric Dialysis Team.

Pediatric Critical Care Nursing.

My wife.