CHAPTER 22: QUALITY

IMPROVEMENT AND PATIENT

SAFETY
McKenzie Drapola, Mackenzie Santillo, Alaina Lytle,
Jenna Baughman, Robert Johnston
The Urgent Case for Quality
Improvement in the U.S. Health System
■ In 2000 the Institute of Medicine reported that 98,000 patients die each year due to
preventable medical errors including…
– Overuse of expensive invasive technology
– Underuse of inexpensive care services
– Error-prone implementation of care that could harm patients and waste money

■ Other reports claim that…

– 30% of Americans failed to receive the recommended care
– Patients are subjected to at least one medication error each day
STEEP

■ The quality chasm report details five guiding aims for improvement that should be
used by every individual and group involved in health care:
– Safety: preventing injuries to patients from care that is intended to help them
– Timely: reducing waits and sometimes harmful delays for those who receive and
provide care
– Effective: providing services based on scientific knowledge to all who could benefit
– Efficient: preventing waste, including waste of equipment, supplies, ideas and energy
– Patient centered: providing care that is respectful of and responsive to individual
patient preferences, needs and values and ensuring that patient values guide all
clinical decisions
 Improvement Initiatives

■ 10 simple rules that nurses follow to improve the quality of healthcare:

1. Care is based on continuous healing relationships
2. Care is customized according to patients’ needs and values
3. The patient is the source of control
4. Knowledge is shared and information flows freely
5. Decision making is evidence-based
6. Safety is a system property
7. Transparency is necessary
8. Needs are anticipated
9. Waste is continuously decreased
10. Cooperation among clinicians is a priority
Principles of Quality Improvement

■ Assessment and improvement of work processes while focusing on what customers

want and need

– Example: Susan and her ”customer”

■ Susan’s job as a nurse is to perform all of the postoperative tasks knowing that her
customer or patient wants to recover quickly from surgery without complications
Quality

■ To better appreciate the importance of quality improvement, a customer’s

perspective of quality must be considered
– Includes personal interactions they experience with the organization

■ Does not just include the physical items, but also the overall experience of the
customer
Scientific Approach

■ Emphasizes the significant improvements in organization processes

– Decisions are based on sound, valid data and the people managing the
processes must have a clear understanding of the nature of variation

■ Process - a series of linked steps necessary to accomplish work

– Steps necessary to complete a new medication order

■ Variation - the difference in how the steps in the process might be accomplished
All One Team

■ Effective team functioning embodies the principles of believing in people

■ Having trust and respect for all coworkers

■ Must rely more on cooperation, rather than competition

Where Does Quality Start?

■ Quality of health care started in the 1800’s when Nightingale stated that health care
environments include temperature, lighting, aspects of nature, and patient comfort

■ Quality has slowly come back to Nightingale’s statement starting with building
quality
– Making the healthcare environment open and including nature, such as gardens
and easy access to the outdoors
– This allows patients to become less nervous and the healthcare facility to
become more of a place of healing rather than an intimidating experience

https://www.youtube.com/watch?v=jq52ZjMzqyI
Advancing Quality Through Regulation
and Accreditation
■ Today, almost all health care regulatory and voluntary accrediting agencies require
QI in some form.

■ The Joint Commission (TJC) was one of the first accreditation agencies to embrace QI
principles as an accreditation requirement in hospital-based settings.

■ In 1997, TJC introduced ORYX, a performance measurement and improvement

initiative, as part of the accreditation process

■ These standardized measures are now referred to as National Hospital Quality

Measures.
Advancing Quality Through Regulation
and Accreditation
Websites
National Hospital Quality Measures (Joint Commission Website) http://jointcommission.org/performance_measurement.aspx

Public performance data for hospitals across the country (TJC website at Quality Check) www.qualitycheck.org and through
www.medicare.gov/hospitalcompare/

Value-Based Purchasing information (Quality Initiatives section of CMS website) www.cms.gov/Medicare

For more information, nurses are encouraged to visit the Performance Measurement section of the TJC website
www.jointcommission.org
Clinical Indicators and Process
Improvement Tools
■ The basic foundation of the monitoring and evaluation process required by QI
principles is in the use of clinical indicators, which are measurable items that reflect
the quality of care.

■ Clinical indicators help to identify the goals of quality improvement, whereas process
improvement skills and tools support the quantitative understanding of key work
processes.

■ The tools in this section (flow charts, Pareto charts, cause-and-effect diagrams, run
charts) are all used in each of these various methods of quality improvement.
Clinical Indicators and Process
Improvement Tools and Skills
■ Various tools, such as flowcharts, Pareto charts, cause-and-effect diagrams, and run
charts, may be used to accomplish each of these six steps.

1. Analyzing and clearly understanding the process

2. Selecting key aspects of the process to improve
3. Establishing “trial” targets to guide improvement measures
4. Collecting and plotting data
5. Interpreting results
6. Implementing improvement actions and evaluating effectiveness
Understanding, Improving, and
Standardizing Care Processes
■ Standardized processes have shown to be the foundation for improvements in all
areas of business today, but especially in the clinical care setting

■ There is a typical resistance to standardizing practices, especially when they involve

providing patient care and services
– Most employees receive little training on how to do their jobs. Instead, the
majority are left to learn by watching a more experienced employee.
– Most employees have developed their own unique versions of any general
procedures they witnessed or were taught. They think “My way is the best way”.
– Changes to procedures happen haphazardly; individuals constantly change
details to counteract problems that arise or in hopes of discovering a better
method. Tampering is rampant.
Understanding, Improving, and
Standardizing Care Processes
■ At first glance, it would be assumed that all care practices are based on scientific
evidence & research, and although many are, others exist simply because that was
how the practitioner originally was educated.

■ Those practices that are research based, even though they represent best known
methods, may still not be widely practiced and therefore result in lack of
standardization
 Understanding, Improving, and
Standardizing Care Processes
During the past few years, a number of methods have been used in health care settings for the purpose of supporting
standardization of care processes

Clinical Pathways or Clinical Protocols or

Critical Pathways Algorithms

■ Typically defines the optimal ■ Represent more of a decision path

sequencing and timing of that a practitioner might take
interventions by physicians, nurses, during a particular episode or need
and other interprofessional team – Exist for treatment of
members when providing care for a hypertension, provision of both
patient with a particular diagnosis basic and advanced life
or procedure support, and general
diagnostic screening
Breakthrough Thinking to Improve
Quality
■ Similar to standardization, the notion of breakthrough thinking and swift
application of best-known methods for practice is critical to the foundation of health
care improvement.

■ The premise behind breakthrough thinking and its resulting action is threefold:
– 1. Substantial knowledge exists about how to achieve better performance than
currently prevails
– 2. Strong examples already exist or organizations that have applied that
knowledge and broken through to substantial improvements
– 3. The stakes are high and relevant to the most crucial strategic needs of health
care
Breakthrough Thinking to Improve
Quality
■ The Institute for Healthcare Improvement recommends a QI model which is
composed of two parts:

■ Part 1 asks three fundamental questions:

– 1. What are we trying to accomplish?
– 2. How will we know that a change is an improvement?
– 3. What changes can we make that will result in improvement?
Breakthrough Thinking to Improve
Quality
■ The Institute for Healthcare Improvement recommends a QI model which is
composed of two parts:

■ Part 2 uses a sequence of steps, starting with developing an action plan based on the
three questions, taking actions to test the plan, making refinements as needed, and
implementing the resulting changes in real work settings
Institute for Healthcare Improvement
(IHI) Quality Improvement Model
Patient Safety

■ As discussed previously, the need for quality improvement (QI) in the area of health
care errors is more evident than anywhere else.

■ The issue of medical mistakes and patient safety is so important that there were
articles placed on the pages of national newspapers, on the agendas of health care
governing boards, and at the forefront of federal government legislation.

■ In response to the focus on patient safety and the need to better understand the
priority concerns, several national initiatives were implemented, which will be
discussed in the following slides.
Institute for Safe Medication Practices

■ One outcome of the patient safety and QI movement was the establishment of the
Institute for Safe Medication Practices (ISMP), a nonprofit organization that is now
well known as an education resource for the prevention of medication errors.

■ The ISMP provides independent, multidisciplinary, expert review of errors reported

through the U.S. Pharmacopeia- ISMP Medication Errors Reporting Program (MERP).
Institute for Safe Medication Practices

■ The ISMP has also developed Medication Safety Self Assessments to allow nurses
and other health care providers to assess the medication safety practices in their
work setting.

■ The assessments are publically available on the ISMP website.

– https://www.ismp.org/assessments/hospitals
Role of Regulatory and Accrediting
Agencies to Promote Patient Safety
■ The leaders of regulatory agencies and accrediting agencies have developed three
standards and programs to promote patient safety.

■ They are as follows:

– Sentinel Event Standard
– National Patient Safety Goals
– Never Events
Sentinel Safety Standard
■ As one response to the increasing emphasis on patient safety, the Sentinel Event
Standard was established in 2010 by The Joint Commission (JMC). This standard
requires organizations to carry out designated steps to fully understand the factors
and systems associated with adverse patient events, given that certain defining
characteristics have been confirmed.

■ The steps revolve around a “‘root-cause’ analysis,” which is a direct application of

the quality improvement principles and methods.

■ The intention behind the root cause analysis is to understand the systems at fault
within the organization so that improvements can be determined and implemented
to prevent any future occurrences.
National Patient Safety Goals

■ The purpose of TJC’s National Patient Safety Goals is to help accredited organizations
address specific areas of concern in regards to patient safety.
■ These goals are based on ongoing analyses of reported sentinel events and the
identified root causes of the events.

■ 2015’s National Patient Safety Goals:

1. Improve the accuracy of patient and resident identification
2. Improve the effectiveness of communication among caregivers
3. Improve the safety of using medications
4. Improve the safety of clinical alarm systems
5. Reduce the risk of health care-associated infections
6. The organization identifies safety risks inherent in its patient population
7. Universal protocol for preventing wrong site, wrong procedure, & wrong person
surgeries
Never Events
■ In 2006, the Centers for Medicare and Medicaid Services (CMS) began to investigate
ways that could help decrease or eliminate the occurrence of never events.

■ Never events are defined as serious and costly errors in health care delivery that
should never happen. Some examples of never events include wrong site surgery,
and mismatched blood transfusions, which can cause serious injury or death to a
patient, leading to increased costs in Medicare.

■ Because of this, Medicare will no longer pay for the additional costs of
hospitalizations for treating hospital acquired conditions that were determined to be
reasonably preventable. A few examples of these hospital acquired conditions
include a foreign body retained after surgery, falls and trauma, pressure ulcers, or
blood incompatibility.
The Professional Nurse and Patient
Safety
■ For nurses, the challenge starts with making patient safety improvement and error
reduction not just as an organizational priority, but a personal one as well.

■ Two significant nursing functions that most closely affect patient safety, quality of
care, and resulting outcomes are:
1. Monitoring for early recognition of adverse events, complications, and errors
2. Initiating deployment of appropriate care providers for timely intervention and
response and rescue of patients in these situations

■ Although defining the appropriate level of staffing is a matter of linkage between

patient outcomes and nurse staffing.
Nursing Quality Indicators
■ The governing body of the American Nurses Association (ANA) established the
National Database of Nursing Quality Indicators in 1998 as part of the ANA’s safety
and quality initiative.

■ This national database program collects designated indicators that strongly affect
patient clinical outcomes for two major purposes:
1. To provide comparative data to health care organizations to support Quality
Improvement activities
2. To develop national data to better understand the link between nurse staffing
and patient outcomes

■ As of 2014, 2,000 hospitals have joined the database with quarterly reports now
being provided to these organizations for analysis of their own care processes and
support systems as related to nurse staffing.
Interprofessional Teamwork
■ Most nurses and other clinical staff assume they already work in teams, however,
teamwork concepts are infrequently taught in health professional educational
programs.

■ Patient care is dependent on effective interpersonal communication to support the

coordination of activities that promote efficiency and safety.

■ One strategy to improve interprofessional teamwork is Team Strategies and Tools to

Enhance Performance and Patient Safety (TeamSTEPPS). TeamSTEPPS was
developed as an evidence-based teamwork system aimed at optimizing patient
outcomes by improving communication and teamwork skills among health care
professionals.
QSEN Competencies

■ There are six listed competencies that have been incorporated into the nursing
education standards and the nursing licensure exam. The reason these competencies
have been included are to hold all nurses accountable in these areas. The guidelines
were also instituted with the intent to standardize the practice of nursing across the
United States. The competencies are as follows:

1. Patient-centered care
2. Teamwork and Collaboration
3. Evidence-based practice
4. Quality Improvement
5. Safety
6. Informatics
 Patient-Centered Care

■ Definition- Recognized the patient as the source of control and partner in providing
compassionate and coordinated care based on the patient’s values, preferences, and needs.
– You need to be able to think on multiple levels. This means you need to understand that
the patient’s culture, ethnicity, and social values, such as family and community, effects
their life.

■ You can implement this knowledge by being respectful of the patient’s beliefs and inform
your health care staff of what you learned.

■ Lastly, an easy way to check if you’re being respectful is trying to see the situation
through the patient's eyes.
Teamwork and Collaboration

■ Definition- function effectively with nursing and interpersonal teams, fostering open
communication, mutual respect, and shared decision making to achieve quality care.

■ One way to achieve this is to understand your own strengths, limitations, and weaknesses. By
understanding yourself, it better enhances the functionality and safety of the team as long as
you communicate it to each other.

■ If you communicate your strengths and weaknesses with one another, it minimizes and limits
the risk of you, a patient, or another staff member getting hurt in the process. By default
increasing the safety of the hospital.
Evidence-Based Practice

■ Definition- integrate the best current evidence with clinical expertise, patient/family
preference, and values for optimal healthcare.

■ In order to do this, you must have basic knowledge of the scientific method and its processes.
You must also be able to distinguish between valid and invalid reasoning for the best care of
the patient.

■ Application of this competency can be done through appropriate data collection and research
activities. Nurses should also consult with clinical experts before deviating from established
protocols.
Quality Improvement
■ Definition- use data to monitor the outcomes of care processes and use improvement
methods to design and test changes to continually improve the quality and safety of the
health care system.

■ One way you can apply this is by staying active and engaged in the clinical setting you’re in
and describe better approaches to change the processes of care.

■ This can be done by seeking information about outcomes of a population served in a care
setting and putting together a designed test.

■ Lastly, a big takeaway is to appreciate the ever-changing quality care improvements and to
realize they play an essential role in medicine.
Safety

■ Definition- minimize the risk of harm to patients and providers through system effectiveness
and individual performance.

■ One should examine human factors and other safety design principles along with commonly
used unsafe practices.

■ You can implement this by being effective in the use of technology and using the preset
guidelines of safety you are provided with while also working to develop your own effective
safety in the care setting.
Informatics

■ Definition- The use of information and technology to communicate, manage knowledge,

lessen errors, and support decision making.

■ A way this is done is by having essential information in a database to support patient care.

■ Some important skills that are need is the ability to navigate the electronic health records, and
the ability to respond appropriately to clinical decision making.
Role of Professional Nurses in Quality
Improvement
■ The shift in health care has became a push towards building a system that does not
harm while increasing the six goals of competency.

■ Florence Nightingale paved the way for innovation in health care during the Crimean
War by limiting the spread of disease and infection. Today, nurses sit in the perfect
position to lead this cultural change.

■ What will you achieve?

Questions

■ The process of quality is defined as…

a. the differences in how the steps can be accomplished
b. a series of linked steps necessary to accomplish work
c. improvements in the healthcare system
d. basing practice on evidence
Questions

■ The process of quality is defined as…

a. the differences in how the steps can be accomplished
b. a series of linked steps necessary to accomplish work
c. improvements in the healthcare system
d. basing practice on evidence
Questions

■ The IHI Quality Improvement Model is also known as the:

a. act-plan-do-check cycle
b. do-check-act-plan cycle
c. plan-do-check-act cycle
d. check-act-plan-do cycle
Questions

■ The IHI Quality Improvement Model is also known as the:

a. act-plan-do-check cycle
b. do-check-act-plan cycle
c. plan-do-check-act cycle
d. check-act-plan-do cycle
Questions

■ What does QSEN stand for?

a. QSEN
b. Quality and Safety Education for Nurses
c. Quantity and Safety Education for Nurses
d. Quit and Study Early Childhood Education
Questions

■ What does QSEN stand for?

a. QSEN
b. Quality and Safety Education for Nurses
c. Quantity and Safety Education for Nurses
d. Quit and Study Early Childhood Education
Questions

■ Which one of the following is not one of the standards and programs that were
developed to promote patient safety?
a. Sentinel Event Standard
b. Interprofessional Teamwork
c. National Patient Safety Goals
d. Never Events
Questions

■ Which one of the following is not one of the standards and programs that were
developed to promote patient safety?
a. Sentinel Event Standard
b. Interprofessional Teamwork
c. National Patient Safety Goals
d. Never Events
Works Cited

Cherry,, B. (2018). Contemporary Nursing. 7th ed. [S.l.]: MOSBY, pp.378-396.

Elf, M., Fröst, P., Lindahl, G., & Wijk, H. (2015). Shared decision making in designing new healthcare environments--time to begin improving quality.

BMC Health Services Research, 15(1), 1–7

Evans, M. (2018). Quality Improvement in Healthcare. [online] YouTube.

ISMP. (2011, April 1). Medication Safety Self Assessment ® for Hospitals. Retrieved from https://www.ismp.org/assessments/hospitals