CHAPTER 6 • MANAGING AND IMPROVING

QUALITY
Quality Management
Quality management moved health care from a mode of identifying failed standards, problems,
and problem people to a proactive organization in which problems are prevented and ways to
improve care and quality of care are sought. A quality management program is based on an
integrated system of information and accountability.
Total Quality Management
Total quality management (TQM) is a management philosophy that emphasizes a commitment
to excellence throughout the organization. The creation of Dr. W. Edwards Deming, TQM was
adopted by the Japanese after World War II and helped transform their industrial development.
TQM Characteristics
Four core characteristics of total quality management are:
● Customer/client focus
● Total organizational involvement
● Use of quality tools and statistics for measurement
● Key processes for improvement identified

Figure 6-1 •PDCA cycle.

Customer/Client Focus. An important theme of quality management is to address the needs of
both internal and external customers. Internal customers include employees and departments
within the organization, such as the laboratory. External customers of a health care organization
include patients, visitors, physicians, Under the principles of TQM, nurses must know who the
customers are and endeavor to meet their needs.
Total Organizational Involvement. The goal of total quality management is to involve all
employees and empower them with the responsibility to make a difference in the quality of service
they provide. The phrase “That’s not my job” is eliminated. Departments work together as a team.
Sharing processes across departments and patient care functions
increases teamwork, productivity, and patient positive outcomes.
Identification of Key Processes for Improvement. All activities performed in an
organization
can be described in terms of processes. Processes within a health care setting can be:
● Systems related (e.g., admitting, discharging, and transferring patients)
● Clinical (e.g., administering medications, managing pain)
● Managerial (e.g., risk management and performance evaluations).
Processes can be very complex and involve multidisciplinary or interdepartmental actions.
Continuous Quality Improvement
TQM is the overall philosophy, whereas continuous quality improvement (CQI) is used to
improve
quality and performance. TQM and CQI often are used synonymously. In health care organizations,
CQI is the process used to investigate systematically ways to improve patient care. As
the name implies, continuous quality improvement is a never-ending endeavor (Hedges, 2006).
CQI means more than just meeting standards and thresholds or solving problems. It involves
evaluation, actions, and a mind-set to strive constantly for excellence.
There are four major players in the CQI process:
● Resource group
● Coordinator
● Team leader
● Team
The resource group is made up of senior management (e.g., CEO, vice presidents). It establishes
overall CQI policy, vision, and values for the organization and actively involves the board
of directors in this process, The CQI coordinator is often appointed by the CEO to provide
day-to-day management of the CQI process and related activities (e.g., training programs).
CQI teams are designated to evaluate and improve select processes. CQI teams range in size from 5
to 10 people, Each CQI team is headed by a team leader who is familiar with the process being
evaluated.
The leader organizes team meetings, sets the agenda, and guides the group through the discussion,
evaluation, and implementation process.
Components of Quality Management
A comprehensive quality management program includes:
● A comprehensive quality management plan. A quality management plan is a systematic
method to design, measure, assess, and improve organizational performance. Critical paths identify
expected outcomes within a specific
time frame. Then variances are tracked and accounted for.
● Set standards for benchmarking. Standards are written statements that define a level
of performance or a set of conditions determined to be acceptable by some authorities.
Standards relate to three major dimensions of quality care:
a. Structure
b. Process
c. Outcome
Structure standards relate to the physical environment, organization, and management of an
organization. Process standards are those connected with the actual delivery of care. Outcome
standards involve the end results of care that has been given.
An indicator is a tool used to measure the performance of structure, process, and outcome
standards. It is measurable, objective, and based on current knowledge. In nursing, both generic and
specific standards are available. An example of a standard is, “Every patient will have a written care
plan within 12 hours of
admission.”
● Performance appraisals. Based on requirements of the job, employees are evaluated
on their performance. This feedback is essential for employees to be professionally
accountable.
● A focus on intradisciplinary assessment and improvement. There will always be a
need for groups to assess, analyze, and improve their own performance. Methods to
assess performance should, however, focus on the CQI philosophy, which involves
group or intradisciplinary performance.
● A focus on interdisciplinary assessment and improvement. Multidisciplinary, patientfocused
teamwork emphasizing collaboration, communication, coordination, and integration
of care is the core of CQI in health care. It is important not to disband departmental
quality functions, such as patient satisfaction,
Six Sigma
Six Sigma is another quality management program that uses, primarily, quantitative data to
monitor progress. Six Sigma is a measure, a goal, and a system of management.
● As a measure. Sigma is the Greek letter—ó—for standard, meaning how much performance
varies from a standard. This is similar to how CQI monitors results against an outcome
measure.
● As a goal. One goal might be accuracy. How many times, for example, is the right medication
given in the right amount, to the right patient, at the right time, by the right route?
● As a management system. Compared to other quality management systems, Six Sigma
involves management to a greater extent in monitoring performance and ensuring favorable
results.
The system has six themes:
● Customer (patient) focus
● Data driven
● Process emphasis
● Proactive management
● Boundaryless collaboration
● Aim for perfection; tolerate failure.
The first three themes are similar to other quality management programs. The focus is on the
object of the service; in nursing’s case, this is the patient.
The latter three themes, however, differ from other programs. Management is actively
involved and boundaries are breached (e.g., the disconnect between departments).
Lean Six Sigma
Lean Six Sigma focuses on improving process flow and eliminating waste. Lean Six Sigma focuses
on identifying steps that have little or no value to the care and cause unnecessary delays. Because
the goal of Lean Six Sigma is to identify and reduce waste, it provides tools that
can be used with a Six Sigma management system.
DMAIC Method
DMAIC is a Six-Sigma process improvement method (as shown in Figure 6-2). Steps in the
method are:
● Define what measures will indicate success
● Measure baseline performance
● Analyze results
● Improve performance
● Control and sustain performance (DMAIC Tools: Six Sigma Training Tools, 2011)
TQM, CQI, Six Sigma, Lean Six Sigma, and DMAIC are quantifiable systems that measure
performance against set standards. The goal is to improve the quality of health care.

Improving the Quality of Care

National Initiatives
The National Quality Forum is a nonprofit organization that strives to improve the quality of
health care by building consensus on performance goals and standards for measuring and reporting
them (National Quality Forum, 2011). Additionally, the Institute of Healthcare Improvement
(IHI) offers programs to assist organizations in improving the quality of care they provide (IHI,
2011). Their goals are:
● No needless deaths
● No needless pain or suffering
● No helplessness in those served or serving
● No unwanted waiting
● No waste
Joint Commission, hospitals’ accrediting body, has adopted mandatory national patient
safety goals (Joint Commission, 2011). They charge hospitals to:
● Identify patients correctly
● Improve staff communication
● Use medicines safely
● Prevent infection
● Check patient medicines
● Identify patient safety risks
●Prevent mistakes in surgery
They recommend that quality measures be based on four criteria:
1. The measure must be based on research that shows improved outcomes. More than one
research study is required for documentation.
2. Reports document that evidence-based practice has been given. Aspirin following an acute
myocardial infarction is an example.
3. The process documents desired outcome. Appropriately administering medications is an
example.
4. The process has minimal or no unintended adverse effects (Chassin et al., 2010)
How Cost Affects Quality
Quality measures can also reduce costs. Wasted resources is an example. Using the Institute for
Healthcare Improvement (2009) project, Transforming Care at the
Bedside (TCAB), Unruh, Agrawal, and Hassmiller (2011) found that improving quality reduces
costs. Specifically, the researchers report that in a three-year period, RN overtime was reduced,
RN turnover was lowered, and fewer patients suffered falls.
Evidence-Based Practice
Evidence-based practice (EBP) suggests that using research to decide on clinical treatments
would improve quality of care, and that might be the case. Barriers, however, prevent EBP from
being widely used by nurses. Such barriers, consistent across settings, include lack of time,
autonomy over their practice, ability to find and assess evidence, and support from administration
(Brown et al., 2008).
Electronic Medical Records
Similar to the argument that EBP improves quality, electronic medical records (EMR) should
do so as well. Instant access to identical records should improve accuracy and speed communication
among care providers. EMR use, is expected to expand and will
provide more data for comparison with quality.
Dashboards
Dashboards are electronic tools that can provide real-time data or retrospective data, known as
a scorecard. Both are useful in assessing quality.
Nurse Staffing
Evidence is growing that increased nurse staffing results in better patient outcomes. Earlier studies
found that a higher
RN-to-patient ratio resulted in reduced patient mortality, fewer infections, and shortened lengths
of stay (Reeves, 2007).
Reducing Medication Errors
In 2009, the federal government passed the Health Information
Technology for Economic and Clinical Health Act (HITECH). The purpose of HITECH is to stimulate
technology use in health care, including improving technology for medication administration.
Studies have shown that when nurses are interrupted during medication preparation, a
25 percent rate of injury-causing errors are made (Westbrook et al., 2010). One strategy to alert
others that a nurse should not be interrupted is the use of a sash or vest that the nurse dons to
prepare medications (Heath & Heath, 2010).
Other strategies to reduce medication errors include computerized prescriber order entry
(CPOE), electronic medication administration record (eMAR), remote order review by pharmacists,
automated dispensing at the bedside, bar code administration, smart pumps, and unit doses
ready to be administered (Federico, 2010). Future strategies include radio frequency identification
and electronic reconciliation, both expensive technologies currently being tested (Federico, 2010).
Peer Review
peer review can be used to identify clinical standards of practice that improve the quality
of care. The purpose is to review the incident, determine if clinical
standards were met or not, and to propose an action plan to prevent a future incident.
The peer review process is appropriate in the following situations:
● An adverse patient outcome has occurred.
● A serious risk or injury to a patient occurred.
● A failure to rescue incident occurred (Fujita et al., 2009).
To aggregate trends, peer review cases can be categorized as:
● Appropriate care with no adverse outcomes
● Appropriate care with adverse/unexpected outcomes
● Inappropriate care with no adverse outcomes
● Inappropriate care with adverse/unexpected outcomes (Hitchings et al., 2008)
Risk Management
Risk management is a component of quality management, but its purpose is to identify, analyze,
and evaluate risks and then to develop a plan for reducing the frequency and severity of accidents
and
injuries. Risk management is a continuous daily program of detection, education, and intervention.
A risk management program:
1. Identifies potential risks for accident, injury, or financial loss. Formal and informal
communication with all organizational departments and inspection of facilities are
essential to identifying problem areas.
2. Reviews current organization-wide monitoring systems (incident reports, audits, committee
minutes, oral complaints, patient questionnaires), evaluates completeness, and determines
additional systems needed to provide the factual data essential for risk management control.
3. Analyzes the frequency, severity, and causes of general categories and specific types of
incidents causing injury or adverse outcomes to patients. To plan risk intervention strategies,
it is necessary to estimate the outcomes associated with the various types of incidents.
4. Reviews and appraises safety and risk aspects of patient care procedures and new
programs.
5. Monitors laws and codes related to patient safety, consent, and care.
6. Eliminates or reduces risks as much as possible.
7. Reviews the work of other committees to determine potential liability and recommend
prevention or corrective action. Examples of such committees are infection, medical
audit, safety/security, pharmacy, nursing audit, and productivity.
8. Identifies needs for patient, family, and personnel education suggested by all of the
foregoing and implements the appropriate educational program.
9. Evaluates the results of a risk management program.
10. Provides periodic reports to administration, medical staff, and the board of directors.
Nursing’s Role in Risk Management
it is the staff, with their daily patient contact, who actually
implement a risk management program.
High-risk areas in health care fall into five general categories:
● Medication errors
● Complications from diagnostic or treatment procedures
● Falls
● Patient or family dissatisfaction with care
● Refusal of treatment or refusal to sign consent for treatment
Nursing is involved in all areas, but the medical staff may be primarily responsible in cases
involving refusal of treatment or consent to treatment.
Incident reports are used to analyze the severity, frequency, and causes of occurrences within the
five risk categories. Such analysis serves as a basis for intervention.
Incident Reports
Incident reporting is often the
nurse’s responsibility. Reluctance to report incidents is usually due to fear of the consequences.
This fear can be alleviated by:
● Holding staff education programs that emphasize objective reporting
● Omitting inflammatory words and judgmental statements
● Having a clear understanding that the purposes of the incident reporting process are
documentation and follow-up
● Never using the report, under any circumstances, for disciplinary action.
A reportable incident should include any unexpected or unplanned occurrence that affects
or could potentially affect a patient, family member, or staff.
Reporting incidents involves the following steps:
1. Discovery. Nurses, physicians, patients, families, or any employee or volunteer may
report actual or potential risk.
2. Notification. The risk manager receives the completed incident form within 24 hours
after the incident. A telephone call may be made earlier to hasten follow-up in the event
of a major incident.
3. Investigation. The risk manager or representative investigates the incident immediately.
4. Consultation. The risk manager consults with the referring physician, risk management
committee member, or both to obtain additional information and guidance.
5. Action. The risk manager should clarify any misinformation to the patient or family,
explaining exactly what happened. The patient should be referred to the appropriate
source for help and, if needed, be assured that care for any necessary service will be
provided free of charge.
6. Recording. The risk manager should be sure that all records, including incident reports,
follow-up, and actions taken, if any, are filed in a central depository.
Examples of Risk
The following are some examples of actual events in the various risk categories.
Medication Errors
A reportable incident occurs when a medication or fluid is omitted, the wrong medication or
fluid is administered, or a medication is given to the wrong patient, at the wrong time, in the
wrong dosage, or by the wrong route.
Diagnostic Procedure
Any incident occurring before, during, or after such procedures as blood sample stick, biopsy,
X-ray examination, lumbar puncture, or other invasive procedure is categorized as a diagnostic
procedure incident.
Medical–Legal Incident
If a patient or family refuses treatment as ordered and prescribed or refuses to sign consent
forms, the situation is categorized as a medical-legal incident.
Patient or Family Dissatisfaction with Care
When a patient or family indicates general dissatisfaction with care and the situation cannot be
or has not been resolved, then an incident report is filed.
Root Cause Analysis
Root cause analysis is a method to work backwards through an event to examine every action
that led to the error or event that occurred; it is a complicated process. A simplified method to
conduct an event analysis follows:
● Patient—what patient factors contributed to the event?
● Personnel—what personnel actions contributed to the event?
● Policies—are there policies for this type of event?
● Procedures—are there standard procedures for this type of event?
● Place—did the workplace environment contribute to the event?
● Politics—did institutional or outside politics play a role in the event? (Weiss, 2009)

Role of the Nurse Manager

Nurse managers
can reduce risk by helping their staff view health and illness from the patient’s perspective. This
individualized attention produces respect and, in turn, reduces risk. Once an incident has occurred,
the important factors in successful risk management are:
● Recognition of the incident
● Quick follow-up and action
● Personal contact
● Immediate restitution (where appropriate)

Handling Complaints
Handling a patient’s or family member’s complaints stemming from an incident can be very
difficult.
The first step is to listen to the person to hear concerns and to help defuse the situation.
Arguing or interrupting only increases the person’s anger or emotion. Sometimes, a simple apology
from a staff member or moving a patient to a different room on
the unit can resolve a difficult situation. All incidents must be properly documented. Information on
the incident form should be
detailed and include all the factors relating to the incident, status changes and should continue until
the patient returns to his or her previous status.
The chart must never be used as a tool for disciplinary comments, action, or expressions of anger.
Handling a complaint without punishing a staff member is a delicate situation.
A Caring Attitude
One of the most important ways to reduce risk is to instill a sense of confidence in both
patients and families by emphasizing and recognizing that they will receive personalized attention
and that their needs will be attended to with competence. This confidence is created
environmentally
and professionally.
Creating a Blame-Free Environment
The health care environment is known to be a blame culture that “is a major source of medical
errors and poor quality of patient care” (Khatri, Brown, & Hicks, 2009, p. 320). Such a culture
inhibits reporting of inadequate practice, underreporting of adverse events, and inattention to
possible safety problems.
A just culture, in contrast, allows for reporting of errors without fear of undue retribution
(Gorzeman, 2008). Khatri, Brown, & Hicks (2009) suggest that transitioning to a just culture does
more than improve reporting mechanisms or initiate training programs. A just culture provides an
environment in which employees can question policies and practices, express concerns, and admit
mistakes without fear of retribution.
Errors can be
categorized as:
● Human errors, such as unintentional behaviors that may cause an adverse consequence
● At-risk behaviors, such as unsafe habits, negligence, carelessness
● Reckless behaviors, such as conscious disregard for standards

What You Know Now

• Total quality management is a philosophy committed to excellence throughout the organization.
• Continuous quality improvement is a process to improve quality and performance.
• Six Sigma is another quality management program that uses measures, has goals, and is a management
system.
• Lean Six Sigma provides tools to improve flow and eliminate waste.
• DMAIC is a Six Sigma process improvement method to define, measure, analyze, improve, and control
performance.
• A culture of safety and quality permeates efforts at the national level.
• Cost may increase or decrease with quality initiatives.
• Evidence-based practice, electronic medical records, and dashboards can be used to improve and monitor
quality.
• Reducing medication errors is a priority for health care organizations and policy makers.
• A risk management program focuses on reducing accidents and injuries and intervening if either occurs.
• A caring attitude and prompt attention to complaints help to reduce risk.
• A just culture is more likely to encourage reporting of adverse events, including near misses, as well as
point out unsafe practices.
Tools for Managing and Improving Quality
1. Remember: Quality management is a system. When something goes wrong, it is usually due to a
flaw in the system.
2. Become familiar with standards and outcome measures and use them to guide and improve your
practice.
3. Strive for perfection, but be prepared to tolerate failure in order to encourage innovation.
4. Be sure that performance appraisals and incident reports are not used for discipline but rather are the
bases for improvements to the system and/or development of individuals.
5. Remind yourself and your colleagues that a caring attitude is the best prevention of problems.
Following an incident:
1. Meet with the risk manager and hospital attorney to review documentation and determine which
staff will be interviewed regarding the incident.
2. Provide any requested information to administration in a timely manner.
3. Audit documentation and processes to determine if an incident is part of a pattern or an isolated
incident.
4. Provide the results of any audits or discussions with staff to appropriate administrators.
5. Educate staff as appropriate.
6. Determine if disciplinary action is required.
7. Follow up with risk management, nursing administration, and human resources as appropriate.
8. Continue to cooperate with the hospital attorney if the incident results in litigation.