Chapter 22
Quality Improvement and
Patient Safety
Urgent Case for Quality Improvement
in the Nation’s Healthcare System
Over the past 20 years, major reports documented major
problems with patient safety and quality in the U.S.
healthcare system
Hospitals/health systems across the country are working to
improve quality and safety
Improvements are being made but problems persist in
areas such as:
adverse drug events
healthcare-associated infections (HAIs)
falls
obstetric adverse events
Ten Simple Rules to Guide Improvements
(Institute of Medicine, 2001)
Care based on continuous healing relationships
Care customized to patient needs and values
The patient is the source of control
Knowledge is shared, and information flows freely
Decision making is evidence based
Safety is a system property
Transparency is necessary
Needs are anticipated
Waste is continually decreased
Cooperation among clinicians is a priority
Cornerstones of Quality Management
Quality: customer defines quality
Scientific approach:
decisions are based on sound, valid data
people managing the processes have a clear
understanding of the nature of variation in processes
organizational support for all employees to develop
knowledge and skills in the science of QI
“All one team”: belief in the people who are
working to serve the customer
Regulatory and Accreditation Agencies
Drive quality improvement efforts in health care
Almost all regulatory and voluntary accrediting
agencies require quality management in some
form
Regulatory organizations
Centers for Medicare & Medicaid Services (CMS)
• Administers the Medicare program
• Requires quality management in “Conditions of Participation”
State licensing authorities require quality
management activities and set quality standards
The Joint Commission (TJC)
Health care organizations voluntarily seek TJC
accreditation to demonstrate that they have achieved a
“gold seal of approval” in quality and safety standards
TJC one of the first accreditation agencies to embrace
QI principles as an accreditation requirement in hospitals
TJC requires accredited hospitals to collect standardized
measures referred to as the National Hospital Quality
Measures
Data for accredited hospitals is publicly reported at TJC’s
website Quality Check ([Link])
National Hospital Quality Measures
Measures are being used along with patient satisfaction
scores and other select clinical measures “pay for
performance”
Goal is to move health care payments away from simply paying for
the provision of services to paying based on the quality process
and outcomes associated with those services
Measures address treatment for many conditions including
acute myocardial infarction
heart failure
pneumonia
perinatal care
children’s asthma care
stroke
immunizations
Critical Thinking Question
1. A patient understands that the hospital where he is
currently having a procedure done is “Joint
Commission” accredited. The patient asks the nurse
how accreditation ensures that patients receive the best
care possible. The nurse informs the patient that there
are several quality initiatives required by The Joint
Commission in order for the hospital to be accredited.
One of these quality initiatives is known as:
A. Pareto charts
B. Never events
C. National Hospital Quality Measures
D. PDSA cycle
Clinical Indicators
Foundation for quality monitoring and evaluation
Measurable aspects of care that show the
degree to which clinical care is carried out (e.g.,
administer correct IV solution at prescribed rate)
Used as an assessment of clinical care to
identify areas in which quality improvement
issues may be present
Help to identify the goals of quality improvement
Process Improvement
Strategies/Models
Lean methodology
Six Sigma
Failure mode and effects analysis
All support the understanding of key work processes:
Analyzing and clearly understanding the work process
Selecting the key aspects of the process to improve
Establishing “trial” targets to guide improvement
Collecting and plotting data
Interpreting results
Implementing improvement actions and evaluating effectiveness
Process Improvement Tools
Flowchart (see Figures 22-1 and 22-2 in text)
Pareto chart (see Figure 22-3 in text)
Cause-and-effect diagram (see Figure 22-4 in
text)
Run chart (see Figure 22-5 in text)
Critical Thinking Question
2. A quality improvement team was collecting data to
determine how nurses use their time and to identify
areas to improve nurses’ efficiency. The team found
that 60% of nurses’ time was spent charting, 30% was
spent in direct patient care activities, and 10% was
spent on patient and family teaching. Which type of
chart would best support the data collected by the
quality improvement team?
A. Cause and effect
B. Flowchart
C. Pareto
D. Time plot
Standardizing Care Processes
Referred to as best known methods or best
practices
Care carried out in uniform, systematic method
Employees trained to perform procedures
according to standards rather than learning by
watching others
Avoids haphazard changes to procedures
Standardized practices should be based on
scientific evidence and research
Institute for Healthcare Improvement
(IHI)
Voluntary organization formed to assist health
care leaders to improve quality
Led development of change concepts for
specific areas
Reducing patient delays
Reducing cesarean deliveries
Reducing adverse drug events
Website: [Link]
Quality Improvement Model
(Langley GJ, Nolan KM, Nolan TW, Norman CL, Provost LPet al:. The
Improvement Guide: A Practical Approach to Enhancing Organizational
Performance. 2nd ed. San Francisco: Jossey-Bass; 2009)
Ask Three fundamental questions
What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make that will result in
improvement?
Implement Plan–Do–Study–Act (PDSA) cycles
(see Figure 22-7 in text)
Patient Safety
Institute for Safe Medication Practices
Nonprofit organization known as an education resource for the
prevention of medication errors
Provides independent, multidisciplinary, expert review of reported
errors
Health care professionals across the nation voluntarily and
confidentially report medication errors and hazardous conditions
that could lead to errors
Offer Medication Safety Self Assessments to allow nurses and
other health care professionals to assess the medication safety
practices in their work setting
[Link]
Programs Initiated to Improve Patient Safety
TJC sentinel event standard
Requires organizations to carry out designated steps & root
cause analysis to fully understand the factors and systems
associated with adverse patient events
National Patient Safety Goals
See Box 22-1 in text for 2018 patient safety goals
CMS “never events”
Serious, costly errors that should never happen and for which
CMS will no longer pay the additional cost of hospitalization to
treat
Nursing Quality Indicators
Provide comparative data to support QI activities
Help to better understand the link between nurse staffing and
patient outcomes
The Professional Nurse and
Patient Safety
Answers for improved patient safety require all care
providers to pull together to review critical circumstances
and learn from key events
Nurses’ challenge is to make patient safety a personal
priority
Two nursing functions closely influence patient safety
and quality
Monitoring for early recognition of adverse events,
complications, and errors
Initiating deployment of appropriate care providers for timely
intervention and response/rescue of patients in these situations
QSEN
(Quality and Safety Education in Nursing)
QSEN project created to support development of six competencies
for nursing students and nurses
Six QSEN competencies
Patient-centered care
Quality improvement
Teamwork and collaboration
Evidence-based practice
Safety
Informatics
Continual improvement in the six competencies allows nurses to
shape the quality and safety of health care systems
Nurses’ Role in Quality Improvement
Enter practice with the knowledge and skills to
make quality improvement part of their regular
work
Quality improvement should not be considered a
separate function within the nursing role but
rather an ongoing part of the professional role