1. •Florence Nightingale
    –Designed method to collect & present statistics
  2. •1903 Nursing Licensure
    –Became mandatory
  3. •1972 Social Security Act
    –Amended to establish Professional Standards Review Organization (PSRO)

    • –Mandate process of review of delivery of health care to clients of Medicare, Medicaid
    • and maternal & child health programs
  4. •1986 National Health Quality Improvement Act
    –Encouraged consumers to become informed about their practice

    –Created clearinghouse of provider malpractice records
  5. •1992 JCAHO
    –Revised accreditation standards replacing quality assurance requirements with quality assessment & improvement requirements
  6. Defining Quality
    • •“Continuously striving for excellence while
    • adhering to set expectations or guidelines”

    • •IOM: “the degree to which health services for
    • individuals and populations increase the likelihood of desired health outcomes
    • and are consistent with current professional knowledge”
  7. Scope of Problem
    •1.6 trillion spent on healthcare

    • •$37 billion spent as a result of medical
    • errors

    •Between 44,000 and 98,000 Americans die as a result of medical errors

    • •Medication errors found to be one of the most
    • common preventable and deadly medical error
  8. Problems with quality of health care
    •Over use

    •Under use

  9. •Very little is known about quality of care in
    the U.S. because:
    –A variety of definitions of quality are used

    –It is difficult to get comparable data from all providers and health care agencies
  10. ANA Nursing Report Card
    • •Developed by ANA (1995) in an effort to
    • standardize patient outcomes that are sensitive to nursing care

    •For use by healthcare organizations

    •Outcomes measured include:

    –Mortality rates

    –Length of stay

    –Adverse incidents; complications

    –Patient satisfaction with nursing care
  11. •Quality Assurance (QA)
    • –methods & tools help agencies conform to standards required by external accrediting
    • agencies

    –Post event investigation
  12. •Continuous Quality Improvement (CQI) / Total Quality Management (TQI)
    • –Focus on problem prevention & continuous
    • improvement

    • CQI not only addresses system problems but is used to maintain and enhance good
    • performance.
  13. •Formative evaluation of program
    • –Evaluation for purpose of assessing whether objectives are met or planned activities are
    • completed (progress)

    –During program; may be ongoing
  14. •Summative evaluation of program
    • –Evaluation to assess program outcomes or as a follow up of program activities
    • (efficiency)

    –At end of program
  15. Procedure for QA/QI
    •Data is collected

    –Chart audits- retrospectively

    •Compare data to established criteria

    •Identify problems

    •Generation and implementation of solutions


    • •Focus is on nurses and institutions rather
    • than on patients

    • •Concern is with groups of patients rather
    • than individuals
  16. Root Causes
    • •The US Joint Commission on Accreditation of
    • Healthcare Organizations (2004) identifies that a “meaningful improvement in patient safety” is dependent upon:

    •· “Identification of the errors that occur.

    • •· Analysis of each error to determine the
    • underlying factors -- the "root causes" --

    • •that, if eliminated, could reduce the risk of
    • similar errors in the future.

    • •· Compilation of data about error frequency
    • and type and the root causes of these errors.

    • •· Dissemination of information about these
    • errors and their root causes to permit

    • •health care organizations, where appropriate,
    • to redesign their systems and

    • •processes to reduce the risk of future
    • errors.

    • •· Periodic assessment of the effectiveness of
    • the efforts taken to reduce the risk oferrors.”
  17. Root Cause Assumptions
    • •Most errors have several factors that
    • contribute to either an actual error or a near miss (Swiss-cheese model)

    •Questions: “What happened?” “What should have happened?" “Why did it happen?” “What can be done to correct the error?”

    • •Goal: Discover factors that contributed to
    • the error
  18. Evaluates three components of care
    • •Structure
    • –Looks at the setting
    • –i.e. bedrails available on each bed

    • •Process
    • –Looks at caregiver activities
    • –i.e. fall risk assessments were completed on all clients

    • •Outcome
    • –Looks at patient responses or grouped pt responses
    • –i.e. no falls during hospital stay or home care duration
  19. Quality Assurance (QA)
    1.Ensure the delivery of quality client care

    2.Demonstrate the efforts of health care provider to deliver quality care

    •Focuses on assessing/ measuring performance

    •Ensures that performance meets standards

    • •Takes action for change when care does not
    • meet standards
  20. Continuous Quality Improvement (CQI)
    •Builds on QA

    •Uses scientific process to look at

    –Work systems

    –Processes of an organization

    •Focuses on internal & external “clients”
  21. Total Quality Management (TQM)
    • •Structured, systematic process of planning
    • for quality

    •Process-driven and “customer”- oriented




    –Employee empowerment

    –Individual responsibility

    –Continuous improvement of processes à better outcomes
  22. Quality websites
    •AHRQ - Agency for Healthcare Research and Quality

    •IHI - Institute for Healthcare improvement

    •JCAHO - Joint Commission on Accreditation of Healthcare Organizations

    • •NAHQ - National Association for Healthcare
    • Quality

    •IOM - Institute of Medicine

    •NCQA - National Committee for Quality Assurance
  23. Failure Mode Effect Analysis (FMEA)
    • •FMEA is a systematic, proactive method for
    • evaluating a process to identify where and how it might fail, and to assess the relative impact of different failures in order to identify the parts of the process that are most in need of change.

    •Steps in the process:

    Failure modes (What could go wrong?)

    Failure causes (Why would the failure happen?)

    Failure effects (What would be the consequences of each failure?)
  24. FMEA Types
    •Sentinel Events

    •Failure to Rescue


    •Rapid Response Team
  25. •Failure to Rescue
    • –The term refers to cases where caregivers fail to notice or respond when a patient
    • is dying of preventable complications in a hospital.
  26. •Sentinel Events
    –A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof and they signal the need for immediate investigation and response
  27. Rapid Response
    The initiative for Rapid Response was also discussed in the video that is available in the clinical shell “Remaking American Health”.
  28. •Rapid Response Team
    • –Purpose is to identify and treat patients before the patients’ condition deteriorates
    • to the point that CPR is needed
  29. •Near-Miss
    • –Based on the recommendations of the Institute of Medicine's 1999 report To Err Is Human, which advocated studying near
    • misses "to detect system weaknesses before the occurrence of serious harm" (IOM, 2000).
  30. Potential outcome benefits..
    • •Application of strategies to five areas of
    • performance could affect both process & outcomes of care.

    –Consistently providing appropriate & effective care

    –Eliminating avoidable mistakes

    –Lowering access barriers

    –Improving responsiveness to patients

    –Eliminating racial/ethnic, gender, socioeconomic & other disparities & inequalities in access and treatment
  31. Model Quality Assurance Program
    • •Primary purpose of a quality assurance
    • program is to ensure that the results of an organized activity are
    • consistent with the expectations

    –Structure (philosophy and objectives)

    –Process (specific appraisal)

    –Outcome (evaluation of outcome standards)

    –Evaluation, interpretation, and action
  32. Approaches

    • –Credentialing, licensure, accreditation, certification, charter, recognition & academic
    • degrees


    • –professional performance, efficient use of resources, minimal risk to the client of illness
    • or injury associated with care & client satisfaction
  33. Credentialing:
    • •Formal recognition that institutions or
    • individuals have met minimal standards of performance

    –Licensure: controls entry into profession

    •Contract between profession and state

    •Written regulations define scope and limits of practice
  34. Accreditation
    (Voluntary) For institutions

    •Perform self-study

    •Evaluated by individuals familiar with type of institution

    • •Physical structure, organizational structure, personnel qualifications, educational
    • qualifications of staff
  35. Certification
    • (Voluntary) Combines features of licensure and accreditation for individuals in
    • specialty areas


    •Educational preparation

  36. Intersection of TQM, Managed Care & Nursing
    •With TQM the organization cannot be transformed if participants are not involved

    •In public health, TQM focus areas are


    –Focus on the “customer” (client, family, group or other health care providers)
  37. Documentation
    • •is essential to the evaluation of quality
    • care in any organization

    –Medical Records
Card Set
Quality improvement