BAPTIST HEALTH SCHOOL OF NURSING NSG 4027: PROFESSIONAL ROLES IN NURSING PRACTICE

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1 BAPTIST HEALTH SCHOOL OF NURSING NSG 4027: PROFESSIONAL ROLES IN NURSING PRACTICE H1 QUALITY IMPROVEMENT 2006 LECTURE OBJECTIVES: 1. Differentiate between the concepts of quality control/assurance and quality improvement. 2. Conceptualize Deming s points of quality management. 3. Identify the benefits of quality management. 4. Implement the six steps of the quality improvement process. 5. Differentiate between quality management and risk management. 6. Apply principles of quality improvement process in the clinical laboratory. READING ASSIGNMENT: Yoder-Wise (3 rd ed.) - Chapter 11, pp and 45. VOCABULARY: continuous quality improvement (CQI) quality indicators quality assurance (QA) quality improvement (QI) quality management (QM) research risk management scientific method standard of care standard of practice triangulation LECTURE OUTLINE: I. Introduction A. Quality of care - must be defined in qualitative terms in healthcare today JCAHO added a requirement for hospitals to evaluate quality of care 2. ANA - established quality indicators, concerned with safety and quality of care. a. Standard of care - minimum level of skills and learning common to members of the profession. b. Standard of practice - defined by ASBN, ANA, JCAHO, and AHD. The expectations for ourselves and others. c. Objective: to assist health organizations to identify links between nursing care and patient outcomes.

2 3. Questions: What is quality care? and How can quality be measured? H2 a. Third party payers - b. Consumer- II. Quality Management A. Definition: prevention of patient care problems. B. Evolution of quality management 1. Past terminology a. Quality control - b. Quality assurance - focused on clinical aspects of provider of care, often in response to errors. Placed blame. 2. Present terminology a. Total quality management - b. Continuous quality improvement 3. Evolving terminology a. Quality managementb. Quality improvementc. Performance improvement- C. Historical Influences of quality management 1. W. Edward Deming - a statistician; a. post WWII lectured in Japan r/t Philosophy - to build quality into every product and service. b. 14 points of quality management 1. Create constancy of purpose for improvement of product and service. 2. Adopt the new philosophy. 3. Cease dependance on inspection to achieve quality. 4. End the practice of awarding business on the basis of price tag. 5. Improve constantly and forever the systems of production and service. 6. Institute training on the job. 7. Institute leadership. 8. Drive out fear. 9. Break down barriers between departments. 10. Eliminate slogans, exhortations, and targets for the workforce. 11. Eliminate numerical quotas for the workforce and numerical goals for management. 12. Remove barriers that rob people of pride and workmanship. 13. Institute a vigorous program of education and self improvement for everyone. 14. Put everyone in the company to work to accomplish the transformation.

3 c. Outcome: efficient production and excellent products. d. America increase in global market, Principles applied to business, industry, education and healthcare. H3 2. J.M. Duran - a. developed a structured process (QI) using self-directed teams. b. Focus - to detect and correct quality problems. 3. Magnet hospitals - use QI factors to attract and retain nurses in times of shortage. a. Structured factors - decentralization, participative management style and influential nurse executives. b. Process factors - professional autonomy and professional development. c. Outcome - a direct correlation between the control nurses report to have in practice setting and patient s rating of quality of care. D. Principles of Quality Management and Quality Improvement 1. Quality management operates most efficiently within a flat, democratic organization structure. 2. Managers and workers must be committed to Quality Improvement. 3. The goal of Quality management is to improve systems and processes, not to assign blame. 4. Customers define quality. 5. Decisions are based on data. E. Benefits of Quality Management 1. Cost containment 2. Greater efficiency and proactive planning to maintain quality. 3. Reduce legal malpractice - 4. Involves everyone F. Planning for Quality Management 1. Multi-disciplinary 2. Takes time and money 3. Poor planning creates a. Increases in cost b. Increases in liability risk c. Negative public image d. Increased employee frustration and turnover.

4 III. Quality Improvement H4 A. Focus: Outcome B. Goals: a. To improve the system and not place blame b. To educate and involve all employees to the process. C. Involvement - everyone vs specialist a. Ultimate responsibility with top management. b. Democratic atmosphere vs fear/control. D. Customers 1. Internal customers - individuals within an organization who receive products/services. 2. External customers - people/groups outside the hospital who receive products/services. 3. Assessing customer satisfaction - safety, effectiveness and timeliness a. Questionnaires b. Interviews c. Focus group discussions d. Observation F. Decisions - based on data gathered and analyzed 1. Statistical tools - used to make objective decisions a. Brainstorming b. Fishbone c. Multi-vote d. Process analysis IV. Quality Improvement Process A. Identify needs most important to the customer. 1. Focus: concentrate on changes to patient care that will have the greatest effect. Also, used for self-evaluation and improved individual performance. 2. Pareto principle - 80% of positive improvement in clinical care comes from focusing on 20% of essential patient care tasks and processes. a. Survey clients -re: physical tasks and/or interpersonal care. b. Research study (2001) identifies priority issues i. Outcome ii. Caring iii. Competence iv. Timeliness

5 H5 v. Professional relationship vi. Scope of practice vii. Environment viii. Support systems B. Assemble a multi-disciplinary teams - review identified customer needs and services. 1. Team - across section of workers involved in the problem. 2. Education - 3. Teamwork C. Collect data - to measure current status of identified services. 1. Data tools D. Establish outcome a. Flowcharts b. Line graphs c. Histograms d. Pareto chart e. Fishbone 1. Involves standard of practice 2. Measurable 3. Bench marking 4. Standardized nursing classification Systems a. NANDA b. NIC c. NOC E. Select and Implement Plan 1. Discussion 2. Selection 3. Implementation 4. Staff education 5. Review policy and procedure F. Evaluation 1. Continue data collection - 2. Analyze outcome 3. Public acknowledgment V. Quality Assurance - periodic inspection to detect errors and determine responsibility. A. Focus - clinical aspects of care

6 H6 B. Methods A. Chart reviews B. Chart audits C. Observation D. Sentinel Events VI. Risk Management - analyzing problems and minimizing losses after an error has occurred. A. Malpractice crisis B. JCAHO (1990) -recognized sentinel events and need for self-reporting C. Functions of risk management 1. Define situation (med errors, falls) 2. Determine frequency 3. Investigation of events 4. Identify potential risk/opportunities to improve care. D. Root cause analysis - develop risk reduction strategies. 1. Five-why Technique - to identify the underlying problem a. Why did it happen? b. Why did the conditions exist? c. Why were you not.... (there, aware, told, etc)? d. Why weren t the proper authorities notified? e. Why weren t Done/available? 2. Triangulation a. Multiple data sources b. Multiple data collection techniques c. Multiple perspectives d. Quantitative methods e. Qualitative methods VII. VIII. IX. Elements of the Quality Improvement Report (See H7- H8) - Course assignment Quality Improvement Evaluation tool (H9) Quality Improvement Report form (H10)