2016 Quality Management

Sandra Webb BSN RN CIC

Quality Management Department

Functions:

Core Measures

Infection Prevention

Patient Safety Officer

Performance Improvement

Performance Improvement

Data is collected, aggregated and

analyzed

Used to drive decision-making

Focus is on processes/systems not

people

Continuing to evaluate outcomes

PDCA – Plan Do Check Act

Methodology

Plan:

Identify the root cause

Generate possible causes

Gather more data

Focus on the causes

Generate and choose the solution

Methodology

Do:

Develop a plan of action

Implement the plan

Monitor closely for deviation

Collect data on the changes

Methodology

Check:

Analyze the data and check the results

Draw conclusions

– Does the process need fine-tuned?

– Did it fail?

– Did it work?

– What are the costs/benefits?

– How can the transition be accomplished?

Methodology

Act:

Standardize the change:

– Flow chart the revised process

– Revise standards, policies/procedures

– Communicate to everyone involved

– Document the project

What can you do?

Look for ways to improve

processes/systems

Report ideas/opportunities to

Supervisor/Director

Serve on teams

Assist with collecting data

National Patient Safety Goals 2016

Goal 1: Improve the accuracy of patient

identification.

– Patient Identification: Use at least two patient

identifiers (name and date of birth) when providing

care, treatment or services.

The patient’s room number or physical location is not

to be used as an identifier.

Label containers that are used for blood and other

specimens in the presence of the patient.

Patient Identification

Before initiating a blood or blood component transfusion:

• Match the blood or blood component to the order.

• Match the patient to the blood or blood component.

• Use a two-person verification process.

Communication Among Caregivers

Goal 2: Improve the effectiveness of communication among caregivers.– Report critical results of tests and diagnostic

procedures on a timely basis.

– Goal: Report critical results/values within 30 minutes of notification and utilize the read back and verified process.

– Exception: The telemetry monitor tech will notify the nurse of critical telemetry values. If patient contact does not occur within 2 minutes, the telemetry monitor tech will implement/call a Code Blue.

Medication Safety

Goal 3: Improve the safety of using

medications.

– Label all medications, medication containers,

and other solutions on and off the sterile field

in peri-operative and other procedural settings.

– Note: Medication containers include syringes,

medicine cups, and basins.

Medication Safety

Reduce the likelihood of patient harm

associated with the use of anticoagulation

therapy.

– Use approved anticoagulant protocols/power

plans

• Heparin, Lovenox (therapeutic), Coumadin

• Provide education to the patient/family

Medication Safety

Maintain and communicate accurate patient medication information. – Obtain a complete medication list including

medications that are taken as needed (prn), over the counter drugs and herbal supplements.

– The medication list will be re-evaluated when the patient transfers from one level of care to another.

– The nurse will review the medication discharge instructions with the patient/family.

Medication Safety

Emergency Department, Radiology Contrast

Testing, Ambulatory Surgery & Office Setting

– Obtain a list of current medications

– At discharge, if the physician writes a prescription,

provide the patient with instructions regarding the

new medications

– If the provider modifies/changes a long term

medication, the entire list of medications will be

reviewed with the patient.

Clinical Alarm Systems

Goal 6: Reduce the harm associated with clinical alarm systems. – Educate staff and licensed independent

practitioners about the purpose and proper operation of alarm systems for which they are responsible.

Healthcare Associated Infections

(HAI)

Goal 7: Reduce the risk of healthcare associated infections.

Hand Hygiene

MDRO

CA-UTI

CLA-BSI

Surgical Site Infections

Education is provided to appropriate staff

Suicide Prevention

Goal 15: The organization identifies safety risks inherent in its patient population.– Conduct a risk assessment that identifies specific

patient characteristics and environmental features that may increase or decrease the risk for suicide

– Address the patient’s immediate safety needs and most appropriate setting for treatment

– When a patient at risk for suicide leaves the care of the hospital, provide suicide prevention information (such as crisis hotline) to the patient and his or her family

Universal Protocol

Conduct a pre-procedure verification process.

– Implement a pre-procedure process to verify the correct procedure, for the correct patient, at the correct site. Note: The patient is involved in the verification process when possible.

– Identify the items that must be available for the procedure and use a standardized list to verify their availability. At a minimum, these items include the following:

• Relevant documentation (for example, history and physical, signed procedure consent form, nursing assessment, and pre-anesthesia assessment)

Universal Protocol

• Labeled diagnostic and radiology test results (for

example, radiology images and scans, or pathology and

biopsy reports) that are properly displayed

• Any required blood products, implants, devices and/or

special equipment for the procedure

• Match the items that are to be available in the procedure

area to the patient.

Universal Protocol

Marek the procedure site

– Mark the procedure site before the procedure is performed

and, if possible, with the patient involved.

– The physician performing the procedure will mark the

surgical site. A written, alternative process is in place for

patients who refuse site marking or when it is technically or

anatomically impossible or impractical to mark the site (for

example, mucosal surfaces or perineum).

Universal Protocol

A time-out is performed before the procedure.– Conduct a time-out immediately before starting the

invasive procedure or making the incision.

– During the time-out, the team members agree, at a minimum, on the following:

• Correct patient identity

• The correct site

• The procedure to be done

Quality Concern Reporting

The hospital notifies the public it serves about how to

contact hospital management or The Joint

Commission to report concerns about patient safety

and quality of care via the:

– Internet

– Guest Directory (Admission Booklet)

– Signage throughout the hospitalby

– Calling (800) 994-6640 or via e-mail at

complaint@jointcommission.org

Quality Management

Questions?

Please call Sandra Webb at extension 2124