Quality Management

Quality Management

By Christina Lauderman RN, BSN, CENQuality ObjectivesThe learner will be able to..Define Quality CareIdentify Standards of Care/BenchmarksIdentify drivers of quality and their roles in the continuous quality improvement (CQI) process.Describe How Total Quality and Continuous Quality Management, Six Sigma, and Lean Six Sigma Addresses Quality.

Our objectives for today include: defining quality care, Identifying standards of care and benchmarks, identify drivers of quality and their roles in the continuous quality improvement process. We will describe how total quality and continuous quality management as well as Six Sigma and Lean Six Sigma address quality issues2Quality ObjectivesIdentify when an Incident report needs filed. Perform a Chart Review on Given Stroke ChartsDevelop a continuous quality improvement project on a nursing unit.

We will differentiate when an incident needs reported. Then in groups we will review stroke charts to look for quality. We will look to see if standards and benchmarks have been met. Mrs. Riggs has assigned a continuous quality improvement projects as part of this unit on quality. 3 What Is Quality?

Let me ask you this- What is Quality?Students will list different aspects of quality care4Quality CareRight Care at the Right time to the Right Patient.Compassionate/EmpatheticCompetentNo HarmMeets StandardsNo ComplicationsNondiscriminatory/Fair

How about the right care at the right time to the right patient. Compassionate/Empathetic care, We want to be competent in the care we give. We pray that we do no harm to our patients. We as nurses want to meet the standards of care set before us. We hope that testing and procedures are without complications. And we always want to be nondiscriminatory and fair by being culture sensitive and give same treatment to uninsured patients as we do insured. 5QUALITYInvolves the pursuit of excellence in the delivery of care and ongoing prevention of potential errorsThe degree to which patient care services increase the probability of desired patient outcomes and reduce the probability of undesired outcomes given the current state of knowledge (JCAHO, 2009)

Here is the definitions of quality- The pursuit of excellence in the delivery of care and ongoing prevention of potential errors.From JCAHO The degree to which patient care services increase the probability of desired patient outcomes and reduce the probability of undesired outcomes given the current state of knowledge6Theoretical FrameworkFlorence NightingaleJean Watson- Theory of CaringDorothea Orem-Self care DeficitJune Larabee-Quality Theories

We learned how to give quality care from the great nurses before us such as Florence Nightingale who gave basic compassionate care to soldiers in the Crimean war and started the first school of nursing. From Jean Watson and her theory of human transpersonal caring. And Dorothea Orem who showed us with her self care deficit theory how to assist patients in a caring supportive way. And A more recent theorist June Larabee who has developed theories on quality care and has done research in the area of how to provide quality care. 7Drivers Of QualityMedicare and Medicaid The Joint Commission (JCAHO)State regulatorsPayersProfessional groupsPatients

Regulators and authorities like Medicare, Joint commission, DOH, Insurance companies, professional groups, and patients all help to set standards and enforce those standards. For example, if a hospital makes a mistake or a patient gets a hospital acquired infection Medicare/Medicaid will not pay for it and the hospital must endure the cost. Joint commission and DOH makes inspections and gives warnings and fines when not in compliance with standards. Professional groups do lobbying for changes in healthcare. Patients if not satisfied can file complaints with the hospital and the department of health. 8Why Is Poor Care Sometimes Given?

So if we all want to give great quality care- Then why does Poor care happen? 9Possible Reasons for Poor CareUnder Or Inexperienced Staff

Human Error

Time, Money, and Space Constraints

AttitudeSome reasons for poor care or standards not being met. Under staffing or inexperienced staff. The research shows that when a unit is adequately staffed more quality care is given. How do you provide quality care when you have 8 patients to take care of.Human error. We all are human and make mistakesThere is not enough time, money, and space restraints. I see this a lot in the Er Patients are dissatisfied because they have to wait for care and they may be treated in the hall. Attitudes- of nurses and of Patients. If a nurse comes to work not feeling well or upset- is he/she going to be able to maintain a caring compassionate attitude. Patients when they dont feel well can also be difficult to deal with. There are also errors that occur with the system or organization. Some times as we try to fix errors we create additional errors.Ineffective communication- Research shows that this is the number one cause why patients are dissatisfied with their careComplications- although we hope everything goes as plan complications happenInability to meet patients expectations. Again we see this in the ER frequently. Patients expect to be seen right away, to get what they came for, and be back on their way without delay. That doesnt always happen in an emergency room. Sometimes the patients expectations arent able to be met or are unreasonable. 10Possible Reasons for Poor CareIneffective Communication

Complications

Inability To Meet Patients Expectations.

System Error

Ineffective communication- Research shows that this is the number one cause why patients are dissatisfied with their careComplications- although we hope everything goes as plan complications happenInability to meet patients expectations. Again we see this in the ER frequently. Patients expect to be seen right away, to get what they came for, and be back on their way without delay. That doesnt always happen in an emergency room. Sometimes the patients expectations arent able to be met or are unreasonable. There are also errors that occur with the system or organization. Some times as we try to fix errors we create additional errors.

11Standard of CareCare Deemed Appropriate Based on Scientific Evidence and Expertise of Expert Professionals in that Area of Care.

Come From JCAHO, DOH, ANA, NLN, NIH, AHA, ATA, ABA, UPMC Standards, Medicare/Medicaid, Insurance Companies etc.Standards of care- a Standard is defined as the care deemed appropriate based on scientific evidence and the expertise of expert professionals in that area of care. Evidence based practice and research play a large role in developing standards. Standards come from Many different sources. Some examples here are Jcaho, Dept. of Health. American Nurses Association, the National league of Nurses, the National institute of Health, The American Heart and Stroke Association, American Trauma and Burn Associations, Facility standards, and again from Medicare and insurance companies. There are many more. 12Where do we learn standards?First learn standards in Nursing School.Learn Policies and Procedures of Facility employed by.As you incorporate Evidence Based PracticeAs you become involved in Research. We first start learning about standards of care in nursing school. We are taught how to care for patients based on those standards. Then as we become employed we learn the policies and procedures of the facility.As you develop your career you will read research and incorporate evidence based practice into your care. As you go even further into your career you may become involved in research and become an expert in your area of care and be the one developing the standards. 13Types of StandardsStructure Standards- Physical Environment, Organization

Process Standards-Delivery Of Care

Outcome Standards-The End Results

There are three types of standards. The first is Structure Standards. These standards control the physical environment and the organization as a wholeThen process standards- These are the standards of your care you give as a bedside nurse.And Outcome standards- these are what we want are final results of our care to be.14Examples of Standards

Who can give me an example of a Standard?15Quality Management ProgramsAfter the Fact IdentificationPrevention of Failed Standards and ProblemsBased on Data Collection and AccountabilityUses Measurement ToolsFocus on No BlameQuality management programs were developed to improve quality and to meet standards of care. Initially quality management programs were only identifying after the fact problems and failed standards. Now we have moved to looking at prevention. Quality management programs are based on data collection and accountability. It needs measurement tools to complete analysis. Promotes a culture of no Blame so nurses dont feel afraid of disciplinary action 16Total Quality Management(TQM)4 CharacteristicsCustomer/Client FocusedTotal Organizational InvolvementUse of Quality Tools and Statistics for MeasurementKey Processes for Improvement Identified

Total Quality Management was a philosophy developed by Dr Edward Deming and used by the Japanese. TQM is customer client focused. A Total organizational involvement. Use of Quality Tools and Statistics for Measurement. Key processes for improvement identified17Total Quality Management(TQM)Customer Client FocusedInternal ClientsEmployees, lab, housekeepingExternal ClientsPatients, Visitors, PhysiciansInsurance Companies

Internal clients are the employees and the departments within an organization. External clients are patients, visitors, physicians, insurance companies 18Total Quality Management(TQM)Total Organizational InvolvementTeam ApproachEmpowerment of EmployeesManagement-TeamTeam approach. Or Total organizational involvement. Empowering employees with the responsibility of the care they provide. Management gets involved with care when needed. No more not my job.

19Total Quality Management(TQM)Use of Quality Tools and Statistics for MeasurementTools such as Graphs, chartsStatistic tools such as percentages, ProbabilityUse Quality tools and statistics for Measurements. The tools of Quality include Graphs charts diagrams. Or similar items that communicate the data.We use statistics in calculating data especially percentages and probability20Total Quality Management(TQM)Key Processes for Improvement IdentifiedSystems Related ClinicalManagerialProcesses that run the facility, admissions discharges, Clinical Processes is the processes involved in patient care Managerial processes hiring disiplinary or praise processes firing process, perfomance evaluations21TQM ContinuedPlan, Do, Check, Act Cycle

Must use measurement tools. Cant manage what you cant measure. Focuses on the plan do check act cycle. Plan process development then implement or do the process, complete checks Quality assurance programs/chart reviews for example. Act try to enhance the process to provided better quality care. Back to plan22Continuous Quality ImprovementTQM Philosophy CQI Process

Never Ending Process

Involves Evaluation, Actions, and a Mind Set to Constantly Strive for Excellence

Continuous quality Improvement. Often used synonymously with TQM but TQM is the philosophy whereas CQI is the process. Continuous quality improvement is just that continuous and never ending. It involves a mind set to strive for excellence, must be active and must be continuously evaluated.23Continuous Quality Improvement4 Key PlayersResource GroupCoordinatorTeam LeaderTeam

4 key players in CQI is first the Resource group. This is administration or board of directors. The Coordinator is a person appointed by administration to conduct the day to day management of CQI. The coordinator then selects team leaders and processes are divided up among them. The team leaders then select teams. That help manage evaluate and improve the process they are assigned to.

24Components of Quality ManagementComprehensive Quality Management PlanMultidisciplinary StandardsBenchmarkingCritical Paths Indicators

A comprehensive quality management plan is a systematic method of designing measuring assessing and improve organizational performance. It is Multidisciplinary. It goal is to meet standards and improve Benchmarks. (We will be 90% compliant with a given process). It must contain critical paths which identify expected outcomes within a specific time frame. Comprehensive Management plan also uses indicators as a tool to measure the performance of structure, process and outcomes standards.. For example the standard in stroke is that a patient has a CT scan in the ER. The bench mark is that we will be 90% compliant in doing so. A critical path is that they will have a CT scan in 25 minutes from arrival. And the indicator is this is done on every patient with diagnosis of cva tia or ich and reviewed each month. 25Components of Quality ManagementPerformance AppraisalsIntra/Interdisciplinary Assessments and ImprovementsComprehensive management plan includes Performance appraisals, Intra and Inter disciplinary assessments and improvements. 26Quality ManagementAuditsRetrospectiveConcurrentPeer ReviewsUtilization ReviewsOutcomes ManagementAudits or chart reviews are done and can be retrospective- after the patient is gone and care is completed. Or Concurrent- While patient is in facility receiving careWe look for standards and quality of care that are or arent being met. A peer review can be done and the person completing the review can review the chart with the nurse and identify areas of improvement or needs for further education.Utilization review looks at the allocation of resources in the processOutcomes Management reviews are done to see if the process outcome goals have been met. 27Six SigmaUses Quantitative DataAs a MeasureAs a Goal

Another Quality Management system is Six Sigma Developed by Motorola Six Sigma seeks to improve the quality of process outputs by identifying and removing the causes of defects (errors) and minimizing variability in manufacturing and business processes. It uses numerical quantitative data It can be used as a statistical measure. The percentage of defect free products made. As a goal. The Motorola company stated that 99.9% of their products would be free from defects. Read Chart28Six SigmaAs a Management SystemCustomer focusData DrivenProcess EmphasisProactive ManagementBoundary-less CollaborationAim for Perfection, Tolerate Failure. As a Management system it is customer focused . The Data drives change. The process is the main emphasis. The management team is proactive and always looking where to cut waste and increase production rates. As a Management system it doesnt have boundaries, It can go across many different departments or disciplinarys and allow collaboration. The aim if for perfection but the system tolerates failure in order to find new and better ways.

29LEAN SIX SIGMA

A system of more tools that came be used to reduce waste (cut the Fat) and increase the process flow further. It is used in conjunction with Six Sigma. Read chart. An example of this is six sigma would increase staffing to meet demands but lean six sigma would also reduce staff when census declines as well. 30National IncentivesInstitute of Medicine- To Err Is Human:

JCAHO- Patient Safety Goals

Institute of Healthcare Improvement

The National Institute of medicine did research and published the article to ERR is Human building a safer Health system. The article looks at where mistakes in healthcare are made and how we can set new standards in order to improve and make safer health care. This was a landmark article completed almost 10 years ago and truly set the movement of quality and safe care . They found that 44-98,000 deaths from medical mistakes. People then started to really look at quality and safety. Jcaho developed the Patient Safety goals. Identifies patients correctly, Improve staff communication Uses Medications safely, Prevent infections You should read about these goals. And the Institute of healthcare improvement set standards of No needless deaths. No needless pain or suffering. No helplessness in those served or serving. No unwanted waiting. No waste. 31Medication ErrorsRight Patient, Right Medication, Right Dose, Right Route, Right Time

Patients Involved In Own Care

Educate Patients About Medications

Errors Need Reported Medication errors is a large player in the decrease in quality. A med error occurs when there is either an error in either the right patient the right medication, the right dose, the right route, and the right time. The research shows that patients need to be more involved in their own care and medication administration. This means as nurse we need to educate patient about their medications and teach them to inquire about their medications. Errors need to be reported to help prevent future errors. Many nurses are afraid to admit their errors but a no blame culture of reporting is essential. 32Risk ManagementProblem Focused- IdentifyAnalyzeEvaluate Risks Develop Plan Risk Management. The role of risk management is to identify, analyze and evaluate risks. These are the people who investigate incidents and medication errors. They then develop a plan to reduce the severity and frequency of these events. 33Risk ManagementEducation BasedMonitors Laws and Codes Related To Patient Safety.Collects Data In Legal ComplaintsProvides Reports to Administration, Medical Staff, and Board of Directors.

Prevention is largely education based. They also monitor laws and codes related to patient safety. They collect data in regards to legal complaints. They then provide reports to administration medical staff and the board of directors.

34Incident ReportingIncidentActual or Potential Risk.Document in Chart and in Incident Report.Be Factual, Non Disciplinary, Honest Case Followed Up by Risk Management

Reporting an incident or error. What is an Incident? It is any unexpected or unplanned occurrence that affects or could affect a patient, family Member or staff. It can be an actual or potential risk. An incident needs to be documented in chart and in an incident report. Documentation needs to be factual only no opinions or disciplinary statements it was the Drs fault he wrote the wrong order Instead the doctors order was Be honest. The case or incident is followed up by risk management as we talked about already. 35IncidentsMedication ErrorsFallsComplications from diagnostic or treatment proceduresPatient/Family dissatisfaction with careRefusal of Treatment or to sign consentSkin BreakdownIv InfiltrationsWhat kind of things are incidents? Medication errors, falls, complications from diagnostic or treatment procedures. Patient or family dissatisfaction with care. Refusal of treatment or to sign consent. Skin breakdown, iv infiltrates. Can you think of any others?36Blame Free EnvironmentEncourage Staff To Report IncidentsNo Blame or Disciplinary Action Unless Absolutely NecessaryNo Finger PointingEncourage a Culture of Safety and Quality

A blame free environment promotes staff to report incidents without fear of disciplinary action. There should be no finger pointing. A blame free environment encourages a culture of safety and quality. Example of Levophed gtt error. 37Handling ComplaintsClear CommunicationMaintain Professional Caring AttitudeListen to ComplaintsDetermine Expectations of Patient or FamilyQuick Follow Up and Action

As a nurse patients or families will complain to you. How do you handle complaints? First is to listen truly listen to complaints dont interrupt or get defensive. Maintain a professional caring attitude. Use good clear communication skills. Determine the expectations of the patient and family. Attempt to meet expectations if possible. Ensure quick follow up and action. The research states miscommunication is a large contributor to dissatisfaction. One major complaint we see in the emergency room is the wait they have to be admitted. Often times they are not kept informed or are mistakenly told in a Little while they will go to their room. Then a room isnt available and they wait hours on end. Their expectation is they will get a bed right away after being told they are going to be admitted to the hospital. Keeping patients informed helps with keeping expectations reasonable and lessens their dissatisfaction. 38Handling ComplaintsPersonal Contact-Utilize Charge Nurse, Nurse Manager, Nursing Supervisor.Maintain Safety For Yourself and For the Patient.

Make Restitution/Meet Expectations When Applicable. Have personal contact dont avoid pt. Good eye contact open listening stance. Respect personal space. Maintain safety for yourself and the patient. Example. If patient is upset with you allow your charge nurse, nurse manager, nursing supervisor to handle situation if you cant. Make sure you inform them of the situation before they go into the room with patient and family. Make restitution if applicable. Always have an exit from the situation incase violence occurs. 39Key Components Meeting Standards Helps to Provide QualityTCM- Philosophy Uses Plan, Do, Check, ActCQM-Never Ending, Strive for Excellence.Six Sigma- Reduce Waste Increase Productivity

KEY COMPONENTSRisk Management Role in QualityIncrease Patient SafetyIncident ReportingHandling Complaints

Questions?ReferencesTextbook- Effective Leadership and Management in Nursing by PearsonGoogle Images