Improving the Quality of Care
National Initiatives The National Quality Forum is a nonprofit organization that strives to improve the quality of health care by building consensus on performance goals and standards for measuring and report- ing them (National Quality Forum, 2011). Additionally, the Institute of Healthcare Improvement (IHI) offers programs to assist organizations in improving the quality of care they provide (IHI, 2011). Their goals are:
● No needless deaths ● No needless pain or suffering ● No helplessness in those served or serving ● No unwanted waiting ● No waste
Joint Commission, hospitals’ accrediting body, has adopted mandatory national patient safety goals (Joint Commission, 2011). They charge hospitals to:
● Identify patients correctly ● Improve staff communication ● Use medicines safely ● Prevent infection ● Check patient medicines ● Identify patient safety risks ● Prevent mistakes in surgery
Define
MeasureControl
Improve Analyze
Figure 6-2 • DMAIC: The Six Sigma Method. Adapted from DMAIC tools: Six Sigma training tools. Retrieved October 21, 2011, from www.dmaictools.com
CHAPTER 6 • MANAGING AND IMPROVING QUALITY 75
Joint Commission collects data on 57 inpatient measures; 31 of these are currently made public with others scheduled to be publicly reported soon (Chassin et al., 2010). The focus is now on maxi- mizing health benefits to patients. They recommend that quality measures be based on four criteria:
1. The measure must be based on research that shows improved outcomes. More than one research study is required for documentation.
2. Reports document that evidence-based practice has been given. Aspirin following an acute myocardial infarction is an example.
3. The process documents desired outcome. Appropriately administering medications is an example.
4. The process has minimal or no unintended adverse effects (Chassin et al., 2010)
Measured standards are used extensively in industrial settings to reveal errors. However, the same cannot be said when measuring human behavior, which can vary and still be effective. Also, if the organization embraces these systems to such an extent that all variance is discour- aged, then innovation is also suppressed. Improvement in quality is sacrificed at the expense of innovative ideas and processes; organizations fail to allow input, become stagnant, and cease to be effective. This is the danger of all living systems that depend on outside input for survival. This is not to say that quality systems are not essential. They are. Organizations must find ways to foster creativity and innovation without compromising quality management.
How Cost Affects Quality Quality measures can also reduce costs. Wasted resources is an example. These include the time nurses spend looking for missing supplies or lab results, the costs of agency nurses because of unfilled positions, and delays in patient discharge due to a lack of coordination or an adverse event (e.g., medication error).
Using the Institute for Healthcare Improvement (2009) project, Transforming Care at the Bedside (TCAB), Unruh, Agrawal, and Hassmiller (2011) found that improving quality reduces costs. Specifically, the researchers report that in a three-year period, RN overtime was reduced, RN turnover was lowered, and fewer patients suffered falls.
Evidence-Based Practice Evidence-based practice (EBP) suggests that using research to decide on clinical treatments would improve quality of care, and that might be the case. Barriers, however, prevent EBP from being widely used by nurses. Such barriers, consistent across settings, include lack of time, autonomy over their practice, ability to find and assess evidence, and support from administra- tion (Brown et al., 2008).
Furthermore, EBP is most reliable when the research study includes a rigorous design (Hader, 2010), and when more than one study has confirmed the results (Chassin et al., 2010). These are not easily surmountable hurdles due to the fast-paced clinical environment and the barriers mentioned above.
Electronic Medical Records Similar to the argument that EBP improves quality, electronic medical records (EMR) should do so as well. Instant access to identical records should improve accuracy and speed commu- nication among care providers. Kazley and Ozcan (2008), however, found limited correlation between the use of EMR and 10 quality indicators in their study of more than 4,000 hospitals in the U.S. In a review of the literature, Chan, Fowles, and Weiner (2010) could not link quality indicators and EMR. Cebul (2008), however, did find direct correlation between the use of EMR and the quality of care provided to diabetic patients. EMR use, is expected to expand and will provide more data for comparison with quality.
76 PART 1 • UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
Dashboards Dashboards are electronic tools that can provide real-time data or retrospective data, known as a scorecard. Both are useful in assessing quality. Ease of access and the visual appearance of the dashboard make its use more likely. Dashboards may report on hospital census or patient satisfac- tion results, for example. Dashboards are also useful to guide staffing and match staffing with pa- tient outcomes (Frith, Anderson, & Sewell, 2010) and to provide accurate financial data on nurse staffing and quality (Anderson, Frith, & Caspers, 2011). As technology advances, widespread use of dashboards to aggregate data and guide decision making is expected (Hyun et al., 2008).
Nurse Staffing Evidence is growing that increased nurse staffing results in better patient outcomes (Frith, Tseng, & Anderson, 2008; Anderson, Frith, & Caspers, 2011). Earlier studies found that a higher RN-to-patient ratio resulted in reduced patient mortality, fewer infections, and shortened lengths of stay (Reeves, 2007). Needleman (2008) agrees that increasing the level of nurse staffing improves quality, but asserts that higher staffing levels also increase costs.
Reducing Medication Errors Ever since Medicare discontinued payment for hospital-based errors, pressure has increased for hospitals to prevent costly errors. In 2009, the federal government passed the Health Information Technology for Economic and Clinical Health Act (HITECH). The purpose of HITECH is to stim- ulate technology use in health care, including improving technology for medication administration.
Studies have shown that when nurses are interrupted during medication preparation, a 25 percent rate of injury-causing errors are made (Westbrook et al., 2010). One strategy to alert others that a nurse should not be interrupted is the use of a sash or vest that the nurse dons to prepare medications (Heath & Heath, 2010).
Other strategies to reduce medication errors include computerized prescriber order entry (CPOE), electronic medication administration record (eMAR), remote order review by pharma- cists, automated dispensing at the bedside, bar code administration, smart pumps, and unit doses ready to be administered (Federico, 2010). Future strategies include radio frequency identification and electronic reconciliation, both expensive technologies currently being tested (Federico, 2010).
Peer Review In addition to its value for self-evaluation and performance appraisal (Davis, Capozzoli, & Parks, 2009), peer review can be used to identify clinical standards of practice that improve the quality of care. Used for quality improvement, the peer review process is not intended to serve as a per- formance appraisal nor to be punitive. The purpose is to review the incident, determine if clinical standards were met or not, and to propose an action plan to prevent a future incident.