Emergency Department Quality Assurance: Creating and Sustaining a High Performance Leadership System Mahmoud Al Hussami, MPH, PhD., DSc. Associate Professor of Leadership & Epidemiology College of Nursing, University of Dammam Mahmoud Al Hussami, MPH, PhD., DSc. Associate Professor of Leadership & Epidemiology College of Nursing, University of Dammam

Six Aims for Improvement Safe-avoiding injuries knowledge scientific-Effective Patient-centered Timely – reducing delays Efficient – avoiding waste Equitable –not vary/people Six Aims for Improvement Safe-avoiding injuries knowledge scientific-Effective Patient-centered Timely – reducing delays Efficient – avoiding waste Equitable –not vary/people Quality Assurance Priority 1 Code of Practice Patients bill of rights Hospital requirements Accessibility Regulation Compliance External Agency Regulation Benchmarking Code of Practice Patients bill of rights Hospital requirements Accessibility Regulation Compliance External Agency Regulation Benchmarking Quality Activities undertaken to provide confidence that the services available maintain the standard of excellence. A measure of excellence or a state of being free from defects, deficiencies, and significant variations Every Defect is a Treasure It Presents an Opportunity for Improvement Every Defect is a Treasure It Presents an Opportunity for Improvement

Quality Assurance 1.A process, not an end-point 2.Must be independent of financial pressures. 3.Must ensure that quality policies are followed. 4.Must have final authority in acceptance or rejection. 5.An integral, not an add-on. 6.Responsible for day-to-day operations and for longer term goal settings. 7.Quantitative discipline with specified parameters.

The Purpose of Quality Assurance  Identification of errors or deficiencies in patient care.  Training E.D. staff.  Overall improvement of quality of care offered

Why is Leadership such a Challenge in Emergency Care? 1.There is no formula for producing successful leaders. 2.There are those who want to lead and can’t, and those who could but won’t. 3.There is the inevitable leader turnover. 4.Leaders first try what worked in their last job; when they figure out that approach is wrong, they master new skills then move to the next level and repeat the same mistake. 5.Leaders are always part of the solutions and part of the problems. 6.Practitioners want leadership titles and more money, but they rarely want to actually lead. 7.Practitioners believe leadership is easy; they just show up and tell people what to do.

What Challenges do ED Leaders Face? Clearly articulate a specific quality agenda for hospital- based emergency care: What do we want to improve / change? (indicators) How will we measure success? (standards) Promote uniform development of ED system: Organizational structures Clinical practice model Staffing, education, and training Successfully balance multiple (competing) agendas: Quality / Safety / Satisfaction Financial Organizational / Operational Innovation / Sustainability

Philosophical Aspects of an Emergency Department Quality Assurance 1.Must have input from all the E.D. staff. 2."Due process" must be assured (for protection of the staff's rights) 3.It must be emphasized that the major goal of the Q/A system is improving patient care and educating the staff (not penalizing or criticizing the staff). 4.Should be an "open" process even though confidentiality of patient's medical information must be assured

Situations Requiring "Automatic" Q/A Review and Report 1.Death of patient in the E.D. 2.Major injury to patient occurring in the E.D. 3.Assault or major injury to E.D. staff. 4.Event requiring institutional "incident report.” 5.Complaint of major error by patient or family. 6.Complaint of major error by consultant or referral physician. 7.Potential life-threatening discrepancy noted on chart audit

Who Should Perform E.D. Q/A 1.Assign specific staff as Q/A reviewer for better consistency. 2.Department administrators need to be directly involved. 3.Each type of department personnel must have input and specific Q/A system duties. 4.Data may be accumulated by non-clinical personnel, but only personnel with clinical experience should be responsible for review & interpretation.

The resources we use and conditions under which we deliver care What happens to patients as a result of our delivering care to them? What we do to patients in the process of delivering care? StructureProcessOutcome System Elements Related to Quality & Quality Assurance Good structures increase the likelihood of good processes, and good processes increase the likelihood of good outcomes

Material resources Human resources Organizational structures Health status Patient satisfaction Representative tasks Representative conditions StructureProcessOutcome Categories & Characteristics of Indicators Quality Assurance Relevant Meaningful (can be influenced by healthcare system, room for improvement) Scientifically sound (validity, reliability) Evidence-based (causal linkage to desired outcomes) Measurable (clearly defined numerator, denominator, technically feasible to collect data) Indicators should be

Structural Indicators of Quality & Quality Assurance of Emergency Care Material Resources Facilities Equipment Financing Human Resources Type & number of staff Staff qualifications Organizational Structures Encourage delivery of cost effective, high quality care Support growth and development: Attractive work environment Desirable career choice Professional recognition StructureProcessOutcome What characteristics of the emergency care system affect the system’s ability to provide the desired emergency care?

Process Indicators of Quality & Quality Assurance of Emergency Care StructureProcessOutcome What did we do to the patient? How well was it done? Process measures ideally need compelling evidence linking them to desired outcomes to be valid When hard evidence doesn’t exist, process measures can be based on expert consensus Representative tasks performed Diagnostics Therapeutics Others Representative conditions seen Common problems Across spectrum of acuity

Outcome Indicators of Quality & Quality Assurance of Emergency Care StructureProcessOutcome What happened to the patient as a result of the care that was provided? To what extent can we expect changes in nursing care delivery to change the outcome? Need for risk adjustment of outcomes? Health Status Morbidity Mortality Disability Patient Satisfaction Overall Impressions Communication Consideration Responsiveness

Examples of External Agency Regulation ISO – International Organization for Standardization ensure compatibility, quality and conformity. S et standards on quality and the environment. JCAHO-Joint Commission on Accreditation of Healthcare Organizations. Provides information to healthcare organizations, professionals, and the public on strategies to improve safety. NCQA-National Committee for Quality Assurance. Accreditation and certification of health plans and utilization review organizations.

Putting it all Together  Building and sustaining an organizational leadership of excellence is hard.  Quality Assurance cannot be done without leaders who are passionately committed to excellence.  Fortunately, you do not need everyone; you just need enough to get it done.  Attract and maintain personnel with necessary skills and attitudes.  Support a vision that sets sights at ever increasing standards of service delivery.