Quality, Safety and Performance Improvement Compiled by Kaye Culberson Wilkie, RN, BSN Autopsy to Determine if Heparin Overdose Killed Texas Newborn Multiple cancer patients killed by improperly programmed chemotherapy pump

There are some patients whom we cannot help There are some patients whom we cannot help. There are none whom we cannot harm. -Bloomfield-

To Err is Human To Err Is Human: Building a Safer Health System (1999 IOM report) 98,000 die each year from medical error Medical error kills more Americans than breast cancer, MVA, or AIDS 7% hospital patients experience serious medication error Cost = $8-29 billion/year Institute of Medicine (IOM) spearheaded initiative to improve quality care IOM – skilled and caring professionals can – and do – make mistakes National agenda to reduce errors through design of safer delivery systems

Impact of the Institute of Medicine’s (IOM) Report Captured media, public, political and professional attention Shocking statistics Errors caused by faulty systems/process focus Congressional hearings, President’s Task Force Implementation of IOM’s recommendations…

IOM Recommendations National focus to enhance knowledge base about safety Identifying/learning from errors Raising standards for improvements in safety (oversight/benchmarking) Creating safety systems by implementing safe practices (safety science) at the delivery level

Factors in Healthcare Errors Workload Interruptions Fatigue Multi-tasking Failure to follow up Poor handoffs Ineffective communication Task fixation Excessive professional courtesy Halo effect Hidden agenda Complacency High-risk Not following policy/procedure

Goal for quality and safety education for nurses is to prepare future nurses with: Knowledge Skills Attitudes

Six competencies: Patient centered care Teamwork and collaboration Evidence-based practice Informatics Quality improvement Safety

Example: Patient-centered care Knowledge Skills Attitudes Examine common barriers to active involvement of patients in their own health care process Describe strategies to empower patients or families in all aspects of the health care process Remove barriers to presence of families and other designated surrogates based on patient preferences Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management Respect patient preferences for degree of active engagement in care process Respect patient’s right to access to personal health records

IOM Recommendations National focus to enhance knowledge base about safety Identifying/learning from errors Raising standards for improvements in safety (oversight/benchmarking) Creating safety systems by implementing safe practices (safety science) at the delivery level

Quality Measure for Patient Centered Care State variation: Adult ambulatory patients who reported good communication with health providers,* 2007

Example: Teamwork and Collaboration Knowledge Skills Attitudes Describe own strengths, limitations, and values in functioning as a member of a team Analyze own strengths, limitations, and values as a member of a team Analyze impact of own advanced practice role and its contributions to team functioning Clarify roles and accountabilities under conditions of potential overlap in team-member functioning Guide the team in managing areas of overlap in team member functioning Initiate and sustain effective health care teams Acknowledge own potential to contribute to effective team functioning Acknowledge own contributions to effective or ineffective team functioning Appreciate the importance of inter-professional collaboration

Repeat as needed until the desired goal is achieved PDSA PLAN: Plan a change or test of how something works. DO: Carry out the plan. STUDY: Look at the results. What did you find out? ACT: Decide what actions should be taken to improve. Repeat as needed until the desired goal is achieved

Failure Mode Effects Analysis (FMEA) Failure modes are any errors or defects in a process, design, or item, especially those that affect the patient, and can be potential or actual. Effects analysis refers to studying the consequences of those failures.

Example: Evidence-based Practice Knowledge Skills Attitudes Explain the role of evidence in determining best clinical practice Analyze how the strength of available evidence influences the provision of care (assessment, dx, tx, and evaluation) Determine evidence gaps within the practice specialty Read original research and evidence reports related to area of practice Critically appraise original research and evidence summaries related to area of practice Exhibit contemporary knowledge of best evidence related to practice specialty Appreciate the importance of regularly reading relevant professional journals Value knowing the evidence base for practice area Value public policies that support evidence-based practice Recognize importance of search skills in locating best evidence

Evidence-based Practice: what we know…

Evidence-based Practice: so…

Quality Measure for Evidence Based Practice Adult surgery patients with postoperative catheter-associated urinary tract infection, overall and by selected comorbid conditions, 2006

Example: Quality Improvement Knowledge Skills Attitudes Describe strategies for learning about the outcomes of care in the setting in which one is engaged in practice Describe strategies for improving outcomes of care in the setting in which one is engaged in practice Explain common causes of variation in outcomes of care in the practice specialty Seek information about outcomes of care for populations served in care setting Use a variety of sources of information to review outcomes of care and identify potential areas for improvement Assert leadership in shaping the dialogue and providing leadership for the introduction of best practices Appreciate how unwanted variation affects care Appreciate the importance of data that allows one to estimate the quality of local care Appreciate that all improvement is change but not all change is improvement

Sentinel Event Unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof Serious injury specifically includes loss of limb or function The phrase “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.

Sentinel Events

Root Cause Analysis (RCA) Aiming performance improvement measures at root causes is more effective than merely treating the symptoms of a problem. To be effective, RCA must be performed systematically, with conclusions and causes backed up by documented evidence. There is usually more than one potential root cause for any given problem. To be effective the analysis must establish all known causal relationships between the root cause(s) and the defined problem. Root cause analysis transforms an old culture that reacts to problems to a new culture that solves problems before they escalate, creating a variability reduction and risk avoidance mindset.

Root Cause Analysis Define the problem. Gather data/evidence. Ask why and identify the causal relationships associated with the defined problem. Identify which causes if removed or changed will prevent recurrence. Identify effective solutions that prevent recurrence, are within your control, meet your goals and objectives and do not cause other problems. Implement the recommendations. Observe the recommended solutions to ensure effectiveness. Variability Reduction methodology for problem solving and problem avoidance.

Example: Safety Knowledge Skills Attitudes Discuss effective strategies for reducing reliance on memory Describe processes used in understanding causes of error and allocation of responsibility (such as, root cause analysis) Use appropriate strategies for reducing reliance on memory (such as, forcing functions and checklists) Use organizational error reporting systems for near miss and error reporting Engage in root cause analysis rather than blaming when errors or near misses occur Appreciate the cognitive and physical limits of human performance Value own role in preventing errors Value vigilance and monitoring (even of own performance of care activities) by patients, families, and other members of the health care team

Quality Measure for Safety Hospital patients with adverse drug events, 2004-2006

Hospital Survey on Patient Safety Culture 12 dimensions 1. Communication openness 2. Feedback & communication about error 3. Frequency of event reporting 4. Handoffs & transitions 5. Management support for patient safety 6. Nonpunitive response to error 7. Organizational learning--continuous improvement 8. Overall perceptions of patient safety 9. Staffing 10. Supv/mgr expectations & actions promoting patient safety 11. Teamwork across units 12. Teamwork within units

Hospital Strengths & Areas for Improvement

Is it QI or is it PI? Quality improvement (QI) and performance improvement are interchangeable terms QI/PI describe approaches to study and improvement of processes…remember Primary focus should be on systems/process rather than individual performance