1. Supporting Quality Care
Chapter 4

2. Standards for Evaluating Health Care
Types of standards
Structural standards
Process standards
Outcome standards

3. Structural Standards
establish guidelines for the facility’s patterns and supports for providing client care
i.e. The nurse patient ratio in ICU is 1:2
All home health nurses will have at least 1 year of acute care experience
Can you think of an example of a structural standard???

4. Process Standards
deal with the methods or the process used in providing client care or services
i.e. The initial nursing care plan will be established within 24 hours of admission.
The patient meal trays will be passed out within 30 minutes of arrival to the unit
Can you think of an example of a process standard???

5. Outcome standards
used to evaluate patient outcomes or the desired result of care
i.e. Post op hip replacement patients will be ambulatory by Day 2.
The incidence of nosocomial infections will be less than 10%.
Can you think of an example of an outcome standard???

6. Question
Each nursing unit will have a fire extinguisher on each side of the hallway. This is an example of a:
a) structural standard
b) process standard
c) outcome standard

7. Answer Structural. Rationale-
Structural standards include the physical plant and equipment.

8. Sources of Standards for Care
Nursing specific standards
Regulatory agency standards
Accrediting agency standards
Clinical practice guidelines as standards
Health facility established standards

9. Question Is the following statement true or false?
A type of standard to which a nurse is held accountable is called a process standard.

10. Answer
True.
Rationale: process standards describe methods of providing services. Process standards are also referred to as performance standards. Protocols and procedures are examples of process standards.

11. Benchmarking
Benchmark – a specific quantitative standard (expressed as a number or percent) to which you compare to your own facility to a similar facility or standards established by JCAHO or another entity.
i.e. 3 falls per 100 patient care days
8% nosocomial infection rate
75 medication errors per year
5% surgical site infection rate

12. Cost Standards Outcomes related to cost Cost-effectiveness
Cost- benefit ratio
Doesn’t take into consideration quality of life or satisfaction

13. Collecting Data for Evaluation- Key Indicators
Selected data that reveal the need for more extensive data collection
i.e. Number of Falls per year evaluates Safety
Number of Nosocomial Infections per year evaluates Infection Control
Number of Medication Errors per year evaluates Safety
Length of stay for Hip Replacement
evaluates Cost

14. Collecting Data for Evaluation- cont.
Quality assurance reports- “Incident report”
Audit-
Retrospective-i.e. Going back to medical records for chart review to see if all medications were signed off.
, concurrent- i.e. Looking at a chart which is currently in use to see if I.V. restarts were charted

15. Collecting Data for Evaluation- cont
Direct Observation
i.e. Going in patient rooms to see if I.V. tubing is labeled
Interview
i.e. Interviewing a patient to see if pain is less than 5 on a scale of 1-10

16. Question
What is the term used for a systematic data collection process that commonly focuses on documentation?
A. Cost-analysis report
B. Benchmarking
C. Audit
D. Survey

17. Answer
C. Audit
Rationale: an audit is a systematic data collection process that commonly focuses on documentation.

18. Analyzing Data and Developing Action Plans
Types of reports
Simple descriptive reports
Percentage and numerical reports
Sophisticated statistics
Analysis of data
Identify discrepancies
Opportunities for improvement

19. Analyzing Data and Developing Action Plans (cont'd)
Detailed approaches to change
Specific
Identify responsible person
Set time frame

20. Using Goals and Objectives in the Evaluation Process
Broad statements of overall intent of an organization, department, unit, or individual
Usually stated in general terms
Objectives
Specific accomplishments that help achieve a goal
Usually have a related time deadline

21. Strengths of Using Goals and Objectives
Everyone knows what is expected
Facilitates change in individual behavior
Evaluation is clear

22. Limitations of Using Goals and Objectives
Cannot be done in isolation
Related to standards of care
Impossible to address all the areas of function
Conflict over goals can occur

23. Quality Assurance and Improvement
Refers to activities that are used to monitor, evaluate, and control services provided to consumers
Goal is to identify areas where standards are not met and improve them

24. Quality Assurance and Improvement (cont'd)
Sentinel events
Defined by the Joint Commission (2007c) as “unexpected occurrences involving death or serious physical or psychological injury, or risk thereof.”

25. Quality Assurance and Improvement (cont'd)
Both errors and near misses
Death from medication error
Suicide of a patient receiving 24/7 care
Surgery on wrong patient or body part
Hemolytic transfusion reaction
Near miss

26. Quality Assurance and Improvement (cont'd)
Root cause analysis
Comprehensive, often complex, process that seeks to identify all the contributory factors to an error and identify their share of causation
What happened
Why it happened
How do you keep it from happening again
Tool for prevention strategies

27. Quality Assurance and Improvement (cont'd)
Acting to prevent error
Addressing system problems
Patient safety goals

28. Question Is the following statement true or false?
A medication error that results in the death of the patient is a sentinel event.

29. Answer
True.
Rationale: sentinel events include both errors and what are commonly referred to as near misses. An example of a sentinel event is a death resulting from a medication error or other treatment-related error.

30. Quality Improvement Movement
Incorporates all aspects of quality assurance
Aimed at improving quality of health care
JCAHO: “Quality assessment and improvement”
Efforts toward evidence-based practice

31. Continuous Quality Improvement
A process in which ongoing analysis and improvement lay the foundation for change
Includes:
Collecting data
Analyzing data
Forming a task force
Planning change
Implementing change
Collecting data again

32. Key Aspects of Quality Improvement
Culture of empowerment
Blame-free environment
Effective data collection systems
Use of teams for problem solving
Focus on the customer
Eliminating waste

33. Barriers to Quality Improvement
Costs
Staff time
Computer programming
Documentation
Improvement may not defray costs

34. Risk Management
Minimizing the risk to the institution or agency from an error or problem that could result in legal action or liability
Think ahead about defense when a legal action is contemplated or actually occurs
Attempts to be proactive in identifying and eliminating areas of risk for the institution
Response of those in the health care system when an adverse event occurs

35. Question What is one purpose of risk management?
A. Change in time when vital signs are done at night
B. Improvement of quality of meals served to patients
C. Defense when legal action occurs
D. Planning of community emergency drills

36. Answer C. Defense when legal action occurs
Rationale: another focus of risk management is to think ahead about defense when a legal action is contemplated or actually occurs.

37. Evaluating Nursing Care You Manage
Identify specific standards of care that you will strive to meet and determine ways of improving care
Goals and objectives may be established informally with a team even when the setting does not have a formal process in place
A philosophy of continuous improvement