Supporting Quality CareSupporting Quality Care

Chapter 4

Standards for Evaluating Health Standards for Evaluating Health CareCare

Types of standards

– Structural standards

– Process standards

– Outcome standards

Structural StandardsStructural 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 experienceCan you think of an example of a

structural standard???

Process StandardsProcess 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???

Outcome standardsOutcome 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???

QuestionQuestion

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

AnswerAnswer

Structural.Rationale-

– Structural standards include the physical plant and equipment.

Nursing specific standards

Regulatory agency standards

Accrediting agency standards

Clinical practice guidelines as standards

Health facility established standards

Sources of Standards for CareSources of Standards for Care

QuestionQuestionIs the following statement true or false?

A type of standard to which a nurse is held accountable is called a process standard.

AnswerAnswerTrue.

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.

BenchmarkingBenchmarking

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

Cost StandardsCost Standards

Outcomes related to costCost-effectivenessCost- benefit ratioDoesn’t take into consideration quality of

life or satisfaction

Collecting Data for Evaluation- Collecting Data for Evaluation- Key IndicatorsKey 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

Collecting Data for Evaluation- cont.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

Collecting Data for Evaluation- Collecting Data for Evaluation- contcont

Direct Observationi.e. Going in patient rooms to see if I.V.

tubing is labeled Interviewi.e. Interviewing a patient to see if pain

is less than 5 on a scale of 1-10

QuestionQuestionWhat 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

AnswerAnswerC. Audit

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

Analyzing Data and Developing Action Analyzing Data and Developing Action PlansPlans

Types of reports– Simple descriptive reports– Percentage and numerical reports– Sophisticated statistics

Analysis of data– Identify discrepancies– Opportunities for improvement

Action plans

– Detailed approaches to change

– Specific

– Identify responsible person

– Set time frame

Analyzing Data and Analyzing Data and Developing Action Plans (cont'd)Developing Action Plans (cont'd)

Using Goals and Objectives in the Using Goals and Objectives in the Evaluation ProcessEvaluation Process

Goals– 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

Strengths of Using Goals and Strengths of Using Goals and ObjectivesObjectives

Everyone knows what is expected

Facilitates change in individual behavior

Evaluation is clear

Limitations of Using Goals and Limitations of Using Goals and ObjectivesObjectives

Cannot be done in isolation

Related to standards of care

Impossible to address all the areas of function

Conflict over goals can occur

Quality Assurance and ImprovementQuality Assurance and ImprovementQuality assurance

– 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

Sentinel events

– Defined by the Joint Commission (2007c) as “unexpected occurrences involving death or serious physical or psychological injury, or risk thereof.”

Quality Assurance and Improvement Quality Assurance and Improvement (cont'd)(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

Quality Assurance and Improvement Quality Assurance and Improvement (cont'd)(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

Quality Assurance and Improvement Quality Assurance and Improvement (cont'd)(cont'd)

Acting to prevent error

– Addressing system problems

– Patient safety goals

Quality Assurance and Improvement Quality Assurance and Improvement (cont'd)(cont'd)

QuestionQuestionIs the following statement true or false?

A medication error that results in the death of the patient is a sentinel event.

AnswerAnswerTrue.

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.

Quality Improvement MovementQuality Improvement MovementIncorporates all aspects of quality assurance

Aimed at improving quality of health care

JCAHO: “Quality assessment and improvement”

Efforts toward evidence-based practice

Continuous Quality ImprovementContinuous Quality ImprovementA 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

Key Aspects of Quality Key Aspects of Quality ImprovementImprovement

Culture of empowerment

Blame-free environment

Effective data collection systems

Use of teams for problem solving

Focus on the customer

Eliminating waste

Barriers to Quality ImprovementBarriers to Quality ImprovementCosts

– Staff time

– Computer programming

– Documentation

Improvement may not defray costs

Risk ManagementRisk 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

QuestionQuestionWhat 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

AnswerAnswerC. 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.

Evaluating Nursing Care You ManageEvaluating 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