Chapter 20

Managing Quality and Risk

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Objectives

Apply quality management principles and strategies. Use the six steps of the quality improvement process.

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

Objectives (contd)

Incorporate roles of leaders, managers, and followers to create a quality management culture of continuous readiness. Apply risk management strategies to an agencys quality management program.

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

Case Study
A significant increase in patient falls resulting in injury has been reported on your unit. In accordance with the National Patient Safety Goals, you are assigned to a multidisciplinary Quality Improvement/Risk Management team to address the problem.

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

Steps in the Risk Management Process

Define high-risk situation.

Patient falls

Determine frequency of falls.

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

Steps in the Risk Management Process (contd)

Intervene and investigate. Identify opportunities to improve care.

Use steps of the QI process.

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

Evolution of Quality Management

Define opportunities. Measure performance. Analyze opportunity. Improve performance. Control performance.

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

Principles of QM and QI

QM most effective in a flat, democratic, organization Managers and workers must be committed to QI. Goal of QM is to improve systems and processes, not to assign blame.

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

Principles of QM and QI (contd)

Customers define quality. QI focuses on outcomes. Decisions must be based on data.

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

Comparison of QA and QI
QA Process
Goal Focus Major tasks Improve quality Discover/correct errors Inspection of nurse activities; Chart audits QA or department personnel Set by QA team with input from staff

QI Process
Improve quality Prevent errors Review nurse activities; Innovation; Staff development Multidisciplinary team Set by QI team with input from staff and patients
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Quality team Outcomes

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

Steps in the QI Process

Identify needs. Assemble multidisciplinary team. Collect data. Establish outcomes and quality indicators. Select and implement plan. Evaluate.

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Identify Need

Compliance with National Safety Goals Reduction of hospital risk/financial loss Reduction in LOS after an adverse fall event Improved patient outcomes

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Assemble Team

Nurses Physicians Unlicensed assistive personnel Pharmacists Facility/environmental management representatives QI/risk management experts

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Collect Data

Define incidence of falls. Determine high-risk patients.

Age Mental status History of falls Medication Physical environment

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

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Outcomes and Indicators

Education of 100% of all direct care providers Completion of Fall Risk Assessment on 100% of patients Reduction in patient falls by 25% within 3 months of program Medical record demonstrating 100% compliance with Fall Prevention Program

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Establish Fall Prevention Plan

Consistent use of ID bracelets based on Fall Risk Assessment score Implementation of bed alarms Staff education (e.g., toileting at-risk patients routinely) Change of environment (e.g., vertical grab bars)

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

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Evaluate

Change in incidence of falls (e.g., through incident reports, sentinel event monitoring)

Root cause analysis

Staff compliance with Fall Prevention Plan Patient/family satisfaction with plan Reliability and validity of Fall Risk Assessment tool

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

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Standards of Care: Fall Prevention

Nurse practice acts Professional organization guidelines Institutional guidelines (e.g., policies and procedures, structure/process standards)

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Standards of Care: Fall Prevention

(contd)

Research/evidence-based practice guidelines Accreditation standards (e.g., JCAHO National Patient Safety Goals)

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

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National Patient Safety Goals

Patient identification Communication among caregivers High-risk medications Infusion pumps

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

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National Patient Safety Goals

(contd)

Risk of health careassociated infections Accurate medication across continuum Patient falls

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

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Risk Management: Malpractice

Duty: Nurse has responsibility to patient. Dereliction: Nurse did not carry out duty. Damage: Patient was injured. Direct cause: Injury secondary to the nurses failure to carry out duties

Copyright 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

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