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ALLEN COLLEGE
NU: 460 Nursing Leadership
Quality Improvement
Chapter 20

Unit Objectives:
1. Outline the difference between risk management and quality improvement (QI).
2. Explain how QI affects the patient and the organization.
3. Relate how the principles of QI are implemented in the organization.
4. Identify the functions of risk management.

I. Quality Management
A. Defined emphasizes teamwork, customer satisfaction, innovation,
employee involvement, and avoiding errors
activities related to establishing, maintaining and assuring high
quality care for patients

B. Quality management vs. risk management

1. QM a philosophy that defines a healthcare culture
(corporate culture) emphasizing customer satisfaction,
innovation, and employee involvement. Top down system.

2. RM minimizes risk by analyzing problems (medication

errors, pt injury, loss of finances)

C. Chart audits / reviews quality assurance periodic inspections

1. tools to collect quality assurance data focusing on clinical
aspects of providers care, frequently in response to
identified problem(s)
2. typically viewed as threat - focus on detecting errors
3. types of audits: clinical, security
structure focuses on the setting in which care takes place or the
delivery system by which nursing care is implemented; includes:
hospitals and clinics. Auditing the physical chart or audit by
observation.

process intended to measure nursing care (what the nurse does

while delivering care), includes:

- concurrent alert that med wasnt given on time

- retrospective
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outcome can again be concurrent or retrospective; measures

results of care administered to patient and evaluates whether
goals were reached (clinical manifestations, patient knowledge,
clients self-care), includes:
May find deficiencies in care
May find deficiencies or inconsistencies in processes

D. QM and QI evolved from TQM

QA CQI & TQM QI & QM & PI (Quality assurance-
continuous quality improvement & total quality management-
quality improvement & quality management & performance
improvement)
QA had an inspection approach to assure hospitals maintained
minimum standards this approach tended to be reactive, fixing
problems after they occurred. Method was mainly the
retrospective chart audit. doing it right
QI doing the right thing very customer focused.

II. QM & QI Principles (Look at table 20-2 on page 375)

A. Priority management commitment (top-down approach), democratic
structure

B. Involvement all employees must be involved in the process. Leaders and

managers are responsible.

C. Goal goal is to provide a system, not on assigning blame (chart audits),

does not stress identification of employee errors, only 15% of errors occur
because of employee incompetence; when problems do occur intervention
should focus on education not punishment

D. Customers define quality; internal and external customers; focus on

increasing customer satisfaction

Use of accountability measures (pg 366)

Hcahpsonline.org

E. Focus focuses on outcomes the results of healthcare

F. Decisions must be based on data; collection of data must be done

without bias
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G. QI Process
Improvement is always possible
Structured series of steps designed to plan, implement, and
evaluate changes in healthcare activities
1. Identify Consumers Needs
2. Assemble a Team
3. Collect Data
4. Establish Outcomes
- Benchmarking = identify best performance against
which to measure others; continual and
collaborative discipline of measuring and
comparing key work processes with those of best
performers.
5. Discuss Plans
6. Evaluate
III. Risk Management
A. Defined attempts to analyze problems and minimize losses after a client
care error occurs (losses include financial due to malpractice, cost of
extended LOS, negative public relations, employee dissatisfaction)
B. Increase of liability suits in 1970s led to RM programs
C. Functions of RM program:
1. Define situations that place system at some financial risk
high risks for hospitals include: falls, medication
errors, suicide attempts
2. Determine frequency of those situations
3. Intervene and investigate identified events
4. Identify potential risks or opportunities to improve care

5. Recognize near-misses and sentinel events

Near miss: A clinical situation that resulted in no injury

but that highlights the need for action

Sentinel event: A serious, unexpected occurrence

involving death or injury, such as suicide, infant abduction,
or wrong site-surgery: must be reported to TJC

Root cause analysis: retrospective analysis of the event to

identify cause to ensure future risk is minimized

D. Risk Management clinical examples:

Falls
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Self-extubation
Malfunctioning equipment while on patient
Wrong meds
Suicide attempts
Wrong surgery
Physician orders not carried out

E. Regulatory Requirements
TJC has introduced National Patient Safety Goals first
introduced in January of 2003. Each year new goals are
published.
Goals focus on: patient safety and prevention of errors

Specific data is collected and reported to be accredited by TJC

Sentinel Event Review

1. Unexpected occurrences involving death or serious
physical or psychological injury to a patient. (see more
below)

Must be investigated immediately

Will include everyone involved, RM team, QI team, and

sometimes administration

F. Means of communicating risks incident report (variance, event,

occurrence, etc.)
1. tool itself must be constructed to collect complete and
accurate information, sometimes called unusual occurrence;
do not include impressions, opinions, interpretations; does
not admit guilt

2. Forms vary among facilities, but must include:

- Name, age, address, and condition of patient or
person involved
- Exact location
- Time and date
- Description of event
- Physicians examination data
- Bedrail status
- Reason for hospitalization
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- Names of witnesses
- Extent of out of bed privileges

3. Prepared for any unusual occurrence involving people or

property, whether or not injury or damage occurs

4. Donts of incident reports:

Blame
Place on patient chart
Make an entry in the patient chart stating you made an
incident report
Report opinion or hearsay

5. Incident reports are used by risk managers to:

- do trend analysis to establish patterns
- education and training of personnel

6. Examples of incidents: Falls, wrong medication, self-

extubation, lack of reporting patient information

G. Successful suits against nurses fall into nine risk categories (Swansburg):
(Nurses in acute care cited most frequently)
Medication errors
Patient falls
Use of restraints
Equipment injuries
Failure to take appropriate nursing action (misinterpretation of signs and
symptoms)
Failure to follow hospital procedure
Failure to supervise treatment
Nosocomial infections
Mistaken identity

H. 6 Major categories of negligence that result in malpractice suits:

1. Failure to follow standards of care
2. Failure to use equipment in a responsible manner
3. Failure to communicate
4. Failure to document
5. Failure to assess and monitor
6. Failure to act as a patient advocate

IV. Evaluating Risks

A. Five Why technique It takes five whys to get to the root of a problem
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B. Triangulation technique

C. Use of standardized approached

SBAR
National Patient Safety Goals

Communication is key in QI
QA is more inspection approach to make sure hospitals were meeting
minimum standards. Looking at chart audits
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ALLEN COLLEGE
NU: 460 Nursing Leadership

Case Study An Incident Report

Mary Reynolds, a staff nurse on a postoperative neurosurgical division had been assigned
five extremely nursing care-dependent patients. Mary was also working with one nursing
assistant. She realized this was a very heavy assignment, but she decided to do her best.
One of her patients, Mr. Morrow, a postoperative craniotomy who had also suffered a
stroke, needed to get up in a chair. Mary and the nursing assistant got hum up and
restrained him in a chair because he remained listless and unresponsive. Mary checked
hum at 12:30, and all was fine. At 1:00, the neurosurgical resident found Mr. Morrow
slumped on the floor. The resident immediately started shouting, and Mary walked into
the room, and tried to explain that Mr. Morrow was fine one half hour earlier. The
resident accused Mary of negligence and continued to an angry diatribe. The head nurse
walked in at this point, and immediately agreed with the doctor. The arguing continued
out into the nurses station, and ended by the doctor leaving the area in mid-sentence, the
head nurse slamming her office door, and Mary crying.

Questions:

1. What are the appropriate steps to take when an accident has occurred?

2. Is an incident report (variance) required?

3. What could Mary have done differently?

4. What could the head nurse have done differently?

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ALLEN COLLEGE
NU: 460 Nursing Leadership

Case Study Consumer Relations - #1

Mr. J, age 74 was admitted to a hospital for the insertion of a permanent pacemaker, and
the procedure proceeded uneventfully. On the day he was to be discharged, he was given
digoxin 0.125 mg, which was intended for another patient on the unit, a different Mr. J.
The new graduate who made the error completed the in-house hospital reporting form
relevant to the error and notified the physician, who indicated that the patient would
probably suffer no consequences as a result of the error. However, a disagreement ensued
among the nursing staff regarding whether the patient should be told about the error and
whether the dose of digoxin should be recorded on the patients medical record.

Discussion:

1. What should the patient be told about the dose of digoxin? (Provide a rationale.)

2. What should be recorded on the patients medical record? (Provide a rationale.)

3. What resources might be available to the nurse to guide her actions?

4. What are Mr. Js rights and preferences in this instance?

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ALLEN COLLEGE
NU: 460 Nursing Leadership

Case Study Consumer Relations - #2

Mrs. F, age 78, had a mitral valve replacement a year ago and recently was admitted for
pneumonia. She is to be discharged today, a day earlier than expected. She will be going
to her own home and has home health services. She lives alone. Her daughter, who lives
in another state, was able to visit but had to go back home and will not be returning until
tomorrow. Since her valve replacement, Mrs. F has been on Coumadin 5 mg daily.
However, during her hospitalization, her INR was high and her dose was reduced to 3
mg, given in the evening. The doctor wrote the discharge order at 9 am and Mrs. F will be
going home via transport service. The doctor asks the nurse to give the patient a dose of
Coumadin 3 mg to take home with her so she can take it that evening because the
patients remaining supply is the wrong dosage, and her daughter wont be able to get the
prescription filled until the next day. This community hospital does not fill out-patient
prescriptions. Mrs. F does not want to wait until evening to be discharged, nor does the
utilization review department want her to stay that long.

Discussion:

1. How would you resolve this problem in consideration of Mrs. Fs preferences?

2. How would you handle the physicians request?

3. What resources might be available in your institution to address this type of

problem?