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chapter 10
Issues of Quality and Safety
OBJECTIVES
After reading this chapter, the student should be able to:
■ Discuss the history of quality and safety within the U.S.
health-care system.
■ Analyze historical, social, political, and economic trends affecting the nursing profession and the health-care delivery system.
■ Explain the importance of quality improvement (QI) for the nurse, patient, organization, and health-care delivery system.
■ Discuss the role of the nurse in continuous quality improvement (CQI) and risk management.
■ Examine factors contributing to medical errors and evidence-based methods for the prevention of medical errors.
■ Explain the use of technology to enhance and promote safe patient care, educate patients and consumers, evaluate health-care delivery, and enhance the nurse’s knowledge base.
■ Describe the effects of communication on patient-centered care, interprofessional collaboration, and safety.
■ Promote the role of the nurse in the delivery of safe, effective quality care in today’s health-care environment.
OUTLINE
2011). The impetus to decrease costs and improve outcomes influences the current movement toward improved quality and safety. These forces include economics, societal demographics and diversity, regulation and legislation, technology, health- care delivery and practice, and environment and globalization.
Economics. Many economic trends and issues affect the U.S health-care delivery system. Busi- nesses, government, and the media criticize the cost of health care within the United States when compared with that of other developed nations ( Jackson, 2006; Kersbergen, 2000; Milton, 2011).
The costs of research and the costs to develop new treatments and technology continue to rise. Edu- cated consumers expect safe, quality care with asso- ciated satisfaction and positive health outcomes.
Nurses need to be prepared to support consumers with a thorough knowledge of quality, account- ability, and cost-effectiveness (AACN, 2008, 2012).
This means that they must have the knowledge to educate patients regarding the technology used in their treatments and explain the rationale behind the treatment selection. While initial expenses may increase, improvements in quality and safety will reduce costs in the long term (Aiken et. al., 2012; Cronenwett et al, 2007; Institute of Medi- cine [IOM], 2003a; Weiss, Yakusheva, & Bobay, 2011).
Societal demographics and diversity. Increased numbers of racial and ethnic groups influence health-care delivery (Billings & Halsted, 2011;
Davis, 2010; Elwood 2007; Health and Human Services [HHS], 2011; Heller, Oros, & Durney- Crowley, 2000; World Health Organization, 2009).
Increased numbers of the elderly, longer life expec- tancy, and improvements in technology result in an emphasis on specialized geriatric care. Both the elderly and ethnic minorities are at-risk popula- tions who suffer disadvantages in access to care, payment for care, and quality of care (Affordable Care Act, 2010; Anderson, Scrimshaw, Fullilove, Fielding, & Normand, 2003). It is hoped that the passage of the Affordable Care Act (ACA) will minimize these disparities as more of these indi- viduals will have access to health-care services (Davis, 2010).
Regulation and legislation. The diverse interests of consumers, insurance companies, government, and regulation affect health-care legislation. For health-care leaders and providers of care, unprec-
edented challenges continue despite the attention that quality and safety have received during the evolution of the existing health-care system. The ACA now provides health care to individuals who previously lacked coverage. This access to care will increase the numbers of individuals who will need providers as well as force changes in regulation and cost management.
Technology. The use of technology and the incor- poration of the electronic health record are pro- jected to decrease costs and improve clinical outcomes, quality, and safety (IOM, 2003a; Poon et al., 2010). Nursing practice must adjust to these health-care delivery trends with the inclusion of concepts in interprofessional collaboration, patient- focused systems, and information literacy (Booth, 2006; Sargeant, Loney, & Murphy, 2008). Addi- tionally, nurses must utilize technology and infor- matics to incorporate evidenced-based practices for improved quality and safety in the health-care delivery system (Hunter, 2011).
Technology also produces advancements in disease treatments, especially in the areas of genet- ics and genomics, and all professionals must inte- grate these advancements into practice (Calzone, Cashion, Feetham, Jenkins, Prows, Williams, &
Wung, 2010; Lea, Skirton, Read, & Williams, 2011). The current advances in genetics and genom- ics continue to allow the redesign of treatments for a variety of genetic disorders, quality improvement (QI), and outcomes in clinical practice often related to pharmacotherapeutics (Trossman, 2006; Lea, Skirton, Read, & Williams, 2011).
Health-care delivery and practice. Health-care professionals should be prepared to provide safe, quality care in all settings, including acute care and community settings. Nurses and other health-care professionals need the knowledge, skills, attitudes, and competencies to function in a variety of set- tings and the ability to support the needs of the increasingly diverse population (Anderson et al., 2003; Ervin, Bickes, & Schim, 2006; Heller, Oros,
& Durney-Crowley, 2000).
The integration of evidenced-based practice serves to improve quality and safety for patients, and improves collaboration and interprofessional teamwork (IOM, 2003a; O’Neill, 1998). Both the IOM (2003a) and the Pew Health Professions Commission (PEW, 1998) identified the need for the health-care delivery system and its profession- als to improve collaboration and to work in an
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interprofessional team to improve quality and safety.
Environment and globalization. The emergence of a global economy, the ease of travel, and advances in communication technology affect the move- ment of people, money, and disease (Heller, Oros,
& Durney-Crowley, 2000; Kirk, 2002). Global warming and climate change have been linked to the emergence of new drug-resistant organisms and an increase in vector-borne and waterborne disease as warmer temperatures promote changes in organ- ism structure and increase the growth rate of bac-
teria. Increased ease of travel allows for migration of affected populations. Safe, quality health care will need to confront the challenges of increasing multiculturalism, potential for pandemic, and the effect of climate change and pollution on health.
In addition, many health-care professionals, government agencies, and supporting organizations have contributed to the evolution of quality and safety within the health-care system. The Histori- cal Timeline (Table 10-1) highlights significant organizations and initiatives of importance to quality and safety.
table 10-1
Historical Timeline
1896 Nurses Associated Alumnae of the United States and Canada formed, later called the American Nurses Association (ANA)
1906 Food and Drug Act signed, which began the regulation of food and drugs to protect consumers
1918 American College of Surgeons founded, which initiated minimum standards for hospitals and on-site hospital inspections for adherence to standards
1930s Employers began offering health benefits, and the first commercial insurance companies arose
1945 Quality management principles developed by Edward Deming were applied successfully to industries such as manufacturing, government, and health care
1951 Joint Commission on Accreditation of Healthcare Organizations (JCAHO) founded; currently referred to as The Joint Commission (JC)
1955 Social Security Act passed; hospitals that had volunteered for accreditation by JCAHO were approved for participation in Medicare and Medicaid
1966 Quality of health-care services defined in the literature
1970 IOM established as a nonprofit adviser to the nation to improve health in the national academies 1979 National Committee on Quality Assurance (NCQA) established
1986 National Center of Nursing Research founded at the National Institutes of Health (NIH) 1989 Agency for Healthcare Research and Quality (AHRQ) established
1990 NCQA began accrediting managed care organizations by using data from Health Plan Employer Data and Information Set (HEDIS)
1990 Institute of Healthcare Improvement (IHI) founded
1991 Nursing’s Agenda for Health Care Reform published by the ANA
1996 National Patient Safety Foundation (NPSF) founded; JC established Sentinel Event Policies 1996 IOM launched three-part initiative to study health-care system quality
1998 IOM National Roundtable on Health Care Quality released Consensus Statement 1999 IOM published To Err is Human: Building a Safer Health System
2001 IOM published Crossing the Quality Chasm: A New Health System for the 21st Century 2001 IOM published Envisioning the National Health Care Quality Report
2001 ANA’s National Database for Nursing Quality Indicators (NDNQI) demonstrated the positive impact of the appropriate mix of nursing staff on patient outcomes
2001 JC mandated hospital-wide patient safety standards
2003 IOM published Priority Areas for National Action: Transforming Health Care Quality, which established priority areas for national action to improve quality of care and outcomes (Box 10-1)
2003 JC established first set of National Patient Safety Goals (NPSG) 2003 IOM published Health Professions Education: A Bridge to Quality
2004 IOM published Keeping Patients Safe: Transforming the Work Environment of Nurses 2004 IOM published Patient Safety: Achieving a New Standard of Care
2005 ANA updated its Health Care Agenda, urging system reform 2006 IOM published Preventing Medication Errors: Quality Chasm Series 2014 JC updated National Patient Safety Goals
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and strategy for health system reform (Box 10-2).
Two in particular, To Err is Human: Building a Safer Health System (IOM, 2000) and Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001), provide a framework upon which the 21st-century health-care system is being built. In 2011 the IOM released a report on The Future of Nursing: Leading Change, Advancing Health (IOM, 2011). This report describes the changes needed in nursing practice and nursing education to promote nursing’s role in the new era of health-care delivery.
To Err is Human, discussed later in this chapter, quantified unnecessary death in the U.S. health- care system and placed emphasis on system failures as the foundation for errors and mistakes. Accord- ing to the report, it is the flawed systems in patient care that often leave the door open for human error.
The report made a series of eight recommendations in four areas (Box 10-3) that aimed to decrease errors by at least 50% over 5 years. The goal of the
• Crossing the Quality Chasm: The IOM Quality Health Care Initiative (1996)
• To Err Is Human: Building a Safer Health System (2000)
• Crossing the Quality Chasm: A New Health System for the 21st Century (2001)
• Envisioning the National Health Care Quality Report (2001)
• Priority Areas for National Action: Transforming Health Care Quality (2003b)
• Leadership by Example: Governmental Roles (2003)
• Health Professions Education: A Bridge to Quality (2003a)
• Patient Safety: Achieving a New Standard of Care (2003)
• Keeping Patients Safe: Transforming the Work Environment for Nurses (2004)
• Academic Health Centers: Leading Change in the 21st Century (2004)
• Preventing Medication Errors: Quality Chasm Series (2006)
box 10-2
IOM Quality Reports (IOM, 2006)
• Enhance knowledge and leadership regarding safety.
• Identify and learn from errors.
• Set performance standards and expectations for safety.
• Implement safety systems within health-care organizations.
box 10-3
Focus Areas of To Err is Human Recommendations (IOM, 2000)
• Asthma • Ischemic heart disease
• Cancer screening • Major depression
• Care coordination • Nosocomial infections
• Children with • Obesity
special care needs • Pain control in advanced
• Diabetes cancer
• End-of-life issues • Pregnancy and childbirth
• Frail elderly • Self-management
• Health literacy • Severe, persistent mental illness
• Hypertension • Stroke
• Immunizations • Tobacco dependence in adults box 10-1
Institute of Medicine Priority Areas (IOM, 2003b)
The Institute of Medicine and the
Committee on the Quality of Health Care in America
The Institute of Medicine (IOM) is a private, non- profit organization chartered in 1970 by the U.S government. The IOM’s role is to provide unbiased, expert health and scientific advice for the purpose of improving health. The result of the IOM’s work supports government policy making, the health- care system, health-care professionals, and consum- ers (Box 10-1).
In 1998 the IOM National Roundtable on Health Care Quality released Statement on Quality of Care (Donaldson, 1998), which urged health- care leaders to make urgent changes in the U.S.
health-care system. The Roundtable reached con- sensus in four areas regarding the U.S. health-care system:
1. Quality can be defined and measured;
2. Quality problems are serious and extensive;
3. Current approaches to quality improvement (QI) are inadequate; and
4. There is an urgent need for rapid change.
This IOM statement launched today’s movement to improve quality and safety for the 21st century U.S. health-care system.
In 1998 the IOM charged the Committee on the Quality of Health Care in America to develop a strategy to improve health-care quality in the coming decade (IOM, 2000). The Committee completed a systematic review and critique of lit- erature that highlighted and quantified severe shortcomings in the heath-care system. Its work led to the series of reports that serves as the foundation
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recommendations was “for the external environ- ment to create sufficient pressure to make errors costly to health-care organizations and providers, so they are compelled to take action to improve safety” (IOM, 2000, p. 4). The recommendations sparked public interest in health-care quality and safety and caused prompt responses by the govern- ment and national quality organizations.
Crossing the Quality Chasm addressed broad quality issues in the U.S. health-care system. The report indicated that the health-care system is fun- damentally flawed with “gaps,” and it proposed a system-wide strategy and action plans to redesign the health-care system. The report stated that the gaps between actual care and high-quality care could be attributed to four key inter-related areas in the health-care system: the growing complexity of science and technology, an increase in chronic conditions, a poorly organized delivery system of care, and constraints on exploiting the revolution in information technology. With the overarching goal of improving the health-care system by closing identifiable gaps, the report made 13 recommenda- tions, some of which are in Box 10-4. Additionally, the report addressed the importance of aligning and designing health-care payer systems, profes- sional education, and the health-care environment for quality enhancements, improved outcomes in care, and use of best practices.
The Future of Nursing: Leading Change, Advanc- ing Health discusses the role of nursing in the 21st century. This document recognizes that the nursing profession confronts many challenges in the chang- ing health-care system. It identifies recommenda- tions for an “action-oriented blueprint for the future of nursing” (RWJF, 2008, p. s-2).
As a professional nurse, you have a responsibility to acknowledge the complexity and deficits of the
health-care system. In managing patient care, you must continually consider the impact of the system on the care you provide and participate in the quality and safety initiatives at the bedside, in your unit, and within your organization to promote quality and safety within the system.