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Quality Control and Risk Management

Leadership and Management

Daniel Montgomery

on 13 November 2012

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Transcript of Quality Control and Risk Management

Quality Control and Risk Management Daniel Montgomery, BSN, RN, CPHQ Objectives (Cont'd) Goals Describe the importance and roles of organizations such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the American Nurses Association (ANA), the Agency for Healthcare Research (AHRQ), and the Centers for Medicare and Medicaid Services (CMS) Describe the national efforts of the Nursing Minimum Data Set (NMDS), Nursing Interventions Classification (NIC), Healthcare Effectiveness Data and Information Set (HEDIS), and ORYX
Gain a basic understanding of risk management and risk management plans Comprehend appropriate standards and criteria for measuring quality Analyze quality control data and determine whether or not standards have been met Identify proper corrective action when standards have not been met Select appropriate quantitative and qualitative tools to measure quality Nursing students will obtain a better understanding of the role and significance of quality control and quality improvement in the healthcare setting The Management Process Involves 5 functions, these include: Planning Organizing Staffing Directing Controlling Quality Control What is it?? Quality Control Programs Hallmarks: Support from top-level administration
Commitment by the organization in terms of fiscal and human resources
Quality goals reflect search for excellence
Continuous, ongoing process Quality Healthcare: A History 1929: First HMO in LA
1965: Passage of Medicare and Medicaid by President Lyndon B. Johnson
1980’s: Diagnosis-Related Groups (DRG’s) and expansion of Medicare benefits
1981: Joint Commission for Accreditation of Healthcare Organizations (JCAHO) mandated all acute-care hospitals have a quality assurance (QA) program Key Terms Bench Marking: process of measuring services against best-performing organizations
HMO: Health Maintenance Organization
CMS: Centers for Medicare and Medicaid Services
Joint Commission: formerly JCAHO; independent, not-for-profit organization that accredits 17,000+ health care organizations and programs in US
Outcome Audit: end result of care
Process Audit: connection between process and quality of care; critical pathways
Structure Audit: relationship between quality care and structure; staffing ratios, ED times, fire extinguishers
AHRQ: Agency for Health Care Research and Quality Quality Control (worksheet) Establish criteria Identify relevant information Determine collection ways Collect and Analyze Compare information against criteria Make a judgement concerning quality Provide information/take corrective action Reevaluate Standards of Clinical Nursing Practice (ANA, 2010) Provides the nursing profession with: First establish 1973 28 separate standards for nursing practice which also reflect specialty nursing (p. 522) Audits A systematic examination of records, processes, structures, environments, or performance evaluations Retrospectively



Most frequently used audits in healthcare - outcome audits, process audits, and structure audits Outcome Audits Determine what results are a direct result of specific nursing interventions for patients

Florence Nightingale:
patient outcomes during the Crimean War

Nursing sensitive outcomes measurements help to link nursing interventions with patient outcomes

Nursing Interventions Classification (NIC) Process Audits Assumes a connection between the nursing process and the quality of care provided

Examples of process audits include:

Critical Pathways/Bundled Care Packages
Standardized Clinical Guidelines Structure Audits Assume relationship between quality of care and appropriate structure of organization

Environment where healthcare is delivered
All elements that exist prior to and separate from interaction between the patient and healthcare worker

Examples - Quality Improvement Models Quality Assurance (QA) Quality Improvement (QI) Difference?? Total Quality Management (TQM)

Toyota Production System (TPS) Total Quality Management QI Model
Also referred to as continuous quality improvement Hallmark of Japanese management system
Assumes that:

"Doing the right things, the right way, the first time and problem-prevention planning lead to quality outcomes." Toyota Production System QI Model
Built on the principle of:

Healthcare organizations that implement this model:
Attempt to solve problems at the time they occur,
and also determine root cause of the problem

Requires tremendous amount of change, amount of staff, and substantial commitment of leadership time and resources QUALITY CONTROL IN THE HEALTHCARE SETTING Who, what, when, why? Constant feedback = constant improvement

Transforming Care at the Bedside (TCAB)
Developed and lead by Robert Wood Johnson Foundation (RWJF) and the Institute for Health Improvement (IHI)

Patient safety officers - Problems? Quality Measurement Mandates Increased tremendously over the last 30 years

Many facilities today have complete Quality Improvement programs



3. Quality Measurement Mandates 1960's: Centers for Medicare and Medicaid Services (CMS)
Government reimbursement for the elderly, disabled, and indigent

1980's: Diagnosis-related groups (DRGs)
Need for monitoring cost-containment, while providing a minimal level of care
Prospective payment system (PPS) Discussion ... With the implementation of DRG's and the PPS, do you believe it has helped contain the rising costs of healthcare while maintaining quality?
In 2009, the national expenditure on US healthcare was 2.486 trillion dollars The Joint Commission 1981: Formerly The Joint Commission for Accreditation of Healthcare Organizations (JACHO)
Mandated all acute care facilities have QA programs
Shift accreditation process from organizational structure to performance/outcome measures

1997: ORYX, a milestone initiative

2002: Core measures program (Quality Measures) to standardize data
Initially targeted:

Also includes: The Centers for Medicare and Medicaid Services (CMS) 1965: Formerly the Health Care Financing Administration (HCFA)

2001: Hospital Quality Initiative (HQI) targeted health and patient outcomes as data source
Easy to understand data sets related to healthcare quality from nursing homes to acute care facilities as well as outpatient clinics
Available to all healthcare consumers - CMS.gov

Pay for Performance(P4P)
Physician Quality Reporting Initiative (PQRI) National Committee for Quality Assurance (NCQA) A private, nonprofit organization that accredits managed cared organizations

Developed Health Plan Employer Data and Information Set (HEDIS):
76 measures across eight domains of care
Numerical and descriptive information
Quality of care, patient outcomes, availability of services, utilization, premiums, and the financial stability/operating polcies

Weakness? Reporting of Medical Errors Risk Management Risk Management Programs MEDICAL ERRORS AND RISK MANAGEMENT Medical Errors Report 1999 Institute of Medicine - To Err is Human:
44,000 - 98,000 Americans die each year as a result of medical errors
8th leading cause of death in US
Which type of medical errors were highest??

Did not occur from individual recklessness - occurred due to basic flaws in the way that the health system is organized. Increase both voluntary and mandatory reporting of medical errors

Goal: Definition (CMS.gov):

The program and supporting processes to manage information security risk to organizational operations (including mission, functions, image, reputation), organizational assets, individuals, other organizations, and the Nation, and includes: (i) establishing the context for risk-related activities; (ii) assessing risk; (iii) responding to risk once determined; and (iv) monitoring risk over time. Patient safety must be the #1 priority, not always true

Assess for culture of safety
Process and analyze results
Set priorities
Take action! Safety and Risk Management Plan Leaders and Managers must:
Educate, educate, educate!
Start at the top
Hold regular meetings and highlight risk management and patient safety
Identify measurement strategies/indicators

Examples? The Future: Large gaps between quality of care patients are ACTUALLY receiving and what they SHOULD BE receiving

HealthGrades (2008):
238,337 "potentially preventable" deaths
3% of Medicare admissions incidence rate
1.1 million in total safety incidents
1:5 chance of dying
$2.0 billion US healthcare dollars

Computerized physician-provider order entry, evidence-based hospital referral, ICU physician staffing, and Leapfrog safe practices scores To Summarize ... Controlling implemented throughout all phases of the management process
Quality control evaluates, monitors, or regulates services rendered to consumers
Organizations must set standards/criteria to guide safe and effective practice
Growing recognition of nursing-sensitive care to patient outcomes
Quality control has evolved primarily from external forces, and not as a voluntary effort to monitor healthcare quality
Everyone in an organization or healthcare facility must be involved in quality control
As nurses, we must be ever conscious of our actions and facility policies to reduce the risk of patient harm and medical errors "Care is driven by the patient's needs, goals, and values, not by the practice's priorities."
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