Quality improvement
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Quality Improvement. Dr. Sheryl Cornelius, EdD, MSN, RN. Objectives:. Upon completion of this module the student will be able to: Describe the role of the nurse in quality improvement. Outline what constitutes a sentinel event. Articulate reporting of a sentinel event.

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Quality Improvement

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Quality improvement

Quality Improvement

Dr. Sheryl Cornelius, EdD, MSN, RN


Objectives

Objectives:

Upon completion of this module the student will be able to:

  • Describe the role of the nurse in quality improvement.

  • Outline what constitutes a sentinel event.

  • Articulate reporting of a sentinel event.

  • Analyze how sentinel events are associated with quality improvement.

  • Describe the role of the nurse in reporting.


What is quality improvement

What is Quality Improvement?

  • The need to improve care

  • The need to maintain quality care

  • The need to continue to improve quality within the organization


Why do we need to improve

Why do we need to improve?

Institute of Medicine (IOM) report

  • To Err is Human: Building a Safer Health System

  • 98,000 deaths in hospitals each year

  • Current system fragmented and poorly organized

Committee on the Quality of Health Care in America

  • Crossing the Quality Chasm

  • Chronic diseases now leading cause of illness, disability, health problems

  • Current system complex, fragmented, disorganized


What is the nurses role

What is the nurses role?

  • Observing any problems

  • Notifying the proper personnel

  • Taking part in pilot studies the facility may undertake


What is a sentinel event

What is a Sentinel Event?

Sentinel Event

  • an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof

Never Event

  • extremely rare medical errors that should never happen to a patient


Sentinel event

Sentinel event


Root cause analysis

Root Cause Analysis

  • What happened?

  • Why did it happen?

  • What circumstances surrounded the event?

  • Framework for conducting a root cause analysis from TJC: http://www.jointcommission.org/Framework_for_Conducting_a_Root_Cause_Analysis_and_Action_Plan/


Role of the nurse in reporting

Role of the nurse in reporting

  • Change the climate of reporting

  • Attend any briefings the facility may have on changes to your systems

  • Keep a hands on approach in the facility workings


Activity

Activity

Find an example online and discuss how the facility handled it


Further readings

Further readings…

  • The Institute of Medicine: To Err Is Human: Building a Safer Healthcare System http://www.iom.edu/Reports/1999/To-Err-is-Human-Building-A-Safer-Health-System.aspx

  • The Institute of Medicine: Crossing the Quality Chasm http://www.iom.edu/Reports/2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx

  • The Joint Commission: Read the “Sentinel Event Alert” under Topics tab http://www.jointcommission.org/


References

References

North Carolina Concept-Based Editorial Board, (2011). Nursing: A Concept Based Approach. Upper Saddle River, New Jersey: Pearson Education, Inc.

Marquis, B. L. & Huston, C. J. (2009). Leadership roles and management functions in nursing: Theory and application. (6th ed.). Philadelphia : Lippincott, Williams & Wilkins.

Taylor, C., Lillis, C., Lemone, P., (2011). Fundamentals of Nursing: The Art & Science of Nursing Care. (7th ed.) Philadelphia, Lippincott, Williams & Wilkins.


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