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Quality Improvement. & EBP. "I see." said the nurse, "You're saying that I have two jobs: doing my job, and making my job better” (Berwick). Quality Improvement. Why do you work to improve care??? How do you know care needs to be improved??? How do we know how well we’re doing ???.

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"I see." said the nurse, "You're saying that I have two jobs: doing my job, and making my job better” (Berwick)

quality improvement1
Quality Improvement
  • Why do you work to improve care???
  • How do you know care needs to be improved???
  • How do we know how well we’re doing???
  • Data reflecting the important elements of care is the only credible way of demonstrating the quality of care provided
data collection
Data Collection
  • It is essential that nurses be taught a systematic process of defining problems, identifying potential causes of those problems, and methods for testing possible solutions to improve care.

Across all systems:

  • The use of statistical monitoring techniques to monitor variation in production or services in order to identify and then correct problems as quickly as possible.
ebp review
EBP Review

Responsibilities of the BSN nurse in research:

  • Read research critically
  • Determine the readiness of research for utilization in clinical practice
  • Identify clinical problems in need or research
  • Participate in data collection and protocols

“Health care has safety and quality problems because it relies on outmoded systems of work. Poor designs set the workforce up to fail, regardless of how hard they try.”

IOM National Academy Press. 2001


Institute of Medicine:

  • Crossing the Quality Chasm 2001
  • Areas that are important for measurement and development in Health Care.
  • Established aims for quality measurement
  • There are six aims marking high quality health care: safe, timely, efficient, effective, equitable, and patient-centered care.
six iom aims
Six IOM Aims
  • Safe . Avoid injuries to patients
  • Effective. Provide services based on scientific knowledge to all who could benefit (avoid over and under use)
  • Patient Centered. Providing care that is respectful of and responsive to individual preferences, needs and values, and ensuring that patient values guide all clinical decisions

Timely. Reduce waits and sometimes harmful delays for both those who receive and those who give care

  • Efficient. Avoid waste, including waste of equipment, supplies, ideas and energy
  • Equitable. Provide care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location and socioeconomic status
quality improvement opportunities
Quality Improvement Opportunities
  • Reduce unnecessary procedures/hospitalizations
  • Utilize appropriate therapies (medications, treatments, etc.)
  • Reduce mistakes (medical errors)
  • Implement preventive healthcare measures
  • Measure outcomes to identify new opportunities to improve care
basic quality tenets
Basic Quality Tenets
  • Customer satisfaction
  • Respect for people
  • Management by fact
  • Continuous improvement
important principles
Important Principles
  • Productive work is accomplished through processes
  • Sound customer supplier relationships are absolutely necessary for sound quality management
  • The main source of quality defects are problems in the process
  • Poor quality is costly
  • Understanding variability of process is key to improving quality
important principles1
Important Principles
  • Quality control should focus on the most vital processes
  • The modern approach to quality is thoroughly grounded in scientific & statistical thinking
  • Total employee involvement is critical
  • New organizational structure can help achieve improvement
  • Quality management employs three basic, closely interrelated activities: quality planning, quality control, and quality improvement

National Demonstration Project, 1990

application of principles
Application of Principles
  • Reduced post operative infection rates (administration of antibiotics within 30 minutes of incision)
  • Reduced myocardial infarct size (aspirin at presentation, angioplasty, ACE inhibitors)
  • Improved pneumonia survival rates (ER administration of antibiotics)
how does it work
How does it work?
  • Mindset: change is possible
  • Stop looking for the bad apples and redesign the work flow
  • Understand where the hand-offs occur
  • Reduce the number of hand offs
  • Reduce variation by standardizing as many processes as possible
  • Measure results
  • Keep looking for improvement
variation measurement in assessing quality of care
Variation & Measurement in Assessing Quality of Care

Benchmarkingin health care is defined as:

  • the continual and collaborative discipline of measuring and comparing the results of key work processes with those of the best performers in evaluating organizational performance
variation measurement in assessing quality of care1
Variation & Measurement in Assessing Quality of Care

Internal benchmarking is used to:

  • identify best practices within an organization
  • compare best practices within the organization
  • compare current practice over for the organization
variation measurement in assessing quality of care2
Variation & Measurement in Assessing Quality of Care

Competitive or external benchmarking:

  • involves using comparative data between organizations to judge performance and identify improvements that have proven to be successful in other organizations

Comparative data are available from national organizations


“These quality problems occur typically not because of a failure of good will, knowledge, effort, or resources devoted to health care, but because of fundamental shortcomings in the ways care is organized”

(Crossing the Quality Chasm p. 25, 2001)

donabedian model
Donabedian model
  • Includes three domains, which are equally important, complementary, and hierarchical:
    • Structure
    • Process
    • Outcome
  • Micro-perspective: indicates capability of a provider to deliver adequate level of health care
    • Tools and resources
    • Physical and organizational settings
  • Macro-perspective: indicates capability of a healthcare delivery system to provide adequate healthcare to all citizens
    • Number of physicians and hospitals per 1,000 population
    • Geographic and specialty distribution of physicians
    • Technology diffusion
    • Access
    • Public health infrastructure
  • The actual delivery of health care
    • Micro-perspective—manner in which health care is delivered by a provider
    • Technical aspects
  • Interpersonal aspects
  • Macro-perspective—manner in which the system is used
    • Use of the public health infrastructure
  • The final results obtained from utilizing the structure and processes of healthcare delivery
  • Micro-perspective—individual outcomes
    • Organizational level: nosocomial infections, iatrogenic illnesses, mortality rates
    • Individual level: recovery, improvement, satisfaction
  • Macro-perspective—population outcomes
    • Population-wide indicators: life expectancy, low birthweight deliveries, incidence and prevalence of disease, etc.
what do measures do
What do Measures Do?
  • Used to improve care
  • Public reporting
    • Guide consumers to the best care
  • Measures need to be reliable so that anyone that measures a particular event, a set of events, or phenomenon measures in the same way and uses the same specifications for the measure.
specification of measures
Specification of Measures
  • Measures must be clearly specified
    • Each reported event defined in the same way
  • Rate =
    • number of events that occurred ÷ inclusion of total population
  • Public reported measures and benchmarking
work to do
Work to do…..

Hospitals, if they wish to be sure of improvement…

  • Must find out what their results are
  • Must analyze their results, to find their strong and weak points
  • Must compare their results with those of other hospitals
  • Must care for what cases they can care for well, and avoid attempting to care for cases which they are not qualified to care for well
work to do1
Work to do….
  • Must assign the cases to members of the staff (for treatment) for better reasons than seniority, the calendar, or temporary convenience
  • Must promote members of the staff on a basis which gives due consideration to what they can and do accomplish for their patients
  • We keep coming back and bringing it up.
    • That is how important it is!
  • Significant lag time between when evidence is found to be important and when it is fully embedded into patient care.
    • Why does this gap exist?
      • Is it easier to continue to practice as you were originally taught and tradition is difficult to alter?
iom 2003
IOM- 2003
  • Healthcare professions education: A bridge to quality
  • Advance the education of health care professionals in order to have highly functioning interprofessional teams focusing on patient-centered care.
    • It is essential that this safe care be guided by evidence, continuous quality improvement outcomes, and optimal use of informatics.
dimensions of performance
Dimensions of Performance
  • Efficacy
  • Appropriateness
  • Availability
  • Timeliness
  • Effectiveness
  • Continuity
  • Safety
  • Efficiency
  • Respect & Caring
importance for nursing
Importance for Nursing
  • The nurse systematically transfers or translates research-based knowledge into clinical practice setting.
  • EBP decreases practice based on tradition, opinion, and unsystematic clinical experiences.
  • Nursing-Sensitive Qualitative Indicators
    • Measures that reflect the impact of nursing care
  • Measures need to have scientific data supporting their validity and reliability before going through the rigorous process to be endorsed

National Quality Forum

in conclusion
In conclusion,
  • Accountability for our practice involves continually examining what is the best way to deliver care
  • If we don’t, we are limiting our role to technical skills and not fully actualizing our professional role
  • Evidence based practice is essential to practicing safely as nurses
quality summary
Quality Summary

“Perfect care may be a long way off, but much better care is within our grasp”

(IOM, Crossing the Quality Chasm)