Managing Quality and Risk

This chapter explains key concepts and strategies related to quality and risk management. All healthcare professionals, including nurses, must be actively involved in the continuous improvement of patient care.

Objectives

• Apply quality management principles to clinical situations.

• Use the six steps of the quality improvement process.

• Practice using select quality improvement strategies to do the following:

• Identify customer expectations.

• Diagram clinical procedures.

• Develop standards and outcomes.

• Evaluate outcomes.

• Incorporate roles of leaders, managers, and followers to create a quality management culture of continuous readiness.

• Apply risk management strategies to an agency’s quality management program.

Terms to Know

benchmarking

continuous quality improvement (CQI)

failure mode and effects analysis (FMEA)

near miss

never event

nursing-sensitive outcome

patient-care outcome

performance improvement (PI)

quality assurance (QA)

quality improvement (QI)

quality management (QM)

risk management

root-cause analysis

sentinel event

total quality management (TQM)

The Challenge

Kathleen M. Hoff RN, BSN Staff Nurse, Infant Special Care Unit, Evanston Hospital, NorthShore University HealthSystem, Evanston, Illinois

Medical errors are one of the most common issues discussed among quality care and risk management healthcare professionals and are of great concern to me as a new graduate. The Institute of Medicine brought the issue of medical errors to the forefront of healthcare awareness with its landmark report To Err is Human: Building a Safer Health System, but the concern existed in hospitals long before that publication and, without further intervention, will continue to be an issue in years to come. Many policies and procedures have been put into place to try to decrease the rate of medical errors in hospitals, such as electronic bar coding. With hospitals growing in capacity and with increasing demands placed on nurses, it is critical that individual units address what they can do to foster quality care and prevent errors.

What do you think you would do if you were this nurse?

Introduction

Healthcare agencies and health professionals strive to provide the highest quality, safest, most efficient, and cost-effective care possible. The philosophy of quality management and the process of quality improvement need to shape the entire healthcare culture and provide specific skills for assessment, measurement, and evaluation of patient care. The goal of an organization committed to quality care is a comprehensive, systematic approach that prevents errors or identifies and corrects errors so that adverse events are decreased and safety and quality outcomes are maximized. Leadership must acknowledge safety shortcomings and allocate resources at the patient care and unit levels to identify and reduce risks (Pronovost, Rosenstein, et al., 2008). Quality management and risk management are focused on optimizing patient outcomes and emphasize the prevention of patient care problems and the mitigation of adverse events. Hospital leaders, including nurses, must sharpen their expertise in healthcare quality and patient safety, and staff at all levels must be empowered to act on nursing performance data (Kurtzman & Jennings, 2008).

Quality Management in Health Care

Healthcare systems that demand quality recognize that survival and competitiveness are built on improved patient outcomes. Success depends on a philosophy that permeates the organization and values a continuous process of improvement. It is essential to integrate patient safety and risk management into broader quality initiatives. Nurses must be prepared to continuously improve the quality and safety of healthcare systems within which they work and must focus on the six competencies identified by Quality and Safety Education for Nurses (QSEN): patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics (Cronenwett et al., 2007). Quality necessitates maintaining safety in patient care, with a continual focus on clinical excellence from the entire multidisciplinary team. Patient safety is a key component of quality improvement and clinical governance. Moreover, the prevention of adverse events is paramount to improved patient outcomes.

The terms quality management (QM), quality improvement (QI), performance improvement (PI), total quality management (TQM), and continuous quality improvement (CQI) are often used interchangeably in health care. Quality-related terminology continues to evolve.

In this chapter, quality management refers to a philosophy that defines a healthcare culture emphasizing customer satisfaction, innovation, and employee involvement. Similarly, quality improvement refers to an ongoing process of innovation, prevention of error, and staff development that is used by institutions that adopt the quality management philosophy. Nurses maintain a unique role in quality management and quality improvement because of the amount of direct patient care provided at the bedside and because they have an understanding of the day-to-day issues and “real world” nursing involved in delivery of care. Involvement of nurses in patient care improvement efforts (e.g., patient flow problems, safe delivery of care during low staffing or high census and high acuity times, communication problems associated with complex patients, improving medication safety) can not only promote quality and safety of patient care but also positively affect job satisfaction and improve the work environment (Hall, Moore, & Barnsteiner, 2008).

Benefits of Quality Management

Healthcare systems employing a comprehensive QM program benefit in a number of ways. First, greater efficiency and proactive planning may overcome some of the resource constraints, including limited reimbursement imposed by prospective payment plans and key staff shortages. Second, successful malpractice suits could be reduced with quality care because QM is based on the philosophy that actions should be right the first time and that improvement is always possible. Third, job satisfaction could be enhanced because QM involves everyone on the improvement team and encourages everyone to contribute. This style of participative management makes employees feel valued as team members who can really make a difference.

Planning for Quality Management

Multidisciplinary planning is integral to the quest for quality. Issues are examined from various perspectives using a systematic process. Planning takes time and money; however, the price of poor planning can be very expensive. Costs of inadequate planning might involve correcting a patient care error, resulting in extended length of stay and added procedures. In turn, this increases the risk of liability for what was originally done, it risks a negative public image, and it magnifies employee frustration and turnover. The costs of errors and ineffective nursing actions are avoidable costs.

Evolution of Quality Management

Non-healthcare industries have excelled in focusing on process improvement as part of their core operating strategies. Numerous business management philosophies have been expanded and modified for use in healthcare organizations. For example, Six Sigma, a data-driven approach targeting a nearly error-free environment, empowers employees to improve processes and outcomes. As healthcare organizations “go lean,” nurses are challenged to eliminate unnecessary steps and reduce wasted processes (saving time and money) to improve quality and the patient experience (de Koning, Verver, van den Heuvel, Bisgaard, & Does, 2006). To achieve this, Six Sigma uses a five-step methodology known as DMAIC, which stands for define opportunities, measure performance, analyze opportunity, improve performance, and control performance to improve existing processes.

In health care, emphasis is placed in the areas of patient safety and patient and employee satisfaction. Leadership development is fostered. The role of the leader or manager in this TQM method is to enable the team, remove barriers, and instill accountability.

Within healthcare systems, QI combines the assessment of structure (e.g., adequacy of staffing, effectiveness of computerized charting, availability of unit-based medication delivery systems), process (e.g., timeliness and thoroughness of documentation, adherence to critical pathways or care maps), and outcome (e.g., patient falls, hospital-acquired infection rates, patient satisfaction) standards. These three factors are usually considered interrelated, and research has been conducted to determine the characteristics of effective structures and processes that would result in better outcomes. The Literature Perspective on p. 392 expands the classic Donabedian model of the structure, process, and outcome framework in promoting quality in healthcare organizations.

Literature Perspective

Resource: Glickman, S. W., Baggett, K. A., Krubert, C. G., Peterson, E. D., & Schulman, K. A. (2007). Promoting quality: The health-care organization from a management perspective. International Journal for Quality Health Care, 19(6), 341-348.

Although agreement exists about the need for quality improvement in health care, the best approach to measuring and achieving quality has not been identified. Avedis Donabedian developed the structure, process, and outcome framework in 1966 to measure quality initiatives, and the Donabedian model continues to be used today. Structural indicators are based on an assessment of an organization’s features or staff characteristics that may affect an organization’s performance and quality. Examples might include factors that contribute to The Joint Commission accreditation or Magnet™ status designation such as the leadership climate and staff governance structure. Process standards are based on evidence relating to the quality of the staff’s work behaviors and include rates of nosocomial infections and medication errors. Outcome standards relate to performance measures that can be attributed to the quality of services performed and include patient satisfaction and patient health status.

The focus in most healthcare arenas has been on process and outcomes, but a need exists to increase the understanding of structure’s role in quality initiatives. An updated view of the Donabedian’s conceptualization of structure emphasizes five key elements that define structure in today’s healthcare arena: executive management, culture, organizational design, incentive structures, and information exchange and technology.

Implications for Practice

The updated Donabedian framework can be used to enhance organizational performance and quality. Healthcare leaders must attend to these core structural components to transform quality improvement initiatives and to actively involve direct care providers to improve the quality and safety of care they deliver to patients.

Recognizing the relationship between quality patient care and nursing excellence, the American Academy of Nursing undertook a study that resulted in the distinction known as Magnet™. The American Nurses Credentialing Center (ANCC) created a process called the Magnet Recognition Program®. The term Magnet™ hospital was chosen to describe a hospital that attracts and retains nurses even in times of nursing shortages. Magnet™ hospital research has examined the characteristics of hospital systems that impede or facilitate professional practice in nursing and also promote quality patient outcomes. Common organizational characteristics of Magnet™ hospitals include structure factors (e.g., decentralized organizational structure, participative management style, and influential nurse executives) and process factors (e.g., professional autonomy and decision making, ongoing professional development/education). Organizations that have not pursued Magnet™ status can implement strategies (e.g., introducing a clinical ladder program, facilitating professional certification, assisting with evidence-based projects, enhancing the new graduate nurse orientation program) to promote a professional practice environment for staff nurses and improve organizational outcomes (Lacey et al., 2008).

Quality Management Principles

The combination of QI ideas from theory and research is sometimes referred to as total quality management (TQM) or, more simply, quality management (QM). The basic principles of QM are summarized in Box 20-1 and are developed further in the next section of this chapter.

BOX 20-1 Principles of Quality Management and Quality Improvement

1. Quality management operates most effectively within a flat, democratic, organization structure.

2. Managers and workers must be committed to quality improvement.

3. The goal of quality management is to improve systems and processes, not to assign blame.

4. Customers define quality.

5. Quality improvement focuses on outcomes.

6. Decisions must be based on data.

Involvement

Leaders, managers, and followers must be committed to QI. Top-level leaders and managers retain the ultimate responsibility for QM but must involve the entire organization in the QI process. Although some healthcare organizations have achieved significant QI results without systemwide support, total organizational involvement is necessary for a culture transformation. If all members of the healthcare team are to be actively involved in QI, clear delineation of roles within a nonthreatening environment must be established (Table 20-1).

TABLE 20-1

ROLES/RESPONSIBILITIES IN QUALITY IMPROVEMENT PLAN

ROLE OF SENIOR LEADER	ROLE OF NURSE MANAGER	ROLE OF FOLLOWER
• Leads culture transformation • Sets priorities for house-wide activities, staffing effectiveness, and patient health outcomes • Builds infrastructure, provides resources, and removes barriers for improvement • Defines procedures for immediate response to errors involving care, treatment, or services and contains risk • Assesses management and staff knowledge of quality management process regularly, and provides education as needed • Implements and monitors systems for internal and external reporting of information • Defines and provides support system for staff who have been involved in a sentinel event	• Is accountable for quality and safety indicator performance within areas of responsibility • Communicates performance priorities and targets to staff • Meets regularly with staff to monitor progress and help with improvement work • Uses data to measure effectiveness of improvement • Works with staff to develop and implement action plans for improvement of measures that do not meet target • Provides time for unit staff to participate in quality improvement measures • Directly observes staff and coaches as needed • Consults quality management team (e.g., Six Sigma) or risk management team as appropriate • Writes and submits to senior leaders periodic action plan including performance measures and plans for improvement • Shares information and benchmarks with other units and departments to improve organization’s performance	• Follows policies, procedures, and protocols to ensure quality and safe patient care • Remains current in the literature on quality and safety specific to nursing; promotes evidence-based practice standards • Communicates with and educates peers immediately if they are observed not following quality and safety standards • Reports quality and safety issues to supervisor/manager • Invests in the process by continually asking self, “What makes this indicator important to measure?” “What has been done to improve it?” “What can I do to improve it?” • Participates actively in the quality improvement activities

To work effectively in a democratic, quality-focused corporate environment, nurses and other healthcare workers must accept QI as an integral part of their role. Nurses have a direct impact on patient safety and healthcare outcomes (Kurtzman & Jennings, 2008). Nursing must be recognized and empowered to mobilize performance improvement knowledge and practice measures throughout the organization. When a separate department controls quality activities, healthcare managers and workers often relinquish responsibility and commitment for quality control to these quality specialists. Employees working in an organizational culture that values quality freely make suggestions for improvement and innovation in patient care. Exercise 20-1 may help nurses make QI suggestions.

Exercise 20-1

Think of something that can be improved in your work setting. Define the problem, using as many specific facts as possible. List the advantages to the staff, patients, and agency of improving this problem. Describe several possible solutions to the problem. Decide whom you would contact about these suggestions.

Goal

The goal of QM is to improve the system, not to assign blame. Managers strive to provide a system in which workers can function effectively. To encourage commitment to QI, nurse managers must clearly articulate the organization’s mission and goals. All levels of employees, from nursing assistants to hospital administrators, must be educated about QI strategies.

Communication should flow freely within the organization. When healthcare professionals understand each other’s roles and can effectively communicate and work together, patients are more likely to receive safe, quality care (Hall et al., 2008). Because QM stresses improving the system, detection of employees’ errors is not stressed; and if errors occur, re-education of staff is emphasized rather than imposition of punitive measures. When patient safety indicators are used to examine hospital performance, the focus of error analysis shifts from the individual provider to the level of the healthcare system (Glance, Li, Osler, Mukamel, & Dick, 2008).

Customers

Customers define quality. Successful organizations measure the factors that are most important to customers and focus their energies on enhancing quality in these areas. As patients become more sophisticated and view themselves as “consumers” who can take their business elsewhere, they want input into treatment decisions. Although typical patients may not be knowledgeable about a specific treatment, they know if they were satisfied with their experience with the healthcare provider.

Every nurse and healthcare agency has internal and external customers. Internal customers are people or units within an organization who receive products or services. A nurse working on a hospital unit could describe patients, nurses on the other shifts, and other hospital departments as internal customers. External customers are people or groups outside the organization who receive products or services. For nurses, these external customers may include patients’ families, physicians, managed care organizations, and the community at large. Some customers (e.g., physicians, patient families) could be either internal or external customers depending on the actual care environment. Managers and staff nurses can use Exercise 20-2 to identify their internal and external customers.

Exercise 20-2

For one week, list every person with whom you interact as a nurse. The internal customers are those people who work for or receive care in your organization. External customers come from outside the organization. What is the best method to obtain feedback from each of these customers?

Public reporting of quality and risk data is changing the way customers make decisions about health care and is intended to improve care through easily accessed information. For example, Hospital Compare (U.S. Department of Health and Human Services, 2009) allows customers to (1) find information on how well hospitals care for patients with certain medical conditions or surgical procedures and (2) access patient survey results about the quality of care received during a recent hospital stay. This information allows customers to compare the quality of care hospitals provide. Hospital Compare was created through the efforts of the Centers for Medicare & Medicaid Services (CMS), the Department of Health & Human Services (DHHS), and other members of the Hospital Quality Alliance (HQA). The information on this website comes from hospitals that have agreed to submit quality information for Hospital Compare to make public.

Consumer satisfaction with health care can be assessed through the use of questionnaires, interviews, focus group discussions, or observation. Patients’ perspectives should be a key component of any quality improvement initiative. However, patients cannot always adequately assess the competence of clinical performance, and therefore patient feedback and patient satisfaction surveys must serve as only one data source for QI initiatives.