Quality assurance to quality improvement: the impact of the agenda for changes

Health care professionals are committed to the continual improvement of the quality of patient care. The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) has launched a major research and development project intended to improve its ability to evaluate health care organizations and encourage greater attention to the quality of daily patient care. This chapter describes JCAHO's challenge to evaluate capability and performance of health care organizations and practitioners. The intent of JCAHO's agenda for change is to focus on patient outcomes and quality improvement through a more precise and objective evaluation of both clinical and managerial performance. Through the agenda for change, JCAHO and the health care organization will participate in a continuous-flow monitoring system in which clinical and organizational data are transmitted from the field to JCAHO, analyzed, and fed back to the health care organization.     

Advanced Organizers: a framework to implement learning readiness in support of broad-scale change

Staff development educators are challenged to bring value to the adoption of new organizational management tools to improve the health care of patients. One strategy used to pursue health care excellence is the adoption of the ISO 9000 standards. However, implementation of this quality management system requires acceptance at all levels of the healthcare organization. This article explores the concept of learning readiness and uses an example of a training design strategy called an "Advanced Organizer." The authors describe its use as a development readiness strategy, outline the methodology for development and implementation, and provide steps for successful implementation. The implications for staff development educators are reviewed for the concept of learning readiness and broad-scale performance improvement initiatives.     

Implementing quality palliative care

Quality palliative care is of interest to everyone who is receiving or providing care. The quality of the care that is provided depends on everyone's understanding of the underlying model that is guiding patient/family care; the organization's mission and vision; and the consistency of the language, practice and treatment guidelines, outcome assessment and performance improvement strategies that everyone is using from day-to-day. Implementation of quality palliative care within an organization starts with careful strategic planning followed by the systematic development of guidelines, outcome measures, indicators, standards and a performance improvement process through an inclusive consensus-building process. By modifying existing widely-accepted models, organizations can expedite their implementation of quality palliative care. Through careful attention to evolving this process over time, everyone will be the benefactors of a high-quality palliative care experience.     

Quality assurance in the endoscopy suite: sedation and monitoring

Education and training is the first line of defense in maintaining patient safety and providing quality care in the Endoscopy suite. Ensuring that the health care provider is well trained minimizes the risk to the patient. Quality assurance begins and ends with training. Quality assurance in the endoscopy suite related to sedation is accomplished through training and ongoing data collection using structure, process, and outcome measures. Monitoring compliance to standards with continual feedback of results allows the endoscopist to evaluate performance on an ongoing basis. The endoscopist has no choice but to become an active participant in the quality assurance process to improve the quality and value of their work.     

A successful practice model for the OR

A practice model that combines shared governance and patient care teamwork to achieve optimal surgical patient care provided the framework for a successful Joint Commission on Accreditation of Healthcare Organizations visit at the Brigham and Women's Hospital, Boston, a university-affiliated teaching hospital. This article describes ways to implement this practice model. Clinical practice, quality improvement, and development councils are explained, as well as membership criteria for the councils and how they function. The need for more sharing of such quality improvement data from other hospitals is needed to establish national standards for measuring nursing performance.     

International Federation of Nurse Anesthetists' Anesthesia Program Approval Process

The International Federation of Nurse Anesthetists is improving anaesthesia patient care through a voluntary Anesthesia Program Approval Process (APAP) for schools and programmes. It is the result of a coordinated effort by anaesthesia leaders from many nations to implement a voluntary quality improvement system for education. These leaders firmly believe that meeting international education standards is an important way to improve anaesthesia, pain management and resuscitative care to patients worldwide. By 2013, 14 anaesthesia programmes from France, Iceland, Indonesia, Philippines, Sweden, Switzerland, Netherlands, Tunisia and the USA had successfully completed the process. Additional programmes were scheduled for review in 2014. Faculty from these programmes, who have successfully completed APAP, show how anaesthesia educators throughout the world seek to continually improve education and patient care by pledging to meet common education standards. As national governments, education ministers and heads of education institutions work to decrease shortages of healthcare workers, they would benefit from considering the value offered by quality improvement systems supported by professional organizations. When education programmes are measured against standards developed by experts in a profession, policy makers can be assured that the programmes have met certain standards of quality. They can also be confident that graduates of approved programmes are appropriately trained healthcare workers for their citizens.     

Using improvement science to promote evidence-based practice in a childhood cancer and hematology center

A major children's cancer and hematology center established a Quality Transformation (QT) Core to develop and monitor empirical outcomes that demonstrate excellence in clinical care. The QT Core, based on the Institute of Medicine's domains of quality health care, aims to ensure that care is safe, effective, patient centered, timely, efficient, and equitable. Specific goals for the first year of the QT Core were to develop a team of improvement science experts, engage faculty and staff in QT initiatives, promote accountability for excellence in clinical care, and establish specific metrics to evaluate process, structure, and outcomes for QT Core projects. The purpose of this article is to discuss the successful development of a quality transformation core within a pediatric subspecialty and demonstrate the principles of improvement science through an actual quality transformation project designed to implement an evidence-based guideline for procedural sedation for children with cancer. The QT Core within this subspecialty was founded on principles of successful transformation of patient care that includes motivation to change, leaders committed to quality, active engagement of staff in meaningful problem-solving initiatives, alignment with organization goals with resource allocation, and integration to bridge boundaries throughout an organization. These key principles are demonstrated through the discussion of the development of the QT Core and implementation of an evidence-based procedure sedation guideline. Pediatric and pediatric subspecialty groups can be on the forefront of national initiatives that promote quality health care, exemplified by the QT Core developed within the cancer and hematology center.     

An institutional quality improvement initiative for pain management for pediatric cancer inpatients

Health care institutions must use the principles of quality improvement to demonstrate appropriate assessment and effective management of pain. Here, we describe the quality improvement initiative implemented at our pediatric institution to improve the quality of pain management. We conducted chart audits for the previous 24 hours during which patients received inpatient care. Over six years, 2,478 charts were audited for 87 24-hour periods (average 1.2 days/month) to answer the following: (1) Was pain intensity assessed as per the institutional pain standard of care, (2) What proportion of audited inpatients had significant pain (>or=5/10), and (3) When significant pain (>or=5/10) occurred, was treatment effective (pain score 相似文献   

Measuring and improving the patient experience in radiology

Recently enacted healthcare legislation and the associated payment reforms have shifted the focus from traditional fee for service models to adding measurable and appreciable value to the patient experience. The value equation links quality to costs, and quality metrics are now directly related to patient outcomes and the patient experience. To participate effectively in this new paradigm requires not only that we provide excellent, timely and appropriate patient-centric care at all times, but that we are able to measure and manage the feedback we obtain from our patients. Of course, in order to provide value-added care, we must know not only who our customers are, but what they value. In this review, we explore factors that impact patient perception and experience with imaging services. We further illustrate different ways that patient feedback can be elicited and provide pros and cons of each approach. Collecting appropriate data is insufficient by itself; such data must be carefully analyzed, and opportunities for improvement must be identified, introduced, and monitored ahead of future surveys.

     

A National Center for EMS Provider andPatient Safety: Helping EMS Providers Help Us

With the strong encouragement of leading health care agencies, business principles are being implemented throughout health care, including emergency medical services (EMS). The reason is simple—quality of care can be enhanced by incorporating the management concepts of continuous quality improvement (CQI). The CQI process couples carefully identified, measurable performance indicators with information systems to monitor, analyze, and trend data. Benchmarking outcomes with other EMS systems allows the identification of “best practices” and the evolution of standards. Emergency medical services professionals must actively participate with the broader health care community in creating performance measurements to ensure that high-quality care is delivered consistently.     

Continuous quality improvement in the ambulatory endoscopy center

What does quality assessment have to do with the practicing gastroenterologist? Why should one spend the time and effort to incorporate CQI activities into an already busy practice? First and foremost, quality improvement should directly benefit the patient by ensuring that they receive the highest quality of care possible. For example, comparing endoscopic use or outcomes, such as procedure success or complications, with national standards or other endoscopists in the same community may identify physicians who could benefit from additional training. Similar analyses may likewise identify outstanding physicians who might serve as resources for other physicians. Surveys of patient satisfaction may reveal deficiencies, which might be unknown to a physician who is otherwise technically excellent; deficiencies that would never have been uncovered by traditional measures of quality. Second, applying the techniques of CQI to study one's own practice can provide a competitive edge when vying for managed care or corporate contracts. In this regard, CQI can be used to document physician or practice performance through tracking of endoscopic use, procedure success and complication rates, and patient satisfaction. Finally, the rising concern among various patient advocacy groups has led to an increased emphasis on quality improvement, and in most cases it is a required activity as part of the accreditation process. Steps to quality improvement There is more to quality improvement than simply selecting and implementing a performance improvement plan. A number of steps have been suggested to achieve fundamental improvement in the quality of medical care [3]. The first is to use outcomes management for improvement rather than for judgment. One of the major criticisms of QA is that it will be used to judge physicians providing care. It is feared that CQI will be used to identify poor performers who will then be punished. This strategy leads to fear and inhibits an honest pursuit of improvement. Second, learning must be viewed as a process. A quality improvement plan that is successful in one setting may not be as favorable in another situation. Clinicians must be able to focus on their individual situations and adapt what others have implemented to their own practice. Third, the most important aspect of the quality improvement is the implementation step. It matters little if elegant studies of endoscopic complications or patient satisfaction are completed if the information is not used to improve the delivery of health care to every single patient. The delivery of medical care continues to evolve. Resources are becoming increasingly scarce and the progressive rise of health care expenditures suggests a need for control. In this zeal for cost constraint, quality must not be sacrificed. This new-found attention to quality must be extended to the level of the individual practitioner to ensure that individual patients' interests are protected and the best possible care is delivered regardless of the economic implications. As providers of health care, endoscopists need to take an active role in these efforts both in understanding and implementing the techniques of quality assessment into their practices. If physicians are not actively involved in data collection and measurement to improve the quality and value of their own work, someone else will undoubtedly assume this role.     

Integrated quality improvement program in patient care

Quality improvement in nursing is paramount among the factors contributing to an institution’s survival and growth. The demand by patients, families, insurance payers, and health professionals for quality in patient care is ever increasing. A review of the literature revealed that existing programs that ensure and monitor quality of care are group-specific based on diagnosis-related groups, time-specific as in care maps and critical pathways, focused on outcomes only, or are not comprehensive by ignoring ‘little things’. Hence, there is a need for a comprehensive, continuous, individual patient-specific, multidisciplinary quality improvement program. To fulfill the need, an integrated quality improvement program (IQIP) is formulated, and a quality monitor format (QMF) is devised. The QMF is planned by the staff nurses for each patient, and includes patient care standards, patient care by other departments, and ‘little things’ like ice water and noise control which have a significance to patients and families. The QMF is maintained from admission to discharge of each patient, non-conformances are analyzed, and problem solving to improve quality is made continually at unit and institution levels. Committed implementation of IQIP ensures delivery of quality care, enhances satisfaction of patients and families, satisfies government regulations, and provides meaning to the efforts of nurses, education, management, and research.     

Assessment of inpatient treatment of mentally ill patients in Thailand: implications for practice

Given the demand for services, psychiatric facilities in Thailand, strive to provide quality care despite limited resources. Patient quality of care initiatives are limited. The purpose of this investigation is to assess the quality of inpatient treatment among a group of acutely mentally ill hospitalized Thai patients. This study presents important data on the standards of care provided to mentally ill patients at one inpatient facility in Thailand. This study is one of the first to look at the inpatient care for Thais with a diagnosis of an acute mental illness. Areas for improvement identfied in this research include master treatment planning and documentation of care, patient teaching, and management of aggressive behavior. This study provides an insight into the patient profile and major nursing problems facing Thai nurses. The article also highlights areas of concern such as the high use of ECT and mechanical restraint. How pervasive these deficiencies are in other settings is not known. The findings in this study were shared with the professional staff. It is hope that the nursing staff armed with the results of this study will develop performance improvement activities to improve the quality of care.     

Quality assurance, control, and monitoring. The future role of information technology from the Joint Commission's perspective

In summary, the Joint Commission's current perspective on "quality assurance" in the 1990s includes three different, but complementary, activities: 1) structure and process triennial reviews (Joint Commission surveys); 2) Case-based reviews conducted by professional review organizations and/or other third parties; and 3) a combination of internal and external data-driven improvement systems. All these systems will work best supported by computers and software programs that foster the manipulation and management of data related to quality of care monitoring systems in addition to those in use today to monitor the hospital's profit and loss position. The Joint Commission's accreditation decision process will continue to be based on surveys of compliance with standards and their key characteristics. Problems related to the organization's performance against the external monitoring systems will not directly impact accreditation status. The Joint Commission will be more interested in how the organization responds to aberrant indicator data and how it conducts problem solving activities. New Joint Commission standards (yet to be developed) will relate to such activity and only then, after standards are written, field tested, and published, could the information generated by the Joint Commission's external indicator monitoring system impact on accreditation status. During a speaking engagement in Florida, a physician on the panel with me from the state's physician monitoring organization shared the following diagnostic label: "Mural Graphic Dyslexia." He defined it as the inability to read the handwriting on the wall. I believe that the handwriting is very clear and can be read very well. Data-driven quality improvement processes are the survival tools of the future.(ABSTRACT TRUNCATED AT 250 WORDS)     

Development of outcome standards in critical care

The forces influencing the development of outcome standards are gaining momentum. These forces are professional nursing issues, accreditation standards, and reimbursement issues. Traditionally, structure and process measures provided the means for evaluating the quality of nursing care. But nurses also play an important role in achieving positive patient outcomes. Outcome standards provide a mechanism for measuring patient outcomes. In 1990 the American Association of Critical-Care Nurses (AACN) published Outcome Standards for Nursing Care of the Critically Ill. The book serves as a model for developing and using outcome standards in critical care units. This chapter describes these outcome standards and recommends ways to use them. The Joint Commission on the Accreditation of Healthcare Organizations' (JCAHO) ten-step model outlines development of unit-specific outcome standards. Methods focus throughout on a quality assurance framework.     

Standard compliance. The process and art of preparation

The primary purpose of most regulatory agencies is to insure that standards for patient care are defined and adequately supported by policy, procedure, and organizational structure. In addition, the regulatory agency evaluates the effectiveness of the organization in implementing and monitoring the standards for providing safe, quality patient care. The objectives of regulatory agencies do not differ significantly from the major responsibilities of nursing administration. Despite similar accountabilities between the surveyor of the regulatory agency and the nurse administrator of an organization, there may be a great deal of anxiety and stress before an accreditation visit. A method of understanding the standards, developing tools to monitor compliance with the standards, educating staff regarding the standards, and assuring nursing practice is in compliance with the standards is presented. A mechanism for organizing materials and information for the survey that will be effective for ongoing monitoring of standards is also discussed.     

Southern California Edison's performance standards: an employer's key to quality care delivery

One of the most significant lessons learned from this process is that setting objectives with performance standards is the key to continuous quality improvement. The critical differences between health administration and health management are threefold: (1) performance standards are developed with clarity, (2) care delivery is monitored and measured against these standards, and (3) improvements are made based on information from these measurements.     

JCI标准在血液净化护理管理中的实践

目的:探讨JCI标准对血液净化护理管理的促进作用。方法:采用"以人为本"的人力资源管理,加强"以患者为中心"的安全管理、医院感染管理,实施"以患者舒适"为目标的优质护理等,持续提高血液净化室的护理质量。结果:JCI标准的实施对血液净化室护理质量提升起到了良好的促进作用,保证了患者的安全,提高了患者满意度,有效控制了护理不良事件和医源性感染的发生。结论:JCI标准指导下的血液净化室护理管理有利于维护患者安全和提高护理质量,体现了以患者为中心的护理理念,值得进一步推广和应用。     

Standards of care and practice: a vital link in quality assurance

In the critical care unit setting, a quality assurance program is based on the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) ten-step model for monitoring and evaluation. The addition of nursing standards of patient care and standards of nursing practice to that ten-step model provides the vital link between patient expectations, staff performance, and quality assurance in that unit.