Questions and Topics We Can Help You Answering; 

Improving Quality
Improving the quality of health care delivery and patient safety continues to be a political concern and has been at the heart of reform issues for many years. The American Nurses Association (ANA) and the Institute of Medicine (IOM) have increased awareness of health care quality and safety issues, as well as advocated for health care reform. The documents featured at the ANA and IOM websites listed in this week’s Learning Resources focus on many of the current issues surrounding quality and safety in the health care industry.
To prepare:
•    Review this week’s Learning Resources, focusing on the Six Aims for Improvement presented in the landmark report “Crossing the Quality Chasm: The IOM Health Care Quality Initiative.”
•    Consider these six aims with regard to your current organization, or one with which you are familiar. In what areas have you seen improvement? What areas still present challenges? As a nurse leader, how can you contribute to improving the organization’s achievement of these aims?
•    Select one specific quality or safety issue that is presenting a challenge in the organization. Consider at least one quality improvement strategy that could be used to address the issue, as well as which of the six aims for improvement would then be addressed.
•    Reflect on your professional practice and your experiences with inter-professional collaboration to improve quality and safety. How has inter-professional collaboration contributed to your organization’s efforts to realize the IOM’s six aims for improving health care? Where has inter-professional collaboration been lacking?
By Day 3
Post a description of the quality or safety issue you selected and a brief summary of the impact that this issue has on health care delivery. Describe at least one quality improvement strategy used to address this issue. Then explain which of the six “aims for improvement” are addressed by the strategy. Finally, explain how inter-professional collaboration helps improve quality in this area.


NURS 6050: Policy and Advocacy for Improving Population Health “Quality Improvement and Safety” Program Transcript [MUSIC] NARRATOR: Delivering safe and quality health care services. STEPHEN F. JENCKS: We are now seeing enormous demand from the public, from the government, from other payers, to say, OK, let's get serious about not having people die in health care systems. NARRATOR: Monitoring to ensure continued improvement. CARMELA COYLE: I think health care reform expands the current efforts to make certain that we are treating patients in the most safe and effective way. We're monitoring the process of care better. NARRATOR: Keeping patient safety and quality care at the foundation of health care delivery. LILLEE GELINAS: Safety needs to be a precondition in an organization, not a priority. If it's a priority, it's going to be cut at the whims of the budget gods. If it's a precondition, then it's a foundational value. It is a core essence in the organization that's never going to change. NARRATOR: This week, our experts focus on improving the quality of care and patient safety in the health care system. CARMELA COYLE: If we know for a heart attack patient there are six or seven steps that always should be taken with each and every heart attack patient, I think the health care reform legislation reinforces that. We need to move beyond the process-- have you done the six or seven things that you need to do?-- and really move on to the outcome. In the end, what happened to that heart attack patient? Did he or she survive? Did he or she have to come back and be readmitted to the hospital? Or did he or she go on to then therapy, some rehabilitation, and on to good health? I think we're really going to see more of a focus in that area. We're not ready to do that in terms of legislating it into place. I think you will begin to see health care providers get out in front of that to say, this is an obligation responsibility that we need to take on. How do we find out more about our patients and their outcomes? © 2012 Laureate Education, Inc. 1 I think one of the greatest challenges is following our patients outside of our facilities. For a hospital today, we can tell you a lot about a patient who's come in through our front doors and about the care we've provided to them while they're in the hospital. What we can't do is to tell you once we've discharged that patient what happened to them. Insurance companies today know more about their enrollee across the full set of services that that individual may have. So for me, my insurance company knows when I've been to my primary care physician, when I've gone to see my specialist, if I was admitted to the hospital, and even if I went to the urgent care center because I cut my finger. They have a longitudinal sense of my health care use that no individual health care provider today has. We've got to figure out how to partner to take advantage of that information and then understand it so that when a hospital sees a patient, we may have knowledge. This is a patient with a series of chronic illnesses, and we are just one phase of the patient and the care that that individual needs. So lots of work, lots of opportunity for partnership yet to come. STEPHEN F. JENCKS: There is no question that the efficiency of the health care system is a huge national priority. We don't have the money to keep doing what we're doing. Employers cannot afford full time employees who need benefits that are so expensive that they can't manage them. And we're going to have to get very serious about that. Now how does that play into the safety and quality agenda? Well, very directly in two ones. First of all, safety events, adverse events, cost money. And in some cases, they cost lots and lots of money. In the second place, one of the most important approaches to reducing costs is not to stop doing things but to do them much more efficiently. And part of doing them efficiently is to standardize things. Standardization is also a vitally important part of creating a safe environment. We know that when a process is reinvented each time we have a patient come into the doctor's office or into a operating room, the result is mistakes, harm, and even death. So these are two places where the money issue and the safety issue converge very sharply. We have come out of a time when it wasn't quite nice to talk about whether the quality of the care delivered was really good. And it wasn't nice at all to talk about whether the care was safe. And nobody even knew how to talk about whether it was efficient. And we are now seeing enormous demands from the public, from the government, from other payers, to say, OK, let's get serious about not having © 2012 Laureate Education, Inc. 2 people die in health care systems. Let's get serious about delivering care that is highly efficient. And let's get serious about talking openly about all these things. One of the major changes then is the sense that this kind of openness and transparency is a part of where we want to go. The second major change in health care, and we really have to understand this, has been that we have started to see adverse events as things that are much more often avoidable. And while 10 years ago we might have said that ventilator associated pneumonia and central line infections were just an inevitable part of having a central line or being on a ventilator. We now see emerging evidence that those things can simply be obliterated. LILLEE GELINAS: What's happened here are these converging forces from a number of different angles, whether it's been the government and legislation and regulation, whether it's been reimbursement through payers, whether it's been the media exposing sentinel events, all these forces have come upon the hospital now that if don't improve performance, if you're not in the upper tier, if you have lots of never events and negative outcomes, you're losing your reputation. You're losing your medical staff. You're losing your patient base. And you're just not going to be in business much longer. Safety and quality should be preconditions of being in business so that all else might change as a result of budgeting or the other forces of whatever's happening around you. But this shall be true. We will have the best safety performance and the best quality performance ever. So that precondition is a foundational value that is just not going to go away, not going to be budgeted away, not going to be strategically planned away. It'll always be there. STEPHEN F. JENCKS: Measuring quality and safety is obviously a real important issue. You measure the structure of the organizations, do they have the right people and to they have enough of them, and so on? Do they have the right procedures? The processes of care actually delivered to the patient. Did the patient who had a heart attack get aspirin and beta blockers? And the outcomes of care. Did the patient with the heart attack get readmitted within 30 days? Did they die? With safety, it's trickier. Because in safety what you're really interested in is the adverse events. A patient is re-hospitalized, a patient dies, but we're also interested in the near misses. Because if you only look at the completed events, you have much less data to go on. Typically the measured events go up as you start to measure them if you've got your team working together and realizing that it's important to get things reported so you can understood them. © 2012 Laureate Education, Inc. 3 LILLEE GELINAS: Well, you can't manage what you can't measure, which is really, really an important concept. If you can't manage what you can't measure, how do we improve? The National Quality Forum work in nursing was really groundbreaking. It began in 2002. It was focused on trying to draw that link between what nurses do and patient outcomes. And it's really hard work because the work of nursing is frequently invisible. So how do you measure what's invisible? How do you measure this nursing intervention and this nursing intervention and how they all come together to take care of the patient? I like to think of the National Quality Forum Nursing Measures-- and we call them the NQF Nursing 15-- as 15 pieces of thread that when you put them all together it's like a piece of fabric over the patient that defines the care around the patient. That particular project was very, very difficult because we could only use measures that were in the public domain and open source. So there were a lot of good measures the proprietary companies and others had, but we couldn't use in the measure set. So that was one of the limitations of the measures set. But what that work has done is really created a plethora of grants and research and academia that are now looking in a very concerted way at the direct correlation between the work of nurses and patient outcomes. So much so that-- we used to be able just to cut costs and say, well, we're going to slash this number of nurses or do this-- now we know that if we cut this nurse or if we mess with this nurse-patient ratio, we might actually be creating harm. We may actually be creating worse outcomes for our organization. And guess what? Now, in this new health reform era, we're not going to get paid. We're not going to get paid for that never event. We're not going to get paid for that hospital-acquired infection. So we need to go all the way upstream, understand the work of nurses, understand what they do, how we measure it as an organization, and how that's going to impact our bottom line at the end of the day. What I think to improve quality and safety in United States, and really the world, is harmonization across three levels. At the personal level, at the organizational level, and at the national level. A national commitment to stop the initiative overload with so many measures, so many different platforms we have to stand on to manage well when you think about all the different organizations that are demanding data out of us or some outcome out of us. So that national entity coming together, creating the conversations, the measures, the infrastructure, the behavioral expectations, and the outcomes is needed. The second is organizational. I was chief nursing officer of a 402-bed acute care hospital before I became CNO at VHA. And I can tell you on any one given day, I might not know what's going on in the lab or what's going on in materials © 2012 Laureate Education, Inc. 4 management because of the silos that exist in the organization. So how can we expect harmonization nationally if our very organizations aren't harmonized and the silos aren't gone? And then that third level is the personal level. Personal accountability, personal behavior, personal commitment to excellence. My performance, my dedication, my accountability. It begins with me. That is so important. But it's also about my approach with others. And asking you to help me, asking you to help me on my lifelong journey that when you see me performing away from the values of the organization, you call that out to me and that's a learning opportunity for me. That we actually have a relationship that builds on trust, builds on confidence. Single most important attribute I see in successful safety leaders is strategic humility. They always want to learn. They always want to teach. And they always on any given day something bad could happen and it could happen on their watch. They're very humble. It's just an attribute that, in health care, goes a long way to building confidence and trust. So don't forget, it begins with me. And I need your help every day, every way. If we all have that attitude, we'll have a safer health care system in a very short period of time. And the government won't have to legislate it. [MUSIC] © 2012 Laureate Education, Inc.