CHAPTER 9. Continuous Quality Improvement
Meg Beturne
OBJECTIVES
At the conclusion of this chapter, the reader will be able to:
1. Define quality in health care.
2. Describe the process of continuous quality improvement (CQI).
3. Describe the concept of total quality management (TQM).
4. Recognize major changes in health care that have had an impact on quality improvement (QI).
5. Identify aspects and key dimensions of quality.
6. List useful sources of data collection.
7. List useful tools for identifying patterns or trends.
8. Recognize issues in perianesthesia settings that affect quality.
I. QUALITY IN HEALTH CARE
A. Doing the right things right the first time
B. According to Donadbedian, quality depends on:
1. Practitioner assessment and/or patient and health system contributions
2. How health and responsibility for health are defined
3. Whether maximally or optimally effective care is sought
4. Whether the optimum is defined according to individual or social preference
C. Juran Institute defines quality as:
1. Freedom from deficiencies: any avoidable intervention required to achieve an equivalent patient outcome
2. Product features: both services and goods that attract and satisfy patients, meet customer expectations, and distinguish one practitioner or organization from others
D. Institute of Medicine (IOM): quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.
E. Agency for Healthcare Research and Quality: quality in health care means:
1. Providers deliver the right care to right patient at the right time in the right way.
2. Patients can access timely care, have understandable and accurate information about benefits and risks, are protected from unsafe care services and products, and have understandable and reliable information on their care.
3. Clinicians and patients have their rights respected.
F. Concept of value
1. Require proof (positive outcomes) that the quality of care received is the best possible for dollars spent and minimize adverse patient outcomes
2. Value-added is key—it includes issues related to access, convenience, service, relationships with physicians, safety, and innovation.
G. Incremental stages of quality
1. Technical quality relies on quality tools, processes, and technology with customer perspective of “persuade them.”
2. Functional quality relies on people and judgment with customer perspective of “satisfy them.”
3. Competitive quality relies on time and flexibility with a customer perspective of “attract them.”
4. Forward quality relies on long-term planning and intuition with customer perspective of “building trust.”
II. CQI
A. Systematic approaches/models to the continuous study and improvement of the processes of providing health care services to meet the needs of individuals and others
B. Shewhart cycle: statistical quality control and cycle for continuous improvement PDCA (plan, do, check, act)
C. FOCUS PDCA model
1. Find
2. Organize
3. Clarify
4. Understand
5. Select
D. Feiggenbaum
E. Organizational Dynamics FADE approach
1. Focus on problem.
2. Analyze problem.
3. Develop a plan for improvement.
4. Execute the plan.
F. Ernst and Young IMPROVE model
1. Identify problem.
2. Measure impact.
3. Prioritize causes.
4. Research root causes.
5. Outline alternatives.
6. Validate solutions.
7. Execute solutions and standardize.
G. QI process
1. Use of team collaborative efforts to study and improve specific existing processes at all levels
2. Prioritizing and analyzing causes of existing process failure, dysfunction, or inefficiency
3. Systematically instituting optimal solutions to chronic problems
4. Analyzing and disseminating best-practice information to staff, patients, and families
5. Using scientific problem-solving method to improve process performance and achieve stated goals
6. Holding the gains through monitoring system
H. Six Sigma strategy
1. Disciplined approach to process improvement
2. Define costs and benefits.
3. Measure input and output.
4. Analyze causes of current or anticipated defects.
I. Lean-thinking approach
1. Use of thought process based on lean principles of:
a. Understanding value
b. Identifying value stream
c. Making service flow
d. Pulling flow from demand (flexibility)
e. Setting targets for perfection
J. The Joint Commission (TJC)
1. Continuous improvement of patient care outcomes
2. Identification of functions and processes with the most significant impact on outcomes
3. Emphasis on integrated system rather than independent units
4. Emphasis on consistent performance standards
5. Use of national performance measurement system for patient outcomes and care processes
6. Continual data collection, risk adjustment, and analysis
7. Use of comparative data for performance improvement
K. Traditional ways of monitoring, evaluating, and measuring quality
1. Retrospective: chart audit
a. Peer review process used in hospitals until 1970s
b. Small sample of patient records reviewed by medical staff with judgment made as to the quality of care provided
c. Problems confirmed and solutions identified
d. Increased emphasis on appropriateness of care in 1980s
2. Prospective, concurrent, and focused monitoring and analysis processes in place
a. On-line clinical data
b. Observation of actual process of care
c. Referrals
d. Special study, case mix, or other data summaries
e. Incident/occurrence reports
3. Evaluation process
a. In-depth assessment of quality of care when
(1) A threshold (trigger point) is reached
(2) A compliance level is/is not met
(3) Control limits are exceeded
4. Indicators
a. Monitor the quality of all aspects of care.
b. Gauge actual performance and compare with targeted objective or standard.
c. Include
(1) Clinical criteria
(2) Clinical standards
(3) Practice guidelines
(4) Protocols
(5) Performance database
d. Stated in objective terms
e. Condition or procedure specific
f. Focus on discrete populations.
g. Accuracy, risk adjustment, and cost are measured through control of information technology.
h. Identify opportunities to improve care.
i. Based on current knowledge or structure and projected needs, standards, or industry changes
j. Classified as outcome or process
k. Address issues of structure.
5. Structure standards
a. Qualifications of the providers
b. Physical facility, equipment, and other resources
c. Characteristics of the organization and its financing
6. Outcomes
a. Things that do (or do not) happen as a result of medical interventions
(1) Complication rates
(2) Functional capacity and performance
(3) Cost-effectiveness
(4) Patient satisfaction
b. Serve as red flags
c. Objective measurements of outcomes
(1) Patient satisfaction
(2) Efficiency
(3) Cost reduction
(4) Results of service
d. Most important concerns
(1) Positive patient outcomes
(2) Cost-effective delivery of care
(3) Provide return on investment
e. Number one competitive factor next to cost in health care
f. Integrative: include contributions of providers and patients
g. Survey target areas for The Joint Commission and Accreditation Association for Ambulatory Health care
h. One of most crucial expectations of managed care and third-party payers
i. Endpoint of outcomes research—clinical practice guidelines, which are intended to assist practitioners and patients in choosing appropriate health care for specific conditions
7. Nursing-sensitive quality indicators
a. Performance measures that capture patient care or its outcomes most affected by nursing care
b. Can be used to create a nursing report card for the organization
c. Examples: pressure ulcers, patient falls, nosocomial infection rate for central lines, staffing mix, patient satisfaction, and staff satisfaction
L. Common steps in QI process
1. Identify/focus on priority areas.
2. Collect data/measure performance.
3. Assess performance.
4. Take action for improvement.
5. Effective team development and interaction
6. Use of statistical, analytical, and consensus tools
7. Failure mode and effects analysis
a. Improvement projects with significant impact
b. Wise to conduct proactive team
c. Identify risks of any process step failure.
d. Analyze the potential severity if any process step fails.
e. Select appropriate responses to minimize impact.
M. CQI key processes relative to data
1. Identify current available data sources.
2. Identify critical information needs.
3. Define data elements.
4. Determine data collection plan.
5. Acquire/collect data.
6. Aggregate and display data.
7. Analyze data.
8. Interpret data/information.
9. Act on information/knowledge.
10. Report data/information/knowledge/decision.
11. Collect more data to monitor/analyze the decision.
N. QI team approach
1. An ongoing interdisciplinary/cross-functional team selected from those who collect or use data and are trained in group process
2. Each site, discipline, department, team, and committee collecting data identified
3. Data to be collected determined by indicators/performance measures
4. Resources provided for the team to hit targets and meet objectives
5. Mechanisms in place for information management education
6. Reviews/monitors internal report from teams
7. Establishes improvement priorities
8. Determines how data defined
O. CQI demands
1. Corporate and organizational commitment to mission, money, management, material
2. Organization-wide culture that talks and acts like quality
3. Identification and understanding of customers, their needs and expectations
4. Ongoing pursuit of customer satisfaction
5. Team emphasis on perfecting systems in delivery of patient care to affect good outcomes
6. Constant learning and improving
7. Interdisciplinary and cross-functional collaboration
8. A planned, systematic approach organized around flow of patient care
P. Responsibility of health care professionals with process and report to administrative and governing bodies
1. Understand principles.
2. Articulate process of
a. Data measurement
b. Analysis
c. Improvement
d. Development of effective strategies
3. Recognize and be sensitive to the differences in quality services as opposed to products.
4. Move quality to the top through the commitment to excellence.
5. Validate current practice or identify opportunities for improvement using these criteria:
a. Total cost
b. Impact
c. Benefit/cost relationship
d. Cultural impact
e. Resistance to change
f. Risk
g. Health, safety, and the environment
III. TQM
A. Evolved from Japanese industry after World War II
1. Edward Deming
a. Developed sampling and data QI strategies and assisted the Japanese in developing high-quality merchandise
b. Expanded statistical methodologies beyond manufacturing to sales and service
c. Created a constancy of purpose toward improvement with the aim of becoming competitive
d. Advocated for leadership perpetuating continuous improvement
e. Promoted the attainment of profound knowledge
f. Demonstrated an understanding of harnessing sources of variation
g. Believed QI means all employees trying every day to do their jobs better to accomplish the transformation
h. Philosophy for QI adapted by American automakers in the 1980s
2. Joseph Juran
a. Expert in quality control who assisted Japanese to apply this method in business functions such as design, marketing, distribution, sales, and service delivery
b. Quality control handbook considered the bible for the QI movement
c. Identified the elements of a system to measure, improve, and lead to optimal outcomes
d. Efficiency (resource use) and quality (performance) viewed as aspects of the whole
e. Developed the Juran Quality Trilogy: simple, logical model for understanding quality management
f. Principles adopted by health care organizations in the late 1980s
3. Kaoru Ishikawa
a. Use of total quality control for open communication
b. Changed product design in accordance with customer tastes and attitudes
c. Encouraged gaining knowledge
d. Promoted company-wide quality assurance emphasizing the importance of customer
e. Believed in quality first, respect for humanity, full participatory and cross functional management to solve problems
4. Philip B. Crosby
a. Known for “zero defects” as performance standard
b. Focused on prevention
B. TQM philosophy
1. Broad management philosophy promoting quality and leadership commitment; provides the energy and rationale for implementation of the process of CQI
2. Creates an environment of continuous improvement of people skills and processes and builds excellence into every aspect of organization
3. Processes continuously improve quality resulting in:
a. Increased customer satisfaction
b. Increased productivity
c. Increased profits
d. Increased market share
e. Decreased costs
4. Key concepts
a. Top management leadership
b. Creating corporate framework for quality
c. Transformation of corporate culture
d. Customer and process focus
e. Collaborative approach to process improvement
f. Employee education and training
g. Learning by practice and teaching
h. Benchmarking
i. Quality measures and statistics
j. Recognition and reward
k. Management integration
5. Fosters a belief in the value of customers, employees/staff, management, and teamwork
6. Views quality as an entity subject to measurement, scientific method, and data-driven problem solving
7. Offers something new to health care
a. New way of looking at delivery of care
b. New paradigm for management (flattens organizational chart)
c. New way of identifying and responding to those who benefit from provision of services (customers)
8. Customer concept in TQM
a. Identify needs, expectations, and preferences.
b. Rely on health care providers for services and products.
c. External customers: those outside the organization receiving services from the organization or vendors
(1) Patient and family
(2) Physician
(3) Purchasers (insurance companies, health plans, government agencies)
(4) Regulators and accrediting agencies
(5) Vendors/suppliers (goods and services, including registries)
(6) Educational institutions
(7) Attorneys
(8) Community businesses, agencies, and residents
d. Internal customers: those performing work, but dependent on others performing work, within the organization
(1) Admitting/front office staff
(2) Administrative staff
(3) Ancillary staff
(4) Care coordination/social services staff
(5) Human resource staff
(6) Physicians
(7) Nurses, technical associates, medical assistants
(8) Pharmacists
(9) Performance improvement/quality management staff
(10) Volunteers
e. Health care customer focus
(1) Truly committed to delivering value
(2) Seeking insight for QI activities
(3) Addressing true needs and value-based expectations
(4) Optimizing outcomes
(5) Enhancing performance of internal processes
(6) Building trust, respect, and loyalty in relationships
IV. ASPECTS OF QUALITY: THE MAP
A. Measurable quality
1. Compliance with or adherence to standards that are guidelines for excellence
2. May take the form of protocols or practice guidelines
3. Establishment of acceptable expectations for processes of care and patient outcomes
4. Acceptable compliance basis for
a. Licensure
b. Accreditation
c. Certification
d. Awards
e. Reimbursement
B. Appreciative quality
1. Comprehension and appraisal of excellence beyond minimal standards and criteria
2. Peer review bodies rely on professionals’ judgments in determining quality of patient-practitioner interactions.
3. Use of expert witnesses to determine reasonable or negligent professional behavior
C. Perceptive quality
1. Degree of excellence perceived and judged by recipient or observer of care
2. Quality based more on degree of caring than technical competence and physical environment
V. KEY DIMENSIONS OF QUALITY PERFORMANCE
A. Appropriateness: relevance
1. Degree to which health care satisfies patients
a. Sensitivity to timing issues
b. Logical flow of activities
c. Tactful, clear communication, including patient feedback
2. Correct, suitable resource utilization as judged by peers
3. Doing the right things in accordance with the purpose
B. Availability
1. Degree to which appropriate care and services are accessible and obtainable
2. Ease and convenience with which health care can be reached in the face of financial, organizational, cultural, and emotional barriers (access)
C. Competency
1. Practitioner’s ability (technical and interpersonal skills) to use the best available knowledge and judgment
a. Ability to convey trust and confidence
b. Ability to perform the promised service dependably and accurately
c. Ability for tactful problem solving
d. Willingness to help patients and provide prompt service
e. Empathetic caring and individualized attention to patients and families
2. Degree to which practitioner adheres to professional and organizational standards of practice and care
D. Continuity
1. Coordination of needed health care services for patient or specified population among all practitioners and across all involved organizations over time
2. Delivery of needed health care as coherent, unbroken succession of services
E. Effectiveness
1. Power of particular procedure or treatment to improve health status and positive results of care delivery
2. Degree to which care is provided in correct manner, given the current state of knowledge to achieve desired or projected outcome(s)
3. Performance that is equivalent to stated requirements (doing the right things right)
F. Efficacy
1. Potential, capacity, or capability of care to produce the desired effect or outcome as already shown through scientific research (evidence-based) findings
G. Efficiency
1. Delivery of a maximum number of comparable units of health care for a given unit of health resources used
2. Relationship between outcomes and resources used to deliver care
3. Combination of skill and economy of energy in producing a desired result
4. Organization and supervision to combat variation in patient care
H. Prevention/early detection
1. Degree to which interventions, including identification of risk factors, promote health and prevent disease
I. Respect and caring
1. Degree to which those providing services recognize
a. Sensitivity for patient’s needs
b. Expectations
c. Individual differences
2. Degree to which individual or designee is involved in his/her own care and decisions
J. Safety
1. Degree to which health care intervention minimizes risks of adverse outcome for both provider and patient
2. Degree to which organizational environment is free from hazard or danger
3. Degree to which the risk of an intervention and care environment is reduced for patients and others, including practitioners
K. Timeliness
1. Degree to which care is provided to individuals at the most beneficial or necessary time
2. Degree to which services are provided to customers in accordance with their perception of promptness
L. Tangibles
1. Appearance of physical facilities, equipment, personnel, and communication materials (brochures, educational handouts)
2. Clear directions—easily readable signage
VI. CHANGES IN HEALTH CARE AFFECTING QUALITY
A. 1970-1980: start of Medicare reform with Diagnosis Related Groups (DRG) and Medicare Prospective Payment systems appeared.
B. 1980-1990: the following services began:
1. Health maintenance organizations (HMOs) and preferred provider organizations (PPOs)
2. Bundling of fees with high competition
3. Delivery system redesign, downsizing, mergers, and reengineering
C. 1990-2000: the following services began:
1. Prenegotiated payment for sets of services
2. Point of service plans
3. Capitation payment
4. Integrated delivery systems (horizontal and vertical)
5. Preferred providers within networks
6. Provider sponsored organizations with direct Medicare contract
D. 2000-2009: the following started:
1. Closure of facilities due to lack of reimbursement
2. Pay for performance
3. Consumer directed health plans
E. Continued reduced length of stay in inpatient settings and use of hospitalists to manage inpatient care
F. Specialists taking on more primary care responsibility for certain chronic conditions, such as congestive heart failure, chronic obstructive pulmonary disease, or catastrophic injuries
G. Implementation of health promotion programs for members and disease management programs for specific populations of patients
H. Risk reality
1. Exorbitant increases in medical malpractice in many states, resulting in movement or closure of some practitioner specialist practices and attempts to get malpractice tort reform through Congress
2. Litigious atmosphere based on increased patient/consumer awareness, greater expectation from medical technology, increased injury, and claims and awards for errors of omission and commission
3. Depersonalization of doctor-patient relationship
I. Increased tension between physicians and managed care due to perceived interference in their practice, administrative burden, and impact on income
J. Academic health centers that provide graduate medical education, formerly financed through higher fee-for-service billing and Medicare reimbursement, need to be adequately funded now.
K. IOM reports
1. Leading Health Indicators for Healthy People 2010: First Interim Report (1998)
2. Statement on Quality of Care: National Roundtable on Health Care Quality—The Urgent Need to Improve Health Care Quality (1998)
3. To Err is Human: Building a Safer Health System (1999): discussed the thousands of Americans who die each year from medical errors and the importance on patient safety
4. Crossing the Quality Chasm: A New Health System for the 21st Century (2001) described
a. Broader quality issues
b. Defined six aims of care
(1) Safe
(2) Effective
(3) Patient-centered
(4) Timely
(5) Efficient
(6) Equitable
c. Presented 10 rules for care delivery redesign
5. Healthcare Quality Report (2002) established:
a. Standardized performance measures
b. Uniform set of guidelines
c. Strategies that encourage adoption of best practices by providers
d. Comparative quality reports
e. National health information infrastructure and a centralized data repository
f. Support for development of computerized clinical records
6. Leadership by Example: Coordinating Government Roles in Improving Health Care Quality (2002)
7. Keeping Patients Safe: Transforming the Work Environment of Nurses (2003): Identifies solutions to problems in health care organization work environments. This includes:
a. Blueprint of actions for all organizations that rely on nursing care addressing issues of
(1) Management practices
(2) Work design
(3) Workforce capability
(4) Organizational culture of safety
b. Presented evidence to address public policy questions:
(1) Nurse work hours
(2) Nurse staffing levels
(3) Mandatory overtime
8. Health Professionals Education: A Bridge to Quality (2003):
a. Presents a vision for institutions and programs involved in clinical education
b. Recommends the implementation of a core set of competencies in five areas to include:
(1) Delivering of patient-centered care
(2) Working as part of interdisciplinary teams
(3) Focusing on QI
(4) Practicing evidence-based medicine
(5) Using information technology
c. Targets various approaches to use including:
(1) Fostering enhanced training environments
(2) Leveraging oversight organizations
(3) Initiating public reporting
9. Medicare’s Quality Improvement Organization Program: Maximizing Potential (2006):
a. Proposed a major restructuring of a quality improvement organization so that it can become a vital natural resource integral to strategies of
(1) Performance measurement
(2) Payment incentives
(3) Public reporting
b. Focus is on offering technical assistance to practitioners and providers aimed at building for QI.
10. America’s Healthcare Safety Net: Revisiting the 2000 IOM Report (2007):
a. Reflected on the rising numbers of
(1) Underinsured and uninsured people
(2) High immigration levels
(3) The aftermath of Hurricane Katrina
(4) New policy and fiscal pressures on care for vulnerable populations
b. Safety net providers find it difficult to meet growing needs for prescription drugs and specialty services (mental health care).
11. Knowing What Works in Health Care: A Roadmap for the Nation (2008):
a. Provides a blueprint for a national program to provide unbiased information about what really works in health care and to assess the effectiveness of clinical services
b. This national program would develop and promote rigorous standards for creating clinical practice guidelines that might minimize utilization of questionable services and target services to patients most likely to benefit.
L. Institute for Healthcare Improvement programs/campaigns
1. 100,000 Lives Campaign (December 2004-June 2006)
a. Included six interventions
(1) Deploy rapid response teams at the first sign of patient decline.
(2) Deliver reliable, evidence-based care for acute myocardial infarction.
(3) Prevent central line infections.
(4) Prevent surgical site infections.
(5) Prevent adverse drug events by implementing medication reconciliation.
(6) Prevent ventilator-associated pneumonia.
b. Total of 3100 hospitals participated
c. Estimated 122,000 lives saved in 18 months
2. 5 Million Lives Campaign (December 2006-December 2008)
a. Accelerating efforts to reduce nonfatal harm, while continuing to fight needless deaths
b. 4000 U.S. hospitals enlisted in this initiative to improve patient safety and to adopt six interventions that reduce patient injuries and save lives
c. Example interventions include:
(1) Preventing harm from high-alert medications
(2) Reducing surgical complications
(3) Preventing pressure ulcers
(4) Reducing methicillin-resistant Staphylococcus aureus (MRSA) infection
(5) Delivering reliable, evidence-based care for congestive heart failure
(6) Defining and spreading best-known leveraged processes so that hospital boards of directors can become far more effective in accelerating organizational progress toward safe care
d. Participating hospital boards provided useful resources
(1) Campaign materials
(2) Getting started kit
(3) Campaign mentor hospitals that will provide support, advice, clinical expertise, and tips on implementation efforts
e. Advice given on how to set powerful aims, build foundation, build will, and drive execution of the campaign at individual interested hospitals.
f. Tools
(1) Safety dashboards and data PowerPoint
(2) Guidelines for using patients’ stories in the campaign
(3) Whole system measures kit
(4) Detailed information on the process
(5) Outcome measures
(6) Recordings of campaign calls for boards of directors
(7) Companion slide set
3. Strategic initiatives that will power future programs include:
a. New health partnerships
b. Pursuing perfection
c. Creating models of excellence
d. Safer patient initiative
e. Transforming care at the bedside
f. Improving staff satisfaction
g. Improving care on medical-surgical units
h. Understanding models that can improve patient experiences and positively impact the entire health communities at a reasonable per capita cost
M. Leapfrog Group: offers hospital rewards program for improvement in clinical areas based on performance measures
VII. SOURCES OF DATA COLLECTION—INTERNAL
A. Objective questionnaires, surveys, and interviews
1. Should be consumer oriented
2. Solicit both consumer complaints and opinions.
3. Mail-back questionnaires tend to generate low response (20%-40%).
B. Postoperative phone call
1. Vital for evaluating patient’s postoperative condition, reinforcing teaching, and obtaining performance feedback
C. Direct observation
D. Patient focus groups
E. Open-ended interviews, either structured or informal
F. Computer-based patient input through available websites or dedicated computer terminals in hospitals
G. Input from family and friends
H. Satisfaction gap analysis
I. Patient/client records (demographic, treatment data, and perception of care)
J. Indexes: permanent topical collections of medical record data required by state laws; to locate cases for statistics and research
K. Registers: permanent chronological listings for maintaining certain statistics (e.g., births, deaths)
L. Reports on:
1. Clinical research
2. Case mix
3. Risk management/claims
4. Patient and environmental safety
5. Utilization management
6. Infection control
M. Clinical review findings:
1. Blood use
2. Pharmacy and therapeutics function
3. Functional outcome status
N. Medication records
O. Variance reports (clinical paths)
P. Department/service quality measurement reports and minutes (physicians, nursing, ancillary staff)
Q. Occurrence/other generic screening reports, including sentinel events and root cause analysis
R. Reviews and audits
1. Data on cost of poor quality—identifies forces that oppose or support options selected
2. Records of quality department
3. Internal audit with all financial reports
4. Management engineering
5. Aggregate performance measure data (process and outcome)
S. Employee satisfaction surveys and staff input questionnaires
T. Long-term strategic goals
U. Issues uncovered during TJC visit
VIII. SOURCES OF DATA—EXTERNAL
A. Reference databases/performance measure report systems (Maryland Quality Indicator Project), download offers automated retrieval from the computerized source
B. Accreditation reports
C. State inspection/licensure reports
D. Third-party payer and employer reports
E. Centers for Disease Control and Prevention reports
F. Recent scientific, clinical, and management literature (e.g., MEDLINE)
G. Sentinel event alerts from TJC
H. Evidence-based practice guidelines and clinical algorithms/protocols (e.g., National Guideline Clearinghouse)
I. Well-formulated/updated performance measures (e.g., National Quality Measures Clearinghouse)
J. Validated clinical pathways
K. Identified best practices
L. State/regional/national rates and thresholds
M. Comparative report cards
IX. USEFUL TOOLS FOR IDENTIFYING PATTERNS OR TRENDS
A. Checklist: identifies how often certain events are happening; simple tool to assist in data collection
B. Flowchart: pictorial representation showing the steps of a process (a graphic sequence of events)
C. Histogram: data-gathering tool used to show frequency of events, distribution showing patterns
D. Control chart: a “run chart” with statistically determined upper control limits and lower control limits (determines how much variation can be expected)
E. Pareto chart: a special form of vertical bar graph to help determine which problems to solve in what order (highest to lowest)
F. Cause-and-effect diagram (Fishbone diagram): represents relationship between some effect and all possible causes; organizes potential causes of a problem to help find the root cause
G. Scatter diagram: a display of possible relationship between one variable and another in order to test for possible cause and effect
H. Benefit/cost analysis
I. Control spreadsheet
J. Run chart: a tool for displaying the variation in data over time
K. Useful process tools
1. Brainstorming: group process used to create as many ideas, concerns, or problems in as short a time as possible
2. Affinity diagram: used to organize large volumes of ideas or issues into major categories
3. Delphi technique: tool used to reach team consensus concerning a particular goal or task
4. Multivoting: a technique used to prioritize a long list of possibilities and to move the team toward consensus
5. Prioritizing matrix: used to select one option from a group of alternatives and promotes objective decision-making
6. Events and causal factors chart: combines flowchart and affinity diagram to identify and document both the sequence of events leading up to an occurrence and the relevant conditions affecting each event or step in the sequence
7. Force field analysis: a technique that displays the driving (positive) and restraining (negative) forces surrounding any change
8. Task list: a listing of things to do or obtain in order to keep the team on schedule or to inventory information; it can be converted to a detailed action plan if appropriate
9. Gantt chart: project-planning tool for developing schedules; a graphic display, a type of bar chart (i.e., bars on a horizontal time scale)
10. Storyboard: visual display of the team and pertinent data/information, analyses, and decisions made during the improvement process
X. UNIQUE ISSUES FOR AMBULATORY CARE
A. Sources of care are sometimes scattered in place and time, with no common medical record and inadequate communication systems.
B. Primary care and specialist providers’ roles and obligations to the patient are ill-defined, and there may be conflict between the expectations of the patient and the public and those self-defined by the practitioners.
C. In managed care, actual authorization of treatment may be controlled by medical group, independent practice association, or health plan rather than the primary care physician or specialist.
D. Expected outcomes of ambulatory care are difficult to predict because of the lack of studies of the natural history of ambulatory conditions; adverse outcomes that are to be prevented may not occur anywhere close to time of health care interaction, so they cannot be easily monitored or tracked back to care episode.
E. Patients are in control of their own diet, medications, personal habits and lifestyle, and care encounters; poor health outcomes result from patients’ failure to seek care early, comply with recommended treatment, or return for follow-up care.
F. Percentage of cost may come from the patient or be under a managed care contract; there is a constant delicate balance in decision-making between cost, benefit, and risk of non-treatment.
G. Payment structure: fixed or packaged fees for standard surgical procedures (PPO/HMO); complications or unplanned admissions to the hospital may incur more expenses.
H. Overnight observation and pain control at a 23-hour extended observation unit in the ambulatory surgery or designated hospital unit is less costly than at the acute care hospital setting; allows more complicated and extensive list of procedures to be done at a lower-cost outpatient setting.
I. Free-standing center must have predetermined plan and agreement with hospital for emergency admission of patients to ensure continuity of quality care.
J. Transient but disturbing side effects such as postoperative pain, nausea and vomiting, dysphagia, and extended somnolence may influence a patient-based assessment for quality of care; delayed recovery may prevent discharge home and require need for continued care and observation overnight.
K. Short length of stay; brief window to obtain desired outcomes
L. Families and significant others share responsibility for postoperative care at home.
M. Emphasize on active patient involvement with wellness as the focus.
N. Cross-training of nurses and support personnel reduces the number of different persons treating a patient and enhances continuity of care.
O. Simplified paperwork and documentation leaves more time for direct care.
P. Age no longer a barrier; well-controlled systemic disease does not disqualify patient from receiving care in an ambulatory setting.
1. Elderly patient: minimizes separation from family and environment but must consider risks of anesthetic, surgery, and home care
2. Younger patient: premature infant or ex-preemies that need postoperative apnea monitoring not appropriate candidates
Q. Teaching
1. Encompasses all ages of patients
2. Thorough postoperative instructions to patient and family member or significant other
3. Use of collaborative approach with patient, including patient empowerment
4. Nurses must consider:
a. Educational background of patient, family member, or significant other
b. Literacy: knowledge, skills, values, and attitudes of patient
c. Determine readiness to learn, learning style, and timeliness of instructions
d. Language barriers
e. Physical impairments (deaf patient requiring signer to interpret verbal instructions) and mental or physical handicaps
f. When and where to obtain follow-up care documented
g. What to do in case of emergency documented
h. Patient and family compliance
i. Patient safety
R. Traditional outcomes: have historically been assessed in terms of surgical and anesthesia-related complications
1. Unplanned hospital admissions
2. Prolonged recovery time after anesthesia
3. Unscheduled postoperative physician or emergency department visit
4. Mortality
5. Major morbidity
S. More recent outcomes focus on patient experience.
1. Incidence of postoperative nausea and vomiting
2. Pain or surgical discomfort
3. Dizziness
4. Sore throat
5. Shivering
6. Return to usual activities
7. Patient satisfaction
XI. ISSUES IN POST ANESTHESIA CARE UNIT (PACU), PHASE I
A. Severe adverse events
1. Return of patient to the operating room because of
a. Loss of peripheral pulses
b. Large blood loss
c. Hematoma formation
d. Wound dehiscence
2. Patient reintubation
3. Inability to extubate patient (delayed awakening and/or return of muscular strength and function)
4. Issues of respiratory compromise:
a. Laryngospasm/bronchospasm
b. Croup
c. Stridor
d. Wheezing
e. Retractions
5. Spontaneous pneumothorax
6. Emergence delirium
7. Malignant hyperthermia
8. New onset of ST depression or elevation
9. New onset of life-threatening dysrhythmia
10. Patient with chest pain, changes in electrocardiogram, rise in level of cardiac enzymes, nausea and sweating (rule out myocardial infarction)
11. Marked hypotension, hypertension, tachycardia, or bradycardia
12. Pulmonary embolism, pulmonary edema
13. Inability to maintain adequate oxygen saturation, greater than 90%, in patients with a baseline saturation of 90% or greater preoperatively
14. Marked fluid imbalance noted from assessing output, skin turgor, and blood pressure
15. Tissue injury, burn, and skin breakdown
16. Severe hypothermia
B. Disturbing events that may influence patient assessment
1. Surgical pain and referred pain
2. Nausea and vomiting
3. Shivering
4. Mild hypothermia
5. Full bladder
6. Pruritis
7. Delay in moving extremities after regional and local anesthesia
8. Headache, muscle aches
9. Pins and needles sensation, numbness in extremities
10. Drug reaction (nonanaphylactic)
11. Somnolence
C. Other patient care issues
1. High level of noise and increased use of lights may cause overstimulation.
2. Lack of privacy with only curtains separating patients
3. Delay in reaching PACU from the operating room
4. Prolonged stay in PACU because of unavailability of nursing unit beds
5. Inadequate supply of beds for morbidly obese patients
6. Close proximity of preoperative and postoperative patients
7. Close proximity of adult and pediatric patient populations
8. Close proximity of PACU patients and intensive care unit overflow patients
9. Less chance for visitation because of overcrowded conditions
10. Lack of appropriate isolation rooms for the increased number of MRSA and vancomycin-resistant enterococci (VRE) cases
11. Acute pain issues in a chronic pain patient
12. Presence of phase I and phase II patients in the same recovery area, requiring a different focus and approach to care
D. Staff satisfaction issues
1. Presence of automated medication/supply dispensing devices reduces time spent in ordering and stocking; keeps adequate supply in close proximity to patient care areas.
2. Proper use of unlicensed assistive personnel enables the PACU nurse to provide nursing care for the patient.
3. Simplified nursing flow sheets, checklists, and computer documentation allows more time for direct care.
4. Practice guidelines, established protocols, policies, and standards guide the PACU nurse from admission to discharge of patients.
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