CONTROLLING Quality Assurance

 Monitoring of the activities to determine

degree of excellence attained in
Controlling implementation of activities
 The regulation of activities in accordance with
the requirements of plans Difference between QA and QI
 Ongoing and continuous process to ensure that  QA-target currently existing quality
activities conform to plan. o Monitor health care programs which
o Quality assurance ensure conformity with standards
o Performance appraisal o “doing it right”
o Fiscal accountability o Assess or monitor performance
o Legal and ethical control professional o Discovery and corrections of errors
control o Inspection of nursing activities
 Actions and decision managers undertake to o Chart adults
ensure the right result o Improve performance when it does not
 The right thing in the right manner and in the meet standards
right time  QI- target ongoing and continually improving
 Monitoring performance and taking action to quality
ensure desired result o “doing the right thing”
o Prevention of errors
 It helps maintain compliance with essential
organizational rules and policies o Meet customer needs
o Reviewing of nursing activities
Steps o Innovations, staff development
 Establish standard o Continually seek better ways to
 Measuring actual performance accomplish desired outcomes
 Finding and analyzing deviations
Domains of Quality
 Corrective actions
 Safety
Control  Effectiveness
 Being order and discipline  Patient centeredness
 Absence of control, lowers employees morale  Completeness
 Efficiency (no waste)
Pros in controlling
 Timeliness
 Future actions
 Equitable
 Reduces chances of mistakes
 Accessibility and convenience
 Facilitate decision making
 Courtesy
 Decentralization of authority
 Positive impact on the behavior of the Approaches of Quality Assurance
employees  Credentialing
 Coordination of activities  Licensure
 Certification
Limitations in controlling
 Accreditation
 No control over government policy, laws and
 Peer review
decrees, technological changes
 Audit
 Expenditures in time and effort
 Standards of performance cannot be quantified Type of performance standards
 Acceptance of the subordinates in the  Structure
organization  Process
 Outcomes
 Structure  Length od stay
 Staff  Adverse incidents
o Number an categories of nursing  Attainment of specific client’s outcome
personnel  Secondary complication
o Education  Client’ adherence to discharge plan
o Personal and professional qualifications  Adverse events
o Proficiencies  Death resource use
o Absenteeism o Cost
o Turn-over rate o Length of stay in the hospital
o Staff-patient ratios  Client/ patient satisfaction with care
o Functions  Quality of life
 Physical facilities  Patient ability to function in daily activities
o Comfort  Example:
o Convenience o “you can go home now. Your test show
o Lay-out the virus was in the MRI machine.”
o Accessibility of support services  The structural characteristics of the place where
o Safety care takes place may influence the process of
 Resources care so that its quality may increase or
o Equipment decrease.
o Supplies
 Productivity Quality improvement strategies
 Finances  Example:
o Salaries o Are you here with Leon Fineman, the 57
o Adequacy and sources year old that came in for a triple
 Example: hemorrhoidectomy? He’s doing fine.”
o “This isn’t what I had in mind when I
requested a semi-private room.” Benchmarking

Process  Sharing of best practices

 How the care should be provided  Performance comparison
 How nursing actions are used to provide care  Gap identification
 Nursing interventions  Changes in the management process
 Staff satisfaction
Regulatory requirements
 Pain management
 Maintenance of skin integrity  DOH standards
 Client education  Accreditors
 Discharge planning
Clinical practice guidelines
 Responsiveness of unplanned client care needs
 Example: a. Clinical/ critical pathways
o “No need for concern. Since you work in o The optimal sequencing and timing of
health care it’s normal to have fear of interventions by physicians, nurses and
compromising Protected Health inter-professional team members when
Information.” providing care to patients with
o “Yes, Mr. Barnes I’m free to talk. As I particular diagnosis or procedure.
recall, you’re the 58 year old divorced o Health care plans for specific group of
back executive with chronic flatulence.” patients with predictable clinical course

Outcomes
 Desired outcome of nursing care
 Morbidity/ mortality rate
 Sentinel events review  It incorporates clinical expertise, research and
 Events are call sentinel the patient’s preferences
 They require immediate investigation  To provide support to meet new challenges in
 Sentinel events- any unexpected events in the clinical delivery care
health care setting that causes death or serious
injury to the patient and not related to the
natural course of illness.
 Types
o Surgery in the wrong patient
o Surgery on the wring body parts
o Wrong procedure surgery
 Common sentinel events
o Suicide
o Patient falls
o Operative/ post-operative
complications
o Medications errors
o Wrong site surgery
o Dealy in treatment
o Assault, rape, homicide Six Sigma
o Transfusion errors  Refers to sic standard deviations from the mean
o Perinatal deaths to define the number of defects or errors
 How to deal with sentinel event/ adverse event produced by process.
 Performance improvement model based on the
idea of minimal defects and concerns
 This is a date driven quality strategy for
improving process variations
o Define the customer
o Measure the performance
o Analyze data collected for root causes
and opportunities for improvement
o Improve the process
o Control to prevent reverting from the
old ways
 How many times the right medication given in
the right amount to the right patient at the right
time by the right route.
 A measure of quality that strives for near
ISO 9001
perfection
 One of the most well-known quality
management system (QMS) standards
 International organization for Standardization
 Identify and address all imposed requirements
as well as improved its organizational
performance

Evidence based care (EBC)

 It is a clinically competent care based on the
best scientific evidences available
 Six Sigma Approach
o Sigma-statistical measurement that
measures how well the product or
process is performing
o A scale for level of goodness or quality
Lean Methodology
 All processes should contain waste-least waste
 Provides a way to do more and more with less
and less (less human effort, less equipment, less
time, less space) while coming closer and closer
to providing what exactly the customer wants
 Seven wastes
1. Over production
2. Unnecessary stock
3. Inefficient transportation
4. Unnecessary motion
5. Waiting times
6. Rejects and defects
7. Inappropriate processing
Leapfrog group
 Help minimize risk to patients
 Example:
o Nurse, get on the internet, go to
surgery.com, scroll down and click on
the “are you totally lost?’ icon.”
FMEA- Failure Mode and Effect Analysis
 The teaching involves in identifying potential
mistakes before they happen to determine
whether the consequences of those mistakes
would be tolerable or intolerable”
o Potential failures are identified in terms
of failure “modes”
o For each mode the effect on the total
system is studied
 Reduce risk of sentinel events
 Prioritize weaknesses, redesign to improve
patient safety
 Known cause of each failure are identified and
numerical score from 1 to 10 is applied based
on the probability of occurrence of the cause
Storyboard
 Sharing works with other using storyboard
 Informing the staff of the QI efforts underway
 Used to communicate information in QI
 “I always enjoy the interesting stories the staff
tell at these holiday parties. Especially if I
recognize the patient names and find out what
they’ve got.”
Patient Satisfaction Data
 Getting feedback from patients
o Fill out questionnaires
o How they felt about their health care
encounter
o Phone call
o Focus group or post care interview
o Talking with patients after their
discharge and getting feedback on their
perception of their stay
Process of identifying, analyzing, treating and
evaluating real and potential hazards.
Risk Events
1. Service occurrences
 An unexpected occurrence that does not result
in clinically significant interruption of services
and that is without apparent patient or
employees injury
o Minor property or equipment damage
o Unsatisfactory provision of service
2. Serious incidents
 Result to significant interruptions of therapy or
service, injury to a client or employee or
significant loss or damage to equipment or
property needing medical interventions
3. Sentinel events
 It is an unexpected occurrences involving death
or serious or permanent physical or
psychological injury or risk to the patient.
 Thy signal the need for immediate investigation
and response
4. Never Events
 Serious preventable patient safety incidents
that should not occur if the available preventive
measures have been implemented
o Wrong site surgery
o Wrong implants (prosthesis)
o Retained foreign objects after surgery
o Falls from unrestricted windows
o Air embolism
5. Morbidity and mortality meeting/ conference
 To improve governance of patient safety
 To monitor hospital care
  Reviewing deaths and complications to provide  Collecting information from nursing reports and
accountability and necessary improvement other documented evidences about patient acre
measures requires for patient safety and the quality of care using QA program
 “This was an especially tough case. We had to  “Are you the lady that ordered an accounting of
up his meds before he’d sign the authorization disclosures?”
for us to use PHI for marketing.”
Quality Nursing Audit
6. Complaint analysis
 Any expression of dissatisfaction by the
Structure audit
customer/ patient and identify areas of
 Resource input such as the environment in
improvement
which health care is delivered
 Complaint are analyzed to safeguard safety and
 Monitor the structure or setting in which
improve service
patient care is provided
Data collection procedures o Finance
o Nursing service
 Record audits
o Staff qualification
 Observations o Medical record
 Interviews and questionnaires o Environment
 Utilization review o Supplies
 “Excuse me doctor, could you spell that medical o Productivity
term? I’m updating all my social media friends  This can occur retrospectively, concurrently,
about this lady’s strange condition.” prospectively
Audit as quality control tool Process audit
 “The lab accidentally faxed your test results to  Measures how nursing care is provided
the wrong doctor’s office. You’’ get a bill for a  Focus on whether or not practice standards are
second opinion.” being fulfilled
Medical Audits  Clinical pathways
 Standardized practice guidelines
 “Before we telecast this procedure over the
internet, we need to take precautions to
protect your privacy.”
 Process
o How the care should be provided
o How nursing actions are used to provide
care
o Examples:
 Staff satisfaction
 Pain management
 Maintenance of skin integrity
 Client education
Audit  Discharge planning
 Responsiveness to unplanned
 Systematic and official examination of records, client care needs
process or account to evaluate performace o “It’s our new security software. That’s
Nursing audit what happens of the system detect
unauthorized access to patient
records.”
 o The actual activities carried out by the
health care providers
 Psychological interventions
 Teaching and counseling
 Physical care measures
o “Somebody threw out these medical
records in the trash. Is it okay to recycle
them for scrap paper?”
o “I don’t know what worse- is trying to
read a doctor’s handwriting in charts or
Watching the care that is being given
their typing errors in the EMR.”
o “I’m writing you a prescription. Do you
want a longer life with less quality or
vice versa?”
Outcome audit
 End result of care
 Determines what result if any, occurred as a
result of specific nursing interventions
 Measures quality of hospital
o Mortality
o Morbidity
o Length of hospital stay
o Adverse incidents
o Attainment of specific client’s’
outcomes
o Secondary complication
o Client satisfaction
o Client’s adherence to discharge plan
Data collection procedures
 Record audits
 Observations
 Interviews and questionnaires
 Utilization review
 “Excuse me doctor, could you spell that medical
term? I’m updating all my social media friends
about this lady’s strange condition.”
 Using standards records are evaluated to
determine whether care plans are being
developed for patients, if they are being
implemented as planned and the expected
outcomes have resulted.
Types of utilization review
 Retrospective
o Necessity of care received by client
after the care has been given
o Conducted after the patient is
discharges and examining the records of
large number of cases
 Prospective
o The assessment of the necessity of care
before giving services
o Attempts to identify how future
performance will be affected by current
interventions
 Whether complete assessments are being done,
whether care is given actually being given as
planned
 Whether interventions are being made
appropriately and as planned and whether
desired outcomes actually have occurred.
Interviews/ questionnaires
 Personal interviews or written questionnaires
distributed to patients, families and those
rendering care can provide information about
the care provided and the outcomes that
resulted.
 “If you didn’t get the patient’s signature on a
HIPAA authorization form, just sign it for them.
That is what good customer service is all
about.”
Utilization review
 Is the process of assessing medical necessity,
the appropriateness of health care services and
the efficiency of care
 It is done to confirm that the patient are getting
the most appropriate care
o “It’s another memo that’s been
censored. Administrations must have
passed a new privacy policy. Please
implement.”
 Assess the appropriateness and efficiency of
resources
 Mandated by the federal government for
Medicare reimbursement as quality control
measures.
o “How much longer you gonna be in
here? The bread ran out last week and
now the coffee and butter are gone.”
 It is done in healthcare agencies where care is
reimbursed by Medicare.
 It is done to ensure that reimbursement are not
being made for trivial or unjustified expenses
 Physician recommendations for treatment are
carefully scrutinized to reduce overutilization.
 “Note to transcriptionist: I’m finished mumbling
and rambling. I expect you to produce a
coherent medical report, correct diagnosis and
treatment plan.”
Tools in addressing medical errors
 Reporting and analyzing errors
o Mandatory and voluntary reporting of
medical errors
o Establish a blame free culture
 Leapfrog group
o Non-healthcare company leaders who
are committed to modernizing the
current healthcare system
o Four evidence-based standards to
reduce medical errors
Computerized physician
provider order entry (CPOE)
Evidence-based hospital referral
ICU physician staffing
Leapfrog Safe Practice scores
 Bar coding to reduce
medication errors
 Smart pumps (IV
therapy infusions)
 Smart pumps- IV
infusion pump
 Safety software inside
and advance infusion
therapy system that
prevents IV medication
errors through
minimum and
maximum dose limits
 Presents limits that
cannot be overridden at
a clinician’s discretion
Bar coded medication administration
 Scan the patient’s identification bracelet and
the unit dose of the medication being
administered
 “It’s just a new patient security system to verify
your identity before we are allowed to give you
any medications or discharge instructions.”
Quality circles
 Employees meet regularly to identify patient’s
problem
 Formulation and implementation of corrective
actions
Balance score card
 Balance between medical, patient satisfaction
and cost outcomes
 Any change in one area must be evaluated as to
how it affects the balance in other area
Evaluates the 4 key areas
 Functional status of the patient
 Clinical status of the patient
 Patient satisfaction
 Cost of care
Risk management
 Process of identifying risks, evaluate those risks
and take positive action to reduce or eliminate
the risks
 Focuses on liability control
 “So you faxed a patient’s records to a wrong
number and you don’t know how got it? Don’t
worry. It’s not a HIPAA violation unless the
patient finds out.”
 Attention to areas of employee wellness and
prevention of injury
 Adherence to standard of care and exercising
the degree of acre that a reasonable nurse
would demonstrate can protect the nurse from
negligent litigations
 Use of incident report
 To collect and analyze data for suture
determination of risk
 “It’s just a new patient security system to verify
your identity before we are allowed to give you
any medications or discharge instructions.”
Risk management functions
 Identify situations that place the agency at
financial risks or my result in lawsuit
 Investigating, analyzing problems and incidents
 Determining types and frequency of incidents
 Identifying opportunities to improve client care
 “Yeah, I’m the Ralph Snyder that had a hernia
repair last month, but I thought what happens
in the hospitals stays ate the hospital.”
 Peer Review
 Nursing are delivered by nurses are evaluated
with nurses of the same rank or standing
according to established standards of practice

Magnet Hospital
 Ward given by the American nurses
Credentialing Center to a hospital that satisfies
the set of criteria to measure the strength and
quality of their nursing
 Delivers excellent patient outcomes where
nurses have a high level of patient satisfaction
and where there is low staff nurse turnover rate
and an appropriate grievance resolution.