Managing and

Improving Quality
Total Quality
Management
Main Fo cus
1. Customer/client focus
2. Total organizati onal
involvement
3. U s e of quality tools
a n d stati sti cs for
management
4. Identification of
key pro c e sses
for improvement
Customer/Client
Focus.
• Needs of both internal and external
customers.
• Internal customers include employees
and departments within the
organization, such as the laboratory,
admitting office, and environmental
services.
• External customers of a health care
organization include patients, visitors,
physicians, managed care
organizations, insurance companies,
and regulatory agencies.
• Providing flexible schedules for employees,
adjusting routines for a.m. care to meet the
needs of patients, extending clinic hours
beyond 5 p.m., and putting infant changing
tables in restrooms are some examples.
Total Organizational
Involvement
• Involve all employees and
empower them with the
responsibility to make a
difference in the quality of
service they provide.
• The phrase “That’s not my job”
is eliminated. Departments
work together as a team.
• Sharing processes across
departments and patient care
functions increases teamwork,
productivity, and patient
positive outcomes.
Use of Quality Tools and
Statistics for Measurement

• A common management adage

is, “You can’t manage what you
can’t (or don’t) measure.”
• There are many tools, formats,
and designs that can be used to
build knowledge, make
decisions, and improve quality.
• Deming applied the scientific
method to the concept of TQM
to develop a model he called the
PDCA cycle (Plan, Do, Check, Act)
Identification of Key
Processes for Improvement

Processes within a health care setting

can be:
 Systems related (e.g.,
admitting, discharging, and
transferring patients)
 Clinical (e.g., administering
medications, managing pain)
 Managerial (e.g., risk
management and performance
evaluations).
Processes can be very complex and
involve multidisciplinary or
interdepartmental actions.
C o n t i n u o u s Quality
Improvement

• Process to
improve quality
a n d performance
• Evaluati on, acti ons, a n d
mind-set to strive for
excellence
 • Resource g ro u p
• made up of senior management (e.g.,
CEO, vice presidents).
• Coordinator
• appointed by the CEO to provide day-to-
day management of the CQI process and
training programs
Four major • Team leader
players: • Familiar with the process being evaluated
and organizes team meetings, sets the
agenda, and guides the group through the
discussion, evaluation, and
implementation process
• Team
• Teams are designated to evaluate and
improve select processes. They are
formally established and supported by the
resource group.
 • Six Sigma is another quality management program that uses,
Six S i g m a primarily, quantitative data to monitor progress.
• Six Sigma is a measure, a goal, and a system of management
Six Sigma Themes
• Process e m p h a s i s
• Boundary-less cooperati on
• Aim for perfection; tolerate failure
• Uses quantitative data to measure progress
• Customer (patient) focus
• Greater emphasis on management monitoring performance and ensuring results
Lean Six Sigma
• Focuses on improving process flow and eliminating waste
• Provides tools that can be used with Six Sigma system
• Effective in reducing inappropriate hospital stays, improving the
quality of care and reducing costs at the same time
D M AIC
• Six S i g m a process
improvement method
• Defi ne measures that
will indicate succe ss
• Measure baseline
performance
• Analyze results
• Improve performance
• Control and sustain
performance
Improving
Quality of Care
• Nati onal Initi ati ves
• Nati onal Quality
Forum focuses on
building co n s e n s u s
on performance
goals and standards
for measuring a n d
reporti ng them
• Joint C om m ission h a s
adopted mandatory
nati onal pati ent safety
goals
 • Insti tute of Healthcare Improvement (IHI) go a l s
• N o n e e d le ss d eath s
National Initiatives • N o n e e d le ss pain a n d suff ering
• N o h e lp le ssn e ss in those s e r ve d or s e r vi n g
• N o unwanted waiti ng
• N o waste
 • Identi fy pati ents correctly
• Imp rove staff communicati on
Joint Commission • U s e medicines safely
• Prevent infecti on
• C h e c k pati ent medicines
• Identi fy pati ent safety risks
• Prevent mistakes in s u rge r y
 • Evidence-based
practice
• Electronic medical
records (EMR)
• Dashboards
• Increased nurse
staffi ng
• Reducing
Improving Quality of medicati on errors
Care • Peer review
Improving Quality of
Care
Risk Mgt
Programs
• Are problem-focused
• Identify, analyze, and
evaluate risks
• Develop a plan for
reducing the
frequency and
severity of accidents
and injuries
Risk Mgt
Programs

• Appraise safety of pati ent

care procedures and new
programs
• Monitor laws and codes
related to pati ent safety
• Eliminate or reduce risks
• Review the work of other
committ ees to determine
potenti al liability
Risk Mgt
Programs
• Identi fy needs for
pati ent, family, and
personnel educati on
• Evaluate the results of
risk management
program
• Provide periodic
reports to
administrati on,
medical staff, and
board of directors
Nurse's Role
• Implement risk m a n a g e m e n t
p ro g ra m
• N e e d clear
u nderstanding of
the p u r p o s e s of
the incident
reporti ng proc ess
• Objecti ve reporti ng
necessary
• N ever u s e report
for disciplinary
acti on
High-Risk Ar e a s
in Health Care

• Medicati on errors
• Complicati ons from
diagnosti c or
treatment procedures
• Falls
• Patient or family
dissati sfacti on with care
• Refusal of treatment or refusal
to s i g n consent for treatment
 • Discovery
• Notification
Reporting • Investi gati on
Incidents • Consultati on
• Action
• Recording
Discovery
• Nurses, physicians, patients, families,
or any employee or volunteer may
report actual or potential risk.
Notification
• The risk manager receives the
completed incident form within 24
hours after the incident. A telephone
call may be made earlier to hasten
follow-up in the event of a major
incident.
Investigation
• The risk manager or representative
investigates the incident immediately.
Consultation
• The risk manager consults with the referring physician,
risk management committee member, or both to
obtain additional information and guidance.
Action
• The risk manager should clarify any misinformation to
the patient or family, explaining exactly what
happened. The patient should be referred to the
appropriate source for help and, if needed, be assured
that care for any necessary service will be provided
free of charge.
Recording
• The risk manager should be sure that all records,
including incident reports, follow-up, and actions
taken, if any, are filed in a central depository.
Root cause analysis
• Method to work backwards through an event to
examine every action that led to the error or
event that occurred
• A simplified method to conduct an event analysis
follows:
• Patient—what patient factors contributed to
the event?
• Personnel—what personnel actions
contributed to the event?
• Policies—are there policies for this type of
event?
• Procedures—are there standard procedures
for this type of event?
• Place—did the workplace environment
contribute to the event?
• Politics—did institutional or outside politics
play a role in the event?
Nurse M a n a g e r ' s Role

• Individualize care
• Handle complaints
• Set tone for a safe a n d
low-risk environment
• Create a blame-free
environment
Blame-Free
Environment

• Just culture
• – Allows reporti ng of errors
without fear of retribution
• System-wide policies
in place for reporti ng
errors
• Staff encouraged to
report adverse events
a n d help find soluti ons
to prevent future
mistakes
 Blame-Free
Environment

• Nurse manager
• Identifies
problems
• Encourages
culture of safety
and quality

Effective Leadership and Management in Nursing, Eighth Edition Eleanor J. Sullivan