Quality Improvement And Patient Safety

Crossing the Quality Chasm defines safe as, “avoiding injuries to patients from the care that is intended to help them” (p. 5). Ideally, this aim is to help protect patients from harm, improve on safe patient-care practices, and utilize the most up to date evidence-based medicine for better outcomes.

Over time the health care industry has become more complex. Health care is rapidly evolving and continuing to complicate our delivery of care, which in turn has the same effect on quality of care. This steady evolution and change results in nursing shortages and an increase in the prevalence of errors being made. In hopes of preventing these errors and creating safe and high quality patient care, with the focus on new and improved ways of thinking, The Quality and Safety Education for Nurses (QSEN) initiative was developed. The QSEN focuses on the following competencies: patient-centered care, quality improvement, safety, and teamwork and collaboration. Their initiatives work to prepare and develop the knowledge, skills, and attitudes that are necessary to make improvements in the quality and safety of health care systems (Qsen.org, 2014).

The main objective of healthcare professionals is to provide the best quality of patient care and the highest level of patient safety. To achieve that objective, there are many organizations that help improve the quality of care. One of the best examples is the Joint Commission. Unfortunately, the healthcare system is not free from total risks. In healthcare activities, there are possible errors, mistakes, near miss and adverse events. All of those negative events are preventable. But, it is clear that errors caused in healthcare result in thousands of deaths in the United States.

Quality improvement is defined by Kelly (2012) as “a systematic process of organization wide participation and partnership in planning and implementing continuous improvement methods to understand, meet, or exceed customer needs and expectations and improve patient outcomes” (p.477). The women’ unit can receive thirty patients from age eighteen to late adulthood. The unit is a receiving facility for everyone Baker acted in the state of Florida. Like any other organization, change is always happening in the women’s unit. One of the areas that need improvement on the unit is a reduction in the number of seclusion and restraint that we do every month. Patients that are violent and present a danger to either

When it comes to health care in the United States, the initial thought many people have are the many growing controversies concerning Obamacare, vaccinations, and making sure all Americans have access to affordable and quality health care. However, what many people fail to realize is a certain aspect in the medical community that, since the early 80’s with the infamous study by Berkman and Frankel, is increasing at such a tremendous rate that the Columbia Medical Review has referred to it as an “epidemic in the medical community.” The statistics regarding the number of individuals who die each year due to medical errors is rising; slowly becoming a major concern in the field. Doctors are busy individuals and at the end of the day still

Substandard quality of health care is duly recognized as a major form of medical crises with potential to jeopardize the functioning and purpose of the American health care system. Whereas on the one hand medical costs of treatment are rising, on the other malpractices and non compliance on the part of medical professionals and institutions compounds the problem and seriously questions the quality of health care being provided to citizens. However, before proceeding further it is important to understand what is exactly meant by the substandard quality of care. The substandard quality of

Amy Wilson-Stronks, M.P.P., Project Director, Health Disparities, Division of Quality Measurement and Research, The Joint Commission. Paul Schyve, M.D., Senior Vice President, The Joint Commission Christina L. Cordero, Ph.D., M.P.H., Associate Project Director, Division of Standards and Survey Methods, The Joint Commission Isa Rodriguez, Project Coordinator, Division of Quality Measurement and Research, The Joint Commission Mara Youdelman, J.D., L.L.M., Senior Attorney, National Health Law Program

As the Joint Commission aims to nationally improve health care systems through health care organizations collaborations, it publishes recommended patient safety goals. As stated by the Joint Commission, “the first obligation of health care is to “do no harm””. The Joint Commission’s 2015 National Patient Safety Goals for hospitals include : Identify patients correctly; Improve staff communication; Use

The National Patient Safety Goals were created in response to the IOM article, To Err is Human: Building Safer Health Systems. These goals were written to address patient safety and are tailored depending on the health care setting to which they are written for. They address system wide solutions rather than focusing on whom or how the error was made. Medical errors have been noted as being the 8th leading cause of death in the U.S. with the most frequent of these errors being medication related (Johnson, K., Bryant, C., Jenkins, M., Hiteshew, C., & Sobol, K. 2010). Therefore a great focus on these goals is needed across the health care continuum. The goals are updated and amended on a regular basis using evidence-based research, in response to areas with high errors in patient safety.

The Institute of Medicine released a report in 1999 titled To Err is Human: Building a Safer Health Care System concerning the number of medical error related deaths. The report states that between 44,000 and 98,000 medical error related deaths occur each year in hospitals across the country (Kohn, L. T., Corrigan, J., & Donaldson, M. S., 2000) In response to this report, the Institute of Medicine released Crossing the Quality Chasm: Health: A New Health Care System for the 21st Century that outlines six aims for the future of the healthcare system: safe, effective, patient-centered, timely, efficient, equitable (Institute of Medicine, 2001). These aims set to establish the quality of healthcare across the country. Quality is defined by the Institute of Medicine as ““the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (2001).

This paper will discuss the National Patient Safety Goal NPSG 0.7.06.01 entitled “ Use proven guidelines to prevent infection of the urinary tract that are caused by catheter” (The Joint Commission, 2015). It will identify reasons why this National Patient Safety Goal was chosen as well as the type of organizations that utilize urinary catheters. It will look into the cost of implementing an educational process compared with the hospital cost of Catheter-Associated Urinary Infections (CAUTI). The Advanced Practice Nurse (APN) will demonstrate a method on how to gather data, design educational tool, implement standard practice and create a committee by collaborating with other health care disciplines. The effectiveness of the educational process will be evaluated through data collection and analysis. Finally, future health care delivery implications will be explored.

According to the AHRQ: National Healthcare Quality Report (2009), the goal of quality of health is to help people stay healthy, learn to live with a disability or chronic disease, recuperate from an illness, and deal with dying and death. However, instead of delivering health care services that are safe, patient centered, equitable, and timely. Many patients do not receive needed care. When care is received many times it is unsafe or too late

“The Best Practices: How the New Quality Movement is Transforming Health Care” is written by Charles Kenny, who is an author, consultant, and former journalists at the Boston Globe. The author serves as a consultant to Blue Cross Blue Shield of Massachusetts, where his primary responsibilities are to improve quality and safety. As a consultant, he is familiar with health care news and the situations of the US Healthcare historically. Around 1990, several horrible cases of medical errors in Boston and other cities became a daily news. Medical errors and complications were the fifth leading cause of death, and almost 98,000 deaths were occurring which could be prevented with a quality care. A group of visionary leaders led by physicians Paul

Many health care leaders, authors, and professionals have given their time and effort to write and discuss quality. Quality is now recognized as one of the key aims in healthcare today. The Institute of Medicine (IOM) has had a profound impact on health care in America and the view of quality within health care facilities. The National Roundtable on Health Care Quality met six different times between 1996 and 1998 to look at changes regarding quality in health care. Within their conclusion they said, “Serious and widespread quality problems exist throughout American Medicine” (IOM, 1998). The terms underuse, overuse, and misuse evolved here to describe the errors occurring in health care. These errors were hurting more patients than the population realized and once published the trust towards healthcare was low and many had questions. Their review at the roundtable combed through what was currently the norm in health care. Based on the experience of the members of the roundtable, it was not up to par and a shift was necessary to improve healthcare outcomes.

Falls in a health care setting are costly to the patient, the health care facility and may affect the reimbursement that insurance gives to hospitals, yet they are preventable. Falls can be minor with just a few bumps and bruises or they can be major which can result in death. Not only are falls harmful to the patient but there is a lot of money and time that gets added up after a fall occurs *** There are many factors as to why a fall could take place, but being aware of the risk that a patient is a fall risk from the beginning can help avoid a fall from ever occurring. Accurately identifying a patient as a fall risk and communicating to other staff within 24 hours of admission is key to help in the prevention of falls.