Quality Improvement

2. Quality Improvement Dr. Sheryl Cornelius, EdD, MSN, RN

3. Objectives: Upon completion of this module the student will be able to: • Describe the role of the nurse in quality improvement. • Outline what constitutes a sentinel event. • Articulate reporting of a sentinel event. • Analyze how sentinel events are associated with quality improvement. • Describe the role of the nurse in reporting.

4. What is Quality Improvement? • The need to improve care • The need to maintain quality care • The need to continue to improve quality within the organization

5. Why do we need to improve? Institute of Medicine (IOM) report • To Err is Human: Building a Safer Health System • 98,000 deaths in hospitals each year • Current system fragmented and poorly organized Committee on the Quality of Health Care in America • Crossing the Quality Chasm • Chronic diseases now leading cause of illness, disability, health problems • Current system complex, fragmented, disorganized

6. What is the nurses role? • Observing any problems • Notifying the proper personnel • Taking part in pilot studies the facility may undertake

7. What is a Sentinel Event? Sentinel Event • an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof Never Event • extremely rare medical errors that should never happen to a patient

8. Sentinel event

9. Root Cause Analysis • What happened? • Why did it happen? • What circumstances surrounded the event? • Framework for conducting a root cause analysis from TJC: http://www.jointcommission.org/Framework_for_Conducting_a_Root_Cause_Analysis_and_Action_Plan/

10. Role of the nurse in reporting • Change the climate of reporting • Attend any briefings the facility may have on changes to your systems • Keep a hands on approach in the facility workings

11. Activity Find an example online and discuss how the facility handled it

12. Further readings… • The Institute of Medicine: To Err Is Human: Building a Safer Healthcare System http://www.iom.edu/Reports/1999/To-Err-is-Human-Building-A-Safer-Health-System.aspx • The Institute of Medicine: Crossing the Quality Chasm http://www.iom.edu/Reports/2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx • The Joint Commission: Read the “Sentinel Event Alert” under Topics tab http://www.jointcommission.org/

13. References North Carolina Concept-Based Editorial Board, (2011). Nursing: A Concept Based Approach. Upper Saddle River, New Jersey: Pearson Education, Inc. Marquis, B. L. & Huston, C. J. (2009). Leadership roles and management functions in nursing: Theory and application. (6th ed.). Philadelphia : Lippincott, Williams & Wilkins. Taylor, C., Lillis, C., Lemone, P., (2011). Fundamentals of Nursing: The Art & Science of Nursing Care. (7th ed.) Philadelphia, Lippincott, Williams & Wilkins.