Quality Improvement Measurement and Analysis Methods

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This appendix presents examples of quality improvement (QI) measurement and analysis methods and information related to quality care. Today there is greater emphasis on continuous quality improvement (CQI), which recognizes that this is an ongoing process that is not completed. This information is applicable to your clinical experiences throughout your nursing program as you develop QI competency and leadership.

Definitions: Errors

Active error: An error that results from noncompliance with a procedure.
Adverse event: An injury resulting from a medical intervention, not due to the patient's underlying condition. It may or may not be due to an error and may or may not be preventable. If the adverse event is viewed as a result of an error, then it is considered preventable.
Common errors: Examples of common errors and situations that lead to errors: Falls, medication errors, development of pressure ulcers due to inadequate skin care or lack of mobility, surgical errors such as wrong site, misdiagnosis (wrong diagnosis, incomplete diagnosis, and so on), wrong patient identification, lack of timely response, development of nosocomial infections, wound infections, not washing hands, equipment failure, inappropriate use of restraints or used in an unsafe manner, documentation errors or inadequate documentation, poor discharge planning or directions.
Error: Failure of a planned action to complete as intended or use of the wrong intervention/plan to achieve a goal.
Misuse: An avoidable complication that prevents patients from receiving the full potential benefit of services.
Near miss: Recognition that an event occurred that might have led to an adverse event. An error almost happened, but staff or the patient/family caught it before it became an error.
Omission: Missed care should also be considered an error.
Overuse: Potential for harm that exceeds the possible benefit from a service.
Sentinel event: Unexpected events that happen to patients resulting in major negative outcomes such as an unexpected death or critical physical or psychological complication that can lead to a major alteration in the patient's health.
Underuse: Failure to provide a service that would have produced a favorable outcome for the patient.

Examples of High-Risk Situations Connected to Errors and/or Reduced Quality Care

Handoffs: A handoff occurs when a patient experiences a change in provider or setting with a transfer of responsibility and care transition.
Health literacy: Health literacy (inability to understand written and/or oral health information) can affect errors-for example, if the patient does not understand the discharge directions or cannot read them, an error could occur.
Medication reconciliation: This method is used to review all of a patient's medications to ensure that the orders are safe and effective for the patient's needs.
The Joint Commission Annual Safety Goals: Safety goals identified annually based on information The Joint Commission collects from its accredited healthcare organizations and then requires that their accredited organizations apply the goals to their services. See the current annual goals posted on the website: http://www.jointcommission.org/standards_information/npsgs.aspx.
Workaround: Occurs when the staff uses a shortcut to get something done, and in doing this they do not complete all the steps, or they substitute different steps in a process. This often happens when the staff is behind; rather than figure out the problem they are experiencing, they use a workaround.
Working in silos: Not working as a team or using poor communication; individuals or several staff working with little consideration of others who may be working on the same issue, with the same patient, and so on.

Examples of Typical Errors or Concerns of Inadequate Quality Care

Hospital-acquired conditions (HACs): These conditions occur in the hospital after admission and can lead to an extensive need for further treatment and costs. The Centers for Medicare & Medicaid Services (CMS) identifies the HACs that are then not covered by CMS reimbursement. The following website provides updates on HACs, which change over time based on CMS data and needs: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/HAC/Hospital-Acquired-Conditions

Agency for Healthcare Research and Quality Inpatient Quality Indicators

Mortality indicators/measures for inpatient conditions: These indicators include conditions for which mortality has been shown to vary substantially across institutions and for which evidence suggests that high mortality may be associated with deficiencies in the quality of care.
Mortality indicators/measures for inpatient procedures: These indicators include procedures for which mortality has been shown to vary across institutions and for which there is evidence that high mortality may be associated with poorer quality of care.
Utilization indicators/measures: These indicators examine procedures for which use varies significantly across hospitals and for which questions have been raised about overuse, underuse, or misuse.
Volume indicators/measures: These are proxy, or indirect, measures of quality based on counts of admissions during which certain intensive, high-technology, or highly complex procedures were performed. They are based on evidence, suggesting hospitals that perform more of these procedures may have better outcomes for them.

Other Terms

Bar coding: Bar coding is used routinely in medication administration and other times when identification of patient and action need to be ensured.
Benchmarking: Measuring quality across healthcare organizations based on the same standards.
Change of shift reports: Clinical reports are done routinely, particularly in hospitals units, to inform oncoming staff about up-to-date information regarding patient status. This report is also an opportunity to discuss quality and safety concerns for individual patients or for the unit or team as a whole and make plans for the shift.
Checklist: A consistent method for ensuring that what needs to be done is done-checking steps to be taken. The checklist is simple and requires limited, if any, training to use it.
Computerized decision support (CDS): CDS offers providers an effective method to improve decision-making and usually is associated with EMRs.
Computerized physician/provider order-entry system (CPOES): The CPOES is used to improve the process of treatment orders, usually reducing time and errors. It is commonly associated with EMRs.
Early warning system (EWS): This is a method using physiological data to assess and determine if a patient is experiencing a critical negative event. This is what triggers the use of the rapid response team to prevent failure to rescue.
Electronic medical/health record (EMR): Documentation is now most commonly done via electronic methods, which improve timely communication and usually have a positive impact on care.
Employee surveys: Written questionnaires used to get information from employees on a particular topic-for example, staff safety, staff satisfaction, and so on.
Failure mode and effects analysis (FMEA): A tool used to evaluate a systematic process and identify where it might have failed so that this analysis can then be used to prevent future failures.
Flow charts and decision trees: Visual methods used to describe a process so it can be clearly understood to improve the process or used to help identify when a process is not effective.
Huddle: This is a means by which a team gets together periodically during a shift to discuss critical issues.
Incident reports: Healthcare organizations require that staff report/describe certain incidents, such as medication errors, in written form using a standard form. This provides a record and helps in tracking errors for improvement.
Interviews: One-on-one collection of data that can be done in person, on the phone, or virtually.
Morbidity and mortality (M&M) conferences: M&M conferences are held in many hospitals on a routine basis to discuss patient care and outcomes.
Observation: Using staff or outside individuals to watch a procedure or work process and collect data on what occurs. This information is then used to track errors, improvement, and so on. An example would be to have observers watching staff to determine compliance with handwashing.
Patient/Family surveys: Written questionnaires used to get information from patients/families on a particular topic-for example, patient and/or family views of quality care and experience while hospitalized.
Patient safety indicators (PSI): A set of indicators providing information on potential in-hospital complications and adverse events following surgeries, procedures, and childbirth. The PSIs were developed after a comprehensive literature review, analysis of ICD-10-CM codes, review by a clinician panel, implementation of risk adjustment, and empirical analyses. They can be used to help hospitals identify potential adverse events that might need further study, provide the opportunity to assess the incidence of adverse events and HACs using administrative data found in the typical discharge record, include indicators for complications occurring in hospitals that may represent patient safety events, and design area-level analogs to detect patient safety events on a regional level.
Plan-do-study-act (PDSA): A process that is used in planning; four steps are followed to reach effective results (plan-do-study-act).
Prevalence and incidence: Prevalence is the proportion of the population that has a condition or risk factor. Incidence is the rate of occurrence.
Primary and secondary data: Primary data are data collected from firsthand experience; secondary data are collected by others, for example, using data from a clinical record that was documented by clinical providers and not the researcher.
Quality measures: Tools that help measure or quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems that are associated with the ability to provide high-quality health care and/or that relate to one or more quality goals for health care. These goals include safety, timely, efficient, effective, equitable, patient/person-centered (STEEEP®) care.
Rapid response team (RRT): A team of critical care experts can be called if there is staff and in some cases patient/family concerns to respond quickly to complex and critical needs of patients. The RRT is trained to provide this on-site consultation within the hospital.
Report cards: A published report that provides information about the quality of care for a healthcare organization or provider or may be for a region or national view.
Root-cause analysis (RCA): A method used by many healthcare organizations today to analyze errors, supporting the recognition that most errors are caused by system issues and not individual staff issues. This in-depth analysis is intended to identify causes and then consider changes that might be required to reduce risk of reoccurrence.
Safety walkarounds: Staff (usually management but can be other staff) walk through the unit or an area of the healthcare organization and identify safety concerns they may see related to patients, families and visitors, and staff. This information is then used to plan improvement including prevention measures.
Situation-background-assessment-recommendation (SBAR): This is a structured method of communication that is used to improve communication; commonly used with teams. When applied, the staff follow each of the steps and provide required information.
Surveillance: This is the ongoing assessment of patient status to identify problems and/or prevention of potential problems; nurses are primarily responsible for surveillance. Not doing surveillance may result in failure to rescue.
Time-out: During a procedure, the team may use a checklist to confirm the right patient, site, and procedure. If any staff member thinks there may be an error, that staff member can call a stop to any actions so that the correct information can be determined-for example, if the wrong site is identified and actions taken to ensure that care provided meets required outcomes.
Trigger points: These are cues that there may be an adverse reaction. Staff may use standardized lists of trigger points when they assess patient situations.
Universal protocol for preventing wrong site, wrong procedure, or wrong person surgery: The Joint Commission established a procedure to prevent wrong-site, wrong-procedure, and wrong-patient surgery errors. This procedure requires staff to utilize the following steps: (1) pre-procedure verification, (2) site marking, and (3) use of checklists and time-outs. Any staff member may call a time-out if the staff member thinks there is a problem at any point during the procedure.

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Appendix A