Quality health care
encompass desired health outcomes that is uniformed with current professional
knowledge. The Institute of Medicines’ report on To Err Is Human found that the
bulk of medical errors are caused by faulty processes and systems. Processes
and systems that are inefficient can lead to an intricate healthcare system.
Based on these factors, The Institute of Medicine placed six goals for
healthcare which includes safe, timely, efficient, effective, patient-centered,
and equitable. The objective for assessing health care quality is to
discover healthcare delivery and its impact on desired outcomes and to evaluate
whether healthcare is following processes that is evidenced based. Moreover, it
is important to implement multiple process improvement strategies to detect
preventable errors, inefficiencies, and ineffective care in order to implement
change. Organizations such as the Joint Commission, The Agency for
Healthcare Research and Quality, and the National Quality Forum support
utilizing measures that are valid and reliable to evaluate safety and quality
to promote an improvement in health care (Hughes, 2008).
With my current healthcare organization, patient
safety is priority, as well as providing high quality care. One way that our
health care delivery is measured for quality and patient safety is through
surveyors from the Joint Commission. Through citations, our health care
organization is required to develop a plan to fix the mistakes. Once the plan
is complete and before implementation, the staff will be educated and the new
policy and plan will be provided at each department for reference. This
improves our healthcare system by helping staff to be more cognizant of better
ways to deliver healthcare and thus can enhance care, promote safety, and
improve patient outcomes. In addition, this can help our healthcare
organization to save money through prevention strategies.
Post#2
How does the management of quality drive patient safety in your
organization?
The management of quality goals in any organization is the sum and total of
how we practice safely. The essence of a High Reliability Organization is not
the depth or strength of the Quality Assurance/Compliance
department. Healthcare is riddled with inherent risks that can prove
hazardous to those entrusted to us for care. There are numerous situations that
can result in an error and certainly no error is ever intentional. Errors are
an opportunity to examine the causative factors, to conduct a root cause
analysis, to determine if the environment, equipment, or human nature
contributed to the error and find solutions to mitigate what factors can be
changed in order to prevent future errors in a non-punitive but accountable
process to reduce the possibility of harm. According to Sherwood and
Barnsteiner (2017), “characteristics of organizations have a culture of safety
and quality, direct involvement of top and middle leadership, safety and
quality efforts aligned with the strategic plan, an established infrastructure
for safety, and continuous improvement with (the most important part) active
engagement of staff across the organization” (156).
For ambulatory departments, one of the JC National Patient Safety Goals for
2021 in Ambulatory Health Care is patient identification. This may seem so
intuitive that why would a nurse fail to correctly identify their patient?
Well, it happened to me and I nearly gave the wrong medication before I
realized I did not have the right patient in front of me! This national goal
has a reason, likely there has been incidents where a patient was misidentified
and instead of a “near-miss”, the mistake was compounded by not catching the
error in time. How the management of quality drives our organization, I would
say, it starts with the individual speaking up for systems and processes that
increase risk, pressure for a caregiver to cut a corner or rush to perform a
procedure (like drug administration) that started with an error and taking that
opportunity to check their practice. Practice drift can be an insidious
slippery slop and I have never forgotten this near-miss and what contributed to
the event. I can only affect what I do, and how I perform, which is my full and
complete responsibility, regardless of the environmental factors. In this case,
there is no blame to be levied. This was an error that I made and it gave me
the moment of pause to check and correct a drifted practice.
How do you think it is or could improve health care systems?
I am employed by a health system that is accredited by the Joint Commission
(JC) and we are currently preparing for a survey. A few years back, the health
system adopted a mantra “survey readiness” which just means that we are ready
all the time, not just in preparation for a survey. I have noticed that level
of attention is present in each of our daily huddles. What in the department
needs to be repaired? How does the workload impact our culture of safety? I am
practicing in a small affiliate of a large health system, so we have more
access to the affiliate leaders. From time to time, our Chief Nurse Executive
will “pop in” and participate in a huddle with us. She wants to know what we
are experiencing good, bad and the ugly. She is leading by example to promote a
safe and quality culture.