projects
quality management system
The goal of this chapter is to provide some fundamental definitions that link patient safety
with health care quality. Evidence is summarized that indicates how nurses are in a key
position
to improve the quality of health care through patient safety interventions and strategies.
Many view quality health care as the overarching umbrella under which patient safety
resides.
For example, the Institute of Medicine (IOM) considers patient safety “indistinguishable
from
the delivery of quality health care.”1Ancient philosophers such as Aristotle and Plato
contemplated quality and its attributes. In fact, quality was one of the great ideas of the
Western world.Harteloh3 reviewed multiple conceptualizations of quality and concluded with a
very abstract definition: “Quality is an optimal balance between possibilities realised and
a
framework of norms and values.” This conceptual definition reflects the fact that quality is
an
abstraction and does not exist as a discrete entity. Rather it is constructed based on an
interaction among relevant actors who agree about standards (the norms and values) and
components (the possibilities).
Work groups such as those in the IOM have attempted to define quality of health care in
terms of
standards. Initially, the IOM defined quality as the “the degree to which health services
for
individuals and populations increase the likelihood of desired health outcomes and are
consistent with current professional knowledge.”4 This led to a definition of quality that
appeared to be listings of quality indicators, which are expressions of the standards.
Theses
standards are not necessarily in terms of the possibilities or conceptual clusters for these
indicators. Further, most clusters of quality indicators were and often continue to be
comprised
of the 5Ds—death, disease, disability, discomfort, and dissatisfaction5—rather than more
positive components of quality.
The work of the American Academy of Nursing Expert Panel on Quality Health focused on the
following positive indicators of high-quality care that are sensitive to nursing input:
achievement of appropriate self-care, demonstration of health-promoting behaviors,
health-related quality of life, perception of being well cared for, and symptom management
to
criterion. Mortality, morbidity, and adverse events were considered negative outcomes of
interest that represented the integration of multiple provider inputs.The latter indicators
were
outlined more fully by the National Quality Forum.Safety is inferred, but not explicit in
the
American Academy of Nursing and National Quality Forum quality indicators.
Patient safety practices have been defined as “those that reduce the risk of adverse events
related to exposure to medical care across a range of diagnoses or conditions.” This
definition
is concrete but quite incomplete, because so many practices have not been well studied with
respect to their effectiveness in preventing or ameliorating harm. Practices considered to
have
sufficient evidence to include in the category of patient safety practices are as follows:
Appropriate use of prophylaxis to prevent venous thromboembolism patients at risk Use of
perioperative beta-blockers in appropriate patients to prevent perioperative morbidity and
mortality Use of maximum sterile barriers while placing central intravenous catheters to
prevent
infections
-
Appropriate use of prophylaxis to prevent venous thromboembolism patients at risk
-
Telemedicine can be Use of perioperative beta-blockers in appropriate patients to prevent perioperative morbidity and mortality
-
Use of maximum sterile barriers while placing central intravenous catheters to prevent infections
-
Telemedicine can be Appropriate use of antibiotic prophylaxis in surgical patients to prevent postoperative infections
-
Asking that patients recall and restate what they have been told during the informed-consent process to verify their understanding
-
Telemedicine can be Continuous aspiration of subglottic secretions to prevent ventilator-associated pneumonia
-
Use of pressure-relieving bedding materials to prevent pressure ulcers
-
Telemedicine can be Use of real-time ultrasound guidance during central line insertion to prevent complications
-
Patient self-management for warfarin (Coumadin) to achieve appropriate outpatient anticoagulation and prevent complications
-
Telemedicine can be Appropriate provision of nutrition, with a particular emphasis on early enteral nutrition in critically ill and surgical patients, to prevent complications
-
Use of antibiotic-impregnated central venous catheters to prevent catheter-related infections