1. Chapter 18
Quality and Safety

2. Definitions (1 of 3)
 Health care quality is an art and science that continues to
evolve.
 Quality refers to characteristics of and the pursuit of
excellence. Health care quality is classically defined 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.
 Inpatient quality indicators are “standardized, evidence-based
measures of health care quality that can be used with readily
available hospital inpatient administrative data to measure and
track clinical performance and outcomes”
 Benchmarking: "includes routinely comparing indicators
(structure, process, and outcomes) against best performance
and seeking out ways to make improvements with the greatest
impact on outcomes.

3. Definitions (2 of 3)
 Continuous quality improvement is defined as “a philosophy
and attitude for analyzing capabilities and processes and
improving them repeatedly to achieve customer satisfaction”
 Fair and just culture: A fair and just culture is defined as
“organizational accountability for the systems they’ve
designed and employee accountability for the choices they
make”
 Patient safety practices are a type of process or structure
whose application reduces the probability of adverse events
resulting from exposure to the healthcare system across a
range of diseases and procedures.
 A performance measure is a quantitative tool (for example,
rate, ratio, index, percentage) that provides an indication of an
organization’s performance in relation to a specified process
or outcome.

4. Definitions (3 of 3)
 Performance/quality improvement program: is an
overarching organizational strategy to ensure
accountability of all employees, incorporating
evidence-based health care quality indicators to
continuously improve care delivered to various
populations.
 Standards are defined as written value statements.
The three basic types of standards for health care
quality are (1) structure, (2) process, and (3)
outcome.

5. Institute of Medicine’s Specific Aims for
Health Care Quality Improvement
1. Safe: patients should not be harmed by the care
2. Effective: refers to care that is based on the use of
systematically acquired evidence to determine whether
an intervention, such as a preventive service, or
diagnostic test better outcomes than do alternatives—
including the alternative to do nothing
3. Patient-centered: ensure that decisions respect
patients’ wants, needs, and preferences; and that
patients have the education and support they need to
make decisions and participate in their own care

6. 3. Timeliness: refers to obtaining needed care and
minimizing unnecessary delays in getting that
care”
4. Efficient: refers to a health care system where
resources are used to get the best value for the
money spent.
5. Equitable: providing care that does not vary in
quality because of personal characteristics such as
gender, ethnicity, geographical location, and
socioeconomic status

7. Interprofessional Collaboration
 The nurse collaborates with other health
professionals and the public to protect human
rights, promote health diplomacy, and reduce
health disparities”
 Collaboration is about relationships. Conflict may
be the result of an undeveloped or poor
interpersonal relationship with a colleague. To
overcome conflicts, it is necessary to strengthen,
not shy away from, the relationship of the two
opposing parties.
 Industrial models of quality

8. Universal Steps in
Quality Planning
 Identify customers and target markets.
 Discover hidden and unmet customer needs.
 Translate these needs into product or service
requirements: a means to meet their needs (new
standards, specifications, etc.).
 Develop a service or product that exceeds customers'
needs
 Develop the processes that will provide the service, or
create the product, in the most efficient way
 Transfer these designs to the organization and the
operating forces to be carried out

9. Standards of Quality
 Quality can be measured using these three
aspects
 1. Structure Standards and Measures: focus on
the internal characteristics of the organization and its
personnel.
 2. Process Standards and Measures: focus on
whether the activities within an organization are
being conducted appropriately and effectively.
 3. Outcomes Standards and Measures: refer to
whether the services provided by the organization
make any difference

10. Creating an Environment
of Health Care Safety
 Nurses and nurse leaders can personally create an
environment that is devoted to health care safety by
doing the following:
 Learning risk identification, analysis, and error
reduction
 Embracing non-punitive error reporting
 Advocating for a non-punitive culture
 Encouraging vigilance in identifying potential risks
 Creating partnerships with patients to promote
communication about safety issues
 Becoming a role model in practicing safety concepts

11. Patient Safety Event Reporting
Key attributes of an effective incident report:
 Supportive environment for event reporting
 Privacy for staff who report occurrences
 Reports received from broad range of personnel
 Summaries of reports disseminated in a timely fashion
 System in place for reviewing reports and developing
action plans

12. Educating Nurses About
Quality and Safety
 Quality and Safety Education for Nurses (QSEN)
has identified six core knowledge, skills, and
attitude competencies related to quality and
safety:
 Patient-centered care
 Teamwork and collaboration
 Evidence-based practice
 Quality improvement
 Safety
 Informatics

13. Question #1
Process Standards and Measures focus on:
A. The activities within an organization.
B. the internal characteristics of the organization.
C. The environment is highly structured.
D. The services provided by the organization.

14. Chapter 19
Measuring and Managing Outcomes

15. Definitions
 Achieving and sustaining quality outcomes is a goal in
every health care organization. This effort requires the
companion efforts of measuring and managing outcomes
as a guide.
 Outcome: is the result or results obtained from the efforts
to accomplish a goal.
 Indicators: Indicators can be used to measure all three of
domains of quality: structure, process, and outcomes.
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16. Outcome Indicators
 1.Patient focused: A patient-focused definition of
outcomes considers them “the results people care
about most when seeking treatment, including
functional improvement and the ability to live
normal, productive lives”
 2. Provider-focused outcomes can include
measures of processes and outcomes of care for
individual professionals as well as health care work
as experienced by workers reflected in such
phenomena as nurse burnout, turnover, job
satisfaction, work environment, and occupational
injuries.
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17.  3. Organization-focused outcomes may include
patient or provider outcomes that are
aggregated to the organizational level, such as
rates of hospital-wide inpatient or 30-day
mortality, errors, hospital acquired conditions,
and other adverse events; or they may
examine aspects of the performance of a
system that are more of concern to managers
than to clinicians or patients.

18. Indicators
 Valid and reliable measures related to
performance
 Three aspects of quality:
 Structure: structure indicators include the supply, skill
level, education, and certification levels of nursing staff
 Process: process indicators measure methods of
patient assessment and nursing interventions
 Outcomes: outcome indicators reflect both patient
clinical and experience outcomes, such as pressure
ulcers and falls, and nurse outcomes such as job
satisfaction or turnover.
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19. Outcomes Management
 Outcomes management is a process used to assist
managers and others in making rational patient care-
oriented decisions based on what is known about the
effect of those choices on patient outcomes
 Outcomes management is a five-step process:
1. Data are collected about outcomes.
2. Trends are identified from data analysis.
3. Variances are investigated.
4. Potential service delivery changes are explored and
selected.
5. Changes are implemented and their impacts
evaluated.
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20. Management of Care
 Potential changes in care delivery or the
management of care are intended to optimize
care or reduce undesirable variances in care for
a group of patients or a larger population. This is
the analytical management of care delivery.
Goals of optimization include robust quality
improvement within a framework of high
reliability and risk reduction.
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21. Types of Research
 1. Outcomes research: a subfield of health
services research that “seeks to understand the
end results of particular health care practices and
interventions” or the extent to which services
achieve the goals of health care. What makes
outcomes research distinct from other bodies of
research that examine end points in patients is
that outcomes researchers seek to tease out the
effects of patient-level care and systems-level
environments from the background demographic,
psychosocial, and clinical characteristics of
patients as influences on end points
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22.  2. Comparative effectiveness research (CER): A
broadening of outcomes research has been the
(CER) and patient-centered outcomes studies, which
include the effects of treatment on health outcomes
in different patient populations. The goal is to
produce new knowledge.
 3. Nursing outcomes research: This is a subspecialty
within the larger field of health outcomes research
that focuses on determining the effect of different
contexts and conditions that are related specifically to
nurses and nursing care on the health status of
patient e.g study the structures or management
strategies for nursing care delivery and the mix of
health care workers best equipped to care for them

23. Measurement of Outcomes
 Outcomes research can provide nurse leaders with
evidence to guide decisions around resource
allocation and ongoing monitoring of patient safety
and quality care outcomes
 Correctly analyzed and interpreted local outcomes
data help nurse leaders make evidence-informed
decisions around creating healthier work
environments and conditions for nurses to provide
effective and efficient care resulting in positive
outcomes and experiences for all
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24. Leadership and Management
Implications
 Outcomes research assists in building evidence-
based practice
 Managers may struggle with determining what
data indicate a need for action
 Use of tracking systems to monitor changes over
time:
 Dashboard
 Balanced score card
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25. Current Issues and Trends
 Mitigating cost-containment requests
 Population Health
 Management of Nursing Outcomes
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26. Question #1
Valid and reliable measures related to
performance are:
A. Outcomes
B. Indicator
C. Process
D. Structure
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