The long-term care center has 225 beds and provides the highest level of patient
ID: 124737 • Letter: T
Question
The long-term care center has 225 beds and provides the highest level of patient care, according to ongoing Department of Health Services annual surveys. The Director of the long-term center has the overall responsibility of ensuring the continuing high level of quality outcomes while also concurrently keeping the facility as risk free as practical. You and the Director have just returned from an annual Long-Term Care Association symposium where you were both introduced to some new groundbreaking initiatives regarding the differences between risk management and quality improvement. Earlier in the week, the Director called for a meeting of the center’s department managers, including the Quality Assurance Nurse and the Manager of Risk Management. After briefing them on the symposium talking points, your Director asks you to come up with a working plan and strategy for how the facility will use both of the concepts you have introduced to arrive at a more centralized and standardized approach. Overall, the desired outcomes focus on adopting a new approach to higher quality with fewer risk factors for the organization. Later that week, the Manager of Risk Management, the Manager of Nursing Quality Assurance, and a representative from Human Resources met to formulate a new plan to reduce the litigation exposure while concurrently increasing the quality of patient outcomes. They set about the complex set of tasks with the expectation that you, as the Director’s designated facilitator, will be closely reviewing their final recommendations. Provide a 250-word executive summary of the research project and recommended plan of action that you will provide to the Director. Address the following:
Questions: 1. What is the necessary background information needed to complete your executive summary?Who are the stakeholders?
2. How do the facility’s current Continuous Quality Improvement (CQI) outcomes correspond with the current litigation prevention systems?
3. What factors within the nursing units are the most critical to consider when examining higher quality outcomes?
4. What factors within the nursing units are the most critical to consider when examining lower litigation adverse actions and operational impact?
5. What future steps must be taken to accomplish this directive?
Explanation / Answer
1. The IOM has defined quality of care as "the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge". To the extent that guidelines are based on scientific knowledge, estimate expected health outcomes, and delineate current professional judgment, they clearly have a role to play in assessing and assuring the quality of care.
Efforts to ensure high-quality care must prevent or, alternatively, detect and overcome three main problems: (1) overuse of unnecessary care and of inappropriate care, (2) underuse of necessary care, and (3) poor performance (in both the technical and interpersonal senses). Most experts now agree that a comprehensive approach to quality of care must address all three problems, perhaps to different degrees depending on the setting or nature of the care and various local or institutional factors. Good practice guidelines have the potential to contribute in each area.
First, guidelines and review criteria that explicitly and clearly describe appropriate care for particular clinical problems provide a solid base for detecting patterns of overuse or underuse. Second, detailed guidelines may improve the technical provision of care. Certainly, some aspects of technique have to do with physical capacity, skill built on experience and repetition, attention to detail, and similar factors. Good performance, however, depends on a solid understanding of what constitutes appropriate care (e.g., choice of antibiotic) or correct performance of a technical task (e.g., sterile technique). Finally, when guidelines include good estimates of outcomes (risks, benefits, harms), they can contribute to better communication and shared decision making on the part of patients and practitioners. These interpersonal processes lie at the heart of the humanistic "art of care" vision of quality.
2. Continuous Quality Improvement (CQI), known to most correctional health care professionals in both positive and negative ways.
The goal of CQI is to improve quality of care and build efficiency into processes and procedures. The National Commission on Correctional Health Care (NCCHC) describes CQI as a pathway to improve health care by identifying problems, implementing and monitoring corrective action and studying its effectiveness. In short, it is a method of continuously examining effectiveness and improving the outcome of care or procedures to deliver service. The CQI model requires that you identify the problem area, and your aim or what you want to improve or change. Once you have identified the problem area and goal for improvement you bring about the desired changes using the CQI circular model of going through the steps 1. plan 2. do 3.study/check 4. act.
• Plan: Analyze the process, determine what changes would most improve the process, and establish a plan for making the improvement.
• Do: Put the changes into motion on a small scale or trial basis.
• Check/Study: Check to see whether the change is working.
• Act: If the change is working, implement it on a large scale. If the change is not working, refine it or reject it and begin the cycle again.
Documentation and communication of CQI results are extremely important. Each CQI study should be written up and shared with others along with the changes in practice, procedures or training. Most important is to CELEBRATE the successes with staff and be PROUD of the CQI work the team accomplishes.
3. There are a number of factors influencing the nursing care quality outcomes a few of them includes;
• Staffing levels are set by administrators and are affected by forces that include budgetary considerations and features of local nurse labor markets. Administrative practices result in a structure of the nursing staff of an agency (nature of supervision) and staff or staff hours assigned to different subunits in a facility. These practices also affect the mix and characteristics of the nurse workforce, the model of care used in assigning staff and in providing care, and a wide range of workplace environments that affect how nurses practice. Other characteristics of the workplace environments noted in the literature included the physical environment, communication systems and collaboration, information systems, and relevant support services. All of these factors ultimately influence the “dose” or quantity of nursing time, as well as the quality of nursing care.
• Variables included in the category of care needs of the patient include the acuity and complexity of the patient’s health status, as well as the patient’s comorbid medical conditions, functional status, family needs/resources, and capacity for self-care. The vulnerabilities of patients for adverse events varies and changes over the course of a hospital stay or episode of care.
• The quality of nursing care relates to the appropriate execution of assessments and interventions intended to optimize patient outcomes and prevent adverse events. The quality of care that nurses provide is influenced by individual nurse characteristics such as knowledge and experience, as well as human factors such as fatigue. The quality of care is also influenced by the systems nurses work in, which involve not only staffing levels, but also the needs of all the patients a nurse or nursing staff is responsible for, the availability and organization of other staff and support services, and the climate and culture created by leaders in that setting.
• Safety outcomes include rates of errors in care as well as potentially preventable complications in at-risk patients. Safe practices that avoid errors and foreseeable complications of care can be thought of as either a basic element of or a precondition for delivering high-quality care, but are generally thought of as only one component of quality.
• Clinical outcomes (endpoints) of importance vary from patient to patient or by clinical population and include mortality, length of stay, self-care ability, adherence to treatment plans, and maintenance or improvement in functional status. Serious errors or complications often lead to poor clinical outcomes. So far, very few positive clinical outcomes have been studied by staffing-outcomes researchers, probably because of limited measures and data sources.
4. Risk management professionals should not take lightly the complexity associated with providing healthcare services. While regulations, third-party payer requirements, and licensing/accreditation standards contribute to this complexity, formalized policies and procedures can mitigate it by promoting workplace safety, regulatory compliance, and the delivery of safe, high-quality patient care. Moreover, well-written, up-to-date policies and procedures reduce practice variability that my result in substandard care and patient harm.
Commonly measured nurse outcomes include job dissatisfaction and burnout. Burnout has been linked to higher rates of absenteeism than the general population, and to increased nurse turnover and decreased job satisfaction . Without adequate resources and supports to meet workload demands, nurses grow dissatisfied and emotionally exhausted; they burn out and leave–sometimes leaving the profession altogether. Holden et al. found that nurse job satisfaction was positively associated with a unit-level workload measure, staffing adequacy; burnout was negatively associated with unit-level staffing adequacy, and positively associated with task-level external demands, such as interruptions. Greater nursing workloads are associated with adverse patient outcomes. Globally, researchers have used nurse-sensitive adverse patient outcomes to study the relationships between nurses’ work environments, their workloads and patient outcomes. Nurse reports of patient adverse events are often used as a proxy for administrative unit-level data (i.e., actual morbidity, mortality rates), because accurate unit-level data are difficult to obtain. Although nurse reports of patient adverse events are prone to recall bias, some research has established concordance between nurse reports and actual patient adverse events, such as falls with injuries .
Many adverse events in nursing homes result in lawsuits, and physicians who work in these environments should proactively protect themselves with good relationships with family members and adequate documentation. Risk-prone events include injurious falls, malnutrition and dehydration, adverse drug events, pressure ulcers, wandering and elopement, inadequate documentation or failure to record treatments, and overuse/misuse of psychotropic medications. Some events are unavoidable even in the best of circumstances, but others are accompanied by such issues as understaffing, poor quality of care, and inaccurate or incomplete transfer of information to and from the acute care setting.21 Risk management, in the end, goes hand in hand with quality care and needs to be a highly visible aspect of the nursing facility’s operations. Family education and good communication skills remain key ingredients to improving care and reducing lawsuits in nursing homes.
5.Good risk management within a nursing facility requires the enthusiastic and unqualified support of the administrator, medical director, and director of nursing if it is to succeed. Monitoring of the care being delivered is a fluid, ongoing process that must empower supervisors and staff to be able to respond to care issues as they arise. The American public has a long history of expecting the very best from its health care system, and the LTC sector will be no exception to these high expectations.
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