...U.S. Health Care Quality Analysis: Legislative History Following up to the 1999 release of the Institute of Medicine (IOM) report, To Err Is Human, in 2002 a Kaiser Family Foundation survey found that only about 5% of physicians considered medical errors as a primary healthcare concern.[1] Congress, however, did not share the physicians’ nonchalant attitude and gave the Agency for Healthcare Research and Quality (AHRQ) an estimated $50 million towards minimizing medical errors.[2] Senator James Jeffords (R-VT) of the 107th Congress introduced the Patient Safety and Quality Improvement Act (S.2590) to the Senate on June 4, 2002[3] attempting to improve the safety of patients and “…reduce the incidence of events that adversely effect patient safety.”[4] In 2003, President Bush signed into law the Medicare Prescription Drug Improvement and Modernization Act (P.L 108-173).[5] A section of this law authorized AHRQ to research effectiveness in treatments in order to set a guideline to improve the quality of care.[6] John Eisenberg helped build this program that generates summaries that can help provide health care providers with evidence-based practices that help improve quality of care delivered.[7] Realizing the importance of this research to quality of care, the president signed the Under the American Recovery and Reinvestment Act of 2009 (H.R. 1) into law on February 17, 2009, providing additional funding to continue effective research.[8] This helps to demonstrate the...
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...of the condition of the patient. Some patients are usually in such disparate and distinct conditions that require carefully crafted professionalism and minimal ineptness from the doctor for them to survive. Proper service requires transparency, care integration, patient engagement, restoration of joy and meaningfulness and medical education reforms. There is always room for quality improvement as the fronts keep widening and each hospital has to keep increasing the quality of service, beginning from its staff to quality of machinery and equipment. There are established approaches to quality. These approaches include PSDA cycle, the six sigma; which identifies the needs and causes for variations in meeting these needs, structured methodology that define, analyze and control (DMAIC). The critical human factors espouse the team performance, understanding of effects, tasks, equipment, organization on human behavior and abilities, workspace and culture. These should guiding principles for those who work within the practice. During my rounds in Sabah Hospital in Kuwait country, I observed quite a number of malpractices, or rather ineptness by practitioners in the medical facility. An example that I state in my report is striking to me, how a simple situation could turn tragic out of negligence or ignorance. I witnessed a patient suffering from gastrointestinal bleeding after taking large amounts of cranberry juice after being discharged. The patient had been discharged contrary...
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...QUALITY DATA COLLECTION Anny streat HCS/588 August 14th, 2013 Quality Data Collection Quality data must be identified to improve organizational quality and respond to stakeholders needs. Quality should be collected, analyzed and used to develop and implement performance improvement. Many data sources and collection can be listed. In this paper, three data collection tools will be identified. Before then, because the main outcome of data collection is to measure and monitor the improvement of performance, three areas of improvement of the organization will be discussed. Furthermore, tools that measure and display the QI data will be selected and compared. Quality data focuses on four areas of improvement: clinical quality, financial performance, functional statues and patient satisfaction. Atlanta medical center (our chosen organization) had a good quality score of 99.3% in the CMS (center of Medicaid and Medicare service) core measures declared Bill Moore (2011). Nevertheless, three areas of improvement will be examined. The first area is patient safety. Kohn Corrigan (2000) states “Many as 98,000 people die every year in hospitals as results of injuries from their care”. For that reason, organization should comply with CMS core measures, the national patient safety goals initiative of the joint commission on accreditation...
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...Quality Improvement Project: Address barriers and leveraging strengths to achieve improvement in your organization. The numbers of medical error that occur in hospital settings are usually under estimated. Improving these events has come a long way since 2005. The Patient Safety and Quality Improvement Act has contributed to the healthcare industry by allowing employees to report without fear of liability to agencies who then identify, analyze, and reduce risks and hazards that often occur when administering care to a patient (Youngberg, 2011). This is a great tool in advancing the training process of the health care team and increasing patient safety. In addition to employees having what I would call free speech to the Patient Safety Organizations, provider’s organizations can have the same privilege so long as they establish a relationship with the PSO who has participated in the peer review process. Any healthcare organization that wants to improve the quality of care their patient receives would encourage their employees to participate. Having a manager with strong leadership skills within the organization can also be a driving force for positive change. Strong leaders are creative, experienced and can motivate employees. They will be able to detect where and how a problem was initiated and can create a plan focused on preventing the problem. They can be an advantage to achieve quality improvements by analyzing data, composing a safety plan for all clients in and out...
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...medical liability system needs reform to promote better patient safety and lower health care costs. In this paper I plan to show different types of reform that are needed in the medical liability system and how those changes will impact patient safety and cost. Also discussed will be the governments backing (or not) of medical liability reform. The current medical liability system was designed to provide monetary compensation to patients who suffer injury due to medical negligence. The system also works to reduce the chances of future patients being harmed by preventable medical errors. However, most individuals in the healthcare industry do not believe it accomplishes any of these goals. The biggest issues, as reported by critics of the system, are the cost and access of liability coverage, impact on patients’ safety, and the administrative costs of lawsuits. To address the shortcomings of the system, some reform has been introduced to modify the current tort system. Included in these reforms are Full disclosure/early offer programs, Certificates of merit programs, Caps on damage awards, periodic interim payment rules, joint and several liability reform, collateral source rule reform, screening panels and health courts. All of these programs are designed to lower the costs of Medical Liability insurance for the health care provider as well as addressing the safety of patients in various ways. They also give both the patient and the health care provider peace of mind because they...
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...CURRICULUM VITAE Profile Goal directed, results-oriented, professional Healthcare Manager successfully managed in diverse areas including Nursing Leadership, Clinical Audit, Quality Management, Training and Education. Personnel Information Name: Fatme Khodor Elrifai Sex: Female Date & place of birth: 09-01-1978 Lebanon Address: Specialized Medical Center Hospital -Riyadh Phone work: 0114343800 x 3990 Mobile number: 0502855808 E-mail: f.alrifai@hotmail.com Languages Arabic Fluently written and spoken English Fluently written and spoken French Fluently written and spoken Education 2013- 2014: Ongoing Masters in Healthcare Administration/ Quality Management – Al Jinan University, North of Lebanon 2006 -2007: BS Degree in Nursing Sciences – Bridging Program 2000 – 2003: Three years in the TS-Nursing program, Technical Superior Degree 1997 – 2000: Three years in the Nursing program, Technical Baccalaureate Degree 1993 – 1995: High school education in Saint Joseph, North of Lebanon 1989 – 1993: Secondary school education in Saint Joseph, North of Lebanon - Nursing Leadership & Management (Deputy Director of Nursing at Kingdom Hospital Consulting Clinics, KSA/ Riyadh, 130 Beds, private, CBAHI and JCIA accredited primary healthcare institution. KHCC is providing various range of medical services including, but not limited to, Internal Medicine,...
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...INTRODUCTION The Quality Improvement Network was established by the RCN’s Quality Improvement Programme in 1989 to contribute to the quality of patient care through the sharing of knowledge, skills and information on quality improvement, patient safety, clinical governance and leadership. The safe transfer of care is a vital component of the quality of care and safe practice (Pothier, et al., 2005). When the process of transfer of care is inadequately undertaken risks to the patient are increased and may subsequently lead to harm (BMA, 2005; Joint Commission, 2007). The Network organised a series of patient safety road shows which were specifically designed to build consensus and concentrate activities on the key topic of transfer of care, to facilitate networking between members of the Network’s regional groups and a range of colleagues working across all care sectors, and to identify the actions required to improve the patients’ experience of transfer of care across all health and social settings. 1.1 Literature Review “A good…handover process is a crucial part of providing quality…care…The conservation of patient data during the handover process is vital to ensure good continuity of care and safe practice. Any errors or omissions made during the handover process may have dangerous consequences…” (Pothier, et al., 2005) Delays in transferring or discharging patients can result in a range of problems for both patients and organisations (Bryan, et al., 2005). For patients...
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...Development Matrix Complete the following matrix depicting the historical development of risk management and quality improvement. Select 8-10 historical regulatory and nonregulatory events and activities over the 20th century that contributed to the theoretical foundations of risk management. The matrix must identify the name, year, and founder of the development; the nature of the development; and its importance in the development of risk management and quality improvement. Use this table as a graphic organizer to summarize the theoretical underpinnings and historical development of risk management and quality improvement. Historical Development (Name, Year) Founder of Event Nature of Development Importance to Development of Risk Management and Quality Improvement 1. The National Health care Quality Report, 2011 Agency for Healthcare Research and Quality The nature of the development is to monitor and control nationally the quality of care in the United States. These reports measure trends in effectiveness of care, patient safety, timeliness of care, patient centeredness, and efficiency of care. In the 20th century new chapters on care coordination, health system infrastructures are put into place. The reports present, in chart form, the latest available findings on quality of and access to health care. According to Priority areas for national action: Transforming health care quality (2003), the committee decided a framework would be useful in helping to identify potential candidates...
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...medications in business, research studies, advances in devices, and new procedures. On the other side, there is widespread concerns about the medical errors, inconsistent quality in health care services, increase in cost, and public awareness about the health care services through Medias, led to the movement of pay-for-performance. This emerged as a cost containment program. Health care system is trying to provide quality, efficiency, accountability, and transparency in health care services through the development of pay-for-performance movement (Henley, 2005). Pay-for-performance refers to the financial incentive program that pay a bonus to the participant of services such as physicians, hospitals, physician groups, or health plan groups who attain a benchmark in quality, efficiency, accountability in health care services and in patient care. This is referred as the pay-for-performance movement. This program provides high credit bonus for preventive care services. As the term indicates, "pay-for performance" is the high quality health care services for the money paid by clients. Pay-for-performance is a term widely used and used increasingly during the implementation of Affordable care Act. This plan provides rewards to the health care providers to reduce the unnecessary health care cost, and improved quality of services. The other names used for pay for performance includes merit pay, knowledge and skill based pay, or...
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...Risk and Quality Management Strategies 4 Executive Summary VOLUME 2 July 2009 Key Recommendations Assess current activities in risk management and quality improvement to evaluate their effectiveness in addressing overlap. Establish a structure to ensure that patient care activities are addressed in a coordinated manner involving risk management and quality improvement functions. Seek legal counsel to ensure that the structure for risk management and quality improvement activities maximizes legal protections granted by state and federal statutes while allowing for the flow of information. Align risk management and quality improvement plans with the strategic goals of the organization. Educate stakeholders on the role of risk management and quality improvement functions. Design systems to coordinate and streamline data collection, analysis, monitoring, and evaluation. Risk Management, Quality Improvement, and Patient Safety In the past, the risk management and quality improvement functions often operated separately in healthcare organizations and individuals responsible for each function had different lines of reporting—an organizational structure that further divided risk management and quality improvement. Today, risk management and quality improvement efforts in healthcare organizations are rallying behind patient safety and finding ways to work together more effectively and efficiently to ensure that their organizations deliver safe and high-quality patient...
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...Annually, millions of Americans receive high-quality health care that restores their health to the best it can be and allows them to carry on functioning in society at their optimum best. Unfortunately this story does not resonate with some Americans who are far from happy about the level of care they received while sick. Quality problems are present in wide variation across board when talking delivery of health care services, in some instance, the issue could be with underutilization of a particular service, and other instances may include misuse of service which is generally preceded at onset by prior unacceptable level of errors. The purpose of this paper is to highlight medication errors as a health care safety issue. One solution involving automation would be explored since it has long been recognized as an important factor in reducing human errors in work processes. It is crucial to showcase this because numerous studies have substantiated the positive effects of health IT on quality and safety improvements, Slovenky & Menachemi (2011). A safety Initiative With new tools provided by the Affordable Care Act, hospitals can now aggressively implement programs with sole aim of assisting in the reduction of preventable errors. The act provides hospitals with incentives to improve the quality of health care, and provide real assistance to medical professionals, to support their efforts to reduce harm, McKinney & Zigmond (2011). The government predicted that this could save...
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...EMR implementation to improve patient outcomes Florida International University The problem Quality of care has been low for Mesey hospital over the past few years. Medical errors, near misses and poor patient safety are at an increased rate. Communication has been lack luster, and patient satisfaction surveys have yielded unsatisfactory results. Mesey has invested in quality training, has had continuous education sessions and in-services in an attempt to improve care but has seen no improvements despite the efforts. The CEO, not realizing that it’s the system not the people, is looking into new and different strategies for improvement, including hiring new employees as the current staff is set in their ways and cannot seem to turn quality around. Mesey is currently using the traditional paper charting system and has not yet converted to electronic medical records (EMR). The CEO has done some research and has learned that the competitor Wellness hospital has been using EMR for over two years and has had great success - high quality rating and excellent patient satisfaction scores. The CEO of Mesey has been contemplating if implementing EMR within the facility will improve patient outcomes and satisfaction through improved safety and quality of care? Traditionally, paper based medical records have been used due to its simplicity and ease of use, low cost implementation, and widespread acceptance. This system does however come with a vast number of disadvantages including...
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...over the responsibility of their livelihood bad safety, their last concern may be that the professional personnel treating them may not be qualified for the job. Structural indicators have one consider not only the demand and need for appropriate staff is adequate but also that the education is up to par for those individuals (Savitz, 2005). Do these professionals hold the degree but not the special certification to preform a specific task or duty? In this scenario, it begs to differ as to why the CNA came to remove the restraints. Was this a direct command from the RN? Is the RN burned out and understaffed causing the CNA to be the only one available to respond to this patients needs? In addition, this CNA is preforming an assessment of a potential skin breakdown/ulcer and furthermore educated the patient's family on the matter. It does not seem clear that the RN assigned to patient is in full communication and authority with the health care team causing delays or misses in identifying and treating a problem. This sheds light on process indicators which include recognition, assessment, and nursing intervention methods (Savitz, 2005). This scenario includes several situations where negative physical and emotional problems were arising without proper identification and intervention. All of which contribute to a negative outcome. Outcome indicators here leave the quality and quantity of nursing care in question. The patient is most likely suffering from a pressure ulcer...
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...Table of Contents Introduction Page 3 Risk Scenario Related to Patient Care and Safety Page 5 Risk Scenario Related to the Physical Plant Page 9 Risk Scenario Related to Staffing Page 13 Best Practices in 4 Hospitals Page 15 Tenet Healthcare Page 16 Cleveland Clinic Stroke Improvement Plan Page 17 Conclusion Page 18 References Page 19 Introduction The issue of risk scenario carries immense importance for most of the hospitals that are part of the healthcare setting. However, there is not only one scenario that can affect the hospitals but there are several scenarios that can create an impact on the functions of the hospital. There are three scenarios that would be highlighted in the current topic. These three scenarios have a tendency to put a hospital at risk for financial stability. The first scenario that can produce a negative impact on the hospital risk is related to patient care and safety. The second scenario is related to the physical plant. The third and last scenario is related to staffing. The role of HIM practitioner in this regard would be very important. They would serve as a clinical quality assessment resource and as a team member to perform their tasks related to healthcare work. Therefore, all the issues related to three scenarios will be discussed in detail. The impetus for quality improvement has been driven in recent years by three main factors: 1. The amount of money that the US spends on healthcare per capita and as...
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...Collaborative Communication: Integrating SBAR to Improve Quality/Patient Safety Outcomes Cynthia D. Beckett, Gayle Kipnis Purpose/Evidence-Based Practice Question Collaborative communication and teamwork are essential elements for quality care and patient safety. Adverse patient occurrences are an extremely common outcome of communication failures (Leonard, Graham, & Bonacum, 2004). In 2004, the Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations) analyzed 2,455 sentinel events from hospitals across the United States and reported through root cause analysis over 70% of the events were due to communication failures, and approximately 75% of the patients involved died (Leonard et al., 2004). Although improving communication has been included as a Joint Commission’s National Patient Safety Goal for hospitals since 2003, in 2006, handoff communications were included as a specific communication subset. NPSG 02.05.01 states ‘‘The organization implements a standardized approach to handoff communications, including an opportunity to ask and respond to questions’’ (Joint Commission, 2006). Michael Leonard, MD, from Kaiser Permanente- Denver introduced a collaborative communication tool to support patient safety and outcomes. The structured communication tool is Situation, Background, Assessment, and Recommendation (SBAR) (Haig, Sutton, & Whittington, 2006). The SBAR tool provides a framework for organizing information...
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