Introduction

These topics have been assigned to us for one reason and

one reason only: to be presented, and to be presented not just in any way, but cohesively, comprehensively, and understandably. These topics are of utmost importance to be discussed since together they form an integral part of our profession and the knowledge we will obtain likewise benefit our clients in the future. Together, they will eventually form a part of us, and of our colleagues, and their dissemination among ourselves is simply an opportunity for us to grow, develop, and achieve.

Objectives
Define quality improvement and discuss the importance

of quality improvement. Identify ways to achieve quality improvement Discuss the purposes of clinical practice guidelines Define clinical pathways Enumerate the differences between audit and research Define utilization review, its importance as well as nurses roles Define what is complaints analysis and its importance Enumerate the the different sentinel events Define what is morbidity/mortality meetings Define or describe credentialing and clinical privileging Discuss variance reporting and analysis

Quality Improvement
What is Quality Improvement?
To understand Quality Improvement (QI), we must first

understand Quality Assurance (QA). QA is an ongoing systematic process designed to evaluate and promote excellence in the service provided to clients. In the health care setting, QA frequently refers to evaluation of the level of care provided in an agency, but it may be limited to the evaluation of the performance of one individual or more broadly involve the evaluation of the quality of the care in an agency.

There are three components of QA:

Structure Evaluation- focuses on the setting in which the

care is given Process Evaluation- focuses on how the care was given Outcome Evaluation- focuses on demonstrable changes in the clients health status as a result of care

 Quality Improvement on the other hand, follows rendering service,

or in the health care setting, client care. It uses a systematic approach with the intention of improvement rather than ensuring the service rendered. It focuses on identifying a systems problems, such as duplication of services in a hospital. QA is also known as continuous quality improvement, total quality management, performance improvement, or persistent quality improvement.

The Center for Quality Improvement and Patient Safety within the Agency for Healthcare Research and Quality has its mission to improve quality and safety through strategic partnerships: Conduct and support user-driven research on patient safety and health care quality measurement, reporting, and improvement Develop and disseminate reports and information on health care quality measurement, reporting, and improvement Collaborate with stakeholders across the health care system to implement evidence based practices, accelerating and amplifying improvements in quality and safety Assess own practices to ensure continuous learning and improvement

 Before a research that leads quality improvement can be

conducted though, the right problem needs to be identified. As such, the Joint Commission on Accreditation of Healthcare Organizations has put a great emphasis of what are called sentinel events. Though this is discussed in another topic, to simply put, a sentinel event is an unexpected occurrence involving death or serious injury. They signal the need for an immediate investigation and response. The findings will improve quality of service.

What are some ways to achieve quality improvement

Across the board, respondents emphasized that a supportive

hospital culture is key to making important advances in quality improvement. They identified several key strategies that help foster quality improvement, including: Supportive hospital leadership actively engaged in the work; Setting expectations for all staffnot just nursesthat quality is a shared responsibility; Holding staff accountable for individual roles; Inspiring and using physicians and nurses to champion efforts; and Providing ongoing, visible and useful feedback to engage staff effectively. While respondents acknowledged these are important factors, there was considerable variation in the extent to which each hospital in the four communities has been able to incorporate these strategies into their individual cultures.

Leadership Support

To create a hospital culture supportive of quality improvement, respondents stressed the importance of hospital leadership being in the vanguard to engage nurses and other staff. As a representative of an accrediting organization said, For any quality improvement project to be successful, the literature shows that support has to trickle down from the top. That is important to success. That level of sponsorship has to be there for quality improvement to be successful. Not only nursing leadership, but across the board from the CEO down. As an example, the CEO of one hospital supported nurses in their efforts to better track and address the prevalence of bedsores among patients, even though doing so required that the information be reported to a state agency. Despite the potential for negative attention for the hospital, the CEO encouraged nursing staff to take ownership of a quality problem where there was an opportunity to improve patient care. Hospital respondents expressed the importance of not just paying lip service to quality improvement, but also to dedicating resources to these activities. Some hospitals, for example, have reportedly expanded their nursing leadership infrastructure in recent years and some have created new nursing positions dedicated to quality improvement (e.g., director of nursing quality). Some respondents reported providing nurses with more support for administrative tasks such as data collection and analysis.

Quality as Everyones Responsibility

A hospital culture that espouses quality as everyones responsibility is reportedly better positioned to achieve significant and sustained improvement. While hospital respondents characterized the role of nurses in quality improvement as crucial, they also emphasized that nursing involvement alone is insufficient because it is not simply nursings work or qualitys work; it is the work of the whole organization.
For most hospitals, quality improvement efforts transcend departments, and nurses are reportedly involved, at some level, in virtually all of these activities because of their clinical expertise and responsibility for the dayto-day coordination of care and other services for patients. To really improve quality, you have to have every staff member engaged, including other clinical staff, such as physicians, pharmacists and respiratory therapists, as well as nonclinical staff, such as food service, housekeeping and materials management. As a director of quality improvement stated, Nursing practice occurs in the context of a larger team. Even on a pressure ulcers team, even though it is primarily a nursing-focused practice, you have the impact of nutrition, for example. On cases that are clinically challenging, like transplants, you would also have the impact of our surgeons, for instance.

Individual Ownership and Accountability

Another key component of a hospital culture conducive to quality improvement is encouraging individual ownership and accountability for patient safety and quality, according to respondents. In one hospital, for example, there were delays in notifying physicians of critical lab results. According to the hospital quality improvement director, when nurses took ownership of the process and started collecting the data, they were able to determine the problem and address it. Hospitals have pursued various strategies to increase staff ownership and accountability. The most commonly reported was to more explicitly include and detail quality improvement responsibilities in job descriptions and performance evaluations for staff and in contracts with physicians. Respondents discussed that this was important for all staff, not just leadership. A hospital CEO stated, We are trying to drive it down further to the nursing staff on the floor, or in the unit, or in the ER, and say, it is part of your job requirements to help us improve patient care and improve patient satisfaction. Hospitals also use other types of rewards to encourage staff ownership and accountability. Respondents discussed a range of ways to reward staff, including public acknowledgement by leadership in staff meetings, writing them thank you notes, formal award recognition ceremonies and dinners, and sending them to national quality improvement meetings, such as those sponsored by the Institute for Healthcare Improvement.

Ongoing Useful Feedback

Hospitals that actively communicate with and provide timely and useful feedback to staff reportedly are more likely to foster quality improvement than those that do not. As one hospital CNO noted, We have tried to be as transparent as we can and share as much information as we can with our nursing staff. They get a lot of information and that helps them stay motivated and engaged in the process. Hospitals use a variety of feedback mechanisms. One widely used mechanism is a periodic scorecard that provides information on how performance, including quality improvement, is progressing toward goals. According to respondents, the information is typically provided at both the hospital and individual unit levels and is visibly displayed throughout the hospital for all staff to see. Other commonly reported methods of providing feedback on quality improvement include newsletters, staff training, new employee orientation, e-mail communications, unit-based communication boards and staff meetings. Respondents cautioned, however, that the key to effective feedback is not just the amount of information provided, but also how meaningful that information is for staff. As a hospital CNO explained, Our quality regimes until now have just been leaning toward giving numbers. That doesnt affect nurses practice, but if you give them more detail, it makes it more meaningful for them.

 Two-way feedback between hospital leadership and staff

is also important. Several respondents reported using patient safety rounds as one way of facilitating this. In one hospital, executives periodically visit individual patient care units and sit down and talk with staff. One of the questions they ask of staff is, What keeps you awake at night?, referring to any patient quality or safety concerns staff may have. This process has reportedly been effective in identifying areas for improvement, such as the need for improved response times for the delivery of supplies and medications to patient care units.

Clinical Practice Guidelines

The standard definition of Clinical practice guidelines

(CPGs) is that of Field and Lohr [1990]: "systematically developed statements to assist practitioners and patient decisions about appropriate health care for specific circumstances".

Introduction
Guidelines are designed to support the decision-making

processes in patient care. The content of a guideline is based on a systematic review of clinical evidence - the main source for evidence-based care. been gaining ground quickly over the past few years, motivated by clinicians, politicians and management concerned about quality, consistency and costs. CPGs, based on standardized best practice, have been shown to be capable of supporting improvements in quality and consistency in healthcare. Many have been developed, though the process is time-and-resource-consuming. Many have been disseminated, though largely in the relatively difficult to use format of narrative text. As yet they have not had a major impact on medical practice, but their importance is growing.

The movement towards evidence-based healthcare has

Purposes of Guidelines
To describe appropriate care based on the best available

scientific evidence and broad consensus; To reduce inappropriate variation in practice; To provide a more rational basis for referral; To provide a focus for continuing education; To promote efficient use of resources; To Act as focus for quality control, including audit; To highlight shortcomings of existing literature and suggest appropriate future research

Guidelines and Protocols

Clinical protocols can be seen as more specific than guidelines, defined in greater detail. Protocols provide "a comprehensive set of rigid criteria outlining the management steps for a single clinical condition or aspects of organization".

Computerized Guidelines
Computerized guidelines encode evidence-based

recommendations for and can automatically generate recommendations about what medical procedures to perform tailored for an individual patient. Computerized guidelines offer benefits over and above those offered by paper-based guidelines: They offer a readily accessible reference, providing selective access to guideline knowledge. They help reveal errors in the content of a guideline; They help improve the clarity of a guideline, e.g. in decision criteria and clinical recommendations; They help offer better descriptions of patient states; They can automatically propose timely, patient-specific decision support and reminders

Clinical Pathways
Clinical Pathways (CP) is multidisciplinary plans of best
clinical practice for specified groups of patients with a particular diagnosis that aid the co-ordination and delivery of high quality care. They are both, a tool and a concept, which embed guidelines, protocols and locally agreed, evidence-based, patient-centered, best practice, into everyday use for the individual patient.

Why Clinical Pathways?

To improve patient care To maximize the efficient use of resources To help identify and clarify the clinical processes To support clinical effectiveness, clinical audit and risk

management

As Active Management Tools

Eliminate prolonged lengths of stay arising from

inefficiencies, allowing better use of resources Reduce mistakes, duplication of effort and omissions Improve the quality of work for service providers
Improve communication with patients as to their expected

course of treatment Identify problems at the earliest opportunity and correct these promptly
Facilitate quality management and an outcomes focus

Four Components of a Clinical Pathway

A Timeline,

Categories of care or activities and their interventions,

Intermediate and long-term outcome criteria, Variance record

Guidelines for the Development and Implementation

Educate and obtain support from physicians and nurse, and

establish a multidisciplinary team. Identify potential obstacles to implementation. Use Quality improvement methods and tools. Determine staff interest and select Clinical Pathways to develop. Collect Clinical Pathway data and medical record reviews of practice patterns. Conduct literature review of clinical practice guidelines. Develop variance analysis system and monitor the compliance with documentation on Clinical Pathways. Use a pilot Clinical Pathway for 3 to 6 months; revise as needed.

Optimum development and implementation strategies

Select a Topic Topic of high-volume, high-cost diagnoses and procedures. For example:- Critical pathway development for cardiovascular diseases and procedures Select a Team Active physician participation and leadership is crucial Representatives from all groups Evaluate the Current Process of Care Key to understanding current variation A careful review of medical records Identify the critical intermediate outcomes, rate-limiting steps, and high-cost areas on which to focus.

Evaluate Medical Evidence and External Practices Evaluate the literature to identify evidence of best practices In the absence of evidence, comparison with other institutions, or "benchmarking," is the most reasonable method to use. Determine the Critical Pathway Format The format of the pathway include a task-time matrix spectrum of pathways of the medical record used as a simple checklist

Benefits
Help reduce variations in patient care (by promoting

standardization) Help improve clinical outcomes Help improve and even reduce patient documentation Support training Optimize the management of resources Can help ensure quality of care and provide a means of continuous quality improvement Support the implementation of continuous clinical audit in clinical practice Support the use of guidelines in clinical practice Help empower patients Help manage clinical risk Help improve communications between different care sectors

Limitations of Clinical Pathways

Implementation of the care pathways has not been tested

in a scientific or controlled fashion. No controlled study has shown a critical pathway to reduce length of stay, decrease resource use, or improve patient satisfaction. Most importantly, no controlled study has shown improvements in patient outcome

Potential Problems and Barriers to the Introduction of Clinical Pathways

May appear to discourage personalized care Risk increasing litigation

Don't respond well to unexpected changes in a patient's

condition Suit standard conditions better than unusual or unpredictable ones Require commitment from staff and establishment of an adequate organizational structure Problems of introduction of new technology May take time to be accepted in the workplace

MS Audit
Introduction:
Nursing audit, is a review of the patient record designed to identify,

examine, or verify the performance of certain specified aspects of nursing care by using established criteria. Nursing audit is the process of collecting information from nursing reports and other documented evidence about patient care and assessing the quality of care by the use of quality assurance programmes. Nursing audit is a detailed review and evaluation of selected clinical records by qualified professional personnel for evaluating quality of nursing care. A concurrent nursing audit is performed during ongoing nursing care. A retrospective nursing audit is performed after discharge from the care facility, using the patient's record.

History of Nursing Audit :

Nursing audit is an evaluation of nursing service. Before

1955 very little was known about the concept. It was introduced by the industrial concern and the year 1918 was the beginning of medical audit. George Groword, pronounced the term physician for the first time medical audit. Ten years later Thomas R Pondon MD established a method of medical audit based on procedures used by financial account. He evaluated the medical care by reviewing the medical records. First report of Nursing audit of the hospital published in 1955. For the next 15 years, nursing audit is reported from study or record on the last decade. The program is reviewed from record nursing plan, nurses notes, patient condition, nursing care.

Purposes of Nursing Audit

1. Evaluating Nursing care given, 2. Achieves deserved and feasible quality of nursing care, 3. Stimulant to better records, 4. Focuses on care provided and not on care provider, 5. Contributes to research.

Difference Between Audit and research

Audit
Is not randomized

Research
May be randomized

Compares actual performance against standards

Identifies the best approach, and thus the sets the standards

Conducted by those providing the Not necessarily provided by those providing the service service Usually led by service providers Does not involve investigation of new treatments, but evaluates the use of current treatments
Usually initiated by researchers Involves comparators between new treatments and placebos

Involves review of records by those Requires access by those not entitled to access them normally entitled to access them Ethical consent not normally requiredMust have ethical consent

Results usually not transferable

Results may be generalisable

Hypothesis used to generate the standard Compares performance against the standard

Testable hypothesis generated

Presents clear conclusions

Methods of Nursing Audit

a. Retrospective view this refers to an in-depth assessment of the quality after the patient has been discharged, have the patients chart to the source of data.

b. The concurrent review this refers to the evaluations conducted on behalf of patients who are still undergoing care. It includes assessing the patient at the bedside in relation to predetermined criteria, interviewing the staff responsible for this care and reviewing the patients record and care plan.

Retrospective audit is a method for evaluating the quality of nursing care by examining the nursing care as it is reflected in the patient care records for discharged patients. In this type of audit specific behaviors are described then they are converted into questions and the examiner looks for answers in the record. For example the examiner looks through the patient's records and asks :
a. Was the problem solving process used in planning nursing care? b. Whether patient data collected in a systematic manner? c. Was a description of patient's pre-hospital routines included? d. Laboratory test results used in planning care? e. Did the nurse perform physical assessment? How was information used? f. Were nursing diagnosis stated? g. Did nurse write nursing orders? And so on.

Method to Develop Criteria :

1. Define patient population. 2. Identify a time framework for measuring outcomes of care, 3. Identify commonly recurring nursing problems presented by the defined patient population, 4. State patient outcome criteria, 5. State acceptable degree of goal achievement, 6. Specify the source of information.

Design and type of tool

Audit as a Tool for Quality Control/Improvement
An audit is a systematic and official examination of a record,

process or account to evaluate performance. Auditing in health care organization provide managers with a means of applying control process to determine the quality of service rendered. Nursing audit is the process of analyzing data about the nursing process of patient outcomes to evaluate the effectiveness of nursing interventions. The audits most frequently used in quality control include outcome, process and structure audits.

1. Outcome audit
Outcomes are the end results of care; the changes in the

patients health status and can be attributed to delivery of health care services. Outcome audits determine what results if any occurred as result of specific nursing intervention for clients. These audits assume the outcome accurately and demonstrate the quality of care that was provided. Example of outcomes traditionally used to measure quality of hospital care include mortality, its morbidity, and length of hospital stay.

2. Process audit
Process audits are used to measure the process of care or

how the care was carried out. Process audit is task oriented and focus on whether or not practice standards are being fulfilled. These audits assumed that a relationship exists between the quality of the nurse and quality of care provided.

3. Structure audit
Structure audit monitors the structure or setting in which

patient care occurs, such as the finances, nursing service, medical records and environment. This audit assumes that a relationship exists between quality care and appropriate structure. These above audits can occur retrospectively, concurrently and prospectively.

Utilization Review
What is Utilization Review? Utilization review consists of examining trends and proposing advantageous disposition of resources. For example, might clients who have had a fractured hip repaired have equivalent outcomes at a lesser cost if transferred from the hospital to a skilled nursing facility sooner? Furthermore utilization review is a process implemented by hospitals, insurance companies, and other types of managed care plans. Included in the utilization review process, is the use of explicit criteria to determine the medical necessity of the treatment or the health care service appropriate for such a service. This is critical in order to assure a health service meets these stringent and generally accepted requirements and is likely to be covered by insurance reimbursement. Physical status is evaluated against the criteria and a determination made as to whether or not a patient requires care at a particular level of service, i.e. hospital, in-patient rehabilitation, etc. The criteria used are usually developed by physicians, a review of current evidence and national guidelines published by specialty organizations.

 There are levels in the utilization review process. The first

level is the initial screening and review of health status and requested service by a licensed healthcare professio nal, usually a registered nurse or license social worker (outpatient therapy). If there is any question regarding the need for services, the review is passed on to a physician, who holds active state licensure. That physician will review all available information, i.e. progress notes, admission history, lab data, x-rays, etc., and assess the appropriateness of the care. If the physician determines that the care needs do not require the health services being received, he or she will sometimes discuss the care with the attending physician and determine an agreed upon treatment plan.

What is the role of the nurse in utilization review?

A utilization review nurse is a registered nurse who reviews

individual medical cases to confirm that they are getting the most appropriate care. These nursing professionals can work for insurance companies, determining whether or not care should be approved in specific situations, and they can also work in hospitals. The goal of members of this profession is to balance the needs of a patient with the need to reinforce policies, keep costs reasonable, and ensure that patients are provided with medical treatment which is suited to their situations. Working as a utilization review nurse can be stressful, as it may involve situations and settings in which nurses are forced to make decisions which they may not personally agree with. For example, a nurse may feel that on compassionate grounds, a patient should have access to a particular treatment, but that the patient is not eligible for the treatment, based on the specifics of the patient's case and the policy of the hospital or insurance company. Members of this profession do need to possess compassion, but they also need to be able to review situations dispassionately to make decisions which are fair, even if they may be uncomfortable.

 At a hospital, a utilization review nurse examines patient cases if the

hospital feels that a patient may not be receiving the appropriate treatment. For example, a doctor might recommend hospitalization, but the utilization reviewer might feel that the patient does not need to be hospitalized, and it would be better to discharge the patient to free up a bed, save the hospital money, and save money for the patient as well. Utilization review nurses also review situations like requests for medical imaging studies, the use of certain medications and treatments, and recommended medical procedures. Hospital nurses may also be concerned about whether or not patient cases meet the standards for reimbursement by insurance companies.
In an insurance company, the utilization review nurse inspects claims to

determine whether or not they should be paid. The nurse weighs the patient's situation against the policy held by the patient, the standards of the insurance company, and the costs which may be involved in treatment. For example, requests for medications which prolong life are probably going to be denied if the patient is in hospice care, as hospice care is designed for end of life treatment. Likewise, if a utilization review nurse feels that a medication, procedure, or treatment is not medically indicated, it may be denied.

 To work in this field, it is usually necessary to hold a current

nursing license, and to have experience in the field. Many utilization review nurses have been nursing for 20 years or more, and they are familiar with nursing administration, hospital procedures, and the process of insurance reimbursement. Job openings are listed in many nursing trade magazines in addition to public forums. Nurses who are interested in specialized work such as utilization review for prisoners or members of the military may need to pass background checks and fulfill other requirements before they can start work.

Complaints Analysis
While feedback from customers is to be dealt with in independent manners, the resolution of the complaint is to be handled by senior management personnel. It is also a good idea to open a number of channels for feedback and complaints, such as a suggestion box or nominating an authorized person independent of production and customer is their entry into the data base on register of complaints. This is for the following reasons: To keep tract of the complaint To carry out root cause analysis and take corrective action immediately so as to eliminate such problems in the future. To take preventive action. To find out the lost of poor quality and other statistical purposes. Every complaint should be duly acknowledged. It should be receive the attention of the top management. The complaints coordinator cannot be from the customer service or from the production or operations to avoid conflict of interest.

Analyze Independently
The complaint coordinator may designate a team or

a person for studying the complaint thoroughly and independently. The team should study the complaint and verify whether it is true. The team should approach the complaint with an open mind and try to analyze whether such mistake could have occurred in their organization. It should recommend to the top management to take corrective action immediately without waiting for the final findings of the team. The team should try to have brainstorming session to find out the root cause of the problems. Therefore they could recommend appropriate solutions to the top management.

Complaint recovery process

Each organization has to establish a process for

receiving complaints, processing them, communicating to costumer and resolving the issue. This process is aimed at satisfying customers, resolving problems and take preventive actions. The resolution should satisfy the customer and also the analysis of the complaint should bring out clearly the root cause of the problem. The complaints should be ranked according to severity and appropriate priority should be given for resolving them.

Mortality and morbidity meetings

Definition:
A routine, structured forum for the open

examination and review of cases which have led to illness or death of a patient, in order to collectively learn from these events and to improve patient management and quality of care.

An effective MMR should:

identify key events resulting in adverse patient outcomes foster open and honest discussion of those events identify and disseminate information and insights about

patient care that are drawn from individual and collective experience reinforce system level and individual accountability for providing high quality care create a forum which supports open and honest discussion through the provision of a just, patient centered culture contribute to clinical governance processes.

Purpose
MMRs are primarily a tool for examining opportunities for

system level improvement. The purpose of MMRs is not to assess an individual senior doctors care per se, but to provide a forum or learning opportunity to assist system level improvement, based around the identification and discussion of key issues. understanding of clinical practice at the individual senior doctor or clinical team level, but only when conducted in a consistent, reproducible fashion within a just culture which emphasises and supports clinical excellence through open discussion of key patient care issues.

MMRs may provide information to support a greater

Design Principles for Successful Use of the Tool

MMRs are most valuable as a driver of culture change and clinical improvement when there is: a focus on patient care support and leadership by senior medical staff this ensures appropriate peer input and engagement a multidisciplinary approach with input from all staff involved a consistent and reproducible approach organizational support a clear link to organizational clinical governance processes.

a safe and supportive environment

a structured process, including a framework to investigate underlying contributing factors a detailed feedback and follow up program.

An example of a structured process is the Learning from a defect tool developed to enhance MMRs (Pronovost, Holzmueller & Martinez 2006). The tool is described as a shorter version of root cause analysis (RCA) and is intended to improve safety and teamwork culture, by providing senior doctors with a structured framework to:

identify what happened with regards to the adverse event

determine why the adverse event happened implement interventions to reduce the probability of its re-occurrence enable those involved to evaluate the effectiveness of those interventions.

How to undertake MMR meetings

MMRs should be undertaken at a level which ensures that peer input is appropriate and available. For smaller hospitals this may be at a whole of hospital or even an interhospital level. For larger hospitals, this may be at the level of a clinical service, department or unit. In general, the approach to developing MMR should mirror the organizational approach to AOS/TCNR, as the AOS/TCNR program should identify most of the cases to be discussed in a MMR setting. 1. MMRs should occur onsite. 2. MMRs should be chaired by a senior doctor who takes responsibility for the process and in doing so has an ability to engage with clinical colleagues and to facilitate change at the patient care level. This may be the medical director, unit/department head or delegate.

3. Where possible, MMRs should be regularly scheduled to maximise participation. 4. Members of other clinical disciplines and junior medical staff should attend. 5. Cases for discussion should be identified by: AOS/TCNR programs senior doctors raising specific cases referral from other MMR meetings. 6. In order to provide sufficient time for adequate discussion no more than two cases should be discussed per hour, although aggregating cases with similar issues into a block discussion may be appropriate.

7. Senior doctors and other clinicians actively involved in the care of the patient to be discussed must be made aware of the intention to discuss the case at least 72 hours prior to the case and must be made aware of the date, time and place of the meeting. If they are unable or unwilling to attend the meeting where the case is to be discussed, the case should be referred to the appropriate medical lead for further investigation or action. Cases must never be discussed in the absence of the senior doctors with primary responsibility for care of the patient.
8. Cases should be presented in verbal format in a de-identified fashion, describing only the facts of the case including any confounding factors. 9. The major issues should be identified during the presentation, with the chair providing further clarification if required.

10. The chair should ensure that following the presentation, the key

discussion points are agreed. These should always include: What went wrong (or right)? How did it go wrong (or right)? Why did it go wrong (or right)? What could we do differently in future? What are the key lessons for the organisation? 11. A consistent approach to problem solving should be used to discuss the case. 12. The chair should ensure that any discussion relates to the facts of the case and not to personal issues. This is not a meeting to attack or openly criticise individuals who have contributed to patient care doing so impedes the development of a just culture. 13. If major performance issues relating to an individual senior doctor become apparent at any stage during the discussion, the chair should immediately halt the discussion and refer the issue to the relevant medical lead (medical director, unit head or equivalent), who should then initiate the organisations usual performance development processes. Discussion around other matters pertaining to the case may continue.

14. At the completion of the discussion, action points should be agreed and prioritised by all present in the meeting. Responses to these issues should be presented at subsequent meetings. 15. Minutes should be kept patient and doctor details should be de-identified. 16. An action list and appropriate accountabilities should be generated and circulated to all participants and to appropriate organisation level clinical governance structures.

Critical risks to consider in using the tool

MMR meetings should be conducted with a view to enquiry for

the purposes of improvement. They must not be perceived as being punitive. It must be safe for all participants.
The major barrier to effective MMRs is the focus on individual

senior doctor rather than a more general, systems approach to issues. This results in a fear of incrimination and recrimination.
Significant problems with an individuals clinical care which are

readily apparent to medical leaders should not be dealt with in an MMR process. Clinical performance issues related to an individual senior doctor would normally be detected through other mechanisms (for example, AOS/TCNR, repeated patient complaints). These issues should be managed using the Partnering for performance framework in line with the organisations performance development and support policy. MMR is not the appropriate forum for this and indeed may be counterproductive.

Limitations for MMRs

administrative issues lack of data procedural concerns includes hindsight and reporting bias, a focus on diagnostic errors, and infrequent occurrence of MMRs educational issues lack of educational/system learning focus.

Sentinel Events and Monitoring

A Sentinel Event is defined by The Joint Commission (TJC) as any

unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient's illness. Sentinel events specifically include loss of a limb or gross motor function, and any event for which a recurrence would carry a risk of a serious adverse outcome. Sentinel events are identified under TJC accreditation policies to help aid in root cause analysis and to assist in development of preventative measures. The Joint Commission tracks events in a database to ensure events are adequately analyzed and undesirable trends or decreases in performance are caught early and mitigated.
The surveillance of sentinel events which has been well under way in

other countries, is an important role of public health. It is an indispensible tool for the prevention of such events and for the promotion of patient safety.

 It is for this reason that the Ministry of Health has

elaborated, with the technical support of Gruppo di lavoro valutazione degli approcci metodologici in tema di rischio clinico", this protocol for monitoring sentinel events with the objective to provide Regions and the Healthcare Trusts an unambiguous method of surveillance and management to be applied throughout the national territory, guaranteeing LEA essential levels of assistance.

Sentinel Event List

Procedure performed to wrong patient Surgery performed to wrong part of body (side, organ or part) Erroneous procedure to correct patient Instruments or other material retained in surgical site which requires

successive interventions or ulterior surgery

Transfusion reaction consequent to ABO incompatibility Death, coma or severe harm originating from error in pharmacologic

therapy
Maternal death or severe illness correlated to labour and/or

childbirth
Death or permanent disability in healthy newborn weighing > 2500

grams not correlated to congenital illness

Death or severe bodily harm due to patient fall Suicide or attempted suicide by patient in hospital Violence performed on patients

 Acts of violence resulting in injury to healthcare workers Death or grievous bodily harm consequent to a

malfunction with the transport system (intra-hospital and extra-hospital) Death or severe injury consequent to the incorrect attribution of a triage code by emergency services department or by (centrale operative 118) emergency telephone call centre Sudden death or injury consequent to surgery All other adverse events that cause death or grievous bodily harm to patient

Credentialing and Privileging

Rationale
The institutes and centers appoint medical staff members (1) to

further their medical or surgical specialty/subspecialty training in a research setting or (2) to conduct clinical research after having completed training. For the candidates initial appointment, following nomination for medical staff membership by senior faculty of the NIH institute or center, the Clinical Center follows established procedures for verifying completion of medical education, postgraduate training, and licensure, and for identification of possible adverse occurrences at other institutions.
The nomination process for initial credentialing generally requests

clinical privileges commensurate with the potential medical staff members training and anticipated Clinical Center activities. Factors to support credentialing decisionmaking include verification of competence from the applicants prior program director, letters of recommendation, and a search, using national databases, for adverse occurrences during previous medical staff appointments.

 Following initial credentialing and awarding of privileges

to a medical staff member, the supervisory senior medical staff should be vigilant to assure the medical staff members sustained cognitive and technical competence.

Standard

The branch chiefs or section heads of the NIH institutes and centers will use a Clinical Competency Assessment form to document continued competence at the time of recredentialing. The practitioners clinical director must review this form before its submission to the Credentials Committee.
Objective data to be considered may include inpatient and outpatient activity, numbers of procedures performed, complications associated with procedures, participation in quality assurance meetings, professional education (including attendance at IC or Clinical Center grand rounds presentations), and adherence to clinical administrative requirements (e.g., completion and timeliness of procedure notes, consult notes, and admission/transfer of service/discharge notes). If senior staff determine that a medical staff member under consideration for recredentialing needs monitoring or specialized training elsewhere, this indication must accompany the request for new privileges. We encourage supervisory medical staff to review the Professional Practice Evaluation form with practitioners at intervals between credentialing cycles because these reviews can be a valuable mentoring and performance improvement tool

Variance Reporting and Analysis

Variance analysis is the rubric for comparing actual results with plan whether budget or rolling forecasts. There are three types: Traditional variance analysis It works like this: compare actual amounts at the natural class account level to budget or forecast with a column that computes the dollar or percentage variance. Alight does this for all combinations of time periods month, year to date, full year, etc. Not so traditional variance analysis It should work like this, but usually doesn't: compare actual units, rates and amounts at the line item level to budget or forecast with columns that compute variances for all three data types. Alight does this. Causal analysis Where actual and plan line items include units and rate as well as dollar amount, you may compute a causal analysis variance. This variance type calculates how much of the total dollar variance is due to higher or lower units (the volume impact) or a higher or lower price/cost (the rate impact). Alight automatically computes volume and rate impacts for all revenue, expense, headcount and balance sheet line items that incorporate units and rates.

 Variance analysis reports help quantify and identify the

difference in actual expenditures or revenues between fiscal years and quarters. In some cases, variance is calculated by comparing budget to actuals and in others the comparison is based solely on actuals. their company's performance by comparing one set of figures to another. This usually means comparing a planned amount to an actual amount. close they've come to hitting forecasted sales targets or to see if they've met their budgetary goals. overspending, and under spending.

A variance report is a way for business executives to gauge

Companies frequently use variance reports to analyze how

A well-rounded budget variance report will address trends,

 Trends: In challenging economic times, it is important for

businesses to carefully monitor overspending and underspending. If there is a trend towards either, then the entire budget may need to be revisited. A graphic depiction of trends should reveal to the analyst if there are minor budget lapses or if there is a more serious problem. to the project, to other projects, and to the company if resources are scarce.

Overspending: Overspending: this can pose a serious threat

Under Spending: Under spending may indicate a problem in

quality control (i.e., the manufacturing process may be cutting corners) if the project budget was correct at first. It can be as serious a problem as overspending.

Lessons Learned

We have learned the difference between QA and QI, the former being an evaluation system and quality enforcer, and the latter being a problem solver and systems improver. We have learned that QI is important because it further enhances the services rendered to people through meticulous research We have learned of the various ways to improve the quality in a health care setting; it is not just an individual role but a collective effort to achieve quality improvement. We have learned what utilization review is all about: it focuses on trends and sees which decisions best fit situations. We have learned that utilization review is important because it provides the best and fair decisions to clients seeking health care. We have learned that a nurse assess people in utilization review and decides what care/decision be mandated upon them as best seen in a nurse working for an insurance company.

 We were able to identify the purposes of clinical practice

guidelines. We were able to define clinical pathways. We were able to identify the types of variance analysis. We have enumerated the differences between audit and research. Weve learned that complaints analysis is important in planning for satisfying the customers. Therefore, organizations should be always receptive to complaints. Weve learned that morbidity/mortality meetings tend is a routine, structured forum for the open examination and review of cases which have led to illness or death of a patient, in order to collectively learn from these events and to improve patient management and quality of care.

BIBLIOGRAPHY

Berman, Snyder, Kozier, Erb. (2008). Fundamentals of Nursing. Implementing and Evaluating., pp. 239-240 Berman, Snyder, Kozier, Erb. (2008). Fundamentals of Nursing. Nursing Informatics. p. 154 Debra A. Draper, Laurie E. Felland, Allison Liebhaber, Lori Melichar. The Role of Nurses in Hospital Quality Improvement. Washington D.C.; HSC Research Brief No. 3 : 2008 http://www.psninc.net/blog/utilization-review/understanding-theutilization-review-process/ 7-6-12 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1026733/ 7-6-2012 http://www.slideshare.net/pradhasrini/clinical-pathways-3610628 7-7-2012 http://www.health.vic.gov.au/clinicalengagement/downloads/pasp mortality_and_morbidity_reviews_case_discussion_meetings.pfd 7-7-2012 http://www.openclinical.org/guidelines.html 7-7-2012

 http://www.cc.nih.gov/ccc/patientcare/standards1.shtml 7-7-2012 http://en.wikipedia.org/wiki/Sentinel_event 7-7-2012

http://www.salute.gov.it/qualita/paginaInternaQualita.jsp?id=1634&

menu=safety&lingua=english 7-7-2012