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In this Nursing 542 session, the focus is on Continuous Quality Improvement (CQI) in healthcare. The chapter covers various objectives, including defining quality, outlining the history of healthcare quality improvement, and explaining different types of medical errors. The role of nurses in quality improvement and recent initiatives to improve healthcare services are also discussed. The session highlights the importance of quality healthcare, consumer expectations, and the history of quality improvement, starting with Florence Nightingale's work. It also explains the role of organizations like the Joint Commission in accrediting healthcare facilities and ensuring quality care. The session concludes by addressing medical care errors and their different classifications. Overall, the session emphasizes the significance of CQI in enhancing patient safety and healthcare quality. Hey, everyone, and welcome back to Nursing 542, Christian Leadership for the ADN. So today we're gonna be going over chapter 18, so let's go ahead and jump right into that. And that chapter is Continuous Quality Improvement, Enhancing Patient Safety and Healthcare Quality. Continuous Quality Improvement, or CQI, in the healthcare is pivotal for enhancing patient safety and overall quality of care. This chapter dives into the multifaceted approaches of CQI, emphasizing its significance to the healthcare industry. So let's go ahead and take a look at some of our objectives for today. There's quite a few of them, as this is a content-heavy topic, overviewing the basics and the history of healthcare quality. So let's go ahead and take a look at those here. First one, we're gonna define the term quality. We're gonna go ahead and outline the history and evolution of quality improvement in healthcare. We're gonna compare and contrast the four different types of medical errors that may occur during healthcare delivery. We're gonna compare and contrast the quality assurance, quality control, total quality management, and continuous quality improvement. Try saying that five times fast. We're gonna explain the PDCA, or Plan, Do, Check, Act cycle used in quality improvement programs, identify internal and external customers in healthcare settings, and describe the process of benchmarking. Specific, we're gonna specify core measurements and nursing-sensitive outcomes for client care delivery. We're gonna outline the professional nurse's role in quality improvement, and we're going to explain how recent quality and safety initiatives improve the quality of healthcare services. All right, so a quick introduction here. Defining quality healthcare, quality healthcare is characterized as safe, timely, efficient, equitable, effective, and client-centered. Number two, consumer expectations. We expect caring providers, timely services, technical competence, error-free care, accurate billing, and improved healthcare status, which doesn't seem like a lot to ask, but it's a lot to deliver. From the nurse's perspective, nurses view quality indicators such as adequate nurse-client ratios, sufficient time with clients, and easy access to resources. All right, let's take a look at a quick overview of some history. We should all be familiar with Florence Nightingale. She can be considered the first nurse who engaged in continuous quality improvement activities. During the Crimean War, she worked at the barrack hospital, and her work demonstrated the effects of quality nursing care on wounded and frail soldiers. Prior to her arrival, the mortality rate at the barrack hospital was 60%. By the time she left that hospital, it had fallen to a fraction, just over 1%. She kept detailed records that included statistics about the effects of cleanliness, good nutrition, and fresh air on the survival of the soldiers. Her diligent attention to detailed records and continuous analysis of the data provided evidence that nursing care could reduce mortality. In 1855, her interventions resulted in a reduced mortality from 33% in January through March to just an astounding 2% by July through September of that same year. So we're talking about a 31% change there, 31% decrease in the mortality rate. So fast forward, let's go to 1913. A group of surgeons concerned about the quality of care in American hospitals formed the American College of Surgeons. By 1918, their work led to the implementation of hospital standardized programs, or HSPs, which involved into the accreditation process for hospitals. So this is how we get accredited originally. The HSP developed minimum standards for physician credentialing, hospital privileges, and methods to evaluate physician care and medical equipment. To create a standardized system for record keeping, the HSP established the first known standards for healthcare recipient medical records. So our first medical records came out. Along with developing standards, hospitals engaging in HSP conducted mortality and morbidity conferences to see what hospitals, what hospital associated factors contributed to death and permanent disability. By the 1920, tumor registries became a standard of practice so that more data regarding cancer could be collected and recorded. In 1951, the HSP evolved into what is known as the Joint Commission of Accreditation of Hospitals. You guys will know this as JACO as we get through this. This is where it's starting in 1951. They are a private non-profit voluntary agency that ascertained a hospital met the American College of Surgeons standards. So they're enforcing those standards. If you have JACO, that means that you have adhered to those standards. Concerned about the quality of care received by subscribers during hospitalization, the Blue Cross Insurance started requiring that participating hospitals be accredited by JCAH, again JACO, by the early 1970s. Eventually, JCAH accreditation became a way for hospitals to prove they met the quality care requirements to receive Medicare program payouts. By the mid-1970s, JCAH accreditation automatically guaranteed Medicare reimbursement. Pretty significant. The other option for hospitals was to design their own system for meeting all Medicare program quality of care requirements, which probably was a daunting process that no one wanted to do. Hospitals began to develop healthcare systems that included primary care services for customers in the mid-1980s. Accreditation by JCAH meant that each healthcare providing organization demonstrated effective, high quality services. JCAH accreditation became a requirement for many healthcare organizations to qualify for insurance company reimbursement. All right, so kind of a big deal there. In addition to ensuring healthcare quality, the Joint Commission on Accreditation of Healthcare Organizations, now known as JACO, accreditation standards addressed efficiency of healthcare interventions and appropriateness of those services that they delivered. Let's take a look at some of the aspects of that. So aspects for quality services included, and still include availability of necessary healthcare intervention, timeliness of the service, effectiveness of healthcare interventions, continuity of healthcare services across various healthcare settings, safety of clients and others, effectiveness of provided care and services, and respect given to consumers and caring with which services are rendered. In 2003, JACO recognized the impact of nursing care on client quality outcomes and established a Nursing Advisory Council to address evolving nursing and client care issues. Today, the Nursing Advisory Council has a nursing organization, a chief nursing officer, staff nurse, magnet hospital research, academic, and nurse leader representation. The Joint Commission also collaborates with the American Nurses Association and has posted ANA material on JACO's website. So, JACO, known as the Joint Commission since 2007, accredits approximately 21,000 healthcare organizations that in general, that include general, pediatric, long-term, acute, rehab, and specialty hospitals, home health agencies, laboratories, and extended care and outpatient facilities as well. So TJC uses standards, performance, outcomes, and consumer perceptions of rendered services as a criteria for accreditation. When an organization has earned accreditation from TJC, it means that it has met all the standards required for delivering high-quality care. So, let's go ahead and take a look at some of the facts leading to the development of these programs. Most healthcare consumers assume that healthcare providers and organizations will keep them safe. However, according to a 2016 study from John Hopkins University, safety experts have estimated that more than 25, or 250,000 Americans died as a result from a medical care error in 2013. So that's a quarter million people. Currently, the reporting of this care is voluntary and there is no centralized system for tracking them in the United States. Deaths from medical errors, however, are extremely hard to track as they do not appear on the death certificates as the cause of death. So, let's be honest. Probably all manufacturing companies and the travel industry would likely be out of business if they had as many errors as those that occur in the healthcare arena. So, let's go ahead and take a look at some of the definitions of medical errors to set up the rest of the conversation. All right, so medical care errors are usually unintentional. Outcomes of medical care errors may be no adversity, reversible problems, temporary or permanent disability, or even worst case scenario, death. When care interventions are either overlooked or not performed, an error of omission has occurred. For example, the prescribing provider forgot to order a medication from the standardized guideline for disease management or a nurse overlooked the delivery of the treatment. Another error is error of commission. It happens when the provider performs the right action, but they do so improperly. Let's go ahead and take a look at an example of that. Maybe if a surgeon nicks a colon when they're removing an ovary and the client develops an infection and the nurse breaks, or a nurse breaks aseptic technique when inserting an indwelling catheter and causes a UTI infection leading to urosepsis. Equipment failures fall into classification of medical care errors as well. Another error, error of communication occurs when there is miscommunication between and among healthcare team members or between the client and the healthcare team members. A diagnostic error happens when there is a misdiagnosed or a delayed diagnosed resulting in a prolonged problem. For example, because a person with severe respiratory symptom tested negative for COVID-19, the healthcare provider may treat the client for pneumonia. However, if the test provided a false negative, the person could spread COVID-19 throughout the community. And we have one more here, contextual errors. These errors occur when members of the healthcare team fail to identify unique situations in the life of a client that might hamper the proper followup care and treatment. For example, an older adult who is discharged from the hospital into the care of a partner, but both have impaired cognitive skills. Hospital nurses today care for more acutely ill patients than in the past, requiring nurses to be able to keep up their thinking rapidly, keep a mental list of multiple tasks to accomplish, document all cares of activity, and supervise unlicensed care providers. And as you guys know, working in the field, it's quite a bit of things to do when you're floor nursing. So according to McMullen and colleagues, nurses tend to make more errors of omission than other forms of errors. There are multiple reasons why nurses commit errors. When recent research findings are compared with findings from many years ago, inadequate staffing, miscommunication, lack of necessary equipment and supplies, ineffective teamwork, and complex work processes remain the key precipitating factors according to the American Nurses Association. All right, let's go ahead and take a look at some of the quality assurance programs out there. Some of these you're probably familiar with. So just reading down our list here, we have mortality rates by department, hospital-acquired infections, client falls, adverse drug reactions, unplanned returns to surgery, hospital-incurred trauma. All right, and let's talk a little bit about quality assurance programs. The quality assurance programs became part of the hospital accreditation process in the 1970s. Quality assurance, or QA, is defined as the planned systemic process for gathering evidence to provide confidence that a system is meeting internal or external standards. The process involves evidence collected retrospectively or after the hospital care is delivered. In contrast, quality control is an internal process that compares the performance levels of a system against the internal standards or benchmarking, which is a predetermined performance goal. People who are closest to and responsible for work implementation should continuously assess the quality of work process and outcome. So the TJC standards require that healthcare organizations, especially hospitals, regularly review the following data as a part of their QA program. So here's a list here. Mortality rates by department or service, hospital-acquired infections, client falls, adverse drug reactions, unplanned returns to surgery, and hospital-incurred trauma, those things that we looked at earlier. QA programs examine client outcomes retrospectively, again. QA also includes the planning, operational, and strategic plans for an organization to compare and contrast performance with current performance, including communications of standards, identifying key indicators for mentoring compliance to standards, as well as assessing the compliance to the standards. Because it's punitive in nature, because of its punitive nature toward individual healthcare providers, a reactive approach to errors QA has become a losing popularity. All right, so let's go ahead and move on to slide seven here. So total quality management and continuous quality improvement. So let's go ahead and take a look at the terms here. The term total quality management and continuous quality improvement, CQI, are sometimes used synonymously in the business and healthcare world or related literature. Both outline structures and processes for improving healthcare delivery. However, total quality management, TQM, uses fundamentals based on scientific management, emphasizing fact-based management, and management becoming the master of all facts by collecting information. After seeking employee input into work processes, methods and decisions for improvement, management assumes responsibility for making the final decision for determining which work processes and methods to implement. Management also consistently implements work processes and methods so that the variance is reduced. Variance in work processes and methods are linked to inferior quality of products and service delivery. In light of the concerns for client health and safety, for client safety and healthcare quality, the IOM conducted a series of quality studies known as the Institute of Medicine Quality Chasm Series. The findings of the first study to ERR is human becoming a safer health system, which came out in the year 2000, shocked many healthcare consumers and providers. The Landmark Study with findings derived from the analysis of aggregate data estimated that between 44,000 and 98,000 people die annually as a result of preventable medical errors. Remember, this is in 2000, all right? So not in the far past here. The report also concluded that medical errors in healthcare settings were the leading cause of unexpected deaths in the United States more than any other country in the world. And any other form of sudden unexpected deaths, including motor vehicle accidents. The report identified ineffective communication as a root cause of 65% of errors that resulted in death or permanent disability. As a result of the report, the US Congress appropriated funds starting the fiscal year of 2001 to 2002 to establish the patient safety network within the agency, the healthcare, research, and quality. That would go, and that would also establish the national safety goals to track progress in safety improvement and fund research in preventing healthcare-related errors. All right, so since then, more studies have been released on this. There's quite a few of those outlined inside your chapter if you guys wanna take a look at those. In response to the IOM Future of Nursing Report, the Robert Wood Johnson Foundation of the American Association of Retired Persons collaborated with the nursing profession to develop a nursing campaign for action to design and implement programs to achieve the four key messages in the report. In the action campaign, each state formed a state nursing coalition in order to prevent duplicative efforts for each key message. The Future of Nursing Campaign for Action in 2021 reported that the following progress of the four messages 10 years after the report was published. Let's go ahead and take a look at three of those. All right, the first one here we have is practice to the full extent. So nurses should practice to the full extent of their education and training. In 2010, only five states permitted the independent practice for APRNs. If you're not familiar with that term, that's advanced practice registered to nurse. In 2020, nine states now permit the full scope of independent practice for RNs. During COVID-19 pandemic, seven states actually granted temporary full scope of independent practice for APRNs as well, just as an interesting side note. In 2010, 16 states allowed for APRNs to have full prescriptive authority, whereas in 2018, APRNs enjoyed a full prescriptive authority in 23 states and the District of Columbia. That brings us to level two here, higher education. Nurses should achieve higher levels of education and training throughout an improved educational system that promotes seamless academic progression. And just a couple facts here. The number of practicing RNs with a Bachelor's of Science in Nursing rose from 59% in 2010 to 2019, and the number of RNs with doctorates increased from 11,589 to 37,852 from 2010 to 2019, so quite a few there. Message number three, nurses should be full partners with physicians and other healthcare professionals in redesigning healthcare in the United States. At the top-ranked nursing schools by the US News and World Report, the number of graduate clinical nursing courses that required collaboration with other graduate student healthcare teams rose from six to 15 from 2010 to 2019. All right, the Center for Workforce Analysis reported that 98% of graduate nursing programs provided opportunities for interprofessional education during 2018 to 2019 academic year, something that at CVU we partake in this as well. Progress towards meeting the recommendations of the IOM quality chasm have been slow, however. Brady reported that from 2010 to 2013 with the implementation of comprehensive unit-based safety programs and TeamSTEPPS, there were 1.3 million fewer hospital-associated complications, a 17% decline, 50,000 lives were saved, and an estimated 12 billion in healthcare expenditures avoided. All right, so let's switch gears a little bit and go ahead and talk about NQF and QSIN. Hopefully you guys are familiar with both of those terms. I feel like everybody's pretty much heard of QSIN, so. The NQF National Quality Forum was established in 1999 as a nonprofit, private, nonpartisan, membership-based organization that works to catalyze improvements in healthcare. The NQF is interested in improving the quality, effectiveness, and efficiency of healthcare delivery in the United States. Its mission is to be the trusted voice driving measurable healthcare improvements. The NQF sets performance standards for the healthcare and establishes routine measures of quality outcomes that have been determined by the consensus of individuals involved in healthcare delivery represented by specialty councils, those being consumers, healthcare plans, health professionals, public and community healthcare providers, suppliers, and industries. Federal, state, and private organizations use NQF-endorsed measures to evaluate performance of healthcare facilities and share this information with consumers. Participating members have access to a dashboard that displays collected data on the key performance indicators of delivery of high-quality healthcare. Something else to mention before we go moving on here. Many healthcare organizations have adopted a just culture for managing errors when they occur. Such a culture emphasizes the work processes rather than the people are usually the cause of the mistakes in the healthcare delivery system. So according to just culture approach, there are two main categories of failure and the levels have differing remedies. The first failure level is that of unintentional harm when an unintended result occurs typically as a result of ambiguous work processes or systems. In this case, focus is placed on the system and how it might be improved. The second failure is the provider carelessness or at-risk behavior such as inattentiveness to details that resulted in an error. The provider received counseling and education about how to avoid repeating the same mistake. The next two levels require some form of punishment because of the severity of their nature. A level three situation includes recklessness which is the complete disregard for established work process or norms resulting in a care error such as a healthcare provider coming into work under the influence of alcohol. The fourth level arises when providers simply refuse to follow standards and procedures or show flagrant disregard for organizational authorities. The last two levels typically result in either a suspension or a suspension form, duty or cessation of employment. The CMS has moved to value-based purchasing. So let's talk a little bit about CMS. CMS has moved to value-based purchasing. Once the industry began looking for ways to provide the best possible health insurance coverage for employees, VBP represented a shift from reimbursement based on fee for service and high volume to reimbursement for the quality of care received in inpatient hospitals. Hospitals received incentive payments for achieving optimal client outcomes. Hospital participants were to achieve error reduction or elimination, adoption of best practice standards that are based on sound evidence, development or processes to enhance client experiences, improved transparency of care and quality for consumers and providers, and increased efficiency to reduce the cost of healthcare delivery. Hospitals receive a score of achievement needing improvement in the following areas. Mortality and complications, hospital acquired infections, client safety, client experience, process, and efficiency and cost reduction. Hospitals receive payments based on how well they perform compared to each other and improved performance compared to a baseline measurement. All right, so let's talk a little bit about QSIN here. So starting in 1995, several annual invitation Dartmouth Summer Symposia were led by Paul Baltadin, a pediatrician who was concerned about the quality of healthcare in the United States. Meeting participants included physicians, nurses, hospital administrators, and other educators who referred to themselves as an interprofessional community of educators devoted to building knowledge for leading improvement in healthcare. Using basic principles of QI, including identification of ways to improve, development of an action plan, implementing the plan, measuring plan results, comparing results with baseline data, and determining the effectiveness of the plan, the participants designed a program to improve safety and quality of education for healthcare professions, especially nursing. So the Robert Wood Foundation agreed to fund the project, which would start by educating the faculty on the quality and safety goals outlined in transforming care at the bedside. This has become known as quality and safety education for nurses, which as we all know is QSIN. So starting in 2005 and ending in 2015, the project participants identified key knowledge, skills, and attitudes or competencies for nurses in order to continuously improve and enhance the quality and safety of healthcare delivery. The following areas were identified as competencies, patient-centered care, teamwork and collaboration, evidence-based practice, and quality improvements, safeties, and informatics. The program was developed and implemented across the four phases. With each phase, more nurses and faculty become involved. The competencies were empirically tested, teaching methods were developed, learning outcomes were assessed, and interprofessional education strategies were developed. They also established a website for sharing their teaching strategies for QSIN competencies. QSIN continues its work and it publishes a monthly newsletter that highlights its current projects. The QSIN website also offers resources to professional nurses, professional nursing programs for integrating the competencies into courses and curriculum. Resources can also be found, be used for interprofessional and nursing continued education programs. All right. So let's go ahead and take a look at a few of the approaches to quality improvement. All right, so here we have number one, W. Edwards Deming. He's one of the leading figures in the quality improvement methodologies. Number two, we have Joseph Duran. He was a key contributor to the quality of management practices. And three, we have Philip Crosby, known for his work on quality improvement and cost of quality. All right, so let's talk a little bit about Deming here. He was a physicist, mathematician, and engineer who was responsible for post-war construction in Japan. In 1950, he presented a quality management workshop that emphasized the importance of statistical control for managers. To maintain a competitive edge, Deming proposed that dedication to quality and productivity was essential. He suggested that errors increased and productivity declined as a result of flawed work processes rather than individual actions. He believed that the productivity and quality would improve when workers became empowered to make decisions about work processes. All right, so let's go ahead and take a look at the Deming cycle. This is the cycle that Deming made here. So first one we have is the plan, do, check, act, or PDCA cycle. All right, so we're understanding the implementation of the PDCA cycle is essential for quality improvement programs. Let's talk a little bit about that cycle there. Deming developed this cycle to improve quality. The cycle is a continuous loop consisting of four steps, plan, do, check, and act. Using the Deming cycle, organizations plan what improvements need to be made by implementing the plan, check the results of the plan implementation using statistical data, and act by correcting the work processes to improve the quality of the services or products. All right, so I'm gonna go ahead and switch over to our other slide here real quick, and you can see how this cycle goes in a circle here. And this thing is completely continuous. This isn't just a single one-time thing around the block. You continuously have this cycle going in the background. All right, Deming also emphasized that a successful QI program requires total commitment and accountability from all workers, including management. So really need some buy-in here. He created 14 points that must be applied for the successful QI processes. So those are in box, let's see, in your book in box 18.2. All right, so you guys can check that out there. So Deming provided businesses with an innovative approach. He outlined strategies for success that empowered workers. In addition, his obstacles warned about the potential catastrophic effects arising from failure to develop strategic plans, relying on technology rather than people to solve problems and generating excuses for suboptimal performance. If Deming's principles are applied to clinical nursing practice, QI efforts would be made to streamline work processes related to direct client care. For example, nurses would not be blamed if errors occurred while taking care of clients. Each error that occurred would be analyzed fully to determine all contributing factors. Work processes would be changed to prevent the errors reoccurrence. Nurses would be empowered to make changes in clinical policies and procedures, as well as assume control over their clinical practice environments. So in addition, Deming included seven deadly diseases that could derail any QI process. So let's go ahead and take a look at those. All right, first one we have here is the lack of consistency of purpose. Everyone working towards a different goal without a single strategic plan to ensure organizational survival. Number two, the emphasis on short-term profits. Quality and productivity may decline if quarterly goals are met or exceeded, which may result in workers and managers scaling back their efforts. Evaluations by performance, merit rating or annual performance reviews. This sets up a competitive environment with potential for destroying teamwork, instilling rivalry, creating despondency, and encouraging management upward mobility. All right, number four, mobility of management away from production or service. Management must understand the work and complete changes for improved productivity and quality, which means managers must be on the job long enough to accomplish these tasks. Let's go ahead and move to our next slide here. So number five, running a company solely on visible figures. The effects of a satisfied or dissatisfied customers remain unknown. And number six, excessive medical costs reveal potential problems within the work environment or no time for employees to engage in health promotion activities. Number seven, excessive cost of warranty fueled by lawyers working for contingency fees. So high losses reveal that inferior goods or services are being provided to customers. All right, and now let's go ahead and take a look at Joseph Duran. All right, he's another prominent figure here. So like Deming, management consultant and engineer, Joseph Duran stressed the importance of careful planning to generate product quality. In 1945, Duran took his concepts to Japan where he used statistical quality control as a management tool. He created the Duran Trilogy consisting of quality planning, quality control, and QI. Quality planning consists of identifying specific customers and their needs and developing products to meet the customer needs, developing processes to produce product features and transferring production plans and product features to operating forces. Quality control consists of evaluating actual performance, comparing it with the product goals and acting on the difference. QI consists of establishing an infrastructure, identifying specific improvement projects, establishing project teams and providing improvement teams with resources, training, education, and motivation. The QI teams work to diagnose the cause of inferior quality, propose and stimulate remedies to identify causes and establish control systems to maintain the gains. So in 1989, Duran also differentiated the quality circles from the QI project teams. Quality circles serve primarily to improve human relationships and secondary to improve quality. They usually occur within a single department where members volunteer to tackle many QI projects, managers and workers hold equal status in quality circles. In contrast, QI project team members, a team membership crosses departmental boundaries. It has a primary mission of improving quality, is run by a manager or the professional and disbands once the project ends. Duran outlined eight factors to distinguish institutions that have improved quality and reduced quality related to cost. Let's take a look at them here. Number one, upper managers lead the quality processes and serve on quality councils as guides. Number two, internal customers, people working within the organization and external customers, people outside the organization receiving products or services are considered as QI processes are applied to businesses and usual operation processes. Number three, senior managers are given clear responsibility to adopt mandated annual QI with a defined infrastructure that identifies opportunities for improvement and they are held accountable for making the improvements. Number four, managers involve everyone who affects the plan in the QI process. All right, next slide here. Number five, managers use modern quality methodology rather than empirical methods in quality planning. Number six, senior managers train all management teams, management team members in quality planning, quality control and QI. Number seven, managers train all workers in how to participate actively in QI. Number eight, QI becomes a major feature in the strategic planning process. All right, so a little bit more. Duran's major contributions to QI include the Duran Trilogy that distinguishes the concept of quality planning, quality control and QI. He adopted the Pareto Principle named after Vilfredo Pareto, a 17th century Italian economist. The Pareto Principle asserts that about 80% of consequences resulted from 20% of the causes, the vital few. By addressing the vital few, Duran noted larger impacts could have been made where identifying areas for quality planning, control and improvement. Duran incorporated the Pareto into his process. All right, and let's go ahead and take a look at Philip Crosby here as well. So another prominent figure. So he's a businessman, about 1979. He asserted that quality is free, but time, manpower and resources cost money. Crosby advocated for doing things right the first time, stating that quality saves money, thereby increasing profits. He defined quality as conformance to requirements. Crosby emphasized that, Crosby emphasizes on doing things right the first time, particularly resonates in the healthcare delivery because healthcare professionals usually only get one chance to deliver effective, safe client care. An example of this, the nurse has only one chance to administer the right medication to the client. He proposed that the organizations needed to create climates in which attitudes and controls make error prevention impossible. So, like Deming, Crosby saw the need for all within an organization to be committed to the QI process. However, Crosby believed that management needs to understand their personal roles and implying quality and engaging employees in the vision of the company. Crosby identified 14 essential elements of a quality management program. Let's go ahead and take a look at those. All right, management commitment to the QI process, two, QI teams to oversee actions, three, measurement tools to appropriate, measurement tools appropriate to the specific activities going through the QI process. Number four, consideration of the cost of quality evaluation, so using estimates as needed. Number five, quality awareness promotion from all involved. Number six, corrective action as needed to correct measurement tools and reduce costs associated with the QI process. Number seven, planning for zero deficits. Number eight, supervisory education and training for management at all levels. Number nine, holding a zero deficit today to celebrate the new standard of performance. Number 10, goal determination for individual workers and work teams. Number 11, worker rather than management removal of causes of error after notification. Number 12, recognition of all involved once performance goals are attained. Number 13, quality circle sharing of ideas, experiences, and problems. And finally, number 14, constant repetition of all steps. QI is a continuous, never-ending process, kind of like we talked about with the PCDA. So Crosby's thesis of the importance of doing things right the first time has been recently expanded by Toyota's. Lean operations is a six-sigma design approach to quality management, so it's still something that's put into process today. You guys can read some more about that in your chapter there. All right, let's go ahead and talk a little bit about implementing continuous quality improvement. All right, so standardizing continuous quality improvement, or CQI. CQI may be viewed as an organizational value and process to deliver the best possible goods and services to consumers. CQI works to improve the, constancy in actions where, while meeting and exceeding product and service standards, this requires standardization. All CQI programs focus efforts on four areas. Number one being customer service, both internal and external, like we talked about before. Number two, ways to improve quality, the quality of key work processes. Number three, development and use of quality tools and statistics. And number four, the involvement of people and organizational departments that provide service to the customer. All right, let's talk a little bit about benchmarking here. Benchmarking is the effectiveness of QI initiatives that they rely on institutional benchmarking, a process that compares the performance with a predetermined standard. Some organizations have set a benchmark, a certain score for their goal attainment, that they apply to all departments for performance in customer service delivery. So really what we're looking at is we're just, are we meeting those goals? And we're measuring ourselves against those predetermined goals. Organizational benchmarks are included in company policies, standardized performance evaluation tools, and compare results within the institution and track gains in quality or with similar institutions to determine how well the organization is performing against others. Comparative benchmarks are frequently determined by external agencies in the healthcare industry, such as the CMS or TJC. When performance falls to reach the benchmark, everyone in the organization works together to fix the process, rather than blaming a specific individual. A balance scorecard is a tool that provides useful information about an organization in four areas, financial, customers, internal processes, and organizational learning growth. The balance scorecards are useful in strategic planning and developing quality improvement strategies. Besides having the ability to translate strategy into action, it facilitates translation of strategic vision into a clear and realistic goals and objectives. The balance scorecard collects data on metrics for performance measurement, standardization, and indications to track organizational performance in attaining its goals. Some organizations post periodic charts containing recently collected data in regards to specific initiatives, including those for QI to increase self-awareness of the process. All right, so let's talk a little bit about celebrating the success. So one of Deming's 14 principles of QI is to recognize participants when performance goals are obtained. Responding to the perception in the 1980s that the American manufacturing industry was trailing the Japanese manufacturing injury, Congress enacted the Malcolm Bridge National Quality Improvement Act, with the objective of encouraging American businesses and other organizations to practice effective quality control in the provision of their goods and services. The law was named after the Secretary of Commerce who had been killed in a rodeo accident the year before, that year, and provided funding for recognizing organizations that excel in QI implementation. Only three Malcolm Baldrige National Quality Awards per category, which were manufacturing, small business services, educational, healthcare, and non-profit are given in any year. All right. So the NIST, the National Institute, revises criteria for the awards and presents them annually. The criteria for these 11 core values are systems perspective, visionary leadership, customer, client, and or student-focused excellence, valuing people, organizational learning and agility, focus on success, managing for intervention, managing innovation, management by fact, societal contributions, ethics and transparency, and delivering value and results. The 11 values are embedded in the systemically, excuse me, the 11 values are embedded in the systemic process of strategy, leadership, operations, workforce, customers, measurement, analysis, and knowledge management. All right, so let's go ahead and talk a little bit about using CQI processes in healthcare. All right, so the first thing we have here is we identify improvement areas. So we're looking for ways to streamline work processes for a better healthcare delivery. Number two, we're organizing teams. So we're forming teams to focus on specific work processes. And then number three, we're implementing and maintaining any of those changes that we may have come up with. So implement improvements and improvement and ensure that they are sustained over time. One of the things that often kills a new policy is that it's not implemented over time. All right, so let's go ahead and take a look at our next slide here. Let's talk a little bit about collaborative and evidence-based efforts to improve the quality of healthcare. All right, first thing, the Institute for Healthcare Improvement. In 1986, a group of healthcare providers saw the gap between an ideal and actual healthcare safety and quality. Their efforts to improve healthcare for all people worldwide led to the formation of the IHI in 1991, a nonprofit organization that works collaboratively with professional healthcare teams to establish scientific foundation for improving the quality and safety of healthcare delivery. Using the goals outlined in the IOM, the IHI developed an always event list that captures what is vitally essential to clients and families when they receive healthcare as well as a never events list. A never events list results in a client's death, permanent disability, or severe, intense suffering of any nature. All right, the Leapfrog Group here. So the Leapfrog Group was established in 2000 when 60 businesses came together over the concern about the quality, safety, and affordability of healthcare in the United States. The Leapfrog Group is a not-for-profit watchdog type organization that drives movement by proposing big leaps towards improving the American healthcare system. The Leapfrog Group convenes expert panels representing various members of the interprofessional healthcare team to confirm currently used measures are valid, relevant, meaningful, and actionable for clients, their families, and the healthcare providers. Current expert panels are addressing outpatient surgery, cultures of safety, hand hygiene, the nursing workforce, intensive care unit, physician staffing, computerized physician order entry, barcode, medication administration, inpatient surgery, pediatric care, maternity care, and client and family caregiver standards. So quite a bit going on there. The addition of client and family caregiver standards is aimed at increasing consumer involvement in the process. All right, so next slide, let's go ahead and talk a little bit about professional nursing roles and quality improvement, all right? So three roles here. We have the caregiver, client advocate, and the change agent. So TQM and CQI provides professional nurses with an opportunity to showcase the unique contributions they make to the interdisciplinary healthcare delivery team. Because nurses have always been concerned with the client safety and quality of care, they can assume leadership roles in the TQM-CQI process. Data collection by nurses as a part of routine care delivery sometimes identifies a quality initiative, an area for improvement. In addition to the professional nurse, in addition, the professional nurse serves as a key player in the TQM-CQI processes and strategizes to improve healthcare quality. All right, let's go ahead and take a look at the integrated approach to quality improvement and safety in healthcare. So first, the Institute of Medicine, it plays a significant role in setting healthcare quality and safety standards. Number two, we have the QCIN competencies. It needs to find competencies for nursing education to improve quality and safety. And then we have the joint commission, which is the accreditation standards and safety goals crucial for maintaining a healthcare quality. So just real quick, a little bit of a recap here, a summary of the significance of practice. So number one, professional nurses skills. Nurses use cognitive communication and clinical skills in the multidisciplinary teams to partner with clients. Number two, CQI programs. They seek to improve healthcare delivery processes to enhance safety, effectiveness, and efficiency. And number three, culture of safety and quality. All health team members must be committed to fostering a culture of safety and quality in healthcare. So this really takes everybody to do this. If not everybody's bought in, we're not gonna make that vision. All right, and that brings us to the end of our slide set. Thank you guys so much for listening in and we'll see you guys on the next one. Oh man, that was long.