Newborn and Infant Nursing Reviews
Volume 8, Issue 2 , Pages 59-60, June 2008

Editorial

Article Outline

 

It is with great pleasure that I introduce Liz Drake, RN, MN, CNNP, as Guest Editor for the June 2008 NAINR issue, who has dedicated this entire issue to neonatal quality and safety issues. Her professional position is the Clinical Nurse Specialist of Children's Hospital of Orange County at Mission. Liz is actively engaged in quality improvement in her institution as well as the Vermont Oxford Network (VON) Collaborative.1, 2 A large proportion of patient errors occur in the neonatal population.3, 4, 5 Pediatric patients, especially neonates, are a high-risk vulnerable population. Quality measures specific to pediatrics are being developed by the National Association of Children's Hospitals and Related Institutions, the National Institute for Healthcare Quality, and the American Academy of Pediatrics.6, 7, 8 Our hope is that this issue of NAINR will provide a variety of neonatal quality and safety information for neonatal and pediatric nurses to consider in their own bedside practice.

It has been stated that there are only two kinds of people in health care: those who have harmed a patient and those who will harm a patient.9 Few clinicians, if any, come to work with the intention of performing poorly. The Institute of Medicine report on preventable medical errors and highlight concerns related to patient safety.10 There are multiple institutions and organizations that focus on patient safety and quality, some of which include the Agency for Healthcare Research and Quality,11 Joint Commission on Accreditation of Health Care Organizations,12 Leap Frog Group,13 National Quality Forum,14 National Patient Safety Foundation,15 and the Institute for Safe Medication Practices16 (see Table 1). Countless hours have been invested by health care providers to improve patient safety; yet the Institute of Medicine goals have not been achieved.17

Table 1. Quality and Patient Safety Organizations
OrganizationWebsite
Agency for Healthcare Research and Qualityhttp://www.ahrq.gov
California Nursing Outcomes Coalitionhttp://www.calnoc.org
Centers for Medicare and Medicaid Serviceshttp://www.cms.gov
Consumer Assessment of Healthcare Providers and Systemshttp://www.cahps.ahrq.gov
Institute for Healthcare Improvementhttp://www.ihi.org
JCAHO National Patient Safety Goalshttp://www.jointcommission.org
JCAHO Staffing Effectivenesshttp://www.jointcommission.org
National Database of Nursing Quality Indicatorshttp://www.nursingquality.org
National Quality Forumhttp://www.qualityforum.org
Press Ganeyhttp://www.pressganey.com

Like most of what we do in health care, most care we provide is not based in proven medical evidence.18 The Agency for Healthcare Research and Quality/Stanford Evidence Report No. 43: Making Healthcare Safer demonstrates this lack of evidence.19 In the absence of good evidence, is it better if we practice medicine based on expert consensus or an individual practitioner preference? The Joint Commission on Accreditation of Health Care Organizations favors “expert consensus” and has used this in developing the National Patient Safety Goals.20 The National Patient Safety Goals apply to all accredited organizations and to those seeking accreditation.

The Centers for Medicare and Medicaid Services encourages the use of nationally recognized and tested quality measures. The Centers for Medicare and Medicaid Services Compendium of performance measures contains neonatal specific measures supported by rigorous clinical evidence and widely accepted clinical practices and standards.21 Evidence-based medicine needs to be embedded into health care delivery systems in a “real-time” manner.

Quality improvement has been defined as “the combined and unceasing efforts of everyone-health care professionals, patients and their families, researchers, payers, planners, educators-to make changes that will lead to better patient outcome, better system performance, and better professional development”.22 Quality improvement is estimated to be only 30 percent application of tools and 70 percent working to create a culture of continual change. Accepting quality improvement as a part of the culture is imperative to sustain improvements.

Quality improvement programs can help prevent patient safety issues in health care. Central to the focus on quality is a method of quantifying quality measures. Hospitals are using a variety of tools to measure and improve quality such as Six Sigma, Lean, and Team Stepps.23, 24, 25 Six Sigma focuses on the efficiency of a single process, using standard deviations as a measure to track performance. The methodology Six Sigma follows is called DMAIC for Define, Measure, Analyze, Improve, and Control.23 Lean also follows the DMAIC methodology, but its focus is on the flow of multiple processes as opposed to the efficiency of a single process. Lean is a tool for improving quality, as guided by customer demands and the desire to minimize waste, while also allowing for flexibility.24 Team Stepps is an evidence-based team work system developed by the Department of Defense aimed at optimizing patient outcomes by improving communication and other teamwork skills among health care professionals.25

Measurement of quality provides a basis for a number of improvement initiatives. Voluntary anonymous error reporting is just one way to increase patient safety.26 The Patient Safety and Quality Improvement (PSQI) Act (Public Law No. 109-41) focuses on improving patient safety and reducing adverse patient events. The PSQI has established the first national system for reporting and tracking medical errors anonymously to a nonprofit safety organization.27, 28 The PSQI Act will encourage the reporting of medical errors, which will result in further systematic research. Quality or performance measures are critical to assessing improvements in quality. As health care costs continue to increase, coupled with our complex neonatal population, the topic of quality has garnered national attention. Limiting variations in quality is essential to assure safety and to instill a culture of safety.

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References 

  1. Institute of Health Care Improvement. ihi.org/ihi [Retrieved April 14, 2008].
  2. Vermont Oxford Network. vtoxford.org [Retrieved April 14, 2008].
  3. Forrest CF, Shipman SA, Dougherty D, Miller MR. Outcomes research in pediatric settings: recent trends and future directions. Pediatrics. 2003;111:171–178
  4. Miller MR, Zhan C. Pediatric patient safety in hospitals: a national picture in 2000. Pediatrics. 2004;113:1741–1746
  5. Stavroudis T, Miller M, Lehmann C. Medication errors in neonates. Clin Perinatol. 2008;35(1):141–161
  6. National Association of Children's Hospitals and Related Institutions (NACHRI). Available at: http://www.childrenshospitals.net/AM/Template.cfm?Section=Homepage&Template=/customSource/homepage/homepage.cfm [Retrieved March 2, 2008].
  7. National Institute for Healthcare Quality (NICHQ). Available at: http://www.nichq.org/nichq [Retrieved March 2, 2008].
  8. American Academy of Pediatrics (AAP). Available at: http://www.aap.org [Retrieved March 2, 2008].
  9. Reason J. Beyond the organisational accident: the need for "error wisdom" on the frontline. Qual Saf Health Care. 2004;13(2):28-33.
  10. IOM (Institute of Medicine). Available at: www.iom.edu/ [Retrieved March 2, 2008].
  11. Agency for Healthcare Research and Quality . Integrated delivery system research network: fact sheet. Agency for Healthcare Research and Quality. 2008;Available at: http://www.ahrq.gov/research/idsrn.htm[Retrieved March 2, 2008]
  12. JCAHO (Joint Commission on the Accreditation of Healthcare Organizations) . Available at: http://www.jointcommission.org2008;[Retrieved March 2, 2008]
  13. The Leap-Frog Group. Available at: http://www.leapfroggroup.org2008;[Retrieved March 2, 2008]
  14. The National Quality Forum: safe practices for better healthcare. Available at: http://www.nationalqualityforum.org [Retrieved March 2, 2008].
  15. National Patient Safety Foundations. Available at: http://www.nspf.org [Retrieved March 2, 2008].
  16. Institute for Safe Medication Practices. Medication safety tools and resources. Available at: http://www.ismp.org [Retrieved March 2, 2008].
  17. Brandon D. Sharing our stories. Adv Neonatal Care. 2006;6(3):98–100
  18. Kohn KT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. San Francisco, California (CA): National Academy Press; 1999;
  19. Making health care safer: a critical analysis of patient safety practices. The AHRQ/Stanford evidence report technology Assessment # 43. Available at: www.ahrq.gov/clinic/ptsafety/pdf/ptsafety.pdf [Retrieved March 2, 2008].
  20. National Patient Safety Goals (NSPG) Available at: www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/08_hap_npsgs.htm NACHRI etc [Retrieved March 2, 2008].
  21. Centers for Medicare & Medicaid Services (CMS) , Division of Quality, Evaluation and Health Outcomes . The guide to quality measures: a compendium. Family and Children’s Health Programs Group Center for Medicaid and State Operations. Medicaid and SCHIP Quality Improvement; Vol. 1.0. 2006;
  22. Batalden PB, Davidoff . What is “quality improvement” and how can it transform healthcare?. Qual Saf Health Care. 2007;16(1):2–3
  23. Brussee W. All about Six Sigma. NY (NY): McGraw Hill; 2006;
  24. Womack JP, Jones DT. Lean thinking. NY (NY): Free Press; 2003;
  25. Team Stepps. 2008;Available at: http://dodpatientsafety.usuhs.mil/index.php?name=News&file=article&sid=31[Retrieved March 2, 2008]
  26. Leape LL, Berwick DM. Five years after “to err is human”: what have we learned?. JAMA. 2005;293:2384–2390
  27. The Patient Safety and Quality Improvement Act of 2005. Available at: www.ahcpr.gov/qual/psoact.htm [Retrieved March 2, 2008].
  28. A bill to amend title IX of the Public Health Service Act to provide for the improvement of patient safety and to reduce the incidence of events that adversely affect patient safety. Available at: www.Thomas.loc.gov/cgi-bin/bdquery/z?d109:s.00544 [Retrieved March 2, 2008].

PII: S1527-3369(08)00028-7

doi:10.1053/j.nainr.2008.03.001

Newborn and Infant Nursing Reviews
Volume 8, Issue 2 , Pages 59-60, June 2008

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