NURS 503 Week 5 Healthcare Quality and Safety Paper Example

A Result Nobody Read Is a Safety Event: The Tenets of Healthcare Quality and Safety Applied to Population Screening Programs

Quality and safety are often discussed in hospitals, around falls, infections and medication errors, but the same principles apply to programs that serve whole populations. When a health system expands screening, it creates thousands of results that must reach the right person and lead to action. If they do not, the program can look successful by its own counts while patients are harmed. This paper explains the core tenets of healthcare quality and safety and applies them to one problem in population health: positive HIV screening results that are never acted on.

Defining Quality and Safety

In the framing of the Institute of Medicine (2001), care has quality to the extent that it makes the outcomes people want more likely, for individuals and for whole populations, and matches what current professional knowledge supports. Safety is the dimension of quality concerned with avoiding harm from the care that is meant to help. Nash et al. (2016) place both at the center of population health management, because a program's value depends on whether its care reliably produces better outcomes for the whole group it serves.

The Foundational Reports

The modern safety movement in the United States began with the report To Err Is Human (Institute of Medicine, 2000), which put the yearly toll of medical error in American hospitals somewhere from 44,000 to 98,000 lives and made the case that bad systems, not bad people, produce most errors. Its successor, Crossing the Quality Chasm, described a gap between the care people should receive and the care they actually receive, and called for redesign of health care systems around patients' needs (Institute of Medicine, 2001).

The Tenets

The Six Aims

The Institute of Medicine (2001) set out six aims for improvement, and its six one-word labels, beginning with safe and ending with equitable, have become the vocabulary of American quality work. The aims are useful because they make plain that quality is several things at once, and that those things can pull against each other. A screening program can be efficient, testing many people quickly, while failing to be safe or timely for the few with positive results.

Structure, Process and Outcome

Donabedian (1988) offered a three-part way to judge care: look at its structure, the people, equipment and organization behind it; its process, the activities of clinicians and patients as care unfolds; and its outcome, what happens to patients' health afterward. In his view the three are linked in sequence, so sound resources and organization make sound care more probable, and sound care makes good results more probable. The model helps a team decide what to measure, since outcomes are often delayed or rare while processes can be tracked every week.

Systems Thinking

The central lesson of the safety literature is that errors usually arise from systems, the way tasks, technology, staffing and communication are arranged, rather than from individual failings. Blaming the person nearest to an error leaves the system that produced it intact. A system designed so that a result can go unread will produce unread results no matter how conscientious its staff are.

Just Culture and Reporting

A just culture sorts lapses into three kinds and answers each differently: an honest slip gets a redesigned process and support for the person, a drift into risky shortcuts gets coaching, and a conscious disregard of known danger gets accountability. When staff trust that reporting an error will lead to improvement rather than punishment, they report near misses, which are the best source of information about where a system is weak.

High Reliability

High-reliability organizations, such as aviation and nuclear power, operate complex, hazardous systems with very few failures. They do so by being preoccupied with failure, reluctant to simplify explanations, sensitive to frontline operations, committed to resilience and deferential to expertise. Health care has adopted these ideas to make safe processes routine rather than dependent on heroics.

Applying the Tenets: Unfollowed Screening Results

Failure to follow up test results is a well-documented safety problem. In a systematic review of 19 studies in ambulatory settings, Callen et al. (2012) reported that, depending on the study, anywhere from 6.8% to 62% of laboratory results and 1.0% to 35.7% of imaging results had no documented follow-up, with consequences including missed cancer diagnoses. They also found few guidelines assigning responsibility for notifying patients, and many people involved in each test's management.

An expanding HIV screening program in an emergency department illustrates how the tenets apply. Viewed through the six aims, a program that tests thousands of patients but leaves positive results unacted on fails to be safe, timely and effective, and it is inequitable if patients without phones or stable addresses are the ones lost. Through Donabedian's model, the structure is the screening protocol, the laboratory, the record and the staff; the process is offering the test, resulting it, notifying the patient and linking the patient to care; and the outcome is people with HIV who know their status and are in treatment. Most programs measure only the first process step, the number of tests, which tells little about outcomes.

Systems thinking redirects attention from the emergency physician who ordered the test, and who may never see the patient again, to the design that sent the result to that physician's inbox. Callen et al. (2012) found that the absence of clear responsibility was a common thread, and the fix is structural: route every reactive result to a named role, such as a nurse navigator, track each one in a registry until the patient is linked to care, and report the link rate monthly. A just culture encourages staff to report near misses, such as a result found days late, without fear, so that the gaps can be found before a patient is harmed. High-reliability thinking would treat even one lost positive result as a signal worth investigating rather than an acceptable rate.

Learning From a Near Miss

Quality improvement turns these tenets into action through small, measured tests of change. Suppose a nurse navigator discovers that a reactive result from a Friday night visit was not seen until Tuesday because the alert went to a physician who was off for the weekend. In a just culture, the navigator reports the near miss without fear. The team then maps the process, sees that weekend results have no owner and tests a change, perhaps routing all reactive results to a shared navigator queue that the on-call nurse checks twice a day. In the first turn of a plan, do, study and act sequence, that team measures the time from result to patient contact for the next month and compares it with the month before. If the change works, it becomes standard; if not, the team tries another. Nash et al. (2016) describe this kind of iterative, data-driven improvement as the engine of population health management, because it lets a program learn from its own failures instead of waiting for a sentinel event.

Measuring Quality in a Screening Program

A balanced set of measures follows from Donabedian's model. Structure measures include whether a navigator role exists and whether reactive results route to it automatically. Process measures include the proportion of eligible patients offered testing, the proportion of reactive results with a documented contact within 72 hours and the proportion linked to an HIV care appointment within 30 days. Outcome measures include the proportion of newly diagnosed patients who reach viral suppression within six months. Reviewed together each month, these measures show where the program is losing people.

The Advanced Practice Nurse's Role

Advanced practice nurses are well placed to lead this kind of quality work. They understand clinical processes, often direct programs such as screening and care coordination, and can design the roles and measures described above. They also model the culture that makes safety possible, by reporting their own near misses, asking why a process failed rather than who failed, and supporting staff who raise concerns.

A Christian Perspective on Faithfulness

Jesus taught that "one who is faithful in a very little is also faithful in much" (English Standard Version Bible, 2001/2016, Luke 16:10). Much of safety consists of small, unglamorous tasks done faithfully every time: a result checked, a call made, a follow-up documented. A quality system honors that teaching by making faithfulness in small things easier and more reliable, so that the care of each person does not depend on whether a busy clinician remembers.

Conclusion

The tenets of healthcare quality and safety, the six aims, Donabedian's model, systems thinking, just culture and high reliability, apply as fully to population programs as to hospital units. In screening programs, the most common failure is not the test itself but what happens after it. Assigning responsibility, tracking every result and measuring linkage to care turn a screening program into a population health program.

References

Callen, J. L., Westbrook, J. I., Georgiou, A., & Li, J. (2012). Failure to follow-up test results for ambulatory patients: A systematic review. Journal of General Internal Medicine, 27(10), 1334-1348. https://doi.org/10.1007/s11606-011-1949-5

Donabedian, A. (1988). The quality of care: How can it be assessed? JAMA, 260(12), 1743-1748. https://doi.org/10.1001/jama.1988.03410120089033

English Standard Version Bible. (2016). Crossway. (Original work published 2001)

Institute of Medicine. (2000). To err is human: Building a safer health system. National Academies Press. https://doi.org/10.17226/9728

Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. National Academies Press. https://doi.org/10.17226/10027

Nash, D. B., Fabius, R. J., Skoufalos, A., Clarke, J. L., & Horowitz, M. R. (2016). Population health: Creating a culture of wellness (2nd ed.). Jones & Bartlett Learning.