Identify a patient care case that involves quality and safety
In an effort to continuously improve quality and safety, your manager has asked you to share one example of patient care from your experience. Your and other team members’ submissions will be used to help facilitate an upcoming training.
In a 700- to 875-word case study, address the following:
Identify a patient care case from your own practice experience that involves quality and safety. Note: If you are not practicing or have not practiced, use a case that has received media attention or one from the textbook.
Summarize the situation.
Describe your (or the nurse’s) role in the patient care situation.
Explain the role the patient played in their own quality- or safety-related situation.
Evaluate the relationship between the patient’s care and the outcome.
Identify how the care environment affected the situation, including the nurse or provider, the patient, and the outcome.
Determine whether a quality model was employed. If yes, identify and explain it. If not, identify one that could have improved the situation.
Explain what actions you might take to improve the outcome or prevent an adverse outcome in the future.
Mistakes and accidents can literally be a matter of life and death in certain industries. For instance, workers in healthcare, construction, aerospace, defense, and airline and automobile manufacturing must be highly attuned to eliminating mistakes and accidents. Presently, the healthcare industry is experiencing alarming rates of physician burnout, which research has shown contributes to accidents that affect patient outcomes. In hyper-competitive industries such as manufacturing and retail, minimizing the waste from mistakes is essential to maintaining price competitiveness. For others, mistakes and accidents can negatively impact the customer experience or damage the organization’s reputation.
To address quality and safety issues, many programs adopted by organizations over the years have focused on tasks but overlook the important role that relationships play in these matters. When relationships in the workplace are disconnected, lukewarm, strained, or even toxic, people don’t give their best efforts, they don’t align their behavior with the team’s goals, they don’t communicate or collaborate as well as they should, and they tend not to make the effort to be creative and innovate. These areas of sub-optimal performance sabotage quality and safety.
In general, most managers are intentional about achieving task excellence, but they fail to be intentional in achieving relationship excellence. This failure sabotages task excellence every time. When relationship excellence is present, however, everyone pulls together to make progress. This easy-to-remember model captures the idea:
Task Excellence + Relationship Excellence = Sustainable Superior Performance.
Begin the process with an attitude of humility. Improving quality and safety requires an individual and collective mindset that acknowledges the necessity of day-to-day continuous effort and realizes that losing focus is all that is required for mistakes and accidents to pop up like weeds.
It’s also important to recognize that “lone rangers” can’t do this; teams must work together to maximize quality and safety. Team members encourage one another to be diligent and help each other identify and address blind spots that might be compromising the team’s quality and safety efforts. Together, recognize that your team always needs to improve and that team effort is required to make substantial progress.
Task excellence requires measuring quality and accidents, identifying gaps, seeking ideas and opinions of employees in how to close gaps, implementing the best ideas, and giving credit where credit is due. Relying on your own intuition can result in self-deception. To measure is to be humble and realistic.
Measurement is necessary to bring objectivity, although we should not idolize the resulting metrics. When metrics are unfavorable and there is a gap from the desired number, it should trigger an investigation to understand why the gap exists and what is required to close it. Go to people on the front line closest to the activity, share the data, and sincerely ask for their ideas and opinions on how the team can close the gap. Implement the best ideas and be sure to give credit where it’s due. That simple step of acknowledging the contribution of others, especially if done publicly, will encourage future engagement.
When complex tasks are involved, checklists are necessary. For instance, the airline industry has developed checklists and it has reduced incidents of pilot error. There is a movement to use checklists in healthcare, too. This also requires humility to acknowledge that we can easily forget mundane but essential steps.
Relationship excellence requires creating a Connection Culture, which research has shown reduces accidents by 20-48 percent.
Case in point: Johns Hopkins Hospital developed a checklist for teams performing open heart surgery. One step on the checklist was for each person on the surgical team to introduce himself or herself, describe his or her role, and explain any potential complications to be on the lookout for. Research found that when surgical team members followed these steps, individuals with lower power and status on the team (typically non-physicians) were more likely to speak up if they saw problems, which helped the team perform better and achieve superior patient outcomes. These steps helped create relationship excellence and a “Connection Culture” among the surgical team members.