Introduction to Quality Assurance

Staff members should not overlook the importance of improving the quality by avoiding the never events and reducing deficiencies in the hospital. This calls for and reinforces the necessity of accurate and thorough documentation and sound medical decision making by all the staff.  Every staff should indeed realize that their judgment in realizing early signs of never events and adverse effects is critical to prevention (Byrnes & Fifer, 2010). Maintaining a safe environment for a patient is fundamental. Evidence from research findings on pressure ulcer prevention and treatment, as well as its prevention, is searchable and available for nurses to use in practice. 

What a "Never Event" is

Never events are errors in medical care that are identifiable, preventable and result in serious consequences ,which may indicate a real problem in the safety and credibility of a health care facility. Examples of never events include surgery on the wrong body part, foreign body left in a patient after surgery, mismatched blood transfusion, and major medication error severe (Reid, 2011). Other types of “never events” include environmental events such as electric shock or burn; product or device events such as using contaminated drugs; and criminal events such as sexual assault of a patient. Byrnes & Fifer (2010) further say that severe pressure ulcer acquired in the hospital and preventable post operative deaths are other examples of never events. 

What Never Event Occurred

The meeting discussed the development of pressure ulcers conditions that occurred to five patient’s after their admission into the facility. Kinnaman (2007) noted that pressure ulcers typically occurred within the first two days of hospitalization. The surgeons indicated that inadequate nurse staffing was associated with higher rates of pressure ulcers. They said that staff effectiveness in preventing the occurrence of pressure ulcers is directly related to the availability of enough personnel to examine, assess and take action upon emerging indicators of the patients change in conditions (Byrnes & Fifer, 2010). The surgeons raised the issue that there was a need for adequate staffing to allow enough time with their patients to perform these functions.  

How to Address the Staff Immediately in that Meeting

Prevention efforts of never events require a cultural change that overcomes organizational barriers, and establishing a new culture takes resources and time.  The staff would be informed to adopt a CMS never event program being taught to administrators and clinicians. The staff should ignore the importance of improving the relationship between patient outcomes and increasing reimbursement that is the link between qualities and finance (Kinnaman, 2007).

In the address, the staff should be informed that nowadays, quality variables must be added to the economic definition of care because a healthcare facility that doers not reduce or prevent never events might not get payment for treatment of those occurrences (Milstein, 2009). At the same time, the need for senior administrators to interact with caregivers or quality management functions in ways that would help them to understand the relationship between the delivery of care and poor outcomes will be addressed.

Never events are wasteful. Kinnaman (2007) noted that the nurses should focus on waste reduction and establish a strong infrastructure for quality management. The staff should realize that cost, quality and service are interrelated and that to succeed, facility has to eliminate waste and enhance the quality. In the healthcare facility, quality and economic variables should be linked for optimal performance (Kinnaman, 2007).

The management will enhance the support of quality assurance approaches, looking for clinical competency during surveys and not simply compliance with defined qualifications (Milstein, 2009). The management will ensure that as quality assurance methods continue being implemented to minimize never events performance improvement will be included in the staff’s quality assurance folder.                   

How to Go about Examining the Validity of their Statements

The validity of their statements can be examined through investigating nursing interventions and treatments the nurses provide in the facility. Milstein (2009) noted that through the use of evidence based practice, it would be possible to capture the effectiveness of nursing interventions performed for identified nursing diagnoses. Examining the interventions captured during treatment will ascertain whether or not their statements are valid (Hall, 2007). The evidence based practice outcomes will measure validity of their statements because they are designed to facilitate comparison of outcomes for patients in the healthcare facility. Since evidence based practice provides a systematic way to measure patient focused outcomes, their statements will be valid if they are inline with the results of interventions that prevent never events (Hall, 2007).

The validity of their statements can be measured against the outcomes of patients post intervention to identify the legitimacy of their claims. Hall (2007) noted that the legitimacy of the statements should be compared with the response of the patients who experience never events. The measure can entail a rating from one to show incremental change over time. Measuring the validity of their statements through evidence based practice outcomes can allow the management to follow trends in specific outcomes with the patients they frequently treat (Watson, 2010).

Another method of measuring the validity of their statements is incorporating evidence based treatment into the healthcare facility. This approach ensures that nurses ascribe to evidence-based practice to guide actions, advance practice and achieve outcomes. The validity of their statements will, therefore, be measured against the available outcomes (Kinnaman, 2007). Through the use of evidence based practice information will be incorporated into quality and performance improvement programs which can in turn be used as the benchmark to measure the validity of staff statements. The type of evidence that can be relied on to validate their statements include clinical practice guidelines and systematic reviews (Reid, 2011).

The Methodology Used to Explore the Validity of their Statements.

The cost of pressure ulcers in terms of waste can be measured and tracked over time. The methodology to explore the validity of their statements can be determined by developing a measure, for instance, the numerator is the number of malpractice claims of pressure ulcers and the denominator is the total number of pressure ulcers. If the methodology establishes that there is a high ratio of claims per pressure ulcers, the statements will be invalid (Hall, 2007). This measure will expose flaws in the nursing processes and care procedures. Unless there is a commitment to corrective actions, measuring the validity of their statements will not work. 

The evidence from the ratio per pressure ulcers will enable the management to judge the strength, synthesize the evidence and assess the feasibility of their claims. Byrnes & Fifer (2010) argue that the ratio from ongoing monitoring can be used to identify the need for further refinements in the facility. Evidence aims to enhance objectivity and to decrease variations in care.

The methodology to measure the validity of their statements will also be based on the effectiveness of interventions for older adults at risk for skin breakdown (Watson, 2010). The absence or rate of recurrence of pressure ulcers will be used as the point of reference to legitimize their statements (Reid, 2011). The validity of their statements will, therefore, be measured by the effectiveness of interventions for pressure ulcers that have developed against the rate of healing and prevention complications.        

Measures Implemented on an Ongoing Basis to Prevent a Recurrence of the "Never Event"

Preventing pressure ulcers is oneof the most important responsibilities of any nurse caring for dependent older adults who have activity or mobility constraints (Reid, 2011). The key intervention for preventing skin breakdown is to ensure adequate circulation and minimal external pressure. The nurses should further ensure that patients with mobility limitations change position at minimum two hours interval. Milstein (2009) says that because fundamental cost and quality of life issues are associated with pressure ulcers, ongoing evidence based prevention practices of skin breakdown can have far reaching positive consequences for older adults who upon admission are at risk for development of pressure ulcers.

Evidence based practice will be implemented in the hospital in order to prevent the recurrence of pressure ulcers (Milstein, 2009). The nurses should first identify which patients are at risk for skin breakdown after their admission to the hospital. Watson (2010) noted that through recording enough information about each patient’s internal risk factors nurses and clinicians can create an ongoing care plan to prevent pressure ulcers. Risk factors are the basis for selecting specific prophylactic interventions (Milstein, 2009). The management should increase the amount of care devoted to the prevention of pressure ulcers by increasing the number of staffs in the hospital.

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