when we left off yesterday we talked about the importance of the levels of evidence whereas the higher levels tended to be from more more robust studies such as rcts metaanalyses and the lower levels of evidence which we still use when we uh Implement practice can be from opinions of respected authorities it's not really a great idea to have our our craft Guided by anec but sometimes that tends to happen quality improvement is not only a process it's a mindset that Healthcare teams and institutions should have even when outcomes and trajectories go the way that we anticipate the way that we hope there's always room for improvement for the most part now that's within reason we need to be receptive to change and open-minded but we also don't want to be in a state of turmoil continuous quality improvement or cqi Partners very nicely with evidence-based practice Improvement we talked about evidence-based practice yesterday there are several tools that we can use as we conduct our quality improvement work these are just a few the pdsa focus pdca and the dmac so let me talk about a couple first on the right hand side the plan do study act you're going to notice that this kind of mirrors a nursing process first in the planning phase we've identified an issue or something that needs to be improved so we're going to do an assessment we're going to get as much information as possible um what the impact is is what the problems are that it's causing and then we're going to start proposing some idealized solutions uh what's the direction that we want toe we're going to um Identify some tools Identify some processes and we're going to um now we're starting to blend into the study phase we're going to go ahead and Implement whatever it is that we designed and in the study phase we're going to look to see what the outcomes were was it effective was it not effective and then finally in the ACT phase we're going to see okay here here's what our results were did it work what worked well what didn't work well where is where are the changes that we need to retain or what are the changes that we need to revise so in short it's what's the issue what do we got to do let's go ahead and plan identify what we can do implement the change how did it work keep what worked revise what didn't now we don't have a Graphic of the focus pdsa but it's very similar to the pdsa so the focus stands for f find a process to improve o we're going to organize and improve the process C we're going to clarify what we know about the process U we're going to understand what's available what are sources of the process and then s is now we're going to select the process Improvement and then the PDS pdca very much mirrors pdsa with the difference being in the study changes to uh C for check the results but it's it's very very similar and then finally dmac uh the acronym just stands for Define measure analyze improve and control I think you can pretty much figure out what the DMI is is involving the C and the control that's where we're going to be discussing monitoring documentation standardization and any training and communication so next let's talk a little bit about the Pico proc process the t is silent um it's another quality improvement tool or process I first became introduced to this method back in like around 2012 2013 and I thought it was like revolutionary and it actually wasn't the Physicians first utilized this way back when when it came time to discuss like patient diagnosis and the way they approach patient care and trying to tease out the differential diagnosis so it was introduced into nursing we learned about it and we'll talk about what the the acronym pic T stands for uh but again just know that it's another tool another process for quality improvement this particular process as we develop the Pico question the P stands for what is the problem what is the patient SL population in this particular example we're going to be discussing we've got some patient falls happening in the unit now in this category we still Al also are considering what's the impact right we're not just going to say hey we've got a problem we need to understand what's the cost what's the expense what's the negative outcomes that we're trying to prevent next is eye intervention what's the intervention or the treatment that we're considering in this particular example we are talking about the use of bed alarms now that's interesting we can talk offline one day about my personal thoughts about bed alarms but nevertheless we're thinking okay that's a pretty good intervention in this particular case that might help C is comparison so we need to start thinking about what other interventions we should be considering in this case we're thinking okay in addition to the bed alarms maybe some other things we could do are putting up some signs to trigger to step that we've got working with a fall risk or maybe we might have to have sitters for certain patients whatever those other Alternatives would be that we're going to consider o stands for the design ired outcome in this case well we don't want our patients to fall and then T is that time frame how long is it going to take us do we think to reach that desired outcome in the instance of Falls of course we want to make sure that we stop falls immediately but here in this example you'll notice that we've teased out that we're going to focus on the night shift but as I mentioned sometimes the time is not necessarily relevant because anytime that we're trying to eliminate a problem or a complication the timeline's always going to be ASAP yesterday we had a nice introduction to what he Healthcare informatics is through the use of Technology we gather information we're able to communicate back and forth we can it helps us manage what we know it also helps us make better decisions and it can really enhance patient safety therefore the overarching purpose of informatics includes the technology the systems in place to help us retrieve data that overall is going to help us promote evidence-based practice promote science Improvement and promote quality improvements and safe patient care this is repetitive from our content discussion yesterday in 521 so bear with me some systems and processes that contribute and help us with nursing informatics and Healthcare informatics as a whole include the internet try to Envision today what our world would be like how would we operate without the internet I can't even wrap my head around that RFID systems that's radio frequency identification systems could include something like the sponges that are used during a surgical case for example let's say that the end of the case we're doing a sponge count and we're short one or two sponges instead of having to open the patient back up there are sponges that have an RFID tag to them so that we rent a scanner above or below the patient to see whether or not the sponge is still inside the patient there are point of care computers and also point of care handheld mortar devices for example the glucometers when we do the glucose checks on patients we dock them we put them back in the base and during that docking phase that information is populated into the electronic health record the data also goes to whoever owns the process usually the lab director so that they can track and do quality um Assurance processes on their end we also have multiple devices where we could run Labs such as the iack we could run you know CBC I mean it's incredible what we can do today again this information together helps us in our decision-making process and overall patient safety and quality improvement next let's talk about critical judgment you've already started this process whether you recognize it or not it's essentially taking our knowledge taking what we're learning not only in the theoretical aspects of it but also skills routines Etc and using that to help us prioritize and identify patient needs figuring out what we need to do and employing what is what it is that we need to do jumping to the bottom of this slide Tanner almost two decades ago designed a model that mirrors the nursing process was it's actually by Design I think what tends to happen sometimes especially in the novice nurses it's very easy to jump from assessing and noticing you're seeing the patients teyia they're breathing fast they're huffing and puffing they're using um accessory muscles Etc and we jump right into the responding the planning and implementation without actually pulling together the analyses and that phase may take you a little bit longer as a student maybe even as an office nurse but it's going to really come back and help you if you force yourself to kind of think in this mindset you can interpret and think okay what does it really mean that particular step also will help you prioritize issues and the evaluation and reflecting stage you know again did what we do was it effective for the patient or do we need to do something else and then back at the top appropriate clinical judgment means we did what we were supposed to and hopefully we have good patient outcomes and in appropriate clinical judgment sometimes again you know I don't believe that anybody comes to work thinking today I'm going to hurt patients it just can be from inexperience or by skipping through the analysis phase or maybe during the assessment phase we weren't skilled enough or we weren't thorough enough and we missed some signs but inappropriate or poor clinical judgment could potentially result in negative patient outcomes the term failure to rescue is when a patient is exhibiting signs or is in a condition or state where they need intervention and we miss signs and we didn't act the National Council of the state boards of nursing or ncsbn those are the keepers of the en clix exam we developed a framework for the development of clinical judgment and there are six steps recognizing Clues analyzing Clues prioritizing generating solution and taking action and evaluating outcomes you'll notice that this terminology is very similar sometimes we have algorithms and systems to help us develop clinical judgment or at least to enhance clinical judgment some examples will be rapid response teams or rrts those are teams in the hospitals that basically are the team that act right before somebody calls a code blue let's say that you have a patient that is exhibiting some signs of concern so there are algorithms to help the nurse determine okay does this patient meet this criteria yes that should trigger it I'm going to go ahead and call an rrt there are also some early warning systems that are implemented as part of the electronic health record this is an example below so say that a patient's blood pressure is below the parameters sometimes they also include um urine output such as in the ICU where patients are on is andos that can trigger a certain score that's the the it's the use and the Muse systems where again the nurse then should call either on rrt or call The Physician spoke a little bit about systems thinking and not just being narrow tunneled Vision but the entity the issues the problems the whatever it is that we're dealing with us um everything is part of a m much larger Spectrum a much larger process think about the interdependencies how everything impacts each other and recognize that our healthare Healthcare delivery it it all functions on a Continuum everything is a peak P of a much larger Pi Stalter defined systems thinking as a dynamic system on a Continuum it includes a holistic or interconnected perspective including all aspects multiple aspects it looks for patterns and ultimately creates transformative change Equity means the ability to be fair impartial healthc care Equity or Health Equity means that we must recognize that some individuals are going to need different things so that they can achieve optimal outcomes disparities in health care can occur because of a variety of different things first and foremost it might be an issue with access to care this could be through a combination of factors a either the re resources are just not available in that area or B it might be that that they're so overwhelmed that the schedule won't allow an appointment for maybe weeks or months another issue might be is a system that requires upfront payment and the patients can't pay Health Care Quality might be an issue I can tell you when I deployed and did my humanitarian missions with the air force that was a concern there were um systems that had poorly trained individuals they were doing their best but they just didn't have the knowledge to take care of certain cases some systems also were so poor they were uh resourced inappropriately they just didn't have what they needed to take care of the patients healthc care disparities could also be a difference in outcomes and we all know that health insurance coverages could vary greatly this is an interesting map created by the Centers for Disease Control so this indicates the darker the color means that at Birth uh the life expectancy is higher based on the darkness of the color so the light States uh you're going to have a shorter life expectancy that you would and the the darker the dark red areas looks like California would have been a good place to be New Mexico whereas that's where I grew up maybe not so much I wanted to compare it to another snapshot they took this or created this in 2018 there are some changes across the map California still remained pretty pretty good in 2018 but Colorado and Missouri for example had some changes Missouri in 2018 the life expectancy wasn't that was was still pretty good in the 70s but as um it emerged over to 2020 now life expectancy in Missouri is a lot better A term that we need to be familiar with is social determinance of Health that b basically refers to the environments where we exist where we're born where we live where we worship where we play everything that affects our quality of life our functioning and our health risks as we Embark in the profession of nursing we must be aware and be cognizant of potential vulnerable groups we need to know and recognize our biases and beliefs um they might be our personal beliefs they might be beliefs and biases that healthcare workers and nurses hold as a whole and then any potential knowledge deficits that we may have and that our colleagues might have we chatted yesterday about the need to recognize that there are populations that have specific and unique needs NE the awareness is the first step some example populations are at the bottom right they could be defined by race ethnicity they could be defined by a variety of different things including spiritual and cultural beliefs Etc next in our overview of professional nursing Concepts let's chat a bit about ethics ethics refers to our the moral principles that govern our activity medical or Health Care ethics divined by defined by the American Nurses Association is a theoretical and reflective domain of human knowledge that addresses issues and questions about morality in human choices actions character and ends bottom line is it's what defines our health care and nursing work individual ethics those govern our lives and they serve as a foundation for understanding organizational and professional ethics so some of the ethical um characteristics might include honesty loyalty and respect organizational ethics those are principles that help motivate and guide employees so that we make good decisions in the workplace and professional ethics can be driven by um again our personal ethics the organizational ethics and also those by imposed by our profession as a whole they might be the State Board of Nursing it might be a professional organization and those are basically principles that again will help us make good decisions in the workplace and as we care for our patients and conduct our nursing work the ethical principles that guide our nursing practice include autonomy that's recognition that the patients have their own right to make their own decisions about their health care their treatment based on their beliefs and their values next is beneficence which is do good non-maleficence same thing but it's an obligation that we will do no harm Fidelity is our duty to keep our promises veracity is Our obligation and duty to tell the truth uh that includes being accurate being honest and it may include having tough decision and answering hard questions and social justice in a nutshell is treating people equally and fairly protecting their rights making sure that there's equitable distribution of resources Healthcare Institution and organizations generally will have some sort of mechanism or a formal Ethics Committee in place the membership is generally comprised of multi-disciplines and what they do is they handle dilemmas that involve Justice fairness and duty to care um and when you go through your orientation phase of your first place of employment you'll generally learn about the process um generally it's anybody can call or request an Ethics Committee meeting the committee will meet they'll discuss the situation they'll consider all avenues and then they'll make a determination let's go through a couple of sample questions so you're caring for a patient that has abdominal pain which of these reflect the competency of teamwork and collaboration a that their pain is rated as a five on a scale of 0 to 10 B that we place them NPO again we're dealing with a patient with abdominal pain C we're paging for the surgical team to come and consult or d review the nursing literature for Best Practices the correct answer is C because um and the competency of teamwork and collaboration we're seeking help from another aspect another profession the surgical team that can actually come in reevaluate the patient maybe offer some recommendations they might have to return to the O redo a procedure or they could actually Implement and order some additional medications take a second to read why the other three were not correct next question a nurse is delegating a specific patient's morning hygiene to assisted Personnel what teaching will the nurse provide to that assistant Personnel select everything that applies a use a soft toothbrush for toothbrushing B kindly comb Mr lemon's hair this morning C fully dry the skin after bathing with gentle soap D use an electric razor not a blade on facial hair e if you have questions don't hesitate to page me f please let me know how the patient tolerates hair and the answer is all of the above last question the the nurse notices that patients return quickly for readmission for heart failure this actually is a a very common problem in the emergency department so what action will the nurse take inform the unit manager of the concern evaluate Trends and develop a plan for improvement contact Hospital quality improvement nurse to ask what to do give other nurses a journal article that addresses National readmission rates for heart failure the correct answer is B and so you're probably wondering is why is it incorrect for me to notify my nurse manager my leader and if you look at it from the perspective that the other options maybe are not incorrect but in the aspect of trying to actually do something about a trend that you're noticing the other options are basically passing the buck to others that concludes the Contex for this chapter