142 unit 2 | Working Within the Organization
of biological, psychological, and social aspects
(Strickland, 1997). For this reason, considerable
effort has been put into identifying the patient out-
comes that are affected by the quality of nursing
care. For example, the ANA identified 10 quality
indicators in acute care that are likely to relate to the
availability and quality of professional nursing serv-
ices in hospitals. Across the United States, data are
being collected from nursing units using these qual-
ity indicators.
A major problem in using and interpreting out-
come measures is that outcomes are influenced by
many factors. For example, the outcome of patient
teaching done by a nurse on a home visit is affected
by the patient’s interest and ability to learn, the
quality of the teaching materials, the presence or
absence of family support, information (which may
conflict) from other caregivers, and the environ-
ment in which the teaching is done. If the teaching
is successful, can the nurse be given full credit for
the success? If it is not successful, who has failed?
It is necessary to evaluate the process as well as
the outcome to determine why an intervention
such as patient teaching succeeds or fails. A com-
prehensive evaluation includes all three aspects:
structure, process, and outcome. However, it is
much more difficult to gather and monitor out-
come data than to measure structure or process.
Risk Management
An important part of CQI is risk management,a
process of identifying, analyzing, treating, and eval-
uating real and potential hazards. The Joint
Commission ( JC) recommends the integration of
a quality control/risk management program to
maintain continuous feedback and communication.
To plan proactively, an organization must identify
real or potential exposures that might threaten it.
As a nurse, it is your responsibility to report adverse
incidents to the risk manager, according to your
organization’s policies and procedures. In many
states, this is a legal requirement.
Risk events are categorized according to severity.
Although all untoward events are important,
not all carry the same severity of outcomes
(Benson-Flynn, 2001).- Service occurrence.A service occurrence is an
unexpected occurrence that does not result in
a clinically significant interruption of services
and that is without apparent patient or employee
injury. Examples include minor property or
equipment damage, unsatisfactory provision
of service at any level, or inconsequential inter-
ruption of service. Most occurrences in this
category are addressed within the patient
complaint process.
2.Serious incident.A serious incident results in a
clinically significant interruption of therapy or
service, minor injury to a patient or employee,
or significant loss or damage of equipment or
property. Minor injuries are usually defined as
needing medical intervention outside of hospital
admission or physical or psychological damage.
3.Sentinel events.A sentinel event is an unex-
pected occurrence involving death or serious/
permanent physical or psychological injury, or
the risk thereof. The phrase, “or the risk there-
of ” includes any process variation for which a
recurrence would carry a significant chance of a
serious adverse outcome. Such events are called
sentinel because they signal the need for imme-
diate investigation and response. When a sen-
tinel event occurs, appropriate individuals
table 10-3
Dimensions of QI in Nursing: Examples
Independent Function Dependent Function Interdependent Function
Structure Pressure ulcer risk assessment High-speed automatic dial-up system Nursing case management
form available puts nurses in touch with physicians model of care adopted on
rapidly rehabilitation unit
Process Assesses risk for development Order to increase dosage of pain Communicates with therapists
of pressure ulcer and medication obtained and about need for customized
implements preventive measures processedwithin 1 hour wheelchair
Outcome Skin intact at discharge Relief from pain Able to enter narrow doorway
to bathroom unassisted
Adapted from Irvine, D. (1998). Finding value in nursing care: A framework for quality improvement and clinical evaluation.Nursing Economics, 16(3),
110–118.