Unit 3: Quality, Patient Safety, Communication, and

Recordkeeping
(8 hours)

Introduction

The focus of today's health-care industry is on providing high-quality services in a safe

atmosphere. This goal necessitates the collaboration of several disciplines, including respiratory
treatment. As a result, respiratory therapists (RTs) should be aware with quality improvement
principles in the context of health care.

RTs must also have specific technical understanding of the direct patient care environment. Aside
from technical abilities, all health care workers must be able to successfully interact with one
another, as well as with patients and their families, and capture essential information.

Learning Outcomes
At the end of this unit, you are expected to:
1. describe the importance of monitoring quality to promote better patient outcomes;
2. identify impediments to care and risk in the direct patient environment;
3. explain how communication can affect patient care;
4. describe the two-patient identifier system;
5. list the factors associated with the communication process;
6. describe how to recognize and help resolve interpersonal or organizational sources of
conflict;
7. explain the legal and practical obligations involved in recordkeeping;
8. explain how to apply good body mechanics and posture to moving patients;
9. describe how to ambulate a patient and the potential benefits of ambulation; and
10. identify the potential physiologic effects that electrical current can have on the body.

Presentation of Contents

I. QUALITY CONSIDERATIONS

What Is Quality in Health Care?

All quality improvement approaches, as the reader can see, have certain basic themes: identifying
process components, boosting efficiency (cutting waste), standardization (reducing common
variance), and a collaboration approach to implementing solutions.

The Centers for Medicare and Medicaid Services (CMS) launched the Hospital Value-Based
Purchasing Program in response to the Patient Protection and Affordable Care Act, which
rewarded or penalized hospitals based on their performance in the domains of process measures
(also known as core measure compliance), outcomes, patient experience, and efficiency.

The National Academy of Medicine recommends the following dimensions in health care quality:
Safety, Timeliness, Effectiveness, Efficiency, Equity, Patient centeredness (STEEP). The patient

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safety dimension is addressed by adopting the "Jidoka" principle - stopping the process when any
team member sees a defect in delivery of the care. RT-run education programs fulfill the patient
centeredness principle.

RTs are also important in the implementation of guideline-based RT protocols and disease
management programs, which constitute a holistic approach to patient care across the health-care
continuum.

Disease Management
• It refers to an organized strategy of delivering care to a large group of individuals with
chronic disease to improve outcomes and reduce cost.

• It has been defined as a systematic population-based approach to identify persons at risk,

intervene with specific programs of care, and measure clinical and other outcomes.

Four essential components of Disease management programs:

1. An integrated health care system that can provide coordinated care across the full range of
patient needs;
2. A comprehensive knowledge base regarding the prevention, diagnosis, and treatment of
disease that guides the plan of care;
3. Sophisticated clinical and administrative information systems that can help assess patterns of
clinical practice; and
4. A commitment to continuous quality improvement.

Chronic diseases like asthma, diabetes, COPD, and congestive heart failure can all benefit from
disease management regimens. These are frequently detailed in documents providing care-specific
branched logic algorithms. Disease management regimens, on the other hand, frequently address
broad groups and are based on a diagnosis.

Monitoring Quality in Respiratory Care

Beyond ensuring that all elements of a high-quality respiratory care program are in place, quality
must be monitored to ensure that it is being maintained.

Intrainstitutional quality assurance often uses skills checks or competencies. Competence is

defined as having suitable or sufficient skill, knowledge, and experience for the purposes of a
specific task. Simulation training in respiratory therapy involves intubation, ventilator
management, arterial line placement, and optimizing teamwork.

The Joint Commission (as the Joint Commission on the Accreditation of Healthcare) was formed
in 1951 by the American College of Surgeons, the American Hospital Association, and the
American Medical Association. TJC requires a hospital service to have a quality assurance plan to
provide a system for controlling quality.

Nine Steps for a Quality Assurance Plan

1. Identify problem
2. Determine cause of problem
3. Rank problem
4. Develop strategy for resolving problem
5. Develop appropriate measurement technique
6. Implement problem-resolution strategy
7. Analyze and compile results of intervention
8. Report results to appropriate personnel
9. Evaluate intervention outcome

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TJC's current certification requirements stress organization-wide efforts to improve performance.
Despite growing emphasis on cost containment, hospitals and respiratory care providers continue
to prioritize excellent care. Performance improvement, also known as continuous quality
improvement, is a continuous process that identifies and corrects issues that obstruct the delivery
of high-quality, cost-effective health care.

The Joint Commission Standards for Performance Improvement

• The hospital collects data to monitor its performance
• The hospital compiles and analyzes data.
• The hospital improves performance on an ongoing basis

Respiratory care protocols create the need for additional quality monitoring benchmarks regarding
correctness, consistency, efficacy, and effectiveness. Specific methods to monitor the quality of
respiratory care protocol programs include conducting care plan audits in real time and ensuring
practitioner training by using case study exercises.

Quality Monitoring Benchmarks

• Monitoring the correctness of respiratory care plans
• Monitoring the consistency of formulating respiratory care plans among therapist
evaluations
• Evaluating the efficacy of algorithms or protocols
• Evaluating the overall effectiveness of the protocol program

II. SAFETY CONSIDERATIONS

Patient movement and ambulation, electrical hazards, fire hazards, and general safety issues are
the main areas of possible risk for patients, RTs, and coworkers in respiratory care. Safety is a
critical component of providing high-quality service.

A. Patient Movement and Ambulation

Basic Body Mechanics
The relationship of the body parts to one another is referred to as posture. A straight spine and the
use of leg muscles to lift the object are required for proper technique. Joints, muscles, and tendons
may be overworked as a result of poor posture.

Figure 3.1 Body mechanics for lifting and carrying objects

Moving the Patient in Bed

The most comfortable positions are those taken by conscious persons. Patients who are bedridden
and have acute or chronic respiratory dysfunction frequently assume an upright position. This
position allows them to breathe more easily. In other circumstances, such as when postural
drainage is used, patients may be required to assume specific positions for therapeutic purposes.

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Figure 3.2 A, Method to pull a bed-bound patient. B, Method to push a bed-bound patient.

Figure 3.3 Method to move a patient up in bed with the patient’s assistance.

Figure 3.4 Methods to assist a patient in dangling the legs at the side of the bed.

Ambulation
Ambulation (walking) helps maintain normal body function. Bed sores and atelectasis (decreased
lung volumes) might result from prolonged bed rest. As soon as the patient is physiologically
stable, ambulation should begin. RTs may assist to ambulate patients while they are on a
mechanical ventilator or while on O2.

Throughout the activity, keep an eye on the patient's level of consciousness, color, respiration,
strength or weakness, and complaints like discomfort or shortness of breath. Every ambulation
session is recorded in the patient's chart, which contains the date and time of the ambulation, the
length of the ambulation, and the patient's tolerance level.

B. Electrical Safety
There is a risk of patients or staff being shocked accidentally by electrical equipment. Electrical
equipment, such as internal catheters and pacemakers, may increase the risk of significant injury

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from an electrical shock. Because respiratory treatment frequently entails the use of electrical
devices, RTs must understand the foundations of electrical safety.

Fundamentals of Electricity
The ability of humans to create and harness electricity is one of the most important developments
in modern times. Despite this, most people who use electricity have a poor understanding of it.
This lack of knowledge is often a major factor in cases of electrocution, according to experts.

Preventing Shock Hazards

The majority of shock hazards are caused by improper or insufficient grounding. Shock hazards
can be avoided or reduced by using proper wiring in patient care locations. All equipment brought
into the patient care area has been approved by Underwriters Laboratories (UL) and is inspected
by a qualified person on a regular basis.

Ground Electrical Equipment Near the Patient

A qualified electrical expert should inspect all electrical equipment, especially those used with
electrically vulnerable patients, for proper grounding on a regular basis. Lights, electrical beds,
ventilators, monitoring or therapeutic devices should all be linked to grounded outlets with three-
wire connections. This eliminates the risk of harmful voltage buildup on the metal frames of
particular electrical devices.

Fire Hazards
Hospitals or hospices account for about 23% of fires in health care institutions. Nursing homes
account for 46%; the kitchen is the most prevalent source of fire. Hospital fires are extremely
dangerous when they occur in patient care areas and when supplemental oxygen is used. Fires in
O2-rich environments are larger, more intense, burn faster and are more difficult to put out.
Hospital fires are also more dangerous because evacuation of critically ill patients is difficult and
slow.

For a fire to start, three conditions must exist:

1. flammable material must be present,
2. O2 must be present, and
3. the flammable material must be heated to or above its ignition temperature.

The existence of static electrical sparks created by friction is a common source of worry. The
overall threat from static sparks with commonly used materials is quite low, even in the presence
of high O2 concentrations. Maintaining a high relative humidity (>60%) can further lessen the
minimal risk that may exist.

A core fire plan that defines the roles of hospital workers is required in every hospital. To reinforce
the instruction, the plan should be taught to all hospital employees and practiced with fire drills.
You must know what to do if a fire breaks out in a patient care area.

The core fire plan follows the acronym RACE:

• Rescue patients in the immediate area of the fire.
• Alert other personnel about the fire so they can assist in the rescue and can relay the location
of the fire to officials.
• Contain the fire.
• Evacuate other patients and personnel in the areas around the fire who may be in danger if the
fire spreads.

General Safety Concerns

RTs must be aware of general safety considerations, such as the direct patient environment, disaster
preparedness, magnetic resonance imaging (MRI) safety, and medical gas safety, in addition to
electrical and fire safety.

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• Direct Patient Environment
The immediate environment around the patient can create risk for patient safety. To reduce the
risk, the patient care environment should be as free of impediments to care as possible. When
care is completed, the RT should ensure that the patient has easy access to the patient call
system.

• Disaster Preparedness
Learning to move and transfer critically ill patients safely is an important part of disaster
preparedness. Preparing for a loss of electricity, whether due to an internal or external disaster,
is another component. In these situations, hospitals use backup generators to keep vital
equipment running. It is critical for the RT to be aware of the hospital's specific policies for
power outages and other potential disasters.

• Magnetic Resonance Imaging Safety

The body is exposed to strong magnetic fields and a little quantity of radiofrequency during an
MRI. Patients, health-care professionals, and equipment may be exposed to this intense
magnetic field. Each radiology department has its own set of guidelines and safety concerns,
which must be presented to all patients, caregivers, and health care personnel.

• Medical Gas Cylinders

The use of compressed gas cylinders by RTs necessitates extra care. Increased risk of fire,
explosive discharge of high-pressure cylinders, and toxic effect of particular gases are all
physical concerns associated with poor cylinder storage or handling. It is never a good idea to
store compressed gas cylinders without some sort of support.

III. COMMUNICATION
Communication is a dynamic human involving sharing of information, meanings, and rules.
Interactions among many participants from several disciplines are required for the delivery of safe,
high-quality health care. Communication is essential to a health care organization's quality
mission.

Figure 3.5 Elements of human communication

Human communication is a two-way process in which the receiver serves an active role. Messages
may be verbal or nonverbal. The channel of communication is the method used to transmit
messages. The most common channels involve sight and hearing, such as written and oral
messages. The last essential part of communication is feedback from the receiver, which allows
the sender to measure communication success.

Communication in Health Care

All health care personnel must correctly identify patients before initiating care using a two–patient
identifier system. The patient identifiers can include name, birth date, and medical record number.
A "read back" scenario verifying the reporter and the receiver of the information should be used.

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 Box 3.1 “Read Back” Process to Ensure Accurate Communication of
Information
PRESCRIBER/REPORTER
• Order or critical test results are read and clearly enunciated, using
two patient identifiers.
• Avoid abbreviations
• Ask receiver to “read back” the information if this is not done
voluntarily.
• Verify with the receiver that the information is correct.

RECEIVER
• Record the order or value.
• Ask “precriber/reporter” to repeat if information is not understood.
• “Read back” the infromation, including two patient identifiers.
• Receive confirmation from the “precriber/reporter” that the
information is correct; if incorrect, repeat the process.

Communication skills can limit your ability to treat patients, work well with others, and find
satisfaction in your employment. As an RT, you will have many opportunities to communicate
with patients, other RTs, nurses, physicians, and other members of the health care team.

Factors Affecting Communication

The "internal" qualities of sender and receiver play a large role in the communication process. The
verbal and nonverbal components of communication should enhance and reinforce each other.
Other factors that can affect communication include the patient's direct health care environment
and their sensory or emotional state. The RT who takes into account all of these aspects will
improve their communication skills.

Figure 3.6 Factors influencing communication. (Modified from Wilkins RL, Sheldon RL, Krider SJ:
Clinical Assessment in Respiratory Care, ed 6. St. Louis. 2010, Mosby.

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 Box 3.2 Purposes of Communication in the Health Care Setting
• To estbalish rapport with another individual, such as a colleague, a
patient, or a member of the patient’s family
• To comfort an anxious patient by explaining the unknown
• To obtain information, such as during a patient interview
• To relay pertinent information, as when charting the results of a
patient’s treatment
• To give instructions, as to when teaching a patient how to perform a
lung function test
• To persuade others to take action, as when attempting to convince a
patient to quit smoking
• To educate and confirm understanding as in a “teach back” scenario

Improving Communication Skills

Learn how to improve your communication skills and overcome common barriers to effective
communication. Focus on improving sending, receiving, and feedback skills, as well as identifying
and overcoming common barriers.

Practitioner as Sender
Your effectiveness as a sender of messages can be improved in several ways. These suggestions
may be applied to the clinical setting as follows:

• Share information rather than telling.

• Seek to relate to people rather than control them.
• Value disagreement as much as agreement.
• Use effective nonverbal communication techniques.

Practitioner as Receiver and Listener

Communication skills are just as important as sender and receiver skills. Messages sent are of no
value unless they are received as intended. Learning to listen requires a strong commitment and
great effort.

A few simple principles can help improve your listening skills, as follows:
• Work at listening.
• Stop talking.
• Resist distractions.
• Keep your mind open; be objective.
• Hear the speaker out before making an evaluation.
• Maintain composure; control emotions.

In health-care communication, active listening is essential. Many of the communications sent are
critical to the patient's care. If you do not listen effectively, important information may be lost and
the care of your patients may be jeopardized.

Providing Feedback
To enhance communication with others, effective feedback needs to be provided:
• Attending.
• Paraphrasing.
• Requesting clarification.
• Perception checking.
• Reflecting feelings.

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 Minimizing Barriers to Communication
In all interactions, a skilled communicator seeks to identify and eliminate or limit the impact of
these barriers. The sender can help ensure that the message is received as intended by limiting the
impact of these barriers.

Key barriers to effective communication are the following:

• Use of symbols or words that have different meanings.
• Different value systems.
• Emphasis on status.
• Conflict of interest.
• Lack of acceptance of differences in points of view, feelings, values, or purposes.
• Feelings of personal insecurity.

To become an effective communicator, identify the purpose of each communication interaction

and your role in it. Use specific sending, receiving, and feedback skills in each interaction. Finally,
minimize any identified barriers to communication with patients or peers, to ensure that messages
are received as intended.

IV. CONFLICT AND CONFLICT RESOLUTION

Conflict is sharp disagreement or opposition among people over interests, ideas, or values. In their
employment, health care providers deal with a lot of disagreement. Rapid changes in the health-
care industry have made everyone's job more difficult and demanding. Because conflict is
unavoidable, all health care providers must be able to identify its sources and assist in resolving or
managing its impact on individuals and organizations.

Sources of Conflict
The first step in conflict management is to identify its potential sources.

The four primary sources of conflict in organizations are:

1. Poor Communication
2. Structural Problems
3. Personal Behavior
4. Role Conflict

Conflict Resolution
Conflict resolution or management is the process by which people control and channel
disagreements within an organization.

The following are five basic strategies for handling conflict:

1. Competing is an assertive and uncooperative conflict resolution strategy.
2. Accommodating is being unassertive and cooperative.
3. Avoiding is both an unassertive and an uncooperative conflict resolution strategy.
4. Collaborating is assertive and cooperative.
5. Compromising is a middle-ground strategy that combines assertiveness and cooperation.

V. RECORDKEEPING
The electronic medical record (EMR) is changing the way health care practitioners document care.
The overall content and concept of what we record remains the same. Medical records are the
institution's property and are kept in absolute confidence. EMRs must be done in a way that makes
sense over days, months, or years.

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Components of a Traditional Medical Record
Each health care facility has its own specification for the medical records it keeps. Most acute care
medical records share common sections (Box 3.3)

Data sheets are designed to report data briefly and to decrease time spent in documentation. Entries
can include many measurements, and review of a sequence of entries can reveal trends in patient
status.

Box 3.3 General Sections Found in a Patient Medical Record

ADMISSION DATA I/O SHEET

Records pertinent patient information Records patient’s fluid intake and output
(e.g., name, address, religion, nearest of over time
kin), admitting physician and admission
diagnosis LABORATORY RESULTS
Sumamrizes the results of laboratory
HISTORY AND PHYSICAL tests
EXAMINATION
Records the patient’s admitting history CONSULTATION NOTE
and physical examination, as performed Records notes by physicians who are
by the attending physician or resident called in to examine a patient to make a
diagnosis
HEALTH MAINTENANCE AND
IMMUNIZATIONS SURGICAL OR TREATMENT
Records the dates of administration CONSENT
Records the patient’s authorization for
PHYSICIAN’S ORDERS sugery or treatment
Records the physician’s orders and
prescriptions ANESTHESIA AND SURGICAL
RECORD
PROGRESS NOTES Notes key events before, during, and
Keeps a continuing account of the immediately after surgery
patient’s progress for the physician

NURSES’ NOTES SPECIALIZED THERAPY

Describes the nursing care given to the RECORDS AND PROGRESS
patient, including the patient’s NOTES
complaints (subjective symptoms), the Records specialized treatments or
nurse’s observations (objective signs), traetment plans and patient progress for
and the patient;s response to therapy specialized therapeutic services (e.g.,
respiratory care, physical therapy)
MEDICATION RECORD
Notes drugs and IV fluids that are given
to the patient SPECIALIZED FLOW DATA
Records measurement made over time
during specialized procedures (e.g.,
ALLERGIES mechanical ventilation. Kidney dialysis)
Notes reaction, severity, type, and date

ADVANCED DIRECTIVES
VITAL SIGNS FLOWSHEET Records wishes and documents
Records the patient’s temperature, pulse, regarding living wills, power of attorney,
respirations, and blood pressure over and do not resuscitate orders
time

Legal Aspects of Recordkeeping

If the RT does not document care given, the practitioner and the hospital may be accused of patient
neglect. Legally, documentation of the care given to a patient means that care was given; no
documentation means that it was not given.

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Practical Aspects of Recordkeeping
Documenting medical records is one of the most significant duties that a health care professional
performs. Accounts of the patient's condition and activities must be charted accurately and in clear
terms. Brevity is essential, but a complete account of each patient encounter is needed.

Problem-Oriented Medical Record

It is an alternative documentation format used by some health care institutions. The POMR
contains four parts:
1. database,
2. problem list,
3. plan, and
4. progress notes.

In the POMR, a problem is something that interferes with a patient's physical or psychologic
health or ability to function. The format used is often referred to as SOAP (S = subjective
information, O = objective information, A = assessment, P = plan of care)

Figure 3.3 Example of a SOAP form for respiratory care progress notes. (From Des Jardin T. Burton
GG: Clinical Manifestations and Assessment of Respiratory Disease, ed 6, St. Louis, 2011, Mosby.)

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 Feedback

1. In your own words, define quality in health care services.

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

2. What is the main reason you should use good body mechanics?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

3. Describe how to ambulate a patient and the potential benefits of ambulation.

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

4. Explain the two-patient identifier system.

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

5. Identify impediments to care and risk in the direct patient environment.

______________________________________________________________________________
______________________________________________________________________________

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______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

6. The text lists five ways to improve your effectiveness as a sender of messages. Describe two of
these that apply to you. Give examples of situation where you communicated well (or not).
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

7. Name and discuss four sources of conflict in health care organizations.

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

8. Discuss the legal and practical essential aspect of recordkeeping.

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

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Summary of the Unit
In this unit, you learned about quality, patient safety, communication, and record keeping. It
should be noted that:
• The Joint Commission (TJC) is an independent, non-for-profit organization that strives to
continuously improve quality and safety of health care services by setting high standards and
evaluating health care organizations for adherence.
• TJC requires hospitals to have quality assurance plans and encourages performance
improvement efforts.
• Hospital accreditation by TJC is based on satisfying specific standards established by
professional and technical advisory committees.
• Good posture is needed when lifting patients or heavy equipment to avoid injury.
• To avoid electrical hazards, always ground equipment and use only equipment that has been
checked for proper wiring.
• Fires in health care facilities most often start in the kitchen, but when they occur in patient care
areas, loss of life and serious injuries are likely.
• Maintain a safe and clutter-free direct patient care environment.
• Store and transport medical grade gases in a safe and effective manner.
• Communication skills play a key role in the ability to identify a patient’s problems, to evaluate
the patient’s progress, to make recommendations for respiratory care, and to achieve desired
patient outcomes.
• Individuals’ prior experiences, attitudes, values, cultural backgrounds, self-concepts, and
feelings play a large role in the communication process.
• To enhance communication ability, focus on improving sending, receiving, and feedback
skills; in addition, be able to identify and overcome common barriers to effective
communication.
• Choose the best strategy for handling conflict considering knowledge of the context, the
specific underlying problem, and the desires of the involved parties.
• The EMR is transforming the way we document care but not the concept and content of what
is documented.
• A medical record is a confidential document that summarizes the care received by a patient;
legally, a failure to document care means that care was not given.
• Following accepted standards, each medication, treatment, or procedure provided to the
patient, including his or her condition and response to therapy, must be documented in accurate
and clear terms.
• When entering notes in a POMR, use a SOAP format.

Reflection
Now that you have reached this far, it is time to reflect and make a move by answering
the following questions
• What is the most important thing you learned from this unit? Why do you think so?
• How did you gain learning?
• What can/should you do with what you know?

References:
Kackmareck, R. M. et. al. (2017). Egan’s fundamentals of respiratory care. Eleventh Edition.
Canada: Elsevier

Eubanks, D. and Bone R. (1990), Comprehensive Respiratory Care. Second Edition. USA:
Curvelwell Publisher

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