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Quality assurance in nursing management

quality assurance in nursing management

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Quality assurance in nursing management

  2. 2. LEARNING OBJECTIVES At the end of discussion student will able to: • Introduce quality assurance • Define quality assurance • Explain models of quality assurance • Enlist steps of quality improvement • Illustrate quality evaluation • Introduce standards • Discuss concept of standard • Explain components of standards
  3. 3. Conti.. • Enlist characteristics of standards • Determine steps of development of standard • To explain techniques used in preparation of standards in nursing • Introduce nursing audit • Define nursing audit • Illustrate advantages & disadvantages of nursing audit • Determine basis of nursing audit • Explain types of nursing audit • Discuss nursing audit process
  4. 4. INTRODUCTION • The quality is not synonymous with luxury or goodness. A product or a service that confirms to its specifications demonstrates quality, whatever the product.
  5. 5. DEFINITION • According to Ellie Green:- Quality is a matter of perception and, like beauty, lies in the eyes of the beholder. • According to AV Fiegenbaum:- Quality is defined as the capability of a product to fulfill its intended purpose, produced with least possible cost.
  6. 6. DEFINITIONS OF QUALITY IN HEALTH CARE - • “Quality is defined as the degree to which health services for the individuals and populations increase the likelihood of the desired health outcomes and are consistent with current professional knowledge”. -Joint Commission on Accreditation of Healthcare Organizations (2002)
  7. 7. Conti…. • “Quality of a service is defined as the totality of features and characteristics of a service that bear on its ability to satisfy the stated and implied needs of the patients.” -International Organization for Standardization (ISO 8402)
  8. 8. QUALITY ASSURANCE • According to Coyne C, Killien M:- Quality assurance is the process for evaluating patient care in a particular setting by developing standards of care and implementing mechanisms for ensuring that the standard are met.
  9. 9. Conti… • WHO (1992) defined quality assurance, as making sure that the services provided by the hospital are the best possible in a given existing resources and current medical knowledge.
  11. 11. MODELS OF QUALITY ASSURANCE AND QUALITY MANAGEMENT There are various models of quality assurance and quality management:- • AMERICAN NURSES’ ASSOCIATION (ANA) MODEL • DONABEDIAN MODEL • WILSON’S MODEL • FOCUS- PDCA Model (Quality Management Model)
  12. 12. AMERICAN NURSES’ ASSOCIATION (ANA) MODEL:- • This model is given by Long & Black in 1975. This is the first proposed and accepted model of quality assurance, which was meant for the nursing profession but was used by various other professionals in the health care. This is a cyclic model. It helps in self determination of patient, and family, nursing health orientation, patient’s right to quality care and nursing contribution.
  13. 13. Basic components of ANA Model:- • 1. Identify value:- in the ANA, value identification looks as such issue as patient , philosophy and spiritual perspective and values philosophy of the health care organization and the provider of nursing services.
  14. 14. Conti… • 2. Identify structure, process and outcome standards and criteria:- identification of standards and criteria for quality assurance begins with writing of philosophy and objectives of organization. The philosophy and objectives of an agency serves to define the structural standards of the agency. • Standards of structure are defined by licensing or accrediting agency. Another standard of structure includes the organizational chart, which shows supervisory methods, communication patterns, staff patterns and sometimes staff assignments. • A group internal or external to the agency does evaluation of the standards of structure. Evaluation process includes peer review, direct observation, interview, questionnaire etc.
  15. 15. Conti… • 3. Select measurement needed to determine degree of attainment of criteria and standards:- measurements are those tools used to gather information, determined by the selection of standard and criteria. The approaches and techniques used to evaluate structural standards and criteria are, nursing audit, utilization reviews, and review of agency documents, self-studies and reviews of physical facilities. • 4. Make interpretations:- the degree to which the predetermined criteria are met is the basis for interpolation about the strengths and weakness of the program. The rate of compliance is compared against the expected level of criteria accomplishment.
  16. 16. Conti…. • 5. Identify course of action:- identify the compliance level. If it is above the expected level , there is great value in conveying positive feedback and reinforcement. If it is below the expected level , then it is essential to improve the situation. • 6. Choose action:- usually various alternative of actions are available to remedy a deficiency. Thus it is vital to weigh pros and cons of alternative. • 7. Take action:- it is important to firmly establish accountability for the action to be taken. • 8. Revaluation:- the final step of QA process involves an evaluation of the results of the action.
  17. 17. DONABEDIAN MODEL • Donabedian quality framework is recognized as a method of measuring quality as structure, process and outcome in the mid of 1960s. structure leads to process, and process leads to outcome. Outcome reflects the results of the application os structure, and process in a specific health care setting.
  18. 18. Conti… • According to model, ‘structure’ include the adequacy of health are facilities, the qualification of practitioners and the financial aspect of care. • The ‘process’ were the aspects of care. • And ‘outcome’ are the precise and concrete measurements of effectiveness of care.
  19. 19. WILSON’S MODEL • Wilson (1987) in the late 1980’s tried to operationalize Donabedian model into a tangible and practical form. He refined it as inputs, methods or procedures and outcomes.
  20. 20. FOCUS- PDCA Model (Quality Management Model) This model has following concepts:- • Find a process to improve • Organize a team that knows the process • Clarify current knowledge of process • Understand causes of variation
  21. 21. Conti… • PDCA (plan-do-check-act) is a four step problem solving process. It is used in quality control. It is also known as the Shewhart Cycle, Deming Cycle. • Plan: Establish the objectives and process necessary to deliver results in accordance with the specifications. • Do: Implement the processes. • Check: Monitor and evaluate the processes & results against objectives and specifications & report the outcome. • Act: Apply actions to the outcome for necessary improvement. • This means reviewing all steps (plan-do-check-act) and modifying the process to improve it before its next implementation.
  22. 22. QUALITY IMPROVEMENT • CONCEPT • The process or processes of reducing variance is quality improvement. It is the process of attaining a new level of performance or quality that is superior to any previous level of quality.
  23. 23. STEPS OF QUALITY IMPROVEMENT According to the quality cycle developed by USAID QA project:- • Planning for quality • Setting a standard • Communicating of standard • Monitoring • Identification and prioritization of improvement opportunities (IQ) • Defining the key IQs • Organizing a team • Analyzing and studying the IQs for root causes • Developing solution and actions for improvement • Implementing and evaluating improvement efforts, then restarting the cycle again.
  24. 24. APPROACH TO QUALITY:- • Juran developed a three-part (trilogy) approach to quality: Quality planning, quality control and quality improvement. • Quality Planning:- it involves determining who the customers are and what their needs are, then developing products based on those needs and designing processes to produce those products. • Quality control:- it is the evaluation of performance to identify discrepancies between actual performance and goals. • Quality improvement:- it establishes an infrastructure and the project teams to carry out process improvement.
  25. 25. QUALITY EVALUATION SYSTEM IN HEALTH CARE • The following are the examples of different approaches to quality evaluation that are used in different countries: • SPECIFIC APPROACHS • REGULATORY APPROACHES
  26. 26. SPECIFIC APPROACHS • 1. Audit system: • 2. Quality awards • 3. Peer Assessment • 4. Utilization review: Utilization review activities are directed towards assuring that care is actually needed & the cost appropriate for the level of care provided. There are three types of utilization review: • Prospective • Concurrent • Retrospective • 5. Clients’ satisfaction
  27. 27. REGULATORY APPROACHES • 1. Licensure • 2. Accreditation • 3. Certification
  28. 28. INTRODUCTION • Standards can be defined as a benchmark of achievement, which is based on a desired level of excellence. As such, standards become model to be initiated & may serve, in turn, as basis of comparisons. (oxford dictionary)
  29. 29. CONCEPTS OF STANDARDS • These are degree of excellence. • Serves as basis of comparison • Are minimum parameters with which a community may be reasonably content • Is recognized as a model for imitation.
  30. 30. COMPONENTS OF STANDARDS • 1. Standards are written. • 2. Standards define the set of rules, actions or outcomes. • 3. Standards are written for customers, staff members and system. • 4. Standards are approved by authority.
  31. 31. CHARACTERISTICS OF STANDARDS • Standards must be: • • Specific • • Measureable • • Appropriate • • Reliable • • Timely bounded
  32. 32. STEPS FOR DEVELOPMENT OF NURSING STANDARDS • • Identify a team or panel of nursing experts. • • Decide an area of nursing practice for which the standards are to be formed. • • Review philosophy, purposes and objectives. • • Review nursing theories or existing nursing care practices, nursing process. • • Identify the patient for nursing services, patients’ role, approaches & strategies of nursing care services.
  33. 33. Conti.. • Discuss with the nursing service administrators to get their approval so that they are made feasible. • • Devise a mechanism for determining the achievement of standards. • • Determine the validity and reliability of the measuring tools. • • Try out the standards for feasibility. • • The standards are then put into practice. • • Quality care is then audited. • • The standards are reviewed & revised.
  34. 34. TECHNIQUES USED IN PREPARATION OF STANDARDS IN NURSING • 1. Professional standards techniques • This category contains the various guidelines & standard documents which health care professionals have published as a basis for quality assurance. These are based upon structure, process & outcome quality assurance model given by ANA.
  35. 35. • 2. Comprehensive Review System • These standards are at high level of generality & several professional bodies suggest that their central standard should be used as a framework for more local exercises in specific standard setting. They local & specific thus grow out of the central and more general.
  36. 36. • 3. Process Appraisal Technique • It focuses primarily on appraisal of the quality of process of care. The process of care comprises all the procedures & activities through which the health professional & support worker deploy their time, skills, knowledge & resources in pursuits of improved patient health & well-being. It has technical, interpersonal & moral components & includes access, diagnosis, treatment, discharge, after care, & health education & promotion.
  38. 38. INTRODUCTION • Nursing audit one of the control tools, responsible for controlling the activities of the nurses that focuses on providing the best possible nursing care. The actual nursing rendered is compared with the standards. This is mainly refers to the clinical nursing audit. The nursing management audit is an evaluation of nursing management as a whole.
  39. 39. DEFINITIONS • According to Elison:- • Nursing audit refers to assessment of the quality clinical nursing. • According to Cott:- • It is the process of evaluating appropriateness & effectiveness of nursing care measures.
  40. 40. • According to RANF:- • Nursing audit is a formal detailed systematic review of records or observation of nursing actions in order to evaluate the quality of nursing care by comparing the documented evidence with accepted standards & criteria.
  41. 41. CLINICAL AUDIT:- • Department of Health, London:- • The clinical audit has been defined ‘the systematic & critical analysis of the procedure used for diagnosis, care & treatment, the associated use of resources and the effect care has on the outcome & quality of life for the patient.
  42. 42. OBJECTIVES OF NURSING AUDIT Following are the main objectives:- • • To improve the quality of nursing care. • • To measure the degree of quality of patient care against a defined criteria. • • To decrease the cost of nursing care. • • To provide a basis for determining nursing negligence. • • To provide education to all the nursing personnel by the process of self education. • • To enhance professional knowledge from past experiences by learning from past mistakes in records.
  43. 43. ADVANTAGE S OF NURSING AUDIT method of measuremen t valuable indicator simple process Tool of quality assurance programme
  44. 44. DISADVANTA GES OF NURSING AUDIT analysis difficulty time consuming trained auditor large number of information
  45. 45. BASES OF NURSING AUDIT • 1. Debit items:- these includes the items like death of the patient, complication of disease, hospital infection, errors in treatment, patient left against medical advice etc. these criteria or variables are against the quality care. • 2. Credit items:-these are the items that gives credit to the care rendered. Number of recovered patients, expansion of health knowledge in patient population, shorter stay of patients etc is the example of this type of items. • 3. Nursing auditors:- Nursing auditors required are of two types: internal and external. These should be trained auditors.
  46. 46. Conti… • 4. Quality:- it is a degree of excellence that need to be defined and predetermined on the basis; the nursing audit is to be done. • 5. Nursing standard:- these should be valid and explicit statement about the quality of fact of nursing care. These are classified as : structure, process & outcome. • 6. Activities:- these are goal oriented transactions required to carry out for auditing. • 7. Resources:- these are in relation to human and material required for auditing and desired health care.
  47. 47. TYPES OF NURSING AUDIT • 1. According to methodology • 2. According to type of auditors
  48. 48. According to methodology Retrospective ConcurrentRetrospective & Concurrent
  49. 49. 2. According to type of auditors: • a) Internal audit: review of work is done by peers or nursing personnel continuously. • b) External audit: the audit is carried out by the outside agency. Usually periodically test, completeness and accuracy of internal audit is done. Review is done by non nursing administrators.
  50. 50. NURSING AUDIT PROCESS Describing phase Preparing phase Implementing phase Analysis phase Concluding phase
  51. 51. 1. Describing phase: • a) Identify topic or issue or problem: this stage involves the selection of a topic to be audited. The topic should be important or significant and interest those conducting the audit. The topic can be selected from various sources:- • Standard given by Indian Nursing Council • Problem encountered in practice • Recommendation of patient
  52. 52. Conti… • b) Identify core group & form an audit team or committee:- • Audit committee comprising of minimum of five members either from unidisciplinary or multidisciplinary, who are interested in quality assurance, are clinically competent & able to work together in a group.
  53. 53. Preferably the audit committee should have:- . chairman, • clinical consultants, • representatives of hospital administrator, • statistical record officer, • representative of nursing personnel of all levels, • special invitee members.
  54. 54. Conti… • c) Set audit criteria and standard: • an audit criteria is a measurable outcome of care aspect of practice or capacity in a statement form that can be used to assess the quality.
  55. 55. Conti.. • d) Develop an audit protocol: • An audit protocol should include: • • Audit objectives • • The target group • • Selection of audit sample • • Method of data collection • • Tools to be prepared
  56. 56. 2. Preparing & implementing phase: • a) Define criteria & prepare audit tools: prepare a rough draft of audit tools after refining criteria. Check the validity & reliability of tools. • b) Make a plan for gathering information: • This should include: • • Who is going to gather information. • • Select the auditors • • When to gather the information. • • How large the target group at one time. • c) Get ethical approval from ethical committee
  57. 57. Conti… • 3. Implementing phase: during this phase data gathering has to be done.
  58. 58. 4. Analysis & Concluding phase: • a) Analyze data & compare results with criteria & standard: after collection, analyze the data. Apply appropriate statistics, usually data is calculated in percentage in order to determine the level of standard. Compare data with set criteria. • b) Make an audit summary: specify how far the standards have been met & the reasons for failures to meet the standards in some cases. Make a brief report & give recommendations after discussion with audit team.
  59. 59. • c) Plan & implementing change: a detailed action plan should be made specifying in detail who, when, what & how the changes are to be implemented. All the members of the committee are required to be informed & members ate to be assigned to monitor the changes implemented. • d) Reaudit : it is undertaken to ensure that the changes have been made in response to first audit & that the practice has improved or how effective the first audit.
  61. 61. • 1. Fabiane Gorni BorsatoI; Mariana Ângela Rossaneis et al. conducted a study on Assessment of quality of nursing documentation in a University Hospital Londrina (PR), Brazil. It was a descriptive, quantitative research study with data collection supported by the available reports of quality assurance in nursing at the institution, from 2002 to 2009. Attributed to the item, "Documentation of Nursing", were these criteria: complete, incomplete, not filled in, and incorrect, for which was adopted as satisfactory: over 80%, below 15%, below 5%, and 0%, respectively. The division of inpatient satisfaction reached in 2007, with 82.2% of the documentation completed. The intensive care units did not achieve satisfaction in any of the criteria. The Maternal-Child Health Division had 90.7% of records complete in 2009.
  62. 62. • 2. Mansoureh Z. Tafreshi, Mehrnoosh Pazargadi et al. conducted a qualitative study on Nurses' perspectives on quality of nursing care in Shaheed Beheshti Medical Sciences University, Tehran, Iran. In this paper data were collected in two phases (ten individual interviews and five focus group discussions). A total of 44 clinical nurses and ten nursing experts participated through a purposeful sampling frame. Data analysis was conducted by latent content analysis to achieve a definition of nursing care quality.
  63. 63. • The findings in this paper show that, according to similarities and differences between nursing experts' and clinical nurses' perspectives on quality, the final definition is “delivery of safety care based on nursing standards which eventuates in patient satisfaction”. Findings reveal that in nurses' perspectives on quality definition two important aspects have been mostly considered: “standard of care” and “patient satisfaction”. Moreover, both participant groups have emphasized the benefits of collaborative work in health care (teamwork). Further in this study, organizational and socio‐cultural roles in delivering quality nursing care have been mentioned such as staffing, budget, leadership, and social perspectives about nursing as a highly educated profession.
  64. 64. • • 3. Sarieh Poortaghi, Mahvash Salsali et al. conducted a descriptive study on findings from a nursing care audit based on the nursing process. In this study nursing audit checklist was designed and validated for assessing nurses’ compliance with nursing process. A total of 300 nurses from various clinical settings of Tehran university of medical sciences were selected. Data were analyzed using descriptive and inferential statistics, including frequencies, Pearson correlation coefficient and independent samples t- tests. The compliance rate of nursing process indicators was 79.71 ± 0.87. Mean compliance scores did not significantly differ by education level and gender. However, overall compliance scores were correlated with nurses’ age (r = 0.26, P = 0.001) and work experience (r = 0.273, P = 0.001). Nursing process indicators can be used to audit nursing care. Such audits can be used as quality assurance tools.
  65. 65. REFRENCES • 1. Joginder vati. Principles and Practice of Nursing Management and Administration. Jaypee publication. Page no. 93- 125, 145-150 • 2. Yoder wise. Leading and Managing in Nursing. Elsevier publications. Page no. 144- 160 • 3. Fabiane Gorni BorsatoI; Mariana Ângela Rossaneis et al. conducted a study on Assessment of quality of nursing documentation in a University Hospital Londrina (PR), Brazil. Acta paul. enferm. vol.24 no.4 São Paulo 2011. • 4. Mansoureh Z. Tafreshi, Mehrnoosh Pazargadi et al. conducted a qualitative study on Nurses' perspectives on quality of nursing care in Shaheed Beheshti Medical Sciences University, Tehran, Iran. international journal of health care quality assurance volume 20, issue 4. Pp 320-328. • 5. Sarieh Poortaghi, Mahvash Salsali et al. conducted a descriptive study on findings from a nursing care audit based on the nursing process. Nurs Midwifery Stud. 2015 Sep 23; 4(3): e30181. doi: 10.17795/nmsjournal30181