NURSING MANAGEMENT SEMINAR ON QUALITY ASSURANCECONTINUOUS QUALITY IMPROVEMENT

NURSING MANAGEMENT SEMINAR ON QUALITY ASSURANCECONTINUOUS QUALITY IMPROVEMENT 17. 08. 2010

TERMINOLOGIES • Quality: It is the measurable and precise confirmation to the established standards. • Quality Management: It refers to a philosophy that defines a corporate culture emphasizing customer satisfaction, innovation and employee involvement. • Continuous Quality Improvement: It is an ongoing process of innovation, prevention of error, and staff development that is used by corporations and institutions that adopt the quality management philosophy.

Quality Assurance: Means of delivering relevant and effective product (medical care) in accordance with the standards. Accreditation: The process of providing an official approval to an organization stating that it has achieved a required standard. JCAHO: Joint Commission on Accreditation of Health care Organization is the primary accrediting organizing for health care institutions. Standards: These are formal statements about how patients should be managed or services be delivered. Audit: An independent review conducted to compare some aspect of quality performance with a standard for that performance.

DEFINITION *“Quality assurance is a judgment concerning the process of care based on the extent to which that care contributes to valued outcomes. ” -Donabedian 1982 *“Quality assurance is the measurement of provision against expectations with declared intention and ability to correct any demonstrated weakness. ” -Shaw

*“Quality assurance is a management system designed to give maximum guarantee and ensure confidence that the service provided is up to the given accepted level of quality, the standards prescribed for that service which is being achieved with a minimum of total expenditure. ” -British Standards Institute * “CQI is an ongoing quality improvement measure using management and scientific methods of quality assurance involving data collection, its analysis, and formulating ways to improve performance outcome according to proposed standards. ”

Quality assurance vs. Continuous quality improvement (Koch, 1993) Quality assurance (QA) Quality Improvement (QI) Inspection oriented (detection) Reaction Correction of special causes Responsibility of few people Narrow focus Leadership may not be vested Planning oriented (prevention) Proactive Correction of common causes Responsibility of all people involved with the work Cross- functional Leadership actively leading Problem solving by authority Problem solving by employees at all levels

OBJECTIVES To successfully achieve sustained improvement in health care, clinics need to design processes to meet the needs of patients. To design processes well, and systematically monitor, analyze, and improve their performance to improve patient outcomes. A designed system should include standardized, predictable processes based on best practices. Set Incremental goals as needed. NASA Ames Research Center Health Unit

Management improvement Public accountability Facilitation of adoption of innovations

To provide technical assistance in designing and implementing effective strategies for monitoring quality To refine existing methods for ensuring optimal quality health care through an applied research programme (Decker, 1985 and Schroeder, 1984).

PURPOSES/ NEED § § § § § Rising expectations of consumer of services. Increasing pressure on allocation of funds. The increasing complexity of health care organizations. Improvement of job satisfaction. Highly informed consumer To prevent rising medical errors Rise in health insurance industry Accreditation bodies Reducing global boundaries.

PRINCIPLES QM operates most effectively within a flat, democratic and organizational structure. Managers and workers must be committed to quality improvement. The goal of QM is to improve systems and processes and not to assign blame. Customers define quality. Quality improvement focuses on outcome. Decisions must be based on data.

According to W Edward Deming; (Deming’s 14 points) i. Crete consistency of purpose for improvement of product and service. ii. Adopt the new philosophy iii. Cease dependence on inspection to achieve quality. iv. End the practice of awarding business on the basis of price tag. v. Improve constantly and forever the systems of production and service. vi. Institute training on the job. vii. Institute leadership.

viii. Drive out fear. ix. Break down barriers between departments. x. Eliminate slogans, exhortations, and target for the workforce. xi. Eliminate numerous quotas for the workforce and numerical goals of management. xii. Remove barriers that rob people of pride and workmanship. xiii. Institute a vigorous programme of education and selfimprovement for everyone. xiv. Put everyone in the company to work to accomplish the transformation.

General approach • • Credentialing Licensure Accreditation Certification Charter Recognition Academic degree Specific approach • • • • Audit Direct observation Appropriateness evaluation Peer review Bench marking Supervisory evaluation Self-evaluation Client satisfaction Control committees Services Trajectory Staging Sentinel

ELEMENTS/ COMPONENTS According to Donabedian; Structure Element- The physical, financial and organizational resources provided for health care. Process Element- The activities of a health system or healthcare personnel in the provision of care. Outcome Element- A change in the patient’s current or future health that results from nursing interventions.

According to Manwell, Shaw, and Beurri, there are 3 A’s and 3 E’s; Access to healthcare Acceptability Appropriateness and relevance to need Effectiveness Efficiency Equity

STANDARDS ‘Standards are written formal statements to describe how an organization or professional should deliver health service and are guidelines against which services can be assessed. ’ Kirk and Hoesing (1991) stated that standards are needed to; Provide direction Reach agreement on expectations Monitor and evaluate results Guide organizations, people and patients to obtain optimal results.

§ AHRQ –Agency for Healthcare Research and Quality § § IHI –Institute for Healthcare Improvement JCAHO –Joint Commission on Accreditation of Healthcare Organizations § NAHQ –National Association for Healthcare Quality § § IOM –Institute of Medicine NCQA –National Committee for Quality Assurance

Outpatient department Training Emergency medical services Areas of QA Specialty services In- patient services

MODELS 1. Donabedian Model (1985):

2. ANA Model: This first proposed and accepted model of quality assurance was given by Long & Black in 1975. This helps in the self- determination of patient and family, nursing health orientation, patient’s right to quality care and nursing contributions. structure outcome Evaluate outcome of standards and criteria Identify structure , standard and criteria Apply the process, standards and criteria process

3. Quality Health Outcome Model: The uniqueness of this model proposed by Mitchell & Co is the point that there are dynamic relationships with indicators that not only act upon, but also reciprocally affect the various components. System (Individual, Group/ organization) Intervention Outcome Client (Individual, Family & Community)

4. Plan, Do, Study, Act cycle: It is an improvement model advocated by Dr. Deming. v. A Plan is developed to test one of the improvement changes. v. During the Do phase, the change is made, and data are collected to evaluate the results. v. Study involves analysis of the data collected in the previous step. Data are evaluated for evidence that an improvement has been made. v. The Act step involves taking actions that will ‘hardwire’ the change so that the gains made by the improvement are sustained over time.

5. Six Sigma: It refers to six standard deviations from the mean and is generally used in quality improvement to define the number of acceptable defects or errors produced by a process. *It consists of 5 steps: define, measure, analyze, improve and control (DMAIC). Define: Questions are asked about key customer requirements and key processes to support those requirements. Measure: Key processes are identified and data are collected. Analyze: Data are converted to information; Causes of process variation are identified. Improve: This stage generates solutions and make and measures process changes. Control: Processes that are performing in a predictable way at a desirable level are in control.

QUALITY TOOLS UDSED FOR CQI chart audits failure mode and effect analysis: prospective view root cause analysis: retrospective view flow diagrams pareto diagram histograms run charts control charts

INDICATORS OF QUALITY ASSURANCE Waiting time for different services in the hospital Medical errors in judgment, diagnosis, laboratory reporting, medical treatment or surgical procedures, etc. Hospital infections including hospital- acquired infections, cross infections. Quality of services in key areas like blood bank, laboratories, X- ray department, central sterilization services, pharmacy and nursing.

Identify needs. QUALITY IMPROVEMENT PROCESS- STEPS Assemble a multidisciplinary team. Collect data. Establish measurable outcomes and quality indicators. Select and implement a plan. Evaluate implementation of plan and achievement of outcomes.

JCAHO quality assurance guidelines/steps: 1. Assign responsibility 2. Delineate scope of care and services 3. Identify important aspects of care and services 4. Identify indicators of outcome (no less than 2; no more than 4) 5. Establish thresholds for evaluation 6. Collect data 7. Evaluate data 8. Take action 9. Assess action taken 10. Communicate

NURSING AUDIT q“Nursing audit refers to the assessment of the quality of clinical nursing. ” q“Nursing - Elison audit is the means by which nurses themselves can define standards from their point of view and describe the actual practice of nursing. ” - Goster Walfer

Improves quality of nursing care Compares actual practice with agreed standards of practice. It includes followup or repeating audit Provides feedback R A H C S C I T IS R E T C A It requires the identification of variations It is formal and systemic. It involves peer review.

To evaluate the quality of nursing care given. To achieve the desired and feasible quality of care. To contribute to research. OBJECTIVES To provide rationalized care thereby maintaining uniform standards worldwide. To provide a way for better records. To focus on care provided and care provider.

METHODS OF AUDIT Retrospective view - It refers to the detail quality care assessment after the patient has been discharged. Concurrent view- It is achieved by reviewing patient care during the time of hospital stay by the patient.

AUDIT CYCLE *According to Payne, the steps in audit or utilization review include; Criteria development Selection of cases Work sheet preparation Case evaluation Tabulation of evaluation Presentation of reports

The basic audit cycle can be depicted as; 4. implement change 1. set standards 3. compare with standards 2. observe practice changes

ADVANTAGES Patient is assured of good service. Better planning of quality improvement can be done. It develops openness to change. It provides assurance, by meeting evidence based practice. It increases understanding of client’s expectations. It minimizes error or harm to patients. It reduces complaints or claims.

DISADVANTAGES It may be considered as a punishment to professional group. Medico- legal importance- They feel that they will be used in court of law. Many components may make analysis difficult. It is time consuming It requires a team of trained auditors.

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