Quality Assurance 2. PPTX in leadership and management

Quality assurance in delivery of health services

1. QUALITY ASSURANCE 1

2. Introduction Quality is difficult to define as it is dependant on the perspective of those concerned. E.g. an accountant will look at the cost effectiveness, others may look at the reliability. At the end of the day quality is considered good and worth having. However most definitions of quality emphasize the degree to which something fulfils requirements. Customers also want quality from their perspective. They want satisfaction, but not necessarily the cost, but look at availability, reliability, effectiveness and courtesy. In a health care setting patients require respect, concerned about waiting time , provision of medicines Therefore quality is a matter of concern for all including client and managing directors. Many quality principles are based on management theories. We shall discuss 2

3. OBJECTIVES At the end of this session, the student should be able to: Define the terms used in Quality Assurance List the Eight q uality management principles Define, and elaborate the quality assurance process Identify key quality standards and framework and discuss their benefit Discuss the methods used in monitoring the nursing care for the quality assurance Identify clinical indicators of quality care 3

4. EXPECTED OUTCOMES OF QUALITY ASSURANCE To ensure the delivery of quality client care To demonstrate the efforts of the health care providers to provide the best possible results Formulate plan of care Attend the patients physical and non-physical needs Evaluate achievement of nursing care Support delivery of nursing care with administrative and managerial services 4

5. DEFINITIONS In order to understand quality assurance the nurse manager needs to understand the legislative, voluntary, and professional bodies associated with QA and also be familiar with the definitions ( Gillies , 1994 ) 5

6. KEY TERMS RELATED TO QUALITY ASSURANCE Quality Quality Assurance Quality Standards Quality Management Total Quality Management (TQM) Continuous Quality Improvement (CQI) Quality Control (QC) 6

7. DEFINITIONS 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) QUALITY ASSURANCE (QA) • “Quality Assurance is an on-going, systematic comprehensive evaluation of health care services and the impact of those services on health care services. – Kozier 7

8. DEFINITIONS OF TERMS Quality assurance focuses on enhancing and improving the process that is used to create the end result, rather than focusing on the result itself. Among the parts of the process that are considered in QA are planning, designing, development, production and service provision . Quality Assurance describes all activities related to establishing, maintaining and assuring high quality care for patients. 8

9. QUALITY STANDARDS A framework for achieving a recognized level of quality within an organization. Achievements of a quality standard demonstrated that an organization has met the requirements laid out by a certifying body e.g. International O rganization for Standardization (ISO) is an international standard setting body, composed of representatives from various national standards organizations. ISO disseminates world wide proprietary industrial and commercial standards. ISO 9000 is a family of standards for quality management systems. It is implemented by 1 million organizations in 175 countries. It is an international reference for quality management requirements in business to business dealings, also (ISO 8402) 9

10. QUALITY MANAGEMENT Systematic policies, methods and procedures used to ensure that goods and services are produced with appropriate levels of quality to meet the needs of clients or patients. Quality management maybe viewed as a proactive or reactive approach, for continuous improvements to minimise errors. 10

11. TOTAL QUALITY MANAGEMENT (TQM) A quality Approach that emphasises a continuous process of improvement, through the involvement of people. An integrated management philosophy and set of practices that emphasize, continuous improvement, meeting customer’s requirements reducing re-work, long thinking, increased employee involvement and team work, process redesign, competitive bench marking, team based problem solving, constant measurement of results and closer relationship with clients. Benefits include better customer satisfaction increase patient outcome 11

12. CONTINUOUS QUALITY IMPROVEMENT (CQI) A theory based management system that looks at processes/outcomes, cultural change, it is a client centred philosophy, tools to help quantify what we do. A search for common causes of variation. Driven by data system processes and client feedback, shared success long term approach. It is likened to a project cycle with has components of assessing planning implementing monitoring and evaluating for the purposes of arriving at an improved product or service. 12

13. QUALITY CONTROL Quality control is a set of procedures intended to ensure/monitor an activity or service that it has reached/maintained a required standard . 13

14. PERCEIVED QUALITY Perception of quality is the opinion, impression or feeling that consumers have of a service 14

15. DEFINITIONS Cont. A standard is the desired quantity, quality, or level of performance that is established as a criterion against which worker performance will be measured. A norm is current level of performance of a selected work group with reference to a given criterion. An Objective is a goal toward which effort is directed. To be effective, an objective should be expressed in observable, measurable terms and should include target date for fulfilment. 15

16. DEFINITIONS Cont. Accountability is the obligation to provide an estimate for one’s actions to the persons who delegated authority for that action. A nursing care Outcome: is the end result of a nursing intervention, a measurable change in the state of a patient’s health that is as a circumstance by nursing action. A criterion is the value free name of a variable that is known to be a reliable indicator of quality. Example, nurses educational preparation affect the quality of patient care decisions. Level of satisfaction 16

17. DEFINITIONS Cont. A Critical clinical indicator is a quantitative measure that can be used as a guide to monitor and evaluate the quality of important patient care activities. E.G. Artificial Ventilator in ICU 17

18. QUALITY MANAGEMENT SYSTEM(QMS) A systematic approach to proactively managing quality based on documented standards and operating procedures. The best known QMSs are those based on the ISO 9000 series quality standards 18

19. PRINCIPLES OF QUALITY ASSURANCE Customer focus Leadership Involvement of people Process approach System approach to management Continual improvement Factual approach to decision making Mutually beneficial supplier relationship 19

20. QUALITY MANAGEMENT PRINCIPLES Customer focus organizations - depend on their customers and therefore should understand current and future customer needs, should meet customer requirements and strive to exceed customer expectations Leadership –leaders establish unity of purpose and direction of the organization. They should create and maintain the internal environment in which people can become fully involved in achieving the organizations objectives Involvement of people - people at all levels are the essence of an organization and their full involvement enables their abilities to be used for the organization’s benefit 20

21. QUALITY MANAGEMENT PRINCIPLES 4 . Process approach – a desired result is achieved more efficiently when activities and related resources are managed as a process. 5. System approach to management –identifying, understanding and managing interrelated processes as a system contributes to the organizations effectiveness and efficiency in achieving its objectives 6 . Continual improvement- continual improvement of the organization’s overall performance should be a permanent objective of the organization 21

22. QUALITY MANAGEMENT PRINCIPLES CONT. 7. Factual approach to decision making –effective decisions are based on the analysis of data and information 8. Mutual beneficial supplier relationship – an organization and its suppliers are interdependent and mutually beneficial relationship enhances the ability of both to create value. 22

23. TOTAL QUALITY MANAGEMENT (TQM) A quality approach that emphasises a continuous process of improvement, through the involvement of people 23

24. COMPONENTS OF QUALITY ASSURANCE STRUCTURE EVALUATION PROCESS EVALUATION OUTCOME EVALUATION QUALITY ASSURANCE PROCESS 24

25. QUALITY ASSURANCE PROCESS 1. Establishment of standards or criteria 2 . Identify the information relevant to criteria 3 . Determine ways to collect information 4 . Collect and analyze the information 5 . Compare collected information with established criteria 6. Make a judgment about quality 7. Provide information and if necessary, take corrective action regarding findings of appropriate sources 8 . Determine ways to collect the information 25

26. MODELS OF QUALITY ASSURANCE System Model 1. Input 2. Throughput 3. Output 4. Feedback ANA Quality Assurance Model - Safety measures devoted to nursing professional practice - Plan , Do, Study, Act cycle 3. Donabedian Model – conceptual model that provides a framework for examining health services –structure process outcome 26

27. QUALITY ASSURANCE PROCESS This is the systematic process of evaluating the quality of care given in a particular unit or institution. It involves setting standards, determining criteria to meet those standards. It involves data collection, evaluating how well the criteria have been met, making plans for change based on the evaluation, and following up on implementation for change 27

28. SETTING STANDARDS The nursing profession should have to design standards of nursing practice that are specific to the patient population served (ANA QA Model) These standards could serve as the foundation upon which all other measures of quality assurance are based. An example of a standard is: Every patient will have a written care plan . 28

29. DETERMINING CRITERIA After standards of performance are established, criteria must be determined that will indicate if the standards are being met and to what degree they are met. Just as with standards of care, criteria must be general as well as specific to the individual unit . One criterion to demonstrate that the standards regarding care plans for every patient are being met would be: A nursing care plan is developed and written by a nurse within 12 hours of admission. This criterion, then, provides a measurable indicator to evaluate performance 29

30. DATA COLLECTION The actual collection of data is the third step in quality assurance. Sufficient observations and random samples are necessary for producing reliable and valid information. A useful rule is that 10 percent of the institutional patient population per month should be sampled for QA. The devised tool to collect data should leave as little room for interpretation by the data collector as possible. Data collectors need to be taught the purpose of quality assurance along with the principles of data collection. 30

31. DATA COLLECTION METHODS Data collection methods include patient observations and interviews, nurse observations and interviews, and review of charts. Flow sheets and Kardexes records of input and output of resources or services, are also resources from which to assemble information about past and present conditions 31

32. QUALITY ASSURANCE POLICY A QA policy should outline guidelines of the reporting of quality assurance data so it is clear who in the organization needs to receive quality assurance information. The QA policy should also state at what level in the organization the analysis of the different criteria is take place, to whom these analyses and recommendations are to be reported, who is responsible for implementing the recommendations, and who is responsible for follow up. Unless definite policies are established, the system may fail and changes in nursing practice are not likely to occur (Sullivan, 1992). 32

33. EVALUATING PERFORMANCE Several methods can be used to evaluate performance . These include reviewing documented records Observing activities as they take place E xamining patients, and interviewing patients, families, and staff. Records are the most commonly used source for evaluation because of the relative ease of their use, but they are not as reliable as direct observations . It is quite possible to write in the patient’s chart activities that were not done or not to record those things that were done. 33

34. EVALUATING PERFORMANCE T he chart only indicates that care was provided ; it does not demonstrate the quality of that care. For example, care plan could be checked as well as nursing diagnosis, interventions planned, and discharge planning. 34

35. MONITORING NURSING CARE In addition to the individual patient care activities described, another component of quality assurance is the ongoing monitoring of nursing care. Several methods are used to monitor nursing care. These include : N ursing audit, peer review, utilization review, and patient satisfaction review 35

36. NURSING AUDIT Nursing Audit can be retrospective or concurrent . A retrospective audit is conducted after a patient’s discharge and involves examining records of a large number of cases. The patients’ entire course of care is evaluated and comparisons made across cases Recommendations for change can be made from the perspective of many patients with similar care problems and with the spectrum of care considered 36

37. NURSING AUDIT A concurrent Audit is conducted during the patient’s course of care It examines the care being given to achieve a desirable outcome in the patient’s health and evaluates the nursing care activities undertaken and recommend changes where necessary. 37

38. PEER REVIEW This occurs when practicing nurses determine the standards and criteria that indicate quality care and then assess performance against these. In this case, nurses are the “experts” at knowing what the indicators of quality care and when such care has been provided 38

39. Critical Indicators (Rate based) Surgical Unit Postoperative pneumonia • Paralytic ileus • Wound infection • Haemorrhage • Urinary tract infection • Phlebitis • Fever 39

40. LEVELS OF EVALUATION OF QUALITY OF CARE National Level Provincial level, District and Local Level 40

41. APPROACHES OF QUALITY IMPROVEMENT General Approaches • Credentialing • Licensure • Accreditation • Certification • Charter • Academic Degrees 41

42. APPROACHES OF QUALITY IMPROVEMENT Specific Approaches Peer Review Committees (Staff Review Committees) Standard as a device for quality assurance 42

43. FACTORS AFFECTING QUALITY ASSURANCE IN NURSING PRACTICE Lack of resources Personnel problems Improper maintenance Unreasonable P atients and attendants Absence of well-informed population Absence of accreditation laws Lack of incident review procedure 43

44. FACTORS AFFECTING QUALITY ASSURANCE IN NURSING PRACTICE Lack of good hospital information system Absence of patient Satisfaction Surveys Lack of nursing care research Miscellaneous Factors 44

45. BARRIERS OF QUALITY IMPROVEMENT EFFORTS The Nurse Manager might become pre occupied with quality assessment It is impossible to identify all factors that influence nursing care quality. Difficulty in defining outcome criteria that result solely from nursing intervention 45

46. BARRIERS OF QUALITY IMPROVEMENT EFFORTS Nurse’s documentation of care measures is at times vague, incomplete and lacking in objectivity There is still no single, all purpose, all site quality assessment tool that is universally appropriate for all health agencies. High cost of Q A 46

47. ROLE OF A NURSE IN QUALITY ASSURANCE Nurses are the active participant of interdisciplinary quality improvement team • Develop mechanism for continually monitoring the effectiveness of nursing care both a collaborative and an individual professional activity. • Contribute innovations and improvement of patient care • Participating in improvement projects and patient safety 47

48. ROLE OF A NURSE IN QUALITY ASSURANCE Participate in continuing educational programs and in- service educational programs for continuing professional development Periodic and continuing appraisal and evaluation of health care situation of the patient. Participate in research works related to quality assurance Identify any area of needed improvement in delivery of care. 48

49. Conclusion Quality is an extremely important ever present strategic tactical and operational management concept. It focuses on effectiveness and efficiency. Quality management begins with the consideration of clients, be they internal employees, other businesses or public. Their wants and needs must be translated into specifications of one kind or another. These specifications need to be developed and tested. Resources and operational plans have to be drawn up. Then delivery of products can begin. The process must be monitored and evaluated and improved upon to meet customer specifications. 49

50. REFERENCES Nursing Management . A Systems Approach, 3rd. ed. W. B. Saunders Company, Philadelphia. Hermann SJ. (1978). Becoming Assertive, A Guide for Nurses. New York, NY: D. Van Nostrand , Co. 27 Kotter , I.P., and L.A. Schlesinger (1979). "Choosing Strategies for Change", Harvard Business Review. Vol 57 (March - April) Lovell, R. (1994). Organizational Behavior . 6th. ed. New York, NY: McGraw- Hill; 404-406 ). Filley , A. C. (1975). Interpersonal Conflict Resolution . Glenview , IL: Scott , Foresman . Gillies , Ann Dee (1994). Nursing Management. A Systems Approach, 3rd. ed. W. B. Saunders Company, Philadelphia . Hermann SJ. (1978). Becoming Assertive, A Guide for Nurses. New York, NY: D . Van Nostrand , Co. 27 Kotter , I.P., and L.A. Schlesinger (1979). Applied Imagination: Principles and Procedures of Creative Thinking; rev. ed. New York: 1957. Ouchi , W.G. (1981). Theory Z: How American business can meet the Japanese Challenge. Reading MA: Addison-Wesley. Sullivan, P. Maureen (1990). Nursing Leadership and Introduction to Management and Leadership for Nurse Managers. 3rd ed. Jones and Bartlett Pub     50