Quality assurance

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1. Quality Assurance

2. DEFINITION Dictionary meaning : Character with respect to fineness, or grade of excellence . ‘Quality is the degree to which a product confirms to specification and workmanship standards.’- John D . McClellan

3. QUALITY ‘ Quality is defined as the capability of a product to fulfill its intended purpose, produced with least possible cost .’ –AV Flegen Baum Quality is an achievable, measurable, profitable, entity once you have commitment and understanding and are prepared for hard work.

4. QUALITY IN HEALTH CARE SETTING “Quality is described as levels of excellence produced and documented in the process of patient care, based on the best knowledge available and achievable at a particular facility.” –The National association of quality assurance professionals.

5. “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)

6. PURPOSE OF QUALITY To meet the needs and expectation of the customers, both external and internal To meet increased demand for effective and appropriate care Need for standardization and variance control To minimize the errors and further eliminated to attain excellence in care

7. Contd… To minimize the errors and further eliminated to attain excellence in care To bring improvement in care and services To bring efficiency in the use of health care resources and effectiveness in the delivery of care and services To reduce the failure and appraisal costs

8. Contd… To fit into the pressure of competition and to enhance marketing For accreditation, certification and regulation To fulfill the ethical code to provide the best and most appropriate care accessible to the patient To fulfill the desire for recognition and to strive for excellence To attract recognition in the field and will encourage other individual, organizations or systems to emulate and follow. (Benchmarking)

9. COMPONENTS OF QUALITY IN HEALTH CARE 1. Safety 2. Effectiveness 3. Patient centeredness 4. Timeliness

10. 1. SAFETY Improving safety means designing and implementing health care processes to avoid, prevent and ameliorate adverse outcome or injuries that stem from the process of health care itself. Safety is best understood in terms of injuries that occur to the patient and the errors and latent failures that lead to these injuries or harm.

11. 2. EFFECTIVENESS Effectiveness is probably the component of health care quality most readily identified because ultimately it represents the ‘bottom’, that is whether care leads to improved outcome in terms of health status and quality of life for patients. Effectiveness should distinguish from efficiency. It refers to avoiding waste, including waste of equipment, supplies, ideas and energy .

12. 3. PATIENT CENTERDNESS It refers to the health care that establishes a partnership among health workers, patients, and their families to ensure that decision respect patient’s wants, need and preferences and that patients have the education and support they need to make decisions and participate in their own care. Patients of different races, cultures, genders and ages have different preferences and beliefs that providers must take into account in order to achieve patient centered care. Patient vary in the degree of autonomy and involvement that they want in health care decision making.

13. 4. TIMELINESS It combines being able to obtain care and getting it promptly. It includes both access to care (people can get care when they need) and coordination of care (once under care, the system facilitates moving people across providers and through the stage of care ).

14. QUALITY ASSURANCE History suggests that the first person that started the quality movement in health care was Florence Nightingale back in the mid 1800’s. The nurse Nightingale was instrumental in noticing that there is a direct correlation between a good nursing care and a quality outcome

15. DEFINITION QUALITY ASSURANCE “Quality assurance is a judgment concerning the process of care, based on the extents to which that care contributes to valued outcomes”. – Donabedian, 1982 “The set of activities that are carried out to set standards and to monitor and improve performance so that the care provided is as effective and as safe as possible”. –Quality Assurance Project.

16. RELATED KEY TERMS Quality Control Quality Improvement Continuous Quality Improvement Quality Management Total Quality Management Institutionalization of Quality Assurance Quality Circle

17. Quality Control It is defined as the process by which actual performance is measured, the performance is compared with goals, and the difference is acted upon. The statistical methods are used to measure the quality.

18. Quality Improvement It is defined as the process and sub process of reducing variation of performance or variance from standard in order to achieve a better outcome to the organization’s customers. Key issue involves ability of this process to identify and act on variance.

19. Continuous Quality Improvement In 1980’s QA was replaced by continuous quality improvement. It involves a coordinated and integrated approach for improving processes that affect patient outcome. Performance management has replaced later CQI. This term is specific. It encompasses three critical programs: a ) awareness b) measurement and c) improvement.

20. Quality management Quality management is a structural umbrella over all processes and activities related to quality assurance and quality improvement. Quality management is responsible for the coordination and facilitation of these activities in an organization. Specifically quality management is involved in the selection of health care quality personnel, the allocation of other resources, the monitoring and evaluation of plans and the launching of improvement teams.

21. Total Quality Management Total quality management is a management approach of an organization centered on quality based on the participation of all its members and aiming at long-term success through customer satisfaction, and benefits to all members of the organization and to the society.

22. Institutionalization of quality assurance Every institution has their own style and system to assure the quality of their product or service. Support from the management to create the environment is very challenging in the institutionalization quality assurance

23. Quality Circle Quality circle is a system where the employees are identified, recognized and their participation is drawn integrated with a system which satisfies their ‘ego’ needs so that they will be more motivated to work effectively than only their participation. The philosophy of quality circle is based on MASLOW Theory. Based on participative management style

24. ELEMENTS OF QUALITY CIRCLE Its people building philosophy Its voluntary Employees help others to develop Everyone participate Training is emphasized Creativity is encouraged Management has to be supportive

25. OBJECTIVES OF QUALITY ASSURANCE According to Jonas (2000), the two main objectives are; To ensure the delivery of quality client care To demonstrate the efforts of the health care providers to provide the best possible results

26. Other specific objectives are: 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

27. PRINCIPLE OF QUALITY ASSURANCE Four major principles include : 1. Focus on customer: Satisfying need of the customers is the primary goal of quality management. Customer may be internal (working within the organization, e.g., CMA of PHC) or external . 2. Teamwork and employee participation: Quality can only be delivered by healthy interpersonal relationships and teamwork that is based on such relationship.

28. Contd… 3. Focus on systems: All components of systems (structures, process and outcomes) need to be assessed, evaluated and improved collectively and individually. If we desire quality, each component must be at the optimal level. No one part can be said to be more important than the other. Quality of the health care system is interdependent on its parts and elements.

29. Contd… 4. Data driven/based: The process of quality improvement (QI), quality assurance (QA) and quality management (QM) is based on documented and calculated progress. Without data quality cannot be measured. And if measurement is not possible, quality cannot be calculated, nor improvements documented. QI training therefore requires a strong component of the collection, appropriate data analysis, the sensible use of tools and data management systems/methods, and effective use of data.

30. Other Principles Include Leadership Commitment Process oriented Outcome driven Participative approach Individual responsibility Employee empowerment Continuous process

31. Contd… Interdisciplinary Education and re-training System of employee reward and recognition Preventive management Various control Benchmarking Mutually beneficial supplier relationship

32. WHY QUALITY ASSURANCE IN HEALTHCARE Increased consumer demand for effective and appropriate care Need for standardization and variance control Necessity for cost saving measures Benchmarking Accreditation , certification, and regulation

33. contd… Assessment of provider performance Requirement to define and meet consumer needs and expectations Need for continuous improvement in care and services Desire for recognition and strive for excellence Ethical and legal consideration

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

35. QUALITY ASSURANCE COMMITTEE AT DIFFERENT LEVEL National quality assurance committee Central quality assurance committee Institutional quality assurance committee Specialize unit level quality assurance committee

36. QUALTY ERROR Quality improvement is essential to focus on systems, policies, procedures and tools because there are concepts that : 85 % = System error that includes policies, procedures and tools . II. 15% = Human/ Worker error

37. FACTORS AFFECTING QUALITY ASSURANCE Patient’s values Social values Structural resources Accreditation bodies Legislature enactments Available resources Administrative values Nursing values Evaluation policy Job description In service education program

38. QUALITY ASSURANCE PROCESS

39. Contd…

40. IMPLEMENTATION OF QUALITY ASSURANCE IN HEALTH CARE SETTING The basic steps include: a. Cultivate leadership commitment. b. Support from national and international . c. Re-organize . d. Increase awareness . e. Determine the intervention methodology and design.

41. Contd… Allocate resources Train Experimental study Assessments and intervention j. Disseminate and evaluate

42. MODELS OF QUALITY ASSURANCE System model American nurses association Donabedian model Focus – PDCA model

43. System Model Of Quality Assurance The basic components of the system are Input Throughput Output Feedback

44. i ) Input :- Can be compared to the present state of the system.   ii) Through put :- The through put to the developmental process.   iii) Out put :- To the finished product.   iv) Feed Back :- It is the essential component of the system because it maintains and nourish growth .

45. American Nurse Association Model For Quality Assurance Identify values Identify structure, process and outcome standards and criteria Select measurement Make interpretation

46. Identify course of action Choose action Take action Reevaluate

47. Donabedian Model structure process outcome

48. Plan, Do, Check, Act Model

49. APPROACHES OF QUALITY IMPROVEMENT General Approaches Credentialing Licensure Accreditation Certification Specific A pproaches Peer Review Committees (Staff Review Committees) Standard as a device for quality assurance Audit as a tool for quality assurance

50. 1) Credentialing: It is generally defined as the formal recognition of professional or technical competence and attainment of minimum standards by a person or agency According to Hinvasky (1981) Credentialing process has four functional components a) To produce a quality product b) To confer a unique identity c) To protect provider and public d) To control the profession.

51. 2. licensure Individual licensure is a contract between the profession and the state, in which the profession is granted control over entry into and exists from the profession and over quality of professional practice. The licensing process requires that regulations be written to define the scopes and limits of the professional's practice. Licensure of nurses has been mandated by law since 1903

52. 3.Accreditation: National league for nursing (NLN) a voluntary organization has established standards for inspecting nursing education's programs. In the part the accreditation process primarily evaluated on agency's physical structure, organizational structure and personal qualification 4.Certification: Certification is usually a voluntary process with in the profession. A person's educational achievements, experience and performance on examination are used to determine the person's qualifications for functioning in an identified specialty area.

53. • Peer Review Committees To maintain high standards, peer review has been initiated to carefully review the quality of practice demonstrated by members of a professional group. Peer review is divided in to two types. One centers on the recipients of health services by means of auditing the quality of services rendered. The other centers on the health professional by evaluating the quality of individual performance

54. • Standard Healthcare standards are statements or guidelines of expectation for the input, process, behavior and outcomes of the health care system. Standards in health care are used to describe guidelines, protocols, standard operational procedures and specifications for clinical and nonclinical activities

55. A udit Nursing audit may be defined as a detailed review and evaluation of selected clinical records in order to evaluate the quality of nursing care and performance by comparing it with accepted standards. To be effective a nursing audit must be based on established criteria and feedback mechanism that provide information to providers on the quality of care delivered.

56. BARRIERS OF QUALITY IMPROVEMENT EFFORT 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.

57. Contd… 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

58. ROLE OF NURSES 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 initiatives

59. Contd… Participate 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 research works related to quality assurance. Identify any area of needed improvement in delivery of care.

60. A study of quality management practices in nursing in universities in Australia . - Mary Cruickshank; Australian Health Review [Vol 26 • No 1] 2003 In Australia, the traditional Quality Assurance approach used in the hospital setting has played an important role in nursing practice. During the past decade, nurses have begun making a paradigm shift from Quality Assurance to Total Quality Management but scant attention has been paid to quality management practices in nursing in the higher education sector. This paper reports on a quantitative study examining the perceptions of nurse academics to the applicability of TQM to nursing in universities.

61. The research study was undertaken in two stages over a period of 18 months. Sample taken were 25 nurse academics. The survey found that only 44.5% of respondents indicated that the school of nursing where they were currently employed had a formal Quality Assurance program and the QA programs that did exist consisted of three major components. They were course review, subject or unit review, and nurse academic staff performance and peer review. Thus, the findings of this research strongly suggest that the introduction of Total Quality Management into nursing education is a challenge to nurse academics.

62. BIBLIOGRAPHY 1. Vati Jogindra , Principles and Practice of Nursing Management and Administration, New Delhi, Jaypee Publishers, 2013. Pg no. 93-110 2. Mehta R.S., Tara Pokharel , Leadership and Management, Kathmandu, Makalu Publishers, second edition, 2010. Pg no. 156-59 3. Dahal R. Achyut , A Textbook of Health Management, Kathmandu, Vidhyarthi Pustak Bhandar , 2012. Pg no. 394-410. 4. Singh Indira, Leading and Managing in Health, Kathmandu, Hisi Offset Printers, 2006. Pg no. 254-62.