Quality assurance -Models & approaches

Hospitals in India have a high burden of infection in their Intensive Care Unit and general wards,many of which are resistant to antibiotic treatment.In antibiotic resistant infections are difficult and sometimes impossible to treat.They lead to longer hospital stays,increased treatment cost and in some cases death.

1. Dr. Archana Selvan Principal RKDF CON, BHOPAL MODELS AND APPROACHES OF QUALITY ASSURANCE By

2. Introduction Hospitals in India have a high burden of infections in their intensive care units (ICU) and general wards, many of which are resistant to antibiotic treatment. A report by Global Antibiotic Resistance Partnership (GARP) . Antibiotic resistant infections are difficult, and sometimes impossible, to treat. They lead to longer hospital stays, increased treatment costs, and in some cases, death.

3. The GARP research estimates that approximately 190,000 neonatal deaths in India ,each year is due to sepsis – a bacterial infection that overwhelms the bloodstream and over 30 % are attributable to antibiotic resistance. Antibiotic resistant hospital infections can be especially deadly because:- Antibiotics are used intensely in hospitals compared with the community. Frequent use drives the development of highly resistant bacteria.

4. Tertiary care hospital in Pune , India (2016) reported Overall Prevalence Of Hospital Acquired Infection (HAI) - 3.76 % Surgical ICU - 25% Medical ICU - 20% Burns ward - 20% Paediatric ward - 12.17% PREVALENCE OF HOSPITAL ACQUIRED INFECTION (HAI)

5. What is HIA - (Hospital acquired infection) An infection occurring in a patient in a hospital or other health care facility, in whom the infection was not present or incubating at the time of admission. This includes infections acquired in the hospital but appearing after discharge, and also occupational infections among staff of the facility . Hospital acquired infection is also called as Nosocomial infection .

6. Potential Sources For HAI Hot/Cold Water Systems Cooling Towers Evaporative condensers Respiratory Equipment Spa pools, Natural pools, Thermal springs Fountains/Sprinklers Humidifiers for food display cabinets Water cooling machine tools Vehicles washes Ultrasonic misting machine

7. Patients at risk of Noso comial infections Age more than 70 years Major trauma Acute renal failure Coma Prior antibiotics Mechanical ventilation Drugs affecting the immune system like steroids, chemotherapy Indwelling catheters Prolonged ICU stay (>3 days).

8. Quality assurance in nursing is about ensuring adherence to quality standards as mandated by nursing regulatory bodies. Quality assurance in nursing assesses what health care processes are in place and what else needs to be implemented to better the system. So What to do - ???.. The Answer is Quality assurance

9. Definition Quality assurance is an on- going, systematic, comprehensive evaluation of health care services and the impact of those services on health care services. Kozier Quality assurance is defined as all activities undertaken to predate and prevent poor quality. Neetvert

10. CONCEPT OF QUALITY IN HEALTH CARE IS : The extent of resemblance between the purpose of healthcare and the truly granted care. Donabedian 1986 To ensure that the product consistently achieved customer satisfaction. A dynamic process through which nurses assume accountability for quality of care they provide.

11. The monitoring of the activities of client care to determine the degree of excellence attained to the implementation of the activities”. (Bull, 1985)  Defining of nursing practice through well written nursing standards and the use of those standards as a basis for evaluation on improvement of client care (Maker 1998).

12. OBJECTIVES OF QUALITY ASSURANCE According to Jonas (2000), the two main objectives are : Ensure the delivery of quality client care. Demonstrate the efforts of the healthcare providers to provide the best possible results.

13. Contributory objectives : 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

14. Factors Affecting Quality Assurance

15. PRINCIPLES OF QUALITY ASSURANCE MUTUALLY BENEFICIAL SUPPLIER FACTUAL APPROACH TO DECISION MAKING CONTINUAL IMPROVEMENT SYSTEM APPROACH TO MANAGEMENT PROCESS APPROACH INVOLVEMENT OF PEOPLE CUSTOMER FOCUS LEADERSHIP

16. COMPONENTS OF QUALITY ASSURANCE Structure evaluation Process evaluation Outcome evaluation

17. Staff Departments Equipment Supplies Environment Pathways Protocols Physicians Orders Nursing Care Housekeeping Transport Six Ds: Death Disease Disability Discomfort Dissatisfaction Destitution (Cost) ANATOMY Process Care Process HEALTH CARE MODEL: DONABEDIAN MODEL Structure Outcome

18. The Donabedian model   is a conceptual model that provides a framework for examining health services and evaluating quality of health care. According to the model, information about quality of care can be drawn from three categories: Structure : It describes the context in which care is delivered, including hospital buildings, staff, financing and equipment. Process : denotes the transactions between patients and providers throughout the delivery of healthcare. the measurement of process is nearly equivalent to the measurement of quality of care because process contains all acts of healthcare . Outcomes : refers to the effects of healthcare on the health status of patients and populations.

19. Donabedian’s model can also be applied to a large health system to measure overall quality and align improvement work across a hospital, group practice or the large integrated health system to improve quality and outcomes for a population.

20. ANA QUALITY ASSURANCE MODEL

21. The basic components of the ANA Model are : Identify values Identify structure, process and outcome standards and criteria Select measurement Make interpretation Identify course of action Choose action Take action Reevaluate

22. ISO QUALITY ASSURANCE MODEL Continual Improvement of the Quality Management System Customers Requirements Satisfaction Output Customers Do Check Act Plan Input Product

23. JOINT COMMISSION ON ACCREDITATION OF HOSPITAL ORGANIZATIONS (JCAHO) - QUALITY ASSURANCE MODEL Delineate scope * Hospital Infection Control * Incidence Identify important aspects of HAI * Awareness * Administrative and clinical set up * Training Requisites * Implementation Identify indicator s * Structure, Process and Outcome criteria Establish standards * Such as <2% incidence of HAI for all procedures/ for evaluation surgical operations/ patient admissions Collect Data Compare with standards * Identify areas of improvement * Take corrective measures Attained Not Attained Enhance standards

24. PREVENTIVE MEASURES Keep all showers, showerheads and taps clean and free from scale Clean and Disinfect cooling towers used in air conditioning systems regularly – every 3 months Clean and disinfect heat exchangers( calorifiers ) regularly- once a year Disinfect the hot water system with high level chlorine for 2-4 hours after work on heat exchangers

25. Contd... Clean and disinfect all water filters regularly- every one to three months. Inspect storage tanks, cooling towers and visible pipe work monthly. Ensure all coverings are intact and firmly in place. Ensure that system modifications or new installations do not create pipe work with intermittent or no water flow.

26. NURSES ROLE IN QUALITY ASSURANCE

27. PLAN , DO, STUDY, ACT CYCLE PLAN DO CHECK ACT

28. APPROACHES FOR A QUALITY ASSURANCE PROGRAMME Major categories of approaches General Specific

29. A. GENERAL APPROACH It involves large governing of official body’s evaluation of a person’s or agency’s ability to meet established criteria or standards at a given time. 1. Credentialing Formal recognition of professional or technical competence and attainment of minimum standards by a person or agency. Credentialing process has four functional components a) Produce a quality product b) Confer a unique identity c) P rotect provider and public d) Control the profession.

30. 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 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 throughout the world by laws and regulations..

31. 3) Accreditation International Organization for Standardization (ISO) The International Organization for Standardization (ISO) is an international standard-setting body composed of representatives from various national standards organizations. Founded on 23 February 1947, the organization promotes worldwide proprietary, industrial and commercial standards . Joint Commission International (JCI) Was founded in the late 1990s to survey hospitals outside of the United States. JCI, which is also not-for- profit, currently accredits facilities in Asia, Europe, the Middle East, and South America.

32. National Accreditation Board for Hospitals & Healthcare Providers (NABH) National Accreditation Board for Hospitals & Healthcare Providers is a constituent board of Quality Council of India Certification, set up to establish and operate accreditation programme for healthcare organizations. NABH was established in year 2006 .

33. National Assessment and Accreditation ( NAAC) The National Assessment and Accreditation Council ( NAAC ) is an organization that assesses and accredits higher education Institutions (HEIs) in India. It is an autonomous body funded by University Grants Commission of Government of India headquartered in Bangalore Accreditation Canada A n accreditation body, works with patients, policy makers and the public to improve the quality of health and social services for all.

34. 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. Specific approaches 1)  Peer review Peer review is divided in to two types. The recipients of health services by means of auditing the quality of services rendered. The health professional evaluating the quality of individual performance.

35. 2 ) Standard as a device for quality assurance Standard is a pre-determined baseline condition or level of excellence that comprises a model to be followed and practiced. The ANA standard for practice include : Standard 1: The collection of data about health status of the patient is systematic and continuous. The data are accessible, communicative, and recorded. Standard 2: Nursing diagnosis are derived from health status data.

36. Standard 3: The plan of nursing care includes goals derived from the nursing diagnoses. Standard 4: The plan of nursing care includes priorities and the prescribed nursing approaches or measures to achieve the goals derived from the nursing diagnoses. Standard 5: Nursing actions provide for patient participation in health promotion, maintenance, and restoration.

37. Standard 6: Nursing actions assist the patient to maximize his health capabilities. Standard 7: The patient’s progress or lack of progress towards goal achievement is determined by the patient and the nurse. Standard 8: The patient’s progress or lack of progress towards goal achievement directs re-assessment , re-ordering of priorities, new goal setting, and a revision of the plan of nursing care.

38. 3) Audit as a tool for quality assurance 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.

39. Prevention of Noso comial Infection Sterilization Isolation Hand washing Gloves Surface sanitation Antimicrobial surfaces

40. CONCLUSION * Staff Education * Surveillance * Interrupting Transmission

41. Thank you