QUALITY ASSURANCE IN NURSING: QUALITY ASSURANCE IN NURSING Mrs.VINILI SIMPSON INTRODUCTION: INTRODUCTION Field of quality assurance as old as modern nursing. Florence Nightingale – concept of quality in nursing care. Quality – interactive process between the customer and provider. DEFINITION: DEFINITION Quality-extend of resemblance between the purpose of health care and the truly granted care. (Donabedian 1986). In economic dimension quality – extent of accomplished relief case with a justified use of means and services. (Williamson 1999 ). DEFINITION OF QUALITY ASSURANCE: DEFINITION OF QUALITY ASSURANCE Judgment concerning the process of care, based on the extend to which that contributes to valued outcomes. (Donabedian 1982). 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). APPROACHES: APPROACHES General Involves large governing of official body’s evaluation of persons or agency’s ability to meet established criteria or standards at a given time. PowerPoint Presentation: Credentialing Formal recognition of professional or technical competence & attainment of minimum standards by a person or agency. 4 functional components Produce a quality product Confer a unique identity Protect provider & public Control the profession PowerPoint Presentation: Licensure Individual license is a contract between the profession and the state. Licensure of nurses has been mandated law since 1903. Accreditation NLN a voluntary organization has established standards for inspecting nursing education program. PowerPoint Presentation: Certification a person educational achievement, experience performance on examinations are used to determine the persons qualification for functioning in an identified specialty area. PowerPoint Presentation: SPECIFIC APPROACHES QA are methods used to evaluate identified instances of provides and client interaction. Peer review committee designed to monitor client specific aspects of care appropriate for certain levels of care. The major tool used is the audit process. PowerPoint Presentation: Utilization Review UR are directed towards assuring the care is actually needed and that the cost appropriate for the level of care provided 3 Types Prospective assessment of the necessity of care before giving service. Concurrent review of the necessity of care while the care is given. Retrospective review of the necessity of the service after the care has been given. PowerPoint Presentation: ADVANTAGES 1. To avoid unnecessary care 2. Care options by providers such as home health care than hospitalization 3. Need for client hospitalization 4. Length of hospital stay 5. Accountability to the consumer DISADVANTAGES Not all clients fit for the classic picture presented by the explicit criteria that serves as the basis for approval of care. PowerPoint Presentation: EVALUATION STUDIES 1.Donabedian structure – process – outcome model 2. Tracer model 3. Sentinel model DONABEDIAN’S STRUCTURE-PROCESS-OUTCOME MODEL: DONABEDIAN’S STRUCTURE-PROCESS-OUTCOME MODEL Structure Process Outcome Facility resources personnel mix and skills, philosophy, policies, client mix Standards, attitudes, nursing care plan effectiveness, client satisfaction. Client’s health care goals met, efficiency, effective -ness of services. TRACER METHOD: TRACER METHOD measure of both process and outcomes of care identify a volume of client with particular characteristic resuming specific health are management HT,UTI establish criteria for good medical and nursing management provider: nurses with data to show the differences in outcome as a result of nursing care standards. SENTINEL METHOD: SENTINEL METHOD Examining specific instances of client care. CHARACTERISTICS: cases of unnecessary disease, disability, deaths counted circumstances surrounding unnecessary event are examined review of morbidity/mortality health status indicator : Social, economic, political and environmental CLIENT SATISFACTION: CLIENT SATISFACTION Assessed using personal or telephonic interviews & mailed questionnaire. Used to measure structure, process, and outcome of the care gives. INCIDENT REVIEW: INCIDENT REVIEW Reports of critical incidents are of legal value. Reports should contain the name, age, exact time and place, description of how occurred, any precautions taken, condition of the patient before and after the incident. RISK MANAGEMENT: RISK MANAGEMENT Developed for the purpose of eliminating or controlling health care situations that has the potential to inure endangers or create risk to clients. “do the client no harm”. MALPRACTICE LITIGATION: MALPRACTICE LITIGATION Specific approach to be imposed on the health care delivery systems by the legal systems. Results from client dissatisfaction with provider & with the content of care received. QUALITY IMPROVEMENT: QUALITY IMPROVEMENT DEFINITION Approach to the continuous study and improvement of the process of providing health care services to meet needs of clients and others. (JCAHO 1997) Principles of TQM: Principles of TQM Continuous quality improvement. Knowledge of consumer expedition needs. Processes of consumer supplier relationship. Belief in people. Statistical analysis. Costs of poor quality. Conditions of TQM: Conditions of TQM Employer involvement. Improvement. An environment that supports risk taking. Team work. Data collection and analysis skills. Group interaction skills. Structure and management to enable improvement. Tools to facilitate the improvement. Steps in quality improvement: Steps in quality improvement Quality defined. Professional standard. Policies. Outcomes. Components of QI program.: Components of QI program. Establish responsibility and accountability for a G.I program. Define the scope of service for a chemical area. Define the key aspects of service for the chemical area. Develop quality indicators to monitor the outcomes and appropriateness of care delivered. Establish thresholds for evaluation of indicators Contd……: Contd…… Collect and analyze data from monitoring activities. Evaluate results of monitoring activities to determine the need for change in practice. Resolve problems through development of action plans. Reevaluate to determine if the plan successful. Communicate Q.I results to the organization Models of quality assurance: Models of quality assurance Based on structure, process, and outcome. Provide structure to guide nurses through the nursing process to reach desired client outcomes. Each has all three components. Donabedian model: Donabedian model A system model for implementation of unit based quality assurance: A system model for implementation of unit based quality assurance Involves making changes in organizational structure and individual roles. Basic components: Input – present state of systems. Throughput – developmental process. Output – finished product. Feedback American Nurses Association Model: American Nurses Association Model ANA Quality Assurance Model: ANA Quality Assurance Model Quality Health Outcome Model: Quality Health Outcome Model Hoesing & Krik Quality Management Model: Hoesing & Krik Quality Management Model Omaha system: Omaha system Patient classification scheme – offers nurse a holistic, standardized method for client assessment and nursing diagnosis & problem identification. Intervention scheme – provides a framework for documenting plans & interventions in the client record. Supervisory shared visit tool – a supervisors evaluation instrument. Problem rating scale for outcomes – used to document client progress in the record & during case conferences. Upwardly spiraling Quality Assurance Model: Upwardly spiraling Quality Assurance Model Quality practice setting model: Quality practice setting model The TQM approach: The TQM approach Quality indicators: Quality indicators A quantitative measure of an important aspect of service that determines whether the service conforms to established standards or requirements. Focus for quality improvement program, with the staff monitoring criteria. Types of quality indicators: Types of quality indicators Structure indicators – evaluate the structure or systems for delivering care. Process indicators – evaluate the manner in which care is delivered. Outcome indicators – evaluate the end result of care delivered. Establishing thresholds for evaluation.: Establishing thresholds for evaluation. Threshold is the standard for determining whether a problem exists. Select a quality indicator. Determine ways to quantitatively measure the indicator. Observe the times occurrence of the indicator. Measurement that falls below the threshold indicates problem. Data collection & analysis: Data collection & analysis Many organization conduct formal research studies. When formal research is not conducted, staff may involved in simple evaluation studies. Evaluation of care: Evaluation of care Monitoring the quality indicators. If results exceed or meet threshold-process is performing well. When thresholds are not met-find the cause of the problem. Form QI team. Team recommends approaches for improving the process. Resolution of problems.: Resolution of problems. After evaluation, staff develops action plans to improve process & outcomes. The action plan should be more direct. Implement the change. Check or analyze results of change. Act on the findings. Evaluation of improvement: Evaluation of improvement After implementing action plan, the staff must re-evaluate its success. The result may be positive or negative. Communication of results.: Communication of results. Results of QI activities must be communicated to staff in all appropriate organizational department. Regular discussion of QI activities through staff meetings, newsletter, and memos. Factors affecting QA in nursing. : Factors affecting QA in nursing. Lack of resources. Personnel problems. Improper maintenance. Unreasonable patients & attendants. Absence of well informed population. Absence of accreditation laws. Lack of good & hospital information system. Absence of patient satisfaction surveys. Lack of nursing care records. PowerPoint Presentation: Lack of good supervision. Absence of knowledge about philosophy of nursing care. Lack of policy & administrative manuals. Substandard education & training. Lack of evaluation technique. Lack of in-service & continuing education program. Lack of written job description & job specification. STANDARDS.: STANDARDS. Definition. “A model of established practice which has general recognition & acceptance among registered professional nurses & is commonly accepted as correct standards of practice. (ANA 1996). Definition.: Definition. “ An authoritative statement that describes a common level of care as performed by which the quality of practice can be determined or measured. (Hubes 1996) Importance of standards in nursing.: Importance of standards in nursing. It is an authoritative statement by which the quality of nursing practice, service and education can be judged. In nursing practice, standards are established criteria for the practice of nursing. It is a guideline and a guideline far is a recommended path to safe conduct an aid to professional performance. PowerPoint Presentation: It provides a baseline for evaluating quality of nursing care, increase effectiveness of care and improve efficiency Standards help supervisors to guide nursing staff to improve performances. Standards may help to clarify nurses’ area of accountability. Standards may help nursing to clearly define different levels of care. Standards is a device for quality assurance as quality control Purposes of standards.: Purposes of standards. Improve the quality of nursing. Decrease the cost of nursing. Determine the nursing negligence Characteristics of standards.: Characteristics of standards. Statement must be broad enough to apply a wide variety of settings Must be realistic, acceptable and attainable. Nursing care must be developed by members of the nursing profession. Must be understandable and stated in unambiguous term. Must be based on current knowledge and scientific practice. Must be reviewed and revised periodically. Must be directed to wards on optional standard Sources of nursing care standards.: Sources of nursing care standards. Professional organization like TNAI, INC. Licensing bodies like State Nursing Registration Council Departments of the institution Patient care unit Government unit at national, state and local government unit. Individual personal standard. Classification of standards.: Classification of standards. Physical standards Cost standards Capital standards Revenue standards Programme standards Intangible standards Goal standards Strategies standards Nursing care standards: Nursing care standards End standards. Mean standards. According to frame of references, relating to nursing structure, process & outcome. Structure standards Process standards Outcome standards Quality improvement in public health institutions.: Quality improvement in public health institutions. Definition: An institutions, offering wide range of services to meet the needs of those who need the service most through their full participation, with least health risks, in the area of the vicinity of it, having integrated with desired set of elements, within limits and norms & goals set by the federal state. Elements of TQM: Elements of TQM Quality planning. Quality assurance. Quality circles. Quality control. Quality surveillance. Quality circle.: Quality circle. A small voluntary group of people from the same work area who meet together on a regular basis for the purpose of identifying, selecting, analyzing, and solving quality, productivity, cost reduction, safety, customer services, & other work related problems in their work area, leading to the improvement in their work effectiveness and enrichment of their work life. Structure of QC: Structure of QC Structure of QC in public health: Structure of QC in public health GENUINE DEMAND FOR IMPROVING QUALITY At state level Steering committee At Dist. Level at D.H.O At PHC/CHC/ HOSP.LEVEL At village or community level QCC QCC QCC QCC Nursing audit: Nursing audit Definition; “Assessment of quality of clinical nursing”. (Elicson ). “Exercise to find out whether good nursing practices are followed”. (Gooter Walfer). “Method of evaluating quality of care through appraisal of nursing process as it is reflected in the patient care records for discharged patients”. (Phaneuf ) Purposes of nursing audit: Purposes of nursing audit Necessitating adequate documentation of nursing care provided to the client through the entire nursing process. Directing attention to the design and utility of the charting record. Encouraging the use of the problem oriented nursing system. Supporting and becoming an integral part of nursing by objective program. Facilitating the co-operative planning and delivery of client care by physicians and nursing service employees. PowerPoint Presentation: Increasing the priority for a results oriented performance evaluation program for nursing service employees. Enriching and providing direction to in service education effects. Providing a specific management technique in carrying out evaluation and control function. Identifying ways to improve patient care. Providing a meaningful ways for nursing staff members to participate and achieve career growth. Concepts of nursing audit.: Concepts of nursing audit. Debit-all negative activities. Debit items. Death of the client that can be prevented. Complications of diseases leading to morbidity. Hospital infection. Errors in treatment. Absence of total client care. Lack of application of nursing process. PowerPoint Presentation: Credit – positive activities. Credit items. Number of recovered patients. Shortens stay in the hospital. Expansion of health knowledge in client population. Regular follow up in community. Measures to improve public image. Research as need for problem oriented care approach. Types of auditors.: Types of auditors. Internal auditors – nursing experts as specialists in the hospital appointed by the hospital management. External auditors – experts from the external statutory agencies like TNAI, INC etc. PowerPoint Presentation: Thank You Organization of nursing audit: Organization of nursing audit The increasing cost of the care. The need to improve the quality of care. The need for the proof of the quality of care actually delivered, proof for the –a) Nurse. b) Agency. c) Client. Steps of nursing audit process: Steps of nursing audit process Selection of a topic for study. Selection of explicit criteria for quality care. Review of records to determine whether criteria are met. Peer review of all cases that do not meet criteria. Specific recommendations to correct problem. Follow- up to determine whether problems have been eliminated. JCAH audit procedure: JCAH audit procedure Standards & criteria established. Measurement of actual practice against criteria. Evaluation of results. Action taken to correct deficiencies. Follow up & assessment. Report to nursing service administration & needed staff. Methods to develop criteria: Methods to develop criteria Define patient population. Identify a time framework for measuring outcomes of care Identify commonly recurring nursing problems presented by the defined patient population. State patient outcome criteria. State acceptable degree of goal achievement. Specify the source of information. Design and type of tool. Audit cycle: Audit cycle Types of nursing audit: Types of nursing audit Retrospective audit In-depth assessment of the quality after the patient has been discharged, have the patients chart to the source of data. Advantages of retrospective audit: Advantages of retrospective audit Comparison of actual practice to standards of care. Analysis of actual practice findings. A total picture of care given. More accurate data for planning corrective action. Disadvantages of retrospective audit: Disadvantages of retrospective audit The focus evaluation is directed away from ongoing care. The clients’ problems are identified after discharge. Concurrent audit: Concurrent audit Also called “open chart audit”. Evaluations conducted on behalf of patients who are still undergoing care. Purposes: To assess the past & present care given to a client. Components of concurrent audit: Components of concurrent audit Assessing the client. Interviewing the nursing staff. Reviewing the clients’ record and care plan. Advantages of concurrent audit: Advantages of concurrent audit Indications of problem at the time of caring. Provision of a mechanism for identifying and meeting clients’ needs during care. Implementation of measures to fulfill professional responsibilities. Provision of a mechanism for communicating on behalf of the client. Disadvantages of concurrent audit: Disadvantages of concurrent audit It is a time consuming procedure. It is costly to implement than the retrospective audit. Does present the total picture of care that the client ultimately well receives. Rosenthal effect: changing results at expectations of care givers. Audits used for quality control : Audits used for quality control Outcome audit – end results of care. Process audit – measure the process of care or how the care carried out. Structure audit – monitors structure or setting in which patient care occurs. Members of audit committee: Members of audit committee Clinical care co-coordinators. Supervisors. Head nurses. Clinical specialists. Nurse clinicians. Licensed practical nurses. Nursing assistants. Other client care personnel. Medical records administrator. Functions of audit committee: Functions of audit committee During the 1st phase: Development of purposes and objectives. Establishing standards and criteria. Establishing guidelines for conducting audits. Deciding upon audit forces (JCAH forms). Initiating the auditing process. Keeping up brief, pertinent minutes of all audit committee meetings. During the 2nd phase: It begins with the actual implementation and maintenance of all audit committee meetings. Responsibilities of audit committee: Responsibilities of audit committee Planning audit sessions and scheduling. Arrange for medical records to pull charts for retrospective audits and retrieve data. Evaluating audit results in committee. Conducting process audits. PowerPoint Presentation: Preparing summaries of all audits. Teaching professional nursing personnel the auditing process. Assisting nursing staffs in using audit results. Making recommendations. Keeping brief pertinent minutes of audit committee meetings. Reporting audit results: Reporting audit results A committee’s work. Summary of audit activity. An organized presentation of general findings. Follow through action that has taken place. Impact of follow up action on problem conditions Factors influencing auditing process: Factors influencing auditing process Lack of resources. Personnel problems. Unreasonable clients and attendants. Improper maintenance. Absence of accreditation. PowerPoint Presentation: Legal redress. Lack of incident review procedure. Lack of good hospital information system. Absence of survey condition routine. Lack of nursing case records. Miscellaneous factors. Advantages of nursing audit: Advantages of nursing audit Can be used as a method of measurement in all areas of nursing. Functions are easily understood. Scoring system is fairly simple. Results easily understood. Assesses the work of all those involved in recording care. May be a useful tool as part of a quality assurance programme in areas where accurate records of care are kept. Disadvantages of nursing audit: Disadvantages of nursing audit Appraises the outcomes of the nursing process, so it is not so useful in areas where the nursing process has not been implemented. Many of the components overlap making analysis difficult. Is time consuming. Requires a team of trained auditors. Deals with a large amount of information. Only evaluates record keeping. It also serves to improve documentation, not nursing care.