Guality Assurance.docx

INTRODUCTION The field of Quality Assurance is as old as modern nursing. Florence Nightingale introduced the concept of quality in nursing care in 1855 while attending the soldiers in the hospital during the Crimean war. It is a matter of pride for nurses that the nursing profession has attained a distinct position in the search for quality in health care. Quality is rapidly becoming a concern to both consumers and the providers of the services. In health care quality is being demanded and providers are judged by the quality of services. And hence there is a need to sensitize and train nursing personnel to provide quality care.

DEFINITIONS Quality Assurance is the defined as a nursing practice through well written nursing standards and the use of those standards as a basis for evaluation on improvement client care [Maker 1998] Quality assurance is the monitoring of the activities of the client care, to determine the degree of excellence attained to the implementation of the activities. (Bull 1985).

OBJECTIVES     

To ensure the delivery of quality client care To demonstrate the efforts of the health care providers To provide technical assistance in correcting systematic deficiencies To refine existing methods for ensuring optional quality health care. To provide the best possible results.

MEANING OF QUALITY Quality is doing the right thing right the first time and doing it better the next time. Quality is defined as the extent to resemblance between the purpose of health care and truly granted care.

ELEMENTS OF QUALITY  Appropriateness The service or procedure is what the population or individual actually needs.  Equity A fair share is available for all the population.  Accessibility Services are not compromised by undue limits of time and distance.  Effectiveness Services are achieving the intended benefits for the individual and for the population.  Acceptability Services are provided such as to satisfy the work expectations of patients, providers and the Community.

NEED FOR QUALITY ASSURANCE IN NURSING  To ensure quality, nursing care provided by nurses in order to meet the expectations of receiver , management and regulatory body.  Improves and maintains the patients state of health.  Improves and maintains the patients functional abilities.  Develops the patient’s psychophysical condition.  To refine existing methods for ensuring optimal quality health care

PRINCIPLES OF QUALITY ASSURANCE There are five basic principles of quality assurance: 1. 2. 3. 4. 5.

Quality assurance is oriented towards meeting the needs and expectations of our clients. It focuses on systems and processes. It uses data to analyze service delivery. It encourages the use of teams in problem – solving and quality improvement. It uses effective communication to improve service delivery.

FACTORS AFFECTING QUALITY ASSURANCE IN NURSING PRACTICE           

Lack of resources Personnel problem Improper maintenance Unreasonable patients and attendants Absence of well-informed population Absence of accreditation laws Lack of incident review procedure Lack of good hospital information system Absence of patient Satisfaction Surveys Lack of nursing care research Miscellaneous Factors

QUALITY ASSURANCE PROCESS Quality assurance process is the systematic process of evaluating the quality of care given in a particular unit or institution It includes:      

Setting standards Determining criteria to meet those standards Data collection Evaluating how well the criteria have been met Making plans for change based on the evaluation Implementation for change

1. Setting standards The nursing profession should have to design standards of nursing practice that are specific to the patient population served. 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 treatment chart. 2.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 specific to the individual unit. One criterion to demonstrate that the standard regarding care plans for every patient are being met would be: A nursing care plan is developed and written by a nurse within 10 hours of admission. This criterion, then, provides a measurable indicator to evaluate performance. 3.Data Collection It is the 3rd step in quality assurance. Sufficient observations and random samples are necessary for producing reliable and valid information. A useful rule is that 10% of the institutional patient population per month should be sampled. 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. Data collection methods include: a. Patient observations and interviews b. Nurse observations and interviews. c. Review of charts. A 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 policy should also states at what level in the organization the analysis of the different criteria is to 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 changing in nursing practice are not likely to occur. 4.Evaluating Performance Various methods can be used to evaluate performance. 1. Reviewing documented records 2. Observing activities as they take place 3. Examining patients 4. 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. The chart only indicates that care was provided, it does not demonstrate the quality of that care. For example, care plan could be checked nursing diagnosis, interventions planned, and discharge planning. 5. Making plans for change based on the evaluation It includes taking the actions for improving quality care by changing the present scenario and incorporate new policies for the same.

THE 10-STEP PROCESS IN A QUALITY ASSURANCE PROGRAM Step 1-Assign Responsibility Nursing departments and services must assign overall responsibility for their monitoring and evaluation activities. Step 2-Delineate Scope of care and services Intended to assure that all nursing activities are considered in monitoring and evaluation Types of patients served a. Types of patients served b. Condition and diagnosis c. Types of nursing staff providing care and services d. All existing standards of patient care. Step 3-Identify important Aspect of care and services It is important for nursing staffs to remember that important aspect of care are activities of department that will be continually monitored and periodically evaluated to determine if care can be improved or if problems are present. Nursing staff should identify those aspects of care and services that:

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Occur frequently or affect large numbers of patients. Place patient at high risk. Have intended in the past to produce problems.

Step 4-Identify Indicators Indicators are measurable variables related to the structure. Process or outcomes of care:   

Structures – Elements that facilitate care (resources, equipment, numbers and qualification of staff) Process – Functions carried out by practitioners (assessment, treatment, planning and medication administration) Outcomes – Includes complications, adverse effects, short and long term results of treatment)

Step 5-Establish Threshold for Evaluation  

Thresholds are accepted levels of compliance with any indicators being measured. Thresholds for evaluations are the level or point at which intensive evaluation is triggered.

Step 6-Collect and Organize Data Some common date can be found in:          

Patients, records Medication sheets Infection control Meeting minutes Patient surveys Incident reports Department logs Laboratory reports Direct observation Formal evaluation

Step 7-Evaluate Care Once threshold for an indicator is reached, the critical step of evaluation is initiated. The most important purpose of monitoring and evaluation is to foster overall continuous improvement in the level of performance. Some examples are;        

Lack of knowledge and skill Staff members knew what to do but did not do so Equipment deficiencies Deficiencies in medical record documentation Policy \ procedure violation Lack of adequate staffing Infection control violation Inappropriate therapy, diagnostics.

Evaluation must be designed to identify the opportunities for improvement by: 

Objectively examining the possible causes for the level of performance

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Recommending action pertinent to those causes to improve the performance.

Step 8-Take Actions to Solve Problems or Otherwise improve Some possible actions if the problem involves deficiencies in systems, include:        

Changing communication channels Changing organizational structure Adjusting staffing or redistributing staff Revising job descriptions Reallocating resources Adding or revising policies and procedures Altering the use of equipment Purchasing and repairing equipment.

Some possible actions, if the problem involves deficiencies in staff knowledge, include:    

Modifying orientation procedures Providing focused in-service education Providing focused continuing education Circulating written policies and procedures or other informational material.

Some possible actions, if the problem involves behavior or performance deficiencies, include:      

Revising job descriptions Informal counseling Changing assignments Disciplinary sanctions Limiting staff prerogatives relating to patient care Transferring to another unit/Department.

Step 9- Assess the Effectiveness of Actions Monitoring and evaluation does not end when actions are taken. Staff continues to monitor the aspect of care future opportunities for improvement, but they must determine whether are taken successfully in improving care or service. Step 10- Communicate Relevant Information to the organization-Wide Quality Assurance Program It is essential that monitoring and evaluation information be communicated through established channels. Appropriate; dissemination of information helps to assure that quality assurance activities are coordinated and that knowledge regarding monitoring, evaluation and problemsolving methods is Shared. APPROACHES FOR A QUALITY ASSURANCE PROGRAM Two major categories of approaches exist in quality assurance; A. General B. Specific

General

Specific

Approaches s

Approaches

Peer review committee The Audit processUtilizat

Credentialing Licensure Accreditation Certification

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 give time. 1) Credentialing;A person generally defines it as the formal recognition of personal or technical competence and attainment of minimum standards by a person or agency. According to Hinsvark [ 1981] credentialing process has four functional components;  To provide a quality product  To confer a unique identity  To protect provider and public  To control the profession. 2) Licensure;Individual licensure is a contract between the profession and the state, in which the is granted control over entry into and exists from the profession and professional practice the licensing process requires that regulations be written to define the scopes and limits of the professionals practice. Law has mandated licensure of nurses since 1903 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. In 1990,more emphasis was placed on evaluation of the outcomes of care and on the educational qualifications of the person providing care. 4) Certification;Certification is usually a voluntary process within the profession. A person’s educational achievement, and performance on examination are used to determine the person’s qualifications for functioning in an identified specialty area.

SPECIFIC APPROACHES Quality assurances are methods used to evaluate identified instances of provider and client interaction. A. Peer Review Committee

These are designed to monitor client-specific aspects of care appropriate for certain levels of care. The audit has been the major tool used by peer review committee to ascertain quality of care. B. The Audit process-[Stan Hope Caster,2000]  Follow-up of problem Topic study selected.  Recommendations for correcting deficiencies, explicit criteria selected for quality care.  Peer review of all cases not meeting criteria.  Records review NURSING AUDIT Nursing audit is evaluation of patient care through analysis of written records maintained by nurses in patient’s treatment profile. - Avtar Brar GOALS OF NURSING AUDIT • To improve quality of health care. • To promote improved communication among nurses & other health team members. • To improve quality of nursing care. • To detect & analyze problems & errors. NURSING AUDIT PROCESS

ADVANTAGES OF NURSING AUDIT        

Provides quality of nursing A patient is assured of good services. It will give valuable and pertinent information for the staff. It will lead to between co-operation and communication among the nurse & health team. It will help each professional nurse for her self evaluation. It helps the administration as better planning. It will reduce the incidence of medical legal complication. It will broaden and strengthen nursing service.

C. Utilization Review (UR)

Utilization review activities are directed towards assuring that care is actually needed and that the cost appropriate for the level of care provided . There are 3 types of Utilization Reviews. They are; i. ii. iii.

Prospective: It is an assessment of the necessity of care before giving service. Concurrent: It is a review of the necessity of care while the care is being given. Retrospective: It is an analysis of the necessity of the services received by the client after the care has been given.

Utilization Review (UR) has been used primarily in hospitals to establish need for client admission and the length of hospital stay. The UR process includes the development of explicit criteria that serves as indicators of the need for services and length of services. Advantages of Utilization Review    

It is designed to assist to avoid unnecessary care. It may serve to encourage the consideration of care options by providers, such as home health care than hospitalization. It can provide guidelines for staff of program development. It provides a measure of agency accountability to the consumer.

Disadvantage of Utilization Review Not all clients are fit for the classic picture presented by the explicit criteria that serve as the basis for approval or denial of care.

COMPONENTS OF QUALITY IMPROVEMENT PROGRAMS          

Establish responsibility & accountability. Define scope of service for clinical area. Define key aspects of service for clinical area Develop quality indicators to monitor outcomes & appropriateness of care delivered. Establish threshold for evaluation of indicators. Collect & analyze data from monitoring activity. Evaluate results of monitoring activities to determine the need for change in practice Resolve problems through development of action plans. Reevaluate to determine if plan was successful. Communicate quality improvement results to organization.

Evaluation Studies Three major models have been used to evaluate quality, they are; 1. Donabedian’s structure – process- outcome model 2. The Tracer model 3. The sentinel model

Donabedian’s structure - process- outcome model Donabedian’s introduced 3 major methods of evaluating quality care. 1. Structural Evaluation This method evaluates the setting and instruments used to provide care such as facilities, equipments and characteristics of the administrative organization and qualification of the health

providers. The data for the structural evaluations can be obtained from the existing documents of an agency or from an inspector of a faculty. 2. Process Evaluation This method evaluates activities as they relate to standards and expectations of health provider in the management of client care, data for this can be collected through direct observations of provider encounters and review of records, audit, checklist approach and the criteria mapping approach are used to establish the client encounter protocol. 3. Outer Evaluation The net changes that occur as a result of health care or the net results of health care. The data of this method can be collected from vital statistical records such as death certificates or telephone client interviews, mailed questionnaire and client records. The Tracer Method It is a measure of both process and outcome of care. To use the tracer method, one must identify a volume of client with a particular characteristic resuming specific health care management. Physicians and nurse practitioners, to identify persons with certain illness such as HTN, Ulcers, and UTI and to establish criteria for good medical and nursing management of the illness have used the tracer method. This method provides nurses with data to show the differences in outcome as a result of nursing care standards. The Sentinel Method It is an outcome measure for examining specific instances of client care. The characteristics of this method are;  Cases of unnecessary disease, disability deaths are counted.  The circumstances surrounding the unnecessary event or the sentinel is examined in detail.  In review of morbidity and mortality are used as an index.  Health status indicator such as changes in social, economic, political and environmental factors are reviewed which may have an effect on health outcomes.

Quality Assurance in nursing according to the Norma Lang model In literature, one can trace many models to evaluate the quality of nursing. Most models use as their basis Norma Lang’s model from 1976, which has seven levels. The Norma Lang model has seven levels that run through three phases. i.

Description:

In the first phase Description, we identify the values and attitudes that lead us to nursing. Then we select criteria for excellent nursing in standards covering the structure, process and outcome. ii.

Measurement:

In the second phase Measurement, we choose the methodology that is used to determine what our practice is like in comparison with standards and criteria for excellent nursing, which we have set internally or we st externally. The resuls obtained are analysed and then we decide if and why we need changes. iii.

Action:

In the third phase Action, we choose the changes and paths along which the changes will run in our environment and finally introduce the changes in our routine work.

Frameworks for Quality Assurance Maxwell(1984): Maxwell recognized that,in a society whole resources are limited, selfassessment by health care professionals is not satisfactory in demonstrating the effiency of a service .The diamensions of quality he proposed are     

Access to service Relevance to need Equity Social acceptance Efficiency and economy.

2.Wilson(1987): Wilson considers four essential components toa quality assurance program. These are    

Setting objectives Quality promotion Activity monitoring Performance assessment.

3.Lang(1976): This framework has subsequently been adopted and developed by the ANA. The stages includes:          

Identify and agree values Establish structure,plans,outcome criteria and standers Review literature Analyze available programs Determine most appropriate program Evaluate current levels of nursing practice Identify and analyze factors contributing to results Select appropriate actions to maintain or improve care Implement selected actions Evaluation

Philosophy of Quality Assurance Model in Nursing  Indian nursing council believes that nurse will do good for person/receiver of care, do no harm, maintain respect for life and human dignity, believe in human justice and fairness to individuals in terms of access to resources and care and protect the vulnerable.  Have moral obligation to provide services as prescribed by the regulatory body / health care system/ organization/ institution even if it is in conflict with her.  Be committed to understanding of dynamic nature of his / her role in interdisciplinary health team.  Be obligated to create public awareness and consider social expectations before making decisions for providing nursing care.  Be obligated to include receiver in making choices in planning and implementation of care.  Work in conjugation with legislation, accreditation and political system.

 Have obligation to promote education of self and others.  Be committeed to advancement of profession.

Purposes of Quality Assurance model  

To ensure quality nursing care provided by nurses inorder to meet the expectations of the receiver, management and regulatory body. It also intends to increase the commitment of the provider and the management.

Goals of Quality Assurance model     

Develop confidence of the receiver that quality care is being rendered as per assurance. Develop commitment of the management towards quality care. Increase commitment of providers to adhere to set standards for nursing practice and strive for excellence. Strengthen documentation of nursing care. Promote optimum utilization of resources in providing cost effective nursing care.

Models of Quality Assurance 1.System Model for Quality Assurance System model is used for implementation of unit based quality assurance program.It involves making changes in organizational structure and individual roles.In system model, task is broken down into manageable components based on defined objectives. The basic components of the system are: a. Input -- The input can be compared to the present state of systems. b. Throughput -- It is developmental process. c. Output -- It is finished product or result. d. Feedback -- It is essential component of system because it maintains and nourishes growth. 2. ANA Quality Assurance Model. The basic components of the American Nurses Association Model

3. JCAHO(Joint Commission on Accrediation of Health Care rganization) Quality Assurance Model

4. ISO (International Standards Organisation) Quality Assurance Model

Selecting a Nursing Quality Assurance Model        

Select or develop a structure that first with the organizational structure and the style management practiced in the organization. Decide on the format that makes the best use of resources and manpower available Keep the format simple and streamlined Use a consistent model throughout the division of nursing In a skilled nursing facility, use a consistency model throughout the facility It is a tool for assuring and improving quality of care. Used to monitor and evaluate the quality and appropriateness of care. It is the ongoing process to examine care, to find potential problems and opportunities for improvement and to do something about them.

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

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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

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 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

CONCLUSION From the foregoing, it can be clearly seen that professional nursing education can be greatly enhanced by quality assurance . The importance of evaluation to ensure this can never be overemphasized. This is because both nursing education and practice are practically oriented. In the course of course of training student nurses, there are skills (both simple and complex), concepts, values and concrete body of knowledge to be acquired by the students. When Quality assurance is implemented as suggested above, the quality of product from nursing education is sure to improve and their ability as care givers greatly enhanced. There can be no improvement in nursing efficiency without adequate information about the structure , process and outcome of quality nursing services rendered to the health needs of the 21st century society.

BIBLIOGRAPHY BOOKS: 1. Soni Samta,2013, Text book of Advanced Nursing Practice, , Jaypee Brothers Publishers, New Delhi, 2013 : 14 - 22 2. Brar Navdeep Kaur, Text Book of Advanced Nursing Practice, Jaypee Brothers, New Delhi , 2015 : 76-91. 3. Shebeer.P.Basheer, Text Book of Advanced Nursing Practice,1st edition, Emmess Medical Publishers, Bangalore, 2013 : 50-60. INTERNET: 1. www. Slide share . net 2. https://www.slideshare.net/rautrav/quality-assurance-ppt

3. https://www.slideshare.net/HareeshSasidharan/quality-assurance-26354281