SeminarSeminarOnOn

Quality Assurance in Quality Assurance in NursingNursing

Introduction:Introduction:

  

TERMINOLOGIES:TERMINOLOGIES:       Quality Quality : Its is a relative term that : Its is a relative term that

describes something with high merit or describes something with high merit or excellence which is compared to an accepted excellence which is compared to an accepted standard (degree of excellence).standard (degree of excellence).

           Quality care Quality care : means that the services : means that the services

provided match the needs of the population provided match the needs of the population are technically correct, achieve beneficial are technically correct, achieve beneficial results.results.

                Assurance Assurance : Those activities those make : Those activities those make

certain that services are actually provided certain that services are actually provided (formal guarantee, certainty)(formal guarantee, certainty)

Cont….Cont…. Standards of care Standards of care : desired goals : desired goals

that can help in planning and that can help in planning and evaluation of nursing practicesevaluation of nursing practices

Quality assuranceQuality assurance: refers to : refers to process of achieving excellence in process of achieving excellence in the service rendered to every client. the service rendered to every client. Its also called quality control processIts also called quality control process

Cont….Cont…. Quality improvement Quality improvement ; it’s a systematic ; it’s a systematic

approach to control and improve quality approach to control and improve quality form the perspective of both professionals form the perspective of both professionals and clients. its also called total quality and clients. its also called total quality improvement or total quality management.improvement or total quality management.

Quality CircleQuality Circle: a participative management : a participative management approach in which employees and managers approach in which employees and managers share the responsibility for decision making share the responsibility for decision making and problem solving in client care.and problem solving in client care.

Cont….Cont…. Quality IndicatorsQuality Indicators: Quality focused objective used : Quality focused objective used

as markers to determine whether a goal has been as markers to determine whether a goal has been achieved and to measure client outcomes or achieved and to measure client outcomes or process out comes.process out comes.

Audit  Audit  : an organized effort where by practicing : an organized effort where by practicing professional monitor , assess and make judgments professional monitor , assess and make judgments about the quality and appropriateness of nursing about the quality and appropriateness of nursing care provided by peers are measured against care provided by peers are measured against professional standards of practiceprofessional standards of practice

Bench markingBench marking: studying another’s processes in : studying another’s processes in order to improve one’s own processesorder to improve one’s own processes

Cont….Cont…. Peer review : Peer review : An organized system by which peer An organized system by which peer

professionals assess the quality of care being delivered.professionals assess the quality of care being delivered.

Credentiality:Credentiality: Formal recognition of a person as a Formal recognition of a person as a professional with technical competence or of an agency professional with technical competence or of an agency that has met minimum standards of performance.that has met minimum standards of performance.

Accreditation: Accreditation: process whereby a professional process whereby a professional association or non-governmental agency grants association or non-governmental agency grants recognition to a school or health care institution for recognition to a school or health care institution for demonstrated ability to meet predetermined criteria for demonstrated ability to meet predetermined criteria for established standards.established standards.

Historical dvpt :Historical dvpt : Quality assurance have been evident in nursing Quality assurance have been evident in nursing

since the days of Florence Nightingale she was since the days of Florence Nightingale she was a pioneer in setting standards for nursing care.a pioneer in setting standards for nursing care.

              In 1860 Nightingale called for the In 1860 Nightingale called for the development of a uniform method to collect development of a uniform method to collect and present hospital statistics to improve and present hospital statistics to improve hospital treatmenthospital treatment

              In later 1800s the impetus for establishing In later 1800s the impetus for establishing nursing schools in the U.S came from a desire nursing schools in the U.S came from a desire to set standards that would upgrade nursing to set standards that would upgrade nursing carecare

Cont….Cont….               In 1900s efforts were begun to set similar In 1900s efforts were begun to set similar

standards for all nursing schools by various standards for all nursing schools by various accrediting organization , two of the most influential accrediting organization , two of the most influential organizations are ANA- American nurses association organizations are ANA- American nurses association (1890) and NLN- National league for nursing (1952). (1890) and NLN- National league for nursing (1952).

From 1912-1939 the interest in quality nursing From 1912-1939 the interest in quality nursing education led to the development of nursing education led to the development of nursing organization involved in accrediting nursing organization involved in accrediting nursing programs.programs.

          In 1892 Licensure has been a major issue in In 1892 Licensure has been a major issue in nursing.nursing.

Cont….Cont…. In 1923, all states has permissive / In 1923, all states has permissive /

mandatory laws directing nursing practice . mandatory laws directing nursing practice . 

        After World War II the attention of the After World War II the attention of the emerging nursing profession focused on emerging nursing profession focused on establishing a scientific method of practice.establishing a scientific method of practice.

            In 1950s they brought the development In 1950s they brought the development of tools to reassure quality assurance. One of tools to reassure quality assurance. One of the first tool created was nursing audit .of the first tool created was nursing audit .

Cont….Cont….             In 1972, the congress for nursing practice In 1972, the congress for nursing practice

was charged with developing standards to be was charged with developing standards to be used to institute quality assurance programs.used to institute quality assurance programs.

            In 1972, The Joint Commission on In 1972, The Joint Commission on Accreditation of hospitals (JCAH) clearly Accreditation of hospitals (JCAH) clearly stated the responsibilities of nursing in its stated the responsibilities of nursing in its description of standards for nursing services.description of standards for nursing services.

          The JCAH called on the nursing industry to The JCAH called on the nursing industry to clearly plan document and evaluate nursing clearly plan document and evaluate nursing care provided .care provided .

Cont….Cont….     In mid 1980s JCAH became the joint In mid 1980s JCAH became the joint

commission on accreditation of health commission on accreditation of health care organization (JCAHCO) and began care organization (JCAHCO) and began developing quality control standards for developing quality control standards for home health nursing and hospital home health nursing and hospital nursing.nursing.

          In 2007, it was renamed as The Joint In 2007, it was renamed as The Joint

Commission (TJC) .Commission (TJC) .

DEFINITION:DEFINITION: 1.   Definition of quality assurance1.   Definition of quality assurance        Quality assurance means delivery Quality assurance means delivery

of efficient and effective medical care in of efficient and effective medical care in accordance with the professional standards.accordance with the professional standards.

2.    Definition of Quality Assurance in 2.    Definition of Quality Assurance in Nursing:Nursing:

                    Quality Assurance is the defining of Quality Assurance is the defining of nursing practice through well written nursing nursing practice through well written nursing standards and the use of those standards as standards and the use of those standards as a basis for evaluation on improvement of a basis for evaluation on improvement of client care (Maker 1998).client care (Maker 1998).

GOALS & PURPOSES:GOALS & PURPOSES: i) Goals:i) Goals: ·  To ensure the delivery of quality client care·  To ensure the delivery of quality client care ·  To demonstrate the efforts of the health provider to ·  To demonstrate the efforts of the health provider to

provide the best possible resultsprovide the best possible results    ii) ii) Purpose of Quality Assurance:Purpose of Quality Assurance: Sets standards for care.Sets standards for care. Help patients and potential patients by improving quality Help patients and potential patients by improving quality

of care.of care. Assess competence of medical staff, serve as an impetus Assess competence of medical staff, serve as an impetus

to to keep  up to date and prevent future mistakes andkeep  up to date and prevent future mistakes and Bring to notice of hospital administration the deficiencies Bring to notice of hospital administration the deficiencies

and in correcting the causative factors and in correcting the causative factors Helps to exercise a regulatory function, restricting Helps to exercise a regulatory function, restricting

undesirable undesirable ProceduresProcedures

Need for quality control:Need for quality control:

Quality control is essential to make the efficiency of health Quality control is essential to make the efficiency of health institutions possible through.institutions possible through.

a)   Improvement of existing obsolete processes and a)   Improvement of existing obsolete processes and proceduresprocedures

b)   Improved layout of office and working environmentb)   Improved layout of office and working environment c)   Economy in human effortc)   Economy in human effort d)   Suggesting the best use of money and materiald)   Suggesting the best use of money and material e)   Improved design of the goods or services provided by e)   Improved design of the goods or services provided by

the organizationthe organization f)     Improved performancef)     Improved performance g)   Job satisfactiong)   Job satisfaction h)   Improved flow of workh)   Improved flow of work i)     Standardization of processes and products.i)     Standardization of processes and products.

V. Approaches/ Techniques for V. Approaches/ Techniques for Quality assurance:Quality assurance:

                    Two major categories of Two major categories of approaches exist in quality approaches exist in quality assurance they are:assurance they are:

A.   GeneralA.   General B.   SpecificB.   Specific

Cont…..Cont…..1)   Credentialing:1)   Credentialing: It is generally defined as the formal It is generally defined as the formal

recognition of professional or technical recognition of professional or technical competence and attainment of minimum competence and attainment of minimum standards by a person or agency.standards by a person or agency.

              Licensure:Licensure: It is a contract between the It is a contract between the profession and the state, in which the profession and the state, in which the profession is granted control over entry profession is granted control over entry into and exists from the profession and into and exists from the profession and over quality of professional practice. over quality of professional practice.

Cont….Cont….               Accreditation:Accreditation: National league for nursing (NLN) a National league for nursing (NLN) a

voluntary organization has established standards voluntary organization has established standards for inspecting nursing education’s programs. In for inspecting nursing education’s programs. In the part the accreditation process primarily the part the accreditation process primarily evaluated on regency’s physical structure, evaluated on regency’s physical structure, organizational structure and personal organizational structure and personal qualification. In 1990 more emphasis was placed qualification. In 1990 more emphasis was placed on evaluation of the outcomes of care and on the on evaluation of the outcomes of care and on the educational qualifications of the person providing educational qualifications of the person providing care.care.

             

Cont….Cont….

Certification:Certification: Certification is usually a voluntary Certification is usually a voluntary

process with in the professions. A person’s process with in the professions. A person’s educational achievements, experience and educational achievements, experience and performance on examination are used to performance on examination are used to determine the person’s qualifications for determine the person’s qualifications for functioning is an identified specialty area.functioning is an identified specialty area.

Cont…….Cont…….

B.   Specific Approach:B.   Specific Approach:

1.      1.      Peer Review Committee:Peer Review Committee: These are designed to monitor These are designed to monitor

client specific aspects of care client specific aspects of care appropriate for certain levels of care. appropriate for certain levels of care. The audit has been the major tool The audit has been the major tool used by peer review committee to used by peer review committee to ascertain quality of care.ascertain quality of care.

Cont….Cont….

Nursing auditNursing audit::                 An audit is an organized effort whereby An audit is an organized effort whereby

practicing professionals monitor, assess, and practicing professionals monitor, assess, and make judgments about the quality and make judgments about the quality and appropriateness of nursing care provided by appropriateness of nursing care provided by peers as measured against professional peers as measured against professional standards of practicestandards of practice

          The toolsThe tools include record reviews, checklist, include record reviews, checklist, questionnaires, and surveys. questionnaires, and surveys.

               

Cont….Cont….

Auditing can occur Auditing can occur retrospectively, retrospectively, concurrentlyconcurrently, or , or prospectively.prospectively.

Retrospective audit are performed after Retrospective audit are performed after the patient receives the service.the patient receives the service.

Concurrent audits are performed while Concurrent audits are performed while the patient is receiving the service. the patient is receiving the service.

Prospective audits attempt to identify how Prospective audits attempt to identify how future performance will be affected by future performance will be affected by current interventions.current interventions.

Cont…..Cont…..The audit includes outcome audit , process audit, The audit includes outcome audit , process audit,

and structure audits:and structure audits: Outcome audit Outcome audit It can be defined as the end result of care, or It can be defined as the end result of care, or

how the patient’s health status changed as result how the patient’s health status changed as result of the interventionof the intervention

Process auditProcess audit::    Process audits are used to measure the Process audits are used to measure the

process of care or how the care was carried out process of care or how the care was carried out and assume that a relationship exists between the and assume that a relationship exists between the process used by the nurse and the quality of care process used by the nurse and the quality of care provided.provided.e.g.e.g. a process audit is used to establish a process audit is used to establish whether fetal heart tones or blood pressures were whether fetal heart tones or blood pressures were checked according to an established policychecked according to an established policy

Cont….Cont…. Structure auditStructure audit:: Structure audit assume that a Structure audit assume that a

relationship exists between quality care and relationship exists between quality care and appropriate structure. appropriate structure. E.g.E.g. staffing ratios, staffing ratios, availability of fire extinguishers in patient care availability of fire extinguishers in patient care areas would all be structure measures of areas would all be structure measures of quality carequality care

2.      Utilization review:2.      Utilization review: Utilization review activities are Utilization review activities are

directed towards assuring that care is actually directed towards assuring that care is actually needed and that the cost appropriate for the needed and that the cost appropriate for the level of care provided.level of care provided.

Cont….Cont….

Types of Utilization review:Types of Utilization review:                i. Prospective:i. Prospective: It is an assessment of the necessity of It is an assessment of the necessity of

care care                         before giving servicebefore giving service            ii.Concurrentii.Concurrent::  A review of the necessity of care while the  A review of the necessity of care while the                               care is being givencare is being given                iii.Retrospective:iii.Retrospective: In analysis of the necessity of the services In analysis of the necessity of the services

                                      Received by the client after the care has being given.Received by the client after the care has being given. Utilization review has been used primarily in hospitals to Utilization review has been used primarily in hospitals to

establish need for client admission end the length of hospital establish need for client admission end the length of hospital stay. The Utilization review process includes the development of stay. The Utilization review process includes the development of explicit criteria that serves as indicators of the need for services explicit criteria that serves as indicators of the need for services and length of services.and length of services.

Advantages of Utilization Advantages of Utilization Review:Review:

·        It is designed to assist clients to avoid ·        It is designed to assist clients to avoid unnecessary careunnecessary care

·        It may serve to encourage the ·        It may serve to encourage the consideration of care options by providers, consideration of care options by providers, such as home health care rather than such as home health care rather than hospitalization.hospitalization.

·        It can provide guidelines for staff of ·        It can provide guidelines for staff of program development.program development.

·        It provides a measure of agency ·        It provides a measure of agency accountability to the consumer accountability to the consumer

3.Client Satisfaction:3.Client Satisfaction: Client satisfaction can be assessed using person or Client satisfaction can be assessed using person or

telephone interviews and mailed questionnaire. Data telephone interviews and mailed questionnaire. Data from client satisfaction surveys are used to measure from client satisfaction surveys are used to measure structure, process and outcome of care given.structure, process and outcome of care given.

4.Incident Review:4.Incident Review: During a patient’s hospitalization several incidents During a patient’s hospitalization several incidents

may occur which have a bearing on the treatment and may occur which have a bearing on the treatment and patients final recovery. The report should contain the patients final recovery. The report should contain the name, age, exact time and place, description of how it name, age, exact time and place, description of how it occurred any precaution taken conditions of patient occurred any precaution taken conditions of patient before and after the incident etc. since these reports before and after the incident etc. since these reports are of legal value it should be written carefully given are of legal value it should be written carefully given importance to all the details and should be filed importance to all the details and should be filed safely.safely.

5.Risk Management:5.Risk Management: It can be defined in a program that is developed It can be defined in a program that is developed

for the purpose of eliminating or controlling health for the purpose of eliminating or controlling health care situations that has the potential to endangers care situations that has the potential to endangers or creates risk to clients. Risk management or creates risk to clients. Risk management activities are directed towards the identifications, activities are directed towards the identifications, analysis and evaluationanalysis and evaluation of situations to prevent of situations to prevent injury and subsequent financial loss.injury and subsequent financial loss.

6.Malpractice litigation:6.Malpractice litigation: It is a specific approach to be imposed on the It is a specific approach to be imposed on the

health care delivery systems by the legal systems. health care delivery systems by the legal systems. Malpractice litigation results from client Malpractice litigation results from client dissatisfaction with the provider and with the dissatisfaction with the provider and with the content of care received.content of care received.

VI. Quality Assurance Committee VI. Quality Assurance Committee (QAC):(QAC):

The committee should consist of the The committee should consist of the following:following:

1.    Medical administrator1.    Medical administrator 2.    Two senior clinicians2.    Two senior clinicians 3.    Pathologist3.    Pathologist 4.    Radiologist4.    Radiologist 5.    Nurse administrator5.    Nurse administrator 6.    Medical records officer – secretary6.    Medical records officer – secretary 7.    Additional personnel such as super-7.    Additional personnel such as super-

specialists and consultants can be co-opted specialists and consultants can be co-opted on the committee as and when required. on the committee as and when required.

VII. Quality Assurance VII. Quality Assurance Committee in Nursing:Committee in Nursing:

The members of the committee should include The members of the committee should include representative of all levels of professional nursing representative of all levels of professional nursing includingincluding

    Client Care coordinatorsClient Care coordinators     SupervisorsSupervisors     Head NursesHead Nurses     Clinical SpecialistsClinical Specialists     Nurse CliniciansNurse Clinicians     Licensed practical NursesLicensed practical Nurses     Nursing AssistantsNursing Assistants     Other client care personnelOther client care personnel     Medical records AdministratorMedical records Administrator

vii.a) Functions of the Quality vii.a) Functions of the Quality assurance committee:assurance committee:

1.    Coordination:1.    Coordination:               Collecting informationCollecting information                 Consider activities that should be related, e.g. Consider activities that should be related, e.g.

quality appraisal and continuing educationquality appraisal and continuing education                Communicate across patient care disciplinesCommunicate across patient care disciplines                 Coordinate actions of hospital authority groupsCoordinate actions of hospital authority groups

2.    Information:2.    Information:                Provide a centralized source of reports to the Provide a centralized source of reports to the

boardboard                Suggest need for intervention to hospital Suggest need for intervention to hospital

authority groupsauthority groups

Cont….Cont….3.    Planning:3.    Planning:                Establish prioritiesEstablish priorities

4.    Prodding:4.    Prodding:                Insist on effective, productive quality Insist on effective, productive quality

appraisal efforts from all hospital appraisal efforts from all hospital componentscomponents

5.    Consultation:5.    Consultation:                Provide specific assistance, usually Provide specific assistance, usually

through the coordinatorthrough the coordinator

Cont….Cont…. 6.    Response:6.    Response:                Internally, acknowledge issues of importance Internally, acknowledge issues of importance

to individual and departments when suggesting to individual and departments when suggesting high-priority areas for immediate attentionhigh-priority areas for immediate attention

                Externally, provide the organizational home for Externally, provide the organizational home for responding to quality requirements of external responding to quality requirements of external agencies, if any, e.g. medical companies.agencies, if any, e.g. medical companies.

7.    Search for expertise:7.    Search for expertise:                Operate openly, not behind closed doors seek Operate openly, not behind closed doors seek

out the specific clinical and/or management out the specific clinical and/or management expertise necessary to reach sound conclusionsexpertise necessary to reach sound conclusions

Cont….Cont….

8.    Follow-up:8.    Follow-up: Insists on reports of the impact of Insists on reports of the impact of

implemented changes.if quality assurance is to be implemented changes.if quality assurance is to be effective rather than threatening, controversial, and effective rather than threatening, controversial, and counterproductive. Committee members must counterproductive. Committee members must recognize that their major functions are:recognize that their major functions are:

                                i.        To coordinate, not to controli.        To coordinate, not to control                                    ii.        To inform, not to scoldii.        To inform, not to scold                                    iii.        To plan, prod, and suggest priorities, iii.        To plan, prod, and suggest priorities,

not to do detailed studies “in committee”, and not to do detailed studies “in committee”, and                                     iv.        To recommend and report, not to iv.        To recommend and report, not to

intervene directly.intervene directly.

Factors affecting quality Factors affecting quality assurance in nursing care:assurance in nursing care:

1) Lack of Resources:1) Lack of Resources:Insufficient resources, infrastructures, Insufficient resources, infrastructures,

equipment, consumables, money for equipment, consumables, money for recurring expenses and staff make it possible recurring expenses and staff make it possible for output of a certain quality to be turned for output of a certain quality to be turned out under the prevailing circumstances.out under the prevailing circumstances.

2) Personnel problems:2) Personnel problems:Lack of trained, skilled and motivated Lack of trained, skilled and motivated

employees, staff indiscipline affects the employees, staff indiscipline affects the quality of care.quality of care.

Cont….Cont….3) Improper maintenance:3) Improper maintenance:Buildings and equipments require proper maintenance for Buildings and equipments require proper maintenance for

efficient use. If not maintained properly the equipments efficient use. If not maintained properly the equipments cannot be used in giving nursing care. To minimize equipment cannot be used in giving nursing care. To minimize equipment down time it is necessary to ensure adequate after sale down time it is necessary to ensure adequate after sale service and service manuals.service and service manuals.

4) Unreasonable Patients and Attendants:4) Unreasonable Patients and Attendants:Illness, anxiety, absence of immediate response to treatment, Illness, anxiety, absence of immediate response to treatment,

unreasonable and unco-operative attitude that in turn affects unreasonable and unco-operative attitude that in turn affects the quality of care in nursing.the quality of care in nursing.

5) Absence of well informed population.5) Absence of well informed population.To improve quality of nursing care, it is necessary that the To improve quality of nursing care, it is necessary that the

people become knowledgeable and assert their rights to people become knowledgeable and assert their rights to quality care. This can be achieved through continuous quality care. This can be achieved through continuous educational program.educational program.

Cont….Cont….5) Absence of well informed population:5) Absence of well informed population:To improve quality of nursing care, it is necessary that the To improve quality of nursing care, it is necessary that the

people become knowledgeable and assert their rights to people become knowledgeable and assert their rights to quality care. This can be achieved through continuous quality care. This can be achieved through continuous educational program.educational program.

6) Absence of accreditation laws:6) Absence of accreditation laws:There is no organization empowered by legislation to lay down There is no organization empowered by legislation to lay down

standards in nursing and medical care so as to regulate the standards in nursing and medical care so as to regulate the quality of care. It requires a legislation that provides for quality of care. It requires a legislation that provides for setting of a stationary accreditation / vigilance authority to:setting of a stationary accreditation / vigilance authority to:

a) Inspect hospitals and ensures that basic requirements are a) Inspect hospitals and ensures that basic requirements are met.met.

b) Enquire into major incidence of negligence b) Enquire into major incidence of negligence c) Take actions against health professionals involved in c) Take actions against health professionals involved in

malpracticemalpractice

Cont….Cont….7) Lack of incident review procedures 7) Lack of incident review procedures During a patients hospitalizations reveal During a patients hospitalizations reveal

incidents may occur which have a bearing incidents may occur which have a bearing on the treatment and the patients final on the treatment and the patients final recovery. These critical incidents may be:recovery. These critical incidents may be:

a) Delayed attendance by nurses, surgeon, a) Delayed attendance by nurses, surgeon, physicianphysician

b) Incorrect medicationb) Incorrect medicationc) Burns arising out of faulty proceduresc) Burns arising out of faulty proceduresd) Death in a corridor with no nurse / d) Death in a corridor with no nurse /

physician accompanying the patient etc. physician accompanying the patient etc.

CONT….CONT….8) Lack of good and hospital information system8) Lack of good and hospital information systemA good management information system is essential for A good management information system is essential for

the appraisal of quality of care.the appraisal of quality of care.a) Workload, admissions, procedures and length of stay a) Workload, admissions, procedures and length of stay b) Activity audit and scheduling of procedures.b) Activity audit and scheduling of procedures.9) Absence of patient satisfaction surveys9) Absence of patient satisfaction surveysAscertainment of patient satisfaction at fixed points on Ascertainment of patient satisfaction at fixed points on

an ongoing basis. Such surveys carried out through an ongoing basis. Such surveys carried out through questionnaires, interviews to by social worker, questionnaires, interviews to by social worker, consultant groups, and help to document patient consultant groups, and help to document patient satisfaction with respect to variables that are satisfaction with respect to variables that are

a) Delay in attendance by nurses and doctors.a) Delay in attendance by nurses and doctors.b) Incidents of incorrect treatmentb) Incidents of incorrect treatment

Cont….Cont….10) Lack of nursing care records10) Lack of nursing care recordsNursing care records are perhaps the most Nursing care records are perhaps the most

useful source of information on quality of useful source of information on quality of care rendered. The records.care rendered. The records.

a) Detail the patient conditiona) Detail the patient conditionb) Document all significant interaction b) Document all significant interaction

between patient and the nursing personnel.between patient and the nursing personnel.c) Contain information regarding response to c) Contain information regarding response to

treatment treatment d) Have the dates in an easily accessible form.d) Have the dates in an easily accessible form.

Cont….Cont….11) Miscellaneous factors11) Miscellaneous factorsa. Lack of good supervisiona. Lack of good supervisionb. Absence of knowledge about philosophy of b. Absence of knowledge about philosophy of

nursing carenursing carec. Lack of policy and administrative manuals.c. Lack of policy and administrative manuals.d. Substandard education and trainingd. Substandard education and traininge. Lack of evaluation techniquee. Lack of evaluation techniquef.  Lack of written job description and job f.  Lack of written job description and job

specificationsspecificationsg. Lack of in-service and continuing g. Lack of in-service and continuing

educational programeducational program

Development Development of standardsof standardsa. Definition of standard:a. Definition of standard: A standard is a predetermined level of A standard is a predetermined level of

excellence that serves a guide for practice.excellence that serves a guide for practice.

b.Characters:b.Characters:                 Predetermined Predetermined                 Established by an authorityEstablished by an authority                 Communicated to and accepted by Communicated to and accepted by

the people affected by themthe people affected by them               They must be measurable, achievableThey must be measurable, achievable

Cont….Cont…. c. Typesc. Types               Organizational standards:Organizational standards: this outline levels of acceptable practice within the this outline levels of acceptable practice within the

institution for example: each organization develops a policy institution for example: each organization develops a policy and procedures manual that outlines its specific standards. and procedures manual that outlines its specific standards. These standards may be minimizing or maximizing in terms These standards may be minimizing or maximizing in terms of the quality of service expected. Such standards of of the quality of service expected. Such standards of practice allow the organization to measure more objectively practice allow the organization to measure more objectively unit and individual performance.unit and individual performance.

                Standardized clinical guidelines:Standardized clinical guidelines: provides diagnosis based, step by step provides diagnosis based, step by step

interventions for providers to follow in an effort to promote interventions for providers to follow in an effort to promote high quality care while controlling resource utilization and high quality care while controlling resource utilization and costs. They are all developed by Agency for Health care costs. They are all developed by Agency for Health care Research and Quality (AHRQ)Research and Quality (AHRQ)

Cont….Cont…. x.d. Sources of nursing care standards:x.d. Sources of nursing care standards:

1.   Professional organization E.g. TNAI 1.   Professional organization E.g. TNAI AssociationsAssociations

2.   Licensing bodies E.g. INC,2.   Licensing bodies E.g. INC, 3.   Institutions/ health care agencies E.g. JIPMER3.   Institutions/ health care agencies E.g. JIPMER 4.   Department of institution E.g. department of 4.   Department of institution E.g. department of

nursingnursing 5.   Patient care units E.g. specific patient care unit5.   Patient care units E.g. specific patient care unit 6.   Individual E.g. personal standards6.   Individual E.g. personal standards  

Cont…Cont…e. Professional standards review organization:e. Professional standards review organization:

a.   PSRO- Professional standards review board a.   PSRO- Professional standards review board legislation(1972)legislation(1972)

b.   Prospective payment systemb.   Prospective payment system c.   JCAHO- The Joint Commission for Accreditation of c.   JCAHO- The Joint Commission for Accreditation of

health care Organizationshealth care Organizations d.   Centers for Medicare and Medicaid services d.   Centers for Medicare and Medicaid services

(CMS)(CMS) e.   National committee for quality assurance(NCQA)e.   National committee for quality assurance(NCQA) f.   Maryland hospital association quality indicator f.   Maryland hospital association quality indicator

projectproject

Cont….Cont….f. Nursing scopes and standards of practice f. Nursing scopes and standards of practice

    (ANA-2004)    (ANA-2004)

Since the 1930s the American nurses association Since the 1930s the American nurses association has played a key role in developing standards for has played a key role in developing standards for the profession. Currently there are more than 20 the profession. Currently there are more than 20 different ANA standard for nursing practice that different ANA standard for nursing practice that reflect different areas of specialty nursing reflect different areas of specialty nursing practice (ANA, 2001).the standards of clinical practice (ANA, 2001).the standards of clinical nursing practice , originally published by ANA in nursing practice , originally published by ANA in 1991 and subsequently revised in both 1998, 1991 and subsequently revised in both 1998, 2004 provides a foundation for all registered 2004 provides a foundation for all registered nurses in clinical practice.nurses in clinical practice.

Cont….Cont…. Nursing scope and standards of practice:Nursing scope and standards of practice:Standards of practice:Standards of practice: 1.   Assessment: the registered nurse collects comprehensive 1.   Assessment: the registered nurse collects comprehensive

data pertinent to the patient’s health or the situationdata pertinent to the patient’s health or the situation 2.   2.   Diagnosis:Diagnosis: the registered nurse analyze the assessment the registered nurse analyze the assessment

data to determine the diagnoses or issuesdata to determine the diagnoses or issues 3.   3.   Outcomes identificationOutcomes identification: the registered nurse identifies : the registered nurse identifies

expected outcomes for a plan individualized to the patient or expected outcomes for a plan individualized to the patient or the situationthe situation

4.   4.   Planning:Planning: the registered nurse develops a plan that the registered nurse develops a plan that prescribes strategies and alternatives to attain expected prescribes strategies and alternatives to attain expected outcomesoutcomes

5.   5.   Implementation:Implementation: the registered nurse implements the the registered nurse implements the identified planidentified plan

6.   6.   Evaluation:Evaluation: the registered nurse evaluates progress the registered nurse evaluates progress toward attainment of outcomestoward attainment of outcomes

  

Cont….Cont…. Standards of professional performance:Standards of professional performance: 7.   Quality of practice7.   Quality of practice: the registered nurse : the registered nurse

systematically enhances the quality and systematically enhances the quality and effectiveness of nursing practiceeffectiveness of nursing practice..

8.   8.   EducationEducation: the registered nurse attains : the registered nurse attains knowledge and competency that reflects current knowledge and competency that reflects current nursing practicenursing practice

9.Professional practice evaluation9.Professional practice evaluation; the ; the registered nurse evaluates own nursing practice in registered nurse evaluates own nursing practice in relation to professional practice standards and relation to professional practice standards and guidelines, relevant statutes, rules and regulationsguidelines, relevant statutes, rules and regulations

10.Collegiality:10.Collegiality: the registered nurse interacts the registered nurse interacts with and contributes to the professional with and contributes to the professional development of peers and colleaguesdevelopment of peers and colleagues

Cont….Cont…. 11.Collaboration11.Collaboration: the registered nurse collaborates with the : the registered nurse collaborates with the

patient, family, and others in the conduct of nursing practice.patient, family, and others in the conduct of nursing practice.

12.Ethics;12.Ethics; the registered nurse integrates ethical provisions the registered nurse integrates ethical provisions in all areas  of practice .in all areas  of practice .

13.Research:13.Research: the registered nurse integrates research the registered nurse integrates research findings in practice.findings in practice.

14,Resource utilization14,Resource utilization: the registered nurse considers : the registered nurse considers factors related to safety, effectiveness, cost, and impact on factors related to safety, effectiveness, cost, and impact on practice in planning and delivering nursing services.practice in planning and delivering nursing services.

15.Leadership15.Leadership: the registered nurse provides leadership in : the registered nurse provides leadership in the   the   

    professional practice setting and the profession.professional practice setting and the profession.

XI. Total quality managementXI. Total quality management::

xi.a. Definition :xi.a. Definition : It’s a systematic approach to It’s a systematic approach to

control and improve quality from the control and improve quality from the perspective of both professionals and perspective of both professionals and clients. its also called continuous clients. its also called continuous quality improvement quality improvement

  

Total Quality Management Total Quality Management Principles: (Deming)Principles: (Deming)

                            1.      Create a constancy of purpose for the 1.      Create a constancy of purpose for the improvement of serviceimprovement of service

                            2.      Adopt a philosophy of continual 2.      Adopt a philosophy of continual improvementimprovement

                            3.      Focus on improving processes, not on 3.      Focus on improving processes, not on inspection of services.inspection of services.

                            4.      End the practice of awarding 4.      End the practice of awarding business on price alone; instead minimize total business on price alone; instead minimize total cost by working with a simple supplier.cost by working with a simple supplier.

                            5.      Improve constantly every process for 5.      Improve constantly every process for planning, production and serviceplanning, production and service

Cont….Cont…. 6.      Institute job training and retraining.6.      Institute job training and retraining.

7.      Develop the leadership in the organization.7.      Develop the leadership in the organization.

8.      Drive out fear by encouraging employees to 8.      Drive out fear by encouraging employees to participate actively in the process.participate actively in the process.

9.      Foster interdepartmental cooperation and 9.      Foster interdepartmental cooperation and break down barriers between departments.break down barriers between departments.

10.    Eliminate slogans, exhortations, and targets 10.    Eliminate slogans, exhortations, and targets for the work forcefor the work force

                        

Cont….Cont….

11.    Focus on quality and not just quantity11.    Focus on quality and not just quantity

12.    Promote teamwork rather than 12.    Promote teamwork rather than individual accomplishmentsindividual accomplishments

13.    Educate/ train employees to maximize 13.    Educate/ train employees to maximize personal developmentpersonal development

14.    Charge all employees with carrying out 14.    Charge all employees with carrying out

the total quality management packagethe total quality management package

JCAHO’s 10 steps for Quality JCAHO’s 10 steps for Quality Improvement -process:Improvement -process:

                              1.      Establish responsibility and accountability for a QI 1.      Establish responsibility and accountability for a QI

ProgramProgram                            2.      Define the scope of service for a chemical area2.      Define the scope of service for a chemical area                            3.      Define the key aspects of service for the chemical 3.      Define the key aspects of service for the chemical

areaarea                            4.      Develop quality indicators to monitor the 4.      Develop quality indicators to monitor the

outcomes and appropriateness of care delivered.outcomes and appropriateness of care delivered.                            5.      Establish thresholds for evaluation of indicators5.      Establish thresholds for evaluation of indicators                            6.      Collect and analyze data from monitoring activities6.      Collect and analyze data from monitoring activities                            7.      Evaluate results of monitoring activities to 7.      Evaluate results of monitoring activities to

determine the need for change in practicedetermine the need for change in practice                            8.      Resolve problems through development of action 8.      Resolve problems through development of action

plansplans                            9.      Reevaluate to determine if the plan was successful9.      Reevaluate to determine if the plan was successful                        10.    Communicate QI results to the organization..10.    Communicate QI results to the organization..

Tools in Quality managementTools in Quality management

                      Statistical tools utilized in quality Statistical tools utilized in quality management studies includemanagement studies include

                    Tools for process description, for data Tools for process description, for data collection and for data Analysis.collection and for data Analysis.

1.   Tools for data collection:1.   Tools for data collection:    2.   Tools for Data Analysis:2.   Tools for Data Analysis: 3.   Tools for process description:3.   Tools for process description:

  

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