Mr. Harsh Raman

NURSING MANAGEMENTSEMINAR

ONQUALITY ASSURANCE- CONTINUOUS QUALITY

IMPROVEMENT

TERMINOLOGIES• Quality: It is the degree to which a product

confirms to specification and workmanship standards. (John D. McClellan)

• Quality Management: It refers to a philosophy that defines a corporate culture emphasizing customer satisfaction, innovation and employee involvement.

TERMINOLOGIES

• Continuous Quality Improvement: It is an ongoing process of innovation, prevention of error, and staff development that is used by corporations and institutions that adopt the quality management philosophy.

Quality Assurance: Means of delivering relevant and effective product (medical care) in accordance with the standards.

Accreditation: The process of providing an official approval to an organization stating that it has achieved a required standard.

JCAHO: Joint Commission on Accreditation of Health care Organization is the primary accrediting organizing for health care institutions.

Standards: These are formal statements about how patients should be managed or services be delivered.

Audit: An independent review conducted to compare some aspect of quality performance with a standard for that performance.

DEFINITION*“Quality assurance is defined as making sure that the services provided by hospital are the best possible in a given existing resources and current medical knowledge.”-WHO (1992)

*“Quality assurance is a judgment concerning the process of care based on the extent to which that care contributes to valued outcomes.”

-Donabedian 1982

*“Quality assurance is a management system designed to give maximum guarantee and ensure confidence that the service provided is up to the given accepted level of quality, the standards prescribed for that service which is being achieved with a minimum of total expenditure.”

-British Standards Institute

*“CQI is an ongoing quality improvement measure using management and scientific methods of quality assurance involving data collection, its analysis, and formulating ways to improve performance outcome according to proposed standards.”

OBJECTIVES To successfully achieve sustained improvement in health

care, clinics need to design processes to meet the needs of patients.

To design processes well, and systematically monitor, analyze, and improve their performance to improve patient outcomes.

A designed system should include standardized, predictable processes based on best practices.

Set Incremental goals as needed.

NASA Ames Research Center Health Unit

Public accountabil

ity

Management

improvement Facilitation

of adoption

of innovation

s

 

To provide technical assistance in designing

and implementing effective strategies for

monitoring quality

To refine existing methods for ensuring optimal

quality health care through an applied research

programme

(Decker, 1985 and Schroeder, 1984).

PURPOSES/ NEED

Rising expectations of consumer of services.

Increasing pressure on allocation of funds.

The increasing complexity of health care organizations.

Improvement of job satisfaction.

Highly informed consumer

To prevent rising medical errors

Accreditation bodies

Reducing global boundaries.

IMPORTANCE

To prepare nursing personnel for implementing of quality assurance model in nursing.

Introduce code of ethics and professional conduct for nurses in India.

PRINCIPLES

QM operates most effectively within a flat, democratic and

organizational structure.

Managers and workers must be committed to quality

improvement.

The goal of QM is to improve systems and processes and not

to assign blame.

Customers define quality.

Quality improvement focuses on outcome.

Decisions must be based on data.

TYPES OF QUALITY ASSURANCE:-

*External Quality Assurance:- Quality assurance can be evaluated by independent assessors or people from outside the institution/hospital.*Internal Quality Assurance:- Quality assurance can be evaluated by local assessors or senior person from the same institution/hospital.

BARRIERS OF CONTINUOUS QUALITY

IMPROVEMENT:

1. Difficult to foster collaboration between multiple

stakeholders.

2. Difficult to identify which processes to prioritize

improvement efforts.

3. Ill suited process management tooling.

4. Governing/controlling change

5. Lack of employee engagement

SOLUTIONS OF THE QUALITY IMPROVEMENT: Individual

problem solving

Rapid team problem solving

Systematic team problem

solving

Process improvement

solving

General approach

• Credentialing• Licensure• Accreditation• Certification • Charter• Recognition• Academic

degree

Specific approach

• Audit• Direct observation• Appropriateness evaluation• Peer review• Bench marking• Supervisory evaluation• Self-evaluation• Client satisfaction• Control committees• Services• Trajectory• Staging• Sentinel

ELEMENTS/ COMPONENTS According to Donabedian;

Structure Element- The physical, financial and

organizational resources provided for health care.

Process Element- The activities of a health system or

healthcare personnel in the provision of care.

Outcome Element- A change in the patient’s current or

future health that results from nursing interventions.

According to Manwell, Shaw, and Beurri, there are 3A’s

and 3E’s;

Access to healthcare

Acceptability

Appropriateness and relevance to need

 

Effectiveness

Efficiency

Equity

STANDARDS‘Standards are written formal statements to describe

how an organization or professional should deliver health service and are guidelines against which services can be assessed.’

Kirk and Hoesing (1991) stated that standards are needed to;

Provide direction Reach agreement on expectations Monitor and evaluate results Guide organizations, people and patients to obtain optimal

results.

AHRQ –Agency for Healthcare Research and

Quality

IHI –Institute for Healthcare Improvement

JCAHO –Joint Commission on Accreditation of

Healthcare Organizations

NAHQ –National Association for Healthcare Quality

IOM –Institute of Medicine

NCQA –National Committee for Quality Assurance

Sources of Nursing Care Standards *Professional organisation, e.g. Associations, TNAI, *Licensing bodies, e.g. Statutory bodies, INC, * Institutions/health care agencies, e.g. University

Hospitals, Health Centres. *Department of institutions, e.g. Department of

Nursing. * Patient care units, e.g. specific patients' unit. *Government units at National, State and Local

Government units. * Individual e.g. personal standards

LIST OF NURSING STANDARDS:-

Normative and Empirical

Ends and Means

Structure,Process and Outcome

LIST OF NURSING STANDARDS (Acc to ANA):-

Quality of Practice

EducationProfessional Practice

evaluationCollegiality

Ethics

Collaboration

Research

Resource utilization

Leadership

Areas of QA

Outpatient

department

Emergency

medical services

In- patient services

Specialty services

Training

MODELS1. Donabedian Model (1985):

2. ANA Model: This first proposed and accepted model of quality assurance was given by Long & Black in 1975. This helps in the self- determination of patient and family, nursing health orientation, patient’s right to quality care and nursing contributions.

Identify structure , standard and criteriaApply the process,

standards and criteriaEvaluate outcome of

standards and criteriaoutcom

e

structure

process

3. Quality Health Outcome Model: The uniqueness of this model proposed by Mitchell & Co is the point that there are dynamic relationships with indicators that not only act upon, but also reciprocally affect the various components.

System

(Individual,

Group/ organization)

Intervention Outcome

 

Client

(Individual, Family & Community)

4. Plan, Do, Study, Act cycle: It is an improvement model advocated by Dr. Deming.

A Plan is developed to test one of the improvement changes.

During the Do phase, the change is made, and data are collected to evaluate the results.

Study involves analysis of the data collected in the previous step. Data are evaluated for evidence that an improvement has been made.

The Act step involves taking actions that will ‘hardwire’ the change so that the gains made by the improvement are sustained over time.

5. Six Sigma: It refers to six standard deviations from the mean and is generally used in quality improvement to define the number of acceptable defects or errors produced by a process.

*It consists of 5 steps: define, measure, analyze, improve and control (DMAIC).

Define: Questions are asked about key customer requirements and key processes to support those requirements.Measure: Key processes are identified and data are collected.Analyze: Data are converted to information; Causes of process variation are identified.Improve: This stage generates solutions and make and measures process changes. Control: Processes that are performing in a predictable way at a desirable level are in control.

*WILSON’S MODEL:- Wilson 1987 in the late 1980’s tried to operationalize Donabedian model into a tangible and practical form. He redefined it as inputs, methods or procedures and outcomes. He described inputs as personnel, equipment and environment. Methods as procedures became the everyday practice and the outcome are the targets of care or services as measured by productivity, quality and client satisfaction.

MARKER’S UMBRELLA MODEL:- This is a system for providing continuity, consistency and competency in clinical patient care. The goal is to provide the above by developing a structure to standardize professional nursing clinical practice. The model describes connecting the characteristics for a comprehensive quality assurance model are:*Standard development.*Continuous advanced training.*Confirmation of technical authority.*Evaluation of execution of cares measures*Examination*Risk management*Control of demand resources*Active problem identification.* 

QUALITY TOOLS UDSED FOR CQI

chart audits

failure mode and effect analysis: prospective view

root cause analysis: retrospective view

flow diagrams

pareto diagram

histograms

run charts

control charts

INDICATORS OF QUALITY ASSURANCE

Waiting time for different services in the hospital

Medical errors in judgment, diagnosis, laboratory

reporting, medical treatment or surgical procedures, etc.

Hospital infections including hospital- acquired

infections, cross infections.

Quality of services in key areas like blood bank,

laboratories, X- ray department, central sterilization

services, pharmacy and nursing.

Identify needs.

Assemble a multidisciplinary team.

Collect data.

Establish measurable

outcomes and quality

indicators.Select and implement

a plan.Evaluate

implementation of plan and

achievement of outcomes.

QUALITY IMPROVEMENT PROCESS- STEPS

JCAHO quality assurance guidelines/steps:

1. Assign responsibility

2. Delineate scope of care and services 

3. Identify important aspects of care and services  

4. Identify indicators of outcome (no less than 2; no more than 4) 

5. Establish thresholds for evaluation

6. Collect data  

7. Evaluate data 

8. Take action 

9. Assess action taken 

10. Communicate

FACTORS AFFECTING QUALITY ASSURANCE IN NURING CARE

-Lack of resourcesPersonnel problemsUnreasonable Patients and attendantsImproper maintenanceAbsence of well informed populanceAbsence of accreditation lawsInspect hospitals and ensure that basic requirements are met.Lack of incident review proceduresDelayed attendance by physician/nurseLack of good hospital information systemAbsence of conducting patient satisfaction surveysLack of nursing care recordsMiscellaneous

FUNCTIONS OF NURSE IN QUALITY ASSURANCE*Encourage team member to be actively involved in quality process.*Implement quality control and improvement*Communicates standards of care too team members *Assess appropriate source of information *Evaluate quality and activity*Assist in the planning and organization of quality assurance program *Assist in developing annual auditing scheduled*Attend and participate in workshop and seminar*Develop and implement plan and action to correct deficiencies.

NEW TRENDS IN QUALITY ASSURANCE PROGRAME

Quality Council

Standard of care

Concurrent monitoring

Interdisci-plinary quality

assurance

Performan-ce appraisal

Performa-nce

appraisal

*Quality assurance practices in Europe: a survey of molecular genetic testing laboratories.

*In the 2000s, a number of initiatives were taken internationally to improve quality in genetic testing services. To contribute to and update the limited literature available related to this topic, we surveyed 910 human molecular genetic testing laboratories,of which 291 (32%) from 29 European countries responded. The majority of laboratories were in the public sector (81%),affiliated with a university hospital (60%). Only a minority of laboratories was accredited (23%), and 26% was certified. A total of 22% of laboratories did not participate in external quality assessment (EQA) and 28% did not use reference materials (RMs). The main motivations given for accreditation were to improve laboratory profile (85%) and national recognition (84%).

*Quality assurance practices in Europe: a survey of molecular genetic testing laboratories.

*Nearly all respondents (95%) would prefer working in an accredited laboratory. In accredited laboratories, participation in EQA (Po0.0001), use of RMs (P¼0.0014) and availability of continuous education (CE) on medical/scientific subjects (P¼0.023), specific tasks (P¼0.0018), and quality assurance (Po0.0001) were significantly higher than in non-accredited laboratories. *we showed that accredited laboratories (average score 92) comply

better than certified laboratories (average score 69, Po0.001), and certified laboratories better than other laboratories (average score 44, Po0.001), with regard to the implementation of quality indicators. *We conclude that quality practices vary widely in European genetic

testing laboratories. This leads to a potentially dangerous situation in which the quality of genetic testing is not consistently assured.

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