Quality Frameworks Course Post Graduate Certificate in Nursing/Midwifery (Applied

Clinical and Professional Development

Module Contemporary Issues in Nursing and Midwifery

Lecturer Professor Zena Moore, Dr Tom O’Connor, Ms Chanel

Watson.

RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn

What is quality? What is quality assurance?

• Quality: positive characteristics; general excellence

• Quality Assurance: quality assurance n. the maintenance

of a desired level of quality in a service or a

manufactured product, esp. by means of attention to

every stage of the process of delivery or manufacture

(Oxford English Dictionary)

In the academic world...

• ‘the measurement of actual level of service provided plus the efforts to modify when necessary the provision of these services in the light of the results of the measurement’

(Williamson 1979)

• ‘all activities undertaken to predict and prevent poor quality’

(Øvretveit 1992)

• In nursing: ‘purpose of is to assure the consumer of nursing of a specified degree of excellence through continuous measurement and evaluation’

(Schmadl 1979)

Key elements:

“standards, measurement, actions, continuing”

Quality...historical context.

• Initially emerged as a concept in the manufacturing

industry in the USA & Japan in the 1950s by writers such

as Deming and Juran.

• Concentration on productivity and on measuring and

capturing those things that made organisations less

efficient and effective (Sale 2005)

• Deming & Juran first proponents of system wide,

systematic, continuing multifaceted approaches to

quality

• PDCA Cycles (Deming)

Development of the quality agenda

• Evolved from being the ‘indicators of institutional

effectiveness’ (Winn & Cameron 1998) where quality

was one of the desired outcomes

• Became ‘the’ singular goal of organisations and

organisational culture

• Working proactively instead of reactively

• Organisations became quality orientated rather that

desiring quality as a by-product

• QI, TQM

TQM

Quality Theorists

• MAXWELL

• 6 dimensions of quality

– Appropriateness

– Equity

– Accessibility

– Effectiveness

– Acceptability

– Efficiency

Quality Theorists

Donabedian

Quality in Healthcare

• Drivers of quality in healthcare: – Cost

– Error/Patient Safety (To Err Is Human: Building a Safer Health System)

– Effectiveness

– Consumerism

(Wakefield 2008)

• A recognition that the quality of care could not solely rely on individual processional performance or responsibility

• Core principles of successful quality improvement – Leadership on all levels

– A pervasive culture that supports learning throughout the care process

– Emphasis on development of effective teams

– Greater use of IT

(Ferlie & Shortell 2001)

Quality & Nursing & Midwifery

• Nurses at first glance may see quality as inherent to what they do

• For example:

– Quality and Safety Education for Nurses (QSEN) (Cronnenwett et al 2007)

• Core competencies

– Patient-centered Care

– Teamwork and Collaboration

– Evidence-based Practice (EBP)

– Quality Improvement (QI)

– Safety

– Informatics

• The difficulty in capturing the quality of nursing (Aiken et al 2014)

• How can quality initiatives be different or how can they help?

Quality at different levels

International

(WHO)

National (HIQA)

Organisational (QA)

Local (Ward initiatives)

Quality frameworks

• What is it?

• “a framework for evaluating and continuously improving

the quality of services. It shows key concepts and the

relations between them to guide analysis or other

actions”

• Puts structures on the processes that go to ensure

quality

Examples of Frameworks

• Quality Framework Mental Health Services in Ireland

Examples of frameworks

HIQA: National Standards for Safer Better

Healthcare

Considering error and risk, why do errors

happen?

• Person Approach – Errors as a result of

personal failings (tiredness, laziness, inattention etc)

– Errors become moral issues and attempts to alleviate them appeal to sense of guilt and just

– Pros: Satisfying, legally convenient

– Cons: no learning, ignores the context in which errors take place

• System Approach – Recognition that

humans are always susceptible to error

– Errors consequences of system factors rather than causes

– Safeguards must be put in place to prevent error and also for the fact that humans are fallible

The Swiss cheese model of how defences, barriers, and safeguards may be penetrated by an

accident trajectory.

Reason, James. (2000) Human Error: Models and Management. BMJ Vol 320(768)

©2000 by British Medical Journal Publishing Group

Safety Culture in Organisations

• Highly developed ideas about safety culture in certain industries (aeronautical and oil & gas exploration)

• Development as HRO (High Reliability Organisations)

• Culture of Safety; – Informed: managers know what is going on in their organisation and

the workforce are willing to report their own errors and near misses.

– Wary: the organisation and its constituent individuals are on the lookout for the unexpected, maintaining a high degree of vigilance.

– Just: the organisation is normally a “no blame” culture, although some actions are agreed by all to be totally unacceptable, deserving some retribution.

– Flexible: such organisations reflect changes in demand and adapt rapidly to changes in circumstances, providing both high tempo and routine modes of operation.

– Learning: organisations expect to have to change, are ready to learn and can do what needs to be done to improve.

Hudson (2003)

The evolution of safety cultures.

Hudson P Qual Saf Health Care 2003;12:i7-i12

Copyright © BMJ Publishing Group Ltd and the Health Foundation. All rights reserved.

Human Factors & Patient Safety

• Human traits are inherent in error

• Human factors:

“refer to environmental, organizational and job factors,

and human and individual characteristics which

influence behaviour at work in a way which can affect

health and safety” (WHO 2009)

• Humans factors associated with patient safety:

– Situational Awareness

– Leadership

– Empowerment

– Communication.

Situational Awareness

• "the perception of elements in the environment within a

volume of time and space, the comprehension of their meaning, and the projection of their status in the near future" (Endsley, 1995)

• Knowing what is going on, dependent on:

– The task: Predictability, familiarisation, complexity

– The individual: Arousal or alertness, ability to recall, understanding, focus

– The environment: Complexity, ease of communication handover

• Stages of situational awareness:

1. Perception, gathering of information

2. Comprehension, interpretation

3. Projection, anticipation

Leadership

• “a process whereby an individual influences a group of

individuals to achieve a common goal.” (Northouse

2007)

• Leaders must be aware of their own leadership styles

and how it effects others

– E,g Democratic, leader seeks a consensus opinion from the

group regarding the course of action.

– Autocratic/Authoritarian, state what is to be done, when and how.

– Delegatory, leads to group members making their own decisions

without central coordination.

• Decision making: creative versus algorithm or SOP

Empowerment

• Empowerment: “the ability to get things done in the

organization” (Irvine et al. 1999).

• Structural empowerment (Kanter 1993), four aspects:

– having opportunity for advancement or opportunity to be involved

in activities beyond one’s job description;

– access to information about all facets of the organisation

– access to support for one’s job responsibilities and decision

making

– access to resources as needed by the employee

• Empowerment and safety

– The ability to speak out

– The ability to report error

Communication

• “The single biggest problem in communication is the

illusion that it has taken place.” George Bernard Shaw

• Modes of Communication:

– Written

– Verbal

– Paraverbal

– Body language

• Communication is essential to teamworking

environments and to the prevention of error

Mildred's Story

• Identify the characters who seem to be aware of

what is going and those who don’t

• What kind of leadership styles do you see in the

video and how does it influence what happens?

• What issues of empowerment are evident in the

video?

• What role does communication /

miscommunication play in the scenario?

References

• Cronenwett L et al (2007) Quality and Safety Education for Nurses. Nursing Outlook 55(3):122-31.

• Evaluation of quality improvement programmes

• Hudson P. (2003) Applying the lessons of high risk industries to health care Qual Saf Health Care 12(1)

• Irvine D., Leatt P., Evans M.G. & Baker R.G. (1999) Measurement of staff empowerment within health service organisations. Journal of Nursing Measurement, 7(1), 79–95.

• Kanter, R. M. (1993) Men and Women of the Corporation. NY: Basic Books.

• Kanter, R. M. (1993). Men and women of the corporation. New York, NY: Basic Books, Inc.

• Northouse, P.G. (2007) Leadership: Theory and practice, 4th ed.

• Øvretveit, J & Gustafson D. (2002) Quality improvement research: Evaluation of quality improvement programmes. Qual Saf Health Care 2002;11:3 270-275 doi:10.1136/qhc.11.3.270.

• Sale D. (2005) Understanding Clinical Governance & Quality Assurance. Palgrave Macmillan, Basingstoke.

• Wakefield, D. S., & Wakefield, B. J. (2008). The complexity of healthcare. In A. Kovner & J. Knickman (Eds.), Health care delivery in the United States (9th ed.). Springer Publishing Company.

• WHO (2009) Better knowledge for safer care; Human Factors in Patient Safety Review of Topics and Tools. World Health Organisation, Geneva.

• Winn B & Cameron K (1998) Organisational Quality: An Examination of the Malcom Baldrige National Quality Framework