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  1. 1. Seminar On Quality Assurance in Nursing
  2. 2. Introduction:
  3. 3. TERMINOLOGIES:  Quality : Its is a relative term that describes something with high merit or excellence which is compared to an accepted standard (degree of excellence).  Quality care : means that the services provided match the needs of the population are technically correct, achieve beneficial results.  Assurance : Those activities those make certain that services are actually provided (formal guarantee, certainty)
  4. 4. Cont….  Standards of care : desired goals that can help in planning and evaluation of nursing practices  Quality assurance: refers to process of achieving excellence in the service rendered to every client. Its also called quality control process
  5. 5. Cont….  Quality improvement ; it’s a systematic approach to control and improve quality form the perspective of both professionals and clients. its also called total quality improvement or total quality management.  Quality Circle: a participative management approach in which employees and managers share the responsibility for decision making and problem solving in client care.
  6. 6. Cont….  Quality Indicators: Quality focused objective used as markers to determine whether a goal has been achieved and to measure client outcomes or process out comes.  Audit : an organized effort where by practicing professional monitor , assess and make judgments about the quality and appropriateness of nursing care provided by peers are measured against professional standards of practice  Bench marking: studying another’s processes in order to improve one’s own processes
  7. 7. Cont….  Peer review : An organized system by which peer professionals assess the quality of care being delivered.  Credentiality: Formal recognition of a person as a professional with technical competence or of an agency that has met minimum standards of performance.  Accreditation: process whereby a professional association or non-governmental agency grants recognition to a school or health care institution for demonstrated ability to meet predetermined criteria for established standards.
  8. 8. Historical dvpt :  Quality assurance have been evident in nursing since the days of Florence Nightingale she was a pioneer in setting standards for nursing care.  In 1860 Nightingale called for the development of a uniform method to collect and present hospital statistics to improve hospital treatment  In later 1800s the impetus for establishing nursing schools in the U.S came from a desire to set standards that would upgrade nursing care
  9. 9. Cont….  In 1900s efforts were begun to set similar standards for all nursing schools by various accrediting organization , two of the most influential organizations are ANA- American nurses association (1890) and NLN- National league for nursing (1952).  From 1912-1939 the interest in quality nursing education led to the development of nursing organization involved in accrediting nursing programs.  In 1892 Licensure has been a major issue in nursing.
  10. 10. Cont….  In 1923, all states has permissive / mandatory laws directing nursing practice .  After World War II the attention of the emerging nursing profession focused on establishing a scientific method of practice.  In 1950s they brought the development of tools to reassure quality assurance. One of the first tool created was nursing audit .
  11. 11. Cont….  In 1972, the congress for nursing practice was charged with developing standards to be used to institute quality assurance programs.  In 1972, The Joint Commission on Accreditation of hospitals (JCAH) clearly stated the responsibilities of nursing in its description of standards for nursing services.  The JCAH called on the nursing industry to clearly plan document and evaluate nursing care provided .
  12. 12. Cont….  In mid 1980s JCAH became the joint commission on accreditation of health care organization (JCAHCO) and began developing quality control standards for home health nursing and hospital nursing.  In 2007, it was renamed as The Joint Commission (TJC) .
  13. 13. DEFINITION:  1. Definition of quality assurance Quality assurance means delivery of efficient and effective medical care in accordance with the professional standards.  2. Definition of Quality Assurance in Nursing: Quality Assurance is the defining of nursing practice through well written nursing standards and the use of those standards as a basis for evaluation on improvement of client care (Maker 1998).
  14. 14. GOALS & PURPOSES: i) Goals: · To ensure the delivery of quality client care · To demonstrate the efforts of the health provider to provide the best possible results ii) Purpose of Quality Assurance:  Sets standards for care.  Help patients and potential patients by improving quality of care.  Assess competence of medical staff, serve as an impetus to  keep up to date and prevent future mistakes and  Bring to notice of hospital administration the deficiencies and in correcting the causative factors  Helps to exercise a regulatory function, restricting undesirable  Procedures
  15. 15. Need for quality control:  Quality control is essential to make the efficiency of health institutions possible through. a) Improvement of existing obsolete processes and procedures b) Improved layout of office and working environment c) Economy in human effort d) Suggesting the best use of money and material e) Improved design of the goods or services provided by the organization f) Improved performance g) Job satisfaction h) Improved flow of work i) Standardization of processes and products.
  16. 16. V. Approaches/ Techniques for Quality assurance: Two major categories of approaches exist in quality assurance they are:  A. General  B. Specific
  17. 17. Cont….. 1) Credentialing: It is generally defined as the formal recognition of professional or technical competence and attainment of minimum standards by a person or agency. Licensure: It is a contract between the profession and the state, in which the profession is granted control over entry into and exists from the profession and over quality of professional practice.
  18. 18. Cont…. 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 regency’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.
  19. 19. Cont…. Certification: Certification is usually a voluntary process with in the professions. A person’s educational achievements, experience and performance on examination are used to determine the person’s qualifications for functioning is an identified specialty area.
  20. 20. Cont……. B. Specific Approach: 1. 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.
  21. 21. Cont…. Nursing audit: An audit is an organized effort whereby practicing professionals monitor, assess, and make judgments about the quality and appropriateness of nursing care provided by peers as measured against professional standards of practice The tools include record reviews, checklist, questionnaires, and surveys.
  22. 22. Cont…. Auditing can occur retrospectively, concurrently, or prospectively.  Retrospective audit are performed after the patient receives the service.  Concurrent audits are performed while the patient is receiving the service.  Prospective audits attempt to identify how future performance will be affected by current interventions.
  23. 23. Cont….. The audit includes outcome audit , process audit, and structure audits:  Outcome audit It can be defined as the end result of care, or how the patient’s health status changed as result of the intervention  Process audit: Process audits are used to measure the process of care or how the care was carried out and assume that a relationship exists between the process used by the nurse and the quality of care provided.e.g. a process audit is used to establish whether fetal heart tones or blood pressures were checked according to an established policy
  24. 24. Cont….  Structure audit: Structure audit assume that a relationship exists between quality care and appropriate structure. E.g. staffing ratios, availability of fire extinguishers in patient care areas would all be structure measures of quality care  2. Utilization review: Utilization review activities are directed towards assuring that care is actually needed and that the cost appropriate for the level of care provided.
  25. 25. Cont….  Types of Utilization review: i. Prospective: It is an assessment of the necessity of care before giving service ii.Concurrent: A review of the necessity of care while the care is being given iii.Retrospective: In analysis of the necessity of the services  Received by the client after the care has being given. Utilization review has been used primarily in hospitals to establish need for client admission end the length of hospital stay. The Utilization review process includes the development of explicit criteria that serves as indicators of the need for services and length of services.
  26. 26. Advantages of Utilization Review:  · It is designed to assist clients to avoid unnecessary care  · It may serve to encourage the consideration of care options by providers, such as home health care rather than hospitalization.  · It can provide guidelines for staff of program development.  · It provides a measure of agency accountability to the consumer
  27. 27. 3.Client Satisfaction: Client satisfaction can be assessed using person or telephone interviews and mailed questionnaire. Data from client satisfaction surveys are used to measure structure, process and outcome of care given. 4.Incident Review: During a patient’s hospitalization several incidents may occur which have a bearing on the treatment and patients final recovery. The report should contain the name, age, exact time and place, description of how it occurred any precaution taken conditions of patient before and after the incident etc. since these reports are of legal value it should be written carefully given importance to all the details and should be filed safely.
  28. 28. 5.Risk Management: It can be defined in a program that is developed for the purpose of eliminating or controlling health care situations that has the potential to endangers or creates risk to clients. Risk management activities are directed towards the identifications, analysis and evaluation of situations to prevent injury and subsequent financial loss. 6.Malpractice litigation: It is a specific approach to be imposed on the health care delivery systems by the legal systems. Malpractice litigation results from client dissatisfaction with the provider and with the content of care received.
  29. 29. VI. Quality Assurance Committee (QAC):  The committee should consist of the following:  1. Medical administrator  2. Two senior clinicians  3. Pathologist  4. Radiologist  5. Nurse administrator  6. Medical records officer – secretary  7. Additional personnel such as super- specialists and consultants can be co-opted on the committee as and when required.
  30. 30. VII. Quality Assurance Committee in Nursing:  The members of the committee should include representative of all levels of professional nursing including  Client Care coordinators  Supervisors  Head Nurses  Clinical Specialists  Nurse Clinicians  Licensed practical Nurses  Nursing Assistants  Other client care personnel  Medical records Administrator
  31. 31. vii.a) Functions of the Quality assurance committee: 1. Coordination: Collecting information Consider activities that should be related, e.g. quality appraisal and continuing education Communicate across patient care disciplines Coordinate actions of hospital authority groups 2. Information: Provide a centralized source of reports to the board Suggest need for intervention to hospital authority groups
  32. 32. Cont…. 3. Planning: Establish priorities 4. Prodding: Insist on effective, productive quality appraisal efforts from all hospital components 5. Consultation: Provide specific assistance, usually through the coordinator
  33. 33. Cont….  6. Response: Internally, acknowledge issues of importance to individual and departments when suggesting high- priority areas for immediate attention Externally, provide the organizational home for responding to quality requirements of external agencies, if any, e.g. medical companies. 7. Search for expertise: Operate openly, not behind closed doors seek out the specific clinical and/or management expertise necessary to reach sound conclusions
  34. 34. Cont…. 8. Follow-up: Insists on reports of the impact of implemented changes.if quality assurance is to be effective rather than threatening, controversial, and counterproductive. Committee members must recognize that their major functions are: i. To coordinate, not to control ii. To inform, not to scold iii. To plan, prod, and suggest priorities, not to do detailed studies “in committee”, and iv. To recommend and report, not to intervene directly.
  35. 35. Factors affecting quality assurance in nursing care: 1) Lack of Resources: Insufficient resources, infrastructures, equipment, consumables, money for recurring expenses and staff make it possible for output of a certain quality to be turned out under the prevailing circumstances. 2) Personnel problems: Lack of trained, skilled and motivated employees, staff indiscipline affects the quality of care.
  36. 36. Cont…. 3) Improper maintenance: Buildings and equipments require proper maintenance for efficient use. If not maintained properly the equipments cannot be used in giving nursing care. To minimize equipment down time it is necessary to ensure adequate after sale service and service manuals. 4) Unreasonable Patients and Attendants: Illness, anxiety, absence of immediate response to treatment, unreasonable and unco-operative attitude that in turn affects the quality of care in nursing. 5) Absence of well informed population. To improve quality of nursing care, it is necessary that the people become knowledgeable and assert their rights to quality care. This can be achieved through continuous educational program.
  37. 37. Cont…. 5) Absence of well informed population: To improve quality of nursing care, it is necessary that the people become knowledgeable and assert their rights to quality care. This can be achieved through continuous educational program. 6) Absence of accreditation laws: There is no organization empowered by legislation to lay down standards in nursing and medical care so as to regulate the quality of care. It requires a legislation that provides for setting of a stationary accreditation / vigilance authority to: a) Inspect hospitals and ensures that basic requirements are met. b) Enquire into major incidence of negligence c) Take actions against health professionals involved in malpractice
  38. 38. Cont…. 7) Lack of incident review procedures During a patients hospitalizations reveal incidents may occur which have a bearing on the treatment and the patients final recovery. These critical incidents may be: a) Delayed attendance by nurses, surgeon, physician b) Incorrect medication c) Burns arising out of faulty procedures d) Death in a corridor with no nurse / physician accompanying the patient etc.
  39. 39. CONT…. 8) Lack of good and hospital information system A good management information system is essential for the appraisal of quality of care. a) Workload, admissions, procedures and length of stay b) Activity audit and scheduling of procedures. 9) Absence of patient satisfaction surveys Ascertainment of patient satisfaction at fixed points on an ongoing basis. Such surveys carried out through questionnaires, interviews to by social worker, consultant groups, and help to document patient satisfaction with respect to variables that are a) Delay in attendance by nurses and doctors. b) Incidents of incorrect treatment
  40. 40. Cont…. 10) Lack of nursing care records Nursing care records are perhaps the most useful source of information on quality of care rendered. The records. a) Detail the patient condition b) Document all significant interaction between patient and the nursing personnel. c) Contain information regarding response to treatment d) Have the dates in an easily accessible form.
  41. 41. Cont…. 11) Miscellaneous factors a. Lack of good supervision b. Absence of knowledge about philosophy of nursing care c. Lack of policy and administrative manuals. d. Substandard education and training e. Lack of evaluation technique f. Lack of written job description and job specifications g. Lack of in-service and continuing educational program
  42. 42. Development of standards a. Definition of standard:  A standard is a predetermined level of excellence that serves a guide for practice. b.Characters:  Predetermined  Established by an authority  Communicated to and accepted by the people affected by them  They must be measurable, achievable
  43. 43. Cont…. c. Types  Organizational standards: this outline levels of acceptable practice within the institution for example: each organization develops a policy and procedures manual that outlines its specific standards. These standards may be minimizing or maximizing in terms of the quality of service expected. Such standards of practice allow the organization to measure more objectively unit and individual performance.  Standardized clinical guidelines: provides diagnosis based, step by step interventions for providers to follow in an effort to promote high quality care while controlling resource utilization and costs. They are all developed by Agency for Health care Research and Quality (AHRQ)
  44. 44. Cont….  x.d. Sources of nursing care standards: 1. Professional organization E.g. TNAI Associations 2. Licensing bodies E.g. INC, 3. Institutions/ health care agencies E.g. JIPMER 4. Department of institution E.g. department of nursing 5. Patient care units E.g. specific patient care unit 6. Individual E.g. personal standards
  45. 45. Cont… e. Professional standards review organization: a. PSRO- Professional standards review board legislation(1972) b. Prospective payment system c. JCAHO- The Joint Commission for Accreditation of health care Organizations d. Centers for Medicare and Medicaid services (CMS) e. National committee for quality assurance(NCQA) f. Maryland hospital association quality indicator project
  46. 46. Cont…. f. Nursing scopes and standards of practice (ANA- 2004)  Since the 1930s the American nurses association has played a key role in developing standards for the profession. Currently there are more than 20 different ANA standard for nursing practice that reflect different areas of specialty nursing practice (ANA, 2001).the standards of clinical nursing practice , originally published by ANA in 1991 and subsequently revised in both 1998, 2004 provides a foundation for all registered nurses in clinical practice.
  47. 47. Cont….  Nursing scope and standards of practice: Standards of practice: 1. Assessment: the registered nurse collects comprehensive data pertinent to the patient’s health or the situation 2. Diagnosis: the registered nurse analyze the assessment data to determine the diagnoses or issues 3. Outcomes identification: the registered nurse identifies expected outcomes for a plan individualized to the patient or the situation 4. Planning: the registered nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes 5. Implementation: the registered nurse implements the identified plan 6. Evaluation: the registered nurse evaluates progress toward attainment of outcomes
  48. 48. Cont….  Standards of professional performance:  7. Quality of practice: the registered nurse systematically enhances the quality and effectiveness of nursing practice.  8. Education: the registered nurse attains knowledge and competency that reflects current nursing practice  9.Professional practice evaluation; the registered nurse evaluates own nursing practice in relation to professional practice standards and guidelines, relevant statutes, rules and regulations  10.Collegiality: the registered nurse interacts with and contributes to the professional development of peers and colleagues
  49. 49. Cont….  11.Collaboration: the registered nurse collaborates with the patient, family, and others in the conduct of nursing practice.  12.Ethics; the registered nurse integrates ethical provisions in all areas of practice .  13.Research: the registered nurse integrates research findings in practice.  14,Resource utilization: the registered nurse considers factors related to safety, effectiveness, cost, and impact on practice in planning and delivering nursing services.  15.Leadership: the registered nurse provides leadership in the professional practice setting and the profession.
  50. 50. XI. Total quality management:  xi.a. Definition : It’s a systematic approach to control and improve quality from the perspective of both professionals and clients. its also called continuous quality improvement
  51. 51. Total Quality Management Principles: (Deming) 1. Create a constancy of purpose for the improvement of service 2. Adopt a philosophy of continual improvement 3. Focus on improving processes, not on inspection of services. 4. End the practice of awarding business on price alone; instead minimize total cost by working with a simple supplier. 5. Improve constantly every process for planning, production and service
  52. 52. Cont…. 6. Institute job training and retraining. 7. Develop the leadership in the organization. 8. Drive out fear by encouraging employees to participate actively in the process. 9. Foster interdepartmental cooperation and break down barriers between departments. 10. Eliminate slogans, exhortations, and targets for the work force
  53. 53. Cont…. 11. Focus on quality and not just quantity 12. Promote teamwork rather than individual accomplishments 13. Educate/ train employees to maximize personal development 14. Charge all employees with carrying out the total quality management package
  54. 54. JCAHO’s 10 steps for Quality Improvement -process: 1. Establish responsibility and accountability for a QI Program 2. Define the scope of service for a chemical area 3. Define the key aspects of service for the chemical area 4. Develop quality indicators to monitor the outcomes and appropriateness of care delivered. 5. Establish thresholds for evaluation of indicators 6. Collect and analyze data from monitoring activities 7. Evaluate results of monitoring activities to determine the need for change in practice 8. Resolve problems through development of action plans 9. Reevaluate to determine if the plan was successful 10. Communicate QI results to the organization..
  55. 55. Tools in Quality management Statistical tools utilized in quality management studies include Tools for process description, for data collection and for data Analysis. 1. Tools for data collection: 2. Tools for Data Analysis: 3. Tools for process description:
  56. 56. Thank you