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Quality assurance in nursing


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a presentation on quality assurance in nursing.

Published in: Health & Medicine

Quality assurance in nursing

  2. 2. AIM:  At the end of the seminar, the group is able to identify and describe the quality assurance in nursing.
  3. 3. SPECIFIC OBJECTIVES:  The group is able to define Quality, and certain other terms in relation to it.  The group is able to understand the concept of quality in health care.  The group is able to enumerate the purposes of quality assurance.  The group is able to identify various approaches of quality assurance programme.  The group is able to state the principles of quality assurance in nursing.  The group is able to outline the frameworks of quality assurance in nursing.  The group is able to explain in brief about JCAHO, and list down its components.  The group is able to illustrate the various models of Quality assurance.
  4. 4. CONTD..  The group is able to express on the ANA model of quality assurance.  The group is able to identify the various AHRQ quality indicators, and interpret a few.  The group is able to recognize the factors affecting quality assurance in nursing.  The group is able to discuss about the quality assurance in nursing standards.  The group is able to summarize on the topic of quality assurance in nursing.
  5. 5. INTRODUCTION:  Assessing the quality of university education has been presented as one of the main issues on the agenda of education reforms worldwide.  Ensuring quality is a combination of planned and systematic actions that are necessary to provide the adequate reliability that a product or service meets the requirements given for quality, which should be supported in meeting the expectations of customers.  Quality assurance is based on planning, production, presentation, distribution, statistical techniques of control and staff training.
  6. 6. DEFINITION:  Quality Assurance: It is a systematic, ongoing and continuous review, analysis and evaluation of the level of compliance with the standards set at local, national and international level.
  7. 7. CONCEPT OF QUALITY ASSURANCE:  Quality is defined as the extent of resemblance between the purpose of healthcare and the truly granted care (Donabedian 1986).  Quality assurance originated in manufacturing industry “to ensure that the product consistently achieved customer satisfaction”.  Quality assurance is a dynamic process through which nurses assume accountability for quality of care they provide.  It is a guarantee to the society that services provided by nurses are being regulated by members of profession.  “Quality assurance is a judgment concerning the process of care, based on the extent to which that cares contributes to valued outcomes”. (Donabedian 1982).  “Quality assurance as the monitoring of the activities of client care to determine the degree of excellence attained to the implementation of the activities”. (Bull, 1985)
  8. 8. BENEFITS AND PURPOSES OF QUALITY ASSURANCE:  Quality assurance (QA) enables ..  •bring internal benefits to the university/faculty/department/school/program and the staff;  •bring external benefits to the students and the reputation of the institution;  •continuously improve themselves, the students and the work of the university. Continuous improvement is both the medium and outcome of quality assurance;  •serve accountability and accreditation requirements;  •enhance the reputation of the faculty/department/school/university, and meet external demands for demonstrating quality, quality assurance and quality enhancement.
  9. 9. APPROACHES FOR A QUALITY ASSURANCE PROGRAMME:  Two major categories of approaches exist in quality assurance they are  1. General  2. Specific
  10. 10. GENERAL APPROACH:  It involves large governing of official body’s evaluation of a persons or agency’s ability to meet established criteria or standards at a given time.  1) Credentialing  formal recognition of professional or technical competence and attainment of minimum standards by a person or agency  Credentialing process has four functional components:  a) To produce a quality product  b) To confer a unique identity  c) To protect provider and public  d) To control the profession.
  11. 11. CONTD..  2) Licensure  Individual licensure 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.  3) Accreditation  ISO  JCI  NABH  NAAC  Accreditation Canada  4) Certification  Voluntary process.
  12. 12. SPECIFIC APPROACHES :  1) Peer review  •Peer review is divided in to two types.  a. The recipients of health services by means of auditing the quality of services rendered.  b. The health professional evaluating the quality of individual performance.  2) Standard as a device for quality assurance  Standard is a pre-determined baseline condition or level of excellence that comprises a model to be followed and practiced.  3) Audit as a tool for quality assurance  Nursing audit may be defined as a detailed review and evaluation of selected clinical records in order to evaluate the quality of nursing care and performance by comparing it with accepted standards.
  13. 13. PRINCIPLES OF QUALITY ASSURANCE:  •Managers need to be committed to quality management.  •All employees must be involved in quality improvement.  •The goal of quality management is to provide a system in which workers can function effectively.  •The focus quality management is on improving the system.  •Every agency has internal and external customers.  •Customers define quality.  •Decision must be based on facts.
  14. 14. FRAMEWORKS FOR QUALITY ASSURANCE:  1. Maxwell (1984)  Maxwell recognized that, in a society where resources are limited, self- assessment by health care professionals is not satisfactory in demonstrating the efficiency or effectiveness of a service. The dimensions of quality he proposed are:  •Access to service  •Relevance to need  •Effectiveness  •Equity  •Social acceptance  •Efficiency and economy
  15. 15. CONTD..  2. Wilson (1987)  Wilson considers there to be four essential components to a QA programme. These are:  •Setting objectives  •Quality promotion  •Activity monitoring  •Performance assessment
  16. 16. CONTD..  3. Lang (1976)  This framework has subsequently been adopted and developed by the ANA. The stages includes;  •Identify and agree values  •Review literature, Known QAP  •Analyse available programmes  •Determine most appropriate QAP  •Establish structure, plans, outcome criteria and standards  •Ratify standards and criteria  •Evaluate current levels of nursing practice against ratified structures  •Identify and analyse factors contributing to results  •Select appropriate actions to maintain or improve care  •Implement selected actions  •Evaluate QAO
  17. 17. JCAHO:  JCAHO is the nation’s predominant standards-setting and accrediting body in health care.  Since 1951, The Joint Commission has maintained state-of-the-art standards that focus on improving the quality and safety of care provided by health care organizations.  The Joint Commission’s comprehensive accreditation process evaluates an organization’s compliance with these standards and other accreditation requirements.  To earn and maintain The Joint Commission’s Gold Seal of Approval, an organization must undergo an on-site survey by a JCAHO survey team at least every three years. (Laboratories must be surveyed every two years.)
  18. 18. WHO IS ELIGIBLE?  The Joint Commission provides evaluation and accreditation services for the following types of organizations:  •General, psychiatric, children’s and rehabilitation hospitals  •Critical access hospitals  •Medical equipment services, hospice services and other home care organizations  •Nursing homes and other long term care facilities  •Behavioural health care organizations, addiction services  •Rehabilitation centres, group practices, office-based surgeries and other ambulatory care providers  •Independent or freestanding laboratories
  19. 19. STANDARDS AND PERFORMANCE MEASURES:  JCAHO standards address the organization’s level of performance in key functional areas, such as patient rights, patient treatment, and infection control.  The standards focus not simply on an organization’s ability to provide safe, high quality care, but on its actual performance as well.  The Joint Commission develops its standards in consultation with health care experts, providers, measurement experts, purchasers, and consumers.
  20. 20. MODELS OF QUALITY ASSURANCE:  1. System Model  •Tasks are broken down into manageable components based on defined objectives.  The basic components of the system are  1. Input  2. Throughput  3. Output  4. Feedback  The input can be compared to the present state of systems, the throughput to the developmental process and output to the finished product. The feedback is the essential component of the system because it maintains and nourishes the growth.
  21. 21.  2) ANA Quality Assurance Model  The basic components of the ANA model are:  1. Identify values  2. Identify structure, process and outcome standards and criteria  3. Select measurement  4. Make interpretation  5. Identify course of action  6. Choose action  7. Take action  8. Re-evaluate
  22. 22.  1) Identify Value  In the ANA value identification looks as such issue as patient/client, philosophy, needs and rights from an economic, social, psychology and spiritual perspective and values, philosophy of the health care organization and the providers of nursing services.  2) Identify structure, process and outcome standards and criteria:  •Identification of standards and criteria for quality assurance begins with writing of philosophy and objective of organization.  •The philosophy and objectives of an agency serves to define the structural standards of the agency.  •Standards of structure are defined by licensing or accrediting agency.  •Evaluation of the standards of structure is done by a group internal or external to the agency.  •The evaluation of process standards is a more specific appraisal of the quality of care being given by agency care providers.
  23. 23.  3) Select measurement needed to determine degree of attainment of criteria and standards  •Measurements are those tools used to gather information or data, determined by the selections of standards and criteria.  •The approaches and techniques used to evaluate structural standards and criteria are, nursing audit, utilization’s reviews, review of agency documents, self-studies and review of physicals facilities.  •The approaches and techniques for the evaluation of process standards and criteria are peer review, client satisfactions surveys, direct observations, questionnaires, interviews, written audits and videotapes.  •The evaluation approaches for outcome standards and criteria include research studies, client satisfaction surveys, client classification, admission, readmission, discharge data and morbidity data.  4) Make interpretations  •The degree to which the predetermined criteria are met is the basis for interpretation about the strengths and weaknesses of the program.  •The rate of compliance is compared against the expected level of criteria accomplishment.
  24. 24.  5) Identify Course of Action  •If the compliance level is above the normal or the expected level, there is great value in conveying positive feedback and reinforcement  •If the compliance level is below the expected level, it is essential to improve the situations.  •It is necessary to identify the cause of deficiency. Then, it is important to identify various solutions to the problems.  6) Choose action  •Usually various alternative course of action are available to remedy a deficiency.  •Thus it is vital to weigh the pros and cons of each alternative while considering the environmental context and the availability of resources.
  25. 25.  7) Take Action  •It is important to firmly establish accountability for the action to be taken.  •This step then concludes with the actual implementation of the proposed courses of action.  8) Re-evaluate  •The final step of QA process involves an evaluation of the results of the action.  •The reassessment is accomplished in the same way as the original assessment and begins the QA cycle again.  Careful interpretation is essential to determine whether the course of action has improves the deficiency, positive reinforcement is offered to those who participated and the decision is made about when to again evaluate that aspect of care.
  26. 26. WHAT ARE THE AHRQ QUALITY INDICATORS?  The Quality Indicators (QIs) developed and maintained by the Agency for Healthcare Research and Quality (AHRQ) are one response to the need for multidimensional, accessible quality measures that can be used to gage performance in health care.  These measures are currently organized into four modules: the Prevention Quality Indicators (PQIs), the Inpatient Quality Indicators (IQIs), the Patient Safety Indicators (PSIs), and the Paediatric Quality Indicators (PDIs).
  27. 27. The AHRQ QI Modules:  The AHRQ PQIs are one set of quality measures that can be used to identify potential problems; follow trends over time; and ascertain disparities across regions, communities, and providers.  The PQIs help answer questions such as  •Does the admission rate for diabetes complications in my community suggest a problem in the provision of appropriate outpatient care to this population?  •How does the admission rate for congestive heart failure vary over time and from one region of the country to another?
  28. 28. THE INPATIENT QUALITY INDICATORS (IQIS):  The AHRQ IQIs provide information about the quality of medical care delivered in a hospital.  The provider-level volume IQIs are:  •Oesophageal resection volume  •Pancreatic resection volume  •Abdominal aortic aneurysm (AAA) repair volume  •Coronary artery bypass graft (CABG) volume  •Percutaneous transluminal coronary angioplasty (PTCA) volume
  29. 29. THE PATIENT SAFETY INDICATORS (PSIS):  The PSIs are a set of quality measures that use hospital inpatient discharge data to provide a perspective on patient safety.  •Postoperative pulmonary embolism or deep vein thrombosis  •Postoperative respiratory failure  •Postoperative sepsis  •Postoperative physiologic and metabolic derangements  •Postoperative abdominopelvic wound dehiscence
  30. 30. THE PAEDIATRIC QUALITY INDICATORS (PDIS):  The AHRQ PDIs are a set of quality measures that use hospital administrative data and involve many of the same challenges associated with measure development for the adult population.  •Accidental puncture and laceration  •Decubitus ulcer  •Foreign body left in during procedure  •Iatrogenic pneumothorax in neonates  •Iatrogenic pneumothorax in non-neonates  •Paediatric heart surgery mortality
  31. 31. FACTORS AFFECTING QUALITY ASSURANCE IN NURSING CARE:  1) Lack of Resources  2) Personnel problems  3) Improper maintenance  4) Unreasonable Patients and Attendants  5) Absence of well-informed population  6) Absence of accreditation laws  7) Lack of incident review procedures  8) Lack of good and hospital information system  9) Absence of patient satisfaction surveys  10) Lack of nursing care records  11) Miscellaneous factors
  32. 32. QUALITY ASSURANCE IN NURSING: STANDARDS:  INTRODUCTION:  A standard is a means of determining what something should be. In the case of nursing practice standards are the established criteria for the practice of nursing. Standards are statements that are widely recognised as describing nursing practice and are seem as having permanent value.  A nursing care standard is a descriptive statement of desired quality against which to evaluate nursing care. It is guideline. A guideline is a recommended path to safe conduct, an aid to professional performance.
  33. 33. CHARACTERISTICS OF STANDARD:  •Standards statement must be broad enough to apply to a wide variety of settings.  •Standards must be realistic, acceptable, and attainable.  • Standards of nursing care must be developed by members of the nursing profession; preferable  • Nurses practising at the direct care level with consultation of experts in the domain.  • Standards should be phrased in positive terms and indicate acceptable performance good, excellence etc.
  34. 34. CONTD..  • Standards of nursing care must express what desirable optional level is.  • Standards must be understandable and stated in unambiguous terms.  • Standards must be based on current knowledge and scientific practice.  • Standards must be reviewed and revised periodically.  •Standards may be directed towards an ideal, i.e., optional standards or may only specify the minimal care that must be attained, i.e., minimum standard.  • And one must remember that standards that work are objective, acceptable, achievable and flexible.
  35. 35. PURPOSES OF STANDARDS:  •Setting standard is the first step in structuring evaluation system. The following are some of the purposes of standards.  •Standards give direction and provide guidelines for performance of nursing staff.  • Standards provide a baseline for evaluating quality of nursing care  • Standards help improve quality of nursing care, increase effectiveness of care and improve efficiency.  • Standards may help to improve documentation of nursing care provided.  • Standards may help to determine the degree to which standards of nursing care maintained and take necessary corrective action in time.
  36. 36. CONTD..  • Standards help supervisors to guide nursing staff to improve performance.  • Standards may help to improve basis for decision-making and devise alternative system for delivering nursing care.  • Standards may help justify demands for resources association.  •Standards my help clarify nurses area of accountability.  • Standards may help nursing to define clearly different levels of care.
  37. 37. MAJOR OBJECTIVES OF PUBLISHING, CIRCULATING AND ENFORCING NURSING CARE STANDARDS ARE TO:  1. Improve the quality of nursing care,  2. Decrease the cost of nursing, and  3. Determine the nursing negligence.
  38. 38. 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
  39. 39. RESEARCH:  A number of the AHRQ QIs have been used in health care research projects. On the whole, researchers use the indicators because of the quality and level of detail of the AHRQ documentation of the QIs as well as the fact that these measures capture important aspects of clinical care. The AHRQ QIs, their documentation, and the related software reside in the public domain and are downloadable from the AHRQ Web site, free of charge. The QIs can be used with readily available administrative data, which researchers have ready access to in the form of HCUP. Further, researchers appreciate the fact that they can dissect indicator results and relate them back to individual records, which helps to gain a better understanding of the logic used in the measures, which, in turn, assists in distinguishing data quality issues from actual quality problems .Topics of studies using the AHRQ QIs include an analysis examining the association between the Joint Commission accreditation scores and the AHRQ IQIs and PSIs, the effect of resident physician work hour limits on surgical patient safety, and the determination of whether persons with Alzheimer’s disease were at greater risk for in-hospital mortality than non-Alzheimer’s patients.
  40. 40. ANY DOUBTS???
  41. 41. CONCLUSION:  To ensure quality nursing care within the contemporary health care system, mechanisms for monitoring and evaluating care are under scrutiny. As the level of knowledge increases for a profession, the demand for accountability for its services likewise increases. Individuals within the profession must assume responsibility for their professional actions and be answerable to the recipients for their care. As profession become more interdependent, it appears that the power base will become more balanced, allowing individual practitioners to demonstrate their competence and expertise. Quality assurance programme will helps to improve the quality of nursing care and professional development.
  42. 42. BIBLIOGRAPHY:  INTERNET SOURCES:    organizations-jcaho-2/  organizations-jcaho-2/  