QUALITY ASSURANCE AND QUALITY IMPROVEMENT IN NURSING MANAGEMENT
DEFINITION OF TERMS 1. Nursing Audit – a method for evaluating care through the appraisal appraisal of the nursing process as it is reflected in the patient care records for discharged patients 2. Quality Assurance – the process of establishing establishing a target degree of excellence of nursing intervention and taking steps to ensure that each patient receives the agreed upon level of care; it is the process of setting standards, standards, monitoring practices, evaluating practice problems and resolving practice problems. 3. Quality management – a comprehensive comprehensive management approach that focuses on the systematic, ongoing and continuous awareness, monitoring and improvement of quality in clinical, professional and administrative services TOTAL QUALITY MANAGEMENT (TQM) - A man manag agem emen entt phi philo loso soph phy y tha thatt emphasizes a commitment to excellence throughout the organization (Decker & Sullivan, 1996) - Characteristics: 1. Cust Custom omer er// clie client nt focu focus s 2. Total Total organi organizat zation ional al involve involvemen mentt 3. The use of qua qualit lity y tools tools and and statistics for measurement measurement 4. Identi Identific ficati ation on of key key proce processe sses s for improvement - TQM components 1. Qual Qualit ity y ass assur uran ance ce / improvement – the systematic monitoring process that identifies opportunities for improvement in patient care delivery, designs ways to improve service, and continues to evaluate follow-up actions to make certain that improvement occurs 2. Infect Infection ion contro controll manag manageme ement nt – transmission transmission modes and communicable disease causes are necessary concepts that the health care provider must know to practice in a safe environment
3. Utiliz Utilizati ation on man manag ageme ement nt – the the planning, organizing, directing, directing, controlling of the health care product in a cost-effective manner while maintaining quality of patient care and contributing to the overall goals of the institution 4. Safety Safety manag manageme ement nt – inc includ ludes es disaster preparedness ad preventive maintenance maintenance programs 5. Risk Risk man manag agem emen entt demonstrates an ongoing improvement process that determines potential and actual organizational losses (eg. Professional liabilities, liabilities, malpractice insurance) CONTINUOUS QUALITY IMPROVEMENT (CQI) - the the pro proce cess ss used used to inve invest stig igat ate e systematically systematically ways to improve patient care - invo involv lves es eval evalua uati tion on,, act actio ions ns,, and and a mind-set to strive constantly for excellence - four four maj major or pla playe yers rs in the the CQI CQI proc proces ess: s: o resource group CQI coordinator o o Team leader CQI team o GOALS OF QUALITY MANAGEMENT Comprehensive goal: Provision of high quality care Specific goals: o Strives to create a positive, open and honest culture that provides health care services judiciously Assist the consumer and o provider in maximizing resource management Education of the consumer and o agency staff about what is reasonable and acceptable health care services at affordable prices Increase agency morale o Quality Assurance vs. Quality Improvement Quality Assurance Quality Improvement QA QI
Inspection oriented (detection)
Planning oriented (prevention)
Reactive
Proactive
Correction of special clauses (individual, machine)
Correction of common causes (system)
Responsibility of few
Responsibility of all
Narrow focus
Cross-functional
Leadership may not be vested
Leadership actively leading
Problem solving by authority
Problem solving by employees at all levels
* JCAHO (Joint Commission for Accreditation of Healthcare Organizations, 1991)
Approaches to QA/ QI (Frameworks from which nursing care can be evaluated) 1.
2.
Structure – focuses on the delivery system which nursing care is implemented a. Nursing department’s philosophy and objectives b. The health agency building c. Organization structure d. Financial resources e. Equipment f. Agency licensure g. Attitudes of patients and employees h. Policies i. Procedures j. Job descriptions k. Orientation schedules l. In-service schedules m. Charting Process – includes what the nurse does while delivering patient care a. Nursing process (assessing. planning, implementing, and evlauting ) b. Subsystems within the nursing process (taking a health history, performing a physical examination, making nursing diagnoses, determining patient care, constructing a nursing
care plan, performing each prescribed care task, measuring patient outcomes, and reporting patient’s response to care/ treatment ) WEAKNESSES IN PAST QA ACTIVITIES 1. Focuses on clinical aspects of care and neglect of managerial issues 2. Compartmentalization of QA activities according to organizational structure rather than patient care 3. Focus on performance of individual employees, rather than work groups 4. Initiating improvements only to remedy identified problems 5. Separating care effectiveness from care efficiency FEATURES OF JCAHO PROGRAM 1. Require ongoing assessment and improvement program that systematically monitors all care elements 2. Advocates that patient care problems be identified through “CRITICAL CARE INDICATORS” (problem signs) Example: ER leaving against advise Cardiac arrest QA COORDINATOR ROLE AREAS 1. knowledge base for QA 2. professionalism 3. teaching others 4. self-growth 5. self-validation 6. employee/ patient rights 7. safety/ risk management 8. legal issues 9. goal setting/ participation 10. direction/ coordination of others 11. communication 12. working relationships 13. confidentiality 14. problem solving/ decision making 15. research 16. planning 17. reporting/ evaluation 18. integration/ standardization 19. Joint commission liaison 20. support 21. rounds 22. tracking PRINCIPLES UNDERLYING QUALITY IMPROVEMENT EFFORTS
1. All health care professionals should collaborate in projects to measure and improve care. 2. The activities of various health professionals must be coordinated to ensure that efforts of diverse caregivers enhance those of others 3. Managers should undertake costbenefit studies to ensure that resource expenditure for quality assurance activities is appropriate in amount 4. Nurses should monitor only critical performance factors, that is, those activities that yield the greatest health and financial benefit 5. The key to improving patient care quality is accurate evaluation of care and the key to successful evaluation of care is adequate documentation of care 6. The ability to achieve nursing objectives depends on the optimal functioning of every step in the process, and effective monitoring of nursing systems is based on the feedback from all subsystems of the nursing suprasystem 7. Evaluation of care alone will not improve nursing practice 8. Peer pressure can provide the impetus needed to effect the prescribed practice changes 9. Reorganization of care at the unit level may require changes in formal organization structure 10. For quality-improvement efforts to be effective, the collection and analysis of quality-assessment data must be performed by a nurse who has decisionmaking authority
achievable, measurable and desirable 2. Patient care concurrent process audit Concurrent process audit (review): patient care is observed as it is given; processes designed to evaluate care that is still in progress; primary purpose is to identify current strengths and weakness for immediate staff feedback; patient outcomes and staff activities currently occurring are observed 3. Patient care retrospective chart audit •
•
Also: retrospective assessment/ chart review: assessing charts for documented evidence of desired behaviors; discovering patterns of care; obtains information oleading to decisions about making changes that will improve patient care 4. Continuous monitoring of critical clinical indicators Critical clinical indicator: a • quantitative measure that serves as a guide to monitor and evaluate the quality of an important aspect of patient care i. Examples of critical indicators: (rate based) SURGICAL UNIT GERIATRIC UNIT Postoperative Patient fall pneumonia Decubitus Paralytic ileus ulcer (pressure Wound sore) infection Urinary tract Hemorrhage infection Wound Fecal dehiscence impaction Urinary tract Contracture infection Elopement Phlebitis from facility Fever Cardiac arrest other examples: mortality, nosocomial infections •
•
QUALITY IMPROVEMENT ACTIVITIES 1. Professional standards setting •
•
•
Standard setting: establishing as a standard criterion the desired quantity, quality, or level or performance against which worker performance will be measured Standard: defined as a basis for measurement; an established or accepted model; a definite level of excellence or adequacy required, aimed at, or possible Nursing context: a professionally agreed level of performance appropriate to the population addressed, which is observable,
Retrospective Chart Audit: patient care is evaluated only after the patient’s discharge from the health facility
• •
• •
•
• •
•
•
• •
• • •
•
5. Peer review Definition: A process by which • employees of the same
•
•
profession, rank, and setting evaluate one another’s job performance against accepted standards Characteristics: i. Representatives of the peer review group develop criteria for performance evaluation ii. The representative of the group decide which aspects of each nurse’s performance should be evaluated by peers and what information about the nurse’s performance peers must obtain to evaluate performance accurately iii. The peer review group develop a performance appraisal tool for calculating the value of each aspect of the nurse’s performance to be evaluated by peers iv. Appraisers for each nurse meet as a group to determine who is to evaluate each aspect of the nurse’s performance Peer review activities: i. Observe nurse giving care to one to two patients in caseload ii. Review nurse’s records of history and physical examination findings iii. Observe the nurse’s instruction of patients, families, and other staff members iv. Observe nurse’s participation in multidisciplinary patient care conferences v. Review nurse’s documentation of care on medical records vi. Review nurse’s change of shift reports, casemanagement reports vii. Review care plans, case studies, scholarly papers written by the nurse
Peer group: a group of people of approximately the same age, social status and interests 6. Quality circles •
•
•
Definition: A group of 5 to 15 employees who perform similar work and meet for one hour each week to solve work-related problems; a group of employees who perform similar duties and meet at periodic intervals often with management, to discuss work-related issues and to offer suggestions and ideas for improvements, as in production methods or quality control Activities of Quality circles: i. Identification of problems associated with their common tasks ii. Concentration on one problem at a time Is done iii. Exploring of problem causes iv. Identification of possible solutions v. Proposing of preferred solution to management
HOW TO DEVELOP QUALITY ASSURANCE PROGRAMS •
•
•
There must be a quality assurance committee composed of individuals from different fields of health care (e.g. medical doctors, PTs, OTs, Nurses, etc.) Some institutions even have lawyers in their groups. Members must represent all areas and divisions of the agency and are knowledgeable about the realities and pressures that will affect program implementation Based on the pooled evaluation data about critical and clinical indicators, the group will now develop a quality assurance program that will satisfy a set of standard criteria by the quality assurance committee.
PROBLEMS ASSOCIATED WITH “QI” EFFORTS 1 The nurse-manager might become preoccupied with quality assessment that he/ she may lose sight of the fact that the program goal is improved patient welfare rather than improved nurse status
2 3
4
5
It is impossible to identify all factors that influence nursing care quality Difficulty in defining outcome criteria that result solely from nursing interventions Nurses’ documentation of care measures are at times vague, incomplete, and lacking in objectivity There is still no single, all-purpose, allsite quality assessment tool that is universally appropriate for all health agencies
JCAHO’S 10-STEP MONITORING AND EVALUTATION PROCESS 1. Assign responsibility 2. Delineate scope of care 3. Identify important aspects of care 4. Identify indicators 5. Establish thresholds for evaluation 6. Collect and organize data 7. Evaluate care 8. Take action to improve care 9. Assess actions and document improvement 10. Communicate information
