SEMINAR ON QUALITY ASSURANCE

Quality:
Quality is defined as a continual striving for excellence and a conforming to specific approaches or guidelines (Davis, 1994).

The Institution of Medicine (2001) defines Quality as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.

Quality Assurance:
Quality Assurance/Quality Improvement is the promise or guarantee that certain standards of excellence are being met in delivery of care. The Quality Assurances, or Quality control process does three things (Kinney, Freedman, and Cook, 1994).

 It sets standards for care. It evaluates care provided on the basis of the standards. It takes action to bring about change when care does not meet standards.

Goals:
Increase the proportion of persons with health insurance. Increase the proportion of persons who have a specific source of ongoing care. Reduce the proportion of families that experience difficulties. Increase the proportion of schools of medicine, schools of nursing and other health professional trainers.

Quality assurance model:Nurses who are trained as per Indian nursing council regulations and registered with state nursing registration council are safe to provide care. Indian nursing council has developed a quality assurance for nursing in India. The programme is expected to develop mechanisms for ensuring quality of nursing practice.

Quality assurance model in nursing: Quality assurance model in nursing in the set of
elements that are related to each other and comprise of planning for quality, development of objectives, setting and actively commutating standards, developing indicators, setting thresholds, collecting data to monitor compliance with set standard for nursing practice and applying solutions to improve care

Approaches to Quality Improvement:

Two basic approaches exist in quality improvement 1. General Approaches. 2. Specific Approaches.

Credentialing:
defined as the formal recognition of a person as a professional with technical competence, or of agency that has met minimum standards of performance.

Credentialing can be mandatory or voluntary. Mandatory credentialing requires laws. Eg: State nurse practice acts. Voluntary credentialing is performed by an agency or an institution. Eg: Certification examinations offered by the ANA through American Nurses Credentialing center.

Accreditation:
accreditation is a type of quality assurance process under which services and operations of an educational institution or program are evaluated by an external body to determine if applicable standards are met. If standards are met, accredited status is granted by the agency.

In most countries in the world, the function of educational accreditation is conducted by a government organization, such as a ministry of education. Accreditation applies external pressure and places demands on institutions to improve quality of care. The accreditation process primarily evaluated an agencies physical structure, organizations structure and personal qualifications.

Licensure:
Licensure refers to the granting of a license, which gives a 'permission to practice.' Such licenses are usually issued in order to regulate some activity that is deemed to be dangerous or a threat to the person or the public or which involves a high level of specialized skill

Certification:
Another general approach to quality, combines features of license and accreditation. Certification is usually a voluntary process within professions. Educational achievements, experience and performance on an examination determine a persons qualifications for functioning in an identified speciality area.

Eg: To become a certified community health nurse, one must have a baccalaureate degree in nursing and 2years of practice as a community health nurse immediately before application. It is a voluntary process major concerns exist about certification as a quality assurance.

Charter:
A charter is the grant of authority or

rights A document granted by a ruler or government by which an institution is created or rights are defined

Recognition:
It is a process whereby one agency accepts the credentialing status of and the credentials conferred by another. Eg: Some state boards of nursing accept nurse practitioner credentials that are awarded by the American Nurses Credentialing center or by one of the security credentialing agencies.

Traditional Quality Assurance:

Traditional Quality Assurance programs can fit well with the CQI process. Because organizations may implement only parts of the TQM process, it is important to understand existing traditional Quality assurance programs

Goals: To identify problems between provider and client To intervene in problem cases To provide feedback regarding interactions between client and provider To provide documentation of interactions between client and provider

Staff review committee:

Staff review committee are the most common approacties to quality assurance. The audit process consists of six steps. Select a topic for study select explicit criteria for quality care Review records to determine whether criteria are met Do a peer review for all cases that do not meet criteria Make specific recommendations to correct problems Follow up to determine whether problems have been eliminated

Audit Process :
Two types of audits are used in nursing peer review concurrent and retrospective Concurrent audit is a process audit that evaluates the quality of ongoing care by looking at the nursing process. Concurrent audit is used to by medicine and Medicaid to evaluate care being received by public health clients.

Advantages: Identification of problems at the time care is given Provision of a mechanism for identifying and meeting client needs during care. Implementation of measures to fulfill professional responsibilities.

Disadvantages: It is time consuming It is more costly to implement than the retrospective audit Because care is ongoing, it does not present the total picture of care that the client ultimately will receive.

The Retrospective Audit or Outcome audit, evaluates quality of care through evaluating the nursing process after the clients discharge from the health care system.

Advantage: Comparison of actual practice to standards of care Analysis of actual practice findings A total picture of care given More accurage data for planning corrective action

Disadvantages: The focus of evaluation is directed away from ongoing care Client problems are identified after discharge

Utilization Process:
The purpose of utilization review is to ensure that care is needed and that cost is appropriate. There are 3 types of utilization review. 1. Prospective: An assessment of the necessity of care before given service. 2. Concurrent: A review of the necessity of services while care is being given 3. Retrospective: An analysis of the necessity of the services received by the client after the care has been given

Advantages: It helps clients avoid unnecessary care. It may encourage clients to consider alternative care options, such as home health care. It can provide guidelines for staff and program development

Disadvantage: That not all clients fir the class picture presented by the explicit criteria used or determine approval or denail of care.

Professional Review Organizations:

Professional Review Organizations (PROs) replaced professionals standards review organizations (PSROs). PROs replaced PSROs and are directed by the federal government to reduce hospital admissions for procedures that can be performed safely and effectively in an ambulatory surgical setting on an outpatient basis

 The goal was to reduce inappropriate or unnecessary admissions or invasive procedures by specific practitioners or hospitals. Quality measures include reducing unnecessary admissions caused by previous substandard care, avoidable complications and deaths, and unnecessary surgery or invasive procedures.

 PROs must define their operational objectives and are required to consult with nurses and other non physician health care providers. When reviewing the activities of those professionals. PROs monitor access to care and cost of care professional working under the regulations of PROs should develop accurate and complete documenting procedures to ensure compliance with the criteria of the PRO.

The benefit of the PSRO/PRO system has been the development of standards and the peer review mechanisms to increase accountability for care provided.

steps for implementing total quality management (1982).

 Individual employees are both suppliers of input and customers of other output. All work process are subject to continuous improvement to increase customer satisfaction. Customers need and experience with service are determined and communicated through out the agency.

 Managers are responsible for improving organizational systems, so that workers can improve performance. Employees at all levels must be trained in TQM and through how to perform properly all job functions.

 Each department should generate statistical measurement data that shall empower employees to improve work process. Data collection of quality assessment occurs at the employee level. Employees participate with quality assessment personnel in data analysis.

 A collaborative approach is used to inaugurate all suppliers in to TQM process. Team work is needed to foster problem solving and eliminate barriers between specialty areas and roles. Corporate culture must change, by establishing long term goals to support quality, maintaining performance standard overtime, empowering employees, openly demonstrating quality monitoring and developing problem

Koont and weitrich (1988) have identified the following eight types of standards the most organization must establish.

1.Physical standard which include patient activity ratings to establish nursing care hours per patent day. 2. Cost standards, which include the cost per patient activity. 3. Capital standard, which include the review mandatory investment or new programs.

4.Revenue standards, which include the revenue per patient day for nursing care. 5. Program standards, which guide the development and implementation of programs to meet client needs. 6. Intangible standards, which include staff development or personnel orientation costs.

7. Goal standard, which outline qualitative goals in short and long-term planning. 8. Strategies plan standards, which outline check points in developing and implementing the organizations strategic plan. All these standards provides yardstick for measuring quality care.

From community health coalation

Prepare and analyze community health profiles

Problem identification and prioritization cycle

Identify critical health issues

health

issue Health Issue

Health Issue

Analyse health issue

Monitor process and outcomes

Inventory process

Analysis and implementation cycle

Implement strategy Develop health improvement strategy

Develop indicator set Identify

Evaluative Studies:
Domabedians Model introduced three major methods for evaluating quality care 1.Structure: Evaluating the setting and instruments used to provide care 2.Process: Evaluating activities as they relate to standards and expectations of health providers in the management of client care. 3.Outcome: The net change that occurs as a result of health care or the net result of health care.