What is this? Why it stands for ? ,what means this ?

SEMINAR ON QUALITY ASSURENCE

GUIDE :- MADAM Mrs. RAVEENA DUTTE READER SHRI SHANKARACHARYA COLLEGE OF NURSING

INTRODUCTION
Quality assessment is an examination of service where as quality assurance implies that efforts are made to evaluate are made to evaluate and ensure and ensure quality health care The field of quality assurance is as old as modern nursing. Florence nightingale introduced the concept of quality in nursing care in 1855 while attending the soldiers in the hospital during the Crimean war

MEANING
QUALITY MEANS:DEGREE OF EXELLENCE Assurance: It implies a commitment to take corrective action of care does not meet the criteria

CONT
To a patient :Quality means being treated with empathy ,respect and concern. To a professional: Quality means delivering the most advanced knowledge and skills to help and save patient . For medical audit: Quality means having the best achievable outcome for each patient.

DEFINITION
Bull 1985 defined quality assurance as the monitoring of the activities of client care to determine the degree of excellence attained to the implementation of the activities Qualities 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

Philosophy of quality circle

1) Reduce errors

2) Encourage more effective team work 3) Promote job indolent and participation 4) Increase employee motivation 5) Create problem solving capability 6) Built an attitude of problem prevention 7) Improve communication in the organization 8) Improve harmonious relationship 9) Promote cost reduction 10) Bringing about attitudinal changes for better team work

Need for Quality Assurance in Health Care :

It is an important managerial function which assures confidence among customers. It involves evaluation in order to secure improvement and development on a condition basis. It is needed to indicate standard of agency

GOALS OF QUALITY ASSURANCE

The major goal of quality assurance is to identity areas where standards have not been met and correct them, or in other terms quality assurance are: To ensure the delivery or quality care .  To evaluate the efforts of the health care provider to provide best possible results .

Purpose of Quality Assurance

Help patients and potential patients by improving quality of care. Assess competence of medical staff, sure as an impetus to keep up to date and prevent future mistakes. Being to notice of hospital administration the deficiencies and in correcting the cases factors

PHILOSOPHY OF QUALITY CIRCLE

1) 2) 3) 4) 5) Reduce errors Encourage more effective team work Promote job indolent and participation Increase employee motivation Create problem solving capability

CONT
6) Built an attitude of problem prevention 7) Improve communication in the organization 8) Improve harmonious relationship 9) Promote cost reduction 10) Bringing about attitudinal changes for better team work

Need for Quality Assurance in Health Care

It is an important managerial function which assures confidence among customers. It involves evaluation in order to secure improvement and development on a condition basis. It is needed to indicate standard of agency.

GOALS OF QUALITY ASSURANCE

a) To ensure the delivery or quality care. b) To evaluate the efforts of the health care provider to provide best possible results.

Purpose of Quality Assurance

Help patients and potential patients by improving quality of care. Assess competence of medical staff, sure as an impetus to keep up to date and prevent future mistakes. Being to notice of hospital administration the deficiencies and in correcting the cases factors

ELEMENTS THAT CONTRIBUTE TOWARDS QUALITY ASSURANCE

Commitment from top level management Commitment from all personal of the organization /institution. Setting clear responsibility for quality activity willingness to change. Accurate documentation. Effective communications at all levels. Ongoing training program in quality improvement

PRINCIPLES OF QUALITY ASSURENCE

1) Customer focused 2) Identify key processes to improve quality 3) Use of quality tools and statistics 4) Involve all people and department to find solution 5) Leadership

6) Commitment 7) Individual responsibility 8) Employee empowerment 9) Data driven decision making 10) Education and retaining

Barriers to the quality Improvement

Primary barrier in implementing effective quality improvement is cost. Tradition and failure to realize, the charger are needed. Authoritative leadership style, do not value innovators. Lack of evidence based practice.

5) STRATEGIES OF QUALITY ASSURANCE:

1) Setting standards. 2) Appraising actual achievements. 3) Planning and improvement

6) QUALITY ASSURANCE PROCESS

Assessment of outcome Assessment of content Assessment of process Assessment of resources Assess efficiency

7) THE QUALITY ASSURANCE CYCLE:

Nursing staff development Suspected problem area Hospital quality assurance

Nursing committees Standards of care (a) Recommendation for change (e) Measurement criteria (b) Quality care wheel Assessment ( c)
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Documented problems (d)

APPROACHES FOR A QUALITY ASSURANCE PROGRAMME

1) General 2) Specific

1) General
CREDENTIALING: LICENSURE: ACCREDITATION CERTIFICATION

SPECIFIC APPROACHES

Peer review committee

There 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

The audit process (Stanhope-Han caster 2000) Utilization review (UR)

Types of UR Prospective Concurrent Retrospective

EVALUATION STUDIES
THREE MAJOR MODELS HAVE BEEN USED TO EVALUATE QUALITY THEY ARE
DONABEDIANS STRUCTURE PROCESS OUTCOME MODEL THE TRACER MODEL THE SENTINEL MODEL

(1) DONABEDIANS STRUCTURE PROCESS OUTCOME MODEL

introduced 3 major methods of evaluating quality care
a) Structural evaluation b) Process evaluation c) outcome evaluation

2) The Tracer Method

It is used to identify persons with certain illness such as HT, Ulcers, UTI and to establish criteria for good medical and nursing management of the illness have used the trace methods

3) The Sentinel Method

It is an outcome measure cases of unnecessary disease, disability death are counted. Client satisfaction: - it can be assessed using person or telephone interventions and mailed questionnaire. Data from client satisfaction surveys are used to measure structures process and outcome of care given

PRINCIPLES AND CONDITIONS FOR TOTAL QUALITY MANAGEMENT

Principles Continuous quality improvement Knowledge of customer s expectation needs. Processes of customers supplies relationship. Belief in people. Statistical analysis. Costs of poor quality

Conditions
Employer involvement Improvement An environment that supports risk taking Team work Data collection and analysis skills Group interaction skills Structure and management to enable improvement Tools to facilitate the improvement

framework for quality assurance

Quality in nursing practice:
The point commission on accreditation of health care organization (JCAHO)1997 defines quality improvement (QI) as an approach to the continuous study and improvement of the process of providing health care services to meet the needs of client and others.

STEPS IN QUALITY IMPROVEMENT

1) Professional standards: 2) Outcomes .3) Developing quality improvement team:

1) Professional standards:
They are authoritative statements used by the professional in describing the responsibilities for which its practitioners are accountable (Peter 1995)
A) Policies b)Job descriptions

2) Outcomes
Outcomes are the conditions to be achieved as a result of care delivery. An outcome tells what interventions are effectiveness, whether clients progress, how well standards are being met. and whether changes are necessary. a) Professional outcome b) Client outcome:

.3) Developing quality improvement team:

This team composed of staff from all departments with in a hospital

FACTORS CONTRIBUTING THE SUCCESS OF THE QUALITY ASSURANCE PROGRAM

 Philosophy and commitment of management  Stability of the management and continuity of leadership for the program  Clarity of organizational and operational goals  Establishment of targets, yardsticks

 Involvement of employees in respect department and QAP  Motivation and commitment of employers Documentation and reporting system  Feedback systems to management and employers  Action plans, implementation, review systems  Incentives and recognition system

10) QUALITY ASSURANCE COMMITTEE (QAC):

Medical administrator Two senior clinicians Pathologist Radiologist Nurse administrator (Matron) Medical records officer- Secretary

SPECIFIC FUNCTIONS OF QAC:

1) Coordination:
Collecting information Consider activates that should be related, eg. quality appraisal or continuing education. Communicate across patient care. Coordinate the action with hospital authority

 2) Information:
Collect data reports about medical records. Interaction between the patient and the care provider. Information regarding response to treatment

 3) Planning- Establish priorities. 4) Prodding- Insist on effective, productive, efforts from all hospital components. 5) Consultation Provide specific assistance usually through the coordinator. .

 6) Response:
A) Internally provide importance to individual and department. B) Externally provide organizational home for responding to quality requirement of external agencies, e.g. medical companies.

7) Search for expertise: Operate openly not behind closed doors. 8) Follow up: Insert of report provide implemented change

Functions of Committee members

To coordinate, not to control To inform, not to scold To plan and suggest priorities, not to do studies To recommend and report, not to intervene directly

11) QUALITY ASSURANCE MODEL

Nurses who are trained as per Indian Nursing Council recreation and registered with state nursing registration councils are safe to provide care. Quality assurance model in nursing is the set of elements that are related to each other and comprise of planning for quality, development of objectives, setting and actively communicating standards, developing indicator, collecting data to monitor compliance with set standards, for nursing practice and applying solutions to improve care

PURPOSE OF QUALITY ASSURANCE MODEL:

To ensure quality nursing care provided by nurses in order to meet the expectations of receiver, management and regulatory body, It also intends to increase the commitment of provider and the management

GOALS OF QUALITY ASSURANCE MODEL:

Develop confidence of the receiver (s) that quality care is being rendered as per assurance. Develop commitment of the management towards quality care. Increase commitment of providers to adhere to set standards for nursing practice and strive for excellence. Strengthen documentation of nursing care. Promote optimum utilization of resources for providing cost effective nursing care.

12) MODELS OF QUALITY ASSURANCE:

The basic components of the system are:
a) Input b) Throughput c) Out put d) feed back

SYSTEM MODEL

Input Previous quality assurance program

Through put Structural change process

Output Unit Based quality assurance program

Feedback

SYSTEM BASE FOR UNIT BASED QUALITY ASSURENCE

American Nurses Association model

H. REEVALUATE A. IDENTIFY VALUES

G. TAKE ACTION

B . IDENTIFY STANDARD & CRITERIA

F. CHOOSE ACTION

C. SECURE MEASUREMENT

E . CAUSES OF ACTION

D. MAKE INTERPRETATION

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 prospective and value philosophy of the health care organization and the provides of nursing sciences.

Identify structure, process and outcome standards and criteria:

The focus may be the staff, the clients, the organization or all three or any combination of the three. Standards and criteria: although the focus of the QA activity is decided, standards must be selected or formulated. Standards are defined as an agreed upon, level of practice. These standards generally are broad statements that reflect values and the level of care.

Select measurement needs to determine degree of attainment of criteria and standards

Measurement 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, utilizations reviews, review of agency documents, self studies and review of physical facilities approaches and techniques for the evaluation process standards and criteria are peer review client satisfaction survey, direct observation, questionnaires, interviews, written audits and videotapes

Make interpretations:
predetermined criteria are met is the basis for interpolation about the strength and weakness of the program. The late of compliance is compared against the expected level of criteria

Identify course of action:

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

Choose action
Usually various alternative course of action are available to remedy a deficiency. There it is vital to weigh the prosl cons of each alternative while considering the enviormental context and the availability of resources.

Take action
important to firmly establish accountability for the action to be taken. It is essential to answer the questions of who will do? What? By when?

Reevaluate:
final step of QA process involves an evaluation of the results of the action. The reassessment is accomplishment in the say same way as the original assessment and begins the QA cycle again

. Maxwell six dimension model(1984)

Relevance in the needs. Accessibility Equality Effectiveness Acceptability Efficiency and Economy

Joint commission model:

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Establish responsibility and accountability for a QI program. Define the scope of service for a clinical area. Define the key aspects of service for the clinical area. Develop quality indicators to monitor the outcomes and appropriateness of care delivered. Establish threshold for evaluation of indicators. Collect and analyze data from monitoring activities. Evaluate results of monitoring activities to determine the need for change in practice. Resolve problems through development of action plans. evaluate to determine if the plan was successful. communicate QI results to the agencies

PROGRAM EVALUATION MODEL (PEM)

two major types of program evaluation:
Formative evaluation Summative evaluation

Program evaluation includes

Determine focus Establish purpose Define appropriate type of evaluation. Formulate data gathering questions. Gather data. Make data based judgment. Formulate report.

FACTORS AFFECTING QUALITY ASSURANCE IN NURSING CARE

Lack of resources Personnel problems. Improper maintenance. Unreasonable patients and attendants. Absence of well informed population. Absence of accreditation laws. Lack of incident review procedures

Lack of good and hospital information system. Absence of patient satisfaction surveys. Lack of nursing care records. Legal redness Delay in attendance by doctors, nurses and helpers. Miscellaneous factors. Lack of good supervision

Lack of policy and administrative manners. Substandard education and training. Lack of evaluation technique. Lack of written job description and job specifications. Lack of in service and continuing educational program

QUALITY ASSURANCE SETTING STANDARDS

For more than 100 years, a authors have written about the evaluation of nursing practice as a process with minimal elements of
Setting standards Comparing nursing practice to such standards. Instituting changer to increase the adherence to the standards.

Definition:
Standards is an established rule as basis of comparison in measuring or finding capacity, quality context and value of objects in the some category. Standard is a broad statement of quality

Professional nursing standards in nursing practice

a standard in model of established practice which has general recognition and acceptance among registered professional nurses and its commonly accepted as correct standards of practice are agreed n levels of competence as determined by the ANA and specially nursing ranizations (ANA-1996)

 Standards are defined as authoritative statements that describe a common level of care as performed by which the quality of practice can be determined or measured. standard help define professional practice (hubes -1996)

IMPORTANCE IN STANDARDS IN NURSING

It is the authoritative statement by which the quality of nursing practice, service and education can be judged In nursing practice, standards are established criteria for the practice of nursing It is a guideline and a guideline far is a recommended path to safe conduct an aid to professional performance

 It provides a baseline for evaluating quality of nursing care, increase effectiveness of care and improve efficiency Standard helps supervisors to guide nursing staffs to improve performances Standard may helps to clarify nurses area of accountability Standards may helps nursing to clearly define different levels of care standard s a device of quality assurance and quality control

Purpose:
Improve the quality of nursing. Decrease the cost of nursing. Determine the nursing negligence

Characteristics of standard
statement must be board enough to apply a wide variety of settings must be realistic, acceptable and attainable nursing care must be developed by members of nursing profession must be understandable and stated correct knowledge and scientific practice Must be based on current knowledge and scientific practice must be reviewed and revised periodically must be directed towards an optimal standard

SOURCES OF NURSING STANDARDS

Professional organizations like TNAI Licensing bodies IC, MCI and DCI etc. Departments of the institution. Patient care unit. Individual personal standard Government unit at national, state and local government unit

Classification of standards
1) Physical standard Which includes patient s activity rating to establish nursing care hours per patient per day 2) Cost standard Which includes cost per patient per day 3) Capital standard Which include the review of monitory investments as new program 4) Revenue standards
Which includes the revenue per patient day of nursing care

5) Program standards Which guide the development and implementation of program to meet clients need 6) Intangible standard Which guide the development of personal orientation cost 7) Goal standard Which outlines qualitative goal in short and long term planning 8) Strategies plan standard This outlines check point in developing and implementing the organization strategic plan

ROLE OF NURSE IN QUALITY ASSURANCE

Professional nurses have an obligation to ensure that the care they provided is evidence based. Ensure services provided is consumer centered. Provide quality care to the individual and to the public in reality with the desired outcome. Care provided should be consistent with current professional knowledge. Functions as leader and managers in various health care settings which provide quality care. Responsible to promote standards, measurement and involve in continuous quality improvement. Effective care to the clients should be the primary focus of all nurses

Role of nurse administrator in implementing quality assurance

Initiator: Creates an awareness or sensitizes the nurses about the importance of quality assurence

Facilitator: She facilitates to develop, implement, monitor and evaluate standard of nursing practice in all times

Coordinator
She coordinates the different units of quality assurance programe and coordinates the activities with hospital quality assurance program

 Educator
She gives orientation to nursing personal regarding the nees

Leader
She communicate the quality message to all nursing staffs

Evaluators
She evaluates the implementation of nursing practice

Supervisor
She supervise the activities of the different committees,she supervises the nurses firstand secnd level of leadership positions

IN A NUTSHELL, QUALITY ASSURANCE PROMOTES

Comprehensive, cost effective and contractual aspect. Accessible, accredited, acceptable. Relevant, reliable, resourced. Efficient, equitable and effective care.