Introduction to Quality Nursing Management

Southwestern University

Cebu City

Graduate SCHOOL

of Health Science, Management, And Pedagogy

MODULE IN NSG 500N

I.             Course Code: NSG 500N

II.           Course Title: Introduction to Quality Nursing Management

III.          Course Unit: 3 units

IV.          Course Prerequisites: None

V.            Course Description:

This course introduces the MAN student to the concepts of quality nursing management and the use of critical analysis. This course also provides in depth explanation of quality management commonly used in practice, education, and research. The students are to analyze theories and apply them to situations found in the different fields of nursing practice.

Introduction

The goal of this subject is to provide pivotal and fundamental definitions that link patient safety with health care quality. Evidence is summarized that indicates how nurses are in a key position to improve the quality of health care through patient safety interventions and strategies.

Quality Care

Many view quality health care as the overarching umbrella under which patient safety resides. For example, the Institute of Medicine (IOM) considers patient safety “indistinguishable from the delivery of quality health care.” Ancient philosophers such as Aristotle and Plato contemplated quality and its attributes. In fact, quality was one of the great ideas of the Western world. Harteloh reviewed multiple conceptualizations of quality and concluded with a very abstract definition: “Quality [is] an optimal balance between possibilities realised and a framework of norms and values.” This conceptual definition reflects the fact that quality is an abstraction and does not exist as a discrete entity. Rather it is constructed based on an interaction among relevant actors who agree about standards (the norms and values) and components (the possibilities).

Work groups such as those in the IOM have attempted to define quality of health care in terms of standards. Initially, the IOM defined quality as the “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” This led to a definition of quality that appeared to be listings of quality indicators, which are expressions of the standards. These standards are not necessarily in terms of the possibilities or conceptual clusters for these indicators. Further, most clusters of quality indicators were and often continue to be comprised of the 5Ds—death, disease, disability, discomfort, and dissatisfaction⁵—rather than more positive components of quality.

The work of the American Academy of Nursing Expert Panel on Quality Health focused on the following positive indicators of high-quality care that are sensitive to nursing input: achievement of appropriate self-care, demonstration of health-promoting behaviours, health-related quality of life, perception of being well cared for, and symptom management to criterion. Mortality, morbidity, and adverse events were considered negative outcomes of interest that represented the integration of multiple provider inputs. The latter indicators were outlined more fully by the National Quality Forum.⁸ Safety is inferred, but not explicit in the American Academy of Nursing and National Quality Forum quality indicators.

The most recent IOM work to identify the components of quality care for the 21st century is centred on the conceptual components of quality rather than the measured indicators: quality care is safe, effective, patient centred, timely, efficient, and equitable. Thus safety is the foundation upon which all other aspects of quality care are built

Patient Safety

A definition for patient safety has emerged from the health care quality movement that is equally abstract, with various approaches to the more concrete essential components. Patient safety was defined by the IOM as “the prevention of harm to patients.” Emphasis is placed on the system of care delivery that (1) prevents errors; (2) learns from the errors that do occur; and (3) is built on a culture of safety that involves health care professionals, organizations, and patients. The glossary at the AHRQ Patient Safety Network Web site expands upon the definition of prevention of harm: “freedom from accidental or preventable injuries produced by medical care

Patient safety practices have been defined as “those that reduce the risk of adverse events related to exposure to medical care across a range of diagnoses or conditions.” This definition is concrete but quite incomplete, because so many practices have not been well studied with respect to their effectiveness in preventing or ameliorating harm. Practices considered to have sufficient evidence to include in the category of patient safety practices are as follows:

• Appropriate use of prophylaxis to prevent venous thromboembolism in patients at risk
• Use of perioperative beta-blockers in appropriate patients to prevent perioperative morbidity and mortality
• Use of maximum sterile barriers while placing central intravenous catheters to prevent infections
• Appropriate use of antibiotic prophylaxis in surgical patients to prevent postoperative infections
• Asking that patients recall and restate what they have been told during the informed-consent process to verify their understanding
• Continuous aspiration of subglottic secretions to prevent ventilator-associated pneumonia
• Use of pressure-relieving bedding materials to prevent pressure ulcers
• Use of real-time ultrasound guidance during central line insertion to prevent complications
• Patient self-management for warfarin (Coumadin®) to achieve appropriate outpatient anticoagulation and prevent complications
• Appropriate provision of nutrition, with a particular emphasis on early enteral nutrition in critically ill and surgical patients, to prevent complications
• Use of antibiotic-impregnated central venous catheters to prevent catheter-related infections

Many patient safety practices, such as use of simulators, bar coding, computerized physician order entry, and crew resource management, have been considered as possible strategies to avoid patient safety errors and improve health care processes; research has been exploring these areas, but their remains innumerable opportunities for further research.

Nursing As the Key to Improving Quality through Patient Safety

Nursing has clearly been concerned with defining and measuring quality long before the current national and State-level emphasis on quality improvement. Florence Nightingale analysed mortality data among British troops in 1855 and accomplished significant reduction in mortality through organizational and hygienic practices. She is also credited with creating the world’s first performance measures of hospitals in 1859. In the 1970s, Wandelt  reminded us of the fundamental definitions of quality as characteristics and degrees of excellence, with standards referring to a general agreement of how things should be (to be considered of high quality). About the same time, Lang proposed a quality assurance model that has endured with its foundation of societal and professional values as well as the most current scientific knowledge (two decades before the IOM definition was put forth).

In the past, we have often viewed nursing’s responsibility in patient safety in narrow aspects of patient care, for example, avoiding medication errors and preventing patient falls. While these dimensions of safety remain important within the nursing purview, the breadth and depth of patient safety and quality improvement are far greater. The most critical contribution of nursing to patient safety, in any setting, is the ability to coordinate and integrate the multiple aspects of quality within the care directly provided by nursing, and across the care delivered by others in the setting. This integrative function is probably a component of the oft-repeated finding that richer staffing (greater percentage of registered nurses to other nursing staff) is associated with fewer complications and lower mortality. While the mechanism of this association is not evident in these correlational studies, many speculate it is related to the roles of professional nurses in integrating care (which includes interception of errors by others—near misses), as well as the monitoring and surveillance that identifies hazards and patient deterioration before they become errors and adverse events. Relatively few studies have had the wealth of process data evident in the RAND study of Medicare mortality before and after implementation of diagnosis-related groups. The RAND study demonstrated lower severity-adjusted mortality related to better nurse and physician cognitive diagnostic and treatment decisions, more effective diagnostic and therapeutic processes, and better nursing surveillance.

Conclusion

Patient safety is the cornerstone of high-quality health care. Much of the work defining patient safety and practices that prevent harm have focused on negative outcomes of care, such as mortality and morbidity. Nurses are critical to the surveillance and coordination that reduce such adverse outcomes. Much work remains to be done in evaluating the impact of nursing care on positive quality indicators, such as appropriate self-care and other measures of improved health status.

INTRODUCTION TO QUALITY NURSING MANAGEMENT

• Quality refers to excellence of a product or a service, including its attractiveness, lack of defects, reliability, and long-term durability.

• Quality assurance provides the mechanisms to effectively monitor patient care provided by health care professionals using cost-effective resources.
• Nursing programmes of quality assurance are concerned with the quantitative assessment of nursing care as measured by proven standards of nursing practice.
• Quality assurance system motivates nurses to strive for excellence in delivering quality care and to be more open and flexible in experimenting with innovative ways to change outmoded systems.
• Florence Nightingale introduced the concept of quality in nursing care in 1855 while attending the soldiers in the hospital during the Crimean war.

CONCEPT OF QUALITY IN HEALTH CARE

• 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) 
• 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).

APPROACHES FOR A QUALITY ASSURANCE PROGRAMME

Two major categories of approaches exist in quality assurance they are

1. General
2. Specific

A. 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.

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.
• The licensing process requires that regulations be written to define the scopes and limits of the professional’s practice.
• Licensure of nurses has been mandated throuhout the world by laws and regulations..

3) Accreditation

• ISO
• JCI
• NABH
• Accrediation Canada
• NAAC

ACTIVITY/ REQUIREMENT 1:

Please create a self-survey assessment of any of the accrediting agency mentioned above for your hospital or institution. (FULL SELF SURVEY ASSESSMENT)

4) Certification

• Certification is usually a voluntary process with in the profession.
• A person’s educational achievements, experience and performance on examination are used to determine the person’s qualifications for functioning in an identified specialty area.

B. Specific approaches

1)  Peer review

• Peer review is divided in to two types.
1. The recipients of health services by means of auditing the quality of services rendered.
2. 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. The ANA standard for practice include:

• Standard 1: The collection of data about health status of the patient is systematic and continuous. The data are accessible, communicative, and recorded.
• Standard 2: Nursing diagnosis are derived from health status data.
• Standard 3: The plan of nursing care includes goals derived from the nursing diagnoses.
• Standard 4: The plan of nursing care includes priorities and the prescribed nursing approaches or measures to achieve the goals derived from the nursing diagnoses.
• Standard 5: Nursing actions provide for patient participation in health promotion, maintenance, and restoration.
• Standard 6: Nursing actions assist the patient to maximize his health capabilities.
• Standard 7: The patient’s progress or lack of progress towards goal achievement is determined by the patient and the nurse.
• Standard 8: The patient’s progress or lack of progress towards goal achievement directs re-assessment, re-ordering of priorities, new goal setting, and a revision of the plan of nursing care.

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.

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.

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. Reevaluate

ACTIVITY/ REQUIREMENT 2:

Using this model, create a quality assurance module for your institution/ hospital.

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 providres 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.

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.

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.

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) Reevaluate

• 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.

QUALITY ASSURANCE PROCESS

1. Establishment of standards or criteria
2. Identify the information relevant to criteria
3. Determine ways to collect information
4. Collect and analyze the information
5. Compare collected information with established criteria
6. Make a judgment about quality
7. Provide information and if necessary, take corrective action regarding findings of appropriate sources
8. Determine ways to collect the information

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.

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.

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

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.

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

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.

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

ACTIVITY/ REQUIREMENT 3:

Please enumerate the problems encountered in the institution/ hospital you are currently working with their corresponding action plans for every factor. (At least 20 perceived problems)

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

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

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
• Analyze 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 analyze factors contributing to results
• Select appropriate actions to maintain or improve care
• Implement selected actions
• Evaluate QAO

STAGES OF THE DEVELOPMENT OF INTERNATIONAL STANDARDS

An International Standard is the result of an agreement between the member bodies of ISO. It may be used as such, or may be implemented through incorporation in national standards of different countries.

International Standards are developed by ISO technical committees (TC) and subcommittees (SC) by a six-step process:

• Stage 1: Proposal stage
• Stage 2: Preparatory stage
• Stage 3: Committee stage
• Stage 4: Enquiry stage
• Stage 5: Approval stage
• Stage 6: Publication stage

The following is a summary of each of the six stages:

Stage 1: Proposal stage

The first step in the development of an International Standard is to confirm that a particular International Standard is needed. A new work item proposal (NP) is submitted for vote by the members of the relevant TC or SC to determine the inclusion of the work item in the programme of work.

The proposal is accepted if a majority of the P-members of the TC/SC votes in favour and if at least five P-members declare their commitment to participate actively in the project. At this stage a project leader responsible for the work item is normally appointed.

Stage 2: Preparatory stage

Usually, a working group of experts, the chairman (convener) of which is the project leader, is set up by the TC/SC for the preparation of a working draft. Successive working drafts may be considered until the working group is satisfied that it has developed the best technical solution to the problem being addressed. At this stage, the draft is forwarded to the working group's parent committee for the consensus-building phase.

Stage 3: Committee stage

As soon as a first committee draft is available, it is registered by the ISO Central Secretariat. It is distributed for comment and, if required, voting, by the P-members of the TC/SC. Successive committee drafts may be considered until consensus is reached on the technical content. Once consensus has been attained, the text is finalized for submission as a draft International Standard (DIS).

Stage 4: Enquiry stage

The draft International Standard (DIS) is circulated to all ISO member bodies by the ISO Central Secretariat for voting and comment within a period of five months. It is approved for submission as a final draft International Standard (FDIS) if a two-thirds majority of the P-members of the TC/SC are in favour and not more than one-quarter of the total number of votes cast are negative. If the approval criteria are not met, the text is returned to the originating TC/SC for further study and a revised document will again be circulated for voting and comment as a draft International Standard.

Stage 5: Approval stage

The final draft International Standard (FDIS) is circulated to all ISO member bodies by the ISO Central Secretariat for a final Yes/No vote within a period of two months. If technical comments are received during this period, they are no longer considered at this stage, but registered for consideration during a future revision of the International Standard. The text is approved as an International Standard if a two-thirds majority of the P-members of the TC/SC is in favour and not more than one-quarter of the total number of votes cast are negative. If these approval criteria are not met, the standard is referred back to the originating TC/SC for reconsideration in light of the technical reasons submitted in support of the negative votes received.

Stage 6: Publication stage

Once a final draft International Standard has been approved, only minor editorial changes, if and where necessary, are introduced into the final text. The final text is sent to the ISO Central Secretariat which publishes the International Standard.

IMPACT OF ISO IN A LOCAL HOSPITAL:

Positive impacts:

1. Nurses are accountable for their actions and, professionally, we have responsibility to evaluate the effectiveness of our care
2. Nurses can deliver a high standard of care, and being empowered to identify and resolve problems can add to personal satisfaction with work
3. Documents state clearly how the health service should perform and what the patient can expect
4. Guaranteeing standards of care to the public must be a duty of all those who work within the health service
5. Nurses are actively involve in audit, service reviews, standard-setting and customer relations
6. Improves the overall quality of nursing care
7. Improves all types of documentation and communication
8. Helps in professional growth

Negative impacts:

1. Lack of adequate resources
2. Lack of trained, skilled and motivated employees, staff indiscipline affects the quality of care.
3. ISO activities may overburden the nursing personnel
4. Nurses will not get adequate time to spent with the patient, most of the time may be spending for recording and reporting
5. The hospital will be restricted only to ISO standards
6. Hospital has to provide special training for all the staffs those who are involved in ISO inspection
7. All types of services will be under the control of ISO

IMPACT OF ISO IN A LOCAL  NURSING EDUCATIONAL INSTITUTIONS:

Positive impacts:

1. Improves the quality of nursing education
2. improves the quality of nursing practice
3. Helps to maintain international standard
4. Helps to compare the standard with another institution
5. Helps in personnel development of teachers
6. Helps to maintain all the records in time
7. Avoids malpractice and bias
8. Encourages extra-curricular activities also
9. Act as a control for all the activities
10. Improves professional growth

Negative impacts:

1. Gives more importance to documentation
2. Over-burden for the teachers
3. Teachers need to take special training in maintaining the standards
4. Not observing the actual practice
5. Organizational philosophy and policies has to be modified according to the ISO standards

CRITICAL ANALYSIS:

• Strengths: ISO helps to improve and maintain the quality of educational institutions and hospitals
• Weakness: Standards are set by the institution itself, it may be biased
• Opportunities: Helps in professional growth
• Threats: Organizational philosophy and policies may not be considered

ACTIVITY/ REQUIREMENT 4:

Using ISO Standard, create a quality assurance matrix for your institution/ hospital. (Explain no less than 500 words).

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.

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