AMBROSIO TOTAL QUALITY MANAGEMENT

8/7/2019 AMBROSIO TOTAL QUALITY MANAGEMENT

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AMBROSIO, Jhoanna Jean G. 2007-4627 BSN 415 TOTAL QUALITY MANAGEMENT

Source: http://currentnursing.com/nursing_management/total_quality_management_health_care.html

INTRODUCTION

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. In addition, they motivate practitioners in nursing to strive for excellence in delivering quality care and to be more open and flexible inexperimenting with innovative ways to change outmoded systems

The field of quality assurance is an old as modern nursing. Florence Nightingale introduced the concept of quality in nursing care in 1855 whileattending the soldiers in the hospital during the Crimean war. It is a matter of pride for nurses that the nursing profession has attained a distinct

position in the search for quality in health care.

CONCEPT OF QUALITY IN HEALTH CARE

Defining quality is difficult. The expense of quality is an interactive process between customer and provider. The customer does not receive anything

tangible, mostly only a piece of paper with a promise for a better future e.g. Doctors writing prescriptions.

Quality

1. Quality is defined as the extent of resemblance between the purpose of healthcare and the truly granted care (Donabedian 1986).2. In an economic dimension quality is the extent of accomplished relief case with a justified use of means and services (Williamson 1999)

3. Government and those who pay of the care will see quality as a weighing out between results and costs to fulfill certain expectations in healthcare.

CONCEPT OF QUALITY ASSURANCE

Quality assurance originated in manufacturing industry. The idea was ³to ensure that the product consistently achieved customer satisfaction´.Qualityassurance 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.

³Quality assurance is a judgment concerning the process of care, based on the extent to which that cares contributes to valued outcomes´.

(Donabedian 1982).



³Quality assurance as the monitoring of the activities of client care to determine the degree of excellence attained to the implementation of theactivities´. (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) Credentiali ng:

It is generally defined as the formal recognition of professional or technical competence and attainment of minimum standards by a person or agency

According to Hinsvark (1981) 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 by law since 1903.

3) Accred itation:



National league for nursing (NLN) a voluntary organization in US has established standards for inspecting nursing education¶s programs. In the partthe accreditation process primarily evaluated on agency¶s physical structure, organizational structure and personal qualification

4 ) Cer tification:

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:

Quality assurances are methods used to evaluate identified instances of providers and client interaction.

1) Peer revi ew

To maintain high standards, peer review has been initiated to carefully review the quality of practice demonstrated by members of a professionalgroup. Peer review is divided in to two types. One centers on the recipients of health services by means of auditing the quality of services rendered.

The other centers on the health professional by evaluating the quality of individual performance.

2) S tand ard as a device for quality assur ance

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;

y Standard 1: The collection of data about health status of the patient is systematic and continuous. The data are accessible, communicative, andrecorded.

y Standard 2: Nursing diagnosis are derived from health status data.y Standard 3: The plan of nursing care includes goals derived from the nursing diagnoses.

y 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.y Standard 5: Nursing actions provide for patient participation in health promotion, maintenance, and restoration.y Standard 6: Nursing actions assist the patient to maximize his health capabilities.

y Standard 7: The patient¶s progress or lack of progress towards goal achievement is determined by the patient and the nurse.y 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) Aud it as a tool for quality assur ance:



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. To be effective a nursing audit must be based on established criteria and feedback mechanism

that provide information to providers on the quality of care delivered. To evaluate quality nursing care regularly, many staff nurses do indeedwelcome opportunity to develop criteria, to review nursing care retrospectively and concurrently, and to discover methods of achieving higher levels

of quality nursing care.

MODELS OF QUALITY ASSURANCE

1) A S yst em M odel for i mpl ementation of unit Based Quality assur ance:

The implementations of the unit based quality assurance program, like that of any other program, involves making changes in organizational structure

and individual roles. One method of facilitating and structuring the change process is the system approach in which the task is broken down intomanageable 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. The boundaries of the system define its integrationis the environment is to the other tasks and goals of nursing department, to the process of nursing science in relation to evaluation. Their boundaries

should be semi-permeable so that they allow necessary information and energy into and out of the change process.

2) ANA Quality Assur ance M odel :

ANA quality Assurance Model (from Susan Clemene, Diana Geeber: Comprehensive, family and community health nursing, 3rd edition Pg 851)

The basic components of the ANA model can be summarized as follows:

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

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.Another standard of structure includes the organizational chart, which shows supervisory methods, communication patterns, staff patterns andsometimes staff assignments. 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. An agency can choose to

use the standards of care set forth by the providers professional organization such as the ANA nursing standards or the agency can use the nursing process and apply it to the activities of the nurses as the activities correspond to the procedures of care defined by the agency. The primary

approaches for process evaluation include the peer review committee and the client satisfaction survey. The techniques included are direct

observation, questionnaire, interview, written audit and videotape of client and provider encounter.

The evaluation of outcome standards reveals the end results of nursing care. To be able to identify the net changes in the client¶s health status as a

result of nursing care will give nursing profession data to show the contributors of nursing to the health care delivery system. Research studies usingthe trace method or the sentinel method to identify client outcomes and client satisfaction surveys are approaches that may be used to evaluate

outcome standards. Technique used is client classification systems that are admission data on the clients¶ level of dependence or problems anddischarge data that may show changes in the level of dependence.

3) Select measurement needed to determine degree of attainment of criteria and standards:



3. Determine ways to collect information4. Collect and analyze the information

5. Compare collected information with established criteria6. 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 Resour ces:

Insufficient resources, infrastructures, equipment, consumables, money for recurring expenses and staff make it possible for output of a certainquality to be turned out under the prevailing circumstances.

2) Personnel pr obl ems:

Lack of trained, skilled and motivated employees, staff indiscipline affects the quality of care.

3) Impr o per mai nt enance:

Buildings and equipments require proper maintenance for efficient use. If not maintained properly the equipments cannot be used in giving nursingcare. To minimize equipment down time it is necessary to ensure adequate after sale service and service manuals.

4 ) Unreasonabl e P ati ent s and Att end ant s

Illness, anxiety, absence of immediate response to treatment, unreasonable and unco-operative attitude that in turn affects the quality of care innursing.

5) Absence of well i n formed po pulation.

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 accred itation 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 i nci dent revi ew pr oced ures

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 g ood and hospital i n formation s yst em

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 pati ent sati s faction surve ys

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 nursi ng 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) M i scellaneous 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

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:

y Access to servicey Relevance to need

y Effectivenessy Equityy Social acceptance



y Efficiency and economy

2. Wilson (1987)

Wilson considers there to be four essential components to a QA programme. These are:

y Setting objectives

y Quality promotiony Activity monitoring

y Performance assessment

3. Lang (1976)

This framework has subsequently been adopted and developed by the ANA. The stages includes;

y Identify and agree values

y Review literature, Known QAPy Analyze available programmes

y Determine most appropriate QAPy Establish structure, plans, outcome criteria and standards

y Ratify standards and criteria

y Evaluate current levels of nursing practice against ratified structures

y Identify and analyze factors contributing to resultsy Select appropriate actions to maintain or improve care

y Implement selected actionsy 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:

y Stage 1: Proposal stage

y Stage 2: Preparatory stagey Stage 3: Committee stagey Stage 4: Enquiry stage



met, the standard is referred back to the originating TC/SC for reconsideration in light of the technical reasons submitted in support of the negativevotes received.

S ta ge 6: P ublication sta ge

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:

P ositi ve i mpact s:

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 service5. Nurses are actively involve in audit, service reviews, standard-setting and customer relations

6. Improves the overall quality of nursing care7. Improves all types of documentation and communication

8. Helps in professional growth

Neg ati ve i mpact s:

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 reporting5. 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 inspection7. All types of services will be under the control of ISO

IMPACT OF ISO IN A LOCAL NURSING EDUCATIONAL INSTITUTIONS:

P ositi ve i mpact s:

1. Improves the quality of nursing education

2. improves the quality of nursing practice3. Helps to maintain international standard



4. Helps to compare the standard with another institution5. Helps in personnel development of teachers

6. Helps to maintain all the records in time7. Avoids malpractice and bias

8. Encourages extra-curricular activities also

9. Act as a control for all the activities10. Improves professional growth

Neg ati ve i mpact s:

1. Gives more importance to documentation2. Over-burden for the teachers

3. Teachers need to take special training in maintaining the standards4. Not observing the actual practice

5. Organizational philosophy and policies has to be modified according to the ISO standards

CRITICAL ANALYSIS:

y S t reng t hs: ISO helps to improve and maintain the quality of educational institutions and hospitals

y W eak ness: Standards are set by the institution itself, it may be biasedy O

ppor tuniti es: Helps in professional growthy T hreat s: Organizational philosophy and policies may not be considered

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 professionmust 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 andexpertise. Quality assurance programme will helps to improve the quality of nursing care and professional development.

Reaction:

Total Quality Management in relation to the f ield of Nursing is important. It should be given good attention and f air application in order f or one to attain satisf action.

Nurses, along with their skills and knowledge on how to give proper care to their clients should always maintain or improve the quality of service they are rendering to

every unique individual. TQM helps promote and enhance the eff ectiveness of the quality of care being rendered by every nurse to every patient. It decreases the needs of



f ollow-ups by increasing the productivity of the nurse in a certain period of time. Through which, by applying TQM in our daily lives, I believe that we all shall be able to

increase the productivity of the work we put into a task and eliminating the f actors that could make a patient come back sooner than expected.

AMBROSIO TOTAL QUALITY MANAGEMENT

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