king Saud university college of nursing

Managing and improving quality

of patient care

Prepared by: Dr-Fatimah Baddar

Outlines

Introduction. Definitions of Quality Historical Development of

Quality . Factors contributing to Quality. Dimensions of Quality Development of Quality programs Quality control Quality assurance Approaches of Quality assurance

Models of Quality assurance Quality assurance measures

performance. Quality improvement Comparison of Quality assurance and

Quality improvement JCAHO’s model for Quality

improvement (10 steps ) Total Quality management Components of total quality management Quality improvement

tools and technique

Introduction

In today’s highly competitive health care environment, each member of the health care organization must be accountable for the quality and cost of health care , which found in the concept of total quality management ,which has evolved into a model continuous quality improvement designed to improve system and process performance .

The techniques, tools, and approaches of quality management are useful to health care providers and managers in making tough decisions about reducing costs while managing or improving access and quality.

We can see the effects of quality improvement

program in the environment through this example..

So ,What is Quality?

Fitness for purpose (Juran,1964)

Process which seek to attain the highest degree of

excellence in the delivery of patient care (lange,1995)

The effect of care in health of the individual (Rutstein).

Conformance to specification (crosby,1979).

degree of agreement between the reality and previously

set criteria. ( Donabedian,1988)

So ,What is Quality? measure of closely a good or service conforms to

specialized standard ( Tersin).

The degree to which patient care services increase the

probability of desired outcomes and reduce the probability

of undesired outcome given the current state of knowledge (JCAHO).

The ability of a product or service to meet consumer needs (George)

Historical Development of Quality Quality assessment and control in health care

dates back to the mid nineteenth century in England, where Florance Nightingale serves as a nurse during the Crimean war.

Nightingale was the first to identify a positive correlation between the introduction of adequate nursing care to wounded soldiers and the lower mortality rate among them. she attributed a positive outcome to quality of care

Historical Development of Quality In 1810, Abraham Flexner present famous report

documenting his study of physician education in U.S.A in

which he emphasized that the quality of care the patient

received is directly related to physician education and the

medical education: Education certification and licensure

become very important in qualifying health care

professional and educational institution several professional

associations were established to provide these services.

Historical Development of Quality In 1914, Ernest Codiman, surgeon at Massachusetts

general Hospital, studied general surgeries and their

follow ups. This promoted the American college of

surgeons. In 1918 to create the hospital standardization

program, which provided criteria and standard for

accreditation that were later adopted by the Joint

commission

What is health care quality? Quality means different things to

different people

To the PATIENT:

Get well – feel better – recover

Skilled and helpful staff

Effective health outcomes

Welcoming atmosphere

What is health care quality?

To the STAFF: Standards of care

Up to date and working equipment

Continuing education and training

Effective team work

What is health care quality?

To the HOSPITAL MANAGEMENT

Positive health outcomes for patients

Continuous quality development at all levels of the organization

Providing education and training for staff

Stable and trained work force.

What is health care quality ?

To the GOVERNMENT & POLICY MAKERS:

Effective health care system

Improved quality of life for people

Research-based continuous quality development

Monitoring of results/achievements and taking actions to improve outcomes

What is Healthcare Quality? Achieving and producing health and satisfaction

(Donabedian)

Health Care Quality:

The degree to which health services for individuals and

populations increase the probability of desired health

outcomes and reduce the probability of undesired

outcome , are consistent with current professional

knowledge.

(JCAHOs)

Importance of Quality

1. Need for cost containment

2. Competition

3. Desire for recognition and strive for excellence.

4. Rapid advances in medical science

5. Ethical considerations

6 .Need for continual improvement in health care

Factors contributing to Quality There are underlying factors of greater significance

in creating quality services / goods. Among these factors are policy design, equipment & tools, consumer education, and service after delivery.

Policy :-Organizational policy is a major contributor to quality. Design :-Design includes such factors as the used materials, the inner

working of the service (or product ) and the plan of its work.

Factors contributing to Quality Equipment and tools :-

High quality service cannot be achieved without high quality equipment and tools.

Consumer’s education :

The determination of quality doesn’t end with providing high-quality services. Consumer education is necessary to increase the chances that a service will be used for its intended purpose.

Dimensions of quality

High- quality care is efficacious ,

appropriate, effective, safe, efficient, and

coordinated over time and across practitioners and

settings. It is also available when needed, delivered in

a timely fashion, and perceived by the patient to be

provided in a manner that is respectful

and caring .

Dimensions of quality Accessibility. Appropriateness. Continuity. Effectiveness. Efficacy. Efficiency. Patient perspective issues. Safety. Timeliness.

JCAHOs, 1990

Dimensions of quality

Acceptability Legitimacy Equity Amenities

Accessibility

"The ease with which users "The ease with which users can obtain the care that they can obtain the care that they need when they need it" need when they need it" Physical accessibility. Financial accessibility. Organizational

accessibility. Socio-cultural

accessibility. Psychological accessibility.

Appropriateness of Care"The degree to which the correct care (the care that

is relevant to the patient’s/users medical needs) is provided, given the current state of knowledge".

Continuity of care

"The degree to which the care needed by patients/users is coordinated among practitioners, organizations and over time".

Effectiveness of Care

"The degree to which the care "The degree to which the care given to patients/users is given to patients/users is provided correctly (i.e. provided correctly (i.e. without error), given the without error), given the current state of knowledge".current state of knowledge". Doing the right thing.

Effectiveness of care has 3 components:

1. Performance of providers- Technical competence- Interpersonal relation / art of care

2. Minimizing risks to patients as far as possible

3. Documenting patient's health status and the care provided accurately and completely

Efficacy of Care

"The degree to which a service/care has the potential to meet the need for which it is planned under ideal circumstances.""The ability of the science and technology of health care to bring about improvements in health when used under the most favorable circumstances".

BACKBACK

Efficiency of Care

"The relationship between the outcomes (results of care) and the resources used to deliver the care".

"The degree to which the care received

has the desired effect with a minimum

of effort, expense or waste.“

Doing the right thing right.BACKBACK

Patient Perspective Issues Patient Perspective Issues

"The degree to which patients/users and their families are satisfied with their care and involved in the decision-making processes of their care and to which those providing the care do so with sensitivity and respect for the patient’s needs, expectations and individual difference."

BACKBACK

Safety of the Care EnvironmentSafety of the Care Environment

"The degree to which the environment is free from risk (hazard or danger) for both users and providers."

BACKBACK

Timeliness of CareTimeliness of Care

"The degree to which care is provided to patients/users when it is needed i.e., at the most beneficial or necessary time."

Acceptability:Acceptability:

Conformity to the wishes, desires, and expectations of patients and responsible members of their families.

Legitimacy: Legitimacy:

Conformity to social preferences as expressed in ethical principles, values, norms, laws, and regulations.

Equity: Equity:

Conformity to a principle that determines what is just or fair in the distribution of health care and its benefits among the members of a population.

Amenities:Amenities:

Refers to features of health services that do not directly relate to medical procedures but leads to patient satisfaction and willingness to continue and return for further health care.

Quality is free..

If you do a quality job it will not cost you, what costs you is non

quality.

BASIC CONCEPTS OF QUALITY Quality

Quality control

Quality assurance

Quality improvement

Continuous quality improvement

Quality management

Total quality management

Development of Quality programs Quality Control : It involves determining the extent to which a service match

some specific quality standard.

It focus on performance

Quality control occurs on three levels :- Pre-action control : Which include setting standard or goals of

care Concurrent control: which include monitoring of the care given Feedback control: which include evaluation the level of

practice

Development of Quality programs

Problem Identification

Selection of problem for study

Analysis by circle

Solution

Presentation tomanagement

Implementation of chosen solution

Development of Quality programs Quality Assurance :

Is the measurement of actual level of the service provided plus the efforts to modify when necessary.

It focus on process

According to JCAHO

Is the process for objectively and systematically monitoring and evaluating the quality and appropriateness of patient care, for pursuing opportunities to improve patient care, and for resolving identified problems.

Development of Quality programs

Standard : a greed level of excellence . a greed level of performance for practitioners, and offers a measure against

which current practice can be measuredCriteria: Predetermined elements of health care against which the aspects of quality

of medical service may be compared .Clinical indicator: Clinical indicator is quantitative measures that can be used as a guide to

monitor and evaluate of important patient care and support service activities.

Audit: Is evaluation of the quality of medical care as reflected in medical records-concurrent - Retrospective

Approaches of Quality assurance

Structures approaches: The structure approach focus on the characteristics

of the organization such as : Policy, procedure , rule, regulation . Size (number of beds) Ownership (private or public , for profit or not for

profit ) Fiscal resources. Types and Qualification of professionals Number and appropriateness [of non professionals &

support personnel Physical facilities and equipment.

Approaches of Quality assurance

Process Approaches :- Process approach examines the interaction between patient and staff. The nature and sequence of events or activities in the delivery of health care. Action that are taken by the nurse or care received by the patient.

Outcome approach :- The outcome elements are changes in patient health status that result from

nursing intervention. These changes include modification of symptoms, signs, knowledge

, attitudes, satisfaction and skills. Outcome refers to the end result. Structure Outcome measure level of improvement in health or quality of life for

the patient

Development of Quality programs

Quality improvement: Is an ongoing process of innovation , prevention of error, staff

development that is used by corporations and institution who adopt the quality management philosophy

Is a process used in a unit to systematically investigate ways to improve patient care and services.

Goals of quality improvement To achieve optimal patient outcomes in term of both improved

well being and patient satisfaction

Comparison of Quality assurance and quality improvement

Quality assurance processQuality improvement process

Goal To improve QualityTo improve quality

Focus Discovery and correction of errorsPrevention of error

Task - Inspection of nursing activities

- Chart audits

-Review of nursing activities

-innovation staff developmentQuality team Quality assurance or department

personnel

Multidisciplinary team

Outcome

Set by QA team with input from staff

Reaction

Narrow focus

Problem solving by authority

Leadership may not vested

set by QI team with input from staff and clients customers

proactive

cross – Functional

problem solving by employees at all levels

Leadership actively

JCAHO’s model for quality improvementJCAHO’S 10-STEP Monitoring and Evaluation

Process

1-Assign responsibility

2-Delineate scope of care

3-Identify important aspects of care

4-Identify indicator-(quantitative)

5-Establish threshold for evaluation

JCAHO’s model for quality improvement (cont)

6-Collect and organize data

7-Evaluate care

8-Take action to improve care

9-Assessment of action and documentation of improvement

10-Communicate information

Development of Quality programs

Continuous Quality Improvement (CQI)

Cyclical process Continuously improve Q even in absence of problems Never ending Daily part of everyday functions

Basic Principles: Teamwork Includes customer perspective Measurement of work process Willingness, even eagerness to change

CQI ask "WHY" not "WHO"

"why" the problem happens ? not "who" did it ?,

What was wrong with the system ?

What can I do to improve the system ?

Development of Quality programs

Quality management

Creating and following policies and procedures in order to ensure

that a project meets the defined needs it was intended to meet .

Example:

The nurse gives a wrong medication ,,a system must be established ,accepted and used by all the staff .

Development of Quality programs

Total Quality management:

Is holistic , organizational – wide approach to improve and maintain quality. All of organization’s activities and resources are directed toward achievement of goal that is , optimum patient outcome in terms of patient well being and customer satisfaction with care given.

"TOTAL"

Injects a system meaning of wholeness into quality.

Quality cannot be guaranteed without

involving the whole organization, across all functions and through all levels.

Benefits of Quality ManagementQuality Improvement

Improved ProductivityImproved outputs (product/service)Better resource use (Efficiency)

Decreased Production Costs

Lower Prices

Increased Customer Satisfaction

Increased Market Share/Enhanced competitive position

Increased Profit

Components of Quality management

In order to address the quality of health care services provided today, administrators must use:-

1.Quality assessment and improvement .

2. Utilization management .

3. Risk management and safety.

4. Infection control.

Development of Quality programs

Performance Improvement (PI)

Designed to replace CQI.

It focuses on measuring and improving performance, both of an individual or an organization

It is a facility- and individual-oriented tool

QC & QA focus on meet needs of patients and performance..

While

QCI & TQM focus on all quality approaches

Quality improvement tools and techniques

QUALITY TOOLS

Quality improvement tools and techniques

Tools for Definition

•IPO diagram•SIPOC diagram•Flow diagram

Tools for Measurement

•cause and effect diagram

Or(Fish bone

OrHead & tail

Or IshikawaDiagramor Six M)

•Pareto chart

Tools for Analysis

• Swot analysis•The five why

Tools for Improvement

•Brainstorming•Nominal group

Tools forControl

•Gantt chart•The PDCA

Recommendation to nursing administration

The nurse manager has to follow some step toward quality management :

ensuring that employees have the resources , knowledge , skills, and abilities to do their work.

Sharing authority with empowered employees. Increased employee participation in the matters that affect

employees is encouraged.

Involving delegation, motivation, and working in and for self- led teams.

Recognition of nursing care mistakes. Adoption & implementation of quality policy as well as its

determination and following up of its objectives. Encourage and motivation to the nurses to improve quality

and safety. Establishing of education and training about CQI.