QUALITY ASSESSMENT IN NURSING PRACTICE.docx

QUALITY ASSESSMENT IN NURSING PRACTICE ====================================== 1.0 INTRODUCTION ---------------- 3.1 Concept of Quality Assessment --------------------------------- Williamson (1962) defines quality assurance as "the measurement of the actual level of the service provided, plus eff...

QUALITY ASSESSMENT IN NURSING PRACTICE ====================================== 1.0 INTRODUCTION ---------------- 3.1 Concept of Quality Assessment --------------------------------- Williamson (1962) defines quality assurance as "the measurement of the actual level of the service provided, plus efforts to modify, when necessary, the provision of these services in the light o f the results of the measurement." Smith and Hibberd (1998) also describe quality assurance as the systematic process wherein there is a data-based, judgmental appraisal of a selected element of care and subsequent improvement. These definitions show that there is a commitment to respond positively to results obtained from an assessment of services provided. However, assessment of services without effort to improve it is not quality assurance activity. So in quality assurance actual practice is assessed against a given standards, deficiencies identified and action are then taken to remedy and prevent them from recurring in the future. ### Aims and Objectives of Quality Assessment Programme 1. To assess the quality of performance in provision of nursing care and management of other services within patient‟s environment. 2. To provide nursing personnel with information on their level of performance in relation to set standards in the organisation. 3. To serve as a tool to increase awareness on medico-legal implications of nursing practice. 4. To identify specific needs for additional in-service-training of personnel and staff development. 5. To provide statistical data concerning the management process of organised nursing services and utilisation of resources (human and material). 3.2 Elements of Quality Assessment ---------------------------------- Quality assurance ensures that health care provided to patient is consistentl y of good quality. However, the quality of care the patient receives in any situation is determined by certain variables. Four of the principal elements are: 1. [The provider i.e. the peopl](http://www.pdfcomplete.com/cms/hppl/tabid/108/Default.aspx?r=q8b3uige22)e who give the care. This takes [cognizance of the education,](http://www.pdfcomplete.com/cms/hppl/tabid/108/Default.aspx?r=q8b3uige22) intelligence and experience of health profession. 2. The standards that are maintained in the agency providing care. 3. The environment, or setting in which the care is given. 4. The recipient of care, i.e. the patient. 3.3 Components of Quality Assessment ------------------------------------ 1. **Quality Design:** This is a planning process within which goals are set, resources allocated and standards of service delivery set. 2. **Quality Control:** This consists of monitoring, supervision and evaluation of care to ensure that standards are met and good quality is consistentl y maintained. It ensures that a programme of activities take place as designed, more importantly it may uncover, flaws in design and thus point to changes that could improve quality. For effective good quality control the following must be present: i. Measurable indicators of quality ii. Timely data collection and analysis iii. Effective supervision. 3.4 Framework for Quality Assessment ------------------------------------ [been mostly adopte d](http://www.pdfcomplete.com/cms/hppl/tabid/108/Default.aspx?r=q8b3uige22) by the nursing profession. In this framework the [structure describes th](http://www.pdfcomplete.com/cms/hppl/tabid/108/Default.aspx?r=q8b3uige22) e resources in the systems that are required to meet the standards (for e xample, the quality and number of staff who and what is needed). The process describes how the service is to be carried out, and the outcome standard describes the desired results to be achieved. The formulation of structure, process and outcome criteria which was aimed at helps to epitomise the desired quality improvements. Table 1 below shows the type of information required for quality assurance. **Table 1: Types of Information Required for Quality Assessment** -- -- Source: Adapted from A. Donabedian, "Evaluating the Quality of Medical Care," Milbank Quarterly, 44 (Supplement, 3, 1996), pp. 166-- 203. [3.5](http://www.pdfcomplete.com/cms/hppl/tabid/108/Default.aspx?r=q8b3uige22) [Steps to Quality Assess m](http://www.pdfcomplete.com/cms/hppl/tabid/108/Default.aspx?r=q8b3uige22)ent Review --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 1. 2. 3. 4. 5. 6. 7. 8. 2. Standards and criteria 3. Collect data ### Fig. 3: Steps to Quality Assessment Review If the nursing unit or institution is the focus of the quality assurance review, it might examine the administrative structure, the physical plant and equipment, or staffing. For example, a review could be implemented to determine whether required educational records for nurses in the critical care units are up to date. When nursing care or a nursing care problem is the focus of the review, it is generally best to limit the scope to a certain population (for example, patients with certain diagnoses, surgical procedures, nursing care problems, or degree of all the variab les to be considered. It is critical to remember that the perspective of the consumer must be considered in any evaluation. In selected instances, such as using patient outcomes or in attempting to validate patient care plans with patients themselves, consumer input is essential. ### Step 1: Identify Values Before the implementation of the quality assurance mod el, there must be an examination of the societal, professional, and individual values that guide the health care in the respective agency. The very word quality implies that someone somewhere has determined that certain outcomes have more value than others. As applied to nursing care, the individual nurse, nursing unit, hospital, and community will interact to influence the development of criteria to be used in the review process. ### Step 2: Identify Standards and Criteria A standard is the desirable or achievable level or range of performance of a certain criterion, or a framework against which performance is [compared. An example of a stand](http://www.pdfcomplete.com/cms/hppl/tabid/108/Default.aspx?r=q8b3uige22)ard is, "Every patient will have an [admission assessment by a registere](http://www.pdfcomplete.com/cms/hppl/tabid/108/Default.aspx?r=q8b3uige22)d nurse." A criterion measure is that variable believed to be the indicat or of the quality of care, for example, "The assessment form will b e completed by the adm itting nurse within 8 hours of admission." ### Measure Degree of Attainment of Standards and Criteria Multiple methods are available to collect data to assess the attainment of the standards and criteria. The degree to which the actual practice exceeds, meets, or falls below the validated criteria provide the data necessary to evaluate the strengths and weaknesses of the nursing care programme. Data collection methods might include questionnaires, staff interviews, patient interviews, self-assessment questionnaires, performance evaluation, utilisation review, audits, patient or staff complaints, and direct observation. Whatever the method selected, the data should be easily accessible, and questions of efficienc y and accuracy should be considered. Data collected are tabulated, and the results indicate whether the percentage of yes/no responses corresponds to the previously established level of performance (per cent compliance) for each criterion. If the level of performance does not achieve expectations, the criterion element has not been met. ### Step 4: Interpret Strengths and Weaknesses The degree to which the levels of performance have been met serves as the basis for describing the strengths and weaknesses of the nursing care programme. However, it is essential that certain subtle factors not be overlooked before final judgments are made. Consider the following: One of the outcome criteria for a patient with a pacemaker is, "The patient or significant other is able to take a pulse. " A retrospective nursing audit was done on patients with pacemakers to determine whether the outcome was being met. On nursing Unit A, 95 per cent of the patients could take their pulse, whereas on nursing Unit C, only 65 per cent of the patient data revealed that, in general, patients on Unit C were older, had fewer significant others, and were frequently discharged to extended care facilities. Comparing the two units on these factors provided insights into reasons for their differences that ma y have been missed if the evaluator had not questioned these differences. ### Step 5: Identify Possible Courses of Action After identifying the strengths and weaknesses, possible courses of action to correct the weaknesses are developed. The goal of the action plan is elimination of the weaknesses and reinforcement of the strengths [of the existing programme. Some c](http://www.pdfcomplete.com/cms/hppl/tabid/108/Default.aspx?r=q8b3uige22)onsideration should be given to how [best to motivate the nursing staf f](http://www.pdfcomplete.com/cms/hppl/tabid/108/Default.aspx?r=q8b3uige22) to implement the desired changes. Generally the best results will be obtained when those staff most affected by the quality assurance review is involved in the planning of subsequent courses of action. ### Step 6: Select a Course of Action ### Step 7: Take Action ### Step 8: Reevaluate 3.6 Methods of Nursing Assessment --------------------------------- ### 3.6.1 Incident Reports ### 3.6.2 Nursing Audit The nursing audit is a method of evaluating the quality of client care. The purpose of the nursing audit is to examine nursing care that has been given to clients and to verify that acceptable standards are being met. The audit is conducted during or after care has been provided and is a method of accounting for outcomes achieved. Aud its are usuall y based on the assumption that when expected client outcomes are achieved, nursing process criteria are also met. The nursing audit team compares predetermined criteria with the documentation found in the patient record. **Types of Nursing Audit** There are two types of audit: retrospective and concurrent. #### The Concurrent Audit **This** has also been called the open chart audit, because it occurs while a client is receiving care in a health care facility. A concurrent audit is a critical examination of the patient‟s progress toward a desired health status (outcome) and patient care management activities (processes) while the care is in progress. The purpose of the concurrent audit is to assess the past and present care given to a client. This type of audit can provide information to care givers that may alter a particular client‟s care plan. Patient questionnaires, interviews, and observation and review of the patient record are possible sources of data for a concurrent review. Concurrent review has the advantage of providing opportunities for making changes in the ongoing care programme. #### Retrospective Audits #### Nursing Audit Team 1. Head of Nursing Research Unit or Continuing Education Unit -- Chairman. 2. Representatives from all cadres of nurses -- members. 3. A represent ative of the professional Nursing Association -- member. 4. Representatives of other hospital professionals e.g. Medical Record Officers/Librarian -- Consultants. 5. Director of Nursing Services -- Ex-officio member. can at the same time deliver quality patient care, which is its reason for existence. ### 3.6.4 Peer Review Nursing peer review occurs when nurses establish standards and criteria and evaluate the quality of patient care among themselves. The peer review process may be performed within a single unit or by specialty, for examp le, orthopedic nurses. Clinical nurse specialists also frequently have a peer review group to monitor their practice. ### 3.5.5 Patient Satisfaction Questionnaire A patient satisfaction questionnaire is generally used when written data regarding a patient‟s perceptions of his or her hospitalization are needed, for example, by hospital management or a nurse researcher. Man y hospitals routinely distribute these questionnaires to all patients and request that they complete them. Other hospitals have patient ombudsmen who visit patients, question them regarding their hospitalisation experience, answer any questions they may have, and intervene on their behalf, if necessary. ### 3.5.6 Staff Satisfaction Surveys Staff satisfaction surveys, either questionnaires or interviews, are used by the administration to assess general employee satisfaction or to test responses to certain program changes. ### 3.5.7 Utilisation Review The utilisation review programme was mandated by the JCAH in 1978. Its primary goal is the appropriate allocation of hospital resources. This programme does not focus primarily on nursing, but it does provide data that may require nursing involvement in a more thorough evaluation. ### 3.5.8 Infection Control Reports Because nurses are involved in the direct care of patients, they may at times be included in infection surveillance and infection control programs. Even when the nursing staff is not involved directly, the y should be familiar with the monthly report of nosocomial infections on their respective unit. Questions can be raised about nursing procedures and practices that may affect the infection rate on the unit. [3.7](http://www.pdfcomplete.com/cms/hppl/tabid/108/Default.aspx?r=q8b3uige22) [The Role of the Nurse](http://www.pdfcomplete.com/cms/hppl/tabid/108/Default.aspx?r=q8b3uige22) in Rendering Quality Nursing [Care](http://www.pdfcomplete.com/cms/hppl/tabid/108/Default.aspx?r=q8b3uige22) -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ### 1. Provision of Therapeutic Ward Milieu ### 2. Staffing ### 3. Delegation of Responsibility ### 4. Leadership Style ### [5.](http://www.pdfcomplete.com/cms/hppl/tabid/108/Default.aspx?r=q8b3uige22) [Discipline/Co](http://www.pdfcomplete.com/cms/hppl/tabid/108/Default.aspx?r=q8b3uige22) ntrol Quality nursing care demands that the nurse should have a good control of staff and the activities in the unit/ward/ hospital. He/she should be able to evaluate both the activities and the staff. Do the nursing actions meet the objectives? Monitoring the staff to ensure that jobs are performed according to specification. Thus the nurse needs to be firm, just, knowledgeable and hardworking in order to ensure a good control of the subordinates. ### 6. Staff Development Knowledge update is a key to provision of quality nursing care. The nurse should take advantage of opportunities for continuing education programme through continuing training, reading of professional journals, financial, political and international literature. The nurse in- charge arranges or sponsors subordinates for conferences, seminars and courses. ### 7. Motivation This is a process of ensuring that the best is obtained at all times from every worker. The need to motivate subordinates for quality nursing care to patients cannot be over emphasised. Different things motivate different workers. The nurse must be conversant with different theories of motivation such as satisfaction theory, incentive theory, intrinsic theory, Hertzberg‟s dual-factor theory, McClelland three factor theories, Theory X and Y etc. In addition, the nurse must be ready to give appropriate reward to ensure high productivity from his subordinates through recognition of good performance. ### 8. The use of the nursing process It is through the use of Nursing Process that nurses can render quality nursing care. It is through this that nursing assessment can be made to identify patients need, pl an and implement appropriate nursing activities to take care of identified need, and then evaluate the nursing action implemented to ensure the achievement of good goals earlier formulated. To provide adequate nu rsing care the nurse must ensure full implementation of nursing process in rendering care at his unit/ward/hospital. She should use her position to cover the constraints that may militate against the provision of logistic support.