3 Quality ImprovementDefinitionQuality: is defined as the process of a target degree ofexcellence of nursing intervention then taking steps toensure that each pt. received the agreed upon level ofperformance.It is the process of establishing desirable standards ofnursing care & then planning & providing the type of carethat will meet those standardsQuality improvement process involves: (Q.I)1- Setting standards of care.2- Determining criteria.3- Evaluating how well the criteria have been met.4- Making plans for change based on the evaluation.5- Following up the implementation of change..
4 Aims of Q.I.- Measuring the quality of nursing care- Improving the quality of nursing care.These aims can be achieved by:1- Establishing professional standards of care.2-Concurrent audit i.e. evaluation of patient's care bydirect observation, (in hospital)3- Retrospective audit i.e. evaluation of patient's careafter discharge.
5 Auditing:• Definition: An audit is a systemic & official examination ofa record process - structure-environment or account to evaluateperformance.• Auditing provides managers with a means of applying thecontrol process to determine the quality of services offered.• Auditing can occur: retrospective – concurrent.• The audits must frequently used in quality include: structure,process and outcome audits.• Patient care audit is a control tool used to :- Improve the quality of care.- Teach staff how to establish nursing care priorities & to be ableto analyze problems.
6 Principles of QI:Collaboration of activities is needed to ensure theobjectives & activities of each health profession are enhanced nurses-physicians.2. Ensure that the resource expenditure (financial) for quality activities is appropriate.3. Successful & accurate of auditing patient care is the key to ensure quality pt's care.4. Effective monitoring of the nursing operationsdepends on receiving feedback from all ptsconcerning the nursing process elements.
7 5. Feedback to nurses is the aim of QI report in order to have good practice & correct performance.6. Quality assessment may perceive the need for changing theorganizational structure that supports the unit plans i.e.methods & strategy.7. Collection & analysis of quality data should be linked to thedecision making process.
8 Approaches to quality improvement: Nursing can be evaluated through (3) elements are:• Structure.• Process.• & outcome.Any improvement of one of these (3) elements leads tofavorable change in the other two elements.
9 1- Structural elements of nursing care: It includes:- Physical settings.- Hospital philosophy and objectives.- Equipments-resources.- Financial resources.
10 2- Process elements of nursing care It includes the steps of nursing process:- Performing physical examination (assessment).- Determine nursing care goals.- Writing nursing care plans.- Reporting and recording patient's care responses totreatment.
11 3- Outcome elements of nursing care: These are changes in patient's health status resultingform nursing care, it includes modifications of:- Sings and symptoms- Knowledge.- Patient's satisfaction & compliance with treatment.
12 The development of standards: • A standard is a predetermined level of excellence thatserves as a guide for practice.• Standards are predetermined, established by anauthority & communicated & accepted by the people .• Standards are used as measurement tools- they mustbe objective, measurable, and achievable.
13 • Each organization & profession must set standards and objectives to guide individual practice inperforming safe and effective care.• Organizational standards outline levels of acceptablepractice within the institution i.e. each organizationdevelops a policy and procedure manual that outlinesits specific standards – these standards of practiceallow the organization to measure more objectivelyunit and individual performance.
14 Developing quality improvement criteria: A criterion may be defined as: a descriptivestatement of performance - behavior. - Circumstances orclinical status that represents a satisfactory or excellentstate of care. It is an item that selected as relevantindicator of the quality of care.
15 Characteristics of criteria: When writing the criteria of pt's care, it should be:• Relevant to be specifically related to the objective of the practice.• Measurable: each criterion should include time frame of the activity and its frequency.• Clearly understandable and achievable.• Clinically reviewed periodically.• Reflective of all aspects of pt's care e.g. care elements → vital signs - dressings - discharge plan etc.
16 Importance of standards: • Obtaining means of clarifying what constitutes goodpractice.• Monitor care.• To assess level of service.• Enable nurses to describe in measurable the care they provide for patients - what is required to carry out that care and the expected outcome will be.
17 Steps in the quality improvement process: The quality improvement process is a structured series of steps designed to plan, evaluate, and propose changes for health care activities.1- Select a nursing activity for improvement:Quality improvement efforts need to be concentrated on nursing care changes that will have the greatest impact.-Nursing activity will be selected after investigating all elements of nursing care in order to improve nursing skills and procedures.
18 2- Assemble a multidisciplinary team: *The team members should represent a cross section of workers who are involved with the problem (e.g. nurses - physicians – pharmacists ...).*Team members need to be educated about their roles before starting the quality improvement process.*The group set boundaries for the identified activity & explained all the activity components.
19 3- Collect data to measure the current status of the activity:*The team collects data to determine the present statusof the activity (e.g. giving I.V medications).*A variety of statistical methods may be used to analyze& present this information.
20 1- After analyzing data, the team sets a goal for improvement. 4- Set a measurable standard for the activity:1- After analyzing data, the team sets a goal forimprovement.2- This goal involves a standard of practice& measurablecare outcome or indicator.3- Input from the clients is important for deciding thelevel of improvement needed.
21 5- Discuss various plans to meet the standard: The team discusses various strategies & plans to meet the newstandard on outcome.This outcome should be measurable result e.g. 90% of admittedpatients have initial nursing care plans.One plan is selected for implementation & the process of changebegins.Changing strategies emphasize open communication & educationof workers affected by the new standard and outcome.Polices and procedures may need to be reviewed or rewrittenduring the quality improvement process. Frequent review andupdating of polices is important.
22 6- Select and implement one plan to meet the standard: As the plan is implemented, the team continues to gather andevaluate data to document that the new standard is met.If the new standard is not met, revisions in the implementationplan are needed.The interdisciplinary team may need to meet periodically tohandle any new problem that develops with the implementationof any new process or procedure.
23 7- Evaluate the implementation of the plan and revise as needed:The focus of evaluation for quality improvement is on outcomes.The outcomes evaluated are: clinical care outcomes of the pt.,professional practice of the staff, and administrative system ofthe organization.The nurse manager has to reward or reinforce the success ofeach quality improvement team. She must also evaluate the workof the team and the ability of individual team members to worktogether effectively.
24 8- Giving feed back to staff: Feedback information could be about: nursing structure –Process or pt's outcomes.Feedback information could be oral or written form. Datashould be reported for correction of malpractice andachievements of high standard should be rewarded.Administrative support is needed for the qualityinformation to be communicated to different nursingcategories.
25 9- Remedying deficiencies: Most of these deficiencies are due to: lack of knowledgeand skills of staff. So, quality improvement programsshould be closely lied to the in-service educationprograms to provide remedial instructions.
26 Quality improvement tolls and techniques: 1-Logs: Is a simple and basic tool used to identify or follow eventsor uncommon problems.2-Check Sheets: Check sheets are tools used to mark the frequencyof events.3-Surveys/Questionnaires: are preplanned, written tools used toobtain responses to selected question from key people.4-Interviews: are guided approaches to obtaining verbal responsesto pre-established questions from an individual or small group.
27 5-Focus Groups: are meetings of individuals (usually a representative sample of consumers) brought together to providefeedback on a predetermined topic.6-Brain Storming: is a group activity used to identify the range orscope of problems or situations, reason underlying a situation. Itis effective approaches that stimulates and encourage creativity.7-Control Charts: it uses statistically determined upper and lowerlimits to define a range of acceptability.