Quality Improvement Prepeared By Dr: Manal Moussa

Quality Improvement Definition Quality: is defined as the process of a target degree of excellence of nursing intervention then taking steps to ensure that each pt. received the agreed upon level of performance. It is the process of establishing desirable standards of nursing care & then planning & providing the type of care that will meet those standards Quality 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..

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 by direct observation, (in hospital) 3- Retrospective audit i.e. evaluation of patient's care after discharge.

Auditing: • Definition: An audit is a systemic & official examination of a record process - structure-environment or account to evaluate performance. • Auditing provides managers with a means of applying the control 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 able to analyze problems.

Principles of QI: Collaboration of activities is needed to ensure the objectives & 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 operations depends on receiving feedback from all pts concerning the nursing process elements.

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 the organizational structure that supports the unit plans i.e. methods & strategy. 7. Collection & analysis of quality data should be linked to the decision making process.

Approaches to quality improvement: Nursing can be evaluated through (3) elements are: • Structure. • Process. • & outcome. Any improvement of one of these (3) elements leads to favorable change in the other two elements.

1- Structural elements of nursing care: It includes: - Physical settings. - Hospital philosophy and objectives. - Equipments-resources. - Financial resources.

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 to treatment.

3- Outcome elements of nursing care: These are changes in patient's health status resulting form nursing care, it includes modifications of: - Sings and symptoms - Knowledge. - Patient's satisfaction & compliance with treatment.

The development of standards: • A standard is a predetermined level of excellence that serves as a guide for practice. • Standards are predetermined, established by an authority & communicated & accepted by the people . • Standards are used as measurement tools- they must be objective, measurable, and achievable.

• Each organization & profession must set standards and objectives to guide individual practice in performing safe and effective care. • Organizational standards outline levels of acceptable practice within the institution i.e. each organization develops a policy and procedure manual that outlines its specific standards – these standards of practice allow the organization to measure more objectively unit and individual performance.

Developing quality improvement criteria: A criterion may be defined as: a descriptive statement of performance - behavior. - Circumstances or clinical status that represents a satisfactory or excellent state of care. It is an item that selected as relevant indicator of the quality of care.

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.

Importance of standards: • Obtaining means of clarifying what constitutes good practice. • 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.

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.

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.

3- Collect data to measure the current status of the activity: *The team collects data to determine the present status of the activity (e.g. giving I.V medications). *A variety of statistical methods may be used to analyze & present this information.

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 for improvement. 2- This goal involves a standard of practice& measurable care outcome or indicator. 3- Input from the clients is important for deciding the level of improvement needed.

5- Discuss various plans to meet the standard: The team discusses various strategies & plans to meet the new standard on outcome. This outcome should be measurable result e.g. 90% of admitted patients have initial nursing care plans. One plan is selected for implementation & the process of change begins. Changing strategies emphasize open communication & education of workers affected by the new standard and outcome. Polices and procedures may need to be reviewed or rewritten during the quality improvement process. Frequent review and updating of polices is important.

6- Select and implement one plan to meet the standard: As the plan is implemented, the team continues to gather and evaluate data to document that the new standard is met. If the new standard is not met, revisions in the implementation plan are needed. The interdisciplinary team may need to meet periodically to handle any new problem that develops with the implementation of any new process or procedure.

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 of the organization. The nurse manager has to reward or reinforce the success of each quality improvement team. She must also evaluate the work of the team and the ability of individual team members to work together effectively.

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. Data should be reported for correction of malpractice and achievements of high standard should be rewarded. Administrative support is needed for the quality information to be communicated to different nursing categories.

9- Remedying deficiencies: Most of these deficiencies are due to: lack of knowledge and skills of staff. So, quality improvement programs should be closely lied to the in-service education programs to provide remedial instructions.

Quality improvement tolls and techniques: 1-Logs: Is a simple and basic tool used to identify or follow events or uncommon problems. 2-Check Sheets: Check sheets are tools used to mark the frequency of events. 3-Surveys/Questionnaires: are preplanned, written tools used to obtain responses to selected question from key people. 4-Interviews: are guided approaches to obtaining verbal responses to pre-established questions from an individual or small group.

5-Focus Groups: are meetings of individuals (usually a representative sample of consumers) brought together to provide feedback on a predetermined topic. 6-Brain Storming: is a group activity used to identify the range or scope of problems or situations, reason underlying a situation. It is effective approaches that stimulates and encourage creativity. 7-Control Charts: it uses statistically determined upper and lower limits to define a range of acceptability.