Quality assurance

8 de Jun de 2016

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Quality assurance

  1. Mr. Harsh Raman
  2. TERMINOLOGIES • Quality: It is the degree to which a product confirms to specification and workmanship standards. (John D. McClellan) • Quality Management: It refers to a philosophy that defines a corporate culture emphasizing customer satisfaction, innovation and employee involvement.
  3. TERMINOLOGIES • Continuous Quality Improvement: It is an ongoing process of innovation, prevention of error, and staff development that is used by corporations and institutions that adopt the quality management philosophy.  Quality Assurance: Means of delivering relevant and effective product (medical care) in accordance with the standards.  Accreditation: The process of providing an official approval to an organization stating that it has achieved a required standard.
  4.  JCAHO: Joint Commission on Accreditation of Health care Organization is the primary accrediting organizing for health care institutions.  Standards: These are formal statements about how patients should be managed or services be delivered.  Audit: An independent review conducted to compare some aspect of quality performance with a standard for that performance.
  5. DEFINITION *“Quality assurance is defined as making sure that the services provided by hospital are the best possible in a given existing resources and current medical knowledge.”-WHO (1992) *“Quality assurance is a judgment concerning the process of care based on the extent to which that care contributes to valued outcomes.” -Donabedian 1982
  6. *“Quality assurance is a management system designed to give maximum guarantee and ensure confidence that the service provided is up to the given accepted level of quality, the standards prescribed for that service which is being achieved with a minimum of total expenditure.” -British Standards Institute * “CQI is an ongoing quality improvement measure using management and scientific methods of quality assurance involving data collection, its analysis, and formulating ways to improve performance outcome according to proposed standards.”
  7. OBJECTIVES  To successfully achieve sustained improvement in health care, clinics need to design processes to meet the needs of patients.  To design processes well, and systematically monitor, analyze, and improve their performance to improve patient outcomes.  A designed system should include standardized, predictable processes based on best practices.  Set Incremental goals as needed. NASA Ames Research Center Health Unit
  8. To provide technical assistance in designing and implementing effective strategies for monitoring quality To refine existing methods for ensuring optimal quality health care through an applied research programme (Decker, 1985 and Schroeder, 1984).
  9. PURPOSES/ NEED  Rising expectations of consumer of services.  Increasing pressure on allocation of funds.  The increasing complexity of health care organizations.  Improvement of job satisfaction.  Highly informed consumer  To prevent rising medical errors  Accreditation bodies  Reducing global boundaries.
  10. IMPORTANCE To prepare nursing personnel for implementing of quality assurance model in nursing. Introduce code of ethics and professional conduct for nurses in India.
  11. PRINCIPLES  QM operates most effectively within a flat, democratic and organizational structure.  Managers and workers must be committed to quality improvement.  The goal of QM is to improve systems and processes and not to assign blame.  Customers define quality.  Quality improvement focuses on outcome.  Decisions must be based on data.
  12. TYPES OF QUALITY ASSURANCE:- *External Quality Assurance:- Quality assurance can be evaluated by independent assessors or people from outside the institution/hospital. *Internal Quality Assurance:- Quality assurance can be evaluated by local assessors or senior person from the same institution/hospital.
  13. BARRIERS OF CONTINUOUS QUALITY IMPROVEMENT: 1. Difficult to foster collaboration between multiple stakeholders. 2. Difficult to identify which processes to prioritize improvement efforts. 3. Ill suited process management tooling. 4. Governing/controlling change 5. Lack of employee engagement
  14. SOLUTIONS OF THE QUALITY IMPROVEMENT: Individual problem solving Rapid team problem solving Systematic team problem solving Process improvement solving
  15. General approach • Credentialing • Licensure • Accreditation • Certification • Charter • Recognition • Academic degree Specific approach • Audit • Direct observation • Appropriateness evaluation • Peer review • Bench marking • Supervisory evaluation • Self-evaluation • Client satisfaction • Control committees • Services • Trajectory • Staging • Sentinel
  16. ELEMENTS/ COMPONENTS  According to Donabedian; Structure Element- The physical, financial and organizational resources provided for health care. Process Element- The activities of a health system or healthcare personnel in the provision of care. Outcome Element- A change in the patient’s current or future health that results from nursing interventions.
  17.  According to Manwell, Shaw, and Beurri, there are 3A’s and 3E’s; Access to healthcare Acceptability Appropriateness and relevance to need Effectiveness Efficiency Equity
  18. STANDARDS ‘Standards are written formal statements to describe how an organization or professional should deliver health service and are guidelines against which services can be assessed.’ Kirk and Hoesing (1991) stated that standards are needed to;  Provide direction  Reach agreement on expectations  Monitor and evaluate results  Guide organizations, people and patients to obtain optimal results.
  19.  AHRQ –Agency for Healthcare Research and Quality  IHI –Institute for Healthcare Improvement  JCAHO –Joint Commission on Accreditation of Healthcare Organizations  NAHQ –National Association for Healthcare Quality  IOM –Institute of Medicine  NCQA –National Committee for Quality Assurance
  20. Sources of Nursing Care Standards *Professional organisation, e.g. Associations, TNAI, *Licensing bodies, e.g. Statutory bodies, INC, * Institutions/health care agencies, e.g. University Hospitals, Health Centres. *Department of institutions, e.g. Department of Nursing. * Patient care units, e.g. specific patients' unit. *Government units at National, State and Local Government units. * Individual e.g. personal standards
  21. LIST OF NURSING STANDARDS:- Normative and Empirical Ends and Means Structure,Process and Outcome
  22. LIST OF NURSING STANDARDS (Acc to ANA):- Quality of Practice Education Professional Practice evaluation Collegiality Ethics Collaboration Research Resource utilization Leadership
  23. Areas of QA Outpatient department Emergency medical services In- patient services Specialty services Training
  24. MODELS 1. Donabedian Model (1985):
  25. 2. ANA Model: This first proposed and accepted model of quality assurance was given by Long & Black in 1975. This helps in the self- determination of patient and family, nursing health orientation, patient’s right to quality care and nursing contributions. Identify structure , standard and criteria Apply the process, standards and criteria Evaluate outcome of standards and criteriaoutcome structure process
  26. 3. Quality Health Outcome Model: The uniqueness of this model proposed by Mitchell & Co is the point that there are dynamic relationships with indicators that not only act upon, but also reciprocally affect the various components. System (Individual, Group/ organization) Intervention Outcome Client (Individual, Family & Community)
  27. 4. Plan, Do, Study, Act cycle: It is an improvement model advocated by Dr. Deming. A Plan is developed to test one of the improvement changes. During the Do phase, the change is made, and data are collected to evaluate the results. Study involves analysis of the data collected in the previous step. Data are evaluated for evidence that an improvement has been made. The Act step involves taking actions that will ‘hardwire’ the change so that the gains made by the improvement are sustained over time.
  28. 5. Six Sigma: It refers to six standard deviations from the mean and is generally used in quality improvement to define the number of acceptable defects or errors produced by a process. *It consists of 5 steps: define, measure, analyze, improve and control (DMAIC). Define: Questions are asked about key customer requirements and key processes to support those requirements. Measure: Key processes are identified and data are collected. Analyze: Data are converted to information; Causes of process variation are identified. Improve: This stage generates solutions and make and measures process changes. Control: Processes that are performing in a predictable way at a desirable level are in control.
  29. *WILSON’S MODEL:- Wilson 1987 in the late 1980’s tried to operationalize Donabedian model into a tangible and practical form. He redefined it as inputs, methods or procedures and outcomes. He described inputs as personnel, equipment and environment. Methods as procedures became the everyday practice and the outcome are the targets of care or services as measured by productivity, quality and client satisfaction.
  30. MARKER’S UMBRELLA MODEL:- This is a system for providing continuity, consistency and competency in clinical patient care. The goal is to provide the above by developing a structure to standardize professional nursing clinical practice. The model describes connecting the characteristics for a comprehensive quality assurance model are: *Standard development. *Continuous advanced training. *Confirmation of technical authority. *Evaluation of execution of cares measures *Examination *Risk management *Control of demand resources *Active problem identification.
  31. QUALITY TOOLS UDSED FOR CQI chart audits failure mode and effect analysis: prospective view root cause analysis: retrospective view flow diagrams pareto diagram histograms run charts control charts
  32. INDICATORS OF QUALITY ASSURANCE Waiting time for different services in the hospital Medical errors in judgment, diagnosis, laboratory reporting, medical treatment or surgical procedures, etc. Hospital infections including hospital- acquired infections, cross infections. Quality of services in key areas like blood bank, laboratories, X- ray department, central sterilization services, pharmacy and nursing.
  33. Identify needs. Assemble a multidisciplinary team. Collect data. Establish measurable outcomes and quality indicators. Select and implement a plan. Evaluate implementation of plan and achievement of outcomes. QUALITY IMPROVEMENT PROCESS- STEPS
  34. JCAHO quality assurance guidelines/steps: 1. Assign responsibility 2. Delineate scope of care and services 3. Identify important aspects of care and services 4. Identify indicators of outcome (no less than 2; no more than 4) 5. Establish thresholds for evaluation 6. Collect data 7. Evaluate data 8. Take action 9. Assess action taken 10. Communicate
  35. FACTORS AFFECTING QUALITY ASSURANCE IN NURING CARE -Lack of resources Personnel problems Unreasonable Patients and attendants Improper maintenance Absence of well informed populance Absence of accreditation laws Inspect hospitals and ensure that basic requirements are met. Lack of incident review procedures Delayed attendance by physician/nurse Lack of good hospital information system Absence of conducting patient satisfaction surveys Lack of nursing care records Miscellaneous
  36. FUNCTIONS OF NURSE IN QUALITY ASSURANCE *Encourage team member to be actively involved in quality process. *Implement quality control and improvement *Communicates standards of care too team members *Assess appropriate source of information *Evaluate quality and activity *Assist in the planning and organization of quality assurance program *Assist in developing annual auditing scheduled *Attend and participate in workshop and seminar *Develop and implement plan and action to correct deficiencies.
  37. NEW TRENDS IN QUALITY ASSURANCE PROGRAME Quality Council Standard of care Concurrent monitoring Interdisci- plinary quality assurance Performan- ce appraisal Performa- nce appraisal
  38. *Quality assurance practices in Europe: a survey of molecular genetic testing laboratories. *In the 2000s, a number of initiatives were taken internationally to improve quality in genetic testing services. To contribute to and update the limited literature available related to this topic, we surveyed 910 human molecular genetic testing laboratories,of which 291 (32%) from 29 European countries responded. The majority of laboratories were in the public sector (81%),affiliated with a university hospital (60%). Only a minority of laboratories was accredited (23%), and 26% was certified. A total of 22% of laboratories did not participate in external quality assessment (EQA) and 28% did not use reference materials (RMs). The main motivations given for accreditation were to improve laboratory profile (85%) and national recognition (84%).
  39. *Quality assurance practices in Europe: a survey of molecular genetic testing laboratories. *Nearly all respondents (95%) would prefer working in an accredited laboratory. In accredited laboratories, participation in EQA (Po0.0001), use of RMs (P¼0.0014) and availability of continuous education (CE) on medical/scientific subjects (P¼0.023), specific tasks (P¼0.0018), and quality assurance (Po0.0001) were significantly higher than in non-accredited laboratories. *we showed that accredited laboratories (average score 92) comply better than certified laboratories (average score 69, Po0.001), and certified laboratories better than other laboratories (average score 44, Po0.001), with regard to the implementation of quality indicators. *We conclude that quality practices vary widely in European genetic testing laboratories. This leads to a potentially dangerous situation in which the quality of genetic testing is not consistently assured.