Quality Health Care Reviewer
Content
QUALITY HEALTH CARE AND NURSING The Patient’s Bill of Rights 1. The patient has the right to considerate and respectful care irrespective of socio-economic status. 2. The patient has the right to obtain from his physician complete current information concerning his diagnosis, treatment and prognosis in terms the patient can reasonably be expected to understand. When it is not medically advisable to give such information to the patient, the information should be made available to an appropriate person in his behalf. H has the right to know by name or in person, the medical team responsible in coordinating his care. 3. The patient has the right to receive from his physician information necessary to give informed consent prior to the start of any procedure and/or treatment. Except in emergencies, such information for informed consent should include but not necessarily limited to the specific procedure and or treatment, the medically significant risks involved, and the probable duration of incapacitation. When medically significant alternatives for care or treatment exist, or when the patient requests information concerning medical alternatives, the patient has the right to such information. The patient has also the right to know the name of the person responsible for the procedure and/or treatment. 4. The patient has the right to refuse treatment/life – giving measures, to the extent permitted by law, and to be informed of the medical consequences of his action. 5. The patient has the right to every consideration of his privacy concerning his own medical care program. Case discussion, consultation, examination and treatment are confidential and should be conducted discreetly. Those not directly involved in his care must have the permission of the patient to be present. 6. The patient has the right to expect that all communications and records pertaining to his care should be treated as confidential. 7. The patient has the right that within its capacity, a hospital must make reasonable response to the request of patient for services. The hospital must provide evaluation, service and/or referral as indicated by the urgency of care. When medically permissible a patient may be transferred to another facility only after he has received complete information concerning the needs and alternatives to such transfer. The institution to which the patient is to be transferred must first have accepted the patient for transfer. 8. The patient has the right to obtain information as to any relationship of the hospital to other health care and educational institutions in so far as his care is concerned. The patient has the right to obtain as to the existence of any professional relationship among individuals, by name who are treating him. 9. The patient has the right to be advised if the hospital proposes to engage in or perform human experimentation affecting his care or treatment. The patient has the right to refuse or participate in such research project. 10. The patient has the right to expect reasonable continuity of care; he has the right to know in advance what appointment times the physicians are available and where. The patient has the right to expect that the hospital will provide a mechanism whereby he is informed by his physician or a delegate of the physician of the patient’s continuing health care requirements following discharge. 11. The patient has the right to examine and receive an explanation of his bill regardless of source of payment. 12. The patient has the right to know what hospital rules and regulation apply to his conduct as a patient.
A. Quality Standards For Health Provider Organizations 1. Patient Rights and Organizational Ethics STANDARDS • Respect and support for patients’ rights and responsibilities • Opportunities for patients’ involvement in care provision • Confidentiality and security of patients’ information and communication • Feedback to patients • Staff code of ethics • Resolution of ethical issues Goal: To improve patient outcomes by respecting patients’ rights and ethically relating with patients and other organizations. 2. Patient Care Standards ACCESS STANDARDS • Information about services • Access to services Goal: The organization is accessible to the community that it aims to serve. ENTRY STANDARDS • Prompt and timely attention • Efficient triaging • Unique patient identification • Informed consent • Planning for discharge and continuing care Goal: The entry processes meet patient needs and are supported by effective systems and a suitable environment. ASSESSMENT STANDARDS • Physical, psychological, social assessment • Coordinated assessment by professionals • Regular assessments • Proper documentation of assessments • Appropriate diagnostics • Special needs assessments Goal: Comprehensive assessment of every patient enables the planning and delivery of patient care. CARE PLANNING STANDARDS • Relevant to patients’ needs • Evidence-based care plan • Clear and accessible information on care Goal: The health care team develops in partnership with the patients a coordinated plan of care with goals. IMPLEMENTATION OF CARE STANDARDS • Timely, safe, appropriate and coordinated care delivery • Respect for patients’ needs and rights • Coordinated care delivery among professional • Patient education • Standardized drug administration • Standardized treatment procedures • Appropriate care for patients with special needs Goal: Care is delivered to ensure the best possible outcomes for the patient.
EVALUATION OF CARE STANDARDS • Analysis of process and outcomes data • Actions for improvement activities Goal: The health care team routinely and systematically evaluates and improves the effectiveness and efficiency of care delivered to patients. 3. Leadership and Management THE MANAGEMENT TEAM STANDARDS • Leadership • Effective working relationships • Committee meetings • Management performance assessment • Policies and procedures for operations Goal: The organization is effectively and efficiently governed and managed according to its values and goals to ensure that care produces the desired health outcomes, and is responsive to patients’ and community needs. EXTERNAL SERVICES STANDARDS Goal: The organization ensures that services provided by external contractors meet appropriate standards. 4. Human Resource Management HUMAN RESOURCES PLANNING STANDARDS • HR needs assessment • Workload monitoring Goal: The organization provides the right number and mix of competent staff to meet the needs of its internal and external customers and to achieve its goals. STAFF RECRUITMENT, SELECTION, APPOINTMENT AND RESPONSIBILITIES STANDARDS • Procedures • Job descriptions • Staff accountabilities • Service provision by appropriate staff Goal: Recruitment, selection and appointment of staff comply with statutory requirements and are consistent with the organization’s human resource policies. STAFF TRAINING & DEVELOPMENT STANDARDS • Orientation, training and development programs • Supervision Goal: A comprehensive program of staff training and development meets individual and organizational needs. Information Management 5. Information Management DATA COLLECTION, AGGREGATION AND USE STANDARDS • Timely and efficient data collection • Standardized information • Detailed medical charts • Coding and indexing of data Goal: Collection and aggregation of data are done for patient care, management of services, education and research. RECORDS MANAGEMENT STANDARD • Accessible records of data are done for patient care, management of services, education and
Goal: Integrity, safety, access and security of records are maintained and statutory requirements are met. 6. Safe Practice and Environment PATIENT AND STAFF SAFETY STANDARDS • Plan of safe and effective environment of care • Provision of safe and effective environment of care • Routine evaluation of environment of care Goal: Patients, staff and other individuals within the organization are provided a safe, functional and effective environment of care. MAINTENANCE OF THE ENVIRONMENT OF CARE STANDARDS • Emergency light, power supply, water and ventilation • Regular maintenance of facilities and equipment • Maintenance of equipment by qualified personnel • Current information on products is available Goal: A comprehensive maintenance program ensures a clean and safe environment. INFECTION CONTROL STANDARDS • Infection control program • Risk reduction of nosocomial infection • Standardized cleaning and sterilization procedures • Internal and external reporting Goal: Risks of acquisition and transmission of infections among patients, employees, physicians and other personnel, visitors and trainees are identified and reduced. EQUIPMENT & SUPPLIES STANDARDS • Planning and acquisition of equipment and supplies • Specialized equipment operated by qualified staff • Safe reuse guidelines Goal: The provision of equipment and supplies supports the organization’s role. ENERGY & WASTE MANAGEMENT STANDARDS • Standardized waste handling and disposal program • Implementation of a waste disposal program demo Goal: The organization demonstrates its commitment to environmental issues by considering and implementing strategies to achieve environmental sustainability. 7. Improving Performance STANDARDS • Organization-wide approach • Collaboration in new processes of care • Management responsibility • Service unit and staff responsibility • Evaluation of quality improvement program • Better service and care • Confidentiality of data Goal: The organization continuously and systematically improves its performance by invariably doing the right thing the right way the first time and meeting the needs of its internal and external clients. B. Rationale and Steps for Performance Improvement Performance Improvement (PI) - is a method for analyzing performance problems and setting up systems to
ensure good performance.
Performance - refers to the way people do their jobs and the results of their work.
Factors That Affect Performance Certain factors need to be in place for workers to be able to perform well on their jobs: 1. Clear job expectations 2. Clear and immediate performance feedback 3. Adequate physical environment, including proper tools, supplies and workspace 4. Motivation and incentives to perform as expected 5. Skills and knowledge required for the job. The PI Process Framework The following graphic illustrates the typical PI process:
Stage 1: Consider constitutional context. The goal of this stage is to have the PI facilitator and team members understand the institutional and cultural context of the organization you are working with. Stage 2: Obtain and maintain stakeholder agreement The goal is to involve key decision-makers in a transparent and participatory process that results in agreements about: The stakeholder group The expected outcomes of the process Next steps in the process. Stage 3: Define desired performance Desired performance statements may contain any of the following measures: Quality, or how well the performance meets a specification or standard. Quantity, or how much of the performance should occur. Time, or when performance should occur. Cost, or how much material or labor is used to produce a given performance. Stage 4: Describe actual performance
Possible sources of performance data include clinic records, ministry of health statistics, and previous projects and studies completed in the same area. The data gathered for this stage will serve as the baseline for determining the effectiveness of the interventions. Stage 5: Describe performance gaps These gaps always refer to the difference between desired and actual performance for the performance in question. Stage 6: Find root causes There are two advantages in anchoring root causes to performance factors: (a) Interventions become clear and more focused; (b) The root causes closest to the performer and his or her work environment are identified. Stage 7: Select and design interventions The goal of this stage is to select interventions that will close the performance gaps identified during the previous stages. The design team should include, at a minimum: Intervention specialist(s) The key client Other client representatives Representatives of the groups targeted for the intervention. Stage 8: Implement interventions The outputs of this stage are: The intervention team list A written record of intervention arrangements made with cooperating agencies An implementation plan Interim reports on milestone achievements reflecting measures of intervention effectiveness Completed interventions. Stage 9: Evaluation The outputs of this stage are: The results data The evaluation report. C. TQM Program Implementation Steps Total Quality Management (TQM) - is a structured system for meeting and exceeding customer needs and expectations by creating organization-wide participation in the planning and implementation of breakthrough and continuous improvement processes. It integrates with the business plan of the organization and can positively influence customer satisfaction. William Edwards Deming (1900–1993) – was an American statistician, professor, author, lecturer, and consultant. From 1950 onwards he taught top management how to improve design and service, product quality, testing and through various methods, including the application of statistical methods. A core concept in implementing TQM is Deming’s 14 points, a set of management practices to help companies increase their quality and productivity:
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.
Create constancy of purpose for improving products and services. Adopt the new philosophy. Cease dependence on inspection to achieve quality. End the practice of awarding business on price alone; instead, minimize total cost by working with a single supplier. Improve constantly and forever every process for planning, production and service. Institute training on the job. Adopt and institute leadership. Drive out fear. Break down barriers between staff areas. Eliminate slogans, exhortations and targets for the workforce. Eliminate numerical quotas for the workforce and numerical goals for management. Remove barriers that rob people of pride of workmanship, and eliminate the annual rating or merit system. Institute a vigorous program of education and self-improvement for everyone. Put everybody in the company to work accomplishing the transformation.
D. The Documentation – Evaluation – Action Trend Documentation - the proper, systematic and permanent recording of information - an organized way of documenting data as per time place, circumstances, and attribution Safety in documentation In documentation, safety is to provide care for the client and to yourself by means of recording all the assessments, planning, actions, and the interventions you’ve done with the client. Consistency of purpose Recording all the assessment, planning, implementation, and other procedures done with the client, from the diagnosis to prognosis.
Standardization Using the standard way of recording all the data gathered for the patient’s care and all the procedures done to him/her.
Improvement Assessing whether the client’s condition has improved with all the interventions done to him/her to meet your goal. Evaluation This Performance Evaluation links the expectations of professional staff to actual performance. The principal objective of the evaluation is to assist in professional development by identifying strengths and areas for improvement. Evaluations enable management to asses an individual’s job performance and determine appropriate promotion opportunities and compensation.
Action - is the concept of measuring the output of a particular process or procedure, then modifying the process or procedure to increase the output, increase efficiency, or increase the effectiveness of the process or procedure. 1. Identify which employees need to improve their performance and why. 2. Create an assessment tool, such as a rating system for a list of job duties that you can use for all employees who perform the same role. 3. Schedule a time to speak with employees about the expectations associated with their jobs. 4. Be prepared to discuss potential solutions to the problem(s) you have addressed. 5. Create an action plan for improvement. 6. Schedule a follow-up meeting to review performance issues and identify areas of improvement as well as areas that still need work.
E. The Plan-Do-Check-Act (PDCA) Cycle
The Plan-Do-Check-Act (PDCA) cycle - is an organized and disciplined approach to problem solving. A tool which uses brainpower and rational thinking, it is an important element for assuring continuous improvement. When to use PDCA cycle: o As a model for continuous improvement. o When starting a new improvement project. o When developing a new or improved design of a process, product or service. o When defining a repetitive work process. o When planning data collection and analysis in order to verify and prioritize problems or root causes. o When implementing any change.
PDCA or Deming Cycle
F. Quality Improvement Tools 1. Problem Identification Tools Affinity diagram - is a tool that gathers ideas, opinions, and issues and organizes them into groupings based on their natural relationships.
Steps to create the Affinity Diagram: 1. Organize a brainstorming meeting involving a group of individuals who are committed to resolving issues based on logic and patterns. 2. Record individual ideas on sticky notes or cards. At this stage, the ideas are only collated and not categorized. 3. Group ideas based on pattern similarities. If some ideas appear to belong to more than one pattern group, create another group. A team consensus is imperative to ratify the individual groups where the ideas are placed. 4. Create an identity or a name for each certified group and write an appropriate description which describes exactly what the group refers to. The identity or name is placed on the top of each group. 5. During a brainstorming session, discuss the themes or individual groups, and try to determine patterns or relationships among these individual groups. 6. Ensure that a consensus is arrived at, and that the categorization of the groups is well understood. In case there are some doubts about validity, reiterate through the above steps as required until there is an agreement on the established groupings.
Brainstorming - is a popular tool that helps you generate creative solutions to a problem.
To run a group brainstorming session effectively, do the following: 1. Find a comfortable meeting environment, and set it up ready for the session. 2. Appoint one person to record the ideas that come from the session. These should be noted in a format than everyone can see and refer to. 3. Use exercise or ice breaker before starting. 4. Define the problem you want to be solved. 5. Let all give their ideas, making sure that you give everyone a fair opportunity to contribute. 6. Encourage an enthusiastic, uncritical attitude among members of the group. 7. Ensure that no one criticizes or evaluates ideas during the session. 8. In a long session, take plenty of breaks so that people can continue to concentrate.
Flowchart - Is a visual representation of the sequence of the content of your product it is also a picture of the separate steps of a process in sequential order.
Production Flowchart Checklist: 1. All major elements of the project are indicated. 2. The elements are clearly labeled. 3. Sequence of elements is clear and there are no gaps or dead ends. 4. Sequence of elements is logical from user's point of view. 5. Flowchart symbols are used correctly.
Nominal Group Technique (NGT) - a possible alternative to brain storming is Nominal Group Technique (NGT), more-controlled variant of brainstorming used in problem solving sessions to encourage creative thinking, without group interaction at idea-generation stage
The steps to follow in NGT are: 1. Divide the people present into small groups of 5 or 6 members, preferably seated around a table. 2. State an open-ended question 3. Have each Person spend several minutes in silence individually brainstorming all the possible ideas and jot these ideas down.
4. Have the groups, collect the ideas by sharing them round robin fashion (one response per person each time), 5. Have each person evaluate the ideas and individually and anonymously vote for the best ones 6. Share votes within the group and tabulate. 7. Allow time for brief group presentations on their solutions. 2. Problem Description Tools Bar Chart or Bar Graph - is a chart with rectangular bars with lengths proportional to the values that they represent. The bars can be plotted vertically or horizontally. - It is very useful if you are trying to record certain information whether it is continuous or not continuous data. Bar charts also look a lot like a histogram. They are often mistaken for each other.
Check Sheet - a structured, prepared form for collecting and analyzing data. When to Use a Check Sheet When data can be observed and collected repeatedly by the same person or at the same location. When collecting data on the frequency or patterns of events, problems, defects, defect location, defect causes, etc. When collecting data from a production process.
Force Field Analysis - is a useful technique for looking at all the forces for and against a decision. In effect, it is a specialized method of weighing pros and cons.
Line Graph - is useful for showing trends or changes over a period of time. It shows the relationship between two parameters.
Pareto Chart - named after Vilfredo Pareto, is a type of chart that contains both bars and a line graph, where individual values are represented in descending order by bars, and the cumulative total is represented by the line. Vilfredo Federico Damaso Pareto (1848 –1923) - was an Italian engineer, sociologist, economist, political scientist and philosopher. He made several important contributions to economics, particularly in the study of income distribution and in the analysis of individuals' choices.
Pie Chart or Circle Graph - is a circular chart divided into sectors, illustrating proportion.
3. Problem Analysis Tools Fishbone Diagram - a useful way of mapping the inputs that effect quality is the Cause & Effect Diagram; also known as the Fishbone or Ishikawa Diagram. It is also a useful technique for opening up thinking in problem solving. Basic steps in constructing a fishbone diagram: 1. Draw the fishbone diagram.... 2. List the problem/issue to be studied in the "head of the fish". 3. Label each ""bone" of the "fish". 4. Use an idea-generating technique (e.g., brainstorming) to identify the factors within each category that may be affecting the problem/issue and/or effect being studied. The team should ask "What are the machines issues affecting/causing..."
5. Repeat this procedure with each factor under the category to produce sub-factors. Continue asking, "Why is this happening?" and put additional segments each factor and subsequently under each sub-factor. 6. Continue until you no longer get useful information as you ask, "Why is that happening?" 7. Analyze the results of the fishbone after team members agree that an adequate amount of detail has been provided under each major category. Do this by looking for those items that appear in more than one category. These become the 'most likely causes". 8. For those items identified as the "most likely causes", the team should reach consensus on listing those items in priority order with the first item being the most probable" cause.
Matrix Diagram - an analysis tool that facilitates the systematic analysis of the strengths of relationships between two or more sets of elements. - it can be used in almost all types of decision making that involves several options or alternatives, or is affected by several factors. Examples of these include: 1) equal distribution of major and minor assignments among members of a given project; 2) selection of a process, equipment, or material for a given purpose; 3) identifying the most critical factors affecting a given problem area; 4) matching of tasks to objectives, etc.
Scatter-Plot Diagram - a tool for determining the potential correlation between two different sets of variables. - this diagram simply plots pairs of corresponding data from two variables, which are usually two variables in a process being studied. - it does not determine the exact relationship between the two variables, but it does indicate whether they are correlated or not.
4. Solution Development Tools Prioritization Matrix - is a useful technique you can use with your team members or with your users to achieve consensus about an issue. The Matrix helps you rank problems or issues (usually generated through brainstorming) by a particular criterion that is important to your organization.
Process –Decision Program Chart (PDPC) - systematically identifies what might go wrong in a plan under development. Countermeasures are developed to prevent or offset those problems. By using PDPC, you can either revise the plan to avoid the problems or be ready with the best response when a problem occurs. When to use: Before implementing a plan, especially when the plan is large and complex. When the plan must be completed on schedule. When the price of failure is high.
Tree Diagram - is a graphic organizer used to list all possibilities of a sequence of events in a systematic way. Tree diagrams are one method for calculating the total number of outcomes in a sample space.
5. Quality Monitoring Tools Control Chart - are used to routinely monitor quality. Two types of control chart: 1. Unvariate control chart - is a graphical display of one quality characteristic. 2. Multivariate control chart - is a graphical display of a statistic that summarizes or represents more than one quality characteristic.
Histogram - is a graphical representation, showing a visual impression of the distribution of data.
Radar Chart - is a graphical method of displaying multivariate data in the form of a twodimensional chart of three or more quantitative variables represented on axes starting from the same point.
G. Quality Circles and Quality Teams Quality Circle - A participatory management technique that enlists the help of employees in solving problems related to their own jobs.
H. Quality Improvement Activities Clinical Pathways - also known as “Critical Pathways” are acre management plans for patients with a given diagnosis or condition. Follow Path - are typically generated and used by facilities that deliver care for similar conditions to many patients. A Multidisciplinary committee of clinicians at the facility usually develops clinical pathways. The overall goals are to: Establish a standard approach to care for all providers in the facility. Establish roles for various members of the health care team. Provide a framework for collecting data on patient’s outcomes. Tried and True Pathways are based on evidenced from reliable sources, such as benchmarks, research and guidelines. The committee gathers and uses information from peer-reviewed literature and experts outside the faculty. Outlines and Timelines Clinical Pathways usually outline the duties of all professionals involved with patient care. They follow specific timelines for indicated actions. They also specify expected outcomes, which serve as checkpoints for the patient’s progress and care giver’s performance. Nursing Audit Audit – means the examination or review of records. Retrospective Audit – is the evaluation of the client’s record after discharge from an agency. Retrospective – relating to the past events. Concurrent Audit – is the evaluation of the client’s healthcare while the client is still receiving care from agency. These evaluations use interviewing, direct observation of nursing care, and review of clinical records to determine whether specific evaluate criteria has been met. Peer review – another type of evaluation of care. In nurse peer review, nurses functioning in the same capacity, that is, peers appraise the quality of care or practiced performed by other equally qualified nurses. 2 types of peer reviews: Individual audits - focuses on the performance of an individual nurse. Nursing audit – focusing on evaluating nursing care through the review of records. Utilization reviews Utilization reviews consists of examining trends and proposing advantageous disposition of recourses . Example: Clients who have had a fractured hip repaired have equivalent outcomes at lesser cost if transpired from the hospital to a skilled nursing facility. Both internal and external stakeholders in health care organizations need to know that the services and the activities of the organization have positive results. Once standards, pathways, key indicators, and other vital data have been identified and described. Quality is considered a process and not an end point.
A. Quality Standards For Health Provider Organizations 1. Patient Rights and Organizational Ethics STANDARDS • Respect and support for patients’ rights and responsibilities • Opportunities for patients’ involvement in care provision • Confidentiality and security of patients’ information and communication • Feedback to patients • Staff code of ethics • Resolution of ethical issues Goal: To improve patient outcomes by respecting patients’ rights and ethically relating with patients and other organizations. 2. Patient Care Standards ACCESS STANDARDS • Information about services • Access to services Goal: The organization is accessible to the community that it aims to serve. ENTRY STANDARDS • Prompt and timely attention • Efficient triaging • Unique patient identification • Informed consent • Planning for discharge and continuing care Goal: The entry processes meet patient needs and are supported by effective systems and a suitable environment. ASSESSMENT STANDARDS • Physical, psychological, social assessment • Coordinated assessment by professionals • Regular assessments • Proper documentation of assessments • Appropriate diagnostics • Special needs assessments Goal: Comprehensive assessment of every patient enables the planning and delivery of patient care. CARE PLANNING STANDARDS • Relevant to patients’ needs • Evidence-based care plan • Clear and accessible information on care Goal: The health care team develops in partnership with the patients a coordinated plan of care with goals. IMPLEMENTATION OF CARE STANDARDS • Timely, safe, appropriate and coordinated care delivery • Respect for patients’ needs and rights • Coordinated care delivery among professional • Patient education • Standardized drug administration • Standardized treatment procedures • Appropriate care for patients with special needs Goal: Care is delivered to ensure the best possible outcomes for the patient.
EVALUATION OF CARE STANDARDS • Analysis of process and outcomes data • Actions for improvement activities Goal: The health care team routinely and systematically evaluates and improves the effectiveness and efficiency of care delivered to patients. 3. Leadership and Management THE MANAGEMENT TEAM STANDARDS • Leadership • Effective working relationships • Committee meetings • Management performance assessment • Policies and procedures for operations Goal: The organization is effectively and efficiently governed and managed according to its values and goals to ensure that care produces the desired health outcomes, and is responsive to patients’ and community needs. EXTERNAL SERVICES STANDARDS Goal: The organization ensures that services provided by external contractors meet appropriate standards. 4. Human Resource Management HUMAN RESOURCES PLANNING STANDARDS • HR needs assessment • Workload monitoring Goal: The organization provides the right number and mix of competent staff to meet the needs of its internal and external customers and to achieve its goals. STAFF RECRUITMENT, SELECTION, APPOINTMENT AND RESPONSIBILITIES STANDARDS • Procedures • Job descriptions • Staff accountabilities • Service provision by appropriate staff Goal: Recruitment, selection and appointment of staff comply with statutory requirements and are consistent with the organization’s human resource policies. STAFF TRAINING & DEVELOPMENT STANDARDS • Orientation, training and development programs • Supervision Goal: A comprehensive program of staff training and development meets individual and organizational needs. Information Management 5. Information Management DATA COLLECTION, AGGREGATION AND USE STANDARDS • Timely and efficient data collection • Standardized information • Detailed medical charts • Coding and indexing of data Goal: Collection and aggregation of data are done for patient care, management of services, education and research. RECORDS MANAGEMENT STANDARD • Accessible records of data are done for patient care, management of services, education and
Goal: Integrity, safety, access and security of records are maintained and statutory requirements are met. 6. Safe Practice and Environment PATIENT AND STAFF SAFETY STANDARDS • Plan of safe and effective environment of care • Provision of safe and effective environment of care • Routine evaluation of environment of care Goal: Patients, staff and other individuals within the organization are provided a safe, functional and effective environment of care. MAINTENANCE OF THE ENVIRONMENT OF CARE STANDARDS • Emergency light, power supply, water and ventilation • Regular maintenance of facilities and equipment • Maintenance of equipment by qualified personnel • Current information on products is available Goal: A comprehensive maintenance program ensures a clean and safe environment. INFECTION CONTROL STANDARDS • Infection control program • Risk reduction of nosocomial infection • Standardized cleaning and sterilization procedures • Internal and external reporting Goal: Risks of acquisition and transmission of infections among patients, employees, physicians and other personnel, visitors and trainees are identified and reduced. EQUIPMENT & SUPPLIES STANDARDS • Planning and acquisition of equipment and supplies • Specialized equipment operated by qualified staff • Safe reuse guidelines Goal: The provision of equipment and supplies supports the organization’s role. ENERGY & WASTE MANAGEMENT STANDARDS • Standardized waste handling and disposal program • Implementation of a waste disposal program demo Goal: The organization demonstrates its commitment to environmental issues by considering and implementing strategies to achieve environmental sustainability. 7. Improving Performance STANDARDS • Organization-wide approach • Collaboration in new processes of care • Management responsibility • Service unit and staff responsibility • Evaluation of quality improvement program • Better service and care • Confidentiality of data Goal: The organization continuously and systematically improves its performance by invariably doing the right thing the right way the first time and meeting the needs of its internal and external clients. B. Rationale and Steps for Performance Improvement Performance Improvement (PI) - is a method for analyzing performance problems and setting up systems to
ensure good performance.
Performance - refers to the way people do their jobs and the results of their work.
Factors That Affect Performance Certain factors need to be in place for workers to be able to perform well on their jobs: 1. Clear job expectations 2. Clear and immediate performance feedback 3. Adequate physical environment, including proper tools, supplies and workspace 4. Motivation and incentives to perform as expected 5. Skills and knowledge required for the job. The PI Process Framework The following graphic illustrates the typical PI process:
Stage 1: Consider constitutional context. The goal of this stage is to have the PI facilitator and team members understand the institutional and cultural context of the organization you are working with. Stage 2: Obtain and maintain stakeholder agreement The goal is to involve key decision-makers in a transparent and participatory process that results in agreements about: The stakeholder group The expected outcomes of the process Next steps in the process. Stage 3: Define desired performance Desired performance statements may contain any of the following measures: Quality, or how well the performance meets a specification or standard. Quantity, or how much of the performance should occur. Time, or when performance should occur. Cost, or how much material or labor is used to produce a given performance. Stage 4: Describe actual performance
Possible sources of performance data include clinic records, ministry of health statistics, and previous projects and studies completed in the same area. The data gathered for this stage will serve as the baseline for determining the effectiveness of the interventions. Stage 5: Describe performance gaps These gaps always refer to the difference between desired and actual performance for the performance in question. Stage 6: Find root causes There are two advantages in anchoring root causes to performance factors: (a) Interventions become clear and more focused; (b) The root causes closest to the performer and his or her work environment are identified. Stage 7: Select and design interventions The goal of this stage is to select interventions that will close the performance gaps identified during the previous stages. The design team should include, at a minimum: Intervention specialist(s) The key client Other client representatives Representatives of the groups targeted for the intervention. Stage 8: Implement interventions The outputs of this stage are: The intervention team list A written record of intervention arrangements made with cooperating agencies An implementation plan Interim reports on milestone achievements reflecting measures of intervention effectiveness Completed interventions. Stage 9: Evaluation The outputs of this stage are: The results data The evaluation report. C. TQM Program Implementation Steps Total Quality Management (TQM) - is a structured system for meeting and exceeding customer needs and expectations by creating organization-wide participation in the planning and implementation of breakthrough and continuous improvement processes. It integrates with the business plan of the organization and can positively influence customer satisfaction. William Edwards Deming (1900–1993) – was an American statistician, professor, author, lecturer, and consultant. From 1950 onwards he taught top management how to improve design and service, product quality, testing and through various methods, including the application of statistical methods. A core concept in implementing TQM is Deming’s 14 points, a set of management practices to help companies increase their quality and productivity:
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.
Create constancy of purpose for improving products and services. Adopt the new philosophy. Cease dependence on inspection to achieve quality. End the practice of awarding business on price alone; instead, minimize total cost by working with a single supplier. Improve constantly and forever every process for planning, production and service. Institute training on the job. Adopt and institute leadership. Drive out fear. Break down barriers between staff areas. Eliminate slogans, exhortations and targets for the workforce. Eliminate numerical quotas for the workforce and numerical goals for management. Remove barriers that rob people of pride of workmanship, and eliminate the annual rating or merit system. Institute a vigorous program of education and self-improvement for everyone. Put everybody in the company to work accomplishing the transformation.
D. The Documentation – Evaluation – Action Trend Documentation - the proper, systematic and permanent recording of information - an organized way of documenting data as per time place, circumstances, and attribution Safety in documentation In documentation, safety is to provide care for the client and to yourself by means of recording all the assessments, planning, actions, and the interventions you’ve done with the client. Consistency of purpose Recording all the assessment, planning, implementation, and other procedures done with the client, from the diagnosis to prognosis.
Standardization Using the standard way of recording all the data gathered for the patient’s care and all the procedures done to him/her.
Improvement Assessing whether the client’s condition has improved with all the interventions done to him/her to meet your goal. Evaluation This Performance Evaluation links the expectations of professional staff to actual performance. The principal objective of the evaluation is to assist in professional development by identifying strengths and areas for improvement. Evaluations enable management to asses an individual’s job performance and determine appropriate promotion opportunities and compensation.
Action - is the concept of measuring the output of a particular process or procedure, then modifying the process or procedure to increase the output, increase efficiency, or increase the effectiveness of the process or procedure. 1. Identify which employees need to improve their performance and why. 2. Create an assessment tool, such as a rating system for a list of job duties that you can use for all employees who perform the same role. 3. Schedule a time to speak with employees about the expectations associated with their jobs. 4. Be prepared to discuss potential solutions to the problem(s) you have addressed. 5. Create an action plan for improvement. 6. Schedule a follow-up meeting to review performance issues and identify areas of improvement as well as areas that still need work.
E. The Plan-Do-Check-Act (PDCA) Cycle
The Plan-Do-Check-Act (PDCA) cycle - is an organized and disciplined approach to problem solving. A tool which uses brainpower and rational thinking, it is an important element for assuring continuous improvement. When to use PDCA cycle: o As a model for continuous improvement. o When starting a new improvement project. o When developing a new or improved design of a process, product or service. o When defining a repetitive work process. o When planning data collection and analysis in order to verify and prioritize problems or root causes. o When implementing any change.
PDCA or Deming Cycle
F. Quality Improvement Tools 1. Problem Identification Tools Affinity diagram - is a tool that gathers ideas, opinions, and issues and organizes them into groupings based on their natural relationships.
Steps to create the Affinity Diagram: 1. Organize a brainstorming meeting involving a group of individuals who are committed to resolving issues based on logic and patterns. 2. Record individual ideas on sticky notes or cards. At this stage, the ideas are only collated and not categorized. 3. Group ideas based on pattern similarities. If some ideas appear to belong to more than one pattern group, create another group. A team consensus is imperative to ratify the individual groups where the ideas are placed. 4. Create an identity or a name for each certified group and write an appropriate description which describes exactly what the group refers to. The identity or name is placed on the top of each group. 5. During a brainstorming session, discuss the themes or individual groups, and try to determine patterns or relationships among these individual groups. 6. Ensure that a consensus is arrived at, and that the categorization of the groups is well understood. In case there are some doubts about validity, reiterate through the above steps as required until there is an agreement on the established groupings.
Brainstorming - is a popular tool that helps you generate creative solutions to a problem.
To run a group brainstorming session effectively, do the following: 1. Find a comfortable meeting environment, and set it up ready for the session. 2. Appoint one person to record the ideas that come from the session. These should be noted in a format than everyone can see and refer to. 3. Use exercise or ice breaker before starting. 4. Define the problem you want to be solved. 5. Let all give their ideas, making sure that you give everyone a fair opportunity to contribute. 6. Encourage an enthusiastic, uncritical attitude among members of the group. 7. Ensure that no one criticizes or evaluates ideas during the session. 8. In a long session, take plenty of breaks so that people can continue to concentrate.
Flowchart - Is a visual representation of the sequence of the content of your product it is also a picture of the separate steps of a process in sequential order.
Production Flowchart Checklist: 1. All major elements of the project are indicated. 2. The elements are clearly labeled. 3. Sequence of elements is clear and there are no gaps or dead ends. 4. Sequence of elements is logical from user's point of view. 5. Flowchart symbols are used correctly.
Nominal Group Technique (NGT) - a possible alternative to brain storming is Nominal Group Technique (NGT), more-controlled variant of brainstorming used in problem solving sessions to encourage creative thinking, without group interaction at idea-generation stage
The steps to follow in NGT are: 1. Divide the people present into small groups of 5 or 6 members, preferably seated around a table. 2. State an open-ended question 3. Have each Person spend several minutes in silence individually brainstorming all the possible ideas and jot these ideas down.
4. Have the groups, collect the ideas by sharing them round robin fashion (one response per person each time), 5. Have each person evaluate the ideas and individually and anonymously vote for the best ones 6. Share votes within the group and tabulate. 7. Allow time for brief group presentations on their solutions. 2. Problem Description Tools Bar Chart or Bar Graph - is a chart with rectangular bars with lengths proportional to the values that they represent. The bars can be plotted vertically or horizontally. - It is very useful if you are trying to record certain information whether it is continuous or not continuous data. Bar charts also look a lot like a histogram. They are often mistaken for each other.
Check Sheet - a structured, prepared form for collecting and analyzing data. When to Use a Check Sheet When data can be observed and collected repeatedly by the same person or at the same location. When collecting data on the frequency or patterns of events, problems, defects, defect location, defect causes, etc. When collecting data from a production process.
Force Field Analysis - is a useful technique for looking at all the forces for and against a decision. In effect, it is a specialized method of weighing pros and cons.
Line Graph - is useful for showing trends or changes over a period of time. It shows the relationship between two parameters.
Pareto Chart - named after Vilfredo Pareto, is a type of chart that contains both bars and a line graph, where individual values are represented in descending order by bars, and the cumulative total is represented by the line. Vilfredo Federico Damaso Pareto (1848 –1923) - was an Italian engineer, sociologist, economist, political scientist and philosopher. He made several important contributions to economics, particularly in the study of income distribution and in the analysis of individuals' choices.
Pie Chart or Circle Graph - is a circular chart divided into sectors, illustrating proportion.
3. Problem Analysis Tools Fishbone Diagram - a useful way of mapping the inputs that effect quality is the Cause & Effect Diagram; also known as the Fishbone or Ishikawa Diagram. It is also a useful technique for opening up thinking in problem solving. Basic steps in constructing a fishbone diagram: 1. Draw the fishbone diagram.... 2. List the problem/issue to be studied in the "head of the fish". 3. Label each ""bone" of the "fish". 4. Use an idea-generating technique (e.g., brainstorming) to identify the factors within each category that may be affecting the problem/issue and/or effect being studied. The team should ask "What are the machines issues affecting/causing..."
5. Repeat this procedure with each factor under the category to produce sub-factors. Continue asking, "Why is this happening?" and put additional segments each factor and subsequently under each sub-factor. 6. Continue until you no longer get useful information as you ask, "Why is that happening?" 7. Analyze the results of the fishbone after team members agree that an adequate amount of detail has been provided under each major category. Do this by looking for those items that appear in more than one category. These become the 'most likely causes". 8. For those items identified as the "most likely causes", the team should reach consensus on listing those items in priority order with the first item being the most probable" cause.
Matrix Diagram - an analysis tool that facilitates the systematic analysis of the strengths of relationships between two or more sets of elements. - it can be used in almost all types of decision making that involves several options or alternatives, or is affected by several factors. Examples of these include: 1) equal distribution of major and minor assignments among members of a given project; 2) selection of a process, equipment, or material for a given purpose; 3) identifying the most critical factors affecting a given problem area; 4) matching of tasks to objectives, etc.
Scatter-Plot Diagram - a tool for determining the potential correlation between two different sets of variables. - this diagram simply plots pairs of corresponding data from two variables, which are usually two variables in a process being studied. - it does not determine the exact relationship between the two variables, but it does indicate whether they are correlated or not.
4. Solution Development Tools Prioritization Matrix - is a useful technique you can use with your team members or with your users to achieve consensus about an issue. The Matrix helps you rank problems or issues (usually generated through brainstorming) by a particular criterion that is important to your organization.
Process –Decision Program Chart (PDPC) - systematically identifies what might go wrong in a plan under development. Countermeasures are developed to prevent or offset those problems. By using PDPC, you can either revise the plan to avoid the problems or be ready with the best response when a problem occurs. When to use: Before implementing a plan, especially when the plan is large and complex. When the plan must be completed on schedule. When the price of failure is high.
Tree Diagram - is a graphic organizer used to list all possibilities of a sequence of events in a systematic way. Tree diagrams are one method for calculating the total number of outcomes in a sample space.
5. Quality Monitoring Tools Control Chart - are used to routinely monitor quality. Two types of control chart: 1. Unvariate control chart - is a graphical display of one quality characteristic. 2. Multivariate control chart - is a graphical display of a statistic that summarizes or represents more than one quality characteristic.
Histogram - is a graphical representation, showing a visual impression of the distribution of data.
Radar Chart - is a graphical method of displaying multivariate data in the form of a twodimensional chart of three or more quantitative variables represented on axes starting from the same point.
G. Quality Circles and Quality Teams Quality Circle - A participatory management technique that enlists the help of employees in solving problems related to their own jobs.
H. Quality Improvement Activities Clinical Pathways - also known as “Critical Pathways” are acre management plans for patients with a given diagnosis or condition. Follow Path - are typically generated and used by facilities that deliver care for similar conditions to many patients. A Multidisciplinary committee of clinicians at the facility usually develops clinical pathways. The overall goals are to: Establish a standard approach to care for all providers in the facility. Establish roles for various members of the health care team. Provide a framework for collecting data on patient’s outcomes. Tried and True Pathways are based on evidenced from reliable sources, such as benchmarks, research and guidelines. The committee gathers and uses information from peer-reviewed literature and experts outside the faculty. Outlines and Timelines Clinical Pathways usually outline the duties of all professionals involved with patient care. They follow specific timelines for indicated actions. They also specify expected outcomes, which serve as checkpoints for the patient’s progress and care giver’s performance. Nursing Audit Audit – means the examination or review of records. Retrospective Audit – is the evaluation of the client’s record after discharge from an agency. Retrospective – relating to the past events. Concurrent Audit – is the evaluation of the client’s healthcare while the client is still receiving care from agency. These evaluations use interviewing, direct observation of nursing care, and review of clinical records to determine whether specific evaluate criteria has been met. Peer review – another type of evaluation of care. In nurse peer review, nurses functioning in the same capacity, that is, peers appraise the quality of care or practiced performed by other equally qualified nurses. 2 types of peer reviews: Individual audits - focuses on the performance of an individual nurse. Nursing audit – focusing on evaluating nursing care through the review of records. Utilization reviews Utilization reviews consists of examining trends and proposing advantageous disposition of recourses . Example: Clients who have had a fractured hip repaired have equivalent outcomes at lesser cost if transpired from the hospital to a skilled nursing facility. Both internal and external stakeholders in health care organizations need to know that the services and the activities of the organization have positive results. Once standards, pathways, key indicators, and other vital data have been identified and described. Quality is considered a process and not an end point.
