Total Quality Management

7/18/2019 Total Quality Management

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Total Quality Management (TQM) in Nursing Care

INTRODUCTION

Quality refers to excellence of a product or a service, including itsattractiveness, lack of defects, reliability, and long-term durability.

Quality assurance provides the mechanisms to eectively monitor patientcare provided by health care professionals using cost-eective resources

Nursing programmes of quality assurance are concerned with thequantitative assessment of nursing care as measured by proven standards of nursing practice.

Quality assurance system motivates nurses to strive for excellence indelivering quality care and to be more open and exible in experimentingwith innovative ways to change outmoded systems.

!lorence Nightingale introduced the concept of quality in nursing care in"#$$ while attending the soldiers in the hospital during the %rimean war.

CONCEPT OF QUALIT IN !EALT! CARE

Quality is de&ned as the extent of resemblance between the purpose ofhealthcare and the truly granted care '(onabedian ")#*+.

Quality assurance originated in manufacturing industry to ensure that theproduct consistently achieved customer satisfaction.

Quality assurance is a dynamic process through which nurses assumeaccountability for quality of care they provide.

t is a guarantee to the society that services provided by nurses are beingregulated by members of profession.

Quality assurance is a /udgment concerning the process of care, based onthe extent to which that cares contributes to valued outcomes. '(onabedian")#0+.

Quality assurance as the monitoring of the activities of client care to

determine the degree of excellence attained to the implementation of theactivities. '1ull, ")#$+

Quality assurance is the de&ning of nursing practice through well writtennursing standards and the use of those standards as a basis for evaluationon improvement of client care '2aker "))#+.

PRO"RAMME APPROAC!E# FOR A QUALIT A##URANCE

3wo ma/or categories of approaches exist in quality assurance they are

A$ "eneral A%%roa&'

t involves large governing of o4cial body5s evaluation of a persons oragency5s ability to meet established criteria or standards at a given time.



"+ %redentialing

formal recognition of professional or technical competence and attainment of minimum standards by a person or agency

%redentialing process has four functional components

a+ 3o produce a quality product

b+ 3o confer a unique identity

c+ 3o protect provider and public

d+ 3o control the profession.

0+ 6icensure

ndividual licensure is a contract between the profession and the state, inwhich the profession is granted control over entry into and exists from theprofession and over quality of professional practice.

3he licensing process requires that regulations be written to de&ne thescopes and limits of the professional5s practice.

6icensure of nurses has been mandated throughout the world by laws andregulations..

7+ 8ccreditation

9:

;%

N81<

8ccrediation %anada

N88%

=+ %erti&cation

%erti&cation is usually a voluntary process with in the profession.8 person5s educational achievements, experience and performance onexamination are used to determine the person5s quali&cations for functioningin an identi&ed specialty area.

$ #%e&i& a%%roa&'es

"+ >eer review

>eer review is divided in to two types.

3he recipients of health services by means of auditing the quality of services

rendered.

3he health professional evaluating the quality of individual performance.

0+ 9tandard as a device for quality assurance



9tandard is a pre-determined baseline condition or level of excellence thatcomprises a model to be followed and practiced. 3he 8N8 standard forpractice include?

9tandard "? 3he collection of data about health status of the patient issystematic and continuous. 3he data are accessible, communicative, andrecorded.

9tandard 0? Nursing diagnosis are derived from health status data.

9tandard 7? 3he plan of nursing care includes goals derived from the nursingdiagnoses.

9tandard =? 3he plan of nursing care includes priorities and the prescribednursing approaches or measures to achieve the goals derived from thenursing diagnoses.

9tandard $? Nursing actions provide for patient participation in healthpromotion, maintenance, and restoration.

9tandard *? Nursing actions assist the patient to maximi@e his healthcapabilities.

9tandard A? 3he patient5s progress or lack of progress towards goalachievement is determined by the patient and the nurse.

9tandard #? 3he patient5s progress or lack of progress towards goalachievement directs re-assessment, re-ordering of priorities, new goalsetting, and a revision of the plan of nursing care.

7+ 8udit as a tool for quality assurance

Nursing audit may be de&ned as a detailed review and evaluation of selectedclinical records in order to evaluate the quality of nursing care andperformance by comparing it with accepted standards.

MODEL# OF QUALIT A##URANCE

". 9ystem 2odel

3asks are broken down into manageable components based on de&nedob/ectives.

3he basic components of the system are

". nput

0. 3hroughput

7. :utput

=. !eedback

3he input can be compared to the present state of systems, the throughput

to the developmental process and output to the &nished product. 3hefeedback is the essential component of the system because it maintains andnourishes the growth.

0+ 8N8 Quality 8ssurance 2odel

3he basic components of the 8N8 model are?



dentify values B dentify structure, process and outcome standards andcriteria

9elect measurementB 2ake interpretation B dentify course of action

%hoose action B3ake action B Ce-evaluate

"+ dentify Dalue

n the 8N8 value identi&cation looks as such issue as patientEclient, philosophy,needs and rights from an economic, social, psychology and spiritual perspectiveand values, philosophy of the health care organi@ation and the providers ofnursing services.

0+ dentify structure, process and outcome standards and criteria?

denti&cation of standards and criteria for quality assurance begins withwriting of philosophy and ob/ective of organi@ation.

3he philosophy and ob/ectives of an agency serves to de&ne the structuralstandards of the agency.

9tandards of structure are de&ned by licensing or accrediting agency.

Fvaluation of the standards of structure is done by a group internal orexternal to the agency.

3he evaluation of process standards is a more speci&c appraisal of thequality of care being given by agency care providers.

7+ 9elect measurement needed to determine degree of attainment of criteriaand standards

2easurements are those tools used to gather information or data,determined by the selections of standards and criteria.

3he approaches and techniques used to evaluate structural standards andcriteria are, nursing audit, utili@ation5s reviews, review of agency documents,self studies and review of physicals facilities.

3he approaches and techniques for the evaluation of process standards andcriteria are peer review, client satisfactions surveys, direct observations,questionnaires, interviews, written audits and videotapes.

3he evaluation approaches for outcome standards and criteria includeresearch studies, client satisfaction surveys, client classi&cation, admission,readmission, discharge data and morbidity data.

=+ 2ake interpretations

3he degree to which the predetermined criteria are met is the basis for

interpretation about the strengths and weaknesses of the program.

3he rate of compliance is compared against the expected level of criteriaaccomplishment.

$+ dentify %ourse of 8ction



f the compliance level is above the normal or the expected level, there isgreat value in conveying positive feedback and reinforcement

. f the compliance level is below the expected level, it is essential to improvethe situations.

t is necessary to identify the cause of de&ciency. 3hen, it is important toidentify various solutions to the problems.

*+ %hoose action

Gsually various alternative course of action are available to remedy ade&ciency.

3hus it is vital to weigh the pros and cons of each alternative whileconsidering the environm and the availability of resources.

A+ 3ake 8ction

t is important to &rmly establish accountability for the action to be taken.

3his step then concludes with the actual implementation of the proposedcourses of action.

#+ Ceevaluate

3he &nal step of Q8 process involves an evaluation of the results of theaction.

3he reassessment is accomplished in the same way as the originalassessment and begins the Q8 cycle again.

%areful interpretation is essential to determine whether the course of actionhas improves the de&ciency, positive reinforcement is oered to those whoparticipated and the decision is made about when to again evaluate thataspect of care.

QUALIT A##URANCE PROCE##

Fstablishment of standards or criteria

dentify the information relevant to criteria

(etermine ways to collect information

%ollect and analy@e the information

%ompare collected information with established criteria

2ake a /udgment about quality

>rovide information and if necessary, take corrective action regarding&ndings of appropriate sources

(etermine ways to collect the information

FACTOR# AFFECTIN" QUALIT A##URANCE IN NUR#IN"CARE

*) 6ack of Cesources



nsu4cient resources, infrastructures, equipment, consumables, money forrecurring expenses and sta make it possible for output of a certain qualityto be turned out under the prevailing circumstances.

+) >ersonnel problems

6ack of trained, skilled and motivated employees, sta indiscipline aectsthe quality of care.

,) mproper maintenance

1uildings and equipments require proper maintenance for e4cient use. f notmaintained properly the equipments cannot be used in giving nursing care.

3o minimi@e equipment down time it is necessary to ensure adequate aftersale service and service manuals.

-) Gnreasonable >atients and 8ttendants

llness, anxiety, absence of immediate response to treatment, unreasonableand unco-operative attitude that in turn aects the quality of care in nursing.

.) 8bsence of well informed population

3o improve quality of nursing care, it is necessary that the people becomeknowledgeable and assert their rights to quality care.

3his can be achieved through continuous educational program.

/) A0sen&e o1 a&&re2itation la3s

3here is no organi@ation empowered by legislation to lay down standards innursing and medical care so as to regulate the quality of care. t requires alegislation that provides for setting of a stationary accreditation E vigilanceauthority to?

a+ nspect hospitals and ensures that basic requirements are met.

b+ Fnquire into ma/or incidence of negligence

c+ 3ake actions against health professionals involved in malpractice

4) 6ack of incident review procedures

(uring a patients hospitali@ations reveal incidents may occur which have abearing on the treatment and the patients &nal recovery. 3hese criticalincidents may be?

a+ (elayed attendance by nurses, surgeon, physician

b+ ncorrect medication

c+ 1urns arising out of faulty procedures

d+ (eath in a corridor with no nurse E physician accompanying the patient

etc.

5) 6ack of good and hospital information system

8 good management information system is essential for theappraisal of quality of care.

a+ Horkload, admissions, procedures and length of stay



b+ 8ctivity audit and scheduling of procedures.

6) 8bsence of patient satisfaction surveys

8scertainment of patient satisfaction at &xed points on an ongoing basis.9uch surveys carried out through questionnaires, interviews to by social

worker, consultant groups, and help to document patient satisfaction withrespect to variables that are

a+ (elay in attendance by nurses and doctors.

b+ ncidents of incorrect treatment

*7) La&8 o1 nursing &are re&or2s

Nursing care records are perhaps the most useful source of information on

quality of care rendered. 3he records.

a+ (etail the patient condition

b+ (ocument all signi&cant interaction between patient and the nursingpersonnel.

c+ %ontain information regarding response to treatment

d+ <ave the dates in an easily accessible form.

**+ 2iscellaneous factors

a. 6ack of good supervision

b. 8bsence of knowledge about philosophy of nursing care

c. 6ack of policy and administrative manuals.

d. 9ubstandard education and training

e. 6ack of evaluation technique

f. 6ack of written /ob description and /ob speci&cations

g. 6ack of in-service and continuing educational program

FRAMEWORKS FOR QUALITY ASSURANCE:

". 2axwell '")#=+

2axwell recogni@ed that, in a society where resources are limited, selfassessment by health care professionals is not satisfactory in demonstratingthe e4ciency or eectiveness of a service. 3he dimensions of quality heproposed are?

8ccess to service E Celevance to need E Fectiveness E Fquity E 9ocial

acceptanceF4ciency and economy

0. Hilson '")#A+

Hilson considers there to be four essential components to a Q8 programme. 3hese are?



9etting ob/ectives E Quality promotion E 8ctivity monitoring E >erformanceassessment

7. 6ang '")A*+

3his framework has subsequently been adopted and developed by the 8N8.

3he stages includesB

dentify and agree values

Ceview literature, Inown Q8>

8naly@e available programmes

(etermine most appropriate Q8>

Fstablish structure, plans, outcome criteria and standards

Catify standards and criteriaFvaluate current levels of nursing practice against rati&ed structures

dentify and analy@e factors contributing to results

9elect appropriate actions to maintain or improve care

mplement selected actions

Fvaluate Q8:

#TA"E# OF T!E DE9ELOPMENT OF INTERNATIONAL

#TANDARD#

8n nternational 9tandard is the result of an agreement between the memberbodies of 9:. t may be used as such, or may be implemented throughincorporation in national standards of dierent countries.

nternational 9tandards are developed by 9: technical committees '3%+ andsubcommittees '9%+ by a six-step process?

9tage "? >roposal stage

3he &rst step in the development of an nternational 9tandard is to con&rmthat a particular nternational 9tandard is needed. 8 new work item proposal'N>+ is submitted for vote by the members of the relevant 3% or 9% todetermine the inclusion of the work item in the programme of work.

3he proposal is accepted if a ma/ority of the >-members of the 3%E9% votes infavour and if at least &ve >-members declare their commitment toparticipate actively in the pro/ect. 8t this stage a pro/ect leader responsiblefor the work item is normally appointed.

9tage 0? >reparatory stage

Gsually, a working group of experts, the chairman 'convener+ of which is thepro/ect leader, is set up by the 3%E9% for the preparation of a working draft.9uccessive working drafts may be considered until the working group issatis&ed that it has developed the best technical solution to the problembeing addressed. 8t this stage, the draft is forwarded to the working groupJsparent committee for the consensus-building phase.



9tage 7? %ommittee stage

8s soon as a &rst committee draft is available, it is registered by the 9:%entral 9ecretariat. t is distributed for comment and, if required, voting, bythe >-members of the 3%E9%. 9uccessive committee drafts may beconsidered until consensus is reached on the technical content

:nce consensus has been attained, the text is &nali@ed for submission as adraft nternational 9tandard '(9+.

9tage =? Fnquiry stage

3he draft nternational 9tandard '(9+ is circulated to all 9: member bodiesby the 9: %entral 9ecretariat for voting and comment within a period of &vemonths. t is approved for submission as a &nal draft nternational 9tandard'!(9+ if a two-thirds ma/ority of the >-members of the 3%E9% are in favourand not more than one-quarter of the total number of votes cast are

negative. f the approval criteria are not met, the text is returned to theoriginating 3%E9% for further study and a revised document will again becirculated for voting and comment as a draft nternational 9tandard.

9tage $? 8pproval stage

3he &nal draft nternational 9tandard '!(9+ is circulated to all 9: memberbodies by the 9: %entral 9ecretariat for a &nal KesENo vote within a period of two months. f technical comments are received during this period, they areno longer considered at this stage, but registered for consideration during afuture revision of the nternational 9tandard. 3he text is approved as annternational 9tandard if a two-thirds ma/ority of the >-members of the 3%E9%

is in favour and not more than one-quarter of the total number of votes castare negative. f these approval criteria are not met, the standard is referredback to the originating 3%E9% for reconsideration in light of the technicalreasons submitted in support of the negative votes received.

9tage *? >ublication stage

:nce a &nal draft nternational 9tandard has been approved, only minoreditorial changes, if and where necessary, are introduced into the &nal text. 3he &nal text is sent to the 9: %entral 9ecretariat which publishes thenternational 9tandard.

IMPACT OF I#O IN A LOCAL !O#PITAL:

Positi;e im%a&ts:

Nurses are accountable for their actions and, professionally, we haveresponsibility to evaluate the eectiveness of our care

Nurses can deliver a high standard of care, and being empowered to identifyand resolve problems can add to personal satisfaction with work

(ocuments state clearly how the health service should perform and what thepatient can expect

Luaranteeing standards of care to the public must be a duty of all those whowork within the health service



Nurses are actively involve in audit, service reviews, standard-setting andcustomer relations

mproves the overall quality of nursing care

mproves all types of documentation and communication

<elps in professional growth

Negati;e im%a&ts:

6ack of adequate resources

6ack of trained, skilled and motivated employees, sta indiscipline aectsthe quality of care.

9: activities may overburden the nursing personnel

Nurses will not get adequate time to spent with the patient, most of the timemay be spending for recording and reporting

3he hospital will be restricted only to 9: standards

<ospital has to provide special training for all the stas those who areinvolved in 9: inspection

8ll types of services will be under the control of 9:

IMPACT OF I#O IN A LOCAL NUR#IN" EDUCATIONALIN#TITUTION#:

Positi;e im%a&ts:

mproves the quality of nursing education

improves the quality of nursing practice

<elps to maintain international standard

<elps to compare the standard with another institution

<elps in personnel development of teachers

<elps to maintain all the records in time

8voids malpractice and bias

Fncourages extra-curricular activities also

8ct as a control for all the activities

mproves professional growth

Negati;e im%a&ts:

Lives more importance to documentation

:ver-burden for the teachers

3eachers need to take special training in maintaining the standards

Not observing the actual practice



:rgani@ational philosophy and policies has to be modi&ed according to the9: standards

CRITICAL ANAL#I#:

9trengths? 9: helps to improve and maintain the quality of educationalinstitutions and hospitals

Heakness? 9tandards are set by the institution itself, it may be biased

:pportunities? <elps in professional growth

3hreats? :rgani@ational philosophy and policies may not be considered

CONCLU#ION

3o ensure quality nursing care within the contemporary health care system,mechanisms for monitoring and evaluating care are under scrutiny. 8s the

level of knowledge increases for a profession, the demand for accountabilityfor its services likewise increases. ndividuals within the profession mustassume responsibility for their professional actions and be answerable to therecipients for their care. 8s profession become more interdependent, itappears that the power base will become more balanced, allowing individualpractitioners to demonstrate their competence and expertise. Qualityassurance programme will helps to improve the quality of nursing care andprofessional development.

Do&umentation and record keeping are important to ensure

accountability,

facilitate coordination of care between providers and for service

improvement.

<owever, the importance of documentation and record keeping may be

overlookedEovershadowed by the focus on direct services to clients. 8s such,proper

documentation and record keeping may be neglected

T'e 1ollo3ing se&tion provides three reasons why it is important to

document

and maintain proper records?

+$* Continuity o1 &are$ Cecords provide a case history and a more holistic

picture in order to follow-up on services or try dierent approaches to

assist the client. 3his is especially for clients with long-term or complex



needs, or who require multiple services. 8ccurate and up-to-date

recording is important especially when there is an emergency and the

sta-in-charge is not available 'due to illness, vacation, resignation,

etc.+. Lood records and documentation will facilitate communication

between service providers to ensure coordinated, rather than fragmented,

service.

+$+ A&&ounta0ility$ t is important to be able to provide relevant client

information at any given time and the organisation5s response to their

needs. 3he information may be needed to respond to queries from

stakeholders, who may include the client5s family, funders, donors or the

courts. :ne important source of information is the client records.

(ocumentation forms the nature of the professional relationship with the

client. nformation on problems encountered and the agency5s response

would assist in the event of a crisis or investigations.

+$, #er;i&e im%ro;ement$ Hell-documented records can also lead to

improved services to the clients by helping the sta organise hisEher

thoughts. 8ggregated client information can also facilitate service*

planning, service development and service reviews. 3he information

can also form primary data to conduct evidence-based research.

7 <aving established the importance of documentation and record keepingas

essential elements of professional practice and service to clients, %hapters 0and 7

will provide guidelines and best practices of documentation respectively.%hapter =

will elaborate on record-keeping and %hapter $ will highlight the importanceof

having good records for service improvement.

9ummary

Re&or2<8ee%ing an2 2o&umentation are im%ortant

%ro&esses t'at1a&ilitates:

Continuity o1 &are

A&&ounta0ility



#er;i&e im%ro;ement

Process Evaluation

Overview

Building process evaluation activities into programme implementation and using the results of

these activities to conduct continuous quality improvement is perhaps one of the most important

yet overlooked strategies in public health practice. This section provides information on how to

design a process evaluation that will inform and improve programme implementation. Details on

types of tools and assessments that can be used, and examples of indicators specific to ND

evaluations will be provided. !" will be used as an example to illustrate a broad range of

process activities including those used across a variety of settings including school settings, work

places, health care settings and the community at large. Drawing from field experiences, the

challenges of collecting process data in diverse settings will be addressed and potential solutions

provided.

#rocess evaluation may occur with or without outcome evaluation and may include a

combination of qualitative and quantitative data collection strategies. "owever, if resources,

time and feasibility are a road block to conducting a full evaluation study, it is highly

recommended that a good process evaluation study be incorporated.

Process Evaluation Questions

The types of questions asked when designing a process evaluation are different from those asked

in outcome evaluation. The questions underlying process evaluation focus on how well

interventions are being implemented. Typical questions asked include, but are not limited to$

• What intervention activities are taking place?

• Who is conducting the intervention activities?

• Who is being reached through the intervention activities?

• What inputs or resources have been allocated or mobilized for programme

implementation?

• What are possible programme strengths, weaknesses, and areas that need improvement?

Process Evaluation Strategies

Both qualitative and quantitative research methods %mixed method& are used in process

evaluation. !t is often the richness of qualitative methods that provides the more detailed, in'

depth, language, context and relationship between ideas that best informs programme process.

The following list presents the possible strategies to use to collect process level information$



o Interviews where open ended questions regarding feelings, knowledge, opinions,

experiences, perceptions are used and data recorded

o Focus groups

o Forums and discussion groups

o In-depth interviews using key informant or other community members( semi'

structured and structured

o Delphi method using expert opinion and reiteration

o Observations from fieldwork descriptions of activities

o

Case Studies

o Ethnographic studies that are enmeshed and of long duration

Document review of

written materials from organi)ations including$

o clinical files

o

programme records

o correspondence

o publications and reports

o diaries

o photographs

* good process evaluation plan will include a number of indicators that can be linked to programme and service inputs and programme and service outputs. +xamples of service inputs

!nclude$

o #articipants$ number, health status

o ueuing$ wait time, number waiting

o The locale where services are provided %e.g. rural, urban&

o +conomic status and racial-ethnic background of those receiving services

o uality of services

o !ntervention delivery$ quantity, fidelity to plan



+xamples of service outputs include$

• nits of service$ quantity, type

• /ervice completion$ quantity, type

• !ntervention$ dosage received, satisfaction

PLAN

Establish the objectives and processes necessary to deliver results in accordance with the expected

output (the target or goals). By establishing output expectations the co!pleteness and accuracy o" the

speci"ication is also a part o" the targeted i!prove!ent.



#$

%!ple!ent the plan execute the process !a&e the product. 'ollect data "or charting and analysis in the

"ollowing 'E'*+ and A',+ steps.

'E'*

-tudy the actual results (!easured and collected in #$+ above) and co!pare against the expected

results (targets or goals "ro! the PLAN+) to ascertain any di""erences. Loo& "or deviation in

i!ple!entation "ro! the plan and also loo& "or the appropriateness and co!pleteness o" the plan to

enable the execution i.e. #o+. 'harting data can !a&e this !uch easier to see trends over several

P#'A cycles and in order to convert the collected data into in"or!ation. %n"or!ation is what you need "or

the next step A',+.

A',

'arry out corrective actions on signi"icant di""erences between actual and planned results. Analye the

di""erences to deter!ine their root causes. #eter!ine where to apply changes that will include

i!prove!ent o" the process or product. /hen a pass through these "our steps does not result in the need

to i!prove the scope to which P#'A is applied !ay be re"ined to plan and i!prove with !ore detail in

the next iteration o" the cycle or attention needs to be placed in a di""erent stage o" the process.

A se=uen&e o1 ste%s t'at must 0e ta8en>

or a&ti;ities t'at must 0e %er1orme2 3ell> 1ora strategy to su&&ee2$ An a&tion %lan 'as t'reema?or elements (*) #%e&i& tas8s: 3'at 3ill 0e2one an2 0y 3'om$ (+) Time 'ori@on: 3'en 3ill it0e 2one$ (,) Resour&e allo&ation: 3'ats%e&i& 1un2s are a;aila0le 1or s%e&i& a&ti;ities$Also &alle2 a&tion %rogram$

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Total Quality Management