Unit 25 Adminstration

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  • 8/11/2019 Unit 25 Adminstration


  • 8/11/2019 Unit 25 Adminstration


    individual treatment plans; to give skilled nursing care and therapy; and to direct, monitor, and evaluate

    the nursing care furnished.

    (2)The staffing pattern must insure the availability of a registered professional nurse 24 hours each

    day. There must be adequate numbers of registered nurses, licensed practical nurses, and mental health

    workers to provide the nursing care necessary under each patient's active treatment program.

    (e)Standard: Psychological services.The hospital must provide or have available psychological

    services to meet the needs of the patients.

    (f)Standard: Social servi ces.There must be a director of social services who monitors and evaluates

    the quality and appropriateness of social services furnished. The services must be furnished in

    accordance with accepted standards of practice and established policies and procedures.

    (1)The director of the social work department or service must have a master's degree from an

    accredited school of social work or must be qualified by education and experience in the social services

    needs of the mentally ill. If the director does not hold a masters degree in social work, at least one staffmember must have this qualification.

    (2)Social service staff responsibilities must include, but are not limited to, participating in discharge

    planning, arranging for follow-up care, and developing mechanisms for exchange of appropriate,

    information with sources outside the hospital.

    (g)Standard: Therapeutic activit ies.The hospital must provide a therapeutic activities program.

    (1) The program must be appropriate to the needs and interests of patients and be directed toward

    restoring and maintaining optimal levels of physical and psychosocial functioning.

    (2)The number of qualified therapists, support personnel, and consultants must be adequate to provide

    comprehensive therapeutic activities consistent with each patient's active treatment program.

    Model for Minimum Staffing Patterns for Hospitals Providing Acute Inpatient Treatment for

    Children and Adolescents with Psychiatric Illnesses.

    Acute psychiatric treatment for children and adolescents requires the use of intensive and complex

    resources. We have the responsibility to our patients to ensure the quality and effectiveness of thistreatment. The standards are designed to be a minimum in terms of both staffing structure and numbers

    of staff.

    Various factors of patient selection and program objectives require increased staffing. Training ad

    research programs are examples. It should be noted that the requirements for psychiatrists are fordiagnostic and psychiatric management only. Individual and family psychiatrists are for diagnostic and

    psychiatric management only. Individual and family psychotherapy, done by the attending

    psychiatrists, are considered to require additional time commitment.

    The availability of a sufficient number of high quality staff is an absolute necessity to qualify a

    program to provide acute psychiatric hospital treatment. While there are many appropriate variations in

    programs and staffing, it is important that a model be established for minimum patterns of staffing.

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    Team and Authority

    Staffing for an inpatient program depends on the mission of the program, severity of the illness, the

    degree of impairment, and the complexity of the situation. Program focus and physical design interactwith program staffing. The responsibility for balancing these interactive factors rests with the program

    administrative team.

    At a minimum, the program administrative team with the responsibility for the entire treatmentprogram must include a qualified child and adolescent psychiatrist, and a qualified psychiatric nurse.

    The program must be consistent with a hospital administration as conveyed by an appropriate

    representative of the administration.

    The program is developed by the administrative team and approved by the medical staff and hospitaladministration.

    Staffing and program organization and other ancillary services such as psychology, education, social

    work, pediatric medicine and occupational therapy, need to be professionals in those disciplines.

    It is the responsibility of the child and adolescent psychiatrists to maintain the integrity of professionaljudgements and behaviors independent of influence of the source of compensation (Principles of

    Practice of the American Academy of Child and Adolescent Psychiatry).

    The staff of various disciplines must meet the facility's specific written criteria for credentials andclinical privileges.

    The administrative team has the responsibility for a program of continuous quality improvement.

    Attending Psychiatrist


    A licensed physician who has completed an approved program in child and adolescent psychiatry. Forpatients 14 years of age and older, a general psychiatrist with documented specialized training,

    supervised experience and demonstrated competence in work with adolescents and their families, may

    be considered a qualified attending psychiatrist. Continuing medical education is essential.


    There will be a sufficient number of qualified attending psychiatrists to prove the basic functions of

    evaluations, admissions, diagnoses, prescribing of treatment, and discharging patients, and to supervisethe clinical treatment team.

    Basic Functions:

    At a minimum, functions must be performed as outlined at the frequency prescribed in theDocumentation of Medical Necessity of Child and Adolescent Psychiatric Treatment: Guidelines for

    Use in Managed Care, Third-Party Coverage and Peer Review (AACAP, October 1990).

    At a minimum, the attending psychiatrists must document psychiatric management with progress notesevery three days.

    At a minimum and not including individual, group or family psychotherapy, the attending psychiatristmust spend sufficient hours per week in the patient's psychiatric management and treatment to properly

    provide for admission, discharge, treatment team, family and staff conferences, ordering and

    supervising treatment, communication with parents, ongoing psychiatric assessment, and

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    documentation. Week-by-week the time will increase or decrease according to the number of

    admissions, initial evaluations, basic evaluations or comprehensive examinations. Ordinarily it would

    be expected that these responsibilities would require no less than 2.5 hours per week.

    This minimum number of hours will need to be increased to account for additional medical factors,

    training and research.

    Social Worker or Other Professional Responsible for Family Contacts


    Mental health professional who has a master's degree in social work or related field. A mental health

    professional with a bachelor's degree supervised by a master's-level social worker is also considered

    qualified. Continuing education and in-service training is essential.

    The staff must include at least one social worker who has experience in child and adolescent inpatienttreatment.


    The number of social workers, or another discipline charged with family assessment and family

    contacts per week, should be at least one-full time equivalent to 10 patients. The number of staff may

    need to increase if extensive supplementary functions are included.

    Basic Functions:

    A basic family assessment within three days of admission.

    A comprehensive social assessment within 14 days.

    A weekly family and/or agency contact and progress note documenting the staff's active involvement in

    the implementation of treatment plan goals.

    Coordination of discharge planning. Participation in at least one treatment team meeting a week.

    Supplemental Functions:

    Family therapy and group therapy.

    Family, parent and patient education.

    Psychiatric Nurses


    Registered nurse with appropriate state license supervised by a qualified psychiatric nurse, i.e., abachelor's - or - master's - level nurse with experience in child and adolescent psychiatric inpatientnursing. Continuing education and in-service training is essential.


    A program requires one psychiatric nurse per shift for each 12 patients. An additional group of 10

    patients. This number also needs to be adjusted according to the acuity, medical treatment, medication

    and extensive functions.

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    Basic Functions:

    Initial assessment of patient's nursing needs and documentation of nursing needs and documentation ofnursing components of an initial treatment plan.

    A daily assessment and documentation of the patient, the patient's treatment and response to treatment.

    Supervision of assessments done by psychiatric technicians and countersigning of their documentation. Provision and documentation of medical treatment and medication as needed.

    Development of the appropriate psychiatric nursing components of the treatment plan.

    Implementation of the interventions in the treatment plan that are designated for psychiatric nurses.

    Implement milieu management.

    Health teaching.

    Supplemental Functions:

    Primary nursing.

    Individual milieu interventions (individualized behavioral management).

    Group therapy. Specialized treatment for high-acuity patients, e.g., suicidal, assaultive, severely disorganized,

    elopement risk, acute medical distress (unstable diabetes or asthma).

    Child and Adolescent Psychiatric Technician

    Also known as a child care worker, mental health specialist, child care specialist, mental health



    Educational credentials vary. Extensive pre-service and ongoing in service training is essential. The

    assignment of clinical responsibilities must consider careful evaluation of the combination of training,experience and personal characteristics such as maturity, empathy and objectivity.


    This is determined by considering general/generic supervision in the treatment milieu. (See finalsection on generic staffing).

    Basic Functions:

    Establish and maintain behavioral supervision of children.

    Maintain implementation of safe, therapeutic milieu.

    Implement specific assigned aspects of the treatment plan.

    Observe, assess, and document the patient's status.

    Assist in planning and supervision of leisure activities.

    Participate in the observation and documentation of the patient's treatment.

    Functions Shared By Nur se and Psychiatri c Technician:

    Certain functions are done by the nurse and/or psychiatric technician.

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    Observation, assessment and documentation of the patient's condition on each shift. Where the

    observation and documentation is done by the psychiatric technician, the note is countersigned by the

    nurse responsible for the patient on that shift.

    Supervision of the patients and maintaining the safety and therapeutic quality of the milieu. (Both have

    responsibility for this).

    Assisting, as necessary, the children in their daily activities, including leisure activities, transportation,activities related to personal hygiene.

    Shared Supplemental F unctions:

    Individual patient discussions.

    Assisting in group therapy.

    Leading various therapeutic activities.

    Mental health education with parents and patients.

    Behavioral management classes.

    Ratio for General Staffing/Generic Supervision

    In these parameters, units are considered to be from 9 to 24 child or adolescent patients.

    When the children are occupied primarily in the program unit during the day and evening, the

    minimum number is three staff to nine patients, proceedings in a three-to-one ratio.

    With this staffing pattern staff can accomplish their basic responsibilities. Supplemental complex or

    intensive interventions will require additional staffing.

    When 18 or fewer patients located on one program unit are asleep, the minimum number of staff is

    two. With over 18 patients asleep, the minimum level is three staff. In either case, there must be anadditional person available to help with sudden change in acuity. This should not reduce the basic

    staffing on another unit.At night, when the patients are asleep there should be one nurse to 50 patients per shift with an on-callnurse who can come on site.

    Ratios are dependent on such variables as the number of children in the living unit, the physical

    configuration of the facilities, the acuity including developmental levels, the frequency of turnover andlength of stay, and the availability of off-unit activities, e.g., specialized recreational activities.

    Other Staffing Requirements:

    Children and adolescents treated in acute psychiatric hospital programs require additional special staff.

    Due to the variability in program structure and patient characteristics, the number of staff is not

    specified. Staff must be available to meet the following program and supervisory functions:

    Psychological Services:

    Sufficient licensed psychologist to provide relevant and appropriate psychological testing. Cognitive

    evaluation is particularly important. In some programs, psychologists may be involved in treatment

    plan development, individual, group and family psychotherapy and other types of therapeuticintervention.

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    Educational Services:

    Educators to assess academic achievement and needs, maintain educational progress and accomplish

    transfer into an appropriate post-hospital educational program. Patients need an educational program 5days per week under the direction of a special educator.

    Therapeutic Recreation Services:

    A therapeutic recreation program provided 7 days per week under the direction of a certified recreationtherapist.

    Relevant and Appropriate Consultation in the Following Areas:

    Medical specialties

    Speech and hearing evaluation

    Occupational therapy

    The Council of the American Academy of Child and Adolescent Psychiatry accepted these Guidelinesfor Minimum Staffing in 1990. The Academy has led in the development of policies, position

    statements and review standards. These labor-intensive efforts are fueled by the Academy's pledge toassure our patients and their families an adequate quality of medically necessary psychiatric treatment.


    Functional, accurate and safe clinical equipments is an essential requirements in the provision of healthservices. Well maintained equipments will give nurses greater confidence in the reliability of its

    performance and contribute to a high standard of client care . Equipment management is an important

    issue for cost and safety in hospitals operations. Planning of equipment and supplies recommends that

    at the outset of each project,; identify project goals, including clinical priorities, budget, schedule andphasing

    Medical equipment and supplies:

    Equipments are defined as those items necessary for the functioning of all services of the facility suchas accounting and records, maintenance of buildings and grounds, laundry, public waiting rooms,public health and related services.

    The term equipment is used for more permanent type of article and may be classified as fixed and

    movables. Fixed equipment is not a structure of the building, but it is attached to the walls or floors

    (egg; steriliser,) Movable equipment includes furniture, instruments etc.

    Supplies are those items that are used up or consumed; hence the term consumable is used for supplies.

    The supplies in hospital include drugs, surgical goods (disposables, glass wares), chemicals,

    antiseptics, food materials, stationeries, the linen supply etc.

    Definition of planning equipments and supplies:

    Planning of equipments and supplies is defined as process of selection and organization of the articlesor items used in the diagnosis, treatment, and monitoring of patients in order to ensure that they are

    safe, available, accurate, and affordable.

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    Need of planning equipments and suppplies:

    Medical equipment and supplies planning includes all the related policies and procedure governactivities from selection and acquisition through to the incoming inspection, acceptance, maintenance

    and eventual retirement and disposal of medical equipment.Planning and management of all

    equipments and supplies used in hospital is need to be done to ;

    ensure that equipment and supplies used in patients care are operational, safe, and properly configured

    to meet the mission of the medical treatment facility.

    manage safety and cost of articles.

    overcome the problems in nursing care or other patient related activities due to inadequacy in

    equipments and supplies.

    stabilize fluctuations in consumptions.

    provide reasonable level of client services.

    satisfy the demands during the period of replenishment.

    cross bureaucratic hurdles in case of imported equipments. know about possible legal or licensure issues.

    Phases of equipment management:

    A typical life cycle of medical equipment has the following phases:

    1. Planning phase:

    The following conditions that should be met to help the decision process in planning phase:

    Demonstrated clinical needs.

    Availability qualified users.

    Aproved and reassured source of recurrent operating budget.

    confirmed maintenance services and support.

    Adequate environment support.

    A clear cut policy should be there on acquisition, utilization and maintenance of equipment need to be

    established.This will help to reduce any future problems arising out of contracts, spare parts and

    maintenance of equipment acquired locally, internationally.





    OF USE &



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    2. Procurement phase:

    Standardize on models or manufacturers of equipment.

    Specify the conditions and special requirements in the purtchase order to specify the supplier withholdpayment if specified conditions are not met.


    Incoming inspections: Incoming inspections should be carefully checked for possible damages; compliance with

    specifications in the purchase ordere; and delivery of accessories, spare parts and operating and servicemanuals.

    4. Equipment inventory and documentation system:

    It provides information to support different aspects of medical equipment management;

    Inventory entries should includes accessories, spare parts and operating and service manuals.

    Make copies of the manuals for distribution to the users, while the originals of the manuals should bekept at the technical document library for safekeeping.


    Commissioning and acceptance: Commissioning can be carried out by hospital technical staff.if they are familiar with that item of

    equipment. If commissioning by the suppliers is needed , the process should be monitored by hospital

    technical staff so that any technical matters can be noted and recorded.

    6. Monitoring of use and performance:

    A link should be maintained between user and supplier and observe any suppliers technical services.

    7. Maintenance:

    Proper maintenance of equipment is essential to obtain sustained benefits and to preserve capital

    investment . Equipment must be maintained in working order and periodically calibrated foreffectiveness and accuracy. Proper maintenance has a direct impact on the quality of care.

    8. De-commissioning:

    Repair existing old equipments.

    Dismantle old units if required.

    De-Commisioned equipment must be deleted to keep the inventory current.



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    Factors affecting selection and planning of equipment

    1. Type of service provided by the hospital: A maternity hospital requires more equipment related to

    gynaecologic procedures than a cardiac hospital.

    2. Age of patients:children need different type and amount of equipments than adults.


    Sex-Men and women sometime require different type of equipment.4. Degree and type of illness-neurologic patients sometimes require more bedsides, rubber mattress and

    linen than patients with other type of illness.

    5. Cost of items-cost of items will limit the purchase of number of equipment.

    General utility services in the hospital

    1. Electric supply and installations : A hospital must have a steady electrical supply at a stable voltage.

    Voltage fluctuations play havoc with sophisticated electronic equipment, endoscope, sterilisers, X-ray

    equipments etc. While planning hospital departments, provision should be made for voltage

    stabilisation in areas with heavy concentration of electrical and electronic equipment. This is preferredover using voltage stabilisers with individual equipment. There should be an emergency generator

    capable of supplying power to all emergency areas of the hospital. This generator should be of right

    capacity and kept in working order by periodic test runs.

    2. Water supply : Since safe water supply is not always assured, hospitals must have their own

    purification system. Also there should be plumbing system.

    3. Disposal of wasteliquids and solids: Disposal of waste both solid and liquid is a totally neglected

    area. A hospital incinarator good for the waste management.


    Refrigeration, air conditioning, ventilation and environment control: Air conditioning is requiredfor protection of sophisticated electronic equipment, X ray, machines etc.

    5. Transport : Lifts are needed for vertical transport. There should be separate lifts for patients, visitors,staff and supply. Patients lift should accommodate a standard hospital bed. Sides of the lift must be

    protected to prevent damage by trolleys. Lift surfaces and flooring should be capable of easy cleaning

    and disinfection. Ventilation, communication and emergency escape system should be provided on alllifts. As for horizontal transport also trolleys and ramps with gentle gradient are useful.

    6. Supply of medical gases , compressed air, hot water, vacuum suction and gas plants: Piped supply

    of medical gases , compressed air, vacuum suction , hot water, steam, necessitates thoughtful planning

    at all stages to consider problems of

    Easy uninterrupted safe supply

    Fire and explosion hazards

    Easy of servicing and maintenance without disrupting hospital services.

    7. Laundry: A hospital laundry has 2 separate areas, with provision for decontamination and sterilising

    of soiled linen.

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    o blood counter

    o analytical balance

    o calorimeter( spectrophotometer)

    o Centrifugea small centrifuge that can accommodate six 15ml tubes should be available.

    o Water bathused for stabilising temperature at 25, 37, 42, or 56degree Celsius.


    Incubator/oven- a small hot air oven to carry out standard cultivations and sensitisations. Refrigeratoran ordinary household refrigerator with a freezer unit, for storing preparations, vaccines,

    blood etc.

    Distillation and purification apparatus - it should be made of metal that resists acid, and alkali and

    should be free standing.

    3) Electrical medical equipment.

    Portable electrocardiograph

    Defibrillator( external)

    Portable anaesthetic unit2 small aesthetic units should be obtained, complete with a range of masks.

    Respiratorit should be applicable for prolonged administration during post operative care. Dental chair unit- a complete unit should be available to carry out standard dental operations.

    Suction pumpone portable and one other suction pump are required.

    Operating theatre lamp- one main lamp with at least 8 shadows lamp and an auxiliary of 4 lamp units.

    Delivery table- it should be standard and manually operated.

    Diathermy unit a standard coagulating unit which is operated by hand or foot switch, with variable

    poor control.

    4) Other equipment

    autoclavefor general stabilisation

    Small sterilisers- for specific services- eg. Stabiliser cold chain and other preventive medical equipment


    5) Small , inexpensive equipment and instruments

    Equipment and instrument, such as BP apparatus, oxygen manifolds, stethoscope, diagnostic sets andspotlights.

    Equipment and supplies required during emergency

    The World Health Organization (WHO), in consultation with other international organizations, has adopted astandard classification that places humanitarian supplies in 10 different categories. This form of identification is

    particularly useful for the sorting and recording of supplies during emergency or disaster:The categories arethe following:


    Water and environmental health,

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    Health supplies/Kits,




    Personal needs/Education,

    Human resources,



    Role of nursing managers in maintaining equipment and supply:

    The nurse manager should apply system approach for maintaining equipment and supply in nursing unit.


    The main objective of input component is to ensure adequate supply of equipment ad supplies of nursing unit.

    The nurse managers need to:

    Take active part in estimating the demand of equipment and supply.

    Be aware of hospital policy for requirement , indenting, stock etc.

    Nursing norms for equipment and supply as per nursing council.

    Develop ward policy as per requirement.

    Communicate higher authority about the gap between demand and supply.

    Conduct meetings with superiors and subordinates for requirement .

    Prepare guidelines for handling and taking over for the staff.



    To maximize the proper utilization of available equipment and supply by the staff and proper

    maintenance of equipment and supplies.

    Mainten current inventory of functional/in working order equipment and supplies.

    Send requisition monthly, weekly, daily as per the policy developed.

    Have inventory control, maintain buffer stock for emergency.

    Do proper distribution for evening , night shift.

    Conduct supervisory round.

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    Check daily and periodically the functioning of emergency and general equipment andlife saving


    Assign and delegate the work to junior staff.

    Make them accountable for any loss and misuse of equipment and supplies.

    Ask them to use the articles for rendering patient care.

    Communicate all the team members about the out of stock and non functioning of equipment.

    Develop orientation plan for the patient and their relatives about the availability and non availability of

    particular article, equipment and supplies and ward policy.

    Maintain record and report of equipment and supplies.

    Regularly maintain the equipment and supply.

    Condemn the non functioning and outdated equipment as per policy.

    Check all the work has been done.



    To render quality patient care;

    All the staff should be aware of policy: hospital, ward related to equipment and supply.

    There should be adequate supply of equipment and supplies without any interruption.

    Equipment s should be in working order.


    (1) The governing body must ensure that a written policies and procedures manual is maintained. In

    addition to meeting the requirements of rule. Policies and Procedures for all facilities, themanual mustinclude the following elements:

    (a) A quality assurance procedure for the assessment of the quality of care. This procedure must

    ensure appropriate treatment has been delivered according to acceptable clinical practice;

    (b) A written program description which must be available to staff, patients and members of the

    public. The description must include, but need not be limited to, the following:

    1. Characteristics of the persons to be served,2. Referral process,

    3. Program rules for patients, and4. Referral mechanisms for services outside the facility (both medical and non-medical);


    (c) Procedures to ensure how the patients parents, guardian, members of the immediate family or

    other responsible adult are to be notified in the case of any unusual occurrence including

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    serious illness, accidents or death.


    DEFINITION:-Qual ity assurance:-

    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)

    Quality assurance "Quality assurance is the monitoring of the activities of client care to determine the

    degree of excellence attained to the implementation of the activities". (Bull, 1985)

    Quality assurance is a judgment concerning the process of care, based on the extent to which that cares

    contributes to valued outcomes. (Donabedian 1982)

    Quality Assurance is the definition of nursing practice through well written Nursing standards and the

    use of those standards as a basis for evaluation on improvement of client care. (Marker 1998)

    Quality assurance system motivates nurses to strive for excellence in delivering quality care and to be

    more open and flexible in experimenting with innovative ways to change outmoded systems.


    According to Jonas (2002), the two main objectives are:-

    To ensure the delivery of quality client care

    To demonstrate the efforts of the health care providers to provide the best possible results.


    Formulate plan of care Attend to the patients physical and non physical needs

    Evaluate achievement of nursing care

    Support delivery of nursing care with administrative and managerial services

    NURSING EDUCATION: - (Decker, 1985 and Schroeder, 1984)

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    To provide technical assistance in designing and implementing effective strategies for monitoring

    quality and correcting systemic deficiencies.

    To refine existing methods for ensuring optimal quality health care through an applied research



    The main 8 Principles of Quality Assurance. Quality Assurance principles are based on the ISO 9001

    standard and are intended to be used by senior Quality Managers to run a business based on continual

    improvement and quality assurance

    1. Customer focus: - The customer is always the most important factor for any business, which is why

    organisations need to understand current and future customer needs and aim to surpass expectations.

    Quality assurance relies on researching and understanding the customers needs and ensuring that the

    organisations objectives are in line with those expectations. A quality management system needs to be

    in place to manage customer relationships and communicate those needs across the organisation.

    2. Leadership:-Quality assurance principles also suggest that an organisation needs leadership in order

    to have purpose and direction. Quality assurance relies on a business having a clear vision of the future

    a vision which should consider the needs of all relevant parties including customers, directions,

    employees, local community etc. Good leadership within an organisation should establish trust and

    remove fear, whilst encouraging and recognising employees contributions

    3. Involvement of people: - An organisation needs to be able to put quality management training into

    practice. People at all levels of the business need to be motivated, committed and fully involved in the

    organisation. This principle of quality assurance involves people evaluating their own performance and

    identifying their constraints, as well as actively seeking opportunities

    4. Process approach: - ISO 9001 training encourages that in order to achieve a desired result, resources

    and activities should be managed as a process. The process should focus on resources, methods and

    materials which affect the key activities within a business. In order to maintain quality assurance within

    a service or product, risks, consequences, the impaction customers and suppliers and other relevant

    parties should be continuously evaluated

    5. System approach to management:- Quality assurance training demonstrates how to create a structure

    system which is designed to achieve the organisations aims and objectives using the most effective and

    efficient methods. Quality management system training should provide a better understanding of the

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    other group techniques. Once a health facility team has identified several problems, it should set quality

    improvement priorities by choosing one or two problem areas on which to focus. Selection criteria will

    vary from program to program.

    6. Defining the Problem Having selected a problem:-

    The team must define it operationally-as a gap between actual performance and performance as

    prescribed by guidelines and standards. The problem statement should identify the problem and how it

    manifests itself. It should clearly state where the problem begins and ends, and how to recognize when

    the problem is solved.

    7. Choosing a Team:-

    Once a health facility staff has employed a participatory approach to selecting and defining a problem,

    it should assign a small team to address the specific problem. The team will analyze the problem,

    develop a quality improvement plan, and implement and evaluate the quality improvement effort. The

    team should comprise those who are involved with, contribute inputs or resources to, and/or benefit

    from the activity or activities in which the problem occurs.

    8. Analyzing and Studying the Problem to Identify the Root Cause:-

    Achieving a meaningful and sustainable quality improvement effort depends on understanding the

    problem and its root causes. Given the complexity of health service delivery, clearly identifying root

    causes requires systematic, in-depth analysis. Analytical tools such as system modeling, flow charting,

    and cause-and-effect diagrams can be used to analyze a process or problem. Such studies can be based

    on clinical record reviews, health center register data, staff or patient interviews, service delivery


    9. Developing Solutions and Actions for Quality Improvement

    The problem-solving team should now be ready to develop and evaluate potential solutions. Unless the

    procedure in question is the sole responsibility of an individual, developing solutions should be a team

    effort. It may be necessary to involve personnel responsible for processes related to the root cause.

    10. Implementing and Evaluating Quality Improvement Efforts:-

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    d) Certification:- Certification is usually a voluntary process with in the profession. A person's

    educational achievements, experience and performance on examination are used to determine the

    person's qualifications for functioning in an identified specialty area.

    e) Charter- It is a mechanism by which a state government agency under state law grants corporate

    state to institutions with or without right to award degrees.

    f) Recognition- It is defined as a process whereby one agency accepts the credentialing states of and

    the credential confined by another.

    g) Academic degree

    II) SPECIFIC APPROACH: - These are methods used to evaluate identified instances of provider

    and client interactions.

    a) Audit- It is an independent review conducted to compare some aspect of quality performance, with a

    standard for that performance. Nursing audit may be defined as a detailed review and evaluation of

    selected clinical records in order to evaluate the quality of nursing care and performance by comparing

    it with accepted standards

    b) Direct observation- Structured or unstructured based on presence of set criteria.

    c) Appropriateness evaluation-The extent to which the managed care organization provides timely,

    necessary care at right levels of service.

    d) Peer review- Comparison of individual providers practice either with practice by the providers

    peer or with an acceptable standard of care. To maintain high standards, peer review has been initiated

    to carefully review the quality of practice demonstrated by members of a professional group. Peer

    review is divided in to two types. One centers on the recipients of health services by means of auditing

    the quality of services rendered. The other centers on the health professional by evaluating the quality

    of individual performance.

    e) Bench marking- A process used in performance improvement to compare oneself with best


    f) Supervisory evaluation

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    g) Self-evaluation

    h) Client satisfaction

    i) Control committees

    j) Services- Evaluates care delivered by an institution rather than by an individual provider.

    k) Trajectory- It begins with the cohort of a person who shares distinguishing characteristics and then

    follows the group going through the healthcare system noting what outcomes are achieved by the end

    of a particular period

    l) Staging- It is the measurement of adverse outcomes and the investigation of its antecedence.

    m) Sentinel- It involves maintaining of factors that may result in disease, disability or complications

    such as;

    Review of accident reports

    Risk management

    Utilization review


    1) Lack of Resources: Insufficient resources, infrastructures, equipment, consumables, money forrecurring expenses and staff make it possible for output of a certain quality to be turned out under the

    prevailing circumstances.

    2) Personnel problems: Lack of trained, skilled and motivated employees, staff indiscipline affects

    the quality of care.

    3) Improper maintenance: Buildings and equipments require proper maintenance for efficient use. If

    not maintained properly the equipments cannot be used in giving nursing care. To minimize equipment

    down time it is necessary to ensure adequate after sale service and service manuals.

    4) Unreasonable Patients and Attendants Illness, anxiety, absence of immediate response to treatment,unreasonable and un co-operative attitude that in turn affects the quality of care in nursing.

    5) Absence of well informed population: To improve quality of nursing care, it is necessary that the

    people become knowledgeable and assert their rights to quality care. This can be achieved through

    continuous educational program.

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    6) Absence of accreditation laws:There is no organization empowered by legislation to lay down

    standards in nursing and medical care so as to regulate the quality of care. It requires a legislation that

    provides for setting of a stationary accreditation / vigilance authority to:

    8) Lack of good and hospital information system: A good management information system is

    essential for the appraisal of quality of care.

    9) Absence of patient satisfaction surveys: Ascertainment of patient satisfaction at fixed points on an

    ongoing basis. Such surveys carried out through questionnaires, interviews to by social worker,

    consultant groups, and help to document patient satisfaction

    10) Lack of nursing care records: Nursing care records are perhaps the most useful source of

    information on quality of care render.


    Quality assurance follows client care rather than organizational structure, focus on process rather thanindividuals and uses a systematic approach with the intention of improving the quality of care The

    main methods of assessing quality assurance are as follows:

    1. Train ing the nur sing staff:- Training includes the explanation of the purpose of each critical

    indicator meaning of each criterion ,proper approach of data collection.

    2. Perf orming the audit:-An audit may be focused on the particular medical diagnosis and related to

    the patient care while he is in the hospital. Audit are of two type

    a) Concurrent audit-In this patient care is observed as it is given


    Retrospective audit-In this patient care is evaluated only aeter the discharge of patient.

    3. Analysis of medical record data:- After screening of sampled medical records ,the surveyor should

    refer records showing variations from established criterion to the desired task,so that they can

    determine whether the variation is justified or corrective action is taken.

    4. Peer view:-Peer view is also one method for increasing nursing accountability for effective decision

    making and interventions.In this view mainly evaluate the performance against accepted standards

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    The nursing process consist of six steps and uses a problem solving approach that has come to be

    accepted as nursings scientific methodology. It is goal directed , with the objective being delivery

    of quality client care.


    Standards of care pertain to professional nursing activities that are demonstrated by the nurse

    through the nursing process. These involve assessment, diagnosis, outcome identification,

    planning, implementation, and evaluation. The nursing process is the foundation of clinical

    decision making and encompasses all significant action taken by nurses in providing psychiatric

    mental health care to all clients.


    The psychiatric/ mental health nurses collects patient health data

    The assessment interview which require linguistically and culturally effective communication

    skills, interviewing, behavioural observation, record review and comprehensive assessment of the

    patient and relevant system enable the mental health nurse to make sound clinical judgement and

    plan appropriate interventions.


    The mental health nurse analyzes the assessment data in determining diagnosis

    Data gathered during the assessment are analysed. Diagnoses and potential problem statement are

    formulated and prioritized.


    The mental health nurse identifies expected outcomes individualized to the patient

    Expected outcomes are derived from the diagnosis. They must be measurable and estimate a time

    for attainment. They must be realistic for the clients capabilities, and are more effective when

    formulated by the interdisciplinary members, the client, and significant other together.


    The mental health nurses develops a plan of care that is negotiated among the patient, nurse,

    family, and health care team and prescribes evidence based interventions to attain expected


    A plan of care is used to guide therapeutic intervention systematically, document progress, and

    achieve the expected patient outcome. The care plan is individualized to the clients mental health

    problems, condition, or need and is developed in collaboration with the client, significant others,

    and interdisciplinary team member. For each diagnosis identified, the most appropriateinterventions are selected.

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    Written policies and procedures shall govern the compilation, storage, dissemination and

    accessibility of patient records. The policies and procedures shall be designed to assure that the

    facility fulfills its responsibility to safeguard and protect the patient record against loss,

    unauthorized alteration, or disclosure of information; to assure that each patient record contains all

    required information; to uniformity in the format and forms in use in patient records; to require

    entries in patient records to be dated and signed.

    The facility shall provide facilities for the storage, processing and handling of patient records,

    including suitably locked and secured rooms and files. When a facility stores patient data on

    magnetic tape, computer files, or other types of automated information systems, adequate security

    measures shall prevent inadvertent or unauthorized access to such data. A written policy shall

    govern the disposal of patient records. Methods of disposal shall be designed to assure the

    confidentiality of information in the records.


    The patient records department shall maintain, control and supervise the patient records, and shall

    be responsible for maintaining the quality.

    A qualified medical record individual who is employed on at least a part-time basis, consistent

    with the needs of the facility and the professional staff, shall be responsible for the patient records

    department. This individual shall be a registered record administrator or an accredited record


    When it can be demonstrated that the size, location or needs of the facility do not justify

    employment of a qualified individual, the facility must secure the consultative assistance of a

    registered record administrator at least twice a year to assure that the patient record department is

    adequate to meet the needs of the facility.


    1 All clinical information pertaining to a patient's stay shall be centralized in the patient's record.

    2. The original or all reports originating in the facility shall be filed in the medical record.

    3. Appropriate patient records shall be kept on the unit where the patient is being

    treated and shall be directly accessible to the clinician caring for the patient.


    The medical record shall contain sufficient information to justify the diagnosis and warrant the

    treatment and end results. The patient record shall describe the patient's health status at the time of

    admission, the services provided and the patient's progress in the facility, and the patient's health

    status at the time of discharge. The patient record shall provide information for the review and

    evaluation of the treatment provided to the patient. When appropriate, data in the patient record

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    shall be used in training, research, evaluation and quality assurance programs. When indicated, the

    patient record shall contain documentation that the rights of the patient and of the patient's family

    are protected. The patient record shall contain documentation of the patient's and, as appropriate,

    family members' involvement in the patient's treatment program. When appropriate, a separate

    record may need to be maintained on each family member involved in the patient's treatmentprogram. The patient record shall contain identifying data that is recorded on standardized forms.

    This identifying data shall include the following:

    1. Full name;

    2. Home address;

    3. Home telephone number;

    4. Date of birth;

    5. Sex

    6. Race or ethnic origin;

    7. Next of kin;

    8. Education;

    9. Marital status;

    10. Type and place of employment;

    11. Date of initial contact or admission to the facility;

    12. Legal status, including relevant legal documents;

    13. Other identifying data as indicated;

    14. Date the information was gathered; and

    15. Signature of the staff member gathering the information.

    The patient record shall contain information on any unusual occurrences such as the following:

    1. Treatment complications;

    2. Accidents or injuries to the patient;

    3. Morbidity;

    4. Death of a patient; and

    5. Procedures that place the patient at risk or that cause unusual pain.

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    As necessary, the patient record shall contain documentation of the consent of the patient,

    appropriate family members or guardians for admission, treatment, evaluation, aftercare or


    The patient record shall contain both physical and psychiatric diagnoses that have been made

    using a recognized diagnostic system.

    The patient record shall contain reports of laboratory, roentgenographic, or other diagnostic

    procedures and reports of medical/surgical services when performed.

    The patient record shall contain correspondence concerning the patient's treatment, and signed and

    dated notations of telephone calls concerning the patient's treatment.

    A discharge summary shall be entered in the patient's record within a reasonable period of time

    (not to exceed 14 days) following discharge as determined by the professional staff bylaws, rules

    and regulations.

    The patient record shall contain a plan for aftercare.

    All entries in the patient record shall be signed and dated. Symbols and abbreviations shall be used

    only if they have been approved by the professional staff, and only when there is an explanatory

    legend. Symbols and abbreviations shall not be used in the recording of diagnoses.

    When a patient dies, a summation statement shall be entered in the record in the form of a

    discharge summary. The summation statement shall include the circumstances leading to death

    and shall be signed by a physician. An autopsy shall be performed whenever possible. When an

    autopsy is performed, a provisional anatomic diagnosis shall be recorded in the patient's record

    within 72 hours. The complete protocol shall be made part of the record within three (3) months.


    Current records shall be completed promptly upon admission. Records of patients discharged shall

    be completed within 14 days following discharge. The staff regulations of the facility shall provide

    for the suspension or termination of staff privileges of physicians who are persistently delinquent

    in completing records.


    A system of identification and filing to ensure the prompt location of a patient's medical record

    shall be maintained.

    The patient index cards shall bear at least the full name of the patient, the address, the birth date

    and the medical record number.

    Records shall be indexed according to disease and physician, and shall be kept up to date. For

    indexing, any recognized system may be used.

    Indexing shall be current within six (6) months following discharge of the patient.

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