Quality Assurance in Healthcare: Principles, Approaches, and Evaluation Methods

1. UNIT II:QUALITY ASSURANCE Mrs.Indumathi Lecturer YNC

2. Introduction • Quality management (QM) and quality improvement (QI) are the basic concepts derived from the philosophy of total quality management (TQM). • Now it is preferred to use the term Continuous Quality Improvement (CQI) since TQM can never be achieved. • The method of monitoring of healthcare for CQI is done with Quality Assurance (QA).

3. Definition • Quality assurance is a judgment concerning the process of care based on the extent to which that care contributes to valued outcomes. - Donabedian 1982

4. Contd… • 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

5. Principles • Principle 1 – Customer focus • Principle 2 – Leadership • Principle 3 – Involvement of people • Principle 4 – Process approach

6. Principle 5 – System approach to management • Principle 6 – Continual improvement • Principle 7 – Factual approach to decision making • Principle 8 – Mutually beneficial supplier relationships

7. According to W Edward Deming; • Create consistency of purpose for improvement of product and service. • Adopt the new philosophy • Cease dependence on inspection to achieve quality. • End the practice of awarding business on the basis of price tag.

8. Improve constantly and forever the systems of production and service. • Institute training on the job. • Institute leadership. • Drive out fear. • Break down barriers between departments.

9. Eliminate slogans, exhortations, and target for the workforce. • Eliminate numerous quotas for the workforce and numerical goals of management. • Remove barriers that rob people of pride and workmanship. • Institute a vigorous programme of education and self-improvement for everyone • Put everyone in the company to work to accomplish the transformation

10. Approaches • General approach • Specific approach

11. General approach • It involves large governing or official bodies evaluating a person or agencies‘ ability to meet established criteria or standard during a given time.

12. a) Credentialing • It is the formal recognition of professional or technical competence and attainment of minimum standards by a person and agency. • Credentialing process has 4 functional components • To produce a quality product • To confirm a unique identity • To protect the provider and public • To control the profession

13. b) Licensure • It is a contract between the profession and the state in which the profession is granted control over entry into an exit from the profession and over quality of professional practice

14. c) Accreditation • It is a process in which certification of competency, authority, or credibility is presented to an organization with necessary standards. d) Certification Confirmation of certain characteristics of an object, person or organization.

15. 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

16. Specific approach • These are methods used to evaluate identified instances of provider and client interactions.

17. a) Audit • It is an independent review conducted to compare some aspect of quality performance, with a standard for that performance b) Direct observation Structured or unstructured based on presence of set criteria

18. 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 provider‘s practice either with practice by the provider‘s peer or with an acceptable standard of care

19. e) Bench marking • A process used in performance improvement to compare oneself with best practice. f) Supervisory evaluation g) Self-evaluation h) Client satisfaction i) Control committees

20. 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

21. 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

22. Elements According to Donabedian; • Structure Element- The physical, financial and organizational resources provided for health care. • Process Element- The activities of a health system or healthcare personnel in the provision of care. • Outcome Element- A change in the patient‘s current or future health that results from nursing interventions.

23. According to Manwell, Shaw, and Beurri, there are 3A’s and 3E’s; • Access to healthcare • Acceptability • Appropriateness and relevance to need • Effectiveness • Efficiency • Equity

24. Indicators of quality assurance

25. Waiting time for different services in the hospital • Medical errors in judgment, diagnosis, laboratory reporting, medical treatment or surgical procedures, etc. • Hospital infections including hospital- acquired infections, cross infections. • Quality of services in key areas like blood bank, laboratories, X- ray department, central sterilization services, pharmacy and nursing.

26. Quality assurance cycle:

28. QI process steps include; • Identify needs most important to the consumer of health care services. • Assemble a multidisciplinary team to review the identified consumer needs and services. • Collect data to measure the current status of these services.

29. Establish measurable outcomes and quality indicators. • Select and implement a plan to meet the outcomes. • Collect data to evaluate the implementation of the plan and achievement of outcomes.

30. Factors affecting quality assurance in nursing care:- 1. Lack of Resources 2. Personal problems 3. Unreasonable patients and attendants 4. Improper maintenance 5. Absence of well informed populace 6. Absence of accreditation laws

31. 7. Legal redress 8. Lack of incident review procedures 9. Lack of good hospital information system 10. Absence of conducting patient satisfaction surveys 11. Lack of nursing care records 12. Miscellaneous factors like lack of good supervision, Absence of knowledge about philosophy of nursing care,

32. TOOLS OF THE CQI:

33. Pareto Charts: • The Pareto chart analysis is used when dealing with chronic problems and helps one identify which of the many chronic problems to attack first.

35. Fishbone Diagram: • One analysis tool is the Cause-and-Effect or Fishbone diagram. • These are also called Ishikawa diagrams because Kaoru Ishikawa developed them in 1943. • They are called fishbone diagrams since they resemble one with the long spine and various connecting branches.

36. Histogram: • This is a vertical bar chart which depicts the distribution of a data set at a single point in time. • A histogram facilitates the display of a large set of measurements presented in a table

37. Run chart: • Most basic tool to show how a process performs over time. • Data points are plotted in temporal order on a line graph. • Run charts are most effectively used to assess and achieve process stability by graphically depicting signals of variation.

39. Models of quality assurance 1.ANA Model • Identify values: Patient,philosophy,needs and right from an economic,social,psychology and spiritual perspective and value philosophy • Identify structure,process,outcome standards and critertia:Philosophy and objectives of the organization and organizational chart • Select measurement :Tools used to gather data • Make Interpretation: strengths and weakness of the program • Identify course of action:alternative courses of action • Take action:accontability for the action • Revaluation:evaluation of the results

40. Donabedian Model Structure Process Outcome Structure:Facility,resources,personal mix and skills, client mix Process:Standards,attitude,nursing care plan,effectiveness,client satisfaction Outcome: Clients health care,goalsmet,efficiency and effectiveness of services

41. PDCA Model(Plan –Do-Check-Act) Plan: Establish the objectives and processes Do: Implement the processes Check: Monitor and evaluate the processes and results Act: Apply actions to the outcome for necessary improvement.

42. CONTINUOUS QUALITY IMPROVEMENT TECHNIQUES:

43. The person doing the job is most knowledgeable about that job. • This people want to be involved and do their jobs well. • Every person wants to feel like a valued contributor.

44. More can be accomplished working together to improve the system than having individual contributors . • A structured problem solving process using graphical techniques. • Graphical problem solving techniques .

46. BARRIERS OF CONTINUOUS QUALITY IMPROVEMENT

47. Lack of a clear definition of the organizational and the quality goals. • Lack of conformity between the quality goals and the operation‘s specificities • Great amount of exceptions in order to serve a determined number of client • Lack of actions that contribute to the continuous improvement

48. Lack of financial indicators; • Don‘t represent the reality of the operations. • Lack of true analyzes concerning the cost of bad quality; • Lack of analyzes of the financial gains obtain with quality management • Lack of a parameter for the investment feedback.

49. SOLUTIONS OF THE QUALITY IMPROVEMENT:

50. Individual problem solving • Rapid team problem solving • Systematic team problem solving • Process improvement solving