QUALITY ASSURANCE;FOR HEALTH PRACTITIONERS

 QUALITY ASSURANCE

INTRODUCTION

Quality assurance in the health care field, is a pledge to the public by health care providers to work towards the goal of achieving excellence in services rendered to the patients

DEFINITION

Quality assurance is a process of meeting quality standards and assuring that care reaches an acceptable level (Mason, 2013).

PRINCIPLES OF QUALITY ASSURANCE

·       Customer/patient Focus

This standard relates to customer needs and costumer services.

Health care providers should understand their clients or patients and seek to meet their requirements. Where possible, they should aim to exceed clients or patient’s expectations.

·       Leadership

This standard relates to the direction of the organization. The organization should have an organized leadership for it to run its affairs. An organization should have clear objectives and employees should be actively involved in achieving this.

·       Involvement of people

It recognizes that an organization is nothing without its staff and that their abilities should be used to full effect for business success.

The benefits of involvement of people

Employee motivation and increased innovation

When people feel that their skills are being used well, they are more likely to work to their maximum potential and contribute ideas.

 

·       Process approach

This relates to efficiency and the understanding that appropriate processes will speed up activities.

The main benefits of this aside of efficiency are reduced costs due to effective use of resources, improved and consistent results and focused improvement.

 

·       Systems approach

Multiple processes are managed together as a system which should lead to greater efficiency. When implemented, this principle allows a business to focus their efforts on the processes that are key to their success as well as aligning complementary processes for improved efficiency.

This process fosters a greater understanding of the interrelation of various business elements.

·       Continual improvement

Continual staff improvement is an important aspect for any institution in order to provide skilled and quality nursing care.

The benefits of this is clear;

Increased ability to embrace new opportunities, organizational flexibility and improved performance.

·       Actual Approach to decision making

Analyze and understand the information before a decision can be made. Informed decisions lead to improved understanding of the information in an institution and the ability to defend past decisions.

·       Mutually Beneficial supplier relations

The relationship between an organization and its clients is interdependent. A strong relationship between the two will enhance productivity and encourage seamless working practices. There is flexibility of joint responses to customer needs and expectations. Care should be taken to ensure that resource expenditure for quality assurance activities is appropriate in amount.

·       Coordination

In planning a total quality assurance program for a health institution, coordination is needed to ensure that objectives and activities of each health profession enhance rather than cancel those of other professionals.

·       Resource Expenditure

Care should be taken to ensure that resource expenditure for quality assurance activities is appropriate in amount.

·       Evaluation

Evaluation of care will give feedback to practitioners and is required both to perpetuate good practice and to replace unsatisfactory interventions with more effective methods.

 

COMPONENTS OF QUALITY ASSURANCE.

Quality assurance requires evaluation of 3 components of care which are:

A)     Structure

B)     Process

C)     Outcome

·       Structure Evaluation

Focuses on the setting in which care is given.it answers this question:What effect does the setting have on quality of nursing care?

Structural Standards describe desirable environmental and organizational characteristics that influence care such as equipment and staffing.

·       Process Evaluation

Focuses on how the care was given.it answers questions such as: Is the care relevant to the client’s needs? Is the care appropriate, complete and timely? Process standards focus on the manner in which the nurse uses the nursing process.

·       Outcome Evaluation

Focuses on demonstrable changes in the client’s health status as a result of nursing care. The outcome criteria are  written in terms of client responses or health status, just as they are for evaluation within the nursing process, for instance, how many clients who have undergone caesarian section develop infection?

CONSUMER DRIVEN QUALITY

DEFINITION

A set of practices for developing strategies to ensure that consumer expectations are met (dictionary.com 2006).

Includes a proactive approach to satisfying customer needs.

Consumer driven quality represents a proactive approach to satisfying customer needs that is based on gathering data about our customers to learn their needs and preferences and then providing products and services that satisfy the customer. Its roots are traced in industry and has only been adapted to the health care industry in recent times and in the health sector it is referred to as total quality management. It involves pursuing new strategic thinking, knowing customers, pursuing a continuous improvement and true customer requirements. It also focuses on prevention and reduction on waste but not correction.

OBJECTIVES OF CONSUMER DRIVEN QUALITY

Ø  To Meet customer requirements

Ø  To Reduce development cycle times

Ø  To Achieve just in time/Demand Flow Manufacturing

Ø  To Set up improvement teams

Ø  To Reduce product and service costs

Ø  To Improve administrative systems training

CONSUMER DRIVEN QUALITY IDEOLOGY

Ø  Quality involves everyone and all activities in the workplace

Ø  conformance to requirements (Meeting customer requirements)

Ø  Quality can and must be managed

CONSUMER FOCUS

The first feature of consumer driven quality(CDQ) is the company’s focus on its customers. The goal is to first identify and then meet customer needs. CDQ recognizes that a perfectly produced product has little value if it is not what the customer wants. Therefore, we can say that quality is customer driven. However, it is not always easy to determine what the customer wants, because tastes and preferences change.

customer expectations often vary from one customer to the next.  Companies need to continually gather information by means of focus groups, market surveys, and customer interviews in order to stay in tune with what customers want. It must always be remembered that there would be no business without customers.

QUALITY IMPROVEMENT

Quality Improvement (QI): is the process of engaging appropriate methodologies and quality management tools to close the gap between current and expected levels of quality (MoH, 2012).

An on-going process of :

Innovation,

prevention of error, and

staff development

used by an organization that has adopted a quality management philosophy.

Quality is securing optimum achievable result for each health care consumer while paying attention to consumer and family needs in a cost effective and documented manner.

is proper performing (according to standards) of interventions that are known to be safe, that are affordable to the society in question and that have the ability to produce an impact on morbidity, mortality, disability and malnutrition.

Quality improvement requires engaging appropriate methodologies to close the gap between current and expected level of quality.

Quality improvement uses principles to address systems deficiencies and improve or redesign Also involves SETTING STANDARDS on which to operate on.

STANDARDS: are statements of what is expected to be done; they are statements of expected quality.

Statements of expectations for inputs, processes and outcomes of a system necessary to ensure quality health care. Efficient and effective health care processes (MoH, 2012).

Quality Assurance vs. Quality Improvement

Individual focused       Systems focused

Perfection myth          Fallibility recognized

Solo practitioners        Teamwork

Peer review ignored    Peer review valued

Errors punished           Errors seen as opportunities for learning.

QUALITY ASSESSMENT

Quality Assessment is a system for evaluating performance, as in the delivery of health services or the quality of products provided to consumers, or patients. This refers to measurement of professional or technical practice or service for comparison with accepted standards to determine the degree of excellence. This helps to answer questions such as: What health resources, barriers, Policies, regulations and organizational factors need to be adjusted?

Quality is increasingly becoming an important aspect of health care. Patients have become more aware of quality issues and want health care of high quality.

User evaluations are important for continuous quality monitoring and improvement of the health care system.

Consumer feedback alerts managers to users' needs and concerns and identifies service delivery failure.

 Consumer surveys also encourage professionalism amongst staff making them accountable for the quality of service they deliver.

There is a general agreement that quality should be assessed from the viewpoints of major stake holders such as patients, care providers, politicians and health administrators.

 Quality assessment Includes:

Resources (both material and human resources)

Barriers

Policies

Regulations and

Organizational factors that need to be adjusted.

MONITORING AND EVALUATION

This aims:

To detect variation in the quality of care

To maintain minimum standards of health care.

To minimize the risk of errors

To help maintain professional competencies in health care.

To provide constant feedback

monitoring is done routinely and assists in day to day management of projects

evaluation is periodical and tends to answer questions of effectiveness and impact

 

Examples of monitoring

Checking TB patient cards on every visit helps to monitor the adherence of patients on treatment.

Weekly review of stock cards helps to monitor the availability of drugs.

Tallying cases of mothers presenting with malaria in pregnancy every week helps to monitor the trends of malaria in an area.

In healthcare, monitoring is often conducted through:

Review records and reports

supervisory assessments

self-assessments; peer assessments

Client feedback

Poll community activities

Benchmarking.

RECAP MONITORING

Continuous process of data collection and analysis about the ongoing project

Keeping track with the progress of the ongoing implementation activities

Done to determine actual performance and could be done daily, weekly, monthly or quarterly

Identifying aspects that are working according to plan and those that may require adjustments

Monitoring and evaluation is essential because:

 it is important to ensure that the implementation process is done well

Is done periodically to know whether or not the actions taken to close performance gaps have closed the gaps and if these can be sustained over time.

Evaluation will enable:

 assessment of progress at a particular point in the life span of the project

determination of extent to which intended objectives have been accomplished

provide feedback on whether plans have been executed adequately and with what modifications if any determination of reasons for success or failure; future planning.

Evaluation refers to the formal systematic time bound measurement of how much things have changed because of the intervention(s) implemented.

Because there are many factors that cause things to change, a formal evaluation tries to demonstrate how much a specific intervention contributed to the change.

Types of Evaluation

Formative Evaluation – needs assessment, of current situation prior to a project.

Situational Evaluation – On-going self-evaluation- small scale, short time period, used by managers participating personnel and community.

Summative Evaluation – End of program. To see if long term objectives have been met.

PURPOSE OF EVALUATIONS

Assess progress made at a particular point in time (mid-term or end of project evaluation)

Assess progress towards achievement of set objectives

Provide feedback on whether plans are being or have been met

Demonstrates how much a specific intervention contributed to a given change.

Answers whether the initial assumptions made were valid; what worked and what failed

Provide reasons for success or failure

Provide a basis of future planning

USES OF EVALUATION

Assess progress made at a particular point in time (mid-term or end of project evaluation)

Assess progress in achieving set objectives

Provide feedback on whether plans were met

Provide reasons for success or failure

Provide a basis of future planning

MONITORING AND EVALUATION TOOLS

Performance Audit

Nursing Audit

Consumer driven quality.

Accreditation

PERFOMANCE AUDIT

Performance audit refers to an examination of a program, function, operation or the management systems and procedures of a governmental or non-profit entity to assess whether the entity is achieving economy, efficiency and effectiveness in the employment of available resource. (Bratton and Gold, 1999).

Measure the effectiveness of the activities that are being undertaken.

The efficiency of the way the activities are performed

The way the economy is considered or the expenditure for the activities.

Performance Audit Measures:

effectiveness of activities being undertaken.

efficiency of activities performed

Economy or the expenditure for the activities.

APPROACHES USED IN PERFORMANCE AUDIT

1.The audit may take a result-oriented approach, which assesses whether pre-defined objectives have been achieved as intended. Also whether the set guide lines are been followed or not.

2. The audit may take a problem- oriented approach, which verifies and analyses the causes of a particular problem(s). Here the audit team may visit an institution with reported abuse of office. They will audit that place to verify the abuse  and a report is written depending on the findings.

3. The audit may take a system-oriented approach which examines the proper functioning of management systems: or a combination of the three.

An example can be drawn from the referral system in our health care system where UTH is a referral institution and as such it has to see patient 

who are referred from other health centers with complicated cases.

Patients are not supposed to come to UTH direct from home so that the referral hospital is not congested. If a patient does this she is made to pay a bypass fee.

The audit team has to see that the referral system is working well.

So they will sit at the opd and count how many patients have been referred and how many are self-referrals. A report has to be written at the end of the exercise on the referral system whether its effective or not. Patients are treated according to treatment protocol.

AREAS OF AUDIT

The following areas are mostly looked into during the process of performance audit. These are often referred to as the three E’s.

Efficiency.

Effectiveness.

Economy

Effectiveness: This relates to the outcomes or results of a program or activity. A performance audit will compare the planned outcomes with actual outcomes. An example could be where disease rates have fallen as a result of healthcare.

Efficiency: This generally refers to the best way of doing things, but with regard to acceptable quality. It is concerned with the relationship between goods and services produced (outputs) and the resources used to produce them (inputs).

That is, getting the most from available resources. An example could be where waiting times for emergency care at hospitals have reduced over time. This can be done through buying of equipment for investigations, employing more personnel etc

Economy: This generally refers to the cheapest way of doing things, but with regard to acceptable quality. It is concerned with minimizing the cost of resources used (e.g. people, materials, equipment). An example could be where healthcare supplies or services are purchased at the best possible price.

Performance audits are important because they seek to improve the accountability and performance of government organizations so that the community receives value for money from government services.

PERFORMANCE AUDIT PROCESS

Performance audits have three key phases:
 Planning: During this phase the performance audit team develops the audit objectives, criteria and plans the audit fieldwork. Audit criteria are standards of performance against which an organization or program is assessed.

Criteria may be based on best practice, international standards, government targets, procedures or guidelines.

Fieldwork: During this phase the performance audit team will collect information relevant to each audit criterion. This generally involves interviewing people within the organization, undertaking surveys, and reviewing documents and data

Reporting: At the end of fieldwork the auditors will meet with the organization’s management team to discuss the audit’s findings. Following this they prepare a draft performance audit report which they will also discuss with management to check that facts presented in the report are accurate and that any recommendations are practical and appropriate. A final report is then provided to the head of the organization and to the government.

ADVANTAGES OF PERFORMANCE AUDIT 

1 . Errors are Located
Auditing is helpful as errors can be located through it and correction of these errors is possible through auditing. The true and fair information about business is available.

2. Frauds are discovered
Auditing is helpful in discovering malpractices in an institution. The guilty persons can be held responsible.

3. High Moral Values
auditing is essential for   moral check on the management and other staff.

Auditing puts the pressure on the staff to work honestly. There is no pending work so there is less chance of errors and frauds and organizational goals are met.                                                                                                     

4. Efficiency Improves
Auditing is beneficial. The auditing determines the efficiency of employees and identifies training needs. Foster professional development.

NURSING AUDIT

Definition –

Nursing audit is an assessment of the quality of nursing care and uses a record as an aid in evaluating the quality of care.

is adopted as a means of developing high quality nursing care which has become essential in the daily health care delivery.

is a way of ensuring quality nursing care.

Nursing Audit is evaluation of Care given to clients patients in order to:

To achieve deserved and feasible quality of nursing care

To stimulate better record keeping

To focus on care provided and not on care provider

To contribute to research in nursing

It includes retrospective and concurrent review

Goal -To review continually and improve the quality of nursing care provided.

 Nurses should understand their responsibility which is so fundamental to the audit approach

 Purpose

Evaluating Nursing care given,

Achieves deserved and feasible quality of nursing care,

Stimulant to better records

Focuses on care provided and not on care provider,

Contributes to research should know how to monitor as well as evaluate the care they offer to clients

 

METHODS USED IN NURSING AUDIT

Two main methods:

A.     Retrospective view - this refers to an in-depth assessment of the quality of nursing care by examining the care as it is reflected in the patient care records after patient has been discharged.

Specific behaviors are described then they are converted into questions and the examiner looks for answers in the record

Example: During maternal death reviews and clinical presentations.

            find out whether quality care was offered and if not what went wrong and how best  

            can we   improve the quality of care.

      B. The concurrent review

           Refers to the evaluations conducted on patients who are still undergoing care.

          It includes assessing the patient at the bedside in relation to pre-determined criteria,

           interviewing the staff responsible for this care and reviewing the patient’s record and

           care plan.

           Example: in our setting this kind of audit is used during nursing rounds and case

           presentations   

           (like the ones done in clinic six and cancer diseases hospital).

           During this review, current cases are reviewed and discussions are done on how best to   

           improve the care being offered.

           Other methods of nursing audit

          Outcome audit – done to determine the end results of nursing intervention.

          assume the outcome accurately and demonstrate the quality of care that was provided

          example used to measure quality of hospital care including mortality, its morbidity, and

           length of hospital stay during clinical presentations..

       

        Process audit - used to measure the process of care or how the care was carried out.

         task oriented, focus on whether or not practice standards are being fulfilled

         used to evaluate the quality of care and the adherence to the prescribed standards.

         done during in-charges/ ward affairs meetings.

    Structure audit - monitors the structure or setting in which patient care occurs, such as the   

          finances, nursing service, medical records and the environment.

          done during performance assessment.

          PRINCIPLES OF NURSING AUDIT

          a. Define the objectives

          b. Set standards to meet the objectives 

          c. Implement the standards

          d. Measure and record the standards set

          e. Monitor new standards and change as appropriate

          f.  clear and free flow communication

             AUDIT PROCESS

             Every audit project is unique, but the audit process is similar for most engagements     

             and  normally consists of four stages:

             A. Preliminary Review

             clients are notified of the audit then discuss the scope and objectives of the examination    

              in a formal meeting with the organization's management.

            Followed by gathering information on the important processes, evaluating existing

            controls,and planning the remaining audit steps.

           

 

              Fieldwork

             The fieldwork concentrates on transaction testing and informal communications.

             Auditor determines whether the controls identified during the preliminary review are  

             operating properly and in the manner described by the client.

             Audit Report

             The principal product is the final report in which opinions are expressed, present the 

             audit findings, and discuss recommendations for improvements.

             To facilitate communication and ensure that the recommendations presented in the

             final report are practical

              Follow-up Review

             review to verify the resolution of the report findings.

            The client responses are reviewed and the actions taken to ensure that the desired results    

             are achieved.

            All unresolved findings will be discussed in the follow-up report.

            ADVANTAGES OF NURSING AUDIT

            Used as a method of measurement in all areas of nursing care as scoring system is fairly 

            simple and the results easily understood.

            It promotes improved communication among colleagues and other professional groups

            useful tool as part of a quality assurance/improvement programme in areas where    

            accurate records of care are kept. improves patient care, continuity of care, cost efficient

            and increased professional satisfaction

             saves time due to changes in practice and encourages self-improvement

          

 

              DISADVANTAGES OF NURSING AUDIT

             Appraises the outcomes of the nursing process, so it is not so useful in areas where the  

             nursing process has not been implemented,

            Many of the components overlap making analysis difficult,
            It is time consuming in conducting the audit and requires a team of trained auditors

            Deals with a large amount of information

            Diminished clinical ownership because of fear of litigation

             CONCLUSION

             Quality Assurance (QA) approach was in the past but has now shifted to quality  

             improvement. This approach focuses on the performer and how he/she can improve

              performance. It aims at raising the quality of health care management, increasing

              effectiveness and contribute to reduction of morbidity and mortality resulting from   

              poor case management.

              Using different methodologies and auditing techniques   helps to identify the gaps that Exist and may arise in our Health Care Delivery System, when these gaps are identified, different interventions or strategies are employed to fill these gaps and thereby improving quality of health care.