QUALITY IMPROVEMENT activities MS. LOURADEL M.

ULBATA, RN, MAN

CONTINUOUS QUALITY IMPROVEMENT (CQI) the process used to investigate systematically ways to improve patient care QUALITY IMPROVEMENT ACTIVITIES Clinical Pathways Medical/Nursing Audit Utilization Review Morbidity and mortality meetings Credentialing and Clinical Privileging 5S METHODOLOGY Clinical pathway Clinical pathways, also known as care pathways, critical pathways, integrated care pathways, or care maps are one of the main tools used to manage the quality in healthcare concerning the standardization of care processes. Generally clinical pathways refer to medical guidelines Multidisciplinary management tool based on evidencebased practice for a specific group of patients with a predictable clinical course, in which the different tasks (interventions) by the professionals involved in the patient care are defined, optimized and sequenced either by hour (ED), day (acute care) or visit (homecare). Outcomes are tied to specific interventions. History

Medical audit the systematic, critical analysis of the quality of medical care, including the procedures for diagnosis and treatment, the use of resources, and the resulting outcome and quality of life for the patient. Purposes of Nursing Audit 1. Evaluating Nursing care given 2. Achieves deserved and feasible quality of nursing care 3. Stimulant to better records 4. Focuses on care provided and not on care provider 5. Contributes to research Methods of Nursing Audit 1. Concurrent nursing audit 2. Retrospective nursing audit Retrospective view This refers to an in-depth assessment of the quality of care after the patient has been discharged, having the patients chart as the source of data. Is performed after discharge from the care facility, using the patient's record. Is a method for evaluating the quality of nursing care by examining the nursing care as it is reflected in the patient care records for discharged patients. Concurrent review This refers to the evaluations conducted on behalf of patients who are still undergoing care. Is performed during ongoing nursing 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 patients record and care plan. Audit as a Tool for Quality Control An audit is a systematic and official examination of a record, process or account to evaluate performance. Auditing in health care organization provide managers with a means of applying control process to determine the quality of service rendered. Nursing audit is the process of analyzing data about the nursing process of patient outcomes to evaluate the effectiveness of nursing interventions The audits most frequently used in quality control: 1. Outcome audit

The clinical pathway concept appeared for the first time at the New England Medical Center (Boston, USA) in 1985 inspired by Karen Zander and Kathleen Bower.

Clinical pathway The pathway design tries to capture the foreseeable actions which will most commonly represent best practice for most patients most of the time include prompts for them at the appropriate time in the pathway document to ascertain whether they have been carried out, and whether results have been as expected. Nursing Audit Nursing audit is a detailed review and evaluation of selected clinical records by qualified professional personnel for evaluating quality of nursing care. Nursing audit refers to assessment of the quality of clinical nursing". Nursing Audit (a) It is the assessment of the quality of nursing care (b) Uses a record as an aid in evaluating the quality of patient care.

Outcomes are the end results of care; the changes in the patients health status and can be attributed to delivery of health care services. Outcome audits determine what results if any occurred as result of specific nursing intervention for clients. Example of outcomes traditionally used to measure quality of hospital care includes mortality, its morbidity, and length of hospital stay.

2. Process audit

2. 3. 4.

Process audits are used to measure the process of care or how the care was carried out. Process audit is task oriented and focuses on whether or not practice standards are being fulfilled. These audits assumed that a relationship exists between the quality of the nurse and quality of care provided.

ensure patients are receiving appropriate services reduce medical adverse reactions Eliminate unnecessary treatment and deliver services more efficiently.

3. Structure audit

Structure audit monitors the structure or setting in which patient care occurs, such as the finances, nursing service, medical records and environment. This audit assumes that a relationship exists between quality care and appropriate structure.

Morbidity and Mortality Conference Provide a safe venue for residents to identify areas of improvement, and promote professionalism, ethical integrity and transparency in assessing and improving patient care. The M&M Conference also provides a forum to teach curriculum on quality improvement and medico legal issues to residents and students and to foster a climate of openness and discussion about medical errors. Credentialing and Privileging Is the first step in a patient safety program Reduces the risk to patients for adverse outcomes by completing the appropriate assessment of staff, reducing the risk for liability Allows for a systematic review that ensures practitioners have kept abreast of new developments and have competencies for approved privileges Credentialing o the systematic process of screening and evaluating qualifications and other credentials, including licensure, required education, relevant training and experience, and current competence and health status Clinical Privileging o the process by which a practitioner is permitted by law and the facility to practice independently, to provide medical or other patient care services within the scope of the individuals license, based on the individual's clinical competence as determined by peer references, professional experience, health status, education, training, and licensure. 5S (methodology) 5S is the name of a workplace organization methodology that uses a list of five Japanese words which are seiri, seiton, seiso, seiketsu and shitsuke. Translated into English, they all start with the letter "S". The list describes how to organize a work space for efficiency and effectiveness by identifying and storing the items used, maintaining the area and items, and sustaining the new order. Phases of 5S There are 5 primary phases of 5S: 1. Sorting (Seiri) 2. Straightening (Seiton) 3. Systematic cleaning (Seiso) 4. Standardizing (Seiketsu) 5. Sustaining. (Shitsuke)

Advantages of Nursing Audit: Can be used as a method of measurement in all areas of nursing. Scoring system is fairly simple Results easily understood Assesses the work of all those involved in recording care. May be a useful tool as part of a quality assurance programme in areas where accurate records of care are kept. Disadvantages of the 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 is time consuming requires a team of trained auditors deals with a large amount of information only evaluates record keeping. It only serves to improve documentation, not nursing care. Utilization Review are used to evaluate the efficiency, appropriateness, necessity and efficacy of health care services that patients receive. It is conducted by auditing medical charts and related documentation about a patient's care. Function 1. Utilization review serves to provide a health care organization with information about how their medical services are being utilized by patients. 2. Health care administrators use the data found in utilization reviews to make projections about things like funding and process improvement protocols. ADVANTAGES: By performing utilization reviews, health care administrators can: 1. maintain patient safety

1. Sorting (Seiri) Eliminate all unnecessary tools, parts, and instructions. Go through all tools, materials, and so forth in the plant and work area. Keep only essential items and eliminate what is not required, prioritizing things per requirements and keeping them in easily-accessible places. Everything else is stored or discarded. 2. Straightening or setting in order / stabilize (Seiton) There should be a place for everything and everything should be in its place. The place for each item should be clearly labeled or demarcated. Items should be arranged in a manner that promotes efficient work flow, with equipment used most often being the most easily accessible. Workers should not have to bend repetitively to access materials. Each tool, part, supply, or piece of equipment should be kept close to where it will be used in other words, straightening the flow path. This phase can also be referred to as Simplifying[1]. 3. Sweeping or shining or cleanliness / systematic cleaning (Seiso) Clean the workspace and all equipment, and keep it clean, tidy and organized. At the end of each shift, clean the work area and be sure everything is restored to its place. This makes it easy to know what goes where and ensures that everything is where it belongs. Spills, leaks, and other messes also then become a visual signal for equipment or process steps that need attention. A key point is that maintaining cleanliness should be part of the daily work not an occasional activity initiated when things get too messy. 4. Standardizing (Seiketsu) Work practices should be consistent and standardized. All work stations for a particular job should be identical. All employees doing the same job should be able to work in any station with the same tools that are in the same location in every station. Everyone should know exactly what his or her responsibilities are for adhering to the first 3 S's. 5. Sustaining the discipline or self-discipline (Shitsuke) Maintain and review standards. Once the previous 4 S's have been established, they become the new way to operate. Maintain focus on this new way and do not allow a gradual decline back to the old ways. While thinking about the new way, also be thinking about yet better ways. When an issue arises such as a suggested improvement, a new way of working, a new tool or a new output requirement, review the first 4 S's and make changes as appropriate.

The Origin of 5S o developed by Hiroyuki Hirano o Japanese o Hirano identified a range of benefits from improved housekeeping o they are all based around the elimination of waste in one form or another. The Objectives of 5S 1. Improved productivity most obvious benefit from items being organized in such a way (i.e. that they are always readily available) often-needed items are stored in the most accessible location and correct adoption of the standardisation approach means that they are returned to the correct location after use 2. Quality Standard Operating Procedure for tool certification is much easier to achieve if the tool to be certified is always in a clearly-marked location 3. improved Health & Safety Clear pathways between workbenches and storage racks can minimise accidents, as can properly-swept floors The Objectives of 5S

The successful implementation of 5S requires that everyone understand why it is being used and what the expected results are. The aim is improvement in business performance; the adoption is not an end in itself.