Assignment on

on

Quality Assurance

Submitted to
Submitted by
Madam A. Mukherjee
Senior Lecturer
M.Sc. Nursing final year student
W.B.G.C.O.N.
W.B.G.C.O.N.
I.P.G.M.E.& R. SSKM Hospital
Kolkata I.P.G.M.E.& R. SSKM Hospital
Kolkata
 Introduction

Morbidity on account of mental illness is set to overtake cardiovascular diseases as the single
largest risk in India. There are over two crore persons in our country who are in need of
treatment for serious mental disorder and about five crore people who are affected by
common mental disorder.

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

Florence Nightingale introduced the concept of quality in nursing care in 1855 while
attending the soldiers in the hospital during the Crimean war.

Quality refers to excellence of a product or a service, including its attractiveness, lack of

defects, reliability, and long-term durability.

Quality assurance provides the mechanisms to effectively monitor patient care provided by
health care professionals using cost-effective resources.

Quality assurance is generally and defined as the process where the performance of a system
or service is assessed and evaluated to ensure that a high quality, safe service is offered and
delivered to those using it, and that it complies with agreed standards, accreditation and any
relevant legislation and safety requirements. Quality assurance generally takes the form of a
range of activities, from the identification and monitoring of appropriate standards
(international, national, regional and local) including clinical safety and clinical standards, to
the formal and Informal monitoring and inspection of services, to the lodging of,
investigation into and reporting of complaints and serious incidents to advocacy for those
using the service. The main objective of these activities is to ensure a good quality and safe
Service system for those using them, their families and carers and a level of assurance for all
the communities.

Meaning of Improved quality in mental health care

 Preserve the dignity of people with mental disorders.

 Provide accepted and relevant clinical and non-clinical care aimed at reducing the impact
of the disorder and improving the quality of life of people with mental disorders.
 Use interventions which help people with mental disorders to cope by themselves with
their mental health disabilities.
 Make more efficient and effective use of scarce mental health resources.
 Ensure that quality of care is improved in all areas, including mental health promotion,
prevention, treatment and rehabilitation in primary health care, outpatient, inpatient and
community residential facilities.

Quality comprises of

– Acceptability

– Affordability

– Effectiveness

– Comprehensiveness

Assurance refers to the process that includes

– The identification of values and standards

– Specification of criteria

– Measurement of observable aspect of care

Aim of QA in psychiatric Nursing

QA is an important aspect of psychiatric nursing

– Funds are available only after evidence is provided that predetermined standards of care
have been met.

– QA helps nurse monitor their own practices in a systematic way.

– QA ensures the public confidence in health care professionals

– QA is one way in which professional nurses regulate their profession in order to maintain
high level of nursing practice and at the same time retain the confidence of the public.

Improving Quality of Mental Health Care

The steps in improving quality are cyclical.

Step 1. Align policy for quality improvement

 Policy-makers have a key role in the quest for quality. They are in a position to establish
the broad parameters of quality through consultation, Partnerships, legislation, funding
and planning.
 Consultation (Functions): Obtaining input from various stakeholders, sharing information
across stakeholder groups and building a common understanding. The development of
such an understanding is an essential task of policy-makers.
 Partnerships (Functions): Partnerships with professional groups, academic institutions,
advocacy groups, Other health and social service sectors.
 These partnerships form the backbone of the quality improvement process and enable
long-term sustainability. They build consensus and consistency in messages related to the
need for quality and can also serve to mobilize resources and other necessary supports.
Legislation: Policy-makers should promote legislation that reflects concern for and
emphasis on quality.
 Funding: Financial systems for mental health care should be aligned so that they
maximize quality and do not become an obstacle to quality improvement.Improved
efficiency is an essential goal in relation to both quality improvement and cost
containment.
 Planning : Quality processes can inform planning by providing a knowledge base for
evidence-based practice. In the course of planning, several issues pertaining to resource
allocation and priority-setting have a bearing on quality.

Step 2. Design standards

 Once policies have been aligned for quality the next essential step is to develop a set
of standards against which services can be measured. Planners and managers should
establish a working group Consult with relevant stakeholders and draft a standards
document.
 The standards document should cover all aspects of a mental health service.
 Criteria for each standard should be specified.
 These criteria should provide a means for rating existing services.
 The rating of services should be supplemented by observations on the quality of all
aspects of mental health care.
Step 3. Establish accreditation procedures

 Accreditation provides the opportunity to assess the quality of care delivered by a mental
health service and to provide the service with the appropriate legal recognition.
 Accreditation is essential because it makes quality a cornerstone of the official licensing
of mental health services or facilities.
 Service planners should ascertain whether any accreditation procedures already exist
which can be used to assess current services.
 Outdated procedures should be reformed in keeping with the evidence for the most
clinically effective and humane forms of mental health care.
 Accreditation procedures should be developed if there are none.
 The standards document developed in step 2 can be used as a structure to provide criteria
and a rating system for assessing services and conferring the appropriate legal status.

Step 4. Monitor the mental health service by using the quality mechanisms

 Use standards to assess the service annually.

 Use of accreditation procedures to assess and accredit new service developments and to
review the ongoing functioning of services.
 Routine information-gathering through existing information systems, particularly by
means of performance and outcome indicators.
 Consultation with independent organizations for to assess people with mental disorders
and advocacy groups.

Step 5. Integrate quality improvement into the ongoing management and delivery of
services

 Managing annual service quality reviews; including quality checks in service planning
targets;
 Building quality improvement into clinical practice through evidence-based practice,
clinical practice guidelines, teamwork and continuing professional development; audit.
 Step 6. Consider systematic reform for the improvement of services.
 An assessment of the quality of a mental health service may indicate a need for
systematic reform or improvement.
 This step may require concrete planning and coordination by various sectors.
Step 7. Review the quality mechanisms

 A review of quality mechanisms is necessary in order update them in accordance with

evidence on the most effective methods of quality improvement.

Key components in quality assurance includes

– Standards of care

– Criteria specific to practice

– Protocols for nursing intervention

– Audits or review of care procedure

– Peer review

– Level of practice

– Professional development activities

– Credentials

– Licensure

– Certification

Standards of care

Standards of care is drawn from available knowledge about human being, the norms of group
who care for patients and values of nurses.

  E.g Rights of client

– to safeguard

– To experience a sense of personal acceptance

Formation of Standards of care

Involves a task forces or other committees and presentation of preliminary statements of

standard to the members of organization for criticism and revision. Nurses who are most
influential in development of standards are those

– who have achieved a significant level of experience in a particular functional area

– Higher education

– Recognized by the peers as being outstanding.

Criteria

Criteria are specific, predetermined rules or principles developed by health care practices for
a given setting and against which the health care practices implemented in that setting are
compared.

Three types of criteria are generally used:

Structure criteria, Process criteria and Outcome criteria.

Structure criteria

It indicates the aim and purposes of institution or agency or program and can be designed for
the institution, or agency, the client or the nurse. Statement may be made about the
philosophy and objectives of the institution, the facilities, administrative organization,
regulations, standards and procedures. E.g of structure criteria are

– The expectation that staff nurses have completed a course in group therapy

– The requirement that each client in each unit has an attendant to provide care.

Process Criteria

Process criteria are used in the evaluation of actions and the sequence of behavior and events
during the provision of client care. E.g documentation of the therapeutic one to one
relationship and progress notes

– Data to indicate whether or not the nursing care plan was developed
Benefits

To identify problems that occur while caring for clients and to take immediate measures that
can change or improve the final outcome of care. Enables the nursing dept. to evaluate the
extent to which care is completed. The implementation of policy and procedures and the
activities.

Outcome criteria

– Developed to evaluate the end result of the care and services provided to the client E.g
client orientation about time, place, person and his responsibility for activities of daily living
when discharged from hospital.

Limitation of outcome criteria

When the outcome or effect of intervention are reviewed and it is found that it is not reaching
the standards or predetermined criteria then It is difficult to determine whether

– it is due to faulty nursing process or

– due to uncooperative patient

Protocols

A protocol is an instrument that guides a practitioner in the collection of data and

recommends specific action based on that data.

– Written statement of specific interventions for certain signs and symptoms

– Guidelines to be used in chronic illness.

In hospital quality assurance programs protocols may be defined as statement of behaviors

identified as discrete steps used by nurses in the attainment of long and short-term goals

Aim

 To become more aware of the procedure.

 To identify specific stages in client care that have been accomplished well or poorly.
 To direct nursing intervention.
 To intervene in client care when physicians are not available.
 To serve as specific statements of nursing behavior that can be incorporated into quality
assurance activities.

Development of protocol

Developed by multidisciplinary committee composed of professional health providers who

function within that setting. Members are physician often because they are recognized as
health team leader and have the right to prescribe medication. Such committee also develop
protocol after a review of literature.

Audits :

Auditing is the verification that the nursing care given to client is appropriate and in
accordance with the predetermined standards of nursing care in a particular area.It is a
mechanism used to asses and verifies the quality of client care.

Methods of nursing audit are the Concurrent view and the Retrospective view

Concurrent audit:

It is a method of evaluating ongoing activities, assessment at the time of review of one

particular aspect of care. E.g whether side rails are up on the beds of confused elderly
client.Benefits are:-

Allows corrective actions to be taken immediately.

Quickly improves the quality of care.

Immediate feedback.

Opportunity to develop greater capabilities in clinical role.

Retrospective audit :

It was applied after services have been rendered. Data one can get from records or interview

Peer review : It is the process by which the quality of nursing care rendered by a nurse is
evaluated by other psychiatric nurses actively involved in clinical nursing practice.

Aim
To improve overall client care.

Allows the contribution of individual nurses to be appraised.

Promote individual accountability and are often the primary way of recognizing clinical
expertise. It allows degree of consistency between practice and predetermined standards.

Levels of practice

Ranking or a degree of performance supported by a particular knowledge base and

development of required skill.The inclusion of the levels of practice concept in a quality
assurance provides a more precise description of the unit being evaluated and the level of
care being rendered.Eg: Psychiatric Registered Nurses, Psychiatric Nurse Practitioners,
psychiatric nurse managers

Professional development : The term professionalism implies

– certain levels of competence in nursing practice and

– educational accomplishments

– that reflect breadth of knowledge, skill, and personal maturity.

Continuing education program: Includes short term planned programs of courses under the
direct direction of staff educators or academicians. Learning experience are designed to
enhance previously acquired knowledge and skill. Post Basic and Post-graduate education:
Includes program of study under the direction of professional educators in college or
university. Function: To prepare nurse specialist with the additional knowledge and skill
necessary to exercise independent judgment.

Diploma in Psychiatric Nursing (DPN):

It is a post basic mental health psychiatric nursing programs, emphasis is usually placed on

– Assessment

– Awareness of the most frequently encountered emotional problems and pathological

conditions,

– Appropriate nursing intervention

– Modes of evaluation
Post graduate in Psychiatric Nursing (MSc-Psychiatric Nursing.) : Is a post graduate mental
health psychiatric nursing programs, emphasis is usually placed on

– Clinical competences in assessment,psycho-pathology of various conditions, diagnostic

criteria, appropriate treatments, nursing interventions and rehabilitation.

– Modes of promotion of mental health and prevention of mental disorders.

– Teaching of mental health nursing.

– Research in the areas of Mental health. Credentials

A credentials attests the institution or a person to function in a function in a particular area of

expertise.

To acquire a credential, an institution or individual is identified by a recognized authority as

credentials are inherent in any quality assurance program and the possession of appropriate
credentials constitutes a part of the audit process.

Four fundamental features are quality, identity, protection and control.

Nursing credentials include Licensure, certification and Accreditation

Licensure : They suggest that institutional licensure will costs and promote efficiency by:

– Providing opportunity for evaluation of individual on site performance

– Allowing for innovative continuing education programme in hospitals

– facilitating career mobility

Certification : It is the formal recognition of the specialized knowledge, skills, and

experience demonstrated by the achievement of standards identified by a nursing specialty to
promote optimal health outcomes.

Practice models : Practice models may be defined as various pattern in delivery of nursing
services by which health care is made available to diverse groups of people in different
settings.
Frame work for Quality Assurance

One suggested framework for quality assurance consists of two key’pillars’, each with a core
set of interrelated functions:

1. Rights and protections

 Protecting the rights of involuntary users of services

 Protecting the rights voluntary users of services and their carers /supporters
 Independent advocacy for users of services and their carers/supporters
 A complaints procedure for users of services and their carers/supporters

2. Quality management

 Setting standards and outcomes

 Independent inspection, monitoring and evaluation
 Pre qualification and licensing of providers
 Reporting and monitoring of sentinel events
 Professional Performance Standards

As the field of nursing grows and changes in defining the role of a nurse, the central theme
will always be that of caring. It can be said that, all other duties and responsibilities of nurses
have centered around, “caring”. With the emergence of the, “caring”, theorists also came the
emergence of “Standards of Profession Performance”.

The American Nursing Association set forth the following requisites for standards of
professional performance.

 Standard I : Quality of care

Psychiatric mental health nurse systematically evaluates :

– Quality of care

– Effectiveness of mental health nursing practice.

 Standard II: Performance appraisal

Mental health nurse evaluates:

– One’s own mental health nursing practice standards

– In relation to national and state statutes and regulations.

Two ways of performance appraisals

1. Administrative performance appraisal:

Involves review, management, regulation of competent psychiatric nursing practice.Involves

supervisory relationship in which a nurse’s work performance is compared with the role
expectations.Helps in identify the competency area and areas of improvement.

2. Clinical performance appraisal:

Guidance provided through a mentoring relationship and clinical supervision with a more
experienced, skilled and educated nurse.

 Standard III: Education

Psychiatric nurse acquires and maintains current knowledge in nursing practice.

 Standards IV : Ethics

The psychiatric nurse’s assessments, actions & recommendation on behalf of the patient are
determined and implemented ethically.

 Standard V : Research

The psychiatric nurse contributes to nursing & mental health through the use of research
methods and findings.

Role of psychiatric nurse in QA

• Acute(Emergency ward)

 Shorten duration of hospital stays

 Prevention of re-hospitalization
 Consideration of human rights
 Family support
  Careful nursing

• Sub-acute(General ward)

 Enhancement of intensive rehabilitation

 Improvement of patient’s QOL
 Enhancement of patient and family psycho-education
 Improvement of adherence

• Recuperation(Convalescent ward)

Enhancement of rehabilitation by interdisciplinary team

•The roles of nursing administrators and managers in improving psychiatric care services

Improvement of patient’s daily life skills and abilities Enhancement of patient mental
education Improvement of adherence and self-care

Conclusion

QA is the process by which the maintenance of excellence in the provision of health care is
ensured. Everyone in need should have access to basic mental health care, the key principles
are that care should be equitable and accessible.

To improve the quality of psychiatric services, the following matters require attention :

Clarifications of psychiatric service goals precise measurement of effects, shortened

hospitalizations. Implementation of patient-centered care includes establishment of trust
relationships with patients based on open communication and effective interdisciplinary team
work. In addition, nursing administrators and managers must judge the clinical competency
of nurses and assign them appropriately.
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