QUALITY IMPROVEMENT
• The process or processes of reducing variance is quality improvement. It is the process of attaining a new level of performance or quality that is superior to any previous level of quality.
STEPS OF QUALITY IMPROVEMENT
According to the quality cycle developed by USAID QA project:-
Planning for quality
Setting a standard
Communicating of standard
Monitoring
Identification and prioritization of improvement opportunities (IQ)
Defining the key IQs
Organizing a team
Analyzing and studying the IQs for root causes
Developing solution and actions for improvement
Implementing and evaluating improvement efforts, then restarting the cycle again.
APPROACH TO QUALITY:-
Juran developed a three-part (trilogy) approach to quality:
Quality planning, quality control and quality improvement.
Quality Planning:- it involves determining who the customers are and what their needs are, then developing products based on those needs and designing processes to produce those products.
Quality control:- it is the evaluation of performance to identify discrepancies between actual performance and goals.
Quality improvement:- it establishes an infrastructure and the project teams to carry out process improvement.
QUALITY EVALUATION SYSTEM IN HEALTH CARE
The following are the examples of different approaches to quality evaluation that are used in different countries:
SPECIFIC APPROACHS
REGULATORY APPROACHES
SPECIFIC APPROACHS
Audit system
Quality awards
Peer Assessment
Utilization review: Utilization review activities are directed towards assuring that care is actually needed & the cost appropriate for the level of care provided.
There are three types of utilization review:
Prospective ,Concurrent, Retrospective
Clients’ satisfaction
REGULATORY APPROACHES
Licensure
Accreditation
Certification
INTRODUCTION
• Standards can be defined as a benchmark of achievement, which is based on a desired level of excellence. As such, standards become model to be initiated & may serve, in turn, as basis of comparisons.
CONCEPTS OF STANDARDS
These are degree of excellence.
Serves as basis of comparison
Are minimum parameters with which a community may be reasonably content
Is recognized as a model for imitation.
COMPONENTS OF STANDARDS
Standards are written.
Standards define the set of rules, actions or outcomes.
Standards are written for customers, staff members and system.
Standards are approved by authority.
CHARACTERISTICS OF STANDARDS
Standards must be:
Specific
Measureable
Appropriate
Reliable
Timely bounded
STEPS FOR DEVELOPMENT OF NURSING STANDARDS
Identify a team or panel of nursing experts.
Decide an area of nursing practice for which the standards are to be formed. Review philosophy, purposes and objectives.
Review nursing theories or existing nursing care practices, nursing process. Identify the patient for nursing services, patients’ role, approaches & strategies of nursing care services.
Discuss with the nursing service administrators to get their approval so that they are made feasible.
Devise a mechanism for determining the achievement of standards.
Determine the validity and reliability of the measuring tools.
Try out the standards for feasibility.
The standards are then put into practice.
Quality care is then audited.
The standards are reviewed & revised.
TECHNIQUES USED IN PREPARATION OF STANDARDS IN NURSING
Professional standards techniques
• This category contains the various guidelines & standard documents which health care professionals have published as a basis for quality assurance. These are based upon structure, process & outcome quality assurance model given by ANA.
Comprehensive Review System
• These standards are at high level of generality & several professional bodies suggest that their central standard should be used as a framework for more local exercises in specific standard setting. They local & specific thus grow out of the central and more general.
Process Appraisal Technique
• It focuses primarily on appraisal of the quality of process of care. The process of care comprises all the procedures & activities through which the health professional & support worker deploy their time, skills, knowledge & resources in pursuits of improved patient health & well-being. It has technical, interpersonal & moral components & includes access, diagnosis, treatment, discharge, after care, & health education & promotion.
NURSING AUDIT INTRODUCTION
• Nursing audit one of the control tools, responsible for controlling the activities of the nurses that focuses on providing the best possible nursing care. The actual nursing rendered is compared with the standards. This is mainly refers to the clinical nursing audit. The nursing management audit is an evaluation of nursing management as a whole.
DEFINITIONS
• According to Elison:- • Nursing audit refers to assessment of the quality clinical nursing.
• According to Cott:- • It is the process of evaluating appropriateness & effectiveness of nursing care measures.
CLINICAL AUDIT:-
The clinical audit has been defined ‘the systematic & critical analysis of the procedure used for diagnosis, care & treatment, the associated use of resources and the effect care has on the outcome & quality of life for the patient.
OBJECTIVES OF NURSING AUDIT
To improve the quality of nursing care.
To measure the degree of quality of patient care against a defined criteria
To decrease the cost of nursing care.
To provide a basis for determining nursing negligence.
To provide education to all the nursing personnel by the process of self education.
To enhance professional knowledge from past experiences by learning from past mistakes in records.
ADVANTAGE S OF NURSING AUDIT method of measurement valuable indicator simple process Tool of quality assurance programme.
DISADVANTA GES OF NURSING AUDIT analysis difficulty time consuming trained auditor large number of information
BASES OF NURSING AUDIT
Debit items:- these includes the items like death of the patient, complication of disease, hospital infection, errors in treatment, patient left against medical advice etc. these criteria or variables are against the quality care.
Credit items:-these are the items that gives credit to the care rendered. Number of recovered patients, expansion of health knowledge in patient population, shorter stay of patients etc is the example of this type of items.
Nursing auditors:- Nursing auditors required are of two types: internal and external. These should be trained auditors.
Quality:- it is a degree of excellence that need to be defined and predetermined on the basis; the nursing audit is to be done.
Nursing standard:- these should be valid and explicit statement about the quality of fact of nursing care. These are classified as : structure, process & outcome.
Activities:- these are goal oriented transactions required to carry out for auditing
Resources:- these are in relation to human and material required for auditing and desired health care.
TYPES OF NURSING AUDIT
According to methodology
According to type of auditors
According to methodology Retrospective ConcurrentRetrospective & Concurrent
According to type of auditors:
• a) Internal audit: review of work is done by peers or nursing personnel continuously.
• b) External audit: the audit is carried out by the outside agency. Usually periodically test, completeness and accuracy of internal audit is done. Review is done by non nursing administrators.
NURSING AUDIT PROCESS
Describing phase Preparing phase Implementing phase Analysis phase Concluding phase.
1-Describing phase:
Identify topic or issue or problem: this stage involves the selection of a topic to be audited. The topic should be important or significant and interest those conducting the audit.
The topic can be selected from various sources:-
Standard given by Indian Nursing Council
Problem encountered in practice
Recommendation of patient
Identify core group & form an audit team or committee:Audit committee comprising of minimum of five members either from unidisciplinary or multidisciplinary, who are interested in quality assurance, are clinically competent & able to work together in a group.
Preferably the audit committee should have:-
chairman,
clinical consultants,
representatives of hospital administrator,
statistical record officer,
representative of nursing personnel of all levels,
special invitee members.
Set audit criteria and standard: an audit criteria is a measurable outcome of care aspect of practice or capacity in a statement form that can be used to assess the quality.
Develop an audit protocol: An audit protocol should include:
Audit objectives
The target group
Selection of audit sample
Method of data collection
Tools to be prepared
2-Preparing & implementing phase:
1-Define criteria & prepare audit tools: prepare a rough draft of audit tools after refining criteria. Check the validity & reliability of tools.
2- Make a plan for gathering information:
This should include:
Who is going to gather Information.
Select the auditors
When to gather the information.
How large the target group at one time.
3-Get ethical approval from ethical committee
3- Implementing phase: during this phase data gathering has to be done.
4- Analysis & Concluding phase:
Analyze data & compare results with criteria & standard: after collection, analyze the data. Apply appropriate statistics, usually data is calculated in percentage in order to determine the level of standard. Compare data with set criteria.
Make an audit summary: specify how far the standards have been met & the reasons for failures to meet the standards in some cases. Make a brief report & give recommendations after discussion with audit team.
Plan & implementing change: a detailed action plan should be made specifying in detail who, when, what & how the changes are to be implemented. All the members of the committee are required to be informed & members ate to be assigned to monitor the changes implemented.
Reaudit : it is undertaken to ensure that the changes have been made in response to first audit & that the practice has improved or how effective the first audit.
INC CODE OF ETHICS
DEFINITION
A code of ethics is a formal statement of group's ideals and values.
PURPOSES
Standards for the behavior of nurse and provide general guidelines for nursing action
Helps to distinguish between right and wrong Enables a correct decision protect the rights of individual USES
Acknowledges the rightful place of individuals in health care delivery system
Contributes towards empowerment of individuals to become responsible for their health and well being
Contributes to quality care Identifies obligations in practice, research and relationships Informs the individuals, families, community and Other professionals about expectations of a nurse
ETHICAL PRINCIPLES
Respect and autonomy Beneficence
Justice Veracity Fidelity
THE ICN CODE
The ICN Code of Ethics for Nurses has four principal elements that outline the standards of ethical conduct.
ELEMENTS OF THE CODE
NURSES AND PEOPLE
The nurse's primary professional responsibility is to people requiring nursing care.
In providing care, the nurse promotes an environment in which the human rights, values, customs and spiritual beliefs of the individual, family and community are respected.
NURSES AND PRACTICE
The nurse carries personal responsibility and accountability for nursing practice and for maintaining competence by continual learning.
The nurse maintains a standard of personal health such that the ability to provide care is not compromised.
The nurse uses judgment regarding individual competence when accepting and delegating responsibility.
NURSES AND THE PROFESSION
The nurse assumes the major role in determining and implementing acceptable standards of clinical nursing practice, management, research and education. The nurse is active in developing a core of research-based professional knowledge.
The nurse, acting through the professional organization, participates in creating and maintaining safe, equitable social and economic working conditions in nursing.
NURSES AND THE COWORKERS
The nurse sustains a co-operative relationship with co-workers in nursing and Other fields.
The nurse takes appropriate action to safeguard individuals, families and communities when their health is endangered by a co-worker or any other person
NURSES AND SOCIETY
Participate and share responsibility with other citizens and other health professionals. Recognize and perform the duties Of citizenship. Aware Of laws and regulations which affect the practice of medicine and nursing
INC CODE OF ETHICS FOR NURSES IN INDIA
• The nurse respects the uniqueness of individual in provision of care.
• The nurse respects the rights of individuals as partner in care and helps in making informed choices.
• The nurse respects individual's right to privacy, maintains confidentiality, and share information judiciously.
Nurse maintains competence in order to render quality nursing care
CONSUMER PROTECTION ACT
The consumer protection act was introduced on 19th December, 1986 and passed on 21M December 1986 in Lok Sabha. It came into force on 15th August 1987 Aims of CPA, 1986 This Act aims to provide better protection to the interests of the consumers To make provisions for the establishment of consumer councils and other authorities to provide speedy and cheap remedy to the consumers It safeguards the rights of consumers
TERMS AND TERMINOLOGY USED IN CPA, 1986 COMPLAINT; an allegation shall constitute a complaint where the goods or services mentioned in the complaint suffer from deficiency in any regard.
COMPLAINANT: any consumer or voluntary consumer association registered under the companies act, 1956; or under any other law for the time being in force; the central or State government
CONSUMER: any person who buys any goods or avails of any service, for a consideration which has been paid or promised to be paid; either fully or partially or in some form of deferred payment
CONSIDERATION; refers to fees or payment paid to the doctor/hospital. This may be paid; either by the patient or guardian any other person on behalf of patient; and in Case of death of a patient; his legal heir becomes the consumer SERVICE: "means service of any description such as banking, financing. insurance, transport, processing, supply of electrical or other energy board or lodging entertainment, amusement or purveying of news or other information; but does not include the rendering of any service free of charge or under contract of personal service"
Introduction
A philosophy of nursing is a statement, sometimes written, that declares a nurse’s beliefs, values, and ethics regarding their care and treatment of patients while they are in the nursing profession.
· Philosophy is derived from Greak word ‘philos’ means love, and ‘sophia’ means wisdom. It is the loving and searching for wisdom and truth
Definition of philosophy
· Philosophy is the science of knowledge. --- Fitche
· Philosophy is the science of all sciences. ---- Coleridge
· Philosophy is an unceasing effort to discern the general truth that lies behind the particular facts ( that is the reality that lies behind the appearances).
Purposes of Philosophy
• Guiding the education system.
• Beliefs and values regarding God, man, life, health, diseases, nursing.
• The philosophical values and beliefs of the institution
• Environment where education takes place.
• Student life activities
• The culture and background of the people.
• The goals and objectives of the health care system.
• The diseases pattern and health awareness and facilities .
• The available resources in term of man, money, and material.
The philosophy of nursing education expresses beliefs regarding teaching / learning process, nursing education and the role of a practical nurse prepared by the nursing faculty.
Type of Nursing Philosophy
TYPES
Traditional philosophies
A. Naturalism
• Concerned with natural self.
• Believe in reality near to nature beyond nature there is no reality
• By naturalist nature is everything, they separate the nature from God.
Definition :
Naturalism is a system of which the salient characteristics is the exclusion of whatever is spiritual or supernatural.
Forms of Naturalism
• Physical Naturalism
• Biological Naturalism
• Mechanical Naturalism
Principles of Naturalism
1) Child centered education
2) Education as the natural development of the child’s power and capacities.
3) Negative education in early childhood.
4) Education should be based on child’s psychology .
5) The role of teacher should be as a guide.
Education implications of Naturalism
By using several methods, the teacher creates a congenital situation from the nature ,to provide sense of freedom for the individual development.
Naturalism and aims of education
1. Self expression.
2. Self-preservation.
3. Redirection of human instincts.
4. Struggle for existence.
5. Education according to the nature
Naturalism and curriculum
There is no rigid curriculum.
Naturalism and methods of education
1. Learning by doing.
2. Play-way method.
3. Observation
4. Experimentation.
5. Self education and self efforts.
Naturalism and Discipline
Naturalism is favor to total freedom.
Naturalism and teacher
• Teacher place is behind the stage.
• He / she arrange the environment with necessary opportunity and material.
• Guiding the child when required .
Idealism Introduction
• It is the oldest philosophy. It derived from Greek word “Idem” , means “to see” .
• Plato is the father of Idealism
• Idealists gives more importance to mind and self rather than matter and body.
Principles of Idealism
· Presence of universal mind.
· Regard man as spiritual beings.
· The world of ideas and values.
· The real knowledge is perceived in mind.
Educational implications of Idealism
• Idealism considered student as an individual with inner potentialities and education should help the student to realize that potentialities.
• Idealism and curriculum
• It consist those knowledge and experiences that attain the development.
Idealism and aims of education
• Self– realization.
• Evaluation of personality through self realization.
• Universal education.
• Development of inventive and creative power.
• Conservation promotion and transmission of cultural heritage.
• Bringing out the cultural environment
• Development of moral senses.
• Cultivation of spiritual values.
Idealism and curriculum
The subjects which assist the child to develop morally, aesthetically, intellectually and physically, are included.
Idealism and methods of teaching
• Kindergarten Questioning Discussion Lecture
Idealism and discipline
• Strict discipline
• Against free discipline
• Idealism and teacher
• It serve a high place for teacher.
• Recognize teacher as a philosopher, friend and guide.
• He serve as a role model to the children.
Pragmatism Introduction :
• It adopt a midway between idealism and naturalism. Pragmatism is derived from Greek word “Pragma” means action.
• It is also known as instrumentalism.
Definition:
Pragmatism is essentially a humanistic philosophy maintaining that men creates his own values in course of activity. That reality is still in making and awaits its parts of completion from the future . (Ross)
Forms of Pragmatism
• Humanistic pragmatism.
• Experimentally pragmatism
• Biological pragmatism.
Principles of Pragmatism
• Biological and social organism.
• Knowledge should be experimentally verified and it should be useful to the learner.
• Pragmatism faith in man’s capacity to shape his destiny.
• No absolute value.
• Practical situations are true.
• It concerned with the present and immediate future.
• Pragmatism accept only knowledge which is experienced by sensory level.
• Only realized ideas in life are real.
Educational implications of Pragmatism
• It revolutionized the education system.
• Pragmatism trends in education is known as progressivism.
• Pragmatism considered the learner as growing biological and social being , ready to adjust the environment needs.
Pragmatism and aims of education
• Harmonious development .
• Continuous experiences.
• Social efficiency.
Pragmatism and curriculum
• Principle of utility.
• Principle of experiences.
• Principle of integration.
Pragmatism and methods of teaching
Pragmatism and discipline
• It does not believe in strict discipline.
Pragmatism and teacher role
• It considered teacher as a friend , philosopher, and guide
• Two important qualities
a) Interest
b) Awareness about social conditions.
Realism Introduction
The first ideology was Aristotle. Later modified by Gemore, Russal, and John wield. According to this philosophy thing we see and perceive are real and knowledge acquired through senses is true.
Definition
“ Realism is the reinforcement of our common acceptance of this world as it appears to us”.
Forms of Realism
• Humanistic realism.
• Social realism.
• Sense realism.
• Neorealism .
Principles of Realism
• Every life reality are true.
• Does not believe in existence of any truth.
• It accept only sensory experiences of the external world as real.
• It looks at a man like a physical being controlled by rules.
• Real knowledge is experienced by sensation.
Education implication of Realism
• The aim of education implication is to prepare the child to face realities of life and to solve the problems.
• The school knowledge and experiences should be appropriate to achieve this aim.
Realism and curriculum
• Subjects and activities which prepare the child for real life .
Realism and methods of teaching
• Observation
• Experimentation
• Activities and demonstration
Realism and teacher
• Honorable position for the teacher.
• He is well known to the content and needs of the children.
• He transfer the knowledge by using scientific methods.
Supernaturalism Introduction :• Also known as theistic realism. Organized as christen philosophy. According to it there is personal a God . God is a author creature of nature and man.
• Education is regarded as active social process.
• It take place in the family school and church.
Supernaturalism and aims of education
• Social development
• Economic competency
• Moral development
• Spiritual perfection
• Physical development
Supernaturalism and curriculum
• Social science
• Behavioral science
• Biological science
. Supernaturalism and discipline
• It is against for rigid discipline .
• Teacher play role as a guider.
Humanistic Existentialism
It is youngest philosophy . Modern philosophy which is primarily build upon the work of the scholars of the 20th century.
Main assumptions
• Man’s existence
• Self knowledge
• Freedom and responsibilities
• Man is not complete
Eclectism
Educationist through motivation, create a new educational philosophy by pooling all good and relevant features from different educational philosophies , this philosophy is known as “Eclectism”.
• Aim of education is to prepare the good citizenship.
• Flexible curriculum.
• Emphasis various co-ordination of various subjects.
• Importance to curricular activities.
• Ensuring availability of subject experts and better teacher.
• Suggest scientific teaching methods based on the learning by doing principle, learning by play, learning by observation.
• Highest responsibilities of the government to provide education.
• Emphasis on the adult and social learning.
AIMS
The aim of the undergraduate nursing program is to :
Prepare graduates to assume responsibilities as professional, competent nurses and midwives in providing promotive, preventive, curative, and rehabilitative services.
Prepare nurses who can make independent decisions in nursing situations, protect the rights of and facilitate individuals and groups in pursuit of health, function in the hospital, community nursing services, and conduct research studies in the areas of nursing practice. They are also expected to assume the role of teacher, supervisor, and manager in a clinical/public health setting.
OBJECTIVES
On completion of the Nursing program the graduate will be able to :
1. Apply knowledge from physical, biological, and behavioural sciences, medicine including alternative systems and nursing in providing nursing care to individuals, families and communities.
2. Demonstrate understanding of life style and other factors, which affect health of individuals and groups.
3. Provide nursing care based on steps of nursing process in collaboration with the individuals and groups.
4. Demonstrate critical thinking skill in making decisions in all situations in order to provide quality care.
5. Utilize the latest trends and technology in providing health care.
6. Provide promotive, preventive and restorative health services in line with the national health policies and programmes.
7. Practice within the framework of code of ethics and professional conduct, and acceptable standards of practice within the legal boundaries.
8. Demonstrate skills in teaching to individuals and groups in clinical / community health settings.
9. Participate effectively as members of the health team in health care delivery system.
10. Demonstrate leadership and managerial skills in clinical / community health settings..
1. Communication Skills Solid communication skills are a basic foundation for any career. But for nurses, it’s one of the most important aspects of the job. A great nurse has excellent communication skills, especially when it comes to speaking and listening. Based on team and patient feedback, they are able to problem-solve and effectively communicate with patients and families. Nurses always need to be on top of their game and make sure that their patients are clearly understood by everyone else. A truly stellar nurse is able to advocate for her patients and anticipate their needs.
2. Emotional Stability Nursing is a stressful job where traumatic situations are common. The ability to accept suffering and death without letting it get personal is crucial. Some days can seem like non-stop gloom and doom. That’s not to say that there aren’t heartwarming moments in nursing. Helping a patient recover, reuniting families, or bonding with fellow nurses are special benefits of the job. A great nurse is able to manage the stress of sad situations, but also draws strength from the wonderful outcomes that can and do happen.
3. Empathy Great nurses have empathy for the pain and suffering of patients. They are able to feel compassion and provide comfort. But be prepared for the occasional bout of compassion fatigue; it happens to the greatest of nurses. Learn how to recognize the symptoms and deal with it efficiently. Patients look to nurses as their advocates — the softer side of hospital bureaucracy. Being sympathetic to the patient’s hospital experience can go a long way in terms of improving patient care. Sometimes, an empathetic nurse is all patients have to look forward to. 4. Flexibility Being flexible and rolling with the punches is a staple of any career, but it’s especially important for nurses. A great nurse is flexible with regards to working hours and responsibilities. Nurses, like doctors, are often required to work long periods of overtime, late or overnight shifts, and weekends. Know that it comes with the territory. The upside is that a fluctuating schedule often means you’re skipping the 9 to 5, cubicle treadmill. Sounds perfect, right? Run errands, go to the movies, or spend time with the family — all while the sun still shines! 5. Attention to Detail Every step in the medical field is one that can have far-reaching consequences. A great nurse pays excellent attention to detail and is careful not to skip steps or make errors. From reading a patient’s chart correctly to remembering the nuances of a delicate case, there’ s nothing that should be left to chance in nursing. When a simple mistake can spell tragedy for another’s life, attention to detail can literally be the difference between life and death. 6. Interpersonal Skills Nurses are the link between doctors and patients. A great nurse has excellent interpersonal skills and works well in a variety of situations with different people. They work well with other nurses, doctors, and other members of the staff. Nurses are the glue that holds the hospital together. Patients see nurses as a friendly face and doctors depend on nurses to keep them on their toes. A great nurse balances the needs of patient and doctor as seamlessly as possible. 7. Physical Endurance Frequent physical tasks, standing for long periods of time, lifting heavy objects (or people), and performing a number of taxing maneuvers on a daily basis are staples of nursing life. It’s definitely not a desk job. Always on the go, a great nurse maintains her energy throughout her shift, whether she’s in a surgery or checking in on a patient. Staying strong, eating right, and having a healthy lifestyle outside of nursing is important too! 8. Problem Solving Skills A great nurse can think quickly and address problems as — or before — they arise. With sick patients, trauma cases, and emergencies, nurses always need to be on hand to solve a tricky situation. Whether it’s handling the family, soothing a patient, dealing with a doctor, or managing the staff, having good problem solving skills is a top quality of a great nurse. 9. Quick Response Nurses need to be ready to respond quickly to emergencies and other situations that arise. Quite often, health care work is simply the response to sudden incidences, and nurses must always be prepared for the unexpected. Staying on their feet, keeping their head cool in a crisis, and a calm attitude are great qualities in a nurse. 10. Respect Respect goes a long way. Great nurses respect people and rules. They remain impartial at all times and are mindful of confidentiality requirements and different cultures and traditions. Above all, they respect the wishes of the patient him- or herself. Great nurses respect the hospital staff and each other, understanding that the patient comes first. And nurses who respect others are highly respected in return.
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