nursing standards and models in nursing management
TRANSCRIPT
RAJKUMARI AMRIT KAUR COLLEGE OF NURSING, LAJPAT NAGAR,
NEW DELHI
A
SYMPOSIUM
ON
“STANDARDS AND MODELS IN
NURSING MANAGEMENT”
SUBMITTEd BY:
MS. SAVITA AHLAWAT
M.Sc FINAL
RAKCON
DEVELOPMENT OR SETTING QUALITY STANDARDS:
Prerequisites:
1. The belief that standard is desirable and useful.
2. The will and knowledge to develop standard is required.
3. The sufficient resources for developing the standards and subsequently for implementing
and for maintaining are required.
4. There should be ability to promote the standards once they are established and to
educate potential users in how to meet them.
5. It should be recognized that the standards must be tailor made if they are intended to
develop.
6. One must take responsibility for the development of standards that can be developed
either by the government agencies or groups of health care facilities.
STEPS FOR THE DEVELOPMENT OF NURSING STANDARDS:
1. Identify a function or system that requires standards: identify high volume, high risk
and problem prone function as per the priority and also use common criteria for selection
among the possibilities as on the basis of importance, feasibility, impact and cost.
2. Identify a team or panel of experts to address standards: the team should include
the right persons in order to address issue necessary to complete task.
3. Identify the inputs, processes and outcomes of function or system: The team must
identify the elements for each of the components i.e. input, processes and outcome of
the function or system.
4. Define the quality characteristics: The team then decides on the quality
characteristics of each key element, then it will lead to define a standard for that.
5. Develop or adapt standards: Team set the standards in the following way:
- Choose a format: mostly the format is selected in the form of:
- Statement
- Algorithms: most applied for process standards as a list of steps, or a few sentence
in paragraph form; and or as a map that outlines a stepwise approach to solve a
clinical problem.
- Flow chart: sometimes called a decision tree e.g. comatose patient management
algorithm: ‘if patient does not respond to stimuli, then you do-----, if respond, then
you do------
- Case management plans, nursing care plans
- Critical paths: Process standards can be in the form of critical paths, which is an
optical sequencing and timing of intervention by physicians, nurses and other staff
for the particular diagnosis or procedure.
- Clinical care protocols: These are practice guidelines which are explicit, criteria
based plans for specific health care problems.
6. Gather background information :information gathered through various methods
- Review of literature
- Confer with experts
- Benchmarking
- Review past experiences
7. Draft the standards:
- Delphi method
- Flow charts
8. Develop the indicators for the standards:
An indicator can be structure, a process or an outcome about which data are collected
during monitoring activities
9. Assess appropriateness of standards and indicators:
Appropriateness relates to the extent to which nursing care is efficacious, i.e. based on
scientific principles, is clearly indicated for the patient, is neither excessive nor deficient
in number for the patient’s needs, and is provided in the appropriate setting, best suited
to the patient’s need.
- standards should be appropriate to the organization.
- The team determines if the standards are valid, reliable, clear and applicable before
they are disseminated.
- Use possible methods as staff meetings, anonymous questionnaire, and face to face
interviews.
- Analyze the feedback and make necessary changes.
- The team should review and should develop a plan to revise and important the
standard.
TECHNIQUES USED IN PREPARATION OF STANDARDS IN NURSING
1. Professional standards techniques:
The professional standards category contains the various guidelines and standard
documents which health care professionals have published as a basis for quality
assurance.
2. Comprehensive review systems:
Many professional bodies have specified standards and guidelines for practice, which
are taken and applied in all settings where the relevant professional work. These
standards are at higher level of generality and several professional bodies suggest that
their central standards should be used as framework for more local exercises in specific
standards setting. The local and specific should thus grow out of the central and more
general.
3. Process appraisal technique:
The process appraisal techniques focus primarily on appraisal of the quality of processes
of care. The process of care comprises all the procedures and activities through which
the health professionals and support workers deploy their time, skills, knowledge and
resources in pursuit of improved patient health and well being. It has technical,
interpersonal and moral components and includes access, diagnosis, treatment,
discharge, after care and health education and promotion.
STANDARDS FOR NURSING SERVICES:
A. American Nurses Association Standards of professional nursing practice:
STANDARD 1: Assessment:
The registered nurse collects comprehensive data pertinent to patient’s health or
situation.
STANDARD 2: Diagnosis:
The registered nurse analyzes the assessment data to determine diagnosis or issues
STANDARD 3: Outcome Identification:
The registered nurse identifies expected outcomes for a plan individualized to the patient
or the situation.
STANDARD 4: Planning
The registered nurse develops a plan of care that prescribes strategies and alternatives
to attain expected outcomes.
STANDARD 5: Implementation
The registered nurse implements the identified plan.
STANDARD 5a:
The registered nurse coordinates care delivery. The registered nurse employs strategies
to promote health and a safe environment.
STANDARD 5b: Health teaching and health promotion
The registered nurse employs strategies to promote health and safe environment
STANDARD 6: Evaluation
The registered nurse evaluates the patient’s progress toward attainment of outcomes.
ANA STANDARDS OF PROFESSIONAL PERFORMANCE:
Standard 7 Quality of care:
The registered nurse systematically enhances the quality and effectiveness of nursing
practice.
Standard 8 Education:
The nurse registered attains knowledge and competency that reflects current nursing
practice.
Standard 9: Professional Practice evaluation:
The registered nurse evaluates one’s own nursing practice in relation to professional
practice standards and guidelines, relevant statutes, rules and regulations.
Standard 10: Collegiality
The registered nurse interacts with and contributes to the professional development of
peers and colleagues.
Standard 11: Collaboration
The registered nurse collaborates with the patient, family and others in the conduct of
nursing practice.
Standard 12: Ethics
The registered nurse integrates ethical provision in all areas of practice
Standard 13: Research
The registered nurse integrates research findings into practice
Standard 14: Resource Utilization
The registered nurse considers factors related to safety, effectiveness, cost and impact
on practice in the professional practice setting and the profession.
Standard 15: Leadership
The registered nurse provides leadership in the professional practice setting and the
profession.
MODELS :
1. DONABEDIAN MODEL:
Donabedian quality framework is recognized as a method of measuring quality as
structure, process and outcome in the mid of 1960’s. Structure leads to process and process
leads to outcome. Outcome reflects the results of the application of structures, and
processes in a specific health setting. Structure may also directly influence outcome. This
model has been widely accepted as the fundamental structure to develop many other
models in QA.
DONABEDIAN MODEL
2. ANA Model: This first proposed and accepted model of quality assurance was given by Long &
Black in 1975, which was meant for the nursing profession but was used by various other
professionals in the health care. This is a cyclic model. This helps in the self- determination of
STRUCTURAL ELEMENTS:
Characteristics of:
Community
Institution
Provider
Patient
Examples:
Geographical location of facility
Nurse-patient ratio
Availability of technologies
Hospital size
PROCESS ELEMENTS:
Treatment process
Stages of treatment
Appropriateness
Services process
Examples:
Use of efficacious therapy
Use of diagnostic tests
Use of procedures
Treatment delays
OUTCOMES:
Death
Adverse events
Readmissions to hospital
Resource use (costs, length of stay in
hospital)
Patient satisfaction with care
Quality of life
Patient ability to function in daily
activities
patient and family, nursing health orientation, patient‘s right to quality care and nursing
contributions. The basic components of the ANA model can be summarized:
ANA MODEL OF QUALITY ASSURANCE
i. Identify values:In the ANA value identification looks as such issue as patient/client,
philosophy, needs and rights from an economic, social, psychology and spiritual perspective
and values, philosophy of the health care organization and the providers of nursing services.
ii. Identify structure, process and outcome standards and criteria:Identification of
standards and criteria for quality assurance begins with writing of philosophy and objective
of organization. The philosophy and objectives of an agency serves to define the structural
standards of the agency.
Standards of structure are defined by licensing or accrediting agency. Another standard of
structure includes the organizational chart, which shows supervisory methods,
communication patterns, staff patterns and sometimes staff assignments. Evaluation of the
standards of structure is done by a group internal or external to the agency.
iii. Select measurement needed to determine degree of attainment of criteria and
standards:The approaches and techniques for the evaluation of process standards and
criteria are peer review, client satisfactions surveys, direct observations, questionnaires,
interviews, written audits and videotapes.
iv. Make interpretations: The degree to which the predetermined criteria are met is the basis
for interpretation about the strengths and weaknesses of the program. The rate of
compliance is compared against the expected level of criteria accomplishment.
IDENTIFY VALUES
IDENTIFY STANDARD CRITERIA
SECURE MEASUREMENT
MAKE INTERPRETATION
IDENTIFY POSSIBLE COURSES OF
ACTION
CHOOSE APPROPRIATE
COURSE OF ACTION
TAKE ACTION
RE-EVALUATION
v. Identify Course of Action: If the compliance level is above the normal or the expected
level, there is great value in conveying positive feedback and reinforcement. If the
compliance level is below the expected level, it is essential to improve the situations. It is
necessary to identify the cause of deficiency. Then, it is important to identify various
solutions to the problems.
vi. Choose action: Usually various alternative course of action are available to remedy a
deficiency. Thus it is vital to weigh the pros and cons of each alternative while considering
the environmental context and the availability of resources. In the recent that more than one
cause of the deficiency has been identified; action may be needed to deal with each
contributing factor.
vii. Take Action:It is important to firmly establish accountability for the action to be taken. It is
essential to answer the questions of who will do? What? By when? This step then
concludes with the actual implementation of the proposed courses of action.
viii. Re-evaluate:The final step of QA process involves an evaluation of the results of the
action. The reassessment is accomplished in the same way as the original assessment and
begins the QA cycle again.Careful interpretation is essential to determine whether the
course of action has improves the deficiency, positive reinforcement is offered to those who
participated and the decision is made about when to again evaluate that aspect of care.
3. QUALITY HEALTH OUTCOME MODEL:
The uniqueness of this model proposed by Mitchell & Co is the point that there are
dynamic relationships with indicators that not only act upon, but also reciprocally affect
the various components.
QUALITY HEALTH OUTCOME MODEL
CLIENT
(Individual,
Family &
Community)
INTERVENTION
OUTCOME
SYSTEM
(Individual,
GROUP/
organisation)
4. FOCUS-PDCA Model (Quality Management Model): Find, Organize, Clarify, Understand, Select, Plan, Do, Check, Act’ Model was
designed in 1930 which has the following concepts: Find a process to improve. Organize a team that knows the process. Clarify current knowledge of process. Understand causes of variation. PDCA CYCLE: PDCA(Plan, Do, Check, Act) is a four step problem solving process. It
is used in Quality Control. It is also known as Shewhart cycle, Deming cycle, Deming Wheel, or Plan-Do-Study-Act cycle.
Once the initial problem analysis is completed,
Plan: Establishthe objectives and processes necessary to deliver results in
accordance with the specificationsis developed to test one of the improvement
changes.
Do:Implement the processes
Check/Study: Monitorand evaluate the processes and results against objectives
and specifications and report the outcome involves analysis of the data collected in
the previous step. Data are evaluated for evidence that an improvement has been
made.
Act:apply actions to the outcome for necessary for necessary improvement.
This means reviewing all steps and modifying the process to improve it before its
next implementation
5. JOINT COMMISSION 10- STEP PROCESS MODEL:
This model includes 10 steps for quality assessment/assurance and quality
management/ quality improvement. These steps provide a systematic methodology for
quality management. This model is used for monitoring and evaluation of services.
The steps are as follows with suggested TQM tools:
PDCA CYCLE
PLAN
DO
CHECK
ACT
S . N O . JO INT C O MMISSIO N 10 - STEP PR O C ESS S U G G E ST ED T Q M T O O L S 1 . A s s i g n r e s p o n s i b i l i t i e s
2 . D e l i n e a t e s c o p e o f c a r e / s e r v i c e s Bra instorming a f finity d iagram 3 . P r i o r i t i z e a s p e c t s o f c a r e / s e r v i c e s
Categorize as high volume, high risk, problem prone, or high cost of poor quality Identify at least two projects to address Flow chart the process
P a r e t o c h a r t Tally/ check Sheet Prioritization matrix Brain storming Matrix diagram Flow chart
4 . Es tabl is h ind ic ators for ident i f ied pro jec t s A f f i n i t y d i a g r a m Flow chart Analysis
5 . E s ta b l is h th re s h o ld s f or e va lu a tion b a s e d on cos tu m e rs s a tis f a ct io n R u n o r c o n t r o l c h a r t
6 . C o l l e c t a n d a n a l y z e d a t a T a l l e y S h e e t
7 . E v a lu a t e e f f e c t i ve n e s s o f c a re a n d d o c u m e n t th e le v e l o f im p ro ve m e n t Pareto or scatter diagram Histogram Run or control chart Fishbone diagram
8 . Determine and implement appropriate actions 9 . E v a lu a t e e f fe c ti ve n e ss o f a ct io n a n d d o c um e n t t he le v el o f im p ro ve me n t T a l l e y s h e e t
Pareto chart Histogram
1 0 . C o m m u n i c a t e r e s u l t s P a r e t o c h a r t Flow chart Histogram Display matrix
1 1 . Co n t in u o u s mo n ito r in g / imp ro v in g o n th e p ro ce s s R u n c h a r t Control chart
This 10- step Model has been used for monitoring and evaluation of nursing care in
1988 at Rush-Presbyterian- St. Luke’s Medical Centre. The structure to implement this
plan was the establishment of department and unit based committees. These committees,
which included both staff nurses and nurse managers, were delegated the responsibilities
for quality management in their respective areas and followed each step which was a great
success.
The Rush Model adds an 11th step to address the lack of continuity of ‘10- step
model’’. The 11th step is: Continuous monitoring/ improving on the process (as shown in the
above table).
6. SIX SIGMA :
It refers to six standard deviations from the mean and is generally used in quality
improvement to define the number of acceptable defects or errors produced by a process. It
consists of 5 steps: Define, measure, analyze, improve and control (DMAIC).
Define: Questions are asked about key customer requirements and key processes
to support those requirements.
Measure: Key processes are identified and data are collected.
Analyze: Data are converted to information; Causes of process variation are
identified.
Improve: This stage generates solutions and make and measures process changes.
Control: Processes that are performing in a predictable way at a desirable level are
in control.
"SIX-SIGMA MODEL BASED ON DMAIC METHODOLOGY”
7. QUALITY CARE MODEL:
Quality Care Model reflects the trends towards the evidence based practice while
simultaneously representing unique contribution of nursing to quality health care.
This model integrates biomedical and psychosocial-spiritual factors associated with quality
health care. This model is grounded in the work of Donabedian and Watson and influenced by
contribution from King, Mitchell and Irvine. The over-riding structure –process-outcomes
components are blended with major constructs in Human Caring Model, and provide the central
components of the model. It has three major components: structure, process, and outcome.
STRUCTURE: it is blended with construct, casual past and includes the participants as
construct. It includes the factors that are present prior to the delivery of health care. These
factors are related to
i. Patient/family
ii. Various health care providers
iii. Health care system
DEFINE
• IDENTIFY PROJECT
•REVIEW HISTORICAL DATA
•DEFINE SCOPE
MEASURE
•SELECT CTQ'S
•DEFINE PERFORMANCE DEATH
•VALIDATE MEASUREMENT SYSTEM
ANALYZE
•ESTABLISH CURRENT CAPABILITY
•DEFINE PERFORMANCE OBJECTIVES
• IDENTIFY SOURCES OF VARIABILITY
IMPROVE
•DISCOVER RELATIONSHIP OF VARIABLE
•ESTABLISH OPERATING TOLERANCE
CONTROL
•VALIDATE MEASUREMENT SYSTEM
•DETERMINE CAPABILITY OF NEW PROCESS
• IMPLEMENT CONTROL
PROCESS: It involves interventions or practices that health care provider offers and is the
focus of this model. Caring relationship dominates the process and establishes the
groundwork for the two relationships, i.e., independent relationships includes those
patient/family- nurse interactions and collaborative relationships includes those activities
and responsibilities that nurse’s share with other members of the health care team.
OUTCOMES: this component corresponds to the future construct of the Human Caring
Model and refers to the end results of health care. These outcomes are related to positive
results of the interventions on the part of health care provider, patient and health care
system. Intermediate outcomes includes the goals on the care plans and clinical pathways
but an also includes the feelings about the health care process. There are reciprocal
interactions between intermediate outcomes and terminal outcomes.
8. PERFORMANCE MANAGEMENT SYSTEM PARADIGM: An organization-wide performance
management system derives three critical programs: awareness, measurement and
improvement.
Awareness: in this program, all the customers and stakeholders are educated to the standards
involved in the organization’s three domains of service, practice and governance.
Measurement: a program that delineates exactly how measurement of key functions and
critical processes will occur in the three domains and how the data will be used to reduce errors
and calculate the cost of nonconformance.
Improvement: a program that will delineate expected outcomes in each domain and
benchmark success against indicators.
In this way,the organization will be able to develop standards in all three domains, can create
and utilizes valid and reliable data from all departments and also able to create a systematic
method for continual organization-wide performance improvement.
PERFORMANCE
MEASUREMENT
PROGRAMME
PERFORMANCE
AWARENESS
PROGRAMME
PERFORMANCE
IMPROVEMENT
PROGRAMME
PERFORMANCE
MANAGEMENT
SYSTEM PARADIGM
MARKER’S UMBRELLA MODEL:
The Marker Model is a system for providing continuity, consistency and competency in
clinical patient care. The goal is to provide the above by developing a structure to
standardize professional nursing clinical practice, while maximizing patient outcomes,
preventing untoward occurrences, and controlling healthcare costs. The model describes
connecting characteristics for comprehensive quality assurance model are:
Standard development
Continuous advanced training
Confirmation of technical authority
Evaluation of the execution of cares measures
Examination
Parallel examination
Risk management
Control of the demand resources
Active problem identification
Marker (1987) using a hierarchical concept provides a framework for dividing nursing
standards into three categories: structure, process, and outcome. The main focus of this
model is: maintaining current competency, creating new competency, or responding to a
quality assurance corrective action. She also suggested all programs be tracked and
monitored in conjunction with the program’s purpose.
QUALITY ASSURANCE CYCLE:
In practice, QA is a cyclical, iterative process that must be applied flexibly to meet the needs
of a specific program. The process may begin with a comprehensive effort to define
standards and norms as described in Steps 1-3, or it may start with small-scale quality
improvement activities (Steps 5-10). Alternatively, the process may begin with monitoring
(Step 4). The ten steps in the QA process are discussed.
STEP-1 Planning for Quality Assurance:
This first step prepares an organization to carry out QA activities. Planning begins with a
review of the organizations scope of care to determine which services should be addressed.
STEP-2. Setting Standards and Specifications
To provide consistently high-quality services, an organization must translate its
programmatic goals and objectives into operational procedures. In its widest sense, a
standard is a statement of the quality that is expected. Under the broad rubric of standards
there are practice guidelines or clinical protocols, administrative procedures or standard
operating procedures, product specifications, and performance standards.
STEP-3: Communicating Guidelines and Standards
Once practice guidelines, standard operating procedures, and performance standards have
been defined, it is essential that staff members communicate and promote their use. This
will ensure that each health worker, supervisor, manager, and support person understands
what is expected of him or her. This is particularly important if ongoing training and
supervision have been weak or if guidelines and procedures have recently changed.
Assessing quality before communicating expectations can lead to erroneously blaming
individuals for poor performance when fault actually lies with systemic deficiencies.
STEP-4. Monitoring Quality
Monitoring is the routine collection and review of data that helps to assess whether program
norms are being followed or whether outcomes are improved. By monitoring key 12
indicators, managers and supervisors can determine whether the services delivered follow
the prescribed practices and achieve the desired results.
STEP-5. Identifying Problems and Selecting Opportunities for Improvement
Program managers can identify quality improvement opportunities by monitoring and
evaluating activities. Other means include soliciting suggestions from health workers,
performing system process analyses, reviewing patient feedback or complaints, and
generating ideas through brainstorming or other group techniques. Once a health facility
team has identified several problems, it should set quality improvement priorities by
choosing one or two problem areas on which to focus. Selection criteria will vary from
program to program.
STEP-6. Defining the Problem
Having selected a problem, the team must define it operationally-as a gap between actual
performance and performance as prescribed by guidelines and standards. The problem
statement should identify the problem and how it manifests itself. It should clearly state
where the problem begins and ends, and how to recognize when the problem is solved.
STEP-7: Choosing a Team
Once a health facility staff has employed a participatory approach to selecting and defining
a problem, it should assign a small team to address the specific problem. The team will
analyze the problem, develop a quality improvement plan, and implement and evaluate the
quality improvement effort. The team should comprise those who are involved with,
contribute inputs or resources to, and/or benefit from the activity or activities in which the
problem occurs.
STEP-8: Analyzing and Studying the Problem to Identify the Root Cause
Achieving a meaningful and sustainable quality improvement effort depends on
understanding the problem and its root causes. Given the complexity of health service
delivery, clearly identifying root causes requires systematic, in-depth analysis. Analytical
tools such as system modeling, flow charting, and cause-and-effect diagrams can be used
to analyze a process or problem. Such studies can be based on clinical record reviews,
health center register data, staff or patient interviews, service delivery observations.
STEP-9: Developing Solutions and Actions for Quality Improvement
The problem-solving team should now be ready to develop and evaluate potential solutions.
Unless the procedure in question is the sole responsibility of an individual, developing
solutions should be a team effort. It may be necessary to involve personnel responsible for
processes related to the root cause.
STEP-10: Implementing and Evaluating Quality Improvement Efforts
The team must determine the necessary resources and time frame and decide who will be
responsible for implementation. It must also decide whether implementation should begin
with a pilot test in a limited area or should be launched on a larger scale. The team should
select indicators to evaluate whether the solution was implemented correctly and whether it
resolved the problem it was designed to address. In-depth monitoring should begin when
the quality improvement plan is implemented. It should continue until either the solution is
proven effective and sustainable, or the solution is proven ineffective and is abandoned or
modified. When a solution is effective, the teams should continue limited monitoring.
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