Steps in quality assurance

This process, when viewed simplistically, can be broken down into three basic steps: Establishment Of Control Criteria Or Standards.

1. . Establishment Of Control Criteria 2. Identifying

Or Standards

Information Relevant To The Criteria

3. Determining the ways to collect the information 4. Collecting and analyzing information 5. Re-evaluation Establishment Of Control Criteria Or Standards. The first step is the establishment of control criteria or standards. Measuring performance is impossible if standards have not been clearly established. Not only must standards exist, but leader-managers also must see that subordinates know and understand the standards. Because standards vary among institutions, employees must know the standard expected of them at their organization. Employees must be aware that their performance will be measured in terms of their ability to meet the established standard For example, hospital nurses should provide postoperative patient care that meets standards specific to their institution. A nurse's performance can be measured only when it can be compared with a preexisting standard. Many organizations have begun using benchmarking, the process of measuring products, practices, and services against best-performing organizations, as a tool for identifying desired standards of organizational performance . In doing so, organizations can determine how and why their performance differs from these exemplar organizations and use them as role models for standard development and performance improvement. Many states have initiated a best practices program that invites health care institutions to submit a description of a program or protocol relating to improvements in quality of life, quality of care,

staff development, or cost-effectiveness practices. Experts review the submissions, examine outcomes, and then designate a best practice. The difference in performance between top-performing health care organizations and the national average is called the quality gap

Identifying Information Relevant To The Criteria The second step in the quality control process includes identifying information relevant to the criteria. What information is needed to measure the criteria? In the example of postoperative patient care, this information might include the frequency of vital signs, dressing checks, and neurological or sensory checks. Often, such information is determined by reviewing current research or existing evidence. Research by Heater, Becker, and Olson suggests that patients who receive care based on evidence from well-designed studies have nearly 30% better outcomes (Bennett, 2007). Bennett suggests that "evidence based practice, a problem solving approach to using best evidence in making decisions about patient care, is no longer an option for staff nurses

Select health services to be monitored. A given health system provides a large number of services, not all of which can be monitored. Monitoring should focus on those services which are considered to have the highest priority.

Describe the process of care. The healthcare process to be monitored must be made explicit by listing the critical activities that must be conducted for the correct delivery of the service or management of the health condition. A flowchart may be a useful tool for mapping the main steps of the care process.

Draw a systems view of the services. A systems perspective of the services that will be monitored will help to better understand the processes to be monitored and to identify the critical inputs and expected outcomes.

Make critical standards explicit. Standards must be defined for each critical system component whose performance is to be monitored. Develop performance indicators. Indicators to measure performance according to each standard are then developed. Such indicators measure the gap between observed and expected performance according to standard Determining the ways to collect the information The third step is determining ways to collect information. As in all data gathering, the manager must be sure to use all appropriate sources. When assessing quality control of the postoperative patient, the manager could find much of the information in the patient chart. Postoperative flowsheets, the physician orders, and the nursing notes would probably be most helpful. Talking to the patient or nurse also could yield information

Choose appropriate data collection methods. Quality monitoring data may be collected

through a variety of methods, including direct observation, patient exit interview, interview with healthcare providers, and record review. Each method has its advantages and disadvantages, and none is adequate for all situations. Using a combination of methods is usually more reliable. The right combination of methods will depend on the resources available (including time), the familiarity of the data collectors with the method, and the specific performance indicators of interest.

Design the monitoring tools. Forms to collect date and tabulate findings must be developed and data collectors trained in their use. Using structured forms helps to decrease variation in the results obtained by different observers.

Test the monitoring tools. Data collection forms should be reviewed with the intended users of the forms and field-tested to verify their appropriateness. Select the monitoring strategy. The monitoring strategy involves determining whose performance will be monitored, the optimal frequency for data collection, how existing information and monitoring systems will be used for quality monitoring purposes, and how the accuracy and validity of data will be ensured. Collecting and analyzing information

The fourth step in auditing quality control is collecting and analyzing information. For example, if the standards specify that postoperative vital signs are to be checked every 30 minutes for 2 hours and every hour thereafter for 8 hours, it is necessary to look at how often vital signs were taken the first 10 hours after surgery. The frequency with which vital signs are assessed is listed on the postoperative flowsheet and then is compared with the standard set by the unit. The resulting discrepancy or congruency gives managers information with which they can make a judgment about the quality or appropriateness of the nursing care If vital signs were not taken frequently enough to satisfy the standard, the manager would need to obtain further information regarding why the standard was not met and counsel employees as needed. This is often done using a process known as critical event analysis (CEA) or root cause analysis (RCA). Both of these processes require data collection, investigation, determination and reporting of root causes, implementation of corrective actions, and monitoring for sus-tainability (: Use the information and results

Collect data. Implementing the quality monitoring system requires planning to prepare and mobilize data collectors. Data collection may be carried out by teams specifically organized for this purpose or may be collected by supervisors as part of routine supervision

Tabulate results. After the data have been collected, they must be tabulated and used to calculate the performance indicators. Disaggregated indicators may be used to present the observed frequency of performance of specific tasks. Aggregated indicators, characterizing overall performance over several related tasks, are sometimes helpful to provide an overall measure of healthcare provider adherence to standards.

Analyze the information. Data analysis seeks to determine the overall performance level of the providers or facilities being monitored, identify best and worst performers, and identify patterns or trends in performance. To decrease the perceived threat associated with quality monitoring, it may be helpful to involve healthcare providers whose performance was assessed in the analysis and interpretation of the results.

Interpret and use results. The data obtained through quality monitoring are then used to identify performance gaps and the root causes of poor performance.

Design a data storage and retrieval system. Once data are collected regularly, they must be stored in an accessible form and location that allows for regular updating of monitoring data.

Disseminate information. Information obtained through quality monitoring should be shared first with the staff whose performance was assessed. Dissemination workshops, management meetings, newsletters, and other informational methods may be used to disseminate monitoring results to internal and external audiences. Re-evaluation The last step in Figure 23.1 is reevaluation. If quality control is measured on 20 postoperative charts and a high rate of compliance with established standards is found, the need for short-term reevaluation is low. If standards are consistently unmet or met only partially, frequent reevaluation is indicated. However, quality control measures need to be ongoing, not put forth simply in response tc a problem. Effective leaders ensure that quality control is proactive by pushing standards to maxima! levels and by eliminating problems in early stages, before productivity or quality is compromised.