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.

BIBLIOGRAPHY:

VatiJogindra, “principles and Practice of Nursing Management & Administration, JAYPEE

Medical publishers, 1st edition, page no. 93-110

BT Basavnthappa ―Nursing Administration, JAYPEE medical publishers, Second edition,

page no.515-537

SakharkarBM(colonel Retd.), Principles of Hospital Administration and Planning,JAYPEE

medical publishers, Second edition, page no.302-309.

eHow.com http://www.ehow.com/about_5110198_basics-continuous-quality-improvement.

http://jama.ama-assn.org/content/266/13/1817.abstract

http://www.unboundmedicine.com/medline/