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This document provides an overview of quality assurance approaches for nurses and other healthcare professionals. It includes chapters on: 1. An introduction to quality assurance, covering the background and key reports that have shaped the field. 2. Total Quality Management (TQM), a method for managing quality throughout an organization. 3. Standards of care, including how to establish, write, and monitor standards to ensure quality. 4. Clinical audit, a quality improvement process using a systematic approach to improve patient care and outcomes. 5. Clinical protocols, which provide guidelines on anticipated patient care pathways and recovery. The document aims to give healthcare professionals practical guidance on implementing and utilizing different quality assurance methods in their
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- 1. Quality Assuranee For Nurses and Other Members of the Health Care Team
- 2. ESSENTIALS OF NURSING MANAGEMENT Annabel Broome: Managing Change, 2nd edition Principles of complex change Leadership and creating change from within Imposed change The nurse as a change agent Identifying training and development needs Appendices June Girvin: Leadership and Nursing The development of theories of leadership Interpretations of leadership Interpersonal skills and leadership Leadership and nursing The story so far... Traditional attitudes and socialisation Motivation Leadership today Vision - foresight, insight and dreams Diana Sale: Quality Assurance, 2nd edition An introduction to quality assurance Total Quality Management Standards of care Clinical audit Clinical protocols Monitoring of providers by purchasers Verena Tschudin with Jane Schober: Managing Yourself, 2nd edition 'Know thyself' Valuing yourself Motivating yourself Asserting yourself Stressing yourself Supportmg yourself Celebrating yourself Developing yourself and your career Geoffrey Woodhall and Alan Stuttard: Financial Management An introduction to finance in the health service The planning and control of capital expenditure Methods of capital appraisal Sources of capital finance The planning and control of revenue expenditure Setting a budget for the first time Monitoring of budget performance Putting it all together Glossary Appendices
- 3. ESSENTIALS OF NURSING MANAGEMENT Quality Assurance For Nurses and Other Members of the Health Care Team Second Edition Diana Sale MACMILLAN
- 4. © Diana N. T. Sale 1996 All rights reserved. No reproduction, copy or transmission of this publication may be made without written permission. No paragraph of this publication may be reproduced, copied or transmitted save with written permission or in accordance with the provisions of the Copyright, Designs and Patents Act 1988, or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London W1P 9HE. Any person who does any unauthorised act in relation to this publication may be liable to criminal prosecution and civil claims for damages. First edition 1990 Reprinted five times Second edition 1996 Published by MACMILLAN PRESS LTD Houndmills, Basingstoke, Hampshire RG21 6XS and London Companies and representatives throughout the world ISBN 978-0-333-66917-4 ISBN 978-1-349-14197-5 (eBook) DOI 10.1007/978-1-349-14197-5 A catalogue record for this book is available from the British Library. This book is printed on paper suitable for recycling and made from fully managed and sustained forest sources. 10 9 8 7 6 5 4 3 2 05 04 03 02 01 00
- 5. This book is dedicated to the memory of my father Michael Tuke-Hastings (1920-93)
- 6. Contents Acknowledgements ix P~a x Chapter 1 An introduction to quality assurance 1 Background 1 Rush Medicus 5 Monitor 6 'In Pursuit of Excellence' 10 'Working for Patients' 10 Medical Audit 11 Defining quality assurance 13 Levels of monitoring the quality of care 13 Levels of evaluation of quality of care 16 Accreditation 16 Evaluation of quality of care 19 Exercise 1 24 Chapter 2 Total Quality Management 29 Background 29 Concepts 31 Approach 34 Exercise 2 34 Chapter 3 Standards of care 37 Background 37 What are standards of care? 40 Why do we need standards of care? 40 How can we use standards? 42 Exercise 3a 42 The quality assurance cycle 43 vii
- 7. Contents Who writes the standards? 44 Exercise 3b 45 Levels of standard setting and monitoring 45 Exercise 3c 47 Terminology used in standard setting 47 Classifying standards 52 Checking standards 56 Monitoring standards 56 Exercise 3d 57 The final stage 61 Summary of points on standard setting 63 Exercise 3e 68 Chapter 4 Clinical audit 71 Definition 71 The audit cycle 71 Why do we need clinical audit? 73 Benefits 73 Four main principles 74 Potential problems 79 The eleven steps to successful audit 81 Grn~~~ ~ Guidelines for success 90 Examples of areas for clinical audit 91 Exercise 4 93 Chapter 5 Clinical protocols 95 Background 95 Example of a clinical protocol 95 Development of a clinical protocol 106 The benefits of working through a clinical protocol 107 Goals of clinical protocols 108 Exercise 5 108 Chapter 6 Monitoring of providers by purchasers 111 The Dorset Health Commission's approach 113 Glossary of terms 123 Index 131 viii
- 8. Acknowledgements I should like to thank the following people who kindly gave me permission to reproduce some of their work in the first edition of this book and which has subsequently been used again in this edition; Dr Alison Kitson (The Royal College of Nursing) and Helen Kendall; Quality Assurance and Standards, Newcastle upon Tyne Polytechnic Products Ltd, for 'Monitor'. I should also like to thank the new contributors to the sec- ond edition of this book. First, Leeds Healthcare for allowing me to use the clinical protocol developed by representatives of St James' Hospital Leeds and myself, and finally Denise Holden of the Dorset Health Commission for the chapter on 'Developing the Commissioning Function of Health Authorities'. DIANA SALE lX
- 9. Preface This is the second edition of the book Quality Assurance which was first published in 1990. The first edition was intended for nursing staff who were interested in learning more about Quality Assurance and wanted to set up Quality Assurance projects of their own. This book, the second edition, is intended pri- marily for nurses but I hope that it will also be of interest to other members of the health care team. Everyone has a part to play in the delivery of high quality care and as we work as multidisciplinary team we should also develop approaches to Quality Assurance as a team. Care of high quality cannot be maintained if members of the same team are working to variable standards. There needs to be an agreed level to which everyone aspires to ensure that patients or clients receive both care and a service of a level that is of good quality. In order to understand Quality Assurance it is important to have some insight into the background of the subject, which is included in Chapter 1. This chapter has been brought up to date and includes developments and events that have occurred since 1990. Chapter 2 looks at Total Quality Management (TQM), which is a method of managing quality issues throughout every as- pect of an organisation. TQM has been applied all over the world in manufacturing and service industries and with some success in the health care setting. On the one hand it is a 'tool kit' which contains the methods, tools and structure, and on the other hand it is a successful approach to cultural change which promotes a system of continuous quality improvement. Chapters 3 and 4 set out some of the approaches by which to measure the quality of service and care received by patients X
- 10. Preface or clients and their families or friends. This includes the set- ting and monitoring of standards and clinical audit. Chapter 3, on standards, has been changed since the last edition to reflect a simpler and more dynamic approach to setting and, in particular, the monitoring of standards. This approach is based on personal experience and working with a variety of groups since the publication of the first edition of this book. My work as a management consultant takes me all over the United Kingdom to Acute Hospitals and Community and Mental Health Trusts and I have discovered there is a large variation on the progress made in the area of setting and monitoring of standards. Some staff have done a great deal of very good work on standards while others have done very little. Some are just beginning to think about setting and monitoring stan- dards using a structured approach. Then there are those who say that they have set their standards and hand me a large, dusty tome, written by a committee in 1990. The standards bear no relation to current clinical practice, are not owned or even acknowledged by the staff and have never been moni- tored. Chapter 3 describes an approach that results in stan- dards that may be seen in everyday practice, that are monitored all the time, based on sound research, valued and owned by the staff and result in good quality care for the patient. Chapter 4, on clinical audit, is a new addition to the book and sets out one approach to setting up and carrying out an audit. This is a fairly detailed step-by-step guide to audit and is intended for a multidisciplinary approach to audit. The chapter on clinical protocols (Chapter 5) derives from work undertaken on behalf of Price Waterhouse with StJames' Hospital in Leeds, with the kind permission of Leeds Healthcare. This particular approach is a combination of a patient track- ing system, anticipated recovery pathways, standards, outcome and workload. The work involved the whole team"caring for a patient undergoing a single, first-time hip replacement and tracks the patient's progress from the point of GP referral to discharge. Chapter 6 looks at the role of the purchaser in Quality As- surance and in particular the monitoring of provider units. This chapter includes a contribution from the Dorset Health xi
- 11. Preface Commission which looks at developing the commission func- tion of Health Authorities. In each chapter there are exercises to help the readers to put into practice what has been read and to decide whether or not this particular approach is suitable, as a method of Quality Assurance, for the area in which they are working. This book is intended as a simple, practical guide to Qual- ity Assurance to help staff with the implementation and run- ning of Quality Assurance initiatives. DIANA SALE xii