TQM PROGRAM IMPLEMENTATION STEPS

RECAP
PERFORMANCE IMPROVEMENT PERFORMANCE PROCESS (POSITIVE DISCIPLINE) PERFORMANCE APPRAISAL PROCESS SITUATIONAL ACTIVITIES/IDENTIFYING MISMANAGEMENT IN THE AREA

Total Quality Management

Is an integral system of principles, methods, and best practices that provide a framework for organizations to strive for excellence in everything they do. TQM: is a collection of principles, techniques, processes, and best practices that over time have been proven effective Most of all world-class organization exhibit the majority of behaviors with TQM (according to Decker, Juran, Deming, Ishikawa, Crosby, Feigenhaven).

STEPS IN TQM
Is a management concept of achieving the best possible results from business inputs and operations. Most companies use TQM to improve customer value and to increase the sales and profitability from goods and services. Different methods may be used for TQM methods, but they will usually include similar steps in achieving company goals.

STEPS IN TQM:
1. 2. 3. 4. 5. CUSTOMER FOCUS PLANNING PROCESS PROCESS MANAGEMENT PROCESS IMPROVEMENT TOTAL PARTICIPATION

CUSTOMER FOCUS
TQM is a customer-based vision of company management to increase the value of goods and services offered to customers. Companies will collect and review customer data regarding satisfaction on goods and services, current demands for new products and suggested changes for existing products. Developing a customer-focused strategy of improving products and meeting customer needs helps companies achieve high TQM process.

PLANNING PROCESS
Using the information gathered from their customer-focused strategy, companies will plan their business processes to meet the desires of customers. Changing production materials, correcting product flaws and creating new product features are part of the planning process of TQM. Businesses must understand that product quality is based on the perception of customers; planning and deciding how to achieve this perception are important in TQM.

PROCESS MANAGEMENT
Once the planning process is complete, management can focus on the actual production process of TQM. Process management includes reviewing products and services to ensure they are consistent in quality standards, to ensure products continue to meet customer needs, and to ensure products are available in all markets. Managers must also review the cost of raw materials and production methods, ensuring that delivering highquality goods can be done at relatively cheap costs.

PROCESS IMPROVEMENT
TQM is driven by the understanding that no consumer market continues to operate at the same level of demand every year. As the business cycle moves through booms and busts, customers change preference and incomes change; companies must be willing to adjust to these changes to ensure TQM for their products and services. Improving processes to reduce costs, finding cheaper raw materials or reducing labor costs are ways businesses may improve processes to remain competitive.

TOTAL PARTICIPATION
All aspects of TQM can be achieved only through total participation from all employees of the company. All division and employees must commit to a customer focus and desire to produce the best goods and services to meet consumer demands. Managers must train, educate and develop the customer focus strategy in each employee working in the company. Solid communication lines must also be created between management and employees; this allows the company to react quickly to any issues that affect the TQM process in the company.

TQM MODEL/ STEPS IN TQM

PRINCIPLES OF TQM IMPLEMENTATION

1. 2. 3. 4. QUALITY IS EVERYONES BUSINESS CUSTOMER EMPHASIS QUALITY MUST BE BUILT INTO THE PRODUCT TQM REQUIRES MANAGEMENT COMMITMENT AND INVOLVEMENT AT ALL LEVELS 5. TQM ACCOMPLISHMENT INVOLVES CONTINUAL TRAINING

PRINCIPLES OF TQM IMPLEMENTATION

6. LEADERSHIP IS SUBSTITUTED FOR SLOGANS AND EXHORTATIONS 7. LONG-TERM EMPHASIS ON MEASURABLE PROCESSES AND PRODUCTIVITY IMPROVEMENT 8. UNDERSTAND THE CURRENT PROCESS BEFORE IMPROVEMENT BEGINS 9. CROSS- FUNCTIONAL ORIENTATION AND TEAMWORK 10. EFFECTIVE USE OF STATISTICAL METHODS AND QUALITY CONTROL TOOLS

PRINCIPLES OF TQM IMPLEMENTATION

11.CONSTANT PROCESS, PRODUCT, AND SERVISE IMPROVEMENT 12.INCENTIVIZE TQM INVOLVEMENT 13.INFORMATION SHARING 14.ELIMINATE COMMUNICATION BARRIERS 15.SUPPLIERS MUST HAVE A TQM PHILOSOPHY

TQM
TQM is a management philosophy that seeks to integrate all organizational functions (marketing, finance, design, engineering, and production, customer service, etc.) to focus on meeting customer needs and organizational objectives.

TQM IN NURSING HEALTH CARE

TQM IN NURSING HEALTH CARE

Quality refers to excellence of a product or a service, including its attractiveness, lack of defects, reliability, and long-term durability. Quality assurance provides the mechanisms to effectively monitor patient care provided by health care professionals using cost-effective resources.

 Nursing programmes of quality assurance: are concerned with the quantitative assessment of nursing care as measured by proven standards of nursing practice. Quality assurance system motivates nurses to strive for excellence in delivering quality care and to be more open and flexible in experimenting with innovative ways to change outmoded systems. Florence Nightingale introduced the concept of quality in nursing care in 1855 while attending the soldiers in the hospital during the Crimean war.

CONCEPTS OF QUALITY IN HEALTH CARE

Quality is defined as the extent of resemblance between the purpose of healthcare and the truly granted care (Donabedian 1986). Quality assurance originated in manufacturing industry to ensure that the product consistently achieved customer satisfaction.

CONCEPTS OF QUALITY IN HEALTH CARE

Quality assurance is a dynamic process through which nurses assume accountability for quality of care they provide. It is a guarantee to the society that services provided by nurses are being regulated by members of profession. Quality assurance is a judgment concerning the process of care, based on the extent to which that cares contributes to valued outcomes. (Donabedian 1982).

 Quality assurance as the monitoring of the activities of client care to determine the degree of excellence attained to the implementation of the activities. (Bull, 1985) Quality assurance is the defining of nursing practice through well written nursing standards and the use of those standards as a basis for evaluation on improvement of client care (Maker 1998).

APPROACH ASSURANCE PROGRAMES FOR A QUALITY

Two major categories of approaches exist in quality assurance they are General Specific

A. General Approach (QUALITY ASSURANCE PROGRAMME)

It involves large governing of official bodys evaluation of a persons or agencys ability to meet established criteria or standards at a given time. 1. CREDENTIALING 2. LICENSURE 3. ACCREDITATIONS 4. CERTIFICATION

CREDENTIALING
formal recognition of professional or technical competence and attainment of minimum standards by a person or agency Credentialing process has four functional components a) To produce a quality product b) To confer a unique identity c) To protect provider and public d) To control the profession.

LICENSURE
Individual licensure is a contract between the profession and the state, in which the profession is granted control over entry into and exists from the profession and over quality of professional practice. The licensing process requires that regulations be written to define the scopes and limits of the professionals practice. Licensure of nurses has been mandated throughout the world by laws and regulations..

CERTIFICATION
Certification is usually a voluntary process with in the profession. A persons educational achievements, experience and performance on examination are used to determine the persons qualifications for functioning in an identified specialty area.

ACCREDITATION
An organization empowered to lay down standards in nursing and medical care as to regulate the quality of care. ISO (INTERNATIONAL STANDARD ORGANIZATION) JCI NABH Accreditation Canada NAAC

B. SPECIFIC APPROACH (QUALITY ASSURANCE PROGRAMME)

1. PEER VIEW 2. STANDARD AS DEVICE FOR QUALITY ASSURANCE 3. AUDIT AS A TOOL FOR QUALITY ASSURANCE/NURSING AUDIT

SPECIFIC APPROACH
A. PEER VIEW: Peer review is divided in to two types.
1. The recipients of health services by means of auditing the quality of services rendered. 2. The health professional evaluating the quality of individual performance.

B. STANDARDS AS A DEVICES FOR QA: Standard is a pre-determined baseline condition or level of excellence that comprises a model to be followed and practiced. The ANA (AMERICAN NURSES ASSOCIATION) standard for practice include: Standard 1: The collection of data about health status of the patient is systematic and continuous. The data are accessible, communicative, and recorded. Standard 2: Nursing diagnosis are derived from health status data.

ANA STANDARDS
Standard 3: The plan of nursing care includes goals derived from the nursing diagnoses. Standard 4: The plan of nursing care includes priorities and the prescribed nursing approaches or measures to achieve the goals derived from the nursing diagnoses. Standard 5: Nursing actions provide for patient participation in health promotion, maintenance, and restoration.

ANA STANDARDS
Standard 6: Nursing actions assist the patient to maximize his health capabilities. Standard 7: The patients progress or lack of progress towards goal achievement is determined by the patient and the nurse. Standard 8: The patients progress or lack of progress towards goal achievement directs reassessment, re-ordering of priorities, new goal setting, and a revision of the plan of nursing care.

SPECIFIC APPROACH
C. AUDIT AS A TOOL FOR QA: Nursing audit may be defined as a detailed review and evaluation of selected clinical records in order to evaluate the quality of nursing care and performance by comparing it with accepted standards. An audit means the examination or review of records.

Nursing Audit
A Retrospective Audit: is the evaluation of a clients record after discharge from an agency. A Concurrent Audit: is the evaluation of a clients health care, while the client is still receiving care from the agency. These evaluation use interview, direct observation of nursing care, and review of clinical records to determine whether specific evaluation criteria have been met.

Nursing Audit
Peer Review: another type of evaluation of care In the peer review, nurses functioning in the same capacity, that other equally qualified nurses. The peer review is based on pre-established standards or criteria. There are 2 Types of Peer Review: Individual Nursing Audits

 Individual peer review: focuses on the performance of an individual nurse. Nursing Audit peer review: focuses on evaluating nursing care through the review of records. The success of these audits depends on accurate documentation, auditors assume that if the data have not been recorded, the care has not been given.

HEALTHY BREAK

QUALITY ASSURANCE PROCESS

Establishment of standards or criteria Identify the information relevant to criteria Determine ways to collect information Collect and analyze the information Compare collected information with established criteria Make a judgment about quality Provide information and if necessary, take corrective action regarding findings of appropriate sources Determine ways to collect the information

FACTORS AFFECTING QUALITY ASSURANCE IN NURSING CARE

1) Lack of Resources Insufficient resources, infrastructures, equipment, consumables, money for recurring expenses and staff make it possible for output of a certain quality to be turned out under the prevailing circumstances. 2) Personnel problems Lack of trained, skilled and motivated employees, staff indiscipline affects the quality of care.

 3) Improper maintenance Buildings and equipments require proper maintenance for efficient use. If not maintained properly the equipments cannot be used in giving nursing care. To minimize equipment down time it is necessary to ensure adequate after sale service and service manuals. 4) Unreasonable Patients and Attendants Illness, anxiety, absence of immediate response to treatment, unreasonable and unco-operative attitude that in turn affects the quality of care in nursing.

 5) Absence of well informed population To improve quality of nursing care, it is necessary that the people become knowledgeable and assert their rights to quality care. This can be achieved through continuous educational program.

 6) Absence of accreditation laws There is no organization empowered by legislation to lay down standards in nursing and medical care so as to regulate the quality of care. It requires a legislation that provides for setting of a stationary accreditation / vigilance authority to: a) Inspect hospitals and ensures that basic requirements are met. b) Enquire into major incidence of negligence c) Take actions against health professionals involved in malpractice

 7) Lack of incident review procedures During a patients hospitalizations reveal incidents may occur which have a bearing on the treatment and the patients final recovery. These critical incidents may be: a) Delayed attendance by nurses, surgeon, physician b) Incorrect medication c) Burns arising out of faulty procedures d) Death in a corridor with no nurse / physician accompanying the patient etc.

 8) Lack of good and hospital information system A good management information system is essential for the appraisal of quality of care. a) Workload, admissions, procedures and length of stay b) Activity audit and scheduling of procedures.

 9) Absence of patient satisfaction surveys Ascertainment of patient satisfaction at fixed points on an ongoing basis. Such surveys carried out through questionnaires, interviews to by social worker, consultant groups, and help to document patient satisfaction with respect to variables that are a) Delay in attendance by nurses and doctors. b) Incidents of incorrect treatment

 10) Lack of nursing care records Nursing care records are perhaps the most useful source of information on quality of care rendered. The records. a) Detail the patient condition b) Document all significant interaction between patient and the nursing personnel. c) Contain information regarding response to treatment d) Have the dates in an easily accessible form.

 11) Miscellaneous factors a. Lack of good supervision b. Absence of knowledge about philosophy of nursing care c. Lack of policy and administrative manuals. d. Substandard education and training e. Lack of evaluation technique f. Lack of written job description and job specifications g. Lack of in-service and continuing educational program

STAGES OF THE DEVELOPMENT OF INTERNATIONAL STANDARDS (ACCREDITATION)

An International Standard is the result of an agreement between the member bodies of ISO. It may be used as such, or may be implemented through incorporation in national standards of different countries.

International Standards are developed by ISO technical committees (TC) and subcommittees (SC) by a six-step process:
Stage 1: Proposal stage Stage 2: Preparatory stage Stage 3: Committee stage Stage 4: Enquiry stage Stage 5: Approval stage Stage 6: Publication stage

STAGE 1: PROPOSAL STAGE

The first step in the development of an International Standard is to confirm that a particular International Standard is needed. A new work item proposal (NP) is submitted for vote by the members of the relevant TC or SC to determine the inclusion of the work item in the programme of work. The proposal is accepted if a majority of the Pmembers of the TC/SC votes in favour and if at least five P-members declare their commitment to participate actively in the project. At this stage a project leader responsible for the work item is normally appointed.

STAGE 2: PREPARATORY STAGE

Usually, a working group of experts, the chairman (convener) of which is the project leader, is set up by the TC/SC for the preparation of a working draft. Successive working drafts may be considered until the working group is satisfied that it has developed the best technical solution to the problem being addressed. At this stage, the draft is forwarded to the working group's parent committee for the consensus-building phase

STAGE 3: COMMITTEE STAGE

As soon as a first committee draft is available, it is registered by the ISO Central Secretariat. It is distributed for comment and, if required, voting, by the P-members of the TC/SC. Successive committee drafts may be considered until consensus is reached on the technical content. Once consensus has been attained, the text is finalized for submission as a draft International Standard (DIS).

STAGE 4: ENQUIRY STAGE

The draft International Standard (DIS) is circulated to all ISO member bodies by the ISO Central Secretariat for voting and comment within a period of five months. It is approved for submission as a final draft International Standard (FDIS) if a two-thirds majority of the P-members of the TC/SC are in favour and not more than one-quarter of the total number of votes cast are negative. If the approval criteria are not met, the text is returned to the originating TC/SC for further study and a revised document will again be circulated for voting and comment as a draft International Standard.

STAGE 5: APPROVAL STAGE

The final draft International Standard (FDIS) is circulated to all ISO member bodies by the ISO Central Secretariat for a final Yes/No vote within a period of two months. If technical comments are received during this period, they are no longer considered at this stage, but registered for consideration during a future revision of the International Standard. The text is approved as an International Standard if a two-thirds majority of the P-members of the TC/SC is in favour and not more than one-quarter of the total number of votes cast are negative. If these approval criteria are not met, the standard is referred back to the originating TC/SC for reconsideration in light of the technical reasons submitted in support of the negative votes received.

STAGE 6: PUBLICATION STAGE

Once a final draft International Standard has been approved, only minor editorial changes, if and where necessary, are introduced into the final text. The final text is sent to the ISO Central Secretariat which publishes the International Standard.

IMPACT OF ISO IN A LOCAL HOSPITAL:

Positive impacts: Nurses are accountable for their actions and, professionally, we have responsibility to evaluate the effectiveness of our care Nurses can deliver a high standard of care, and being empowered to identify and resolve problems can add to personal satisfaction with work Documents state clearly how the health service should perform and what the patient can expect Guaranteeing standards of care to the public must be a duty of all those who work within the health service Nurses are actively involve in audit, service reviews, standardsetting and customer relations Improves the overall quality of nursing care Improves all types of documentation and communication Helps in professional growth

 Negative impacts: Lack of adequate resources Lack of trained, skilled and motivated employees, staff indiscipline affects the quality of care. ISO activities may overburden the nursing personnel Nurses will not get adequate time to spent with the patient, most of the time may be spending for recording and reporting The hospital will be restricted only to ISO standards Hospital has to provide special training for all the staffs those who are involved in ISO inspection All types of services will be under the control of ISO

IMPACT OF ISO IN A LOCAL NURSING EDUCATIONAL INSTITUTIONS:

Positive impacts: Improves the quality of nursing education improves the quality of nursing practice Helps to maintain international standard Helps to compare the standard with another institution Helps in personnel development of teachers Helps to maintain all the records in time Avoids malpractice and bias Encourages extra-curricular activities also Act as a control for all the activities Improves professional growth

Negative impacts: Gives more importance to documentation Over-burden for the teachers Teachers need to take special training in maintaining the standards Not observing the actual practice Organizational philosophy and policies has to be modified according to the ISO standards

CONCLUSION To ensure quality nursing care within the contemporary health care system, mechanisms for monitoring and evaluating care are under scrutiny. As the level of knowledge increases for a profession, the demand for accountability for its services likewise increases. Individuals within the profession must assume responsibility for their professional actions and be answerable to the recipients for their care. As profession become more interdependent, it appears that the power base will become more balanced, allowing individual practitioners to demonstrate their competence and expertise. Quality assurance programme will helps to improve the quality of nursing care and professional development.

End of module 3