Seminar

on
Quality Assurance

Subject – Mental Health Nursing

Submitted to – Submitted by –
Mrs. Renu Ma’am Kavita
Tutor MSc. Nsg 2nd year
NINE, PGIMER NINE, PGIMER
Chandigarh Chandigarh
 INTRODUCTION

Morbidity on account of mental illness is set to overtake

cardiovascular diseases as the single largest risk in India. There are
over two crore persons in our country who are in need of treatment
for serious mental disorder and about five crore people who are
affected by common mental disorder.

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.
 WHAT IS QUALITY ?

 
 Definition of Quality
Assurance

Quality assurance provides the mechanisms to effectively monitor

patient care provided by health care professionals using cost-effective
resources.
 
Quality assurance is generally and defined as the process where the
performance of a system or service is assessed and evaluated to ensure
that a high quality, safe service is offered and delivered to those using it,
and that it complies with agreed standards, accreditation and any
relevant legislation and safety requirements.
 Cont….

 Quality assurance is a judgement concerning the process

of care, based on the extent to which that cares contributes
to valued outcomes
(Donabedian 1982)
 
 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 the improvement of
client care .
(Maker 1989)
 Objectives of Quality
Assurance
The main objective of these activities is to ensure a good quality and
safe Service system for those using them, their families and carers
and a level of assurance for all the communities.

1. To provide the best possible results

2. To refine existing methods for ensuring optional quality health
care.
3. To provide technical assistance in correcting systemic
deficiencies.
4. To ensure the delivery of quality client care.
 Meaning of Improved quality in mental
health care -
Preserve the dignity of people with mental disorders.

Make more efficient and effective use of scarce mental health resources.

Provide accepted and relevant clinical and non-clinical care aimed at reducing the impact of the disorder and improving
the quality of life of people with mental disorders.

Use interventions which help people with mental disorders to cope by themselves with their mental health disabilities.

Ensure that quality of care is improved in all areas, including mental health
promotion, prevention, treatment and rehabilitation in primary health care,
outpatient, inpatient and community residential facilities.
 Quality
comprise
s of
Assurance refers to the process that
includes
 Aim of QA in psychiatric Nursing

QA is an important aspect of psychiatric nursing :-

1. Funds are available only after evidence is provided that

predetermined standards of care have been met.

2. QA helps nurse monitor their own practices in a systematic way.

3. QA ensures the public confidence in health care professionals

4. QA is one way in which professional nurses regulate their

profession in order to maintain high level of nursing practice and

at the same time retain the confidence of the public.

How To Improve Quality Of Mental Health Care

Align policy
Review thefor quality
qualityimprovement
mechanisms
Design
standards
Consider systematic
reform for the
improvement of
services

Establish
accreditation
procedures
Integrate quality
improvement into
the ongoing
management and Monitor the mental
delivery of service health service by
using the quality
mechanisms
Step 1. Align policy for quality improvement -

Policy-makers have a key role in the quest for quality. They are in a position to establish the
broad parameters of quality through consultation, Partnerships, legislation, funding and
planning.

 Consultation (Functions):-
Obtaining input from various stakeholders, sharing information across stakeholder groups
and building a common understanding. The development of such an understanding is an
essential task of policy-makers.

 Partnerships (Functions):-
Partnerships with professional groups, academic institutions, advocacy groups, Other health
and social service sectors.

These partnerships form the backbone of the quality improvement process and enable long-
term sustainability. They build consensus and consistency in messages related to the need for
quality and can also serve to mobilize resources and other necessary supports. Legislation:
Policy-makers should promote legislation that reflects concern for and emphasis on quality.
 Cont..
Funding:-
Financial systems for mental health care should be aligned so that they
maximize quality and do not become an obstacle to quality improvement.
Improved efficiency is an essential goal in relation to both quality
improvement and cost containment.

 Planning :-
Quality processes can inform planning by providing a knowledge base for
evidence-based practice. In the course of planning, several issues
pertaining to resource allocation and priority-setting have a bearing on
quality.
 Step 2. Design standards
Once policies have been aligned for quality the next essential
step is to develop a set of standards against which services
can be measured. Planners and managers should establish a
working group Consult with relevant stakeholders and draft a
standards document.
 The standards document should cover all aspects of a mental
health service.
 Criteria for each standard should be specified.
 These criteria should provide a means for rating existing
services.
 The rating of services should be supplemented by
observations on the quality of all aspects of mental health
care.
 Step 3. Establish accreditation procedures

 Accreditation provides the opportunity to assess the quality of

care delivered by a mental health service and to provide the

service with the appropriate legal recognition.

Accreditation is essential because it makes quality a cornerstone

of the official licensing of mental health services or facilities.

Service planners should ascertain whether any accreditation

procedures already exist which can be used to assess current

services.
 Outdated procedures should be reformed in keeping with the

evidence for the most clinically effective and humane forms of

mental health care.

 Accreditation procedures should be developed if there are none.

 The standards document developed in step 2 can be used as a

structure to provide criteria and a rating system for assessing

services and conferring the appropriate legal status.

Step 4. Monitor the mental health service by using the quality
mechanisms

 Use standards to assess the service annually.

 Use of accreditation procedures to assess and accredit new
service developments and to review the ongoing functioning
of services.
 Routine information-gathering through existing information
systems, particularly by means of performance and outcome
indicators.
 Consultation with independent organizations for to assess
people with mental disorders and advocacy groups.
Step 5. Integrate quality improvement into the
ongoing management and delivery of service

 Managing annual service quality reviews; including quality

checks in service planning targets.

 Building quality improvement into clinical practice through

evidence-based practice, clinical practice guidelines,
teamwork and continuing professional development;audit.
Step 6. Consider systematic reform for the
improvement of services

 An assessment of the quality of a mental health service may

indicate a need for systematic reform or improvement.

 This step may require concrete planning and coordination by

various sectors.
 Step 7. Review the quality mechanisms

A review of quality mechanisms is necessary in order

update them in accordance with evidence on the
most effective methods of quality improvement.
Key components in quality assurance includes -

Protocols for
nursing Audits or
intervention review of care
Certifica procedure
tion Criteria
specific to
practice
Licensur
e
Standard
s of care
Credenti
als

Professional
development
activities Peer
Level of
review
practice
 1. Standards of care
Standards of care is drawn from available knowledge about
human being, the norms of group who care for patients and
values of nurses.  
 To safeguard and to experience a sense of personal
acceptance
Formation of Standards of care –
Involves a task forces or other committees and presentation of
preliminary statements of standard to the members of
organization for criticism and revision.
Nurses who are most influential in development of standards are
those –
 Who have achieved a significant level of experience in a
particular functional area
 Higher education
 Recognized by the peers as being outstanding.
 2. Criteria

 Criteria are specific, predetermined rules or principles

developed by health care practices for a given setting and
against which the health care practices implemented in that
setting are compared.

Three types of criteria are generally used –

 Structure criteria
 Process criteria
 Outcome criteria.
 Structure criteria
 Itindicates the aim and purposes of institution or agency or
program and can be designed for the institution, or agency,
the client or the nurse.
 Statement may be made about the philosophy and objectives
of the institution, the facilities, administrative organization,
regulations ,standards and procedures.

E.g of structure criteria are -

 The expectation that staff nurses have completed a course in
group therapy
 The requirement that each client in each unit has an attendant
to provide care.
 Process Criteria

Process criteria are used in the evaluation of actions and the

sequence of behavior and events during the provision of client
care.E.g documentation of the therapeutic one to one
relationship and progress notes
– Data to indicate whether or not the nursing care plan was
developed.
Benefits –
To identify problems that occur while caring for clients and to
take immediate measures that can change or improve the final
outcome of care.
 Enables the nursing dept. to evaluate the extent to which care
is completed. The implementation of policy and procedures
and the activities.
 Outcome criteria
 Developed to evaluate the end result of the care and services
provided to the client
 E.g client orientation about time, place, person and his
responsibility for activities of daily living when discharged
fromhospital.

Limitation of outcome criteria –

 When the outcome or effect of intervention are reviewed and
it is found that it is not reaching the standards or
predetermined criteria then It is difficult to determine whether
 It is due to faulty nursing process or
 Due to uncooperative patient
 3. Protocols

 A protocol is an instrument that guides a practitioner in the

collection of data and recommends specific action based on
that data.
 Written statement of specific interventions for certain signs
and symptoms
 Guidelines to be used in chronic illness. 
 In hospital quality assurance programs protocols may be
defined as statement of behaviors identified as discrete steps
used by nurses in the attainment of long and short-termgoals
 Aims of protocol
 To become more aware of the procedure.
 To identify specific stages in client care that have been
accomplished well or poorly.
 To direct nursing intervention.
 To intervene in client care when physicians are not available.
 To serve as specific statements of nursing behavior that can be
incorporated into quality assurance activities.
Development of protocol -
 Developed by multidisciplinary committee composed of
professional health providers who function within that setting.
 Members are physician often because they are recognized as
health team leader and have the right to prescribe medication.
 Such committee also develop protocol after a review of
literature.
 4. Audits

 Auditing is the verification that the nursing care given to

client is appropriate and in accordance with the
predetermined standards of nursing care in a particular area.
 It is a mechanism used to asses and verifies the quality of
client care.
 Methods of nursing audit are the Concurrent view and the
Retrospective view.
 Types of Audit

1. Concurrent audit - It is a method of evaluating ongoing

activities, assessment at the time of review of one particular
aspect of care.
E.g whether side rails are up on the beds of confused elderly
client.

Benefits are :-
Allows corrective actions to be taken immediately.
Quickly improves the quality of care.
Immediate feedback.
Opportunity to develop greater capabilities in clinical role.

2. Retrospective audit : - It was applied after services have been

rendered. Data one can get from records or interview
 5. Levels of practice

 Rankingor a degree of performance supported by a particular

knowledge base and development of required skill.

 The inclusion of the levels of practice concept in a quality

assurance provides a more precise description of the unit
being evaluated and the level of care being rendered.

E.g:Psychiatric Registered Nurses, Psychiatric Nurse

Practitioners, psychiatric nurse managers
6. Professional developmental activities

The term professionalism implies -

◦ Certain levels of competence in nursing practice and
Educational accomplishments that reflect breadth of
knowledge, skill, and personal maturity.

Some of the professional developmental activities are -

Continuing education program –
Includes short term planned programs of courses under the
direct direction of staff educators or academicians. Learning
experience are designed to enhance previously acquired
knowledge and skill.
 Cont…
 Post Basic and Post-graduate education: - Includes program
of study under the direction of professional educators in college
or university.
Function: To prepare nurse specialist with the additional
knowledge and skill necessary to exercise independent
judgment.

 Diploma in Psychiatric Nursing (DPN) -Is a post basic mental

health psychiatric nursing programs, emphasis is usually placed
on -
 Assessment
 Awareness of the most frequently encountered emotional
problems and pathological conditions,
 Appropriate nursing intervention
 Modes of evaluation
 Post graduate in Psychiatric Nursing - : Is a post graduate
mental health psychiatric nursing programs, emphasis is
usually placed on-
 
 Clinical competences in assessment, psycho-pathology of
various conditions, diagnostic criteria, appropriate treatments,
nursing interventions and rehabilitation.
 Modes of promotion of mental health and prevention of
mental disorders.
 Teaching of mental health nursing.
 Research in the areas of Mental health.
 7. Credentials

 A credentials attests the institution or a person to function in a

particular area of expertise.
 To acquire a credential, an institution or individual is
identified by a recognized authority as credentials are inherent
in any quality assurance program and the possession of
appropriate credentials constitutes a part of the audit process.
 Four fundamental features are quality, identity, protection
and control.
 8. Licensure

 They suggest that institutional licensure will costs and

promote efficiency by –
Providing opportunity for evaluation of individual on site
performance
Allowing for innovative continuing education programme
in hospitals
facilitating career mobility
 9. Certification

It is the formal recognition of the specialized knowledge, skills,

and experience demonstrated by the achievement of standards
identified by a nursing specialty to promote optimal health
outcomes.
 Practice models

 Practice models may be defined as various pattern in delivery

of nursing services by which health care is made available to
diverse groups of people in different settings.

Purposes –

 Itis required to introduce code of ethics and professional

conduct for nurses in India.
 To prepare staff nurse for implementation quality assurance
model in nursing.
 To provide best care to the patient by maintaining standards.
 Models of Quality assurance
and Quality Management

There are various Models of Quality assurance and Quality

Management but the most commonly used are :-

 American Nurse’s Association (ANA) Model

 Donabedian Model
 Research article

Authors - Moore l, lavoie A, Borgeois G, Lapointe J.

Journal :The journal of trauma and acute care surgery,2015.

Title -“Donabedian's structure-process- outcome quality of care

model: Validation in an integrated trauma system.”

The objective of this study was to assess the performance of an

integrated trauma system in terms of structure, process, and
outcome and evaluate the correlation between quality
domains.
According to Donabedian's health care quality model,
improvements in the structure of care should lead to
Result - This study suggest that Donabedian's structure-
improvements in clinical processes that should in turn
process-outcome model is a valid model for evaluating
improvetraumapatient outcome.
care. Trauma centers thatOutcome
perform well inperformance
terms of was
measuredstructure
using risk-
also tend adjusted
to perform rates
well in terms of mortality,
of clinical
processes, which in turn has a favorable influence on patient
complications, and readmission as well as hospital length of
outcomes. Statistically significant correlations were
stay (LOS).observedCorrelation
between structurewas assessed
and process , processwith
and Pearson's
correlation coefficients. The study evalauated quality of care
outcome.
for patients treated in a Canadian provincial trauma system in
2005-2010 in 57 centers, n = 63,971) using quality indicators
(QIs) developed and validated previously.
 Professional Performance
Standards

 As the field of nursing grows and changes in defining the role

of a nurse, the central theme will always be that of caring.
 It can be said that, all other duties and responsibilities of
nurses have centered around, “caring”.
 With the emergence of the, “caring”, theorists also came the
emergence of “Standards of Profession Performance”.
 The American Nursing Association set forth the following
requisites for standards of professional performance.

Standard I : ●
Psychiatric mental health nurse
Quality of ●
systematically evaluates :-
– Quality of care
care ●
– Effectiveness of mental health nursing
practice.

Standard II:
●
Mental health nurse evaluates -One’s own mental health nursing practice standards in
relation to national and state statutes and regulations.
●
Administrative performance appraisal: Involves review, management, regulation of
competent psychiatric nursing practice. Involves supervisory relationship in which a

Performanc nurse’s work performance is compared with the role expectations. XHelps in identify
the competency area and areas of improvement.

e appraisal ●
Clinical performance appraisal:Guidance provided through a mentoring relationship
and clinical supervision with a more experienced, skilled and educated nurse.
 The American Nursing Association set forth the following
requisites for standards of professional performance.

●
Psychiatric nurse acquires and maintains current
Standard III: knowledge in nursing practice.
Education

●
The psychiatric nurse’s assessments, actions &
recommendation on behalf of the patient are
determined and implemented ethically.

●
The psychiatric nurse contributes to nursing &
Standard V :
mental health through the use of research methods
Research and findings.
 FACTORS AFFECTING QUALITY
ASSURANCE IN NURSING

1. Lack of Resources

2. Personnel problems

3. Improper maintenance

4. Absence of well informed population

5. Absence of accreditation laws

6. Lack of incident review procedures

7. Lack of good and hospital information system

8. Absence of patient satisfaction surveys

9. Lack of nursing care records

 CONT…
10. 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
 
Role of psychiatric nurse in Quality Assurance –

Acute(Emergency ward) -
Shorten duration of hospital stays
Prevention of re-hospitalization
Consideration of human rights
Family support
Careful nursing

 Sub-acute(General ward) -
Enhancement of intensive rehabilitation
Improvement of patient’s QOL
Enhancement of patient and family psycho-education
Improvement of adherence
 
Recuperation(Convalescent ward) -
Enhancement of rehabilitation by interdisciplinary team
 
 
 The roles of nursing administrators and managers in
improving psychiatric care services –

 Improvement of patient’s daily life skills and abilities.

 Enhancement of patient mental education
 Improvement of adherence and self-care

STRUCTURE PROCESS OUTCOME

1. Provide good quality 1. Patient safety 1. Improved quality of

2. Recuperation environment
3. Systematiize of nursing
services
4. Ensure proper and sufficiet
staff assignments
2. Written Informed consent
3. Protection of personal
information
4. Education for staff and
improvement of
techniques.
5. Interdisciplinary
collaboration
psychiatric services
2. Shorten average length of
hospitalization.
3. Improved satisfaction level
4. Improved health
5. Improve knowledge and
health behaviour.
 Role Of Nurses In Quality Assurance

1. Nurses are the active participants of interdisciplinary quality

improvement team.
2. Develop mechanism for continually monitoring of effectiveness of
nursing care both a collaborative and an individual professional
activity.
3. Contribute innovation and improvement of patient care.
4. Participating in improvement projects and patient safety
initiatives.
 CONCLUSION
QA is the process by which the maintenance of excellence in the
  provision of health care is ensured. Everyone in need should
have access to basic mental health care, the key principles are
that care should be equitable and accessible.

To improve the quality of psychiatric services, the following

matters require attention - Clarifications of psychiatric service
goals precise measurement of effects, shortened
hospitalizations.

Implementation of patient-centered care includes establishment

of trust relationships with patients based on open communication
and effective interdisciplinary team work.

In addition, nursing administrators and managers must judge the

clinical competency of nurses and assign them appropriately.
 REFERENCES

1. Quality improvement for mental health :Mental Health Policy and Service Guidance
Package, WHO.2003. http://www.who.int/mental_health/resources/en/Quality.pdf. 24-
Aug-2016.  
    
2.http://www.mentalhealth.wa.gov.au/Libraries/pdf_docs
/WA_QA_Framework_Final_Report_11_October_2011

3.http://currentnursing.com/nursing_management/total_qualitymanagement_health_care.ht
ml
. 24-Aug-2016  
    
4. World Health Organization. (2001b) Atlas: mental health resources in the world.
Geneva: World Health Organization.  
    
5.http://currentnursing.com/nursing_management/total_quality_management_health_care.h
tml
. 24-Aug-2016  
    
6. World Health Organization. (2001a) World Health Report 2001. Mental health: new
 Cont…
7. Koch M.W And Fairly T.M. Integrated Quality Management: The Key To Improving Nursing
Care Quality. 1st Edition.St.Louis,Missouri:MosbyPublications;2009.  
   
8. Yeaman C, et al. (2000) Performance improvement teams for better psychiatric rehabilitation.
Administration and Policy in Mental Health 27:113-2  
    
9. World Health Organization, 2003. Quality improvement for mental health: Mental health policy
and service guidance package. Url: http://www.who.int/mental_health/resources/en/Quality.pdf
  
    
10. Gaebel a, et al. Guidance on quality assurance in mental healthcare. European Psychiatry. 30
(2015). Pp. 360-387  
    
11.http://www.mentalhealth.wa.gov.au/Libraries/pdf_docs/WA_QA_Framework_Final_Report_11
October 2011 
    
12. Developing a Quality Assurance Framework for Mental Health in Western Australia.http://
www.mentalhealth.wa.gov.au/Libraries/pdf_docs/WA_QA_  
    
THANK YOU