Prince Sultan College of Health Sciences

College of Nursing

Nursing Management & Leadership

Quality Management
Objectives:
• Identify the total & continues quality management
• Recognize the components of quality management
• Identify the Key Processes for Improvement
• Differentiate between the types of incidents
• Recognize the principles to manage & improve
quality
Introduction:
• In today’s highly competitive health care environment each
member of the healthcare organization must be accountable
for the quality and cost of healthcare.

• Total quality management is a management philosophy that

emphasizes a commitment to excellence throughout the
organization.
Total Quality Management

• Goal: to involve all the employees & empower them with

responsibility to make difference in the quality of service
they provide.

• All Departments work together as a team to meet this goal.

Focus:
• An important theme of quality management is to address the
needs of both internal and external customers.

• Internal customers include employees & departments within

the organization such as laboratory, admitting office &
environmental services.

• External customers of health care organization include patients,

visitors, & regulatory agencies such as the Joint Commission
International Accreditation (JCIA) & public health departments
 Continuous Quality Improvement (CQI)
• Is the process used to improve quality & performance in health
care organizations. CQI is the process used to investigate
systematically ways to improve patient care.
 Components of Quality Management

The comprehensive quality management program includes:

• A quality management plan is a systematic method to design,

measure, assess & improve organizational performance. Using
a multidisciplinary approach this plan identifies processes &
systems that represent goals & mission of the organization
identifies the customers & specifies opportunities for
improvements.
 Components of Quality Management

• Set standards for benchmarking-standards are written

statement that define a level of performance or set of
conditions determined to be acceptable by some authorities
standards related to their major dimensions of quality care.

 Standards of Structure.

 Standards of Process.

 Standards of Outcome.
 Components of Quality Management

• Structure standards relate to the physical environment,

organization & management of an organization ( qualification,
job categorization)

• Process standards are those connected with the actual delivery

of care (Address nursing activities that nurses perform)

• Outcome standards involve the end results of care that has

been given.
 Components of Quality Management

• An indicator is a tool used to measure the performance of structure,

process & outcome standards. (infection, DVT, fire and safety)

• It is measurable, objective & based on current knowledge. Once

indicators are identified benchmarking or comparing data with other
reliable sources (internally, externally) is a key to quality
improvement.

• A common management quote is “ you can’t manage what you

can’t measure”.
 Identification of Key Processes
for Improvement
All activities performed in the organization can be described in
terms of processes. Processes within a health care setting can
be:

1. Systems related e.g. admitting, discharging & transferring

patients.

2. Clinical e.g. administering medications, managing pain.

3. Managerial e.g. financial risk management, performance

evaluation.
 Nursing Audits
A nursing audit can be retrospective or concurrent.

A. A retrospective audit is conducted after a patient’s discharge

& involves examining records of a large number cases.

B. Concurrent audit is conducted during the patient’s course of

care; it examines the care being given to achieve a desired
outcome in the patients health & evaluate the nursing care
activities being provided, changes can be made if patient
outcomes indicate that.
 Peer Review
• Peer review occurs when trained and expert leaders
or nurses are able to determine the standards &
criteria that indicate quality care & then assess
performance against these for each other.

• In this case, they will determine what the indicators

of quality care are & when such care has been
provided.
 Risk Management
• A program directed toward identifying, evaluating & taking
corrective actions against potential risks that could lead to injury.

High risk areas in health care fall into five general categories:

1. Medications errors.

2. Complications from diagnostic or treatment procedures.

3. Falls. (safety)

4. Patient or family dissatisfaction with care.

5. Refusal of treatment or refusal to sign consent for treatment.

 Incident Report

• An accurate & comprehensive report of unplanned

& unexpected occurrences (outcome) that could
potentially affect a patient family member or staff.
Types of incident (medical
error)
• Medical error is “the failure of a planned action to
be completed as intended or the use of a wrong plan
to achieve an aim.
1- Adverse event
An injury to a patient caused by medical management
rather than the patient’s underlying condition.
2- Error of omission results when an action is not
taken or omitted, such as when a nurse does not
assess a patient after surgery or does not administer a
medication; in both situations, the nurse omitted an
action that is a standard of care.
3- Error of commission results when the wrong
action is taken or committed. Examples of errors of
commission include a nurse giving a medication to
the wrong patient or performing a procedure
incorrectly
4- A sentinel event is a patient safety event that
results in any of the following: death, permanent
harm, and severe temporary harm and intervention
required to sustain life
• Near miss, or a potential error that was
discovered before it was carried out, must be
monitored and reported to ensure safety.
• For example, a nurse enters a patient’s room
to administer a medication and realizes that it
is the wrong patient. She immediately leaves
the room with the medication and avoids the
commission of an error. In this situation, a
near miss occurred and should be investigated
to avoid an actual error in the future.
• Most errors have multiple causes, the most common are related to
human factors, communication, and leadership (Shepard, 2011):

1. Human factors include staffing levels, staff education and

competency, and staffing shortages. When staffing is
inadequate or nurses lack experience, patient safety is
jeopardized.
2. Communication includes interprofessional communication
as well as interactions with patients and their families.
Optimal patient outcomes rely on effective communication.
3. Leadership includes leadership and management at all
levels, organizational structure, policies and procedures,
and practice guidelines. When leadership factors are
inadequate, nurses may make decisions that can result in
adverse events or near misses.
 Reportable Incident
Reporting incidents involves the following steps:

1. Discovery- by nurses, physician’s, employer or volunteer may

report actual or potential risk, it also can be found in patient’s
files or any.

2. Notification- the risk manager receives the completed

incident form within 24 hours after the incident. A telephone
call may be made earlier to have to follow up in the event of
a major incident.
 Reportable Incident

3. Investigation- the risk manager or representative

investigates the incident immediately.

4. Consultation- the risk manager consults with the

referring physician, risk management committee
member or both to obtain additional information
& guidance.
 Reportable Incident
5. Action- the risk manager should clarify any misinformation
to the patient or family, explaining exactly what happened
and the action taken.

6. Recording- the risk manager should be sure that all

records including incident reports, follow-up & actions
taken, if any are filed in central saving system.
Principle to manage & improve quality:

1. Become familiar with standards outcome and measures & use them to
guide & improve your practice.

2. Strive for perfection but be prepared to tolerate failure in order to

encourage innovation.

3. Be sure the performance appraisal & incident reports are not used for
discipline but rather are the bases for improvements to the system &
for development of individuals.

4. Remind yourself & your colleagues that a caring attitude is the best
prevention of problems.
Quality
improvement
process
Models for quality
improvement
1-Donabedian Model. This model provides a
framework for examining and evaluating the quality
of health care by looking at three categories of
information that can be collected to draw inferences
about the quality of health care: 1) structure, the
con- ditions under which care is provided; 2) process,
the activities that encompass health care; and 3)
outcomes, the desirable or undesirable changes in
individuals as a result of health care (Donabedian,
2003)
2- Six Sigma Model
• It has five steps: 1) define, 2) measure, 3) analyze,
4) improve, and 5) control (DMAIC; Table 7-4).
Sigma is a letter from the Greek alphabet () used in
statistics and measures variation or spread. Six
Sigma refers to six standard deviations from the
mean (Tague, 2005). It is used in QI to define the
number of acceptable errors produced by a
process. Six Sigma involves improving, designing,
and monitoring processes to minimize or reduce
waste (Hughes, 2008).
3-(PDSA) cycle or PDCA
• Plan-do-study-act (PDSA) cycle
Plan involves developing a plan to initiate a small
change, do is implementing the plan and collecting
data about the process, study includes studying and
summarizing the results of the change, and act
encompasses three possible actions—adopt the
change, adapt the change, or abandon the change.
Once the cycle is complete, the process starts over
again (IHI, 2014). Using the PDSA promotes
continuous QI. The PDSA cycle is used to identify
issues and improve care
4- Root cause analysis
• (RCA) is a “formalized investigation and problem-
solving approach focused on identifying and
understanding the underlying causes of an event as
well as potential events that were intercepted . . .
used with the under- standing that system, rather
than individual factors, are likely the root cause of
most problems” (Hughes, 2008, pp. 6–7).
Quality improvement tools
1- A run chart communicates data, shows trends over
time, and reflects how a process is operating (Boxer &
Goldfarb, 2011). In a run chart, the vertical axis (y)
represents the process variable and the horizontal
axis (x) represents time. The mean or median of data
is displayed as a horizontal line and allows nurses and
the QI team to see changes in measurements without
having to compute statistics. Data points above the
median indicate an improvement in a process,
whereas data points below the median reflect a
deterioration in the process.
2- Bar chart
• A bar chart is the most common method used to
display categorical data, and the scale must start at
zero. When using a bar chart, categories are listed along
the horizontal axis, and frequencies or percentages are
listed on the vertical axis (Tague, 2005). Nurse leaders
and managers would use a bar chart to illustrate
categorical data. For exam- ple, in looking at the
increase in the number of falls on the unit, the nurse
leader and manager may investigate the staff mix (i.e.,
number of registered nurses, licensed practical nurses,
technicians) on the unit during those time periods.
 3-Fishbone diagram
• also known as an Ishikawa diagram or a cause-and-effect dia-
gram, is used to identify the many possible causes of a problem
and any relationships among the causes (Phillips & Simmonds,
2013). It provides a retrospective review of events and can help
nurse leaders and managers determine the root causes of a prob-
lem. Fishbone diagrams are key tools used to conduct RCAs. They
encourage the team to look at all possible causes and contributing
factors of an issue, not just the most ob- vious. The fishbone
provides a graphic display of the relationship between an outcome
and possible factors, such as people, processes, equipment,
environment, and man- agement. For example, a fishbone diagram
would be used by nurse leaders and man- agers if they wanted to
investigate a medication error or an event such as a patient’s
suicide. The fishbone allows the QI team to consider all possible
causes of the event. Categories of factors that could cause a
problem vary depending on the incident.
4- flow chart
• A flow chart helps clarify complex processes, shows
blocks in activity in the process, and serves as a basis
for designing new processes (IHI, 2016c). Flow charts
provide a picture of the various steps in a sequential
process and allow QI teams to under- stand an
existing process, identify complexity in a process,
identify non–value- added steps in a process, and
develop ideas about how to improve a process.
• Nurse leaders and managers would use a flow chart
to identify problematic areas in the process of
admitting a patient
 JCAHO (JCI)

• The Joint Commission of Accreditation for

Healthcare Organizations has an impressive
comprehensive set of standards that must be met to
receive accreditation. The mission of JCAHO is to
improve the quality of care provided to the public.
CBAHI
The Saudi Central Board for Accreditation of Healthcare Institutes:

is the official agency authorized to grant accreditation certificates

to all governmental and private healthcare facilities operating
today in Saudi Arabia.

The principal function of CBAHI is to set the healthcare quality and

patient safety standards against which all healthcare facilities are
evaluated for evidence of compliance.
Certification is another example of structure standard.
Certification reflects certain qualifications of an individual
rather than an agency for example American Nursing
Association (ANA), (SCFHS)

Certification requirements usually include three

stipulations:
• Written examination in a specific area of competence.

• Active practice in specialty.

• Re-certification at specified periods.

Tank you