Defining quality in a public service context; Avedis Donabedian

Defining quality in a public service context; Avedis Donabedian 150 150 Affordable Capstone Projects Written from Scratch

Defining quality in a public service context can be quite difficult. But generally, it is about improving the patient’s experience, whilst using resources efficiently.

The terms “quality assurance” and “quality improvement” are often used interchangeably. This is incorrect as quality assurance is the process of ensuring that a product or service meets a minimum standard – which is often set by an outside body. Conversely, quality improvement is about continuously improving the quality of a product or service.

Quality Improvement

Avedis Donabedian (1919 – 2000) is generally credited as being the forefather of quality in health care. Donabedian was a Lebanese physician who spent most of his career at the University of Michigan. He developed a conceptual model that provides a framework for evaluating quality of care within health services. This is referred to as the ‘Donabedian Model’. The model has three dimensions: structure, process and outcome.

You should also be aware of William Edwards Deming (1900 –1993) an American who is well known for the “Plan-Do-Check-Act” (PDCA) cycle. From 1950 onwards he taught top business managers in Japan using this cycle. It is now commonly used in healthcare.

The PDCA cycle is a quality improvement model that consists of four repetitive steps which ensures continuous improvement. This design allows feedback from evaluations (the Check step) to be fed back into process allowing the aim of the quality improvement program to be met.

Plan: The first step is to identify and plan the change(s) that are to be made.

Do: The next step is to put the plan into action.

Study: The next step is to look the outcome(s) and examine the results of the changes made.

Act: The next step in the cycle is to take action based on the results of the study. This may mean making modifications to the original changes made. Such modifications also need to go through the “Plan, Do, Study, Act’ cycle. 

Evidence Based Medicine

Professor Archie Cochrane is seen as the forefather of EBP. He believed that the results of randomised control trials (RCTs) provided the best evidence for clinical practice. He argued that, by reviewing and analysing the results of multiple RCTs looking at the same clinical issue you had gold standard evidence.

The Cochrane Collaboration was set up in 1992 and is based in the UK. Its vision is stated as “a world of improved health where decisions about health and health care are informed by high-quality, relevant and up-to-date synthesised research evidence.” Some people claim that EBM grew from the Cochrane Collaboration.

The Joanna Briggs Institute (JBI) is another research institute which promotes evidence based healthcare. JBI was established in 1996, in Adelaide, Australia, and aims to promote evidence synthesis, transfer and utilisation.

 Learning Activity 1: Locating the evidence

 

  1. Visit the Cochrane Collaboration website http://www.cochrane.org/cochrane-reviewsand identify an abstract relevant to your work
  2. Visit the Joanna Briggs Institute http://joannabriggslibrary.org/index.php/index/searchand identify an abstract relevant to your work.
  3. Summarise these abstract and write a couple of sentences on the online discussion forum describing how these abstracts apply to your everyday work.

Others claim that Evidence Based Practice originated from the McMaster Medical School in Canada in the early 1980s. The work that they were undertaking at this point emphasised the individual responsibility of each practitioner to use the best evidence available to them. They used a four step approach outlined below.

 

McMaster Four Step Approach

  1. Formulate a question relating to a clinical problem
  2. Search the literature
  3. Appraise the literature
  4. Use your findings to direct clinical practice.

 

Learning Activity 2: Using the McMaster Four Step approach of reviewing the evidence

Activity 2

Use the McMaster Four Step Approach to guide this task.

Formulate a research question relating to a clinical problem that you face regularly. Post your question on the online discussion forum.

Search the literature and identify relevant studies. Where possible you should limit these studies to those with an experimental design (e.g. RCT) that have been conducted in the last 5 years). In the online discussion forum post the number of articles you have identified.

Pick five articles to read. Summarise their findings and suggest how you could make changes in your work environment. Post your answers on the online discussion forum.

Barker 2010 notes that increasing interest in EBM occurred at the same time as the advent of “expert patients” – that is patients who are informed about their condition and the latest treatments. This was due to the increasing availability of medical information on the Internet.

 

The terms Evidence Based Practice (EBP) and Evidence Based Medicine (EBM) are often used interchangeably.

 

Evidence Base Nursing

The origins of Evidence Based Nursing (EBN) remain divisive. Some people claim that Evidence Based Nursing (EBN) was first practiced by Florence Nightingale (McDonald 2001); while others argue that nursing research has been an active discipline since the 1920s (Brown 2009). Whatever the origins of EBN it is accepted as a move away from the justification that things were done a certain way because “Sister says so” to being grounded in research evidence.

 

“Effective nursing practice requires information, judgement, skills and art” (Brown 2009, p.3)

 

Evidence }
Clinical expertise Evidence Based Practice
Patient preferences
Context of care

(Barker 2010)

Ideally patient care should be based on research evidence. In order for this to occur nurses need have good critical appraisal skills. That is, nurses need to be able to read the research, understand the findings, appraise the methodology and apply their learnings in the workplace. However, many nurses undertake thousand of actions everyday (Brown 2009). Trying to obtain and evaluate research evidence for each action would be overwhelming – this is where clinical care protocols have an important role to play.

The journal of Evidence-Based Nursing was launched in 1998 http://ebn.bmj.com/site/about/

Knowledge Translation

Knowledge translation is the act of getting research findings into clinical practice.

An Overview of Getting Research Findings into Practice

  1. Search for, locate and summarise all of the studies on your clinical problem
  2. Develop research based clinical practice guidelines
  3. Adopt clinical practice guidelines in your facility and make changes necessary for your work environment.

 

As you can see quality improvement, evidence based practice and nursing research are closely linked. This presentation called

Play Video

, further explains the differences between the three fields (9.26 mins).

References

Barker, J 2010, ‘What is evidence-based practice’, in Evidence-Based Practice for Nurses, Sage, Chippenham, Wiltshire, pp. 3–13.

Brown, SJ 2009, ‘The research-practice connection’, in Evidence-Based Nursing: The Research-Practice Connection, Jones and Bartlett Publishers, pp. 3–14.

Hewner, S 2013, ‘Evidence-based Practice, Quality Improvement and Nursing Research’ (online video), 16 April 2013, Buffalo School of Nursing, State University of New York, viewed 16 June 2014 <http://www.youtube.com/watch?v=03AxbqXDZiw>.

McDonald, L 2001, ‘Florence Nightingale and the early origins of evidence-based nursing.’, Evidence-Based Nursing, vol. 4, no. 3, pp. 68–9.

Mozley, C, Sutcliffe, C, Bagley, H, Cordingley, L, Challis, D, Huxley, P & Burns, A 2004, ‘Quality in Care Homes for Older People’, in Towards Quality Care: Outcomes for Older People in Care Homes, Ashgate, pp. 1–9.

 

Further reading

Beyea, SC & Slattery, MJ 2013, ‘Historical perspectives on evidence-based nursing’, Nursing Science Quarterly, vol. 26, no. 2, pp. 152–5.

Reilly, MTO, Courtney, M & Qut, HE 2007, ‘How is quality being monitored in Australian residential aged care facilities?’, International Journal for Quality in Health Care, vol. 19, no. 3, pp. 177–182.

Wallin, L 2009, ‘Knowledge translation and implementation research in nursing’, International Journal of Nursing Studies, vol. 46, pp. 576–587.

Accreditation

In this section of the module you will become familiar with some of the accreditation bodies that ensure safety and quality improvement in the health and aged-care sector in Australia.

 

Australian Council on Healthcare Standards (ACHS) (http://www.achs.org.au/)

The ACHS is an independent, not-for-profit organisation, dedicated to improving the quality of health care in Australia, through measurement and implementation of quality improvement systems. The ACHS produces and delivers accreditation systems and clinical indicators. In 1996, they launched the Evaluation and Quality Improvement Program (EQuIP). EQuIP is a four-year quality improvement program for health care organisations. It promotes excellence in patient care through a customer focussed framework. External, peer reviewers (surveyors) examine how the organisation meets each of the standards using graded ratings.

 

Aged Care Standards and Accreditation Agency (http://www.accreditation.org.au/)

The Aged Care Standards and Accreditation Agency promotes quality care in the Australian Government subsidised residential aged care sector. The Minister for Mental Health and Ageing is the sole member of the company. Quality care is promoted through the accreditation program and an industry education program.

 

Australian Commission on Safety and Quality in Health Care (http://www.safetyandquality.gov.au/)

The Australian Commission on Safety and Quality in Health Care (the Commission) was created in 2006. The Commission is a government agency that leads and coordinates improvements in health care quality and safety across Australia. The Commission is funded by all governments and reports to the Standing Council on Health.

 

National Safety and Quality Health Service Standards (NSQHS)
(
http://www.safetyandquality.gov.au/our-work/accreditation/nsqhss/)

The Commission developed the NSQHS Standards to “improve the quality of health service provision in Australia” (National Safety and Quality Health Service Standards n.d.). This provides a statement of the level of care consumers can expect from health services nationwide.

There are 10 Standards:

  1. Governance for Safety and Quality in Health Service Organisations;
  2. Partnering with Consumers;
  3. Preventing and Controlling Healthcare Associated Infections;
  4. Medication Safety;
  5. Patient Identification and Procedure Matching;
  6. Clinical Handover;
  7. Blood and Blood Products;
  8. Preventing and Managing Pressure Injuries;
  9. Recognising and Responding to Clinical Deterioration in Acute Health Care; and
  10. Preventing Falls and Harm from Falls.

 Learning Activity 3: Accreditation

Identify the accreditation body and quality improvement standards followed in your healthcare organisation

  1. On the online discussion forum post two ways in which this impacts your work in a positive manner

References

Aged Care Standards and Accreditation Agency n.d., Promoting High Quality Care, viewed 25 March 2014, <http://www.accreditation.org.au/>.

Australian Commission on Safety and Quality in Health Care n.d., Home Page, viewed 25 March 2014, <http://www.safetyandquality.gov.au/>.

Australian Commission on Safety and Quality in Health Care n.d., National Safety and Quality Health Service Standards, viewed 25 March 2014, <http://www.safetyandquality.gov.au/our-work/accreditation/nsqhss/>.

The Australian Council on Healthcare Standards n.d., Home Page, viewed 25 March 2014, <http://www.achs.org.au/>.

Further reading

Productivity Commission 2011, Caring for Older Australians; Report No. 53, Final Inquiry Report,, Canberra, pp. 185–236.

Clinical Indicators

What are they?

Clinical indicators are a way of measuring performance through the collection and recording of data. By continuously measuring processes organisations can identify problems and initiate changes where necessary – and measure the impact of those changes.

The ACHS has a well known hospital-wide clinical indicator program, which it has been running since the late 1980s. You can find out more about the ACHS Clinical Indicator Program here: http://www.achs.org.au/programs-services/clinical-indicator-program/

Clinical indicators can be used to measure different types of events:

  • Structure (what is needed)
  • Process (what is done)
  • Outcome (what is achieved or expected).

However, clinical indicators cannot show the complexity of a clinical case and are used as flags of potential problems.

Read the Australian Medical Association’s position statement on clinical indicators: https://ama.com.au/position-statement/clinical-indicators-2012 It provides a thorough overview of the benefits and potential pitfalls of clinical indicators.

 

Clinical indicators can take a number of forms:

  • Comparative rate based indicators – these indicators have a numerator (number of incidents) and denominator (total number of patients) and measurechanges in rates over time. Generally, these indicators are used to measure events that are expected to occur with some frequency e.g. falls and pressure ulcers.
  • Sentinel events– these indicators identify events that are undesirable and may result in death in a significant physical injury. Such an event should trigger further analysis and investigation. The Victorian Department of Health in have a state wide sentinel event program. There are eight types of event that require reporting to the Sentinel Event Program:
  1. procedures involving the wrong patient or body part resulting in death or major permanent loss of function;
  2. suicide in an inpatient unit;
  3. retained instruments or other material after surgery requiring re-operation or further surgical procedure;
  4. intravascular gas embolism resulting in death or neurological damage;
  5. haemolytic blood transfusion reaction resulting from ABO incompatibility;
  6. medication error leading to the death of patient reasonably believed to be due to incorrect administration of drugs;
  7. maternal death or serious morbidity associated with labour or delivery; and
  8. infant discharged to wrong family.

 

An example of a clinical indicator for hospital acquire pressure ulcers

Numerator = the number of admitted patients who develop at least one Stage 1 pressure ulcer during their episode of care in the reporting quarter

Denominator = total number of occupied bed days, for overnight and multi-day patients, during the reporting quarter for all admitted episodes of care

 

Stage 1 pressure ulcer = observable pressure related alteration of intact skin whose indicators as compared to the adjacent or opposite area of the body may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel) and/or sensation (pain, itching).

(Victorian Government Health Information 2009)

The Gerontic Nursing Clinical School at La Trobe University was commissioned by the Department of Health, Victoria to develop a set of clinical indicators for aged care services in Victoria. They developed a set of eleven indicators across five domains. These domains are:

  1. Pressure ulcer stages 1 – 4;
  2. Falls and fall related fractures;
  3. Use of physical restraint;
  4. Residents using nine or more medications; and
  5. Unplanned weight loss.

You can read more about these indicators and the development of appropriate reference ranges in this report: “Development of Reference Ranges for Aged Care Quality Indicators”. This report is of interest as it shows how research findings have been used to inform clinical practice.

Learning Activity 4a:

 

Activity 4a

Choose one of the indicators listed above and think about how you would collect this information in your workplace.

In the online forum create a post which outlines where you would source data for the numerator and denominator. You should also state how you would monitor change in rate for your indicator.

Monitoring a Clinical Indicator

Rate based indicators are most easily tracked by plotting them in a spreadsheet program such as MS Excel.

This section will talk you through the steps you need to take to monitor a clinical indicator.

  1. Set up your spreadsheet ready for your data. It will probably take the following format:
  2. a)     Column 1 – The date
  3. b)     Column 2 – The numerator (that is the thing that you are measuring e.g. number of patients with a pressure ulcer of a certain size)
  4. c)     Column 3 – The denominator (that is the total number of patients that could be affected. This may be the number of patients on the ward during the month.
  5. Enter your data.
  6. To calculate the percentage you need to create a formula (circled below). The “=” sign tells MS Excel that this is a sum. B2 and C2 are the names of the cells (the blocks with text or numbers in them). In this example B2 = 3 and C2=45. After pressing the Enter button (so that the sum calculates) you then press the “%” button (circled) to turn the result into a percentage.
  7. When you set up a spreadsheet it is quite likely that you will have data for a number of months already collected. In which case you can click and pull the black square (circled below) to copy the calculation down the column.
  8. The easiest way to monitor a rate based clinical indicator is to create a chart. To do this you need to select all of your text (see below). You then choose a line chart (circled).

This creates a chart such as the one below. (This chart has been edited to delete the lines representing the numerator and denominator). Such a chart allows you to see at a glance large fluctuations in rates. Such peaks should be investigated by the healthcare delivery team to see what has caused the change in rates. Monitoring and reviewing indicators monthly allows this to be done in a timely manner.

Learning Activity 4b:

 

Activity 4b

Your final task for this module is to set up and monitor a clinical indicator in your workplace for at least two months.

In the online forum you should identify two things that you found helpful about this process and two things that were hard.

 

References

Australian Medical Association 2012, Clinical Indicators – 2012, viewed 25 March 2014, <https://ama.com.au/position-statement/clinical-indicators-2012>.

The Australian Council on Healthcare Standards 2013, Clinical Indicator Program, viewed 25 March 2014, <http://www.achs.org.au/programs-services/clinical-indicator-program/>.

Victorian Government Health Information 2009, The Pressure Ulcer Clinical Indicator Set, Victorian Government, Department of Human Services, viewed 25 March 2014, <http://www.health.vic.gov.au/pressureulcers/puci.htm>.

 

Further reading

ACHS 2012, Australasian Clinical Indicator Report 2004 – 2011, Sydney, NSW, pp. 1–48.

ACHS 2014, Clinical Indicator Program Information 2014, Ultimo, NSW, no. 02, pp. 1–28.

State of Victoria, Department of Health 2011, Development of Reference Ranges for Aged Care Quality Indicators, Melbourne, Victoria.

The Victorian Quality Council 2008, A guide to using data for health care quality improvement, Melbourne, no. June, pp. 1–68

References

Aged Care Standards and Accreditation Agency n.d., Promoting High Quality Care, viewed 25 March 2014, <http://www.accreditation.org.au/>.

Australian Commission on Safety and Quality in Health Care n.d., Home Page, viewed 25 March 2014, <http://www.safetyandquality.gov.au/>.

Australian Commission on Safety and Quality in Health Care n.d., National Safety and Quality Health Service Standards, viewed 25 March 2014, <http://www.safetyandquality.gov.au/our-work/accreditation/nsqhss/>.

Australian Medical Association 2012, Clinical Indicators – 2012, viewed 25 March 2014, <https://ama.com.au/position-statement/clinical-indicators-2012>.

Barker, J 2010, ‘What is evidence-based practice’, in Evidence-Based Practice for Nurses, Sage, Chippenham, Wiltshire, pp. 3–13.

Brown, SJ 2009, ‘The research-practice connection’, in Evidence-Based Nursing: The Research-Practice Connection, Jones and Bartlett Publishers, pp. 3–14.

McDonald, L 2001, ‘Florence Nightingale and the early origins of evidence-based nursing.’, Evidence-Based nursing, vol. 4, no. 3, pp. 68–9.

Mozley, C, Sutcliffe, C, Bagley, H, Cordingley, L, Challis, D, Huxley, P & Burns, A 2004, ‘Quality in Care Homes for Older People’, in Towards Quality Care: Outcomes for Older People in Care Homes, Ashgate, pp. 1–9.

The Australian Council on Healthcare Standards 2013, Clinical Indicator Program, viewed 25 March 2014, <http://www.achs.org.au/programs-services/clinical-indicator-program/>.

The Australian Council on Healthcare Standards n.d., Home Page, viewed 25 March 2014, <http://www.achs.org.au/>.

Victorian Government Health Information 2009, The Pressure Ulcer Clinical Indicator Set, Victorian Government, Department of Human Services, viewed 25 March 2014, <http://www.health.vic.gov.au/pressureulcers/puci.htm>.

Further reading

ACHS 2012, Australasian Clinical Indicator Report 2004 – 2011, Sydney, NSW, pp. 1–48.

ACHS 2014, Clinical Indicator Program Information 2014, Ultimo, NSW, no. 02, pp. 1–28.

Beyea, SC & Slattery, MJ 2013, ‘Historical perspectives on evidence-based nursing.’, Nursing science quarterly, vol. 26, no. 2, pp. 152–5.

Productivity Commission 2011, Caring for Older Australians; Report No. 53, Final Inquiry Report, Canberra, pp. 185–236.

Reilly, MTO, Courtney, M & Qut, HE 2007, ‘How is quality being monitored in Australian residential aged care facilities?’, International Journal for Quality in Health Care, vol. 19, no. 3, pp. 177–182.

State of Victoria, Department of Health 2011, Development of Reference Ranges for Aged Care Quality Indicators, Melbourne, Victoria.

The Victorian Quality Council 2008, A guide to using data for health care quality improvement, Melbourne, no. June, pp. 1–68.

Wallin, L 2009, ‘Knowledge translation and implementation research in nursing’, vol. 46, pp. 576–587.

 


 

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