2. Quality Improvement
Prepeared By
Dr: Manal Moussa

3. Quality Improvement
Definition
Quality: is defined as the process of a target degree of
excellence of nursing intervention then taking steps to
ensure that each pt. received the agreed upon level of
performance.
It is the process of establishing desirable standards of
nursing care & then planning & providing the type of care
that will meet those standards
Quality improvement process involves: (Q.I)
1- Setting standards of care.
2- Determining criteria.
3- Evaluating how well the criteria have been met.
4- Making plans for change based on the evaluation.
5- Following up the implementation of change..

4. Aims of Q.I.
- Measuring the quality of nursing care
- Improving the quality of nursing care.
These aims can be achieved by:
1- Establishing professional standards of care.
2-Concurrent audit i.e. evaluation of patient's care by
direct observation, (in hospital)
3- Retrospective audit i.e. evaluation of patient's care
after discharge.

5. Auditing:
• Definition: An audit is a systemic & official examination of
a record process - structure-environment or account to evaluate
performance.
• Auditing provides managers with a means of applying the
control process to determine the quality of services offered.
• Auditing can occur: retrospective – concurrent.
• The audits must frequently used in quality include: structure,
process and outcome audits.
• Patient care audit is a control tool used to :
- Improve the quality of care.
- Teach staff how to establish nursing care priorities & to be able
to analyze problems.

6. Principles of QI:
Collaboration of activities is needed to ensure the
objectives & activities of each health profession are enhanced nurses-physicians.
2. Ensure that the resource expenditure (financial) for quality activities is appropriate.
3. Successful & accurate of auditing patient care is the key to ensure quality pt's care.
4. Effective monitoring of the nursing operations
depends on receiving feedback from all pts
concerning the nursing process elements.

7. 5. Feedback to nurses is the aim of QI report in order to have
good practice & correct performance.
6. Quality assessment may perceive the need for changing the
organizational structure that supports the unit plans i.e.
methods & strategy.
7. Collection & analysis of quality data should be linked to the
decision making process.

8. Approaches to quality improvement:
Nursing can be evaluated through (3) elements are:
• Structure.
• Process.
• & outcome.
Any improvement of one of these (3) elements leads to
favorable change in the other two elements.

9. 1- Structural elements of nursing care:
It includes:
- Physical settings.
- Hospital philosophy and objectives.
- Equipments-resources.
- Financial resources.

10. 2- Process elements of nursing care
It includes the steps of nursing process:
- Performing physical examination (assessment).
- Determine nursing care goals.
- Writing nursing care plans.
- Reporting and recording patient's care responses to
treatment.

11. 3- Outcome elements of nursing care:
These are changes in patient's health status resulting
form nursing care, it includes modifications of:
- Sings and symptoms
- Knowledge.
- Patient's satisfaction & compliance with treatment.

12. The development of standards:
• A standard is a predetermined level of excellence that
serves as a guide for practice.
• Standards are predetermined, established by an
authority & communicated & accepted by the people .
• Standards are used as measurement tools- they must
be objective, measurable, and achievable.

13. • Each organization & profession must set standards
and objectives to guide individual practice in
performing safe and effective care.
• Organizational standards outline levels of acceptable
practice within the institution i.e. each organization
develops a policy and procedure manual that outlines
its specific standards – these standards of practice
allow the organization to measure more objectively
unit and individual performance.

14. Developing quality improvement criteria:
A criterion may be defined as: a descriptive
statement of performance - behavior. - Circumstances or
clinical status that represents a satisfactory or excellent
state of care. It is an item that selected as relevant
indicator of the quality of care.

15. Characteristics of criteria:
When writing the criteria of pt's care, it should be:
• Relevant to be specifically related to the objective of the practice.
• Measurable: each criterion should include time frame of the activity and its frequency.
• Clearly understandable and achievable.
• Clinically reviewed periodically.
• Reflective of all aspects of pt's care e.g. care elements → vital signs - dressings - discharge plan etc.

16. Importance of standards:
• Obtaining means of clarifying what constitutes good
practice.
• Monitor care.
• To assess level of service.
• Enable nurses to describe in measurable the care they provide for patients - what is required to carry out that care and the expected outcome will be.

17. Steps in the quality improvement process:
The quality improvement process is a structured series of steps designed to plan, evaluate, and propose changes for health care activities.
1- Select a nursing activity for improvement:
Quality improvement efforts need to be concentrated on nursing care changes that will have the greatest impact.
-Nursing activity will be selected after investigating all elements of nursing care in order to improve nursing skills and procedures.

18. 2- Assemble a multidisciplinary team:
*The team members should represent a cross section of workers who are involved with the problem (e.g. nurses - physicians – pharmacists ...).
*Team members need to be educated about their roles before starting the quality improvement process.
*The group set boundaries for the identified activity & explained all the activity components.

19. 3- Collect data to measure the current status of
the activity:
*The team collects data to determine the present status
of the activity (e.g. giving I.V medications).
*A variety of statistical methods may be used to analyze
& present this information.

20. 1- After analyzing data, the team sets a goal for improvement.
4- Set a measurable standard for the activity:
1- After analyzing data, the team sets a goal for
improvement.
2- This goal involves a standard of practice& measurable
care outcome or indicator.
3- Input from the clients is important for deciding the
level of improvement needed.

21. 5- Discuss various plans to meet the standard:
The team discusses various strategies & plans to meet the new
standard on outcome.
This outcome should be measurable result e.g. 90% of admitted
patients have initial nursing care plans.
One plan is selected for implementation & the process of change
begins.
Changing strategies emphasize open communication & education
of workers affected by the new standard and outcome.
Polices and procedures may need to be reviewed or rewritten
during the quality improvement process. Frequent review and
updating of polices is important.

22. 6- Select and implement one plan to meet the standard:
As the plan is implemented, the team continues to gather and
evaluate data to document that the new standard is met.
If the new standard is not met, revisions in the implementation
plan are needed.
The interdisciplinary team may need to meet periodically to
handle any new problem that develops with the implementation
of any new process or procedure.

23. 7- Evaluate the implementation of the plan and revise as
needed:
The focus of evaluation for quality improvement is on outcomes.
The outcomes evaluated are: clinical care outcomes of the pt.,
professional practice of the staff, and administrative system of
the organization.
The nurse manager has to reward or reinforce the success of
each quality improvement team. She must also evaluate the work
of the team and the ability of individual team members to work
together effectively.

24. 8- Giving feed back to staff:
Feedback information could be about: nursing structure –
Process or pt's outcomes.
Feedback information could be oral or written form. Data
should be reported for correction of malpractice and
achievements of high standard should be rewarded.
Administrative support is needed for the quality
information to be communicated to different nursing
categories.

25. 9- Remedying deficiencies:
Most of these deficiencies are due to: lack of knowledge
and skills of staff. So, quality improvement programs
should be closely lied to the in-service education
programs to provide remedial instructions.

26. Quality improvement tolls and techniques:
1-Logs: Is a simple and basic tool used to identify or follow events
or uncommon problems.
2-Check Sheets: Check sheets are tools used to mark the frequency
of events.
3-Surveys/Questionnaires: are preplanned, written tools used to
obtain responses to selected question from key people.
4-Interviews: are guided approaches to obtaining verbal responses
to pre-established questions from an individual or small group.

27. 5-Focus Groups: are meetings of individuals (usually
a representative sample of consumers) brought together to provide
feedback on a predetermined topic.
6-Brain Storming: is a group activity used to identify the range or
scope of problems or situations, reason underlying a situation. It
is effective approaches that stimulates and encourage creativity.
7-Control Charts: it uses statistically determined upper and lower
limits to define a range of acceptability.