Quality Health Care and Nursing PDF

West Visayas State University
COLLEGE OF NURSING
La Paz, Iloilo City, Philippines
Quality
Health Care
& Nursing
Lecture Notes and Compilation
RYAN MICHAEL F. ODUCADO, MAN, MAEd, RN, RM
2014
QUALITY HEALTH CARE AND NURSING ODUCADO, R.M.F. (2014)
DISCLAIMER STATEMENT
This material is not for sale and is used for academic purposes only.
.
There is no guarantee that information contained within this material is correct, complete,
and/or up-to-date. However, the author carefully compiled contents on this material to the best
of his ability. Sources of contents on this material are provided.
The author does not accept any responsibility for any loss which may arise from reliance on
information contained on this material.
This material is open access. Reproduction, distribution, republication, and/or re-transmission

of information contained within this material are not prohibited and permission is not required.
For any copyright infringement, do not hesitate to contact the author at

[email protected] so material may be taken down from circulation.
Powerpoint presentation of materials can be accessed at:
https://www.slideshare.net/roducado/oducado-rm-2014-quality-health-care-and-nursing
West Visayas Sate Univeristy

COLLEGE OF NURSING 2
Contents
Module 1 : Quality Care & Management
Module 2 : Patient Safety
Module 3 : Quality Improvement Tools
Module 4 : Quality Improvement Activities
Appendices : 2012 National Nursing Core Competency Standards

: PhilHealth Quality Standards For Health Provider
Organizations
Joint Commission National Patient Safety Goals

Module
QUALITY CARE &
1 MANAGEMENT
What is QUALITY?
 How good or bad something is.
 A characteristic or feature that someone or something has
 Something that can be noticed as a part of a person or thing.
 A high level of value or excellence (Merriam-Webster Dictionary)
 ―Quality is an optimal balance between possibilities realized and a framework of
norms and values‖ (Harteloh, 2003).
What is QUALITY CARE?

 Fitness to use by the customer (Joseph Duran in WHO, 2001).
 Conformance to requirements (Philip Crosby).
 It is the complete satisfaction of the needs of those who are in most need of
health services, for the lowest organizational costs, within the given limit and
guidelines of higher administrative bodies and those paying (Ovretveit in
Ritonja, 1998)
 This refers to the degree to which health care increases likelihood of desired
health outcomes, and is consistent with current professional knowledge (Lohr,
Institute of Medicine, 1990).
 It takes into account three (3) factors:
a) the variability of the achievement of quality each time care is rendered;
b) health care cannot guarantee the attainment of outcomes that clinicians
and patients expects;
c) scientific evidence and professional standards are crucial in defining
care.

Quality of Care Dynamics: Dimensions and Cross-Dimensional Issues
 High-quality health care is safe, effective, efficient, appropriate, accessible and

patient-centered.
 To achieve high-quality care, provider organizations must address the following
critical issues:
a) individual and organizational competence;
b) continuity of care;
c) information management;
d) the role of evidence-based medicine and accreditation.
 The end goal and ultimate recipient of any effort towards quality of health care
is the patient.
19TH CENTURY QUALITY OF HEALTH CARE THINKING

 The original concept of quality health care can be traced back to the mid-19th
century in England (WHO 2001).
 In 1842, Dr. Edwin Chadwick, a public health activist and pioneer, reported
on unsanitary conditions in communities and the lack of public health
professionals to provide quality service. He recommended the creation of
guidelines for the training of public health workers.
 At about the same time, in the United States, Dr. Lemuel Shattuk published a
similar report on sanitary conditions in Massachusetts.
 A little over a decade later, in 1854, Florence Nightingale, then serving as a
nurse in the Crimean War, introduced the idea of quality care in army hospitals
and posited that adequate nursing care to wounded soldiers would decrease the

mortality rate among them. This was the first time that the relationship between
quality of care and positive outcomes was established (WHO 2001). She
published a book on the matter, Notes on Matters Affecting the Health,
Efficiency, and Hospital Administration of the British Army, Founded Chiefly on
the Experience of the Late War (1858).
 In 1999, the Joint Commission on Accreditation of Healthcare Organizations
(U.S.) published excerpts from this book and another Nightingale work, Notes
on Hospitals (1859), as Florence Nightingale: Measuring Hospital Care
Outcomes.
Why is QUALITY OF CARE important?

Jonas and Rosenberg (1986) have identified four broad categories which explain
the need for quality of care:
• Hippocratic oath principle of primum non nocere (―First do no harm‖);
• The social and humanitarian motivation to use resources for the good of
those in need;
• Professionalism;
• Survival.
In the Philippines, the following conditions point to a similar impetus for this
pursuit of quality:
1. Tougher Competition
 Health care providers that are committed to the pursuit of continuous
improvement, innovation and customer satisfaction are the ones which
survive the competition for a greater market share of consumers and
purchasers of care.
 Hospitals that have loyal patients, supportive stockholders or local
government boards and enthusiastic staff are the ones with better
prospects of long-term viability.
2. Frequent Medical Errors
 Harrowing tales of patients given wrong medications or subjected to
wrong operations erode public trust in the health professions.
 While physicians, nurses and other health professionals are trained to be
highly proficient under stress, they are not immune from committing
errors.
 Organizations should provide opportunities for professionals to learn
from medical errors and take system-wide steps to prevent them.
 In 1998, the Institute of Medicine’s Quality of Health Care in America
Committee recommended that safety systems be created inside health
care organizations through the implementation of safe practices at the
delivery level.
 A culture of continuous improvement with strong leadership and
interdisciplinary training is critical in implementing safety programs
(Institute of Medicine 2000).
 Since then, different organizations led by the health departments of the

United States, Australia, the United Kingdom, and New Zealand, as well
as other private organizations like the JCAHO and the Institute for
Health Care Improvement, have developed mechanisms to monitor and
report medication errors, device errors, and other sentinel events.
 Studying Medical Errors:
• Charles Bosk
 Forgive and Remember: Managing Medical Failure (1979;
2003)
 Study of surgical errors
 Four Categorizes Medical Errors
a. Technical – mistakes in performance of medical
care; forgivable if reported to supervising physicians
but shouldn‘t be repeated; rapid revelation of errors
allows for prompt corrective measures to minimize
complications induced; inevitable in trainees; natural
consequence of inexperience; examples: incorrectly
tied sutures that leads to wound dehiscence, a slip of
a scalpel, pneumothorax because of an attempted
subclavian catheter placement;
b. Judgmental – mistakes made in decisions about the
course of treatment; consist of acting or not acting at
the right moment; operating when one shouldn't or
not operating when one should.
c. Normative – are more often made by subordinates
and involve breaches in informing superordinates of
all unfolding events, as well as interpersonal
difficulties with patients and nurses; “no surprises”
rule.
d. Quasi-normative – what is considered standard
procedure by one attending or in one institution is
considered ―wrong‖ in another.
 Focusing ―social accounting system‖, surgeons practice to
account for errors, Bosk suggests how safety
recommendations are much easier to make than
implement.
 Successful error reduction attempts should focus on how
personnel define errors, understand their causes and think
how they could be remedied.
• Virginia Sharpe and Allan Faden
 Medical Harm: Historical, Conceptual and Ethical
Dimensions of Iatrogenic Illness (1998)
 Highlight the ―do-no-harm‖ dictum as central to the practice
of the medical profession. They reveal that 70% of
iatrogenic complications in the United States could have

been prevented.
3. Rising Costs, Limited Health Expenditures
 Health care has become increasingly dependent on new and expensive
technologies.
 Patients and providers alike equate high tech care with good care.
 Health insurance can encourage patients and providers alike to use high
tech care simply because it has been paid for.
 Fear of malpractice suits compels physicians into defensive practice by
ordering multiple diagnostic tests.
 On the other hand, simply spending more money for health has been
repeatedly demonstrated not to increase good health outcomes
(Donabedian 1992). This has been proven in the United States (World
Development Report 1993).
 Ensuring value for money requires optimal and efficient use of effective
health interventions for the appropriate indications.
 Quantifying the cost of quality illustrates why focusing on quality is
important.
 One has to take into account Crosby‘s statement that the price of quality
can be measured in terms of what it will cost the company should things
be done wrong in the first place (like cost of scrap, rework, engineering
changes, purchase order changes, consumer services, software
correction). Should the cost of quality reach 2.5 percent of income, it
must be seen as a call for improvement (Crosby 1979).
4. Rising Demands, Limited Health Resources
 A health-conscious post-baby boom generation has produced a rising
demand for health care. However, there are limited resources to meet
rising demand.
 This has spawned the need for equitable access, especially for those who
are denied health care--even if they are the ones who need it the most—
either because they do not know about it or do not have money to
purchase it.
 Equitable access also means involving and empowering consumers in
making decisions regarding their own health.
 Ensuring equitable access is critical to economic growth because sick
populations can never achieve full economic productivity; in such a case,
the state is forced to ration health care resources to those who really
need them.
5. Concern with Variations in Health Care Outcomes and Costs
 Medical decision-making is influenced by previous experience, current
knowledge, patient expectations and other biases.
 Unjustified variations in care lead to unwanted variations in processes
and outcomes of care. This in turn leads to unnecessary costs.

 Using valid scientific evidence to plan and implement care will prove
useless unless organizations make their professionals behave more
rationally through a system of rewards and sanctions.
 This requires routine training, monitoring and partnering with health
care team members so that clinical practice guidelines are seen as tools
for improving care and are thus internalized and followed.
WHERE QUALITY OF HEALTH CARE STARTS

Quality health care, whether delivery is seen at the patient‘s end or from the
provider organization‘s perspective, starts with two principal actions:
1. Decision-making – selection of the most appropriate health intervention.
 This is determined by the provider‘s (whether this be the professional or
the hospital) level of knowledge, skill, experience, and the kind and
amount of additional information available.
2. Performance action – effective, efficient and timely application of the selected
intervention.
 This influenced by the adequacy of the processes used in delivering the
intervention.
 Other important influences in both actions include patient‘s preferences,
peer practice patterns, societal values, professional and legal sanctions
as well as economic rewards.
INTERNAL AND EXTERNAL CUSTOMERS

1. Internal Customers
a) Staff and Employees
 The people who run the hospital are not just its most important
resource. They are the hospital. This is true particularly to
patients.
 Hospitals and clinics are only as good as the staff who directly
take care of them.
 Hospitals and clinics owe their doctors, nurses and other
personnel reasonable compensation for their work, an
environment conducive to efficient performance of their roles, and
fulfillment of their professional and social needs.
b) Funders
 All hospitals and clinics owe their funders fiscal responsibility.
 Private organizations must earn money for their owners and/or
stockholders.
 Government hospitals must stay within their budgets even as they
try to generate their own income to augment limited government
subsidies.
 Devolved hospitals must, in addition, serve the socio-political
needs of the local governments that support them as a return of
their investment.
 Partnering with local government officials and the local health

boards increases devolved hospitals‘ chances of competing for
revenue allocations.
 Competitiveness is critical to survival regardless of hospital
ownership.
2. External Customers
a) Patients
b) Payors of Health Care
 External agencies that pay hospitals and clinics for providing care
to its insured members expect good value for their money.
 PhilHealth, as a third party payor, funds hospitals that provide
health care to PhilHealth insured members.
 In return, hospitals must maintain their accreditation and abide
by its warranties.
c) Contractors
 Individuals or external agencies that agree to provide services or
goods to hospitals and clinics expect to be bound by fair contracts
and be paid promptly.
 These contractors include housekeeping and security agencies,
laboratory equipment wholesalers and drug companies.
DIMENSIONS OF QUALITY HEALTH CARE

 Most clusters of quality indicators were and often continue to be comprised of
the 5Ds—death, disease, disability, discomfort, and dissatisfaction—rather than
more positive components of quality.
 The work of the American Academy of Nursing Expert Panel on Quality Health
focused on the following positive indicators of high-quality care that are sensitive
to nursing input:
 achievement of appropriate self-care
 demonstration of health-promoting behaviors
 health-related quality of life
 perception of being well cared for, and
 symptom management to criterion.
 The most recent IOM work to identify the components of quality care for the
21st century is centered on the conceptual components of quality rather than
the measured indicators: quality care is safe, effective, patient centered, timely,
efficient, and equitable. Thus safety is the foundation upon which all other
aspects of quality care are built.

IOM‟s Six Aims for Improving Health Care Quality
1. Safety
 Covers safety issues in phenomena like adverse events, complications
and sentinel events as major objective of any health service provider
should be safety of patients.
 Harm from care, whether by omission of commission, as well as from the
environment in which it is carried out, must be avoided.
 Risk in care delivery process should be minimized.
 Safety of staff and visitors to the health care organization must also be
ensured.
2. Effectiveness
 Treatment receive will produce measurable benefits.
 Related to the extent to which treatment, intervention or service achieves
desired outcomes.
3. Appropriateness
 Develop measures to ensure appropriateness of key medical
interventions, including compliance with selected clinical pathways.
 It is about using evidence to do the right thing to the right patient in a
timely fashion.
 Interventions for the treatment of a particular condition should be
selected based on the likelihood of a desired outcome.
 Utilization reviews can act as a surrogate in assessing appropriateness.
4. Consumer participation
 Patients have a fundamental right to be involved in health care decisions
and delivery.

Develop mechanisms for gathering member‘s input and assessing their

satisfaction level with service providers.
 These mechanisms will provide patients opportunities to participate in
health service planning, delivery, monitoring, and evaluation.
5. Accessibility
 Supports access to health services on the basis of patient need,
irrespective of geography, payment group (indigent, individually paying,
etc), ethnicity, age or gender.
6. Efficiency
 Ensure cost-efficiency through the implementation of case payment,
select contracting and monitoring of compliance with clinical pathways.
 Measures minimize inappropriate resource inputs and allocate resources
to services which provided the greatest benefit.
Assessment focus points of PhilHealth‟s new Quality Assurance framework
CROSS-DIMENSIONAL ISSUES
1. Competence
Three levels of competence to be addressed:
a) Organization Competence
 Facility‘s ability to assess its capacity to perform particular functions or
procedures, or to supply a particular service.
 Tested by the PhilHealth accreditation process.
b) Multidisciplinary Care Team Competence

 The team‘s ability to deliver a optimum outcomes for patients.
 As health services are characterized by multiple boundaries and barriers
among various disciplines, quality health care delivery requires a team
performance.
 Encourage a multidisciplinary team approach to health care delivery
through clinical pathways and accreditation standards.
c) Individual Competence
 The individual health care provider‘s skills, knowledge and attitude.
 While there is currently no system which guarantees individual
competence, the best available evidence suggests that an appropriate mix
of quality improvement tools related to producing individual competence
(selection and recruitment of appropriate staff, credentialing, peer review,
skills assessment, clinical supervision, re-certification, and continuing
education) should be employed.
 No one tool is a guarantee, but when used in combination with others
can improve levels of competence.
2. Information Management
 Improving accuracy, appropriateness, completeness and analysis of
health care data if judgments about clinical quality are to be made.
 Health service providers should be encouraged to prioritize the
development of information systems to promote and support appropriate
use of data for health care quality improvement.
 Members will need to be informed about the use and limits of such data
in making health care decisions.
 Data collection for purposes of accountability and even for evaluation
entails costs.
3. Continuity of Care
 Refers to the extent to which an individual episode of care is coordinated
and integrated into overall care provision.
 Is achieved through admission and discharge planning, communication
and coordination among health care professionals, and linkages between
hospital and community care providers.
 Health promotion and preventive programs are also important in
minimizing the demand on curative and palliative services.
 Improved delivery of health care can reduce the average length of stay in
acute care facilities and increase utilization of community-based and
primary care services.
 Effective care planning allows appropriate linkages with community-
based resources.
 Properly coordinated care processes provide opportunities to make drugs
more accessible to marginalized patients.
4. Evidence-based Medicine, Clinical Practice Guidelines and Clinical
Pathways

Emphasizes the use of evidence-based medicine in making decisions
relevant to care provision.
 Evidenced-based Medicine
 ―Conscientious, explicit and judicious use of current best evidence
in making decisions about the care of individual patients‖ (Tan-
Torres, 2001).
 Attempts to attain care improvement and savings in health
financing through the elimination of unnecessary diagnosis and
treatment (World Bank Institute and World Bank, 2000).
 Concrete applications of evidence-based medicine include the
development and routine use of clinical practice guidelines and clinical
pathways.
 Clinical Practice Guideline
 It is a statement systematically developed to aid practitioner and
patient in making appropriate health care decisions for specific
clinical circumstances (Institute of Medicine, 1990).
 Clinical Pathway
 It is a document that describes the usual sequential way of
providing multidisciplinary clinical care for a particular type of
patient, and allows for annotation of deviations from the norm
aimed at continuous evaluation and improvement.
 Impact on Clinical Economics (the use of cost evaluations to compare
different interventions in clinical care) of Use of Evidence-based Medicine
and Clinical Epidemiology (Tan-Torres, 2001):
• Increasing the availability and appreciation for good quality
information;
• Formulating clinically relevant research questions;
• Reviewing and synthesizing data systematically through meta-
analyses;
• Simplifying reporting of clinical outcomes with resource
implications;
• Improving the collection of cost-data thereby improving
• the cost component of economic evaluations of health care
• services;
• Considering sample size in cost-effectiveness studies thus
improving validity;
• Integrating outcomes, costs and preferences with the use of
decision analytic techniques further assisting physicians and
patients make appropriate decisions regarding care.
5. Education and Training
 To successfully implement this framework, organization shall carry out a
well-planned education program for all stakeholders and set priorities for
the development of clinical practice guidelines and other quality
improvement activities.
6. Accreditation
 Assesses an organization‘s compliance with set standards.
 Shift from the traditional accountability orientation to one of continuous
improvement
 Accreditation shall no longer exclusively zero in on a provider
organization‘s compliance with standards but shall also evaluate the
organization‘s commitment to provide quality care and service.
 While accreditation in itself cannot guarantee quality, it does provide
useful information on the structure and processes required to achieve
outcomes of adequate quality.
What is PATIENT SAFETY?

 It is ―the prevention of harm to patients‖ (Aspden, Institute of Medicine, 2004).
 It is the cornerstone of high-quality health care.
 Emphasis is placed on the system of care delivery that:
 prevents errors;
 learns from the errors that do occur; and
 is built on a culture of safety that involves health care professionals,
organizations, and patients.
 The glossary at the Agency for Healthcare Research and Quality (AHRQ) Patient
Safety Network Web site expands upon the definition of prevention of harm:
―freedom from accidental or preventable injuries produced by medical care.‖
Patient Safety Practices

 Defined as ―those that reduce the risk of adverse events related to exposure to
medical care across a range of diagnoses or conditions‖ (AHRQ).
 Practices considered to have sufficient evidence to include in the category of
patient safety practices are as follows:
 Appropriate use of prophylaxis to prevent venous thromboembolism in
patients at risk
 Use of perioperative beta-blockers in appropriate patients to prevent
perioperative morbidity and mortality
 Use of maximum sterile barriers while placing central intravenous
catheters to prevent infections
 Appropriate use of antibiotic prophylaxis in surgical patients to prevent
postoperative infections
 Asking that patients recall and restate what they have been told during
the informed-consent process to verify their understanding
 Continuous aspiration of subglottic secretions to prevent ventilator-
associated pneumonia
 Use of pressure-relieving bedding materials to prevent pressure ulcers
 Use of real-time ultrasound guidance during central line insertion to
prevent complications

Patient self-management for warfarin (Coumadin®) to achieve

appropriate outpatient anticoagulation and prevent complications
 Appropriate provision of nutrition, with a particular emphasis on early
enteral nutrition in critically ill and surgical patients, to prevent
complications
 Use of antibiotic-impregnated central venous catheters to prevent
catheter-related infections
 Many patient safety practices, such as use of simulators, bar coding,
computerized physician order entry, and crew resource management, have been
considered as possible strategies to avoid patient safety errors and improve
health care processes; research has been exploring these areas, but their
remains innumerable opportunities for further research.
Harm
 Defined as the impact and severity of a process of care failure: ―temporary or
permanent impairment of physical or psychological body functions or structure‖
(National Quality Forum Taxonomy of Patient Safety).
 The origins of the patient safety problem are classified in terms of:
 type (error);
 communication (failures between patient or patient proxy and
practitioners, practitioner and nonmedical staff, or among practitioners);
 patient management (improper delegation, failure in tracking, wrong
referral, or wrong use of resources); and
 clinical performance (before, during, and after intervention).
 The types of errors and harm are further classified regarding domain, or where
they occurred across the spectrum of health care providers and settings. The
root causes of harm are identified in the following terms:
 Latent failure - removed from the practitioner and involving decisions
that affect the organizational policies, procedures, allocation of
resources; exogenous or environmental
 Active failure - direct contact with the patient; endogenous
 Organizational system failure - indirect failures involving
management, organizational culture, protocols/processes, transfer of
knowledge, and external factors
 Technical failure - indirect failure of facilities or external resources
 Finally, a small component of the taxonomy is devoted to prevention or
mitigation activities. These mitigation activities can be:
 universal (implemented throughout the organization or health care
settings);
 selective (within certain high-risk areas); or
 indicated (specific to a clinical or organizational process that has failed
or has high potential to fail).
Nurses at the “Sharp End” of Patient Care

The work environment in which nurses provide care to patients can determine
the quality and safety of patient care. As the largest health care workforce, nurses
apply their knowledge, skills, and experience to care for the various and changing
needs of patients. A large part of the demands of patient care is centered on the work
of nurses. When care falls short of standards, whether because of resource allocation
(e.g., workforce shortages and lack of needed medical equipment) or lack of appropriate
policies and standards, nurses shoulder much of the responsibility. This reflects the
continued misunderstanding of the greater effects of the numerous, complex health
care systems and the work environment factors. Understanding the complexity of the
work environment and engaging in strategies to improve its effects is paramount to
higher-quality, safer care. High-reliability organizations that have cultures of safety
and capitalize on evidence-based practice offer favorable working conditions to nurses
and are dedicated to improving the safety and quality of care. Emphasis on the need to
improve health care systems to enable nurses to not be at the ―sharp end‖ so that they
can provide the right care and ensure that patients will benefit from safe, quality care.
Human Error
 Defined as a failure of a planned action or a sequence of mental or physical
actions to be completed as intended, or the use of a wrong plan to achieve an
outcome (Reason, 1990).
 Do not all result to injury or harm.
 By definition, errors are a cognitive phenomenon because errors reflect human
action that is a cognitive activity.
Near Misses, or “Good Catches,‖

 Defined as events, situations, or incidents that could have caused adverse
consequences and harmed a patient, but did not.
 Factors involved in near misses have the potential to be factors (e.g., root
causes) involved in errors if changes are not made to disrupt or even remove
their potential for producing errors.
Adverse Events
 Defined as injuries that result from medical management rather than the
underlying disease.
Sentinel Events
 Unexpected events causing serious physical or psychological harm or injury
and even death (Joint Commission).
 Signal the need for an immediate response, analysis to identify all factors
contributing to the error, and reporting to the appropriate individuals and
organizations to guide system improvements.
System Thinking

 This is a discipline that allows us to see the whole system and the relationships
of the parts rather than just the isolated parts. High-quality care is more likely
in systems where relationships and interrelationships are considered important.
Reason, (1990) described errors as the product of either;

1. Active factors – Individual factors; sharp end; (i.e., those that result primarily
from systems factors, producing immediate events and involve operators (e.g.,
clinicians) of complex systems); or
2. Latent factors
 System factors; blunt end; (i.e., factors that are inherent in the system).
 Latent factors (e.g., heavy workload, structure of organizations, the work
environment) are embedded in and imposed by systems and can fester
over time, waiting for the right circumstances to summate individual
latent factors and affect clinicians and care processes, triggering what is
then considered an active error (e.g., an adverse drug event).
 Leadership and staff within organizations essentially inherit and can
create new latent factors through scheduling, inadequate training, and
outdated equipment.
 Latent factors or conditions are present throughout health care and are
inevitable in organizations. These factors and conditions can have more
of an effect in some areas of an organization than others because
resources can be ―randomly‖ distributed, creating inequities in quality
and safety.
 The number of hazards and risks can be reduced by targeting their root
causes.
 In doing so, the path between active failures when the error occurred
would be traced to the latent defects in the organization, indicating
leadership, processes, and culture. Then, if organizational factors (e.g.,
latent factors) become what they should be, few active causes of
accidents will come about.
 Organizational factors have been considered the ―blunt end‖ and
represent the majority of errors; clinicians are considered the ―sharp
end.‖

When errors occur, the ―deficiencies‖ of health care providers (e.g., insufficient
training and inadequate experience) and opportunities to circumvent ―rules‖ are
manifested as mistakes, violations, and incompetence. Violations are deviations from
safe operating procedures, standards, and rules, which can be routine and necessary
or involve risk of harm.
Human Factors
 This is an established science that uses many disciplines (such as anatomy,
physiology, physics and biomechanics) to understand how people perform
under different circumstances.
 It is the study of all the factors that make it easier to do the work in the right
way.
 It is the study of the interrelationship between humans, the tools and
equipment they use in the workplace, and the environment in which they work.
Human Performance and Problem-Solving abilities are categorized as:

1. Skill based
 (i.e., patterns of thoughts and actions that are governed by previously
stored patterns of preprogrammed instructions and those performed
unconsciously)


Skill-based errors are considered ―slips,‖ which are defined as
unconscious aberrations influenced by stored patterns of
preprogrammed instructions in a normally routine activity. Distractions
and interruptions can precede skill-based errors, specifically diverting
attention and causing forgetfulness.
 Human susceptibility to stress and fatigue; emotions; and human
cognitive abilities, attention span, and perceptions can influence
problem-solving abilities.
2. Rule based
 (i.e., solutions to familiar problems that are governed by rules and
preconditions); and
 Breaking the rules to work around obstacles is considered a rule-based
error because it can lead to dangerous situations and may increase one‘s
predilection toward engaging in other unsafe actions.
 Work-arounds are defined as ―work patterns an individual or a group of
individuals create to accomplish a crucial work goal within a system of
dysfunctional work processes that prohibits the accomplishment of that
goal or makes it difficult‖.
3. Knowledge based (i.e., used when new situations are encountered and require
conscious analytic processing based on stored knowledge).
 Rule-based and knowledge-based errors are caused by errors in
conscious thought and are considered ―mistakes.‖
Human Factors Theory

How Errors and Incidents Occur
Healthcare professionals are human beings, and like all human beings are
fallible. In our personal and working lives we all make mistakes in the things we do, or
forget to do, but the impact of these is often non-existent, minor or merely creates
inconvenience. However, in healthcare there is always the underlying chance that the
consequences could be catastrophic. It is this awareness that often prevents such
incidents as we purposefully heighten our attention and vigilance when we encounter
situations or tasks we perceive to be risky.
One human factors model that is increasingly well known in healthcare is the
Swiss Cheese Model of organizational accidents (Reason 1990). The Swiss Cheese
Model hypothesizes that in any system there are many levels of defense. Examples of
levels of defense would be checking of drugs before administration, a preoperative
checklist or marking a surgical site before an operation. Each of these levels of defense
has little ‗holes‘ in it which are caused by poor design, senior management decision-
making, procedures, lack of training, limited resources etc. These holes are known as
‗latent conditions‘.
If latent conditions become aligned over successive levels of defense they create a
window of opportunity for a patient safety incident to occur. Latent conditions also
increase the likelihood that healthcare professionals will make ‗active errors.‘ That is

to say, errors that occur whilst delivering patient care. When a combination of latent
conditions and active errors causes all levels of defenses to be breached a patient
safety incident occurs. This is depicted by the arrow breaching all levels of defense the
image below.
When such incidents occur it is uncommon for any single action or ‗failure‘ to
be wholly responsible. It is far more likely that a series of seemingly minor events all
happen consecutively and/or concurrently so on that one day, at that one time, all the
‗holes‘ line up and a serious event results. On investigation it becomes clear that
multiple failings occurred and the outcome appears inevitable, but for those working
in the system it can be shocking as they have often worked with these same
environmental conditions and small errors or slips occurring regularly without harm
ever occurring as a result.
It is very rare for staff in healthcare to go to work with the intention of causing
harm or failing to do the right thing. Therefore we have to ask why there are many
incidents where some of the latent conditions are caused by staff not doing the right
thing, even when they know what the right thing is. Many processes and policies in
healthcare are complex or seem to create difficulties for busy staff thus creating the
temptation to take shortcuts or ‗workarounds‘.
Source: Patient Safety First‟s „How to Guide‟ for Implementing Human Factors in
Healthcare
Health Care Error

 It is a preventable adverse effect of care, whether or not it is evident or harmful

to the patient.
 Errors have been, in part, attributed to:
1. Human Factors
 Variations in healthcare provider training & experience, fatigue,
depression and burnout.
 Diverse patients, unfamiliar settings, time pressures.
 Failure to acknowledge the prevalence and seriousness of medical errors.
2. Medical complexity
 Complicated technologies, powerful drugs.
 Intensive care, prolonged hospital stay.
 System failures
 Poor communication, unclear lines of authority of physicians, nurses,
and other care providers.
 Complications increase as patient to nurse staffing ratio increases.[33]
 Disconnected reporting systems within a hospital: fragmented systems in
which numerous hand-offs of patients results in lack of coordination and
errors.
 Drug names that look alike or sound alike.
 The impression that action is being taken by other groups within the
institution.
 Reliance on automated systems to prevent error.
 Inadequate systems to share information about errors hamper analysis
of contributory causes and improvement strategies.
 Cost-cutting measures by hospitals in response to reimbursement
cutbacks.
 Environment and design factors. In emergencies, patient care may be
rendered in areas poorly suited for safe monitoring. The American
Institute of Architects has identified concerns for the safe design and
construction of health care facilities.
 Infrastructure failure. According to the WHO, 50% of medical equipment
in developing countries is only partly usable due to lack of skilled
operators or parts. As a result, diagnostic procedures or treatments
cannot be performed, leading to substandard treatment.
The Joint Commission's Annual Report on Quality and Safety 2007 found that
inadequate communication between healthcare providers, or between providers and
the patient and family members, was the root cause of over half the serious adverse
events in accredited hospitals] Other leading causes included inadequate assessment
of the patient's condition, and poor leadership or training.
Common Misconceptions About Adverse Events Are:

 "'Bad apples' or incompetent health care providers are a common cause."

Many of the errors are normal human slips or lapses, and not the result of poor
judgment or recklessness.
 "High risk procedures or medical specialties are responsible for most
avoidable adverse events". Although some mistakes, such as in surgery, are
easier to notice, errors occur in all levels of care. Even though complex
procedures entail more risk, adverse outcomes are not usually due to error, but
to the severity of the condition being treated. However, USP has reported that
medication errors during the course of a surgical procedure are three times
more likely to cause harm to a patient than those occurring in other types of
hospital care.
 "If a patient experiences an adverse event during the process of care, an
error has occurred". Most medical care entails some level of risk, and there
can be complications or side effects, even unforeseen ones, from the underlying
condition or from the treatment itself.
What Is It Going To Take To Improve the Safety and Quality of Health Care?
Changes in health care work environments are needed to realize quality and
safety improvements. Because errors, particularly adverse events, are caused by the
cumulative effects of smaller errors within organizational structures and processes of
care, focusing on the systemic approach of change focuses on those factors in the
chain of events leading to errors and adverse events. From a systems approach,
avoidable errors are targeted through key strategies:
1. The Right Work Environment
 The nursing “practice environment” is defined by organizational
characteristics that can either facilitate or constrain professional nursing
practice.
 Changes to the nurses‘ work environment need to focus on enabling and
supporting nurses to provide high-quality and safe care.
2. Patient-Centered Care
 Patient-centered care is considered to be interrelated with both quality
and safety.
 The role of patients as part of the ―team‖ can influence the quality of care
they receive and their outcomes.
3. Teamwork and Collaboration
 In that patient safety is inextricably linked with communication and
teamwork, there is a significant need to improve teamwork and
communication.
 Teamwork and collaboration has been emphasized by the Joint
Commission. The Joint Commission has found communication failures to
be the primary root cause of more than 60 percent of sentinel events
reported to the Joint Commission.
 Ineffective communication or problems with communication can lead to
misunderstandings, loss of information, and the wrong information.

4. Evidence-Based Practice
 Evidence should be used in clinical decision-making whenever possible.
5. A Culture of Safety
 The IOM encouraged the creation of cultures of safety within all health
care organizations.
 Safety culture
 Defined as ―the product of the individual and group values,
attitudes, competencies and patterns of behavior that determine
the commitment to, and the style and proficiency of, an
organization‘s health and safety.
An Overview of TO ERR IS HUMAN: Re-emphasizing the Message of Patient

Safety
 On November 29, 1999, the Institute of Medicine (IOM) released a report called
To Err is Human: Building a Safer Health System.
 The committee‘s approach was to emphasize that “error” that resulted in patient
harm was not a property of health care professionals‟ competence, good
intentions, or hard work. Rather, the safety of care—defined as ―freedom from
accidental injury‖ is a property of a system of care, whether a hospital, primary
care clinic, nursing home, retail pharmacy, or home care, in which specific
attention is given to ensuring that well-designed processes of care prevent,
recognize, and quickly recover from errors so that patients are not harmed.
 The message in To Err is Human was that preventing death and injury from
medical errors requires dramatic, system-wide changes.
 Among three important strategies preventing, recognizing, and mitigating
harm from error—the first strategy (recognizing and implementing the first
strategy (recognizing and implementing actions to prevent error) has the
greatest potential effect, just as in preventive public health efforts.
 Leape (1994) greatly enhanced our understanding of errors by distinguishing
between two types of cognitive tasks that may result in errors in medicine.
1. The first type of task occurs when people engage in well-known, oft-
repeated processes, such as driving to work or making a pot of coffee.
Errors may occur while performing these tasks because of interruptions,
fatigue, time pressure, anger, distraction, anxiety, fear, or boredom.
2. By contrast, tasks that require problem solving are done more slowly and
sequentially, are perceived as more difficult, and require conscious
attention. Examples include making a differential diagnosis and readying
several types of surgical equipment made by different manufacturers.
Errors here are due to misinterpretation of the problem that must be
solved and lack of knowledge.
Basic Concepts in Patient Safety

Opportunities to improve safety have been drawn from numerous disciplines
such as engi-neering, psychology, and occupational health. The IOM report brought

together what had been learned in these fields and then applied the opportunities to
health care, as described in the nine categories that follow.
1. User-Centered Design
 Understanding how to reduce errors depends on framing likely sources of
error and pairing them with effective ways to reduce them.
 The term ―user-centered design‖ builds on human strengths and avoids
human weaknesses in processes and technologies.
 The first strategy of user-centered design is to make things
visible⎯including the conceptual model of the process⎯so that the user
can determine what actions are possible at any moment, for example,
how to return to an earlier step, how to change settings, and what is
likely to happen if a step in a process is skipped.
 Another principle is to incorporate affordances, natural mappings, and
constraints into health care.
2. Avoid Reliance on Memory
 The next strategy is to standardize and simplify the structure of tasks to
minimize the demand on working memory, planning, or problem-solving,
including the following two elements:
 Standardize Process and Equipment. Standardization reduces
reliance on memory and allows newcomers who are unfamiliar
with a given process or device to do the process or use a device
safely.
 Simplify Key Processes. Simplifying key processes can minimize
problem-solving and greatly reduce the likelihood of error.
Simplifying includes reducing the number of steps or handoffs
that are needed.
3. Attend to Work Safety
 Conditions of work are likely to affect patient safety. Factors that
contribute to worker safety in all industries studied include work hours,
workloads, staffing ratios, sources of distraction, and shift changes
(which affect one‘s circadian rhythm). Systematic evidence about the
relative importance of various factors is growing with particular
emphasis on nurse staffing.
4. Avoid Reliance on Vigilance
 Individuals cannot remain vigilant for long periods of time. Approaches
for reducing the need for vigilance include providing checklists and
requiring their use at regular intervals, limiting long shifts, rotating staff,
and employing equipment that automates some functions.
5. Train Concepts for Teams
 People work together throughout health care in multidisciplinary teams,
whether in a practice; for a clinical condition; or in operating rooms,
emergency departments, or ICUs. In an effective interdisciplinary team,
members come to trust one another‘s judgments and expertise and
attend to one another‘s safety concerns. Team training in labor and

delivery and hospital rapid response teams are examples. The IOM
committee believed that whenever it is possible, training programs and
hospitals should establish interdisciplinary team training.
6. Involve Patients in Their Care
 Whenever possible, patients and their family members or other
caregivers should be invited to become part of the care process.
Clinicians must obtain accurate information about each patient‘s
medications and allergies and make certain this information is readily
available at the patient‘s bedside. In addition, safety improves when
patients and their families know their condition, treatments (including
medications), and technologies that are used in their care.
 At the time of discharge, patients should receive a list of their
medications, doses, dosing schedule, precautions about interactions,
possible side effects, and any activities that should be avoided, such as
driving.
 Patients also need clear written information about the next steps after
discharge, such as follow-up visits to monitor their progress and whom
to contact if problems or questions arise.
 Family caregivers deserve special attention in terms of their ability to
provide safe care, manage devices and medication, and to safely respond
to patient needs. Yet they may, themselves, be affected by physical,
health, and emotional challenges; lack of rest or respite; and other
responsibilities (including work, finances, and other family members).
7. Anticipate the Unexpected
 The likelihood of error increases with reorganization, mergers, and other
organization-wide changes that result in new patterns and processes of
care. Some technologies, such as computerized physician order entry
systems (CPOE), are engineered specifically to prevent error. Despite the
best intentions of designers, however, all technology introduces new
errors, even when its sole purpose is to prevent errors. Indeed, future
failures cannot be forestalled by simply adding another layer of defense
against failure.
 Health care professionals should expect any new technology to introduce
new sources of error and should adopt the custom of automating
cautiously, always alert to the possibility of unintended harm, and
should test these technologies with users and modify as needed before
widespread implementation.
8. Design for Recovery
 The next strategy is to assume that errors will occur and to design and
plan for recovery by duplicating critical functions and by making it easy
to reverse operations and hard to carry out nonreversible ones. If an
error occurs, examples of strategies to mitigate injury are keeping
antidotes for high-risk drugs up to date and easily accessible and having
standardized, well-rehearsed procedures in place for responding quickly

to adverse events. Another strategy is to use simulation training, where

learners practice tasks, processes, and rescues in lifelike circumstances
using models or virtual reality.
9. Improve Access to Accurate, Timely Information
 The final strategy for user-centered design is to improve access to
information. Information for decision-making (e.g., patient history,
medications, and current therapeutic strategies) should be available at
the point of patient care..
Principles for the Design of Safe Systems

To address threats to quality and safety by internal drivers, five principles for
the design of safe systems are articulated in To Err Is Human, each of which has
direct relevance to nursing practice.
1. The commitment of senior level managers and leaders of health care
institutions is essential to moving a quality and safety agenda forward in care
settings.
2. Human limits in care processes need to be explicitly identified and strategies
put in place to minimize the likelihood that these limitations are expressed in
the work environment.
3. Effective team functioning, promoted and fostered by the institution, is an
essential component of health care systems that are quality and patient safety
driven.
4. The redesign of systems for safe care involves anticipating the unexpected and
adopting proactive approaches to ensuring safe care.
5. Creating a learning environment addresses the extremely complex work of
changing organizational and academic cultures so that error is viewed as an
opportunity to learn.
CASE STUDY
An Extended Stay
Ross Hilliard, MD,

IHI Open School Northeast Regional Chapter Leader
Learning Objectives:
1. At the end of this activity, you will be able to:
2. Explain how system failures can lead to patient harm.
3. Describe how lack of communication between providers and hospital departments can
lead to patient harm
4. Discuss how to debrief with colleagues after an adverse event.
Description: A 64-year-old man with a number of health issues comes to the hospital because
he is having trouble breathing. The care team helps resolve the issue, but forgets a standard
treatment that causes unnecessary harm to the patient. A subsequent medication error makes
the situation worse, leading to a stay that is much longer than anticipated.

Mr. Stanley Londborg is a 64-year-old man with a long-standing history of a seizure disorder.
He also has hypertension (high blood pressure) and chronic obstructive pulmonary disease
(COPD). He is no stranger to the hospital because of his health issues. At home, he takes a
number of medications, including three for his COPD and three — levetiracetam, lamotrigine,
and valproate sodium — to help control his seizures.
Mr. Londborg came to the emergency department (ED) last week because he was wheezing and
having trouble breathing. The physician in the ED conducted a physical examination that
yielded signs of an acute worsening of his COPD, which is known as COPD exacerbation. (In
many cases, COPD exacerbation is the result of a relatively mild respiratory tract infection, but
could be due to something more serious, such as pneumonia.)
The physician in the ED ordered a chest x-ray, which did not show any signs of pneumonia. He
admitted Mr. Londborg to the hospital for treatment of acute COPD exacerbation, resulting
from a relatively mild respiratory tract infection. Before leaving the ED, Mr. Londborg also
underwent routine blood work, which showed an elevation in his creatinine, a sign that his
kidneys were being forced to work harder due to his infection.
On the medical floor, the care team treated Mr. Londborg with oral steroids and inhaled
bronchodilators (standard medical therapy for his condition), which resulted in a gradual
improvement in his respiratory symptoms. Nurses also gave him IV fluids for the issue with his
kidneys, which slowly resolved.
Mr. Londborg was steadily improving, so it seemed this visit to the hospital would be one of his
shorter ones.
But on his third morning in the hospital, Mr. Londborg complained to the intern (a first-year
resident) on the care team about acute pain in his left leg. This symptom, potentially indicating
deep venous thrombosis (a blood clot in his leg commonly known as DVT), prompted the team
to order an ultrasound of Mr. Londborg‘s lower extremities. (A primary concern with DVT is
that blood clots in the legs may dislodge and travel to the lungs, causing a pulmonary
embolism, which could be deadly.)
The resident on the care team (who oversees the intern) then checked Mr. Londborg‘s
medication orders and was surprised to see that the admitting doctor had not ordered
prophylaxis for DVT (i.e., blood thinners, such as heparin or enoxaparin). The resident was
surprised because patients admitted to the hospital typically receive this treatment to prevent
blood clots from forming while they lie in their hospital beds. Further, nothing about Mr.
Londborg‘s medical record suggested he shouldn‘t have received this treatment as an important
precautionary measure.
Let‘s pause to consider and discuss a couple questions about the case before we continue…
Discussion Questions:
1) The patient did not receive standard treatment to prevent the formation of a DVT. What are
some possible reasons why this error occurred?
2) Can you suggest system process improvements that might reduce the likelihood of similar
errors in the future?

Now let‘s continue with the story …
The ultrasound, unfortunately, confirmed the presence of a blood clot in Mr. Londborg‘s left
calf. Due to his impaired kidney function, treatment for the blood clot required him to remain
in the hospital on IV medication.
Mr. Londborg‘s stay was going to be longer than expected.
10 PM on his eighth day in the hospital, a member of the environmental services (also known
as housekeeping) staff found Mr. Londborg on the floor of his room. She immediately alerted
the nurses on the ward. The nurses noted seizure activity and called the overnight medical
team to Mr. Londborg‘s bedside. The team responded quickly and gave him intravenous
medication that stopped his seizure.
Because no one witnessed his fall and seizure, Mr. Londborg underwent an emergent CT scan
of his head to check for any sign of bleeding. After his mental status improved (it is common for
patients to be confused for a time after a seizure), he complained of pain in his left shoulder
and elbow, but x-rays of these joints showed no evidence of a traumatic fracture from his fall.
After ensuring that Mr. Londborg was stable, the overnight care team reviewed the chart and
the medication history to try to determine the cause of Mr. Londborg‘s sudden seizure. They
found that one of his seizure medications, levetiracetam, had not been given earlier in the day
when it should have been. There was a notation in the medication administration record from
the daytime nurse indicating that the ordered dose was not available in the automatic
medication dispensing system on the floor earlier in the day.
Further discussions the following day with the daily care team of doctors and nurses revealed
that the nurses didn‘t notify the physicians or the pharmacy that the essential medication was
not administered. The medication system didn‘t include an automatic alert, either.
Fortunately, the overnight physicians restarted Mr. Londborg on his medication, and he
suffered no apparent permanent harm. Mr. Londborg was discharged after 10 days in the
hospital. Most hospitalizations for COPD are far shorter. In fact, many last only a couple days.
Discussion Questions:
1) Unfortunately, Mr. Londborg suffered a seizure, a complication that could likely have been
avoided if he had received all of the ordered anti-seizure medications. Identify at least two
specific errors that contributed to this mistake.
2) Based on the types of errors you just identified, can you identify systems issues/failures that
affected Mr. Londborg‟s hospitalization?
3) Identify at least one thing that went well during Mr. Londborg‟s visit to the hospital.
4) Pretend you are the nurse manager on the ward where this adverse event occurred. (In most
hospitals, the nurse manager is responsible for daily operations on a given floor or “unit,”
including the nurses and others who work there.) How would you run a meeting to debrief team
members in the days after Mr. Londborg‟s seizure?

Module
2 PATIENT SAFETY
What is STANDARD?
 Norm
 A general agreement of how things should be (Wandelt, 1970).
 Are used to assess a health care organization‘s performance in service
provision.
 Focus is on what the organization actually does, not its capability.
 Delineate the best possible condition that should exist in the organization for it
to attain quality performance.
 Set maximum achievable performance expectations for activities that affect the
quality of care, like compliance with patient pathways which emphasize the
interface between management units.
 Since standards aim to improve outcomes, there is no prescribed manner on
how to achieve improvement.
What is STANDARDS OF CARE?

 These are the skills and learning commonly possessed by members of a
profession. (Guido, 2006, p. 55)
 These are used to evaluate the quality of care nurses provide and, therefore,
become legal guidelines for nursing practice.
What is NURSING STANDARD?

 It is a valid definition of nursing quality and includes criteria which can be used
to assess efficiency (Mason, 1994).
Why are STANDARDS important?

 Outlines what the profession expects of its members.
 Promotes guides and directs professional nursing practice – important for self-
assessment and evaluation of practice by employers, clients and other
stakeholders.
 Provides nurses with a framework for developing competencies
 Aids in developing a better understanding & respect for the various &
complimentary roles that nurses have.
CLASSIFICATIONS OF STANDARDS
1. Internal Standards - include ―the nurse‘s job description, education, expertise
as well as individual institutional policies and procedures.
2. External Standards- consist of the following:

• Nurse Practice Acts (RA 9173)
• Professional Organizations (ANA, PNA)
• Nursing Specialty Practice Organizations (ANSAP, ORNAP, MCNAP,
PONA)
• Federal Organizations and Federal Guidelines (JCAHO, AHRQ, DOH,
PRC-BON)
ASSESSING QUALITY OF HEALTH CARE

In quality assessment, quality is measured against a set of standards.
 Goals
 Serve as targets for improvement.
 The desired-for situation targeted by a performance improvement
program.
 Standard
 Statements of expectations for the inputs, processes, behaviors and
outcomes of health systems, they can effectively limit variations by
defining what is expected from the organization in its daily activities.
 Criteria
 Lay down specific actions that need to be done to meet the standard.
 Should reflect contemporary best practice principles, be achievable,
easily understood and measurable.
 Are developed to specify the attributes of structure, process and outcome
components of care.
 Whether care is ―good enough‖ depends on the criteria satisfying the
standards.
 Indicators
 Listings of expression of standards.
 These are measurable variables or characteristics that can be used to
determine the degree of adherence to a standard or achievement of
quality goals.
To illustrate:
Goal • Recruitment, selection and appointment of staff comply with statutory
requirements and are consistent with the organization‘s human
resource policies.
Standard • All services are provided by staff members with appropriate

qualifications, experience or training.
Criteria • All doctors, nurses and midwives providing clinical care have current
licenses and documented evidence of appropriate training and
experience.
• All administrative, business and technical services staff have current

licenses and documented evidence of appropriate training and

experience.
Indicator • Percentage of staff with current licenses.
Donabedian Model of Quality of Care Assessment
Traditionally, quality of care assessment is an evaluation of the three

components involved in the delivery of health care (Donabedian 1992). These (3)
components take into account:
 Structural component
 Material and human resources
 Includes the number and capability of the medical and paramedical staff,
the number and adequacy of diagnostic and treatment facilities, and the
physical environment in which care is given.
 Process component
 Non-medical actions
• Include food provision, hospital room/ward maintenance and
regulation of visiting hours.
 Medical actions
 Outcome component
 Physical, psychological and social effects of health care
THREE-TIER LEVELS OF QUALITY IN NURSING CARE (Kadivec, 2002)

1. Level 1: ACCEPTABLE NURSING - MINIMUM standards
 All patients are cared for according to a routine plan.
2. Level 2: COMPARATIVELY GOOD - OPTIMUM standards
 Nursing is planned but the patient is not directly involved in planning
and assessment.
3. Level 3 - EXCELLENT - VERY GOOD NURSING - MAXIMUM standards
 Nursing is planned and assessed together with the patient and his
relatives. The patient is an equal partner in the nursing process.
Nursing that cannot be placed at any level is unacceptable - poor nursing - level 0
CHARACTERISTICS OF GOOD STANDARDS (Purnat, 1996)

The features that are characteristic for good standards are shown with the aid
of the acronym RUMBA, which means:
 R - RELEVANT - real and appropriate with regard to:
 universal standards,
 the unit which is being standardised,
 intervention which is being standardised,
 the group of patients, and
 abilities and responsibilities of the nurse.
 U - UNDERSTANDABLE for:
 nurses who perform and evaluate nursing, and
 students and pupils.
 M - MEASURABLE - which is achieved by designing clear criteria in:
 structures,
 a procedure oriented to the nurse, and
 the result oriented to the patient.
 B - BEHAVIOURAL - objective:
 which must be designed on objective and scientific bases.
 A - ATTAINABLE - achievable and feasible with regard to:
 the group of patients for whom the standard is intended,
 capacity of the department, clinic and profession in the country, and
 abilities of the performers and assessors.
WHAT ARE NURSING-SENSITIVE QUALITY INDICATORS?

Nursing-Sensitive Quality Indicators
 These are those indicators that capture care or its outcomes most affected by
nursing care (American Nurses Association).
10 Nursing-Sensitive Quality Indicators for Acute Care Settings:

1. Mix of RNs, LPNs, and Unlicensed Staff Caring for Patients in Acute Care
Settings: the percent of registered nursing care hours as a total of all nursing
care hours. would be the percent of RN contracted hours of total nursing care
hours.
2. Total Nursing Care Hours Provided per Patient Day: total number of productive
hours worked by nursing staff with direct patient care responsibilities on acute
care units per patient day.
3. Pressure Ulcers : this measure would be defined and calculated as:
Total Number of Patients with Stage I, II, III, or IV Ulcers
Number of Patients in a Prevalence Study
4. Patient Falls : the rate per 1,000 patient days at which patients experience an
unplanned descent to the floor during the course of their hospital stay. The
measure would be computed as:
Total Number of Patient Falls Leading to Injury
Total Number of Patient Days X 1,000
5. Patient Satisfaction with Pain Management: patient opinion of how well nursing
staff managed their pain as determined by scaled responses to a uniform series
of questions designed to elicit patient views regarding specific aspects of pain
management.
6. Patient Satisfaction with Educational Information — A measure of patient
perception of the hospital experience related to satisfaction with patient
education: patient opinion of nursing staff efforts to educate them regarding
their conditions and care requirements as determined by scaled responses to a
uniform series of questions designed to elicit patient views regarding specific
aspects of patient education activities.
7. Patient Satisfaction with Overall Care — A measure of patient perception of the
hospital experience related to satisfaction with overall care: patient opinion of
the care received during the hospital stay as determined by scaled responses to
a uniform series of questions designed to elicit patient views regarding global
aspects of care.
8. Patient Satisfaction with Nursing Care — A measure of patient perception of the
hospital experience related to satisfaction with nursing care: patient opinion of
care received from nursing staff during the hospital stay as determined by
scaled responses to a uniform series of questions designed to elicit patient views
regarding satisfaction with key elements of nursing care services.
9. Nosocomial Infection Rate: this measure would be defined and calculated as:
Number of Laboratory Confirmed Bacteremia Associated with Sites of Central Lines
1,000 Patient Days per Unit
10. Nurse Staff Satisfaction: job satisfaction expressed by nurses working in
hospital settings as determined by scaled responses to a uniform series of
questions designed to elicit nursing staff attitudes toward specific aspects of
their employment situation.
IMPROVING QUALITY OF HEALTH CARE

Evolution in Quality Thinking in Industry and in the Health Service
 Quality Control
 The quality movement first took root in the manufacturing industry.
 Initial efforts at improvement centered on quality control which involved
inspection of finished products aimed at the detection of deviations from
their predetermined design.
 These deviations were considered errors or defects. Defective products
were either re-worked or discarded.
 However, it soon became apparent that quality control was an expensive
and wasteful process. This is very apparent in health care.
 Inspection of the finished surgical work would not ensure that the
correct limb had indeed been amputated.
 Inspection of the cleanliness of a hospital‘s premises would not ensure
that accidents like slips and falls from spilt liquids would not occur.
 Counting adverse drug events would do no good to patients who have
already developed drug hypersensitivities.
 Ideas on quality thus evolved and expanded, leading to concepts like
quality assurance, quality improvement and total quality management.
 Applied in the health care industry, the optimum attainable outcome was
called total quality health care.
 The industrial reconstruction activity in post-war Japan gave birth to the
ideas on statistical quality control and standardization of W. Edward
Deming, an electrical engineer by training with a doctorate in
mathematical physics from Yale.


One of several American production experts recruited by Gen.
Douglas MacArthur to advise Japanese industrialists, Deming
went on to become a renowned quality control guru in Japan,
where that country‘s prestigious quality control award, the
Deming Award, is named after him.
 Deming is known internationally for his simple yet revolutionary
principle that all processes are vulnerable to loss of quality due to
variation. He forwarded the idea that quality improvement results
from management-oriented reduction of levels of variation
(Kennedy 1991; Peters and Austin 1985).
 Quality Assurance
 Deming‘s ideas regarding standardization and variance reduction would
later be appropriated in the quality assurance thinking in health care.
 This perspective looks at the prescription of a set of preventive activities to
ensure the quality of the finished product.
 These activities evaluate whether the processes of planning, execution,
delivery and maintenance of goods and services are being performed
according to stated design.
 The Do-It-Right-The-First-Time Slogan
 Appropriated from the American Telephone and Telegraph
corporate slogan conceived as early as the 1920s.
 This thinking received contemporary validation with Philip
Crosby’s book, Quality is Free (1979) where he reported observing
that American companies were using up a fifth of their time,
capital and management resources in fixing problems.
 His approach revolves around zero-defect.
 Doing things right the first time is better than is always cheaper
than trying to fix defects after they have been created, thus quality
is free.
 Crosby suggested that these resources could be rechanneled to
more productive use if procedures were correctly executed at the
start.
 There is no such thing as the economics of quality, Crosby said,
adding that it is always cheaper to do the job right the fi rst time.
(Caldwell, 1998; Crosby, 1979; Barry, Murcko and Brubaker
2002).
 Quality Improvement
 It is the combined and unceasing efforts of everyone—healthcare
professionals, patients and their families, researchers, payers, planners
and educators—to make the changes that will lead to better patient
outcomes (health), better system performance (care) and better
professional development (Batalden & Davidoff, 2007).

Healthcare will not realize its full potential unless change making
becomes an intrinsic part of everyone‘s job, every day, in all parts of the
system.
 Defined in this way, improvement involves a substantial shift in our idea
of the work of healthcare, a challenging task that can benefit from the
use of a wide variety of tools and methods.
 Quality Management
 This is the organization-wide pursuit of quality.
 The name implies managerial oversight of quality of health care
(Donabedian, 2003).
 The commitment to quality begins with management, and it is also
management that ensures support for the deployment of activities
towards this commitment.
 When the pursuit of quality includes the perspectives of internal (staff
and funders) and external customers (patients, payors and contractors),
the process is called total quality management (TQM).
 But while TQM is a means to achieve total quality, total quality goes
beyond achieving patient satisfaction. It seeks to exceed expectations of
internal and external customers and ensure the sustainability of
organizations by involving all levels of management, maintaining
continuous improvement,and generating income, return of investments
and staff loyalty (Kelada, 1996).
 Management‟s involvement in achieving quality is an important component
of TQM.
 This can be seen in how Deming advocates quality attainment through
the use of statistics, in the belief that such a method leads to self-
inspection (or ―control‖) by the very people involved in production. But
Deming has cautioned against too much focus on statistical figures and
clarified that quality is about people, not products (Peters and Austin,
1985).
 In an apparent effort to show management‘s responsibility in attaining
quality, Deming once said that 85% of production faults were due to
management, not workers (Kennedy, 1991).
 Deming’s 14 Management Responsibilities for Attaining Quality
(Deming 1982; Barry, Murcko and Brubaker 2002; Nelson 1995)
1. Create consistency of purpose.
2. Adopt the new philosophy.
3. Cease dependence on inspection.
4. End the practice of awarding business on the basis of price alone.
5. Improve constantly.
6. Institute training/ retraining.
7. Institute leadership.
8. Drive out fear.
9. Break down barriers between departments.
10. Eliminate arbitrary quotas, exhortations and slogans without

providing resources.
11. Eliminate work standards (quotas) for management.
12. Remove barrier to pride of workmanship.
13. Institute programs for education and self-improvement for
everyone.
14. Transform everyone‘s job to transform the organization.
 Another TQM concept is the shift espoused by Dr. Donald Berwick,
president of the U.S.-based Institute for Health Care Improvement and
principal investigator for the National Demonstration Project for Quality
Improvement in Health Care, from the “Bad Apple Theory”
 A thinking which warns about how the presence of one bad
element will negatively affect the entire unit—to a systems
approach to quality improvement (WHO, 2001).
 James Reason, pioneer and expert on human error and system safety,
talks of the existing “Blame Culture” in health care (Reason, 2000).
 He reiterates that errors in health care happen not because of a
single event, or because of a single person‟s error, but because a
combination of risk factors within the system itself have aligned
and made the error more likely to happen.
 In this thinking, known as the “Swiss Cheese” Model, Reason
says the ―holes‖ in the system align, and open up opportunities for
errors to happen.
 He suggests the logical approach is to identify these ―holes‖ in the
system, fix them, and thus prevent the trajectory of error from
taking a path.
 This perspective in error prevention and performance
improvement is the current mode of thinking in the appraisal and
improvement of conditions under which health care professionals
work.
 Reason (1990) recommends caution in evaluating errors and
identifying culprits. Though it seems easier to pin the blame on
one person or a group of individuals, it is worth remembering that
most people involved in serious accidents are neither stupid nor
reckless, and that hindsight bias may cloud judgment.
 Instead, he suggests a few ways in which to assess and reduce
human error risks.

 While Deming espoused his 14 points in the USA, Joseph M. Juran of

Japan espoused a cross-functional management approach that requires
due consideration to three vital processes:
 Quality planning, or defining the customer, identifying their
needs, and developing the product or process.
 Quality control or establishing standards of performance,
measuring actual performance, and taking steps to bridge the
gaps.
 Quality improvement or implementing improvement
interventions, usually through quality teams.
 Pioneered by Motorola and made famous by General Electric, the Six

Sigma method ranks among the most popular quality management tool.
 It aims to reducing defects or variance in processes by applying a
statistical based problem solving methodology that identifies
variances from the standard mean and tries to eliminate such
variances.
 Six Sigma adopts a structured methodology that involves DMAIC.
DMAIC is define the problem, measure, analyze, implement,
and control. Comparing the baseline process capability with the
actual performance or process capability helps to chalk out

potential solutions for quality improvement.
 Six Sigma works on the assumption that all the key underlying
variables and the interactions among such variables are obvious.
This need not always hold true. Design of Experiments (DoE), or
experimental design is a structured and organized way of
collecting multivariate data for modeling, and helps to determine
whether the variables are under the full control of the
experimenter.
 Lean is a minimalist philosophy that aims at bringing efficiency by using
the minimum required.
 The approach requires identifying customer needs, and improving
processes by eliminating activities that do not add value to the
customer.
 It works on the assumption that removal of waste processes
improve business performance, and that many micro level small
improvements are better than a comprehensive macro system
analysis. It nevertheless leads to reduced flow time, process
efficiency, and less inventory
 Lean works by applying:
 Kaizen (change for the best) or continuous improvement to
improve the process by eliminating waste
 5S (Sort, Set, Shine, Standardize, Sustain), or the
workplace organization methodology that guides how to
organize the workspace for efficiency and effectiveness
 Just in Time (JIT) inventory methods
 Zero defect methodology… and more.
 Effective health care can only be delivered in a safe and efficient
environment, and because patients expect more than just medicines or
treatments, the quality of hospital management becomes just as
important as the care itself.
 TQM being client-driven, participatory, and process- and team-oriented,
it calls for flatter, less hierarchical organizations where managers directly
lead teams built around principal work processes (Milakovich 1995).
 In a hospital setting, this would mean organizing patient entry, care and
discharge teams with each group composed of doctors, nurses and
support staff.
 Other Features of TQM (Milakovich, 1995)
 Decentralized workforce
 Integrated data systems
 Long-term and quality-oriented relationships with other
stakeholders
 Training is integrated with quality and productivity goals
 Quality is measured by client needs and process improvement
 Quality reflects continuous improvement and client satisfaction



PRINCIPLES OF QUALITY (National Quality Center)

1. ―Quality improvement is a journey of many small steps.‖
2. ―Success is Achieved Through Meeting the Needs of Those We Serve‖
3. ―Most Problems are Found in Processes and Systems, Not in People‖
 How Processes Fail:
 Poor design
 Too complex
 Not well understood by those who work in them
 Not set up to deliver what the ―individuals and populations
 Why we Focus of Processes:
 ―Each process is perfectly designed to get the results it achieves‖
 Getting a better result therefore requires re-designing the process
4. ―Actions are Based Upon Accurate and Measured Data‖
5. ―Achieve Continual Improvement Through Small, Incremental Changes‖
6. ―Infrastructure Enhances Systematic Implementation of Improvement Activities‖
7. ―Do not Reinvent the Wheel -Steal Shamelessly, Share Senselessly‖
IMPLEMENTING THE NEW QUALITY ASSURANCE FRAMEWORK

The idea of accreditation as a means to ensure quality care provision began in
1918 when studies on post-operative infections by Dr. Ernest Codman, a surgeon at
the Massachusetts General Hospital, influenced the American College of Surgeons to
establish the Hospital Standardization Program, which was later adopted by the Joint
Commission on Accreditation of Hospitals.
Implementation activities for PhilHealth‟s Quality Assurance framework
Implementation of the QA framework involves the following interrelated

activities:
1. Accreditation Program
 Accreditation Department takes charge of accrediting health care
providers.

 Teams of skilled surveyors conduct two levels of assessments:

• first, they evaluate compliance with documentary requirements.;
and
• second, they visit the provider site to evaluate actual operations.
 Accreditation program verifies the qualifications and capabilities of
health care providers to deliver the desired and expected quality of health
care services.
 Accreditation program is founded on the ideas on assessment of health
care introduced in 1966 by Lebanon-born public health expert Avedis
Donabedian (1919-2000), and which now constitute the principal
paradigm in the evaluation of health care provision (Frenk, 2000).
 Donabedian‘s ideas describe the relationship between structures,
processes and outcomes and posit that an organization with the right
structures and processes in place will produce better outcomes.
 The Donabedian Approach
a. This approach focuses on standards that require the
presence of:
1. Structures (buildings, manpower, equipment,
organizational relationships, etc)
2. Processes (treatment, committee activities, performance
guidelines, etc), and
3. Outcomes (cure, less pain, disability, death).
b. Donabedian urges that all three measures—structure,
process, outcome—be used when assessing and monitoring the
quality of health care.
c. He adds that quality assessment aims to determine how
successful providers have been able to do their work, and that
quality monitoring generates constant surveillance which
facilitates early detection and correction of any deviation from
standards (Jonas and Rosenberg 1986).
 Philip Crosby, quality management expert and author of the book
Quality is Free (1979) wrote that the focus of quality is conformance.
 Applied to the health care setting, it means compliance with
standards.
 An important component of the accreditation process is determination of
compliance with set standards.
 Accreditation standards shall be redeveloped in consultation with the
health care industry.
 Should be equally applicable to all health care organizations regardless of
whether they are a hospital, day surgery unit, community service, or
some other type of health care organization.
 Should reflect contemporary best practice principles, be achievable,
easily understood and measurable.


Section 58 of the PhilHealth Implementing Rules and Regulations (2000)
includes the following health care providers as participants in the NHIP:
a. Institutional Health Care Providers
• Hospitals
• Out-patient Clinics
• Health Maintenance Organizations (HMOs)
• Preferred Provider Organizations (PPOs)
• Community-Based Health Care Organizations
b. Independent Health Care Professionals
• Physicians
• Dentists
• Nurses
• Midwives
• Pharmacists
• Other duly licensed health care professionals
2. Clinical Practice Guidelines and Clinical Pathways
 Ever-increasing evidence points to the role of clinical practice guidelines
and clinical pathways in the reduction of variations in practice and
consequently, in outcomes.
 These guidelines should eventually, through education and
implementation strategies, be adopted as operational pathways in health
service provider organizations.
 PhilHealth has disseminated CPGs on Hypertension, Community-
acquired Pneumonia and Urinary Tract Infection nationwide.
3. Performance Measurements
 Monitoring is an important component in the evaluation of an
organization‘s performance as it allows measurement and assessment of
patient care and other service processes provided by health care provider
organization.
 Performance targets shall be established and the frequency with which
these targets are met (or not met) shall provide quantitative evidence on
the quality of the service.
 Patients have a fundamental right to participate in health care decisions
and delivery. However, they need to have information to effectively
participate. High quality, dependable information on the performance of
health care organizations is not currently available to the public in the
Philippines.
QUALITY ASSURANCE IN NURSING ACCORDING TO THE NORMA LANG MODEL

The Norma Lang Model of Quality Assurance
The Norma Lang model has seven levels that run through three phases:
1. Description
 In the first phase - Description - we identify the values and attitudes that
lead us to nursing. Then we select criteria for excellent nursing in
standards covering the structure, process and outcome.
2. Measurement
 In the second phase - Measurement - we choose the methodology that is
used to determine what our practice is like in comparison with standards
and criteria of excellent (very good) nursing, which we have set internally
or were set externally.
 The results obtained are analyzed and then we decide if and why we need
changes.
 The authoress of this model recommends the inclusion of so-called
SWOT factors (Strengths, Weaknesses, Opportunities, Threats - or
hazards and traps) in the analysis.
3. Action
 In the third phase - Action - we choose the changes and paths along
which the changes will run in our environment and finally introduce the
changes in our routine work.
STANDARDS FOR SAFE NURSING PRACTICE (BON Res. No. 110 Series of 1998)

Safe Nursing Practice refers to appropriate and rational acts of the nurse that
ensure:
• Protection of clients from harm that may result from disruption in physiologic
and sociologic preventive mechanism.
• Promotion of health and wellness.
• Restoration of optimal functioning, early recovery, alleviation of suffering or
when recovery is not possible, a peaceful and dignified death.
• Protection of health care providers, including client‘s family/SO and members
of the community.
• A balanced ecosystem.
NATIONAL NURSING CORE COMPETENCY STANDARDS
2005 Core Competency Standards for Nursing Practice in the Philippines

Legal Basis
Article 3 Sec.9 (c) of R.A. 9173/ ―Philippine Nursing Act 2002‖
Board shall monitor & enforce quality standards of nursing practice necessary to
ensure the maintenance of efficient, ethical and technical, moral and professional
standards in the practice of nursing taking into account the health needs of the
nation.
Significance of Core Competency Standards

• Unifying framework for nursing practice, education, regulation
• Guide in nursing curriculum development
• Framework in developing test syllabus for nursing profession entrants
• Tool for nurses‘ performance evaluation
• Basis for advanced nursing practice, specialization
• Framework for developing nursing training curriculum
• Public protection from incompetent practitioners
• Yardstick for unethical, unprofessional nursing practice
11 Key Areas of Responsibility

1. Safe & quality nursing practice
2. Management of resources & environment
3. Health education
4. Legal responsibility
5. Ethico-moral responsibility
6. Personal & professional development
7. Quality improvement
8. Research
9. Record management
10. Communication
11. Collaboration & Teamwork

2012 National Nursing Core Competency Standards

Introduction
Heightened by the escalating complexity of globalization, dynamics of
information technology, demographic changes, health care reforms and increasing
demands for quality nursing care from consumers, expectations for contemporary
nursing practice competencies emerged. Thus, in 2005, as an output of a key project,
Board of Nursing Resolution no. 112 Series 0f 2005, adopted and promulgated the
Core Competency Standards of Nursing Practice in the Philippines. As mandated, the
Board of Nursing ensured, through a monitoring and evaluation scheme, that the core
competency standards are implemented and utilized effectively in nursing education,
in the development of test questions for the Nurse Licensure Examination (NLE),and in
nursing service as a basis for orientation, training and performance appraisal.
Through the years of implementation, global and local developments in health
and likewise, professional nursing developments prompted the Board of Nursing to
conduct a ―revisiting ― of the Core Competency Standards of Nursing Practice in the
Philippines. In 2009, the Board of Nursing created the Task force on Nursing Core
Competencies Revisiting Project in collaboration with the Commission on Higher
Education Technical Committee on Nursing Education with the primary goal of
determining the relevance of the current nursing core competencies to expected roles
of the nurse and to its current and future work setting.
Legal Bases
Article III, section 9 (c) of Republic Act No. 9173 or the Philippine Nursing Act
of 2002, states that the Professional Regulatory Board of Nursing is empowered to
―monitor and enforce quality standards of nursing practice in the Philippines and
exercise the powers necessary to ensure the maintenance of efficient, ethical and
technical, moral and professional standards in the practice of nursing taking into
account the health needs of the nation.‖ It is, therefore, incumbent upon the Board of
nursing to take the lead in the improvement and effective implementation of the core
competency standards of nursing practice in the Philippines to ensure safe and quality
nursing care, and maintain integrity of the nursing profession.
Significance of the 2012 National Nursing Core Competency Standards

The 2012 National Nursing Core Competency Standards (2012 NNCCS) will
serve as a guide for the development of the following:
• Basic Nursing Education Program in the Philippines through the Commission
on Higher Education (CHED).
• Competency-based Test Framework as the basis for the development of course
syllabi and test questions for ―entry level‖ nursing practice in the Philippine
Nurse Licensure Examination.
• Standards of Professional Nursing Practice in various settings in the
Philippines.
• National Career Progression Program (NCPP) for nursing practice in the
Philippines.

• Any or related evaluation tools in various practice settings in the Philippines
2012 NATIONAL NURSING CORE COMPETENCY STANDARDS

BEGINNING NURSE’S ROLE ON CLIENT CARE
Responsibility 1: Practices in accordance with legal principles and the code of ethics in
making personal and professional judgment.
Responsibility 2: Utilizes the nursing process in the interdisciplinary care of clients that
empowers the clients and promotes safe quality care.
Responsibility 3: Maintains complete and up to date recording and reporting system.
Responsibility 4: Establishes collaborative relationship with colleagues and other
members of the team to enhance nursing and other health care services.
Responsibility 5: Promotes professional and personal growth and development.
BEGINNING NURSE’S ROLE ON MANAGEMENT AND LEADERSHIP
Responsibility 1: Demonstrates management and leadership skills to provide safe and
quality care.
Responsibility 2: Demonstrates accountability for safe nursing practice.
Responsibility 3: Demonstrates management and leadership skills to deliver health
programs and services effectively to specific client groups in the
community settings.
Responsibility 4: Manages a community/village based health facility/component of a
health program or a nursing service.
Responsibility 5: Demonstrates ability to lead and supervise nursing support staff.
Responsibility 6: Utilizes appropriate mechanisms for networking, linkage building and
referrals.
BEGINNING NURSE’S ROLE ON RESEARCH
Responsibility 1: Engages in nursing or health related research with or under the
supervision of an experienced researcher.
Responsibility 2: Evaluates research study/report utilizing guidelines in the conduct of a
written research critique.
Responsibility 3: Applies the research process in improving client care in partnership with
a quality improvement/quality assurance/nursing audit team

Conceptual Framework of the 2012 NNCCS
Description
A work-setting scenario on local and global health industry demands was
determined after conducted assessments, benchmarking studies, and application of
the competency-based framework and creation paradigm. This sets the stage
―beginning‖ professional nursing competencies for the care of clients especially
performance in 3 very distinct and clear ROLES: the Beginning Nurse Role on Client
Care, the Beginning Nurse Role on Management and Leadership, and the
Beginning Nurse Role on Research. These roles set expected patterns of professional
behavior for the professional nurses in society, performed within clearly established
and universally accepted process --- the NURSING PROCESS.
In each of the roles are RESPONSIBILITIES. These are obligations explicitly
carrying the authority afforded by the state to every duly licensed professional nurse.
It spells out very particular mandate in terms of expected performances in order to
decide and act based on scientific evidences as well as ethico-moral-spiritual and legal
basis for nursing care.

These responsibilities are translated in what is to be recognized as CORE

COMPETENCIES referred to as technical capacities needed for doing the tasks and
roles expected of every Filipino Professional Nurse.
At the innermost circle is the raison d‟être (reason for being as nurses). These
consist of individuals, families, population groups, and communities as clients. They
are the recipients of holistic care provided by nurses in any work setting.
PHILHEALTH SEVEN (7) QUALITY STANDARDS FOR HEALTH PROVIDER

ORGANIZATIONS
PhilHealth Quality Standards for Health Care
CODE STANDARDS CRITERIA

1. PATIENT RIGHTS AND ORGANIZATIONAL ETHICS
Goal: To improve patient outcomes by respecting patients’ rights and ethically
relating with patients and other organizations.
1.1 Organizational policies and • Informed consent is obtained from patients prior to
procedures respect and initiation of care.
support patients‘ right to • Policies and procedures which identify and address
quality care and their patients‘ rights and responsibilities are documented
responsibilities in that and monitored.
care. • Patients receive written statements of their rights
and responsibilities.
• The hospital protects patients and respects their
rights during research involving human subjects.
1.2 The organization • Policies and programs to educate patients and

encourages and promotes families on how to take a more pro-active role in

opportunities to involve health care decision making are documented,
patients and their families monitored and evaluated for their effectiveness.
in their care. • Patients and their families are involved in making
care decisions with ethical issues, such as
withholding resuscitation, foregoing life-sustaining
treatment, end of life care, etc.
1.3 The organization • Hospital staff is aware of and follows policies and
documents and follows procedures in addressing patients‘ needs for
policies and procedures for confidentiality, privacy, security, counseling and
addressing patients‘ needs communication.
for confidentiality, privacy, • The hospital systematically determines, monitors
security, religious and improves the extent to which patients‘ needs for
counseling and confidentiality, privacy, security, counseling and
communication. communication are addressed.
1.4 The organization • Policies and procedures for routinely determining
systematically elicits, and improving the level of patient satisfaction with
monitors and acts upon all relevant aspects of care are documented and
feedback from patients, monitored.
their families, visitors and • Policies and procedures for addressing and resolving
communities. patients‘ complaints are documented and monitored.
1.5 The organization‘s • The organization identifies relevant codes of
personnel discharge their professional conduct and other statutory standards
functions according to and informs its personnel about these codes and
codes of ethical behavior standards.
and other relevant • The organization identifies and monitors personnel
professional and statutory compliance with the code of ethics relevant to their
standards. respective disciplines.
• Procedures for resolving ethical issues related to
professional practice or to conflicts of interest are
based on the relevant code of ethics and other
professional and legal standards.
1.6 The organization • Procedures for resolving ethical issues that arise in
documents and follows the course of providing care are monitored for their
procedures for resolving effectiveness.
ethical issues as they arise
from patient care.


2. PATIENT CARE STANDARDS
2.1 Access
Goal: The organization is accessible to the community that it aims to serve.
2.1.1 The organization informs • Information detailing the clinical services offered and
the community about the hours of their availability is strategically distributed
services it provides and and prominently posted.
the hours of their • Clinical services are appropriate to patients‘ needs
availability. and the former‘s availability is consistent with the
organization‘s service capability and role in the
community.
• The community is aware of clinical services offered
and times of availability.
2.1.2 Physical access to the • Entrances and exits are clearly and prominently
organization and its marked, free of any obstruction and readily
services is facilitated and accessible.
is appropriate to patients‘ • Directional signs are prominently posted to help
needs. locate service areas within the organization.
• Alternative passageways for patients with special
needs (e.g., ramps) are available, clearly and
prominently marked and free of any obstruction.
• Major service areas have nearby waiting facilities
that are clean, well-lit, adequately ventilated and
equipped with appropriate fixtures and furniture.
• The organization documents, follows policies and
procedures, and provides resources for the safe and
efficient direction of patients, their families and
visitors, and staff traffic.

• Patients, their visitors and staff can efficiently and

safely move within the confines of the organization.
2.2 Entry
Goal: The entry processes meet patient needs and are supported by effective systems
and a suitable environment.
2.2.1 Patients receive prompt • Patient waiting times are routinely monitored,
and timely attention by evaluated and improved based on standards and
qualified professionals procedures developed by the organization.
upon entry. Depending on their needs, patients are seen within
the planned waiting period.
• Patients are informed of the cause of any delay in
the delivery of services.
• Patients are satisfied with the actual waiting time.
2.2.2 The organization • The staff follows policies and procedures in
documents and follows determining and prioritizing patients‘ clinical needs
policies and procedures, and in identifying clinical services that will best
and provides resources to address them.
ensure proper patient • The staff follows policies and procedures in
triaging. determining admissibility of patients or the need for
referral to other organizations.
• Patients are correctly and efficiently assigned to the
clinical services appropriate to their needs.
2.2.3 The organization uniquely • All patients are correctly identified by their patient
identifies all patients charts.
including newborn infants, • The patient charts contain identifiers unique to each
and creates a specific patient.
patient chart for each • Patient charts are appropriately and systematically
patient that is readily indexed to facilitate retrieval and storage and to
accessible to authorized avoid duplication or loss.
personnel.
2.2.4 The health professional • Prior to admission, patients and/or their families are
responsible for the care of appropriately informed by authorized qualified
the patient obtains personnel of their disease, condition or disability, its
informed consent for severity, likely prognosis, benefits, and possible
treatment. adverse effects of various treatment options, and the
likely costs of treatment.
• Patients and/or their families demonstrate
knowledge of their disease, condition or disability, its
severity, likely prognosis, benefits, and possible
adverse effects of various treatment options, and the
likely costs of treatment.
2.2.5 Planning for discharge • Patients and/or their families are informed of the
begins upon entry into the expected (barring any complications) approximate
organization and ensures a duration of treatment, the extent or frequency of
coordinated approach to reassessment, the likely outcomes and their need for
discharge and continuing follow-up care after discharge.
management. • Patients and/or their families are informed of the
need for and availability of resources to continue

care after discharge.

2.3 Assessment
Goal: Comprehensive assessment of every patient enables the planning and delivery of
patient care.
2.3.1 Each patient‘s physical, • An appropriately comprehensive history and
psychological and social physical examination is performed on every patient
status is assessed. within 24 hours from admission. The history
includes present illness, past medical, family, social
and personal history.
• Whenever appropriate, mental status examinations,
psychological evaluations and nutritional and
functional assessments are performed on the
patient.
2.3.2 Appropriate professionals • Based on collaboratively developed policies and
perform coordinated and procedures, qualified personnel conduct initial
sequenced patient assessments in an efficient and systematic manner
assessment to reduce to avoid repetition.
waste and unnecessary • The order of assessment is determined by the
repetition. patient‘s prioritized needs.
• Previously obtained information obtained is reviewed
at every stage of the assessment to guide future
assessments.
2.3.3 Assessments are • During the course of management, qualified
performed regularly and personnel re-assess the patients‘ physical and
are determined by psychological conditions according to the patient‘s
patients‘ evolving response needs.
to care. • Re-assessment is done whenever the patients‘
condition take an unexpected turn.
• Re-assessment results in a review of the patients‘
management.
• Qualified personnel give patients for surgery
preoperative physical and pre-anesthetic
assessment.
• The status of post-operative patients is assessed
upon admission into, during confinement and upon
discharge from the recovery area.
2.3.4 Assessments are • Legible written records of the initial and ongoing
documented and used by assessments are accomplished for each patient and
the health care team to kept in the patient chart.
ensure effective • Medical records are stored in an area that is safe
communication and and accessible to all members of the health care
continuity of care. team, and whenever appropriate, to external
providers.
2.3.5 Diagnostic examinations • Policies and procedures for the standard
appropriate to the provider performance, monitoring and quality control of
organization‘s service diagnostic examinations are documented and
capability and usual case monitored.
mix are available and are • Policies and procedures for accessing and referring

performed by qualified patients to approved external providers when

personnel. diagnostic services are not available within the
provider organization are documented and
monitored.
2.3.6 Assessments of patients • Policies and procedures identify patients with special
with special needs are needs and the specific types of assessment
determined by policies and appropriate to their needs.
procedures that are
consistent with legal and
ethical requirements.
2.4 Care Planning
Goal: The health care team develops in partnership with the patients a coordinated plan
of care with goals.
2.4.1 The care plan addresses • The plan, aside from delineating responsibilities,
patients‘ relevant clinical, includes goals to be achieved, services to be
social, emotional and provided, patient education strategies to be
religious needs. implemented, time frames to be met, resources to be
used.
2.4.2 The care plan is consistent • The care plan is developed by a multidisciplinary
with scientific evidence, team of health professionals within the organization.
professional standards, • The care plan is developed following search and
cultural values, medico- appraisal of published scientific literature.
legal and statutory • Expert judgment, practice standards and patients‘
requirements. values are considered in developing care plans.
2.4.3 The organization ensures • Care planning is documented in the patient chart.
that information about the • Clinical pathways, algorithms and problem-oriented
patient‘s proposed care is notes in SOAP format are incorporated in the
clear and readily medical record.
accessible to designated
multidisciplinary health
care providers and other
relevant persons.
2.5 Implementation of Care
Goal: Care is delivered to ensure the best possible outcomes for the patient.
2.5.1 Care is delivered in a • In the management of clinical pathway-covered
timely, safe, appropriate conditions, the order and timing of treatments follow
and coordinated manner, the pathway.
according to care plans. • Orders for treatments are implemented within time
intervals established by the organization.
• Referrals to other specialties are made according to
established pathways or guidelines.
• Results of referrals are communicated to relevant
members of the health care team and are considered
in the management.
2.5.2 Rights and needs of • Patients receive explanations on the nature of a test
patients are considered or treatment, the need for it prior to administration,
and respected by all the its likely effects and side effects, and what patients
staff. can do to cope with them.

• Patients‘ wish to decline tests or treatments is

respected.
2.5.3 Care is coordinated to • Policies and procedures that determine the extent of
ensure continuity and to duplicate assessments and treatments performed by
avoid duplication. trainees respect patients‘ rights, and are
documented and monitored.
2.5.4 Appropriate personnel • The organization documents and implements
educate patients and/or policies and procedures, and provides resources to
their families to help them promote interactive, appropriate and relevant
understand patients‘ educational programs for patients.
diagnosis, prognosis, • Patients are aware of their roles and responsibilities
treatment options, health in their health care.
promotion and illness
prevention strategies.
2.5.5 Drugs are administered in • Drugs are administered in a timely, safe, appropriate
a standardized and • and controlled manner.
systematic manner in the • The provider organization documents and follows
provider organization. policies and procedures and allocates resources for
the training, supervision and evaluation of
professionals who administer drugs.
• Only qualified personnel order, prescribe, prepare,
dispense and administer drugs.
• Regular review of prescription orders is undertaken
by appropriately trained staff to ensure safe and
appropriate use of drugs.
• Prescriptions or orders are verified and patients are
identified before medications are administered.
• Telephone orders are countersigned by the ordering
physicians not later than standards set by the
organization and based on statutory requirements.
• Discontinued or recalled drugs are retrieved and
safely disposed of according to established policies
and procedures.
• Drugs are selected and procured based on the
organization‘s usual case mix and according to
policies and procedures that are consistent with
scientific evidence and government policies.
• Drug administration is properly documented in the
patient chart.
• Policies and procedures for detecting, reporting and
monitoring adverse effects are documented and
monitored.
2.5.6 Treatment procedures are • Treatment procedures are performed in a timely,
performed in a safe, appropriate and controlled manner.19
standardized and • The provider organization documents and reviews
systematic manner in the policies and procedures and allocates resources for
provider organization. the training, supervision and evaluation of
professionals who perform procedures.

• Only qualified personnel order, plan, perform and

assist in performing procedures.
• Orders are verified, and patients are identified before
treatment procedures are performed.
• Treatment procedures are legibly and accurately
documented in the patient chart by qualified
personnel.
• Medical devices and equipment are used,
maintained, stored and disposed based on technical
specifications.
• Medical devices and equipment are selected and
procured based on the organization‘s case mix, staff
expertise, service capability and according to policies
and procedures that are consistent with scientific
evidence and government policies.
2.5.7 The care of patients with
special needs is governed
by policies and procedures
that are consistent with
legal and ethical
requirements.
2.6 Evaluation of Care
Goal: The health care team routinely and systematically evaluates and improves the
effectiveness and efficiency of care delivered to patients.
2.6.1 Data relating to processes • The organization routinely collects process and
and outcomes of patient outcomes data from its provision of patient care.
care are analyzed to • The organization provides resources for the formal
provide information for and collaborative evaluation of care using analysis of
care improvement. process and outcomes data.
• Results of evaluation of care are fed back to the
health care providers concerned.
• Results of evaluation of care are routinely presented
and discussed in meetings of top management.
2.6.2 The health care team takes • Evaluation of care leads to formal and collaborative
action to address any performance improvement activities that harness the
improvements required. resources of appropriate services.
2.6.3 Quality improvement •
activities are documented,
enable continuous quality
improvement and
incorporate the following
elements:
➠Monitoring, assessment,
analysis and evaluation of
activities
➠ Appropriate and timely
action
➠ Evaluation of the

effectiveness of any action

taken
➠ Feedback of evaluation
results
2.7 Discharge
Goal: Care is coordinated between the organization and other health care providers in
the community to ensure that the needs of the patient are continuously met.
2.7.1 The discharge plan is part
of the patient‘s care plan
and is documented in the
patient chart.
2.7.2 The organization provides
information about the
continuing management
plan to the patient and
relevant health care
providers in a manner that
maintains patient
confidentiality and privacy.
2.7.3 The organization arranges
access to other relevant
community health services
in a timely manner, and
ensures that patients are
aware of appropriate
services before discharge.
2.7.4 Patients understand the
discharge plans and their
responsibilities for
continuing management.



3. LEADERSHIP AND MANAGEMENT
3.1 The Management Team
Goal: The organization is effectively and efficiently governed and managed
according to its values and goals to ensure that care produces the desired health
outcomes, and is responsive to patients’ and community needs.
3.1.1 The provider organization‘s

management team
provides leadership, acts
according to the
organization‘s policies and
has overall responsibility
for the organization‘s
operation, and the quality
of its services and its
resources.
3.1.2 The organization‘s
management team ensures
the presence of effective
working relationships
within the organization,
with the community, and
with other relevant
organizations and
individuals.
3.1.3 Terms of reference,
membership and
procedures are defined for
the meetings of all
committees within the
organization. Minutes of
meetings are recorded and
approved.
3.1.4 The organization‘s
management team
regularly assesses its own
performance and the
performance of the
organization.
3.1.5 The organization develops • The organization develops its mission, vision and
and implements policies corporate goals based on agreed-upon values.
and procedures which • The organization‘s by-laws, policies and procedures
cover the major services support care delivery and are consistent with its
and aspects of operations. goals, statutory requirements, accepted standards
and its community and regional responsibilities.
• Policies and procedures, aside from being complied
with, are reviewed and revised as necessary.
• The organization communicates its policies and
procedures to all levels of the workforce.25
3.2 External Services
Goal: The organization ensures that services provided by external contractors meet
appropriate standards.
3.2.1 Documented agreements •
and contracts cover

external service providers

and specify that the
quality of services provided
must be consistent with
appropriate set standards.

4. HUMAN RESOURCE MANAGEMENT
4.1 Human Resource Planning
Goal: The organization provides the right number and mix of competent staff to
meet the needs of its internal and external customers and to achieve its goals.
4.1.1 Planning ensures that • The organization defines the qualifications and
appropriately trained and competencies of its staff.
qualified (and where • The organization documents and follows policies and
relevant, credentialed) staff procedures for hiring, credentialing and privileging
are available to undertake of its staff.
the type and level of
activity performed by the
organization. It is includes
those who are consulted
when suitable expertise is
not available within the
organization.
4.1.2 Workload is monitored and • Staff numbers and skill mix are based on actual

appropriate guidelines clinical needs.

consulted to ensure that • Appropriate policies and procedures are monitored
appropriate staff numbers to temporarily compensate for, and to definitively,
and skill mix are available address inadequacies in staff numbers or expertise.
to achieve desired patient
and organizational
outcomes.
4.2 Staff Recruitment, Selection, Appointment and Responsibilities
Goal: Recruitment, selection and appointment of staff comply with statutory
requirements and are consistent with the organization’s human resource policies.
4.2.1 Recruitment, selection, • The organization defines, disseminates and ensures
appointment and compliance with policies and procedures governing
reappointment procedures personnel recruitment, selection and appointments.
ensure appropriate • The recruitment and selection process is open and
competence, training, transparent, is consistent with legal and ethical
experience, licensing and requirements, and allows a fair and unbiased
credentialing of all evaluation of the qualifications and competencies of
appointees. all applicants.
• Relevant staff members participate in the
development and implementation of personnel
recruitment, selection and appointment.
• Selection and appointment and evidence of staff
compliance with selection or appointment standards
are documented
• Relevant licenses are routinely monitored for
renewal.
• Evidence of continuing staff education and training
is routinely monitored and assessed.
4.3.1 Upon appointment, staff • Written job descriptions are given to and discussed
members receive a written with all newly-appointed staff members.
statement of their
accountabilities and
responsibilities that
specifies their role and
how it contributes to the
attainment of the goals
and maintaining quality of
care. The statements are
reviewed when necessary.
4.2.3 Staff members are • The organization ensures that staff accountabilities
accountable for the care and responsibilities are consistent with their
and services they give and qualifications, training, experience, registration and
for the discharge of their licensure.
delineated responsibilities.
4.2.4 All services are provided by • All doctors, nurses and midwives providing clinical
staff members with care have current licenses and documented evidence
appropriate qualifications, of appropriate training and experience.
experience or training. • All administrative, business and technical services

staff have current licenses and documented evidence

of appropriate training and experience.
4.3 Staff Training and Development
Goal: A comprehensive program of staff training and development meets individual and
organizational needs.
4.3.1 There are relevant • The organization assesses the educational needs of
orientation, training and management and staff and identifies and/or
development programs to provides resources to meet those needs.
meet the educational • Policies and procedures for orientation of new
needs of management and management and staff are documented and
staff. monitored.
• The organization evaluates the effectiveness of
training and development programs to ensure that
they meet organizational, community and individual
needs.
4.3.2 The organization clearly • New personnel—including trainees, volunteers, new
defines and ensures graduates and external contractors—are adequately
compliance with the lines supervised by qualified staff.
of authority and • The staff are provided with a documented job
supervision. description outlining accountabilities and
responsibilities.


5. INFORMATION MANAGEMENT
5.1 Data Collection, Aggregation and Use
Goal: Collection and aggregation of data are done for patient care, management
of services, education and research.
5.1.1 Relevant, accurate, • The organization defines the relevant aspects of its
quantitative and operations from which data will be collected.
qualitative data are • The organization defines data sets, data generation,
collected and used in a collection and aggregation methods and the qualified
timely and efficient staff who are involved in each stage.
manner for delivery of • The organization defines policies and procedures to
patient care and monitor and improve the accuracy, completeness
management of services. and reliability of relevant qualitative and quantitative
data relating to its operations.
• The organization provides resources and
opportunities to enable management and staff to use
data in their decision and policymaking activities.
• Policies and procedures on record storage, retention
and disposal are documented and monitored.
5.1.2 The collection of data and • The organization collects and submits reports
reporting of information required by the Department of Health and
comply with professional PhilHealth.
standards, statutory and
PhilHealth requirements.
5.1.3 Every patient has a • Care providers document management details in the
sufficiently detailed patient patient chart. All entries are promptly accomplished,
chart to facilitate accurate, legible, dated and duly signed by the care
continuity of care, and providers whose designations are clearly indicated.
meet education, research, • Patient charts are routinely checked for
evaluation and medico- completeness and accuracy, and action is taken to
legal and statutory improve their quality.
requirements.
5.1.4 Data in the patient charts • Data from the patient charts are routinely collected,
are coded and indexed to aggregated and reported for use in quality
ensure the timely improvement activities, for administrative purposes
production of quality and for mandatory reporting to the Department of
patient care information Health and PhilHealth.
and reports to PhilHealth.
5.2 Records Management
Goal: Integrity, safety, access and security of records are maintained and statutory
requirements are met.
5.2.1 Clinical records are readily • When patients are admitted or are seen for
accessible to facilitate ambulatory or emergency care, patient charts
patient care, are kept documenting any previous care can be quickly
confidential and safe, and retrieved for review, updating and concurrent use.
comply with all relevant • The organization has policies and procedures, and
statutory requirements devotes resources, including infrastructure, to
and codes of practice. protect records and patient charts against loss,
destruction, tampering and unauthorized access or
use. Only authorized individuals make entries in the
patient chart.

6. SAFE PRACTICE AND ENVIRONMENT
6.1 Patient and Staff Safety
Goal: Patients, staff and other individuals within the organization are provided a
safe, functional and effective environment of care.
6.1.1 The organization plans a • The organizational environment complies with
safe and effective structural standards and safety codes as prescribed
environment of care by law.
consistent with its • There are management plans which address safety,
mission, services, and with security, disposal and control of hazardous materials
laws and regulations. and biological wastes, emergency and disaster
preparedness, fire safety, radiation safety and utility
systems.
• There are management plans for the safe and
efficient use of medical equipment according to
specifications.
6.1.2 The organization provides • Policies and procedures that address safety,

a safe and effective security, control of hazardous materials and

environment of care biological wastes, emergency and disaster
consistent with its mission preparedness, fire safety, radiation safety and utility
and services, and with systems are documented and implemented.
laws and regulations. • Policies and procedures for the safe and efficient use
of medical equipment according to specifications are
documented and implemented.
• The design of patient areas provides sufficient space
for safety, comfort and privacy of the patient and for
emergency care.
• All personnel understand and fulfill their role in safe
practice.
• Risks are identified, assessed and appropriately
controlled. Where elimination or substitution is not
possible, adequate warning and protection devices
are used.
• A coordinated security arrangement in the
organization assures protection of patients, staff,
and visitors.
6.1.3 The organization routinely • The effectiveness of safety procedures and devices
collects and evaluates are routinely tested, monitored and improved.33
information to improve the • An incident reporting system identifies potential
safety and adequacy of the harms, evaluates causal and contributing factors for
environment of care. the necessary corrective and preventive action.
6. 2 Maintenance of the Environment of Care
Goal: A comprehensive maintenance program ensures a clean and safe environment.
6.2.1 Emergency light and / or
power supply, water and
ventilation systems are
provided for, in keeping
with relevant statutory
requirements and codes of
practice.
6.2.2 Regular maintenance of
grounds, facilities and
equipment in keeping with
relevant statutory
requirements, codes of
practice, or manufacturers‘
specifications are done to
ensure a clean and safe
environment.
6.2.3 Equipment is serviced only
by people trained in the
maintenance of that
equipment. Registers and
records of equipment and
related maintenance are

kept.
6.2.4 Current information and
scientific data from
manufacturers concerning
their products are
available for reference and
guidance in the operation
and maintenance of plant
and equipment.
6.3 Infection Control
Goal: Risks of acquisition and transmission of infections among patients, employees,
physicians and other personnel, visitors and trainees are identified and reduced.
6.3.1 An interdisciplinary
infection control program
ensures the prevention
and control of infection in
all services.
6.3.2 The organization uses a • The organization undertakes case finding and
coordinated system-wide identification of nosocomial infections.
approach to reduce the • The organization takes steps to prevent and control
risks of nosocomial outbreaks of nosocomial infections.
infections.
6.3.3 The organization uses a • There are programs for prevention and treatment of
coordinated system-wide needlestick injuries, and policies and procedures for
approach to reduce the the safe disposal of used needles are documented
risks of infection the staff and monitored.
are exposed to in the • There are programs for the prevention of
performance of their transmission of airborne infections, and risks from
duties. patients with signs and symptoms suggestive of
tuberculosis or other communicable diseases are
managed according to established protocols.
6.3.4 Cleaning, disinfecting,
drying, packaging and
sterilizing of equipment,
and maintenance of
associated environment,
conform to relevant
statutory requirements
and codes of practice.
6.3.5 When needed, the
organization reports
information about
infections to personnel and
public health agencies.
6.4 Equipment and Supplies
Goal: The provision of equipment and supplies supports the organization’s role.
6.4.1 Planning of facilities and Appropriate equipment and supplies that support
selection and acquisition the organization‘s role and level of service are provided.

of equipment and supplies Consideration is given to at least:

involve input from relevant ➠ the intended use
staff and are undertaken ➠ cost benefits
by appropriately-qualified ➠ infection control
personnel. ➠ safety
➠ waste creation and disposal
➠ storage
6.4.2 Specialized equipment is
operated according to
specifications and only by
appropriately-trained staff.
6.4.3 Items designated by the
manufacturer for single
use are not reused unless
the organization has
specific policies and
guidelines for safe reuse
which take into
consideration relevant
6.5 Energy and Waste Management
Goal: The organization demonstrates its commitment to environmental issues by
considering and implementing strategies to achieve environmental sustainability.
6.5.1 The handling, collection,
and disposal of waste
conform to relevant
6.5.2 The organization
implements a waste
disposal program which
involves reuse, reduction
and recycling.



7. IMPROVING PERFORMANCE
Goal: e organization continuously and systematically improves its
performance by invariably doing the right thing the right way the first time and
meeting the needs of its internal and external clients.
7.1 The organization has a
planned systematic
organization wide
approach to process
design and performance
measurement, assessment
and improvement.
7.2. New processes of care are • There are resources available for developing or
designed collaboratively adopting clinical practice guidelines.
based on scientific • Clinical practice guidelines for the top 10 causes of
evidence, clinical admissions and / or consultations and PhilHealth
standards, cultural values adopted guidelines are disseminated and monitored.
and patient preferences.
7.3. Management is primarily
responsible for developing,
communicating, and
implementing a
comprehensive quality
improvement program
throughout the
organization and
delegating responsibilities
to appropriate personnel
for its day-to-day
implementation.
7.4 All service units and staff
are responsible for, and
demonstrate involvement
in, performance
improvement that results
in better services for
internal and external
clients.
7.5 Managers and staff
evaluate the effectiveness
of the quality improvement
program and take action to
address any improvements
required.
7.6 The organization provides
better care and service as
a result of continuous
quality improvement

activities.
7.7 Quality improvement
activities respect the
confidentiality of data
regarding patients, staff
and other care providers.
JOINT COMMISSION INTERNATIONAL 2014 NATIONAL PATIENTY SAFETY

GOALS
The purpose of the National Patient Safety Goals is to improve patient safety.
The goals focus on problems in health care safety and how to solve them.
Goal 1: Identify patients correctly
 Use at least two ways to identify patients. For example, use the patient‘s
name and date of birth. This is done to make sure that each patient gets the
correct medicine and treatment.
 Make sure that the correct patient gets the correct blood when they get a
blood transfusion.
Goal 2: Improve staff communication
 Get important test results to the right staff person on time.
Goal 3: Use medicines safely

 Before a procedure, label medicines that are not labeled. For example,
medicines in syringes, cups and basins. Do this in the area where medicines
and supplies are set up.
 Take extra care with patients who take medicines to thin their blood.
 Record and pass along correct information about a patient‘s medicines. Find
out what medicines the patient is taking. Compare those medicines to new
medicines given to the patient. Make sure the patient knows which
medicines to take when they are at home. Tell the patient it is important to
bring their up-to-date list of medicines every time they visit a doctor.
Goal 6: Use alarm safely
 Make improvements to ensure that alarms on medical equipment are heard
and responded to on time.
Goal 7: Prevent infection
 Use proven guidelines to prevent infections that are difficult to treat.
 Use proven guidelines to prevent infection of the blood from central lines.
 Use proven guidelines to prevent infection after surgery.
 Use proven guidelines to prevent infections of the urinary tract that are
caused by catheters.
Goal 15: Identify patient safety risks
 Find out which patients are most likely to try to commit suicide.
Universal Protocol for Preventing Wrong Person, Site, & Procedure: Prevent
mistakes in surgery
 Make sure that the correct surgery is done on the correct patient and at the
correct place on the patient‘s body.
 Mark the correct place on the patient‘s body where the surgery is to be done.
 Pause before the surgery to make sure that a mistake is not being made.
Module
QUALITY IMPROVEMENT
3 TOOLS
RATIONALE AND STEPS FOR PERFORMANCE IMPROVEMENT
Achieving total quality is the goal of continuous performance improvement.
This means continuously upgrading performance targets from previously-accepted
minimal standards, a challenge which demands a management philosophy advocating
continuous quality improvement in all levels of the organization, and strategies
operationalizing such philosophy.
Current literature in health care advocates a systems approach to quality
improvement—improve the system, rather than focus on the errors of individuals-
because errors are built into the system anyway (De Geyndt 1994). A TQM philosophy
guides this organization-wide pursuit of quality.
Implementing a TQM program involves three steps:

1. first, awareness of management of the importance of quality improvement;

2. second, mobilization of a quality improvement team; and
3. third, launching of organization-wide improvement activities (Kelada 1996).
In carrying out these steps, the overarching triad of documentation,
evaluation and action should be a primary consideration. Documentation,
evaluation and action are the three building blocks in establishing a performance
improvement program, and the Plan-Do-Check-Act Cycle should be its work
philosophy.
The Documentation-Evaluation-Action Triad and the PDCA Cycle in Performance

Improvement Programs
TQM PROGRAM IMPLEMENTATION STEPS

1. Management Awareness
 Management is primarily responsible for any quality improvement effort in
an organization.
 The choice to achieve quality improvement is ultimately a management
decision; the same goes for the strategies and activities used to achieve
quality improvement.
 Management should decide that efforts towards quality improvement are, in
the long run, worth their financial costs.
 A steering committee, composed of top management-picked senior
supervisors—who must be familiar with quality concepts and should be
prepared to participate directly and continually in improvement activities—
develops and promulgates the organization‘s quality policy, and ensures that
performance improvement is the overriding agenda in any management

meeting.
 Top management appoints a TQM coordinator who is directly accountable to
the CEO, and who takes charge of the planning, implementation, monitoring
and evaluation of the TQM program.
 Top management is responsible for familiarizing the staff with TQM concepts
and explaining how they fit into the organization‘s vision, mission and goals.
 Management needs to fire up each staff member‘s desire to make a personal
contribution in achieving total quality.
2. Mobilization
 The TQM coordinator spearheads an assessment of organizational
readiness—the capability to meet industry and health practice expectations
and standards.
 The morale, size and expertise of the staff as well as the available care
processes and services are also considered.
 Actual and potential patients, government and nongovernment partners and
funders of the organization are identified and their expectations determined.
 As managers and staff must have the necessary knowledge, attitudes and
skills to conduct performance improvement projects, the TQM coordinator
establishes a training program envisioned to carry out a shift from old to
new management paradigms and bring out the necessary change in
organizational culture.
 The TQM coordinator facilitates the creation of quality circles and teams in
all work areas.
 Like-minded staff members are identified as team or circle leaders. Each
leader then organizes a quality team or quality circle.
 Quality circles are small groups whose members belong to the same work
area (for example, the dietary section) and they regularly meet to identify
and solve problems within their work area using their own resources.
 Quality teams are bigger groups than quality circles and consist of
employees and managers who belong to different work areas but are
involved in the same care process (for example, departments involved in
discharging a patient).
3. Launching of Performance–Improvement Activities
 Performance improvement projects are launched in one area which has the
greatest chance of success within a short time.
 These improvement activities are then gradually extended to the entire
organization.
 Momentum is maintained by quickly moving on from one area to another.
 Continuous evaluation of the projects and their outcomes to monitor
effectiveness of the performance improvement projects should be regularly
done.
 Managers must regularly report areas for improvement.

 A process of rewarding performance improvement through positive

reinforcement must be established.
The Documentation–Evaluation–Action Triad

1. Documentation
 Continuous quality improvement requires decision-making based on the
systematic analysis of data.
 Health care organizations operate through systems and processes that
depend on interlinked actions of many disciplines.
 Operations cover administrative, financial, housekeeping, technical and
health care services.
 Writing down policies and procedures that govern the critical systems in
each of these services, and documenting activities, are essential in achieving
total quality care.
 Documentation must cover all important aspects of health operations.
 The extent of documentation is directly linked to the degree of achievement of
the standards.
 The seven PhilHealth standards on performance improvement emphasize the
need for documentation for the following reasons:
• ➠ Safety — Standard Operating Procedures (SOP) provide a step-by-
step guide to clinicians in administering interventions to patients so
that key steps are not missed or interchanged. Well-written SOPs
reduce the risks of error in the health care environment.

➠ Consistency of purpose — Policy manuals enable both managers

•
and staff to behave in accordance with organizational goals and codes
of conduct and provide guidance in resolving ethical dilemmas and
conflicts.
• ➠ Standardization — Explicit job descriptions provide standards
that allow for uniform staff orientation, continuing self-assessment
and transparent performance evaluation. In terms of patient care,
standardization of processes for medical, surgical or diagnostic
interventions reduces variations, which, in turn, translates to cost
efficiency.
• ➠ Improvement — Documented policies and procedures form the
basis for organizational self-assessment. Areas for improvement can
only be identified systematically by referring to written processes and
documented outcomes.
2. Evaluation
 Delivering high quality health care is about consistently benefiting patients
in the cheapest and most acceptable manner possible.
 Because many factors determine the outcomes of treatment, the quality of
care is only as good as the last patient.
 Using the exact set of interventions in closely similar cases will not produce
similar outcomes all the time.
 The key to improvement is reflection and analysis. Learning comes from
taking stock of the intended benefits and unintended harms brought on
patients.
 Real learning comes from deducing guidelines and distilling lessons from all
previous cases and refining future interventions accordingly.
 Donabedian (cited in Jonas and Rosenberg, 1986) urges that all three
measures—structure, process, outcome—be used when assessing and
monitoring the quality of health care.
 The more beneficial interventions are not necessarily the costlier ones. There
is an optimum level of benefits which any intervention should deliver.
Beyond this level, the costs of additional interventions outweigh any
additional benefit. Efficiency levels increase marginally and can even
decrease.
 In assessing patient care, for example, the following questions can serve as
guide:
• Are the right interventions being done? Are they safe and efficacious?
The balance of benefit and harm resulting from an intervention, or a
set of interventions, determines the level of quality. Treatments
should be scientifically proven to be better than no-treatment, and
should be reasonably free of adverse risks.
• Are interventions performed correctly? Once the most efficacious and
safe interventions are selected, the next step is to deliver them as

efficiently as possible and with an eye towards continuous

improvement.
• Are the procedures being done the ones that matter? Health care
outcomes are the ultimate test of quality. They tend to be more
difficult to measure than processes. Nonetheless, every effort should
be expended to evaluate important clinical outcome of care because
even doing the right things right may still lead to undesired
outcomes.
 Donabedian (1992) suggests the following classification and examples of
health care outcomes:
• ➠ Clinical – symptoms, morbidity, accuracy, survival
• ➠ Physiological / biochemical – functional change, stress test
performance
• ➠ Psychological, mental – feelings, beliefs, knowledge
• ➠ Social and psychosocial – coping mechanisms, social role
performance
• ➠ Integrative – mortality, longevity
• ➠ Evaluative – satisfaction, quality of life
3. Action
 Compliance of health care organizations with standards of performance is
best measured through effective identification of problems and opportunities
for improvement, and on how they proceed to improve performance based on
the information.
The Plan-Do-Check-Act (PDCA) Cycle

 The Plan-Do-Check-Act cycle (PDCA), is one strategy to operationalize the
documentation-evaluation-action triad.
 This is also known as the Shewhart cycle or Deming cycle.
 PDSA starts with three (3) key questions:
1. What are we trying to accomplish?
2. How will we know that the change is an improvement?
3. What changes can we make that will result in an improvement?
 FOCUS Methodology is also used. It stands for:
• Find a process to improve
• Organize a team that knows the process
• Clarify current knowledge of the process
• Understand the variability and capability of the process
• Select a plan for continuous improvement
 It can be used at any organizational level but is particularly effective at the
“frontliners” level.
 It is a simple but systematic method for identifying areas for improvement
(Plan), and testing (Do), evaluating (Check) and institutionalizing (Act) solutions.

 Documentation is needed in all four stages of the cycle, but it is critical in the
planning stage since no plan can be sensibly drawn if the problem has not been
sufficiently documented and specified.
 Evaluation is needed during the planning and checking stages. Evaluation is
particularly important in the checking stage because the effectiveness of all
potential solutions must first be established, or the organization runs a high
risk of institutionalizing faulty solutions and committing costly errors.
 Improvement takes place during the ―do‖ and ―act‖ stages. Action is crucial
during the ―act‖ stage when top management must summon its administrative
capacity to institutionalize beneficial changes that would otherwise remain
temporary and limited in scope.
 The ability to institutionalize change is the hallmark of a learning organization. A
learning organization continually evaluates and improves its performance.
 Example:
1. Process: Discharge process for hospitalized heart failure patients over 65.
2. Team: Could include Chief of Cardiology, cardiology nurse,
administration
3. Clarify the process: The team meets to create a flow chart or process map
4. Understand the process: The team measures the process as-is to
determine a range of data, which in this example could be: (1.) what
percentage of patients with heart failure, over 65, are readmitted within
30 days?; (2.) how long does it take the staff to discharge this type of
patient?
5. Select what to improve: The team chooses to reduce the 30-day
readmission rate.
6. Plan: The first plan they select is to set up heart failure patients over 65
with a connected health program upon discharge
7. Do: The team implements this one change during a fixed time period
8. Check: The team measures and checks the results of their connected
health discharge intervention
9. Act: The team acts on the results. If the intervention worked, then the
team keeps this new program in their discharge process. They may even
take some action to try to further improve their 30-day readmission rate
reduction. If the test did not improve 30-day readmission rates, they
would try another idea, and run it through the PDCA Cycle.


Quality Improvement Tools

 The tools discussed here are used to carry out the different steps of the PDCA
cycle. There are five (5) different groups of tools, each addressing specific
concerns in different phases of a performance improvement program.
 The first two of these five groups identify and describe problems in the ―Plan‖
phase of the PDCA.
 The third group, the problem analysis tools, aims to determine the causes of
certain problems and to describe how certain factors impact on their degree of
severity. One tool for example, the fishbone diagram, is very useful in carrying
this out. It is used extensively among quality circles in Japan, though it is
employed less elsewhere because it can be time-consuming and quite tedious.
 The fourth group of tools, the solution development tools, assists in prioritizing
solutions or sets of solutions to be tried on a trial basis in the ―Do‖ step of the
PDCA.
 The ―Check‖ step in the PDCA evaluates the effectiveness of the trial solution in
correcting the problem identified.
 The decision to accept or reject a trial solution constitutes the ―Action‖ step in
the PDCA. If the first solution is not effective, alternates are tried, one after the
other, until an acceptable solution is identified.
 With an acceptable solution found and implemented, its long-term effect can be
monitored using quality monitoring tools.
Tools for the Different Stages of PDSA

 The Japanese and QC Tools
 In 1977, after a 5-year study, a group of Japanese scientists and
engineers came up with what they called the “Seven Management
Tools for Quality Control.” These seven are the:
1. Affinity diagram
2. Relations diagram
3. Tree diagram
4. Matrix diagram
5. Matrix data analysis
6. Process Decision Program Chart, and
7. Arrow diagram.
 Some time earlier, Japanese quality control personnel were made to
undergo widespread training in seven elementary statistical methods,
which have been called “Seven Quality Control Tools,” namely:
1. Check sheet, Histogram
2. Cause and Effect diagram

3. Pareto principle
4. Control chart
5. Scatter diagram, and
6. Graphs.
 Publicity given to Japanese quality control circles led to wide use of
those tools in training courses for quality control in the United States
(Juran 1992, Ishikawa, 1985).
A. Problem Identification Tools

1. Affinity Diagram
 This is an organizing technique used to sort several ideas or issues into

meaningful groups.
 This method simplifies the analysis process as it narrows down the focus on
a certain issue by identifying important aspects or creating useful
categories.
 Used together with flowcharting, it helps to attain agreement on various
issues, processes and results.
 This technique encourages the search for non-traditional links among ideas
and issues.
 How to do it:
1. State the issue under discussion in a clear and concise sentence.
 The team should agree on the choice of words to be used.
2. Brainstorm at least 20 ideas or issues.
 Follow procedures used in brainstorming.
3. Record each idea in large print visible to all.
 Avoid using single words.
4. Sort ideas into five to ten categories into which the ideas are to be
grouped.
 During sorting, focus on the connections between the ideas.
 Let some ideas stand alone, as they may represent
independent groups.
 Once each member feels sufficiently comfortable with the
groupings, sorting slows down.

5. Reach a consensus on the labels—which could either be a word or a

short phrase—for each group of ideas; the labels will be the main
headers in the diagram.
 Each grouping should have a concise sentence summarizing its
central idea and significant subordinate concepts.
 Divide large groups into subgroups when needed and create
the necessary subheaders.
6. Draw the final Affinity Diagram by connecting all main headers with
their groupings.
Sample Affinity Diagram
2. Brainstorming
 Team Thinking
 This a technique used to generate multiple perspectives on a given issue by
generating as many ideas as possible from the team.
 An important characteristic of this technique is its uninhibited and
criticism-free feature which encourages all members of the group to express
their ideas.

 This method welcomes new insights and modes of thinking and encourages
involvement of every member of the group, preventing domination of the
discussion by a few people.
 It can be structured, in which each member gives ideas at a specific turn; or
unstructured, in which any one can contribute an idea as it comes.
 How to do it:
1. Identify a specific issue or problem for brainstorming.
 The issue is stated, agreed upon and written down for everyone
to see.
 To ascertain if everyone understands the issue or problem at
hand, one or two members are asked to paraphrase it.
2. Ask all members for ideas, doing so on a rotation basis or by letting
anyone with a new idea to speak up.
 All ideas are welcomed and none is criticized.
 Everyone contributes until the group exhausts all new ideas.
3. Record all ideas presented, exactly as stated.
 Recording ideas using the exact words used to state them (the
―packaging‖) will allow appreciation of nuances and differences
of seemingly-similar ideas.
 Any member contributing an idea should make sure that his or
her ideas should be recorded accurately, with no abbreviations
that could lead to misinterpretations.
4. Review the list of ideas generated and eliminates redundancies.
 Discard ideas that are practically identical.
 Subtle differences in apparently identical ideas can be
perceived by the use of slightly different wordings.
 Ensure that all the generated ideas are clear.
3. Flowchart

 A flowchart is a map, or a pictorial representation, of the elements of a

process or a sequence of events.
 The elements/events are arranged in such a way to show their chronological
order and interrelationships.
 It is a management tool used to understand the intricacies of a process.
 Flowcharts are best constructed by people who carry out the work being
mapped out.
 By analyzing activities which impact on performance, a team can reach an
agreement regarding steps in a process.
 It also allows for the use of a common language to name the different
elements of a process.
 As a quality improvement tool, it facilitates needed simplification and
standardization by identifying bottlenecks in the process, missing or
redundant steps, and problem areas.
 How to do it:
1. Determine the boundaries of the process.
 Clearly define the starting (input) and the terminal (final
output) points of the process being studied.
 Team members should agree on the level of detail to be shown
on the flowchart for process understanding and problem
identification.
2. Identify the steps in the process.
 Brainstorm a list of major activities, inputs, outputs and
decisions involved from the beginning to the end of the
process.
3. Arrange the steps in sequential order.

Unless flowcharting is being done for a new process,


sequencing should follow the actual order of events employed
in the work process. While initially difficult to do, this allows
identification of probable causes of the problems in the
process.
4. Draw the flowchart using the appropriate symbols.
 Use labels that are understandable to the entire team.

Sample Flowchart for Admission
4. Nominal Group Technique
 Team Thinking
 This is a team brainstorming method useful for balancing member
participation and reaching consensus on the relative importance of issues,
problems or solutions.
 By giving each team member equal chance to rank issues without pressure
from other members who may tend to dominate discussions, this method
allows the team to see major causes of disagreements.
 By starting from individual rankings to reach a consensus, this tool instills
ownership of ideas and commitment to the team‘s choice.

How to do it:
1. Generate a list of statements on issues, problems or solutions to be
prioritized.
 Silent or individual brainstorming—writing ideas in sheets of
paper—is preferable in generating ideas, particularly if team
members are still unfamiliar or uncomfortable with each other.
 Record the statements on a board or flipchart where everyone
can read them.
2. Eliminate duplicates, group together related ideas and/or clarify
meanings of the statements.
 The facilitator/group leader should always ensure that there is
team consensus in the rephrasing and elimination of any
statement and grouping of ideas.
3. Finalize the list of statements.
 Each statement should be represented by a letter.
4. Rank the statements in order of importance.
 The highest number may be used to indicate the highest rank,
the smallest number the lowest rank.
 Add the resulting individual rankings and show the total
scores for each statement.
5. Select the statements with the highest total scores as the team‘s
group decision.
 The group decides on the final number of statements to be
selected.
 Repeat the selection process for the statements if there are
many statements to choose from or the total scores are very
close to each other.
 Each member may briefly make clarifications or comments on
the statements.
B. Problem Description Tools
1. Bar Graph
 A bar graph plots the frequency of occurrence of different kinds of events
during set time intervals.
 It shows differences in data collected during different time periods.
 How to do it:
1. Assign frequency of events to the vertical axis.
 Assign one bar per event.
2. Assign the time intervals to the horizontal axis.
 Uniform time intervals should be marked on the horizontal
axis.
3. Plot the data according to the time intervals.
 The height of each bar should correspond to the frequency of
the event assigned to it.

Bar graph showing the estimated number of beneficiaries of the NHIP

for the period 2000–June 2002.
Bar graph showing PhilHealth claimspayments for the period 1998–June 2002.
2. Check Sheet

 A check sheet is a data-organization tool for the systematic recording and

compilation of historical data or qualitative or quantitative observations on a
certain phenomenon aimed at detection of patterns and trends.
 A check sheet forces agreement within the team, for purposes of data
uniformity, to come up with a common definition or set of characteristics of
conditions or events to be observed.
 This will ensure easy detection of patterns emerging from the collected data.
 How to do it:
1. 1. Agree on the definition of the events or conditions being observed.
 If the list of events or conditions are to be constructed while
observations are being made, agreement must be reached on
the overall definition of the project and terms used in defining
project goals.
2. Collect data over a sufficient period to ensure it represents ―typical‖
results.
 Collect data consistently and accurately.
 Look out for the need to stratify data—the subgrouping of data
to accommodate important differences in the population (where
the data was obtained)—as reflected in the sampling (the
portion of the population being studied).
Accreditation Check Sheet for Health Professionals

3. Force Field Analysis

 This is used to identify and enhance factors (also called ―driving forces‖)
which facilitate organization objectives and pinpoint and minimize those
that act as obstacles (also known as ―restraining forces‖).
 Weighing the pros and cons of a given problem and proposed solutions
encourages serious team reflection on all concerned issues.
 Essentially a change analysis tool, this method allows a team to see what is
needed to solve a certain problem (or designated as ―current situation‖).
 Only when driving forces—which may be external or internal to the
organization—are ―stronger,‖ will change be possible; if not, they should be
strengthened or restraining forces minimized.
 However, simply pushing the positive factors for a change can produce the
opposite effect. It is better to work on removing ―barriers.‖
 A key element in this analysis method is data collection. Whether data is
primary (prospectively collected) or secondary (obtained from existing
records), it is needed for evaluation of the issues.
 Secondary data may be convenient but could prove inaccurate. On the other
hand, while primary data collection takes time and effort to carry out, it may
be more valid.
 How to do it:
1. Identify a certain problem situation and state the desired situation,
which shall be considered as the solution.
 Draw a large ―T‖ on the board or flipchart.
 Write down the problem—a specific, measurable situation that
represents the gap between what is and what should be—and
the desired situation above the horizontal line of the large ―T.‖
 Write down the positive and negative sides of the situation on
opposite sides of the vertical line of the ―T.‖
2. Describe the desired situation.
 Identify the driving forces that would lead to the desired
situation.
 Identify the restraining forces that impede the realization of the
desired situation.
3. Identify needed actions to either strengthen driving forces or minimize
restraining forces.

 Prioritize—through open discussion or by ranking methods like

the nominal group technique—the driving forces to be
strengthened and the restraining forces to be minimized.
Sample Force Field Analysis

4. Line Graph
 Run chart
 This is a data analysis tool which shows the evolution of a process or its
output over a period of time.
 As a performance tool, it measures certain parameters of a process observed
over a given time frame.
 It is also used to spot trends and other patterns occurring in a process as it
shows the peaks and lows reflected in the quantitative data.
 By plotting the developing of a process, a line graph indicates whether the
process is working, whether a certain target level has been reached, and
which areas need or have undergone improvement.
 This is useful in spotting trends at the early stages of data collection.
 How to do it:
1. Decide the kind of data to be collected and how long the collection
should be.
 The data gathering period should be long enough to show a
trend.
 Establish even intervals of time over which the data are to be
arranged.
2. Plot quantitative data and time intervals on their respective axes.
 Assign the quantitative data to the vertical axis (X-axis).
 Assign the time intervals to the horizontal axis (Y-axis).
3. Connect the data points.
Sample Line Graph
Average Value per Claim filed with PhilHealth, 1999-June 2002

5. Pareto Diagram
 Pareto Chart
 Vilfredo Frederigo Samaso Pareto (1848-1923)
 French-born Italian economist and sociologist who developed the
theory on the rise and fall of the governing elite.
 His early work resulted in the formulation of the Pareto Law, which
stipulated that the distribution of incomes could be determined by
mathematical formulas.
 A simpler version of this law says that 80 percent of the wealth of an
economy is owned by 20 percent of the population. It would later be
popularized as the 80-20 rule and appropriated by quality expert
Joseph Juran, who rephrased it to mean that 80 percent of the
problems are a result of 20 percent of the causes.
 Using the Pareto concept, Juran also conceived of the ―vital few‖ and
the ―trivial many.‖
 A Pareto chart is an analysis tool useful in identifying problems that require
further study—due to the frequency of incidence— and in prioritizing the
search for solutions.
 A Pareto chart analysis can show which of the several causes of a problem
are the most significant and which have less bearing in the occurrence of
the problem.
 Used in studying problems with multiple causes, a Pareto chart displays the
significance of problems in a simple, easily interpreted visual format. It
shows in an easy-to-read bar graph the frequency of problems, arranged in
descending order, which affect a given process.
 The graph also shows the percentages of various factors in order of size.
 How to do it:
1. Decide on a topic.
 The topic may be a general one or a specific problem.
2. List the specific problems or causes of the problems to be compared
and rank ordered.
 Compare and rank order the listed problems either by cause-
and-effect analysis (Fishbone diagram), brainstorming or
review of existing data.
3. Choose the most meaningful and feasible unit of measurement to
compare, such as frequency or cost.
4. Choose a time period for the study.
5. Gather the necessary data on each problem category or cause either
prospectively, or by reviewing existing data.
6. Construct a table listing the problem or causes, and their respective
frequencies.
 Calculate the percentages and cumulative percentages (the
cumulative percentage is the first percentage plus the second
percentage, plus the third, and so on).
Sample Computation of Cumulative Percentages
7. Construct a graph, listing the problems or causes in decreasing order

of frequency or size.
 Assign the problems or causes on the horizontal (X) axis.
 Assign the percentages from 0 to 100% on the vertical (Y) axis.
8. Draw the cumulative percentage line showing the portion of the total
that each problem or cause category represents.
 On the vertical line opposite the raw data, write 100% opposite
the total frequency of causes and mark the subdivisions
accordingly.
 Starting with the highest problem category, draw a dot or mark
an x at the upper right hand corner of the bar.
 Add the total of the next problem category to the first and draw
a dot above that bar. Do the same for the next problem
categories and connect the dots with straight lines until 100%
is reached.
Sample Pareto Chart
9. Interpret the results and identify the ―vital few‖ causes (80- 20 rule).
 Generally, the tallest bars indicate the biggest contributors to
the overall problem.
 Dealing with these problem categories will impact the most in
solving the general problem.
6. Pie Chart
 A pie chart is a pictorial representation of an entire unit as constituted by its
different parts.
 The proportions of these different components are displayed and the
interrelationships between the different parts are seen.
 How to do it;
1. Determine proportion of the whole that can be assigned to each of the
items.
 The proportion of the component items are expressed in
percentages.
2. Divide the circle, assigning the slices to each item.
 The sizes of the slices representing specific items correspond to
the percentage they occupy in the entire unit.

Pie chart showing percentage of different kinds of accredited

health care institutions as of June 2002.
C. Problem Analysis Tools

1. Fishbone Diagram
 Ishikawa Diagram
 Cause-and-Effect Diagram
 Kaoru Ishikawa
 According to Ishikawa, a professor of engineering in two Japanese
universities and winner of the Deming Prize, the ideal state of quality
control is where the level of quality is so high that inspection is no
longer needed.
 He believed that quality assurance is attained by eliminating the root
cause of error.
 He created a diagram to illustrate causes and effects.
 It has come to be known as the fishbone diagram, or the Ishikawa
diagram.
 This is a management tool used to show the many possible causes of a
problem and the possible actions to solve it.
 It identifies and graphically displays in increasing detail all possible causes
to a problem or condition to get to its root cause or causes.
 In doing so, ideas for possible solutions are generated.
 Designed to look like a fish skeleton, the ―head‖ of the fish represents the
―effect,‖ or the problem being studied.
 The ―bones‖ connecting to the ―spine‖—or the problems which create the “
effect‖—are then identified and labeled.
 The causes of these problems are then identified until a complete cause-
and-effect picture emerges.
 How to do it;
1. Identify the problem to be solved.

 The problem is labeled as the ―effect‖ and represented in the
diagram as the ―head‖ of the fish located at the right hand end
of a horizontal line.
 Write the statement of the problem in a box on the right side
(―head-of-the-fish‖ side) of the diagram.
 Everyone should agree on the statement of the problem, which
should include as much information (what, where, when, why,
how much) as possible.
2. Brainstorm causes of the problem.
 The possible causes (major cause categories) of the “effect‖
should be grouped together (represented as bones connected to
the spine).
3. Connect the major cause categories to the ―spine.‖
4. Label the major cause categories.
 In the health care industry, major cause categories include:
policies (higher-level decision rules), procedures (steps in a
task), plant (equipment and space), and people (manpower).
 Other frequently-used cause categories include: environment
(buildings, logistics and space) and measurement (calibration
and data collection).
5. Study the results.
 Search for the causes behind the causes until there is a
complete picture.
 Revise the diagram based on the results of data collection and
analysis.

Sample of a Fishbone Diagram

2. Matrix Diagram
 This is used to show a graphic representation of the presence and strength

of relationships between two sets of information or activities.
 In terms of service improvement, it is used to compare the relationship
between certain requirements and the work processes that deliver those
requirements.
 A matrix diagram, by making patterns of responsibilities visible and clear to
the team, promotes even and appropriate distribution of work activities.
 How to do it:
1. Determine the factors needed to make a correct selection or
assignment.
 List the most important resources or responsibilities involved
in performing a specific task.
 Select the key factors affecting successful implementation.
 Assemble the right team, selecting individuals who are
knowledgeable on key factors and can realistically assess the
relative importance of each.

2. 2. Select the type of matrix to be used

 L-shaped matrices are for 2-factor comparisons; T-shaped ones
are for 3-factor comparisons; Y-shaped matrices are for 3-
factor comparisons showing direct relationships.
3. Select relationship symbols to be used.
 Make sure that the team clearly understands the meaning of
the symbols.
 Create a legend section by choosing and defining relationship
symbols.
 Rate the strength of relationships (i.e. high, moderate or low).
4. Complete the matrix by using the appropriate factors and symbols.
 In identifying the persons responsible for specific components
of a task, include those who are directly involved in
implementing and/or evaluating the task.
 In assigning responsibilities, choose only one person to
exercise the primary responsibility. Assign secondary
responsibilities to all other identified persons.
5. Examine the matrix and draw the appropriate conclusion.

Sample L–Shaped Matrix Comparing Personnel Tasks in Patient Orientation
Sample T–Shaped Matrix Comparing Personnel Tasks in Patient Orientation
3. Scatterplot Diagram
 Scatter Diagram
 Dot Chart
 Scatter Chart
 This is one graphical representation of data which shows the relationship
between two variables.
 But while patterns appearing in the diagram allow for visual estimation of
how changes in one affects the other, the scatterplot diagram only indicates
a relationship and does not signal a causation.
 Plotting this diagram demands a big data set, or at least 30 data points.
 How to do it:
1. Collect data on several variables in the process being studied.
 Choose two variables which are suspected to have a
relationship.
 For a value of one variable, determine the value of the other.
2. Plot each observation based on its two coordinates from each of the 2
data sets.
 Both axes should be of the same length.
3. Determine the existence of a correlation between the variables.

 If the resulting graph resembles a nearly-horizontal or nearly-

vertical line, or random points appear in no apparent order,
there is no correlation between the variables.
 If the graph resembles a slanting line, there is a positive (if
upward slant) or a negative (if downward slant) correlation; the
more the pattern resembles a line, the stronger the
relationship.
Sample Scatterplot Diagram
D. Solution Development Tools

1. Prioritization Matrix
 Selection Grid
 This is a screening tool used to narrow down options through a systematic
comparison of choices using a set of criteria.
 This is particularly useful when there are limited resources available for
implementation of a certain activity.

 The prioritization matrix allows basic disagreements on issues to surface for

their prompt resolution.
 It focuses on increasing a team‘s chances of success by identifying the best
actions that can be done and not losing time in pondering all possible ones
that could be done.
 As all options are considered, this activity builds consensus, instills team
ownership of the decision and enhances “ follow through‖ of group
decisions.
 This is best used with a small team (3-8 people), when there are few options
(5-10) and criteria (3-6), and when complete consensus is needed and
serious consequences are at stake should the plan fail.
 How to do it:
1. Agree on the ultimate goal to be achieved and state it in a clear, brief
sentence.
2. Create the list of criteria and a scoring system.
 Reach a consensus on the final set of criteria and their
meanings.
 Use a yes/no system or a point system to indicate fulfillment of
a criterion.
3. Create a list of options.
 Reach a consensus on the final set of options and their
meanings.
4. 4. Create an L-shaped criteria matrix to weigh criteria against each
other.
 List all the criteria on the vertical and the horizontal axes.
 Read across each row and weigh the row criterion against each
of the column criteria.
 Each time a weight is recorded in a row cell, its reciprocal
value must be assigned to the corresponding column cell.
 Total the weights in each row to get the criterion weight for
each row criterion.

5. Create an L-shaped criteria matrix to weigh options against each

other.
 List all the options on the vertical and the horizontal axes.
 Read across each row and weigh the row criterion against each
of the column criteria.
 Each time a weight is recorded in a row cell, its reciprocal
value must be assigned to the corresponding column cell.
 Total the weights in each row to get the option rating for each
row criterion.

6. Create an L-shaped summary matrix to compare each option based

on all the criteria combined.
 List all criteria on the horizontal axis and all options on the
vertical axis.
 For each matrix cell, compute the option scores by multiplying
the criterion weight of each criterion by the option rating of
each option. For each option, add all the option scores
horizontally for a row total.
 Divide the row totals by the grand total. This creates option
ranks for each option.
7. Choose the highest ranking option or options (in the example above,
improving quality is seen as the best option).
 Use common sense as well—as prioritization matrices do not

constitute an exact science, the team should be open to
alternative conclusions, particularly when option ranks are
very close or defy logic.
2. Process Decision Program Chart (PDPC)
 This is used to graphically illustrate contingency planning.

 Possible problems and difficulties in implementation are determined and
strategies for dealing with them are determined in advance.
 This useful in the following situations:
 Implementation of a new or untried plan that has risks involved;
 Implementation of complex plans and the consequences of failure are
serious;

 Implementation of a plan with time constraints, when there is no

sufficient time available to deal with contingent problems as they
occur.
 How to do it:
1. Create a team that is familiar with the process under study – this
usually involves the people directly in charge of the work process.
2. The actual work flow of the activities is clarified and the team
constructs a tree diagram, placing prerequisite activities in a time
sequence.
3. All possible contingencies are identified for each step by asking, ―what
could go wrong here?
4. Contingency plans are placed on the chart.
5. The most feasible countermeasure to each problem identified is
chosen and built into a revised plan.
Sample PDPC Showing Contingency Measures for the Persistent High Turn-Over
of Staff Following Employee Training.
3. Tree Diagram

 Decision Tree
 This is a graphic tool used to map out detailed groups of tasks marked for
implementation. It breaks down a goal expressed in broad terms into
increasing levels of detailed actions (called stratification) that should or may
be done to achieve stated goals.
 The tree diagram aims to ―partition‖ a big idea or problem into its smaller
components, to make the idea easier to understand, or the problem easier to
solve.
 While the tree diagram makes the entire team check all of the logical links
and the completeness of details at every level of a plan, it helps make a
potentially overwhelming project manageable by showing the real level of
complexity of actions involved in the achievement of any goal.
 How to do it:
1. Choose the tree diagram goal statement that is clear and action-
oriented.
2. Assemble a team which consists of 4-6 action planners with detailed
knowledge of the goal.
 The team should take the tree diagram only to the level of
detail that the team‘s knowledge will allow.
3. Generate the major headings, which represent the major task areas.
 Keep the first level of detail broad.
 Avoid jumping to the lowest level of task.
4. Break each major heading into greater detail.
 Asking ―what needs to be done to accomplish this task?‖ can
lead to successively detailed levels.
5. Stop the breakdown of each level up to the point where there are
assignable tasks, or the team reaches the limit to its own expertise.

Template of a Tree Diagram
E. Quality Monitoring Tools

1. Control Chart

 Walter Shewhart
 He was first to developed control charts in the 1920s at Bell Labs as a
quality control tool in manufacturing.
 Shewhart would later create the process improvement approach
known as the Plan-Do-Check-Act cycle, to be used with control
charts.
 The health care industry would appropriate control charts as a
quality improvement tool only in the 1980s (Nelson 1995).
 This is a tool used to monitor developments in a process over time.
 Statistically based in pinpointing process variations, it is most useful in
long-term studies as it indicates the times when a process registers values
outside acceptable limits, times when improvement efforts are needed in a
process.
 This is also used to determine whether changes in a process are due to:
1. Random variability (also called “common” causes), or
 These are flaws inherent in the design of the process.
 They can be measured and monitored but not entirely
eliminated.
2. Unpredictable and occasional causes better known as “special”
causes
 These are variations from standards caused by employees or by
unusual circumstances or events.
 Special causes produce variations that affect quality and must
be monitored, analyzed and eliminated.
 The distinction between the two causes is important as most variations in
processes are caused by system or process flaws rather than employee
errors. When management realizes this, changes in the system can take
place, as the implantation of a culture of blame is prevented.
 There are two types of control charts:
1. Variable data control charts, or measurements charts

This measure quantifiable events (such as weight, volume,

speed, time, length); and
2. Attribute data control charts
 This measure the presence or absence of a quality.
 How to do it:
1. Select the kind of data to be collected, whether variable or attribute.
2. Select the kind of control chart to use.
 Variable data control charts are used to determine the extent
of the statistical control of a process.
 XmR control charts (also known as I-chart, X-Rm, x-R or
X-m) plot individual data measurements and the range
between present and past data values.
 X-S control charts (or the sigma chart) plot the mean and
the standard deviation.
 Attribute data control charts generally examine flawed
products as a fraction of a whole.
 The p chart measures the fraction of defective items in a
sample of either varying or constant size.
 The c chart measures the count of defective items for a
constant sample size.
 The u chart measures the count of defective items for a
sample of either varying or constant size.
3. Collect data.
 Record the data on the appropriate control graph.
4. Calculate upper and lower control limits, and data mean and
standard deviation, if needed.
5. Plot the data points and control limit.
 The control graph is divided into the following three zones:
upper control limit (UCL), standard (average), and lower control
limit (LCL).
6. Interpret the graph.
 The process is ―out of control‖ if:
 One or more data points fall above the UCL or below the
LCL;
 There are at least eight consecutive data points on one
side of the average line (center line);
 At least six consecutive data points steadily increase or
decrease, thus signaling a trend.
 Data Reminders
 If the data fluctuates within the limits, it is the result of common
causes within the process (flaws inherent in the process) and can only
be changed if the system is improved.
 If the data falls outside of the limits, it is the result of special causes
(in human service organizations, special causes can include bad

instruction, lack of training, ineffective processes, or inadequate

support systems). These special causes must be eliminated before the
control chart can be used as a monitoring tool. In a health setting, for
example, staff may need better instruction or training, or processes
may need to be improved, before the process becomes ―under
control.‖ Once the process is ―under control,‖ samples can be taken at
regular intervals to assure that the process does not fundamentally
change.
Sample Control Chart Showing an “Out Of Control”

Process from October to December.
2. Histogram
 Bar Chart
 Frequency Distribution Chart
 William Playfair
 One of the earliest tools in statistical analysis

 First to publish this kind of bar chart in 1786.
 ―Histogram‖ as a word was introduced by Karl Pearson in 1895
(JCAHO 2002).
 A histogram is a bar graph which displays the frequency of occurrence of
data values and shows the spread of data distribution.
 As a graphic summary of data, the horizontal axis shows data size and the
vertical axis displays frequency.
 This tool enables a team to be more familiar with how a process works, as a
histogram allows team members to see patterns of variation occurring in a
process.
 It helps compare current and previous performances as well as predict
future performance.
 How to do it:
1. Gather data about a variable to be studied.
 Determine data categories and time intervals to be used
 Collect enough data points (at least 50 to 100) to be able to
detect patterns of occurrence and calculate the data centering
(like the mean) and data spread (like standard deviation).
 Use historical data to find patterns or to provide baseline
measure of past performance.
 Collect data prospectively for current process information.
 To compare previous and current process performances, the
two data sets (current data and historical data) should have
uniform variables.
2. Construct a frequency table.
 Each time interval should have its corresponding frequency
value.
3. Draw a histogram based on the frequency table.
 Mark the vertical bar o Y-axis from 0 to the highest frequency
value.
 Mark the horizontal bar o X-axis with the lower and upper
limits of the time intervals.
4. Interpret the histogram.
 Centering is that spot in the graph where most data points
cluster, as indicated by the tallest vertical bars.
 Variability, or spread is the distance between the point of
centering to the farthest class intervals on either side.
 If a histogram is symmetrically centered or bell-shaped, the
data points are said to be normally distributed
 A histogram result that leans toward one side is skewed.

Sample Histogram Showing the Number of Claims Compared to

Average Lengths of Stay in a Hypothetical Hospital
3. Radar Chart
 Spider Chart
 Spider Web Chart
 This is a graphical display of the differences between actual and ideal
performance.
 It is useful for defining performance and identifying relative strengths and
weaknesses of activities.
 How to do it:
1. Determine the area to study.
2. Assemble a team with members coming from different areas of the
organization to get varied perspectives and avoid blind spots.
3. Select and define rating dimensions.

4. Collect data on actual performance.

5. Rate all performance dimensions.
6. Draw the chart by tracing a large wheel with a spoke for each
category.
 Label each spoke properly.
 Plot the rating against ideal values.
7. Connect all the dots, the ratings, for each dimension and highlight as
needed.
8. Calculate a gap score for each dimension by subtracting the team
rating from the maximum rating.
9. Interpret and use the results.
Sample Radar Chart Showing the Performance Rating

of a Hypothetical Organization
Module
QUALITY IMPROVEMENT
4 ACTIVITIES
QUALITY CIRCLES AND QUALITY TEAMS
 History
 The Quality Circle, as conceived by Japanese quality expert Kaoru
Ishikawa, is a small group, with a maximum of ten members belonging to
the same work section. They meet voluntarily at least twice a month, and
elect a leader. Among their activities are identification of quality related

problems, understanding of their causes, formulation and

implementation of corrective actions. By promoting involvement of
workers in a particular section, quality circles enhance personnel self-
image and status. In the manufacturing industry‘s experience, QCs have
been highly useful in the elimination of low-incidence defects and making
processes error-proof.
 The United States tried to implement its own version of quality circle
activities—called the Zero Defect (ZD) movement- -in the 1960s. It was
adopted by the Pentagon for its contractors but the movement did not
catch on. Part of the problems with ZD, according to its critics, is the
focus on the output and not on the process that could produce the
desired output (Donabedian 2003, Juran 1992, Ishikawa 1985, Walton
1986).
 A quality circle (QC) is a group of 5 to 10 workers, the frontliners, from one
work area of the hospital who meet regularly to identify and solve problems in
their work area using their own resources.
 Doctors, nurses, other paramedical personnel and support staff can belong to
one quality circle.
 The quality circle approach to problem solving is data-based, participatory and
action-oriented. Problems are identified after systematically collecting
information from the work place.
 Quality circle members are directly involved in all steps of the problem-
identification and problem-solving processes.
 Solutions are feasible, practical, and doable within several months and may be
incorporated into hospital-wide routine or policy.
 A quality team, on the other hand, is a quality circle with a bigger scope in at
least two respects:
 ➠ it involves managers as well as front-liners
 ➠ it involves more than one area or process of work and often tackles
cross-functional issues.
 More efficient discharge of patients is best done by a quality team that includes
different members of the clinical team from the wards, accounting and billing
sections, dietary, rehabilitation and housekeeping departments.
 The first step in initiating a quality circle/quality team activity is the selection
of a person, a QC leader.
 Responsible for facilitating and promoting QC activities in the health care
facility.
 This person should have training on basic quality assurance, statistical
process control and other QC tools.
 QC leaders are supposed to recruit members into the quality circle.
 QC promotion consists of planning and implementing companywide education
programs, overseeing and coordinating activities of quality circles, facilitating
QC meetings and activities (especially when the circle is new), holding QC
conferences, establishing an award-giving system to top performing circles, and
ensuring a mechanism for the adoption of QC recommendations in company

policies.
 Quality circles and teams evaluate performance through self-evaluation and
management evaluation.
Evaluation Points for QC Members
Quality Circle /Quality Team Approach to Problem Solving

QUALITY IMPROVEMENT ACTIVITIES

Matrix of Quality Improvement Activities
1. Clinical Pathway Guidelines

 These are systematically developed statements which assist in formulating
practitioner and patient decisions about appropriate health care for specific
clinical circumstances (Institute of Medicine 1990).
 Properly-designed guidelines are based on scientific evidence and on
judgments and values obtained from consensus among care providers,
patients and other stakeholders.
 These guidelines aid decision-making regarding the aims, benefits, harms
and costs of management alternatives.
 Properly-used guidelines may be effective in reducing the rate of unjustified
or unwanted variations, and thus the extent of inappropriate care.
 Guidelines have been proven to improve both the processes and outcomes of
health care, increasing efficiency and educating patients and providers alike
through the use of guideline-derived measurement tools (for example, a
guideline-derived clinical pathway addressing a specific diagnosis).
 As guidelines are only as good as the current best practice available or as

good as the evidence on which they are based, methods used in searching,
appraising, and synthesizing the evidence should be explicit, unbiased,
reliable and well documented.
 This calls for a systematic and comprehensive review of the medical
literature for the best available and current evidence on a given topic.
 Formal methods of building consensus are then used to incorporate the
judgments and values of professionals and the preferences of patients.
 The resulting recommendations are therefore based on a transparent
process that can be replicated.
 Once the guidelines are constructed, external reviewers examine them for
validity, applicability and relevance.
 Independent reviewers conduct a reality check during dissemination and
implementation to evaluate the feasibility, acceptability and flexibility of the
guidelines. They also monitor the effectiveness of the dissemination and
implementation methods in encouraging compliance.


Flowchart for the Development, Dissemination and Implementation Phases

in the Creation of a Clinical Practice Guideline
2. Clinical Pathways
 This is an interdisciplinary plan of care that outlines the optimal sequencing

and timing of interventions and expected outcomes for patients with a
particular diagnosis, procedure or symptom.

 Clinical pathways are effective educational and communication tools that

benefit both patient and care provider.
 Routine use of clinical pathways is expected to result in more satisfied
patients because they will know what care to expect and what the goals of
treatment are.
 Pathways will also benefit health professionals by facilitating coordinated
care plans. This way, physicians can visualize current care, and anticipate
future care and outcomes.
 It should be possible to develop four to six pathways at the same time, and
have them ready for pilot testing within 3 or 4 months.
 Steps in Developing Clinical Pathways

1. A multidisciplinary pathway team is organized.

2. A disease, procedure or symptom is selected as pathway target.
3. Clinical practice guidelines that cover the disease are searched and
critically appraised.
4. The scientific literature is also searched for high-quality evidence on
the effectiveness of procedures.
 The search includes systematic reviews, meta-analyses and
technology assessments to supplement the information
obtained from clinical practice guidelines.
5. Sample pathways are reviewed.
 In the absence of high-quality studies, existing pathways may
be reviewed and appraised for validity and feasibility.
6. Evidence obtained from steps 3, 4 and 5 are used to determine the
choice, combination and order of tests and treatments in the
pathway.
7. Team members select which aspects of care are to be included in the
pathway.
8. Evidence-based tests and treatments are plugged into appropriate
places in the pathway.
 Interventions with strong supporting evidence are included in
the pathway; interventions with weak supporting evidence or
with strong non-supporting evidence are deleted.
9. Team members review the pathway to assess agreement with their
respective routine activities.
10. The pathway undergoes revision and modification until team
members agree on the best compromise between what is evidence-
based and what is feasible, given local resources.
 Other sources of information that may modify the pathway are
routine hospital data, hospital resources, professional
judgment, patient values and other professional standards of
care.
 Patient outcomes that directly result from following the
pathway are specified.
11. The pathway is reviewed and tested to determine its efficiency,
feasibility and consistency with legal and regulatory requirements.
12. The pathway is placed in the patient‘s medical record, the nursing
Kardex or in a separate folder.
13. A non-technical version may be shared with the patient.
 All caregivers review the pathway at the start of each shift and
throughout the patient‘s stay to evaluate patient‘s progress
toward the day‘s expected outcomes.
 All caregivers document that the planned care activities are
accomplished and that the expected outcomes are achieved.
The if-it-is-not-written-down-it-was-not-done- rule applies here.

14. Deviation or variance from the day‘s care or outcomes is also

documented.
15. The health care team develops an action plan to solve problems and
improve care.
16. The pathway may be reviewed for modification after 3 to 6 months of
use.
Clinical Pathway for Bronchial Asthma in Acute Exacerbation

De La Salle University Medical Center (Provider Version)



PhilHealth‟s Draft of Clinical Pathway for Outpatient Cataract Surgery
3. Medical Audits
 This is used to identify opportunities to improve procedures used in the
diagnosis, treatment and care of specific patients, and the associated use of
resources and resulting outcomes.
 Medical audits provide a comprehensive and step-by-step analysis of quality
of care.
 It can demonstrate variations in clinical practice and their possible causes.
Because it allows for investigation, demonstration and correction of clinical
error, it provides a way to manage the moral, legal and financial risks of
clinical errors.
 Steps in Implementing Medical Audits
1. Determine criteria for selecting the subjects for audit.
 Criteria may include high-risk, high-volume, or problem-prone
patients or clinicians who have a high proportion of these types
of patients.
 Examples of auditable cases are all deaths, patients who
extend their usual length of stay (based on their illness), all
nosocomial infections, all-readmissions, all patient falls, etc.
2. Screen subjects for audit by routinely applying the selection criteria
to all patients or clinicians.

3. Determine criteria for selecting the subjects for audit.

 Criteria may include high-risk, high-volume, or problem-prone
patients or clinicians who have a high proportion of these types
of patients.
 Examples of auditable cases are all deaths, patients who
extend their usual length of stay (based on their illness), all
nosocomial infections, all-readmissions, all patient falls, etc.
4. Screen subjects for audit by routinely applying the selection criteria
to all patients or clinicians.
5. Develop medical review criteria—statements used to assess specific
health care decisions, services and outcomes (U.S. Department of
Health and Human Services 1995)—for evaluating performance.
 Select a guideline or pathway that covers the disease or
condition being audited.
 Identify guideline recommendations and draft the medical
review criteria.
 Level of performance is evaluated by measuring the extent of
conformance to guidelines or pathways.
6. Identify standards—statements of minimum-maximum range of
acceptable results—against which to compare level of performance.
7. Determine what kinds of patient-specific data are to be collected and

how collection is to be done.
 Patient-specific data include the particular diagnostic and
treatment interventions and the resulting health outcomes.
 Data is collected from the review of medical charts either
retrospectively (after care has been given) or concurrently
(while care is still being given).

8. Identify clinicians and sites of care.

9. Define case sample and case sampling period.
 Identify data source.
 Write medical review criteria, specifying acceptable alternatives
and time window.
 Specify data items and data rules.
 Draft data collection forms and procedures.
 Devise analysis procedures.
 Pilot test and revise criteria, forms and procedures, if
necessary.
10. Assemble a peer review team.
11. Conduct review on each medical chart and determine performance
level for each review criterion.
12. Compare performance levels with quality standards and interpret the
results.
13. Report review findings.
 Report the entire review process.
 The main findings are structured around an analysis using the
six dimensions of quality.
 Recommendations include actions required to improve the
quality of care.
14. Act on review findings.
15. Conduct review again to re-evaluate performance.
 Analyze the effectiveness of the action recommended to
improve performance.
 Examine the relevance of the audit and the resulting
performance improvement program to other clinical
departments, facilities or clinical groupings.
 Four Kinds of Medical Audit
Types of Medical Audit
1. Nursing Audit
 This is a patient-focused audit process of nursing care as
defined according to the following dimensions (Miller and
Knapp 1979):
• ➠ application and execution of physician‘s legal orders
• ➠ observation of symptoms and reactions

• ➠ supervision of the patient
• ➠ supervision of other members of the clinical team
other than physicians
• ➠ reporting and recording of facts, including evaluation
results
• ➠ application and execution of nursing procedures and
techniques
• ➠ promotion of physical and emotional health by
direction and teaching
2. Clinical Audit
 This is a patient-focused audit process involving doctors,
nurses and other clinicians who comprise the clinical care
team.
3. Risk Management
 This is a process for identifying risks-- which may have moral,
financial or legal consequences—and which adversely affect the
quality of care and the safety of patients, staff and visitors.
 Risk management evaluates those risks and takes positive
action to eliminate or reduce them (Miles and Lugon 1996).
 Risk management involves the development and
implementation of strategies to prevent patient injury,
minimize financial loss and preserve agency asset.
 It focuses on liability control and includes risk identification,
analysis, treatment, evaluation and follow-up (Stull and
Pinkerton, 1988).

4. Peer Review
 Evaluation or review of a health professional‘s clinical
management by one‘s equals according to some explicit or
implicit criteria thought to represent desirable practice is called
peer review (Kelada 1996).
 The practice of peer review reflects the variety of clinical and
non-clinical staff members who use it as a tool for quality
improvement.
 Typically, three or more clinicians (e.g., doctors, nurses and
allied health professionals) agree to meet regularly to discuss
recent events and outcomes (individual or collective) of patients
under their group‘s care.

 Peer review meetings may be prompted by the identification of

medical cases that satisfy a set of screening criteria.
 These criteria are indicators of possible adverse patient events
during hospitalization. If an adverse event is noted in the
medical records, events that are regarded as serious breaches
in the standard of a care or could reasonably be regarded as
preventable, are forwarded to the appropriate peer group.
 The group then deliberates on whether or not a standard of
care has been achieved or if the adverse event could be
regarded as reasonably preventable.
 Actions to prevent a recurrence are then proposed.
 A peer review report is generated and forwarded to an
appropriate authority within the organization for collating over
time.
 This authority then acts upon the recommendations that
require system-wide involvement, follow-up of unresolved
issues and oversight.
 Confidentiality is strictly upheld and no patient or clinician is
identified in any part of the report.

Flowchart of Peer Review Processes
4. Utilization Review
 This assesses the appropriateness and efficiency of the use of resources.
 It focuses on the cost-effectiveness of interventions used; identifies providers
who need to attain a more efficient resource use; improves overall quality of
care through cost-efficient use of resources; and explicitly shows the
necessary trade-offs between health care outcomes and its costs.
 Utilization review of cases may be done:
1. Retrospectively – cases are accumulated over time before they are
screened and audited for appropriateness and efficiency of care.
2. Concurrently – cases are accumulated over time while ongoing
screening and audit are performed.
3. Audit of pathways and guideline use – quality of care is audited
against practice standards defined by pathways and guidelines.
 Criteria used for reviewing cases may be:
1. Implicit – A clinician reviewer applies his/her own judgment to
quality and/or appropriateness of the care provided. Validity depends
entirely on knowledge, skills and judgment of the reviewer.
2. Explicit and independent of diagnosis – This is a level-of care audit.
Using criteria that reflect severity of illness and intensity of service
needed, medical charts are screened to determine if each hospital
admission was justified. These criteria define levels of medical and
nursing services and nondisease specific patient conditions that

require continuing acute hospital inpatient stay. Cases identified by

the screening criteria are then reviewed in detail by clinicians.
3. Explicit and specific to diagnosis – This is a diagnostic criteria
audit. Clinical practice guidelines that are specific to patient types
and diseases are developed. Review criteria are then derived from the
guidelines and are used to evaluate the appropriateness of care for
each individual patient.
4. Length of stay (LOS) profiles – Region-, hospital- or department-
specific average LOS are calculated and used as a standard against
which average LOS of different regions, hospitals or departments are
compared. Outliers (i.e., those with average LOS that fall beyond two
standard deviations from the mean) are identified for detailed review
of appropriateness and efficiency of care.
5. Complaints Analysis
 While a complaint is defined as any expression of dissatisfaction bya
customer, complaints data are considered welcome opportunities to learn
from dissatisfied patients, and identify areas for improvement.
Matrix of Aspects Useful for Complaints Analysis
 An effective complaint handling process results in the identification of key

areas for improvement by:
 Addressing varying patterns of practice;
 Highlighting deficiencies in protocols, guidelines and procedure;
 Highlighting areas requiring further training and development;
 Providing critical clinical information to concerned individuals and
units;
 Providing an objective mechanism for monitoring clinical outcomes as
an alternative to reliance on peer review and self-regulation; and

Providing the opportunity for complainants to achieve satisfaction by:

• ➠ Demonstrating commitment to providing quality service;
• ➠ Recognizing and acknowledging the consumer‘s right to
complain;
• ➠ Restoring trust and support for the service provider;
• ➠ Legitimizing the value of consumer input into quality
improvement; and
• ➠ Improving communication in patient care.
 Handling Complaints and Conducting Complaints Analysis
 Often, the service or clinician subject of a complaint may disagree with
the complainant about the circumstance that led to the complaint, or
may not feel that the complaint is justified. This is only secondarily
significant.
 What is principally important is that there is a perception of problematic
or substandard quality of care or service.
 The incident should be investigated and considered for its value in
improving the quality of the care or service provided.
 Due process must be observed and the following principles taken into
account:
• Both the complainant and the person against whom the complaint is
lodged must be allowed to freely and openly express their versions of
the event which is the subject of the complaint.
• Assignment of blame to either party should be avoided except in very
serious complaints.
• Mediation should be done between the parties in conflict.
• Actions should focus on implementing corrective measures in the
system to avoid the recurrence of the adverse event.
6. Expanded Incident Monitoring
 An incident monitoring system is used to routinely identify, process, analyze
and report incidents to prevent their recurrence.
 An incident is an event that occurs in connection with patient care that
merits reporting, or is reported because of a deviation from expected or
standard practice.
 This deviation could have or actually have adversely affected a patient‘s
health status.
 Expanded incident monitoring follows conventional incident reporting
mechanisms, but it is enhanced by greater opportunity to identify a bigger
range of incidents than can be expected from current voluntary reporting
methodology.
 It is limited only by the staff‘s capacity to conduct routine monitoring. It may
uncover deeper and more systemic problems with the use of problem-solving
tools. Incidents covered include clinical and non-clinical events.

 It facilitates performance improvement by providing information derived

from reports.
 It clearly delineates events as starting points for quality improvement.
 It enables a team-based, multidisciplinary approach that involves both
senior and junior staff in detecting and preventing incidents.
 Effective incident monitoring is dependent on a commitment to act upon
information that arises from improvement activities.
 This also involves the reporting of incidents or processes that require action
at the facility level.
 Steps in Implementing Expanded Incident Monitoring
1. A clinical team or ward-based unit identifies an appropriate time to
discuss incidents that have occurred in the clinical area for a specific
time period.
2. Voluntarily-reported incidents are basic topics for discussion.
 Other incidents identified based on replies to screening
questions are also included.
3. The set of questions are based on a knowledge of those incidents
which could occur in that clinical setting, and which reflect on the six
dimensions of quality —safety, effectiveness, appropriateness,
consumer participation, access and efficiency.
 The questions and incidents under study may vary for each
clinical team.
 Such incidents should be identified and an appropriate person
nominated to follow up on relevant details of the incident prior
to discussion at the ward/team meeting.

4. A team member should present and discuss the facts about the
incident:
 Patient and provider information should, when possible, be de-
identified;
 Discussion should be robust, but the approach should always
be educational rather than fault-finding;
 Discussion should be focused around identifying the system
issues of the care delivered.
5. If there is no sufficient information available regarding an incident, a

person should be assigned to conduct a follow-up and re-present the
issue in the following meeting.
7. Morbidity and Mortality Meetings (M&Ms)

 Morbidity and mortality meetings review deaths and adverse outcomes
among patients of a specified clinical group or specialty.
 Recommended as a ―core‖ activity for all clinicians, M&Ms provide a venue
to critically analyze the circumstances surrounding the outcomes of care
provided by an individual or a multidisciplinary group of clinicians.
 These outcomes include deaths, adverse outcomes and significant deviations
from regular clinical practice.
 M&Ms should not be used only to review the ―exotic‖ cases that may be of
greater interest to clinicians.
 M&Ms also provide an ideal forum for the regular review of the clinical
indicators relevant to a given specialty or field of practice.
 Recommendations for improving the processes of care given to a particular
group of patients are made following M&Ms.
 Steps in Conducting M&Ms

1. All meetings should be multidisciplinary and should include all

clinicians, technicians, and managers involved in the care of the
concerned group of patients.
 All levels of staff involved in the care of these patients – both
junior or senior should be involved.
2. Meetings should be held on a regular basis, and at least once a
month.
3. All deaths should be identified and if appropriate (e.g. among renal
patients) should include deaths that occurred outside of the acute
care setting.
 Focus should be placed on identifying the issues related to the
processes or system of care that led to the death or incident,
and not on the individuals who provided the care.
4. Discussion should be used for instructional purposes, and not for
putting blame to individuals.
 Discussions should focus on measures that can be
recommended or implemented to prevent a similar incident or
adverse outcome.
5. A brief report should be compiled after each meeting, which identifies
the actions that must be taken following the discussions and review.
 If there are no recommendations for action, that should be so
recorded.
 If action cannot be taken at the clinical level, a report should
be sent to the senior managers of the organization identifying
the issues that should be addressed at that level.
6. All action items should be placed on the agenda for the next meeting.
7. Feedback must always be present.
8. Everyone who is associated with the care being reviewed should have
the opportunity to report.
9. Case reviews should be conducted in a timely manner, within recent
memory of the people involved in the case.
8. Sentinel Event Monitoring

 Sentinel event monitoring identifies potentially serious breaches in practice
standards.
 These breaches are unexpected variations which may have resulted in either
death or serious physical or psychological injury.
 Serious injury, specifically loss of limb or function, represents a significant
adverse event that warrants immediate investigation.
 Sentinel events also include any process variation for which recurrence
would carry a significant chance of a serious adverse outcome (JCAHO
1998).

 But sentinel events are not always adverse events. Unexpected successful
outcomes in health care, which are also considered variations in a process,
are also considered sentinel events.
 Renewed interest on preventable adverse events has come with the attention
on ―errors.‖ However, this may be misleading as it suggests the fault of
individual health care practitioners, when a problem area in the system of
care may be the main culprit (Donabedian 2003).
 The first sentinel event was identified in 1995 – involving the death of a
woman from an overdose of chemotherapy in a famous hospital in Boston
(JCAHO 1998). The health care industry has since institutionalized sentinel
event reporting throughout the United States in order to detect and reduce
serious errors.
 Implementing Sentinel Events Monitoring
1. In monitoring sentinel events, initial strategies should already be in
place for quick response in the event of an occurrence.
 Appropriate personnel should be available to stabilize the
patient, perform necessary surgery or tests, administer
medications, and take actions to prevent further harm.
 The organization should be ready to contain the risk of an
immediate recurrence of the adverse event.
 Evidence of the events that led to the adverse outcome should
be preserved for critical assessment of what happened.
 Appropriate parties should be notified.
 Patients and their families should be notified and told about
the adverse event.
2. Reporting of sentinel events and their investigation should be a
routine organization-wide activity involving clinical and non-clinical
staff.
3. Swift investigation of the event and corrective action should be done.
4. Management should recognize that it is ultimately responsible for a
system that allows such sentinel events to occur.
 Avoid knee-jerk reactions such as witch hunting and finger
pointing.
5. Focus should be on identifying root causes and developing real
solutions that improve the system.

Flowchart of Activities in Case of a Sentinel Event
9. Credentialing and Clinical Privileging

 Credentialing and clinical privileging match the work that practitioners wish
to perform in a hospital with their demonstrated competence and
professional skill.
 These two processes specify the conditions individual practitioners should
meet before being granted clinical privileges.
 They also define the processes for the review, modification and revocation of
clinical privileges.
 The granting of privileges takes into consideration the hospital‘s delineated
role within the community, its designated service, and its support
capabilities.
 Credentialing and clinical privileging facilitate effective risk management for
medico-legal purposes and ensure maintenance of appropriate high-quality
services to guarantee patient safety.
 Implementing Credentialing and Clinical Privileging
1. Assemble a multidisciplinary committee for credentialing and clinical
privileging.
2. Ensure that the credentialing process clearly delineates the range of
clinical privileges granted to each individual.
3. Establish a mechanism for individualized and supervised continuing
education.
4. In formulating advice and recommendations, the following should be
considered:
• ➠ Irregularly undertaken procedures/treatments, even if these
treatments are generally performed by the clinical group to
which the practitioner belongs;
• ➠ New technology;
• ➠ Small departments or services;
• ➠ Maintenance of skills, sufficient caseload and continuing
medical education;
• ➠ Assessment of the infrastructure supporting the privileges to
be delineated e.g. availability of nursing staff for certain
specialized procedures, or of equipment for specific pathology
service; and
• ➠ Practice outside of the normal privileges for a particular
discipline.
10. Variance Reporting and Analysis

 A variance is a deviation from what has been specified in the clinical
pathway.
 Variance reporting and analysis is used to routinely document and identify
the most common causes of deviation from routine care for prioritized
problem-solving.
 This activity is important because it provides a basis for analysis and
consequent adjustments.
 Analysis might lead to revision of the clinical pathway.
 It might also lead to attempts to revise clinician behavior or to resolve
system weaknesses.
 Many quality of care problems are identified by analysis of variance reports.
 For example, if there was a missed or delayed diagnostic test, there should
be a record of this variance and its causes.
 Implementing Variance Reporting and Analysis
1. 1. Record the reason for variance, according to a standard
classification.
 This will facilitate the periodic evaluation process, and
comparison of results with those from other provider
organizations.
 Both positive (deviation produced positive results) and negative
(deviation was detrimental in some way) variances should be
recorded.
2. Tabulate the results according to elements of care and cause or
tabulate variances against outcome data.

Sample Output of Variance Analysis

BIBLIOGRAPHY & REFERENCES
Philippine Health Insurance Corporation. (2004). Benchbook on Performance
Improvement of Health Services.
Agency for Healthcare Research and Quality. 2008. Patient Safety and Quality: An
Evidence-Based Handbook for Nurses.
Professional Regulatory Board of Nursing. (2012). 2012 National Nursing Core
Competency Standards.
World Health Organization. (2006). Quality of Care: A Process for Making Strategic
Choices in Health Systems.
World Health Organization. (2011). Patient Safety Curriculum Guide: Multi-professional
Edition.
Joint Commission International. (2014). Hospital National Patient Safety Goals.
Online Resources :
Agency for Healthcare Research and Quality.
http://www.qualityindicators.ahrq.gov/Default.aspx
Joint Commission International: http://www.jointcommissioninternational.org/
Institute for Healthcare Improvement: http://www.ihi.org/Pages/default.aspx
American Nurses Association: http://www.nursingworld.org/
National Quality Center: http://nationalqualitycenter.org/
National Patient Safety Foundation: http://www.npsf.org/


Quality Health Care and Nursing PDF

Uploaded by

Copyright:

Quality Health Care and Nursing PDF

Uploaded by

Document Information

Original Title

Copyright

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Quality Health Care and Nursing PDF

Uploaded by

Copyright:

What are the main topics covered in the document?

What are the main topics covered in the document?

What are some quality improvement tools discussed?

What are some quality improvement tools discussed?

West Visayas State University

RYAN MICHAEL F. ODUCADO, MAN, MAEd, RN, RM

This material is open access. Reproduction, distribution, republication, and/or re-transmission

For any copyright infringement, do not hesitate to contact the author at

Powerpoint presentation of materials can be accessed at:

West Visayas Sate Univeristy

Module 2 : Patient Safety

Module 3 : Quality Improvement Tools

Module 4 : Quality Improvement Activities

Appendices : 2012 National Nursing Core Competency Standards

West Visayas Sate Univeristy

What is QUALITY CARE?

West Visayas Sate Univeristy

Quality of Care Dynamics: Dimensions and Cross-Dimensional Issues

 High-quality health care is safe, effective, efficient, appropriate, accessible and

19TH CENTURY QUALITY OF HEALTH CARE THINKING

West Visayas Sate Univeristy

Why is QUALITY OF CARE important?

 Since then, different organizations led by the health departments of the

iatrogenic complications in the United States could have

West Visayas Sate Univeristy

WHERE QUALITY OF HEALTH CARE STARTS

INTERNAL AND EXTERNAL CUSTOMERS

 Partnering with local government officials and the local health

DIMENSIONS OF QUALITY HEALTH CARE

West Visayas Sate Univeristy

IOM‟s Six Aims for Improving Health Care Quality

West Visayas Sate Univeristy

Develop mechanisms for gathering member‘s input and assessing their

Assessment focus points of PhilHealth‟s new Quality Assurance framework

b) Multidisciplinary Care Team Competence

What is PATIENT SAFETY?

Patient Safety Practices

West Visayas Sate Univeristy

Patient self-management for warfarin (Coumadin®) to achieve

Nurses at the “Sharp End” of Patient Care

Near Misses, or “Good Catches,‖

West Visayas Sate Univeristy

Reason, (1990) described errors as the product of either;

West Visayas Sate Univeristy

Human Performance and Problem-Solving abilities are categorized as:

West Visayas Sate Univeristy

Human Factors Theory

West Visayas Sate Univeristy

Health Care Error

West Visayas Sate Univeristy

 It is a preventable adverse effect of care, whether or not it is evident or harmful

Common Misconceptions About Adverse Events Are:

West Visayas Sate Univeristy

 "'Bad apples' or incompetent health care providers are a common cause."

West Visayas Sate Univeristy

An Overview of TO ERR IS HUMAN: Re-emphasizing the Message of Patient

Basic Concepts in Patient Safety

West Visayas Sate Univeristy

West Visayas Sate Univeristy

West Visayas Sate Univeristy

to adverse events. Another strategy is to use simulation training, where

Principles for the Design of Safe Systems

Ross Hilliard, MD,