The fifth stage of nursing process: nEvaluation. Documentation
EVALUATION
Evaluation is the fifth step in the nursing process and involves determining nwhether the client goals have been met, have been partially met, or have not nbeen met. Even though it is the final phase of the nursing process, evaluatiois an ongoing part of daily nursing activities that determines the neffectiveness of those activities in helping clients achieve expected outcomes. n
Evaluatiois not only a part of the nursing process, but it is also an integral process nin determining the quality of health care delivered. In addition to discussing nevaluation as part of the nursing process, this chapter also describes the role nof evaluation in delivering quality care.
This nchapter discusses the purposes, components, and methods of evaluation. The nrelationship between evaluation and quality of care is described.
EVALUATION nOF CLIENT CARE
Evaluatiois the measurement of the degree to which objectives are achieved. Therefore, nevaluating the care provided to clients is an essential part of professional nnursing. “Evaluation is a planned, systematic process . . . n[that] compares the client’s health status with the desired expected outcomes” n(Kenney, 1995, p. 195).
The nAmerican Nurses Association (1998), in its Standards of Clinical Nursing nPractice, designates evaluation as a fundamental component of the nursing nprocess (see the accompanying display).
The npurposes of evaluation include:
• nTo determine the client’s progress or lack nof progress toward achievement of expected outcomes
• nTo determine the effectiveness of nursing ncare in helping clients achieve the expected outcomes
• nTo determine the overall quality of care nprovided
• nTo promote nursing accountability n(discussed later in this chapter)
Evaluatiois done primarily to determine whether a client is progressing—that is, nexperiencing an improvement in health status. Evaluation is not an end to the nnursing process, but rather an ongoing mechanism that assures quality ninterventions. Effective evaluation is done periodically, not just prior to ntermination of care. Evaluation is closely related to each of the other stages nof the nursing process. The plan of care may be modified during any phase of nthe nursing process when the need to do so is determined through evaluation. nClient goals and expected outcomes provide the criteria for evaluation of care.
COMPONENTS nOF EVALUATION
Evaluatiois a fluid process that is dependent on all the other components of the nursing nprocess. As shown in Figure 10-1, evaluation affects, and is affected by, nassessment, diagnosis, outcome identification and nplanning, and implementation of nursing care. Table 10-1 shows how evaluatiois woven into every phase of the nursing process.
Ongoing nevaluation is essential if the nursing process is to be implemented nappropriately. As Alfaro-LeFevre (1998) states: Whewe evaluate early, checking whether our information is accurate, complete, and nup-to-date, we’re able to make corrections early. We avoid making decisions nbased on outdated, inaccurate, or incomplete information. Early evaluatioenhances our ability to act safely and effectively. It improves our efficiency nby helping us stay focused on priorities and avoid wasting time continuing nuseless actions. (p. 22)
There are nspecific criteria to be used in the process of evaluation. The evaluatiocriteria must be planned, goal-directed, objective, verifiable, and specific n(that is, strengths, weaknesses, achievements, and deficits must be nconsidered).
Techniques
Effective nevaluation results primarily from the nurse’s accurate use of communication and nobservation skills.
Both nverbal and nonverbal communication between the nurse and the client can yield important ninformation about the accuracy of the goals and expected planned outcomes and nthe nursing interventions that have been executed for resolution of the nclient’s problems. The nurse needs to be sensitive to clients’ willingness or nhesitation to discuss their responses to nursing actions and must use the ntechniques of therapeutic communication to collect all necessary data.
The nnurse must be sensitive to changes in the client’s physiological condition, nemotional status, and behavior.
Because nthese changes are often subtle, they require astute observational skills on the npart of the nurse.
Observatiooccurs through use of the senses. In other words, what the nurse sees, hears, nsmells, and feels when touching the client all provide clues to the client’s ncurrent health status.
Sources of nData
Evaluatiois a mutual process occurring among the nurse, client, family, and other health ncare providers.
Both nsubjective and objective data are used in evaluating the client’s status. Asking clients to describe how they feel results in subjective ndata. Objective data consist of observable facts, such as laboratory nvalues and the client’s behavior. When a nurse communicates an assessment of a nclient’s response to an actual or potential health problem, clients and families nare empowered to discuss their concerns and questions. When feedback is given, nthe nurse must avoid being defensive, because that attitude may cause clients nor families to avoid being open and honest. As a result, they may only say what nthey think the nurse wants to hear or they may completely refuse to participate nin the evaluation process.
The nnurse’s verbal and nonverbal communication establishes the atmosphere in which nclients and families freely share their comments, both positive and negative.
Goals and nExpected Outcomes
The neffectiveness of nursing interventions is evaluated by examination of goals and nexpected outcomes. Goals provide direction for the plan of care and serve as nmeasurements for the client’s progress or lack of progress toward resolution of na problem.
Realistic ngoals are necessary for effective evaluation. These goals must take into nconsideration the client’s strengths, limitations, resources, and the time nframe for achievement of the objectives. Examples of client strengths are neducational background, family support, and financial resources (for instance, nmoney to purchase medications and foods that support the prescribed ninterventions). Examples of client limitations are delayed developmental level, npoverty, and unwillingness to change (lack of motivation).
METHODS nOF EVALUATION
The nnurse who successfully evaluates nursing care uses a systematic approach that nensures thorough, comprehensive collection of data. Evaluation is an orderly nprocess consisting of seven steps, which are explained here.
Establishing nStandards
Specific ncriteria are used to determine whether the demonstrated behavior indicates goal nachievement.
Standards nare established before nursing action is implemented. Evaluation of criteria nexamines the presence of any changes, direction of change (positive or nnegative), and whether the changes were expected or unexpected.
Collecting nData
Assessment nskills are used to gather data pertinent to goals and expected outcomes. The nnurse must be proficient in assessment skills for effective, comprehensive nevaluation to occur. Evaluation data are collected to answer the following nquestion: Were the treatment goals and expected outcomes achieved?
Determining nGoal Achievement
Data nare analyzed to determine whether client behaviors indicate goal achievement. nThis process is validated through analysis of the client’s response to the nspecific nursing interventions that are developed in the plan of care. For nexample, these data can take the form of either physiological responses (such nas the client’s being able to cough productively in order to promote effective nbreathing patterns) or psychosocial responses (such as the client’s being able nto verbalize concerns about an impending surgical procedure in order to nalleviate anxiety).
Relating nNursing Actions to Client Status
Nursing ninterventions are examined to determine their relevance to the client’s needs nand nursing diagnoses. Efficient nursing actions are those that address npertinent client needs and are proven to be primary factors in helping clients nappropriately resolve actual or potential problems.
Judging the nValue of Nursing Interventions
Critical-thinking nskills are employed to determine the degree to which nursing actions have contributed nto the client’s improved status. These skills enable the nurse to apply aanalytical focus to the client’s responses to the nursing interventions and nthus to evaluate the benefits of those actions and identify additional nopportunities for change.
Reassessing nthe Client’s Status
The nclient’s health status is reevaluated through use of assessment and observation skills. nEvaluation focuses on the client’s health status and compares it with baseline ndata collected during the initial assessment. Omissions or incomplete data nwithin the database are identified so that an accurate picture of the client’s nhealth status is obtained.
Modifying the nPlan of Care
If nthe evaluation data indicate a lack of progress toward goal achievement, the nplan of care is modified. These revisions are developed through the following nprocess: reassessment of the client; formulation of more appropriate nursing ndiagnoses; development of new or revised goals and expected outcomes; and nimplementation of different nursing actions or repetition of specific actions nto maximize their effectiveness (for instance, client teaching). See the nNursing Checklist for guidelines for evaluating effective application of the nnursing process to client care.
Evaluatiois performed by every nurse, regardless of the practice setting. For example, nthe home health nurse evaluates the care provided regularly throughout the nclient’s relationship with the agency. Evaluation of the home care client is ncarried out in order to determine whether the care was delivered in aeffective and efficient manner, to modify the plan of care as needed, and to ndecide when the client is ready for discontinuation of home care services. The naccompanying display provides an example of evaluation performed by the home health ncare nurse.
Critical nThinking and Evaluation
Evaluatiois a critical thinking activity. It is a deliberate mechanism used to analyze nand make judgments.
Nurses nneed to remain objective when evaluating client care in order to modify care nbased on reason rather than emotion. One critical thinking strategy, njuxtaposing, is described as “putting the present state conditioext to the noutcome state in a side-by-side contrast” (Pesut n& Herman, 1999, p. 93). Nurses use juxtaposing throughout evaluative activities nby comparing client responses to expected behaviors. They make conclusions nabout whether expected outcomes have been met.
Iorder to make such conclusions, assessment data is needed to determine client nprogress toward achievement of objectives. Evaluation involves analysis and is nmuch more complex than merely answering questions.
EVALUATION nAND QUALITY OF CARE
Evaluatiois performed at the individual and institutional levels. For example, individual nevaluation focuses on the client’s achievement of goals and also on the nindividual nurse’s delivery of care. Quality and evaluation are closely nrelated. This section examines the role of evaluation in assuring the delivery nof quality health care. Because it is the mechanism used by nurses idetermining the need for improvement, evaluation assists in the provision of nquality care. The aspects that need to be evaluated to determine the quality of nhealth care are:
• nAppropriateness (the care provided adhered nto standards and resulted in achievement of goals)
• nClinical outcomes
• nClient satisfaction
• nCost-effectiveness
• nAccess to care
• nAvailability of resources
Quality nmanagement involves constant, ongoing evaluation (monitoring of activities).
Elements iEvaluating the Quality of Care
Organizational nevaluation examines the agency’s overall ability to deliver quality care. nEvaluation can be classified according to what is being evaluated: the nstructure, the process, or the outcome. Table 10-2 provides an overview of the ntypes of evaluation. Figure 10-2 illustrates the variables to be assessed ieach type of evaluation.
Structure nEvaluation
Structure nevaluation is a determination of the health care nagency’s ability to provide the services offered to its client population. This ntype of evaluation focuses on assessing the systems by which nursing care is ndelivered (Barnum & Kerfoot, 1995). Structure nevaluation examines the physical facilities, resources, equipment, staffing npatterns, organizational patterns, and the agency’s qualifications for staff. nThe majority of problems with providing effective health care stems from nproblems in the structural area. The purpose of structure evaluation is to nidentify any system errors, which can then be corrected.
Structure nevaluation involves determining whether client care meets legal and nprofessional standards. A frequently used method to evaluate whether the agency nprovides care within legal parameters is a review of policy and procedure nmanuals to check for compliance with regulations.
Process nEvaluation
Process nevaluation is the measurement of nursing actions nby examination of each phase of the nursing process. This type of evaluation is ndone to determine whether nursing care was adequate, appropriate, effective, nand efficient. Nursing interventions are judged to be effective when use of the naction results in the desired outcome. A nursing intervention is determined to nbe efficient through analysis of the intervention’s cost–benefit ratio (Gillies, 1994). Process evaluation determines the nurse’s nability to establish an environment that promotes the client’s health. See nTable 10-2 for sample questions used during process evaluation.
Outcome nEvaluation
Outcome nevaluation is the process of comparing the nclient’s current status with the expected outcomes. This type of evaluatioexamines all direct care activities that affect the client’s health status. nAccording to Kenney (1995), “Outcome evaluation, though difficult, is the most nmeaningful way to judge the effectiveness of nursing interventions” (p. 200).
Outcome nevaluation focuses on changes in the client’s health status. A basic questioto ask when evaluating the outcome is: Has the expected change occurred? Such nchanges may include “modifications of symptoms; signs; knowledge; attitudes; nsatisfaction; skill; and compliance with treatment regimen” (Gillies, 1994, p. 517). Another variable assessed during noutcome evaluation is the client’s self-care ability. Has the client ndemonstrated an improved ability to care for self? Does the client verbalize nknowledge related to self-care needs? See Table 10-2 for suggested approaches nto performing outcome evaluation.
Nursing Audit
A nnursing audit is the process of collecting and analyzing data to nevaluate the effectiveness of nursing interventions.
A nnursing audit can focus on implementation of the nursing process, client noutcomes, or both in order to evaluate the quality of care provided. Nursing naudits examine data related to:
• nSafety measures
• nTreatment interventions and client nresponses to the interventions
• nPreestablished outcomes used as basis for interventions
• nDischarge planning
• nClient teaching
• nAdequacy of staffing patterns
Audits nare based on components such as institutional policies; federal, state, and nlocal regulations; accreditation standards; and professional standards (see nFigure 10-3). Audits assist in identifying strengths and weaknesses that, iturn, provide direction for areas needing revision. Corrective action plans are ndeveloped in accordance with the audit results.
Peer nEvaluation
Another nmethod of evaluating quality of care is peer evaluation (also referred nto as peer review), the process by which professionals provide to their npeers critical performance appraisal and feedback that are geared toward ncorrective action. According to the ANA (1988): Peer review iursing is the nprocess by which practicing Registered Nurses systematically assess, monitor, nand make judgments about the quality of nursing care provided by peers, as nmeasured against professional standards of practice. (p. 3)
I1984, Lucille Joel postulated that peer review is the basis of nursing’s autonomy and self-governance (Joel, 1984). This nperspective is still very relevant in today’s health care climate. By nevaluating itself, nursing is demonstrating an essential criterion by which nprofessions are recognized. Peer evaluation promotes both professional and individual naccountability.
The nquality of nursing care is strongly evident to coworkers and nurses who are nexpected to assess the work of their peers. “Peer review is nan essential mechanism for evaluating the judgment and performance of clinical nproviders” (Wakefield, Helms, & Helms, 1995, p. 11).
Such njudgment may result in one of the following outcomes:
• nDestructive: Complaints and attacks that nundermine morale and cohesiveness
• nConstructive: Positive feedback that nimproves the quality of care
Peer nevaluation can be destructive if the parties involved begin to personalize the nprocess, misunderstand the purpose, or deliver feedback in an unfeeling and nnonobjective manner. Peer evaluation can be threatening when guidelines have nnot been established for the process and when the assessment focuses oemotions and personalities instead of on behaviors. Conversely, peer evaluatiois constructive when the focus remains on quality improvement and encourages nthe continued growth and learning of all the parties involved. The accompanying ndisplay provides principles that promote the use of objective, nonbiased peer nevaluation.
n
EVALUATION nAND ACCOUNTABILITY
Accountability nmeans assuming responsibility for one’s actions. Evaluation enhances nursing naccountability by providing a mechanism for assisting the nurse to define, nexplain, and measure the results of nursing actions.
Accountability nis increased by ongoing evaluation; nurses are continually checking their owprogress against predetermined standards.
Accountability nis an integral part of professional nursing practice and is an important method nthrough which commitment to quality client care can be demonstrated.
“Nurses are accountable for designing effective care plans, implementing nappropriate nursing actions, and judging the effectiveness of their nursing ninterventions” (Kenney, 1995, p. 195). nIn other words, nurses are accountable, for their judgments, decisions, and nactions, to:
• nClients, families, and significant others
• nColleagues
• nEmployers
• nThe general public (society)
• nThe nursing profession
• nThemselves
Nurses ndemonstrate their commitment in a variety of ways, including:
• nMaintaining expertise in skills
• nParticipating in continuing educatioprograms
• nAchieving and maintaining certification
• nParticipating in peer evaluation
MULTIDISCIPLINARY nCOLLABORATION IN EVALUATION
Evaluating nthe quality of care provided is a responsibility shared among members of the nhealth care team. In addition to those directly involved (the health care nproviders, clients, and families), others interested in the outcomes of nevaluation include the community and third-party payers (both public and nprivate reimbursement organizations).
Aongoing monitoring process is implemented to evaluate quality of care. Ideally, nevery discipline monitors its own quality efforts. No single discipline is nresponsible for all-inclusive evaluation of client care. However, in most nhealth care agencies, nurses are actively involved in monitoring evaluatioactivities. Many agencies have nurses on staff who nfunction either as quality management coordinators, utilization review nevaluators, or both.
Whehealth care providers from all the relevant disciplines are involved ievaluation, the result is decreased fragmentation of care. The team approach nmandates active involvement of all care providers in the evaluation of quality ncare. Multidisciplinary evaluation helps promote a continuum of care for the nclient, from the preadmission phase to discharge planning and follow-up care.
KEY CONCEPTS
• nEvaluation, the fifth step in the nursing nprocess, involves determining whether the client goals have been met, have beepartially met, or have not been met.
• nThe purposes of evaluation are to determine nthe client’s progress or lack of progress toward achievement of client nobjectives, to judge the value of nursing actions in helping clients to achieve nobjectives, to determine the health care agency’s overall ability to deliver ncare in an effective and efficient manner, and to promote nursing naccountability.
• nEvaluation is based primarily on the nskills of communication and observation.
• nEvaluation is a mutual, ongoing process noccurring among the nurse, client, family, and other health care providers.
• nThe effectiveness of nursing interventions nis evaluated by examination of goals and expected outcomes that provide ndirection for the plan of care and serve as standards by which the client’s nprogress is measured.
• nEvaluation is an orderly process consisting nof seven steps: establishing standards; collecting data related to the goals nand expected outcomes; determining goal achievement; relating nursing actions nto client status; judging the value of nursing interventions in assisting nclients to achieve goals and objectives; reassessing the client’s status; and nmodifying the plan of care if necessary.
• nThere is a relationship between quality nmanagement and evaluation. Evaluation is necessary in the provision of quality ncare because it is the mechanism used by nurses in determining how to improve ncare.
• nStructure evaluation judges a health care nagency’s ability to provide the services offered to its client population.
• nProcess evaluation measures nursing nactions by examining each phase of the nursing process to determine the neffectiveness of the actions in helping clients meet expected outcomes and goals.
• nOutcome evaluation compares the client’s ncurrent status with the expected outcomes and examines all direct care nactivities that affect the client’s status.
• nA nursing audit can focus oimplementation of the nursing process, client outcomes, or both in order to nevaluate the quality of care provided.
• nPeer evaluation (peer review) is the nprocess by which professionals provide to their peers performance appraisal nfeedback geared toward corrective action.
• nEvaluation enhances professional nursing naccountability by providing a mechanism for assisting the nurse to define, nexplain, and measure the results of nursing actions.
• nEvaluating the quality of care is a shared nresponsibility among members of the health care team.
MANAGING NURSING CARE
As a result of a global economy, increased competition, and nspiraling health care costs, health care organizations must work to continually nimprove and strive for higher performance. For health care organizations to noperate successfully and instill the drive for excellence in each employee, nstructures must be in place to empower employees to take ownership in their nwork. A new style of leadership that can facilitate teamwork and process nimprovement must prevail.
Quality nof care, cost, and access are dominant themes in health care delivery. Health ncare services must be delivered in a manner that increases the likelihood of ndesired health outcomes and they must be consistent with current knowledge n(Joint Commission on Accreditation of Healthcare Organizations [JCAHO], 1999). nNurses, as well as all other health care providers, are accountable for quality ncare. The challenge for nursing has never been greater as political, economic, nand regulatory requirements increase and the demand for quality care nintensifies.
This nchapter discusses the historical development of quality management in health ncare and describes the principles that form the basis of quality improvement. nIt also presents the structure on which quality management programs can be nestablished and explains the mechanisms and tools by which process improvement ncan be introduced and maintained within health care organizations.
THE nQUALITY MOVEMENT IN HEALTH CARE
A nquality management system in health care is similar to quality management iother businesses. A brief overview of the development of the quality initiative nas it relates to health care is discussed in the following sections.
Evolution
Table n25-1 provides a historical perspective on the development of the quality nmovement. The
Role of the nJCAHO in the Quality Movement
Founded nin 1951, JCAHO has become the largest accrediting organization in health care ntoday. JCAHO provides standards for hospitals, mental health care facilities, nambulatory care facilities, home health care agencies, and long-term care nfacilities. Participation in the accreditation process is a voluntary process nthat is not a condition of licensure but is often a condition for reimbursement nby many payers, such as the Federal Health Care Finance Administration (HCFA).
Ithe 1980s, quality assurance was introduced into JCAHO accreditation standards nwith emphasis on a problem-solving approach. Each department of an organizatiowas monitored and evaluated for service delivery. The 1990s marked a nsignificant change in quality management in health care. There was a shift from ndepartmental review to interdisciplinary performance improvement. This nsubsequent transition from quality assurance to the current approach of continuous nquality improvement was derived from quality management in industry. The nsection entitled Quality Improvement discusses the concepts of quality nassurance and continuous quality improvement in more detail.
JCAHO nhas made the following modifications in their survey process (effective January n2000):
• nRandom unannounced surveys will be nconducted.
• nHealth care organizations will no longer nreceive advance notification of impending random surveys.
• nThe focus and scope of the review during nthe survey will vary from agency to agency.
• nOn-site surveys will occur during nevenings, nights, and weekends rather than be limited to weekdays (Gropper, 1999).
All nof these changes have been made in an attempt to improve the quality of health ncare delivered in organizations participating in JCAHO’s accreditation process.
Defining nQuality
Health ncare has struggled for many years to define and measure quality. Quality is ndefined as meeting or exceeding requirements of the customer/client. A customer nis anyone who uses the products, services, or processes of an organization. nQuality is measured in terms of customer perspective. Clients are concerned nwith the following:
• nAccessibility and availability of service
• nTimely and safe delivery of service
• nCoordination and continuity of care nbetween services
• nEffectiveness of services, that is, the ndelivery and outcome of care
Iits 1998 report, JCAHO identified nine dimensions of quality performance. These ndimensions are described in the accompanying display. Basically, a health care norganization must be concerned with doing the right thing (efficacy, nappropriateness) and doing the right things well (availability, ntimeliness, effectiveness, continuity, safety, efficiency, and respect and ncaring).
Performance nimprovement consists of those activities and nbehaviors that each individual does to meet customers’ expectations. It is ndoing the right thing well and continually striving to do better (JCAHO, 1998).
Imeasuring quality, there are three domains to measure: structure, process, and noutcome. Each of these components is interrelated. The American Nurses nAssociation’s (ANA’s) Standards of Clinical nNursing Practice (1991) uses these three components of care to guide nnursing practice within the framework of the nursing process.
Factors nInfluencing the Quality Movement in Health Care
Today nthere are many consumers of health care in addition to clients and their nfamilies. One major consumer of health care is third-party payers, such as ninsurance companies, managed care organizations, and federal and state ngovernments. The diversity of needs represented by these consumers requires nimprovement in health care delivery systems. The major factors that have ninfluenced the development of the quality movement in health care are consumer ndemands, financial viability, professional accountability, regulatory nrequirements, progress in quality improvement techniques, and changes in health ncare delivery.
Consumer nDemands
Heath ncare consumers are sophisticated, knowledgeable, and selective. Clients no nlonger place blind trust in their physicians and realize that variables ipractice and results occur. Today’s consumers negotiate services and compare nhealth care costs among providers.
Financial nViability
Health ncare has entered an era of increased competitiveness for services, staff, and ncustomers. There is a demand to reduce spending and contain costs. Budgetary nconstraints continue to increase in both the private and public health sectors. nHealth care organizations must strive to reduce professional liability, nincrease reimbursement eligibility, and promote cost effectiveness through nincreased efficiency.
Professional nAccountability
Emphasis non clinician accountability and adherence to codes of ethical practice is nincreasing. Health care professionals must be dedicated to reducing practice nvariances to protect the public.
Regulatory nRequirements
The nHealth Care Financing Administration (HCFA) standards, JCAHO standards, and nnumerous laws require quality improvement programs. HCFA is a subsidiary of the nDepartment of Health and Human Services and is the federal agency responsible nfor administering the Medicare and Medical programs. The regulations nestablished by these organizations for accreditation and reimbursement have nfacilitated the quality initiative in health care. Such externally mandated nregulations have promoted the development of internal monitoring and evaluatiosystems within health care organizations.
Progress iQuality Improvement Techniques
During nthe past decade, health care providers have spent valuable resources on defining nand measuring quality. As a result, evaluation methodologies have improved nconsiderably. Information systems are available through which national and nregional norms for comparative data can be obtained. Measurability methods have nbeen upgraded and include a variety of process improvement models. Process nimprovement examines the flow of client care between departments to ensure nthat the processes work as they were designed and that acceptable levels of nperformance are achieved.
Seminars, nworkshops, videotape training programs, and educational consultants are now navailable to teach process improvement in health care. Overall quality nimprovement methodologies enhance performance and work processes.
Changes iHealth Care Delivery
Significant nchanges in health care delivery have occurred and unprecedented change is nanticipated in the future. Clients being admitted to hospitals today are nsicker, yet are being discharged more quickly.
Alternative ncare options such as home health care, inhome nintravenous therapy, and intermediate care facilities have proliferated, nresulting in an even greater need to coordinate a continuum of services.
Factors nthat have influenced the quality movement in health care have also protected nthose populations most vulnerable to inadequate health care; for example, the nuninsured, the elderly, and low-income families. The nquality movement has promoted access to care, standards of care, cost-effective nservice, and a continuum of care. Thus, the quality movement in health care has nserved as an advocate for consumers.
Legal and nEthical Implications
Nurses, nas well as other health care providers, must understand the roles that law, nregulations, and ethics play in the quality movement. These aspects define nprofessional practice. Laws define legal practice, regulations define nguidelines for delivery of care, and ethics define personal performance.
Legal nConsiderations
Legal nconsiderations have an impact on quality management in several ways:
• nLaws and regulations create the external nstructure for quality management.
• nFailure to provide quality health care caresult in lawsuits.
• nInstitutions can face liability for actiotaken against a practitioner if objective measures are not applied to nperformance and due process is not provided.
Quality nmanagement programs must protect against substandard care and ultimately reduce nlitigation.
Organizations nmust have clearly defined processes for professional review. These nresponsibilities are based on case law and federal regulations.
Case Law
Case nlaw refers to the legal opinion rendered in court cases. Numerous legal cases nhave resulted in rulings that affect quality management. Several landmark cases nhave established the following issues within the quality management movement:
• nHospitals are liable for the care provided nto clients.
• nHospitals are responsible for a ndepartment’s practice.
• nLimited immunity for peer review exists.
Federal Regulations
A nnumber of federal agencies regulate health care standards; for example, HCFA, nthe Food and Drug Administration (FDA), and the Occupational Safety and Health nAdministration (OSHA). Specific regulations issued by these agencies that ndirectly affect quality of care are shown in the accompanying display.
Failure nto adhere to the guidelines in these legislative acts can result in sanctions nfor violation of standards.
Federal nfunding and payment for services can be denied for failure to provide quality ncare.
Ethical nConsiderations
Laws nestablish standards of acceptable conduct; however, they often represent only a nminimum acceptable standard. For example, registered nurse licensure indicates nthat the nurse possesses the basic knowledge, skills, and abilities to nsafely practice general nursing.
Professionals nare expected to adhere to a code of ethical practice that espouses a nresponsibility to self, profession, client, and society. Ultimately, nurses nhave an ethical responsibility to deliver the highest possible quality of nhealth care. Nurses are obligated by licensure to be knowledgeable about the ncare they are providing and to practice according to an established code of nethics and standards of practice, as exemplified by the ANA’s nCode for Nurses (1985). See Chapter 24 for a complete discussion about nethical responsibilities.
Laws nprovide guidelines, and ethics provide a sense of obligation. Individual npractitioners and institutions have a legal and ethical requirement to deliver nquality care.
Quality and nCost
Health ncare costs have skyrocketed in the past decade.
The nprimary source of health insurance in the
Delivery nof poor quality care has a negative financial impact on health care norganizations. Yet, management will often argue that the quality improvement ninitiative is costly because of staff time involved in such activities.
However, none must consider the cost of poor quality, which results in the following nproblems:
• nDuplicated work between departments
• nLoss of time due to inefficient task nperformance
• nLoss of staff due to job dissatisfaction
• nRecruitment and training of new employees
• nExpenditure of energy and time iinvestigation of complaints and allegations
• nLitigation and malpractice settlements
• nEmployees continually executing tasks nincorrectly despite direction
• nReporting and correcting errors
• nExpenses related to overutilization nof diagnostic tests to avoid malpractice
Originally, nthe perception of quality was that of doing more, that is, the performance of nmore tasks that resulted in intensive intervention. Today, it is believed that nefficiency can be improved without compromising quality.
Health ncare leaders must now look at individual and collective effectiveness of norganizational management.
Organizations nmust also begin to examine the cumulative cost associated with a nless-than-optimal ability to plan, delegate, communicate, and listen. The prevailing nphilosophy is to do more with less. Such an approach to health care management nhas resulted in downsizing, cross-training, and reduction of middle management nstaff.
The nprimary cost-containment measure in health care delivery has been the proliferatioof managed care systems.
Ongoing ndebate over the effect of cost containment on quality of care continues. The nSurvey of Physicians and Nurses, a survey of 1,053 physicians and 768 nurses, nwas conducted by the Kaiser Family Foundation and the Harvard School of Public nHealth in 1999. The nurses in this survey (Kaiser Family Foundation, 1999) nstated that managed care has led to the following:
• nDecreased the amount of time they spend nwith clients
• nDecreased clients’ ability to see medical nspecialists
• nDecreased the quality of care for nindividuals who are ill
• nIncreased the likelihood that clients nwould receive preventive services
QUALITY nIMPROVEMENT
Quality nmanagement has its own array of terminology.
Despite nthe similarities, there are differences in the concepts, as outlined below:
• nQuality assurance (QA) is the traditional approach to quality management in which nmonitoring and evaluation focus on individual performance, deviation from nstandards, and problem solving.
• nContinuous quality improvement (CQI) is the approach to quality management in which scientific, ndata-driven approaches are used to study work processes that lead to long-term nsystem improvements.
This nconcept has evolved into systems such as process improvement or performance nimprovement.
• nTotal quality management (TQM) is the method of management and system operation used to achieve nCQI. TQM promotes an organization culture that supports customer need, empowers nemployees to work as teams, emphasizes self-development, and requires a new nleadership style in which employees are viewed as resources.
TQM nis a system of operation, whereas CQI is the desired outcome of a quality nmanagement program. It is difficult to achieve performance improvement without na TQM culture. The goal of a quality management program is to focus on process nimprovement, which will ultimately improve the quality of care.
Principles
Because nCQI examines ways in which the entire organization can improve, the involvement nof everyone, especially administration is required. CQI is based on the nfollowing principles:
1. nQuality is a central theme to the norganization. It is part of the organization’s mission and the core of daily nactivities.
2. nLeadership is committed to an involved icreating an organizational culture (commonly held beliefs, values, nnorms, and expectations that drive the work force) for process improvement.
3. nAll staff members are personally nresponsible for quality; therefore, decision making is done by the people doing nthe work.
4. nEducation and training must be continual nto improve skills and promote self-development.
5. nProcesses and system operation, iaddition to individual performance, are monitored.
6. nWork processes that influence outcome are nstudied and improved, rather than relying solely on problem solving.
8. nGood information is available and must be nused in decision making. Individuals and institutions cao longer use opinioand intuition; they must manage by facts.
Customer nPerspective
Promoting ncustomer satisfaction requires an organizational commitment from top to bottom nwith every employee, especially direct care workers, being sensitive to the needs, nwants and expectations of customers. This commitment requires putting the ncustomer first.
Customers ninclude those internal and external to the organization, such as clients, nsuppliers, third-party payers, families, visitors, employees, and the community.
Managers nmust meet employee needs and service delivery demands. The direct care provider nmust meet client needs, coworker’s needs, and organizational needs.
Organizations nrely on customer relations programs to develop strategies to keep their customers nsatisfied. A program of customer relations can be costly to operate. It ninvolves staff education, cost of survey materials, public relations nrepresentation, administrative time for evaluation and follow-up, and expenses nfor corrective action.
Corrective naction may involve equipment, staffing, education, structural renovations, or nnew procedures. Focusing on the customer can be both time consuming and nstressful because it may require change, which may evoke resistance in both nemployees and managers.
The nreality is that health care agencies do not have unlimited resources allocated nsolely to keeping customers happy. Therefore, the organization and each nemployee must understand the implications of customer dissatisfaction from a nfinancial perspective. The loss of one admission is relatively insignificant to na multimillion dollar budget; however, multiple losses can have a substantial neffect on a health care facility’s financial well-being.
There nis additional potential revenue loss from related ancillary services following nhospitalization, such as home health care, laboratory procedures, npharmaceutical supplies, and office follow-up. A customer’s dissatisfactiowith one facet of service can be generalized to all related delivery systems.
Andersoand Zemke (1998) have identified the 10 leading ncauses of customer dissatisfaction. As you read the accompanying display, think nof how these factors can adversely affect a client’s satisfaction with health ncare services.
Another neffect of customer dissatisfaction is a tarnished community image. There is a nmultiplier effect in which one bad encounter can affect the attitude and nopinion of many. An unhappy client may inform the immediate family, extended nfamily, neighbors, friends, and coworkers. Seemingly simple acts, such as those nlisted below, can result in client dissatisfaction despite a positive health noutcome:
• nA cold food tray
• nFailure to respond to a call light
• nWaiting for tests
• nLate treatment
• nUnemptied bedpan
• nDelayed pain medication
Health ncare organizations must have a strong dispute resolution program to mediate ncustomer complaints. In addition, strong efforts must be made to solicit ncustomer feedback about services. Satisfaction is a subjective perception; ntherefore, health care providers must listen to the customer constantly to ndetermine satisfaction and dissatisfaction. Then, improvements can be ninitiated.
ORGANIZATIONAL nSTRUCTURE FOR QUALITY MANAGEMENT
Because nquality has become a central issue in health care delivery, nurses must nconsider the impact of organizational structure on the quality of care nprovided.
Nurses nare key in establishing a culture for excellence imost health care organizations.
Several nfactors within an organization affect quality management: organizational nculture, work force diversity, empowerment, leadership, and teamwork. To nimprove the quality of care, the organization should be viewed as a system that nis comprised of governance, management, clinical, and support devices. Many nprocesses within the system involve more than one group. Therefore, a framework nmust be established to promote collaboration.
Organizational nCulture
Organizations nhave both formal and informal cultures.
Incongruence nbetween the formal operational style espoused by management in meetings and documents nand the style demonstrated and felt by staff members may be evident. This caresult in an ineffectual organization in which achieving continual improvement nis difficult.
Thus, nthe culture of an organization can affect the quality of care. A positive nculture promotes trust, information sharing, collaboration, and risk taking, nwhereas a negative culture produces divisiveness, resistance, and a desire to nmaintain the status quo. In a negative culture, inertia develops and there is a nlack of creativity and self-direction by employees. Table 25-2 compares ncharacteristics of organizational culture within traditional and nhigh-performance organizations.
Work Force nDiversity
Health ncare will be delivered by a more diverse work force throughout the 21st century. nThe organization, managers, and workers must be able to maximize diversity.
Tomorrow’s nwork force and population will consist of more women, older Americans, people nof color, and collegeeducated individuals. Despite nincreases in these groups, the overall available work force will decrease due nto declining population growth. Employees can become more selective in job nplacement and seek new employment opportunities if dissatisfied. Employees ndesire self-actualization; therefore, job satisfaction will become imperative.
The nslower growth in the work force will result in fewer applicants and a shortage nof technical and professional staff. Rapid advances in technology will increase ncomplexity of jobs and lead to increased competition for skilled workers. A nflatter organizational structure, in which middle management is reduced, will nrequire increased interaction and ability to work together.
Groups nmust enhance ways of communicating to be more productive.
This nchange in the work force will affect methods of delivery; therefore, the norganization must be able to maximize the potential of each employee. To nachieve a work environment that capitalizes on diversity, the organization must nimplement a program that addresses individual, group, and organizational nbiases. Education must be provided to eliminate stereotyping. Such educational nprograms are aimed at:
• nIdentifying individual beliefs and values
• nDiscussing assumptions and biases based ogender, race, age, and religion
• nExplaining cultural differences
• nIdentifying legal responsibilities
• nValuing differences of specific groups.
Management npractices must build an organizational climate that values each individual’s ncontribution to group achievement, and the organization must develop policies nto promote and support cultural needs and differences.
These nactions are essential in reducing the costs of employee turnover and litigatiofrom discrimination and sexual harassment suits. The outcome of such nefforts can be an increase in retention, productivity, market share, ncreativity, flexibility, and optimism of staff while effecting na decrease in complaints, grievances, litigation, and cost. Specific advantages nof having a culturally diverse work force iursing are shown in the naccompanying display. Health care providers must consider transcultural nprinciples and human rights in managing the work force and delivering quality ncare.
Empowerment
For norganizations to operate successfully and instill the drive for excellence ieach employee, the staff must be empowered to take ownership of their jobs. Empowerment nis the process of enabling others to do nfor themselves. Employees need responsibility and nauthority to solve problems and take action in their work group. Empowerment nrecognizes the uniqueness of employees and conveys a message of value. As a nresult of empowerment within a work group, an environment is created in which nthe collective creativity is more diverse than the ideas and knowledge of a nsingle individual.
To nsurvive in today’s health care environment, all providers must work together to naccomplish the organization’s mission, vision, and goals to achieve a nphilosophy of continual improvement. Restructuring health care delivery nrequires each individual to improve work processes. Work redesign, downsizing, nconsortiums, managed care, and cross-functional task sharing are but a few of nthe many efforts underway to reorganize health care in order to reduce waste, nduplication of work, and cost. All health care providers must be involved ithe process of change to minimize fear, reduce resistance, promote naccountability, add credibility, and produce lasting results. To accomplish nchange, health care organizations need to maximize employees’ capabilities and nmotivate them toward continual improvement.
Leadership
Leadership nis the interpersonal process that involves nmotivating and guiding others to achieve goals. Leaders in a health care norganization include the governing body, chief executive officer, senior nmanagers, leaders of the medical staff, department heads, nurse executives, and nsenior nursing leaders.
Effective nleadership works across departmental lines to address multidisciplinary work nfunctions and processes.
Traditionally, nterritorial issues (the so-called turf battles) have produced divisiveness and ncompetition among departments and disciplines. The tools for combating such ndivisiveness and building effective work groups are collaboration and nfacilitation.
Organizational nleadership contributes to the creation of the culture based on CQI beliefs and npractice. Leadership must create a people-oriented culture. In today’s nfast-paced, high-tech, cost-driven health care environment, the human factor is nfrequently overlooked. Although staffing incurs the greatest expense and is a nprimary target for cost reduction, it is the people in the health care norganization who are the greatest asset, and management must focus on ensuring na return on this important resource.
Empowering nemployees, valuing diversity, creating organizational change, and promoting nprocess improvement requires a new style of leadership that shifts from high nmanager/low employee participation. The manager becomes a coach instead of a nsupervisor. In this role, the manager facilitates collaboration and advocacy, nserves as a consultant, and provides support.
Teamwork
Humaresource management has become an essential function of health care managers. nAuthoritarian, hierarchical, and traditional ways of management are no longer neffective; therefore, health care organizations are turning to team-based nstrategies for organizing labor. Improving quality requires team effort.
A nteam is a group of individuals who work together to achieve a commogoal. The dynamics of team interaction are important. Teams must demonstrate commitment, ncooperation, and communication. The way the team communicates and solves nproblems has a significant impact on outcome and delivery of service. For nquality care to occur, work groups must function as teams.
For nquality improvement, teams are used to study processes. There are two types of nprocess improvement teams: functional and cross-functional. A functional nteam is a departmental or unit-specific group whose scope is limited to ndepartmental or work area processes. A crossfunctional nteam is an interdepartmental, multidisciplinary group that is assigned to nstudy an organization-wide process (Figure 25-1). An effective team ndemonstrates mutual respect and trust, displays open communication, builds oskills of members, and seeks consensus.
The nuse of teams to restructure and improve work processes has many advantages, nsuch as:
• nIncreased involvement and understanding
• nMore opportunities to share ideas
• nAssistance in building relationships
• nInvolvement of staff in problem solving
The nteam approach is effective for coordinating and integrating interdepartmental nwork processes.
PROCESS nIMPROVEMENT
For nyears, the focus of health care quality has been on performance improvement. It nwas eventually recognized that no individual’s performance really stands alone. nEach person’s action in an organization is actually a performance step that is nconnected to the action of others. This series of interconnected steps is knowas a process; processes interconnect to form a system.
Prioritization
Quality nimprovement focuses on processes or systems within organizations that nsignificantly contribute to outcome. This requires refocusing from solely ndepartmental issues to crossdepartmental lines. Prior nto a process improvement philosophy, quality improvement efforts were performed nwithin departments. However, processes operate between departments and require nmultidisciplinary involvement.
To ncontinually improve, an organization must realize that it is a system of ninterdependent parts all with the same mission of meeting the needs and nexpectations of customers. Understanding interdepartmental processes is crucial nto quality improvement.
Iprocess improvement, the emphasis is on system variation, not performance of nindividuals. Process improvement does not just address problem solving; it also npromotes ongoing improvement of stable processes and correct establishment of nnew systems. Process improvement is intended to reduce variability, improve nefficiency, and reduce complexity in systems.
Process nimprovement efforts must be directed at analyzing systems that have significant nimpact on the organization of care delivery. Important aspects of care involve nactivities or processes that are:
• nHigh volume: occur nfrequently or affect large numbers of clients
• nHigh risk: place nclients at risk of serious consequences if not provided or provided incorrectly
• nProblem prone: tend to produce problems for clients or staff (JCAHO, 1998)
Organizations nmust effectively use resources by focusing on high-priority systems that affect nclient outcome.
Scientific nApproach
Typically, nproblem solutions are generated without timely analysis. A “ready, fire, aim” napproach to process analysis is frequently used, in which action is takewithout first thoroughly evaluating the problem. To counter this haphazard nmethod, a scientific approach to performance improvement must be undertaken. Ithe scientific approach, data are used to measure process.
Such nan approach results in the following:
• nMinimal use of intuition and opinion
• nMore accurate and effective problem nidentification
• nIncreased understanding of root causes of nvariation
• nImproved evaluation of alternative nsolutions
• nAbility to statistically measure nimprovement
The nscientific approach to improving quality performance consists of the following nsteps:
1. nIdentify an important process to evaluate.
2. nMeasure the current process.
3. nAssess variations.
4. nFormulate improvements.
5. nImplement change in the process.
Tools
A nvariety of tools are used to collect and analyze data so that decisions can be nmade about organizational performance.
The naccompanying display describes mechanisms frequently used to obtain and measure ndata.
Iaddition to measuring processes, data can also be used in benchmarking (a nprocess that evaluates products, services, and priorities against the nperformance of others). Comparative data can be obtained from the literature, npractice guidelines, and an increasing number of external reference databases.
NURSING’S nROLE IN QUALITY MANAGEMENT
The nprimary purpose of nursing is to provide quality care to clients. To do so nmeans always seeking to improve the care delivered. Nurses function as nclinicians, team members, and managers. Each role has specific responsibilities nfor quality performance and requires certain skills to achieve the expected nlevel of performance (Table 25-3).
There nare several characteristics of quality nursing care, including the following:
• nMaintenance of a current knowledge base nand competencies
• nInterpersonal skills (with clients and ncoworkers)
• nCaring and compassion
• nMutual decision making with client and nnurse
• nIndividualized treatment
Whether nfunctioning as a clinician, team member, or manager, nurses continually strive for nexcellence in everything they do. By using a CQI approach, which examines nstructure and process instead of individual performance, nurses can move nforward in the provision of quality care. Quality improvement identifies nsituations wheursing teams are more productive and functioning at a higher nquality level.
KEY CONCEPTS
• nThe nine dimensions of quality performance nas identified by JCAHO are efficacy, appropriateness, availability, timeliness, neffectiveness, continuity, safety, efficiency, and respect and caring.
• nThe quality movement was initiated by nconsumer demands, financial viability, professional accountability, regulatory nrequirements, progress made in quality improvement techniques, and changes ihealth care delivery.
• nCase law and federal regulations establish nguidelines for quality management.
• nHealth care professionals adhere to nethical codes of practice that espouse a responsibility to self, profession, nclient, and society.
• nContinuous quality improvement focuses ostudying work processes that promote system improvements.
• nTotal quality management is a method of norganizational operation that establishes a work environment to achieve ncontinuous improvement.
• nA customer is anyone who uses the nproducts, services, or processes within an organization. Clients, families, nvisitors, employees, suppliers, and the community are all considered customers nwithin the health care system.
• nCustomer dissatisfaction can have nsignificant financial implications for health care organizations.
• nQuality management requires positive norganizational culture, work force diversity, empowerment, leadership, and nteamwork.
• nA variety of tools, such as audits, peer nreviews, and benchmarking are available through which data about variations iprocess improvement can be collected and analyzed.
• nThe nurse is responsible for quality nimprovement as a clinician, team member, and manager.
