Total Quality Management - Nursing Management 6d1k51

1 Patient’s Rights 1. Right to competent care 2. Freedom from harm 3. Right to Informed Consent 4. Right to Withdraw from Participation 5. Right to Confidentiality of Information 6. Right to be Treated with Dignity and Respect

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Historical Information

Factors Affecting Time Requirement of Nursing Care 1. Acuity if the patient’s illness 2. Degree of dependence if the patients on the caregivers 3. Communicability of the ailment 4. Rehabilitation needs and special treatments and procedures

Organizational Ethics - a broad concept that includes not only culture and trust, but also processes, outcomes, and character and Patient Classification System denotes “a way of acting, not a code of I. “Self care” or minimal care patients principles…. [and] is at the heart, pumping II. Intermediate or moderate care blood that perfuses the entire organization III. Total care patients with a common sense of purpose and a IV. Intensive care patients shared set of values” (Pearson, Sabin, & Emmanuel, 2003, p42) Nursing Care Models 1. The Case Method or Total Patient Care Patient's Care Standards 2. The Functional Method  principle A - Each patient shall be treated as 3. Team Nursing 4. Primary Nursing Method a whole, irreplaceable, unique, and worthy 5. Progressive Client Care person. 6. Managed Care Method  principle B - The patient’s safety, 7. Practice Partnership health, or welfare shall be protected and shall 8. Case Management Method not be subordinated to organizational, staff, 9. Modular Method educational, or research interests or to any other end. principle C - The privacy of the patient and the confidentiality of every case and record shall be maintained.  principle D - Patients and/or responsible family shall be informed at all stages of care about personnel responsible for the patient’s care; treatment plans and activities for the patient; facilities; services available to the patient; and responsibilities of the patient and family (referred to collectively as “patient’s care”).  principle E - Behavior reflecting the dignity, responsibility, and service orientation of health care professionals, worthy of the public’s respect and confidence, shall be practiced by all individuals.  principle F - Each patient shall have a responsible attending physician or dentist. HUMAN RESOURCEMANAGEMENT Staffing follows a predictable pattern before a nurse can be hired: preparing to recruit, attracting staff, recruiting and selecting staff through interview, induction, orientation, and job offer. 

Steps in Staffing 1. Determine the number and types of personnel needed 2. Recruit Personnel 3. Interview 4. Induct or Orient the Personnel 5. Job Offer Staffing Pattern 1. Benchmarking 2. Regulatory Requirements 3. Skills Mix 4. Staff

Formula to Determine Staffing Patterns 1. Full Time Equivalent (FTE) 2. Forty-Hour Week Law a. Standard Value for NCH b. Percentage (%) of Professional and Non-Professional (in ratio) c. Distribution per shift d. 40 hour/week e. 48 hour/week Guidelines for Determining the Nursing Personnel Needed Step 1. Determine type of hospital whether it is primary, secondary or tertiary. Step 2. Categorize patients according to levels of care Step 3. Find the NCH needed by patients per day and get the SUM. Step 4. Find the Total NCH x 365 days. Step 5. Find number of working hours per year. Step 6. Find the nursing personnel needed. Step 7. Categorize into Professional and NonProfessional. Step 8. Distribute by shifts. Job Descriptions 1. recruitment, 2. placement and transfer, 3. guidance and distribution, 4. evaluation of performance, 5. reduction of conflict and frustration, 6. avoidance of overlapping of duties, 7. facilitating working relationships with outside bodies such as professional associations, and 8. serving as basis for employees’ salary range. TQM

INFORMATION MANAGEMENT - collection and management of information from one or more sources and the distribution of that information to one or more audiences NURSING INFORMATICS - the use of information and technology to all aspects of nursing practice - facilitate integration of data, information and knowledge

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DATA MANAGEMENT Data Integrity - data that make up the database of information must be maintained with optimal assurance that quality of data exist

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Educating Staff - institute of medicine has strongly emphasized that informatics is the core competency required of healthcare professions including nursing

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System Prompts - managers, staffs and informatics nurses can work with the IS department to develop prompts that alert the to recheck the data that fall in specific range, confirm that the data fall in specific range, confirm that data have been entered correctly

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ing Data - very crucial to having quality data that can be utilized for clinical decision making

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Data Mining - Technology has aided in rapid advances in data capture and storage resulting in large databases of data

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Data Cleansing - used to clean up erroneous data that have been captured and stored in databases

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ROLES OF INFORMATIC NURSES Project Manger - analyze, design, develop, select, test, implement and evaluate new or modified informatics project that optimal data and delivery of quality patient care

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Consultant- project manager, market research, planning conferences, strategic information technology, reviewing clinical software, redeg the workplace and others

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Educator - may educate the staff nurses, managers and others using health care information system

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Researcher - research clinical situations that arise, help implement evidenced-based practice, evaluate the current system for improved outcomes, and conduct research to improve clinical information systems and outcomes

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Product Developer - may develop software applications for clinical and nonclinical healthcare environment

COMMUNICATION FHTH

2 - transmission of infromation, opinions, and intentions between and among individuals - binds organization together to ensure common understanding Lines of Communication  Downward - primarily directed and coordinates activities at various levels of organization what they need to know, what to do and why they are to these; includes policies, rules and regulations, memos, handbooks, interviews, job description and performance appraisal 

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Upward - primarily directed and coordinates activities at various levels of organization what they need to know, what to do and why they are to these.

Reimbursement of Health Insurance  Legal  Health Care Analysis III.

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Horizontal - it is used most frequently in the form of endorsement, between shifts, nursing rounds, journal meetings and conferences or referrals between departments or services. Outward - information’s that flows from care-givers to the patients, and his family. V.

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Reporting and Documentation  Accurately  Completely  Timely  Effective  Pertinent  Concise  Reflective  patient’s needs, problems, capabilities and limitations

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Quality Care

Guidelines for Good Reporting and Documentation  Factual  Accurate  Confidential  Complete  Current  Organized  Ethical Precautions to Observe in Documentation o Only the nurse… o Charting… o Chart all important information.. o Do not make erasures…

Nursing Health History and Assessment Worksheet Graphic Flowsheets Medicine and Treatment Record Nursing Kardex Discharge Summary Nursing Progress Notes Chronological Narrative Charting SOAP Charting

TOTAL QUALITY MANAGEMENT - is an approach that seeks to improve quality and performance which will meet or exceed customer expectations. PROCESSES INVOLVED IN TQM Managing quality design and development • Quality control and maintenance • Quality improvement • Quality assurance •

3 PRINCIPLES OF TQM 1. Focus on achieving customer satisfaction. 2. Seek continuous and long-term improvement. 3. Take steps to ensure the full involvement of the work force in improving Quality.

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Reports 1. Change-of-Shift Reports a. Oral Report b. An audio-tape report c. Nursing Rounds 2. Telephone Reports and Orders 3. Transfer Reports

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Documentation  is anything printed or written that can be used as record or proof for authorization.  a medical record is a comprehensive description of the client’s health status and needs as well as evidence of each health care member’s ability in giving that care.  …pertinent and concise and should reflect patient’s status.

3 PARADIGMS OF TQM 1. Total 2. Quality 3. Management

Purpose of Records  Communication  Legal evidence of care  Education  Financial Billing  Evaluation of quality of care rendered  Research and Statistical Information

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SAFE PRACTICE AND ENVIRONMENT CREATION OF A THERAPEUTIC ENVIRONMENT Therapeutic Environment  Comfortable environment  Good ventilation  Free from odors  Controlled noise level  Proper lighting  Orientation to patients and families  Creation of a Therapeutic Environment I. The Patient’s Clinical Record  Chart  Formal legal document  Treated confidentially

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Purpose of the Documentation  Communication  Planning Patient Care  Research  Education  Audit IX.

Forms for Nursing Documentation TQM

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IMPLEMENTATION STEPS OF TQM Develop new strategic thinking Know the stakeholders Determine quality requirements Plan for contingency Reduce waste Develop a continuous improvement strategy Reduce variation Balance the approach Apply the improvement process

Quality Assurance Achieving a sense of accomplishment and implies a guarantee of excellence. Process of evaluation that is applied to the health care system and the provision of health care services by health workers. Quality Improvement FHTH

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A process of continuously improving a system by gathering data or performance and using multi-disciplinary team to analyze the system, collect measurements, and propose changes.

Nursing Audit Committee  Composed of a representative from all levels of the nursing staff:  Member of the Training staff  Supervising Nurse  Head/Senior Nurse  Staff Nurse

 determine training and developmental needs of employees  improve the performance of work groups by examining , improving and correcting interrelationship between .  improve communication between supervisors and employees  establish standards of supervisory performance  discover the aspirations of employees and reconcile these with goals of institution.  inform employees ‘’where they stand’’ Factors Contributing to an Effective Performance Appraisal System

 PATIENT CARE AUDITS Concurrent audit - one in which patient care is observed and evaluated. • given through: • A review of the patients’ charts while the patients are still confined in the hospital. • Observation of the staff as patient care is given • Inspection of patients and/or observation of the effects of patient care where the focus is on the patient.

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Retrospective Audit - one in which patient care is evaluated • given through: • A review of discharged patients’ charts • Questionnaires sent to or interviews conducted on discharged patient Peer Review • Patient care audits maybe done by peers evaluating another’s job performance against accepted standards

Performance Appraisal, Development, Planning and even Positive Discipline. 

It is a step-to step tool that line manager can use to improve the performance and productivity of employees

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It is also a way for employees to have a clear understanding of what is expected from them in of work performance.

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The key, Rupert says, is in understanding and properly using the process.

Compatibility between criteria for individual evaluation and organization goals. Direct application of rated performance to performance standards and objectives expected of the worker. Development of behavioral expectations which have been mutually agreed upon by both the rater and the worker. Understanding the process and effective utilization of procedure by the rater. Rating the individual by the immediate supervisor. Concentration in the strengths and weaknesses to improve individual performance. Encouragement of from the rated employees about their performance needs and interests. Provision for initiating preventive and corrective action and making adjustments to improve performance.

INFORMAL ACTIONS  Coaching and counselling : in many cases, informal coaching and counselling will be all that is necessary to facilitate improved performance.

RATIONALE AND STEPS FOR PERFOMANCE IMPROVEMENT

 The Objective of coaching is to help the employee to recognize and solve-the problem early on.

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Quality Circles A group of workers doing similar work who meet regularly and voluntarily on PERFORMANCE IMPROVEMENT normal working time, under the Is the concept of measuring the output of a leadership of their supervisor to identify, particular process or procedure, analyze and solve work-related then modifying the process or procedure to problems and to recommend solutions to increase the output, increase efficiency, or management. increase the effectiveness of the process or Utilization of Results procedure. • The Nursing Staff in the unit is given a The concept of performance improvement on the results of the quality can be applied to either individual assurance study. performance. • Positive - reinforces desirable performance. Performance Improvement Process • Negative - should tactfully be ( Positive Discipline) conveyed in a face-to-face solution so  It is ORNL POLICY to identify, that assessment results may easily be communicate and address as early as clarified. possible when job performance is below expected standards. PERFORMANCE APPRAISAL  Performance improvement intervention should be initiated as soon as it becomes Purposes of Performance Appraisal apparent that an employee is not meeting expected performance standards.  determine salary standards and merit  ORNL: Oak Ridge National Laboratory increases  select qualified individuals for Performance Improvement Process promotion/transfer  David Rupert, ORNL’s Director of  identify unsatisfactory employees for Workforce Diversity, says that - The demotion or termination Performance Improvement Process,  make inventories of talents within the is part of the overall Performance institution Management System, which includes:

THE PERFORMANCE IMPROVEMENT COMPONENT OF PERFORMANCE MANAGEMENT PROCESS Consist of both:  Informal actions  Formal actions  (While it is recommended that all actions relatives to correcting performance be documented, the level of documentation is critical at the formal actions stage.)  Employee may enter the process at either state depending on the circumstances.

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TQM

 When the problem occurs or begins to develop regarding work performance, the manager should discuss the situation with the employee before it becomes serious.  During such a discussion, the manager should explain exactly what the performance expectation is and specifically how the employee is failing to meet it.  Once the employee agrees ( or at least understands) that he or she is able for meeting expectations, the employee and manager should tly explore steps, the employee might take to ensure he or she meet expectations in the future.  Ideally, the employee and manager will agree on the approach that will be taken to solve the problem.  If the agreement cannot be reach, it is the manager’s responsibility to ensure that the employee understands what he or she must do to solve the problem, and the consequences for the employee, if the problem is not resolved. FHTH

4  The manager also needs to tell the employee how and when he or she will follow up to provide additional on progress against the agreement. FORMAL ACTIONS  The formal action for performance improvement includes:  An Oral Reminder  A Written Reminder  A Formal Warning accompanied by a DecisionMaking Leave.  At each step, managers must meet with the employee.  Managers should consult with the Human Resource Generalist for assistance before initiating formal action

Normally, each step would last from 30 to 90 days. No matter what the stated duration of the step, additional action may be taken before the stated end of the step if the performance continues to decline noticeably or the employee does not make a good faith effort to meet expectations.

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Actions should be more immediately .

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 Is a coaching session in which manager and employee discuss problem, clarifying expectations and develop solutions that will lead to improvement.

Step 2 : WRITTEN REMINDER  If after the oral warning, performance does not improve to the level necessary to meet expectations or if performance continues to decline, a written reminder session will be conducted.  During this session, the employee will be reminded of prior commitments that not been met.  Performance expectations will be clarified and steps for improvement developed.  The supervisor should seek to obtain the employee’s commitment to resolve the problem, if possible

The duration of each step will vary depending on the performance issue and on the employee’s progress.

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A session will be held in which the employee will be reminded of prior commitments that have not been met and performance expectations will be clarified.

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The employee will then be given one day off with pay ( a Decision – Making Leave) during which time he or she will decide whether he or she can meet performance expectations.

Initiations of this step requires the concurrence of the Division Director and review with the Director of Human Resources.  The employee will be told of the consequences for failure to correct the problem, which, in most cases, would be termination of employment.  Or in the given job for only a short time (< 1 year). By acting promptly and decisively, the organization can avoid long term problems

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PERFORMANCE APPRAISAL PROCESS

- Performance appraisal should also be viewed as a system of highly interactive processes which involved personnel at all levels in TQM

Increase motivation to perform effectively. Increase staff self –esteem Gain new insight into staff and supervisors Better clarify and define job functions and responsibilities Develop valuable communication among appraisal participants. Encourage increased self-understanding among staff as well as insight into the kind of development activities that are of value. Distribute rewards on a fair and credible basis. Clarify organizational goals so they can be more readily accepted. Improve institutional/departmental manpower planning, test validation, and development of training programs.

FACTORS AFFECTING THE EFFECTIVENESS OF PERFORMANCE APPRAISAL 1. 2. 3. 4. 5.

Documented process Communication Training Evaluation of results Follow-up and performance improvement

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Documented process - Effective performance appraisal is formal and not left to chance. More than just asking supervisors and managers to evaluate staff, effective systems provide step-bystep guidance and standardized evaluation forms for all managers to evaluate all employees. This not only lends to consistency, but also allows the results of the evaluations overall to be reviewed and compared to identify areas of strength and areas where there may be opportunities for improvement. Making the process as easy as possible for managers to follow will help ensure that performance appraisal is effective.

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Communication - Communicating the performance appraisal process, not only to new managers but on an ongoing basis, can help remind all supervisors that the process exists, what it is, how it works and where to get advice and assistance if needed. In addition, business leaders and human resources staff should make sure managers and supervisors understand why performance appraisal is important-to employees, managers and the organization.

 Is part of an organization’s overall performance management system.  Performance Appraisals: are regular evaluations of employees’ job performance.  They are used to grade employee performance according to the employee’s expectations, foster twoway communications between employees and supervisors and establish attainable goals for organizational and individual success.

 Consequences for failure to correct the Performance Appraisal Process - “Performance Appraisal is an organizational problem should be stated and the employee should be told. system comprising deliberate processes for  Note : if the employee will not agree upon determining staff accomplishments to the steps required to improve performance, improve staff effectiveness” this must be noted by the manager and compliance with performance standards Rationale for Policy on Performance Appraisal will be mandated. - Can be viewed as the process of assessing and recording staff performance for the purpose of making judgments about staff that DURATIONS OF STEPS lead to decisions. 

OBJECTIVES FO PERFORMANCE APPRAISAL (MOHMAN, RESNICK-WEST AND LAWCER,1989)

Steps 3 : FINAL WARNING

Step 1: ORAL REMINDER

 The employee will be asked to commit to correcting the performance problem and will be told that this is an ORAL WARNING.

differing degrees in determining job expectations, writing job descriptions, selecting relevant appraisal criteria developing assessment tools and procedures, and collecting interpreting, and reporting results.

FHTH

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Training - Supervisors and managers automatically know how to conduct performance appraisals. In addition, processes and philosophies at companies differ, so training and education is critical. Training should take place regularly to provide refreshers and updates on any changes to the process or the evaluation forms. Evaluation of Results - While performance appraisal generally focuses on one individual, looking at the aggregated results of performance appraisals can tell a company a lot about the general level of performance of its staff, areas where there may be training or development needs and trends within and between departments. Follow-Up and Performance Improvement - The greatest affect on performance appraisal effectiveness is how the business uses the results. Employees both individually and across the organization should use the appraisal system as a tool to improve performance. STEPS AND RATIONALE FOR PERFORMANCE IMPROVEMENT

I. PROBLEM RECOGNITION / ASSESSMENT 1. Identify current turnover rate. Rationale: Identifying the turnover rate helps a facility determine areas for improving staff stability, and provides a benchmark for developing a quality improvement action plan. II. CAUSE IDENTIFICATION 2. Seek and identify causes underlying staff turnover. Rationale: Identifying trends, patterns, and causes can help alert the facility to readily address issues that may be resolved with simple approaches, as well as helping to identify other cause-specific interventions. III. MANAGEMENT 3. Identify goals for improving turnover rates. Rationale: Goal setting allows the facility to envision potential achievements through their quality improvement efforts. 4. Develop an action plan to address causes and attain identified goals. Rationale: An action plan provides a “roap” to meeting goals. 5. Implement the action plan. Rationale: The success of the plan depends on various factors, including understanding by involved parties and the given to making definitive changes in work environment, work flow, care processes, etc. IV. MONITORING 6. Evaluate the implementation of the action plan. Rationale: Evaluation of the progress of implementation allows the facility to determine if they are “on the right track” or need to take a different path to try to meet their goal. 7. Update and revise the action plan as indicated by the evaluation process.

Rationale: Positive changes need continuing in order to be sustained. 8. Determine ongoing methods of monitoring the satisfaction and needs of staff. Rationale: Sustained improvement requires monitoring both results and the status of processes and issues that influence those results.

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to practitioners is essential to improve practice. It perpetuates good performance and replaces unsatisfactory interventions with more effective methods.

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Peer pressure provides the impetus effect prescribed changes based on the results of assessment and needed improvements on the quality of care.

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Reorganization in the formal organizational structure may be required if assessment reveals the need for a different pattern of health care.

QUALITY ASSURANCE Quality Circle - a participatory management technique that enlists the help of employees in solving problems related to their own job Quality - is the degree of excellence and assurance means formal guarantee of a degree of excellence; Gives people with different functions in the organization a common language for improvement. Assurance - Means achieving a sense of accomplishment and implies a guarantee of excellence

Quality Assurance - Achieving a sense of accomplishment and implies a guarantee of excellence - Process of evaluation that is applied to the health care system and the provision of health care services by health workers. - It promotes collegial and sharing relationships among workers instead of a feeling of threat when observed and evaluated Total Quality Management - a way to ensure customer satisfaction by involving all employees in the improvement of the quality of every product or service. Continuous Quality Improvement - process of continuously improving a system by gathering data or performance and using multidisciplinary team to analyze the system, collect measurements, and propose changes. Principles Underlying Quality Assurance Efforts 1.

All health professionals should collaborate in the effort to measure and improve care.

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Coordination is essential in planning a comprehensive quality assurance program.

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Resource expenditure for quality assurance activities is appropriate.

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There should be focus on critical factors such as functions and activities that promise to yield the greatest help and financial benefit to reveal significant findings.

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Quality patient care is accurately evaluated through adequate documentation.

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The ability to achieve nursing objectives depends upon the optimal functioning of the entire nursing process and its effective monitoring. TQM

10. Collection and analysis of data should be utilized to motivate remedial action. Nursing Audit Committee - Composed of a representative from all levels of the nursing staff: • Member of the Training staff • Supervising Nurse • Head/Senior Nurse • Staff Nurse PATIENT CARE AUDITS A concurrent audit is one in which patient care is observed and evaluated. It is given through: • A review of the patients’ charts while the patients are still confined in the hospital. • Observation of the staff as patient care is given • Inspection of patients and/or observation of the effects of patient care where the focus is on the patient. A retrospective audit is one in which patient care is evaluated through: • A review of discharged patients’ charts • Questionnaires sent to or interviews conducted on discharged patient Peer Review - Patient care audits maybe done by peers evaluating another’s job performance against accepted standards Quality Circles - A group of workers doing similar work who meet regularly and voluntarily on normal working time, under the leadership of their supervisor to identify, analyze and solve workrelated problems and to recommend solutions to management. Utilization of Results - The Nursing Staff in the unit is given a on the results of the quality assurance study. POSITIVE reinforces desirable performance. NEGATIVE should tactfully be conveyed in a face-to-face solution so that assessment results may easily be clarified.

TOTAL QUALITY MANAGEMENT IMPLEMENTATION STEPS FHTH

6 Define the Problem - Identification of the problem to be address by the health care team. Develop New Strategic Thinking - Utilizing brainstorming and brain writing strategies as effective tools for the development of the solution to the problem. Know The Stakeholder - Focuses on the clients and their expectations to meet their health care needs by doing a survey, interviews and gathering of data

Determine Quality Requirements - Result of your survey will give you a description what is the need of the client and expectations. This will be helpful to determine quality

Reduce Variations - Set of tools to reduce variation in quality of the product and to optimize used of project resources and to minimize quality deficiencies.

Plan For Contingency - Plan for contingency and develop risk response strategy to manage potential threats and uncertainties the surrounds your project.

Balance The Approach - The implementation should run smoothly should not lack of resources and continuous monitor and tracking of project is needed.

Reduce Waste - Minimize waste of resources and reduce a source of waste. Develop A Continuous Improvement Strategy - Ensure the process with multiple iterations and buffers.

TQM

Apply The Improvement Process - The use of the improvement process in every facet of project to start improving the quality of project.

FHTH