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Drafting a Standard

Establish the requirements Agree the process Draft the Standard Test the Standard Implement the Standard

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Maxwell’s Dimensions of Quality

Access Equity Relevance to need Social Acceptability Efficiency Effectiveness

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The Donabedian Approach

Structure - includes the skills of the staff, the buildings and premises, and the equipment the organisation makes available

Process - the methods that are adopted by the organisation to provide its services, or in its production processes

Outcome - the combined results of the structures and processes of the organisation in the production of its products or services.

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Donabedian in healthcare Structure - the resources required to deliver care; the

environment in which care is delivered; the facilities made available; the equipment e.g. bandages, linen, drugs, etc. made available; and the documentation of procedures, policies and guidance to staff.

Process - the actual procedures and practices implemented by staff in their prescription, delivery and evaluation of care; and the monitoring, evaluation and actions to adjust the provision of care

Outcome - the effect of care received by patients as a result of healthcare intervention; the benefits to staff as a consequence of providing this care; and the costs to the organisation of providing care.

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A Donabedian Standard

Standard: nurses work in partnership with elderly residents andtheir relatives in ensuring individualised care in nursing homes

Structure criteria Process criteria Outcome criteria

Care is organisedalong primary nursinglines

The nurse undertakes acollaborativeassessment with theresident, relatives,and/or friends within24 hours of admission

Residents demonstratethat they have a senseof control over theirlives.

An illustrated life-history accompaniesthe resident onadmission

The nurse presentsopportunities for theexercise of choice indaily-living activities

Residents, theirrelatives and friendsparticipate in theirchosen activities

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The Wright Matrix

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A Different ApproachGuiding Principles Standard Statement Monitoring

Topic 1: Reception of Patients

Patients seen in OPD will besure of prompt welcome onarrival

1. Immediately on arrival apatient will be greeted by amember of the OPD team.

A nurse will introduceher/himself when directing apatient into a room forconsultation with the doctor

OPD manager or nominatedperson will make randomchecks on differentclinics/days, once a month,and keep record of whatshe/he finds.

Topic 2: Waiting Time

To reduce waiting time to aminimum and giveexplanation if there is a delay

2.1 Patients will begin theirfirst clinical interaction atthe appointment time

2.2 If waiting time is morethan 15 minutes, thepatient will be informedof the reason for thedelay and then regularlyupdated on the situation

OPD manager or nominatedperson will monitor byobservation and also byasking 20% of patients in adifferent clinic on a differentday of each month

Information fed back to staffat weekly meetings

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Select an issue pertinent to your working environment. Use one of Maxwell’s dimensions and define an appropriate Standard and 3/4 relevant Criteria.Define an appropriate Standard and 3/4 Criteria for Donabedian’s Structure.Take approx. 15 minutes

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Measuring Performance

Tangible “hard” outcomes may be measured quantitatively

Intangible “soft” outcomes may be measured qualitatively

Communicate the results to those involved

Graphic representation can be useful

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Methods of MonitoringConsider:-

what should be monitored, and to what level of details

frequency with which monitoring should take place

cost of monitoring system time taken to monitor possible use of existing systems who will be responsible for monitoring and

acting on results

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Standard: Care should aim to reduce the patient’s risk of developing pressure sores.Criterion 1 The patient’s pressure areas should be attended to every 2 hours.Criterion 2 The patient should be assessed using the Norton Scale at appropriate intervals, given the patient’s condition and mobility.Criterion 3 If the patient has an “at risk” score on the Norton Scale it should be recorded in the care plan.

Construct the audit questions to measure this Standard.

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Evaluation of the Results

There may be more than one cause of the problem and more than one possible solution

Analyse the processes to determine the causes of the problem using brainstorming, flow charts, fishbone diagrams or Pareto diagrams

Consider costs and benefits of potential changes

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“The quality of technical care is defined not by what is done, but by what is accomplished. And consumers are uniquely able to say what outcomes are to be pursued, what risks are to be accepted in return for what prospects of amelioration, and at what cost”(Donabedian, 1992)

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“It can be argued that technical care not congruent with patient preferences has failed in quality… it follows that consumers define (or participate in defining) the quality of technical care by the simple expedient of specifying the goals it must serve. Only the technical means, and the skill by which they are implemented, remain for the clinical expert to govern”(Donabedian, 1992)

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In Consumer audit continuous improvement is only likely to be effective if patients are involved in the construction of the measuring instruments. This is essential for an accurate focus upon issues of patient concern.

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However it is necessary to exercise a degree of caution before assuming that patient empowerment is a panacea to all the problems of service delivery. It is not necessarily paternalistic to argue that some patients may be happy to hand over complete discretion of their care to others.

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Empowerment for some may mean disempowerment for others i.e. the articulate may receive a disproportionate share of resources and attention. A distinction needs to be drawn between empowerment at a collective level and empowerment at an individual level.

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After the Audit

Opportunity to Progress– Research– Continuing system to suggest new areas– Quality Indicators– Improvement in patient care

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Outlining an Audit Project

It is possible to attempt to describe the features of any audit in advance. At this stage it will not be possible to define all the parameters, but consider the main elements required to describe an audit of the outcomes from an initiative titled “Maintaining Healthy Weight in your Practice Population”.

Consider:

Which staff group might lead the audit?Which staff may get involved?What would the objective of such an initiative be?How would potential participants be informed/chosen?What Standard(s) would be specified?Who would be involved in the initiative being audited?Who would be involved in determining the audit criteria?What could be measured/recorded to monitor progress?How would the (success of the) initiative be measured (that is how would it be judged that a Healthy Weight was now being maintained by a larger proportion of the practice population)?What data would be required to inform the initiative and from which sources?Consider whether there is (or could be generated) a willingness to “Achieve a Healthy Weight” within the practice population (and what information could be used to measure the commitment)How would the results of the audit be communicated, and to whom?

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Further Reading

Crosby, P. (1979) Quality Without Tears Mentor, New YorkDeming, W.E. (1986) Out Of The Crisis MIT, Cambridge,

Mass.Department of Health – ChiefMedical Officer (CMO)/ChiefNursing Officer (CNO),(1993)

Clinical Audit – Meeting & ImprovingStandards in Healthcare

Donabedian, A. (1980) Exploration in Quality Assessment andMonitoring Volume I: Definition of Qualityand Approaches to its Assessment

Health AdministrationPress, University ofMichigan, Ann Arbor

Kinn, S.T. (1993) Computers & Clinical Audit Chapman & HallMedical

Kumar, V. & Brown, P.M.(1992)

The Audit Spiral Quality in Healthcare

Maxwell, R. (1984) Quality Assessment in Health British MedicalJournal, 288, 1470-72

Oakland, J.S. (1989) Total Quality Management Heineman

Ovretveit, J. (1992) Health Service Quality – An Introduction toQuality Methods for Health Services

Blackwell ScientificPublications, Oxford