Cebu Normal University Graduate Studies

QUALITY MANAGEMENT DISEASE AND CHRONIC ILLNESS MANAGEMENT QUALITY ASSURANCE IN NURSING: STANDARDS HOSPITAL ACCREDITATION

Submitted by: Dorothy Joy V. Manlosa, RN

Date Submitted: 030312

QUALITY MANAGEMENT
There are some different conceptions of quality management systems development throughout the world at present. The ISO conception is looked upon basic one from the point of HCI. This conception is based on voluntary implementation of requirements and recommendations included into a special set of international ISO 9000 standards. The last version of these standards was issued at the end of 2000 year. These standards are generic it means they can be introduced in each organization regardless its size and products or services offered to customers. An effective implementation of these standards has been already proved. These standards are recognized around the world and their principal meaning is in fact that they can lead the organizations to higher effectiveness and efficiency of their management systems on basis of common. Clear advantages: The patient and other stakeholders trust will increase The level of management and realization processes and level of their repeatability will increase The number of failures and errors at organizational units and number of patient claims will decrease All responsibilities and authorities are clearly defined for each group of employees The overall HCI expenditure will decrease as a result of minimizing of wasted resources caused by failures It builds preconditions for prevention of potential problems occurring at workplaces; It increases quality and effectiveness of services offered to patients It increases competitiveness of HCI Principles of Quality Management The ISO 9000 standard defines eight basic principles of quality management. We will explain their essence and we are going to define main activities within practical implementation of these principles. Principle 1: Customer focus Patient represents a typical customer for HCI. The customer is uncompromising arbiter of product and service quality and every organization fully depends on its customers. Thus, organization must take into account all product and service features and characteristics that can bring value to customers and lead to customer satisfaction, preference, referral and future loyalty. The practical implementation of this principle in HCI asks for following activities: a) The systematic research and fully understanding of customer requirements (needs and expectations). b) It must be ensured that HCI objectives are linked to and derived from customer needs and expectations.

c) The customer requirements must be met very quickly and effectively. d) The HCI must systematically measure customer satisfaction level as an important response to their offer. Principle 2: Leadership Managers must be real leaders. They have to create such environment in organization in which all groups of employees can become fully involved in achievement of the organization objectives. Applying the principle of leadership typically leads to these activities: a) Establishing a clear and customer oriented mission, vision, policies and values of the organization; b) Setting challenging objectives and targets throughout the organization every organizational unit ought to have its objectives; c) Creating and sustaining shared values, fairness and ethical role models at all levels of the organization; d) Involving and motivating all people to continuous improvement activities; e) Providing people with required resources, education and training and providing a freedom to act with responsibility and accountability. It is obvious that this principle also includes ethical aspects and it is related to attitudes and behaviour of HCI managers. Its implementation is therefore very sensitive affair. Principle 3: People involvement The full potential of organizations people is best released through shared values and culture of trust and empowerment that encourages the involvement of everyone. The knowledge of employees is a vital value for every organization and valuing the people means committing to their satisfaction, development and wellbeing. When HCI applies the principle of people involvement it would make an effort to these activities: a) People understanding the importance of their contribution and role in the organization processes by systematic communication and listening them. b) People identifying constraints to their best performance and seeing these barriers as opportunities for improvement. c) People evaluating their performance against their personal goals and objectives. The selfassessment and regular evaluation performed by managers could serve as suitable approaches to these evaluations. d) People freely sharing knowledge and experience as a result of effective motivation for performance improvement. e) Managers lead a dialogue with all levels of employees in order to listen to them and to explain strategic intentions. f) The permanent analysis of employees response is crucial.

Principle 4: Process approach This principle is very important for modern quality management unquestionably. The organization performs more effectively and all results are achieved more efficiently when interrelated activities are managed as a process Principle 5: System approach to management This principle is closely linked with process approach. It says that identifying, understanding and managing interrelated processes as a system contributes to the organizations effectiveness and efficiency in achieving the company objectives. The quality management system is considered as a set of interrelated processes. In order to achieve stage when quality management system is a set of interrelated processes HCI must: a) Structure a management system in the most effective and efficient way b) Discover and understand the interdependencies between the processes of the management system c) Understand organizational capabilities and establish resource constraints prior to action. d) Target and describe how specific activities within a system should operate. Principle 6: Continual improvement Every organization always will have a lot of opportunities for next improvement. The continual improvement must be understood as a basic aim in each HCI. The efficient implementation of this principle leads to serious reducing of failures in health care services, an offer of new products and elimination of internal non-effectiveness in HCI. The following activities are necessary to do in each HCI when implementing this principle: a) It must discover all weaknesses throughout the organization and processes by effective internal and external auditing, self-assessment, process performance measurement, benchmarking, etc. The weaknesses would be looked upon the areas for improvement; b) It must plan and release all resources needed for the improvement projects. c) The top management must create an environment for inventions and must involve itself and work in improvement teams very actively. d) The partial successes within the improvement processes must be recognized and people must be rewarded or motivated to next improvement activities. e) Whereas the step by step improvement is never ending process, the breakthrough improvements project must be very carefully planned and organized. Principle 7: Factual approach to decisions making Effective decisions are based on the analysis of data and information. It means that managers make a decision on basis of various measurements within the management system. The health care institutions must develop and perform such activities as: a) Training of people in order to correct performing the measurements and data analysis. b) Collection of all data from processes needed for analysis and decisions making.

c) Making data accessible to whose functions (persons) throughout the organization that really needs it. d) Permanent and systematic analysis of data and information using valid methods for trends and data projections learning. Owing to this principle the HCI reaches higher level of decisions makings objectivity and transparency, status of comprehensive communication with HCI staff, what can influence their positive motivation and trust. Principle 8: Mutually beneficial supplier relationship Every organization takes use products and services delivered by its suppliers. And every organization works more effectively when it has mutually beneficial relationships with its suppliers built on trust, sharing knowledge and integration. The supplier ought to be a partner not adversary. And what HCI must do when it applies this principle? a) It must structure all suppliers and identify so-called key suppliers. b) It must develop and introduce criteria for supplier selection and assessment. c) It must measure actual performance of suppliers and communicate the results. d) It must offer various kinds of technical aid to important suppliers. e) It must share best practices and knowledge and pool of expertise and resources with suppliers. f) It must openly communicate its requirements and future plans to suppliers in a systematic way. The principles mentioned above must be understood as cornerstones during the quality management system implementation in each organization, including health care sector. Ignoring or underestimating them from the point of managers will certainly cause that the system will not be effective and efficient at all.

Basic steps during quality management system implementation in HCI

Identification of HCI objectives

Obtaining information about ISO 9000 family standards

Decision making about ISO 9000 family standards implementation

Analysis of current status of HCIs management system

Working out the implementation plan and its implementation

Internal auditing of quality management system

Need of conformity assessment Yes

No

Undergoing the external auditing

Continual improvement of quality management system

DISEASE AND CHRONIC ILLNESS MANAGEMENT

Disease Management
Disease management is an approach to healthcare that teaches patients how to manage a chronic disease. Patients learn to take responsibility for understanding how to take care of themselves to avoid potential problems or exacerbation, or worsening, of their health problem.
Disease management represents a comprehensive, ongoing, and coordinated approach to achieving desired outcomes for a population of patients.

For people who can access health care practitioners or peer support it is the process whereby persons with long-term conditions share knowledge, responsibility and care plans with healthcare practitioners and/or peers. Knowledge sharing, knowledge building and a learning community are integral to the concept of disease management. It may reduce healthcare costs and/or improve quality of life for individuals by preventing or minimizing the effects of disease, usually a chronic condition, through knowledge, skills, enabling a sense of control over life (despite symptoms of disease) and integrative care.

Possible outcomes for patients:

Improving patients' clinical condition. Reducing unnecessary healthcare costs. Improving patients' quality of life.

History
Disease management has evolved from managed care, specialty capitation, and health service demand management, and refers to the processes and people concerned with improving or maintaining health in large populations. It is concerned with common chronic illnesses, and the reduction of future complications associated with those diseases. The concept of teaching patients disease management was begun in an effort to improve the quality of a patient's care. In 2005, health insurance companies turned their focus on disease management in an effort to control healthcare costs. The theory was that if patients learned to take better care of their health problems, it would save the insurance company money.

Illnesses that disease management would concern itself with would include:
Coronary heart disease

Chronic obstructive pulmonary disease(COPD) Kidney failure Hypertension Heart failure Obesity Diabetes mellitus Asthma Cancer Arthritis Clinical depression Sleep apnea Osteoporosis Other common ailments

Standards of Disease Management Programs

The disease management standards are organized into seven categories that encompass the minimal component set for effective disease management program. These are as follows:

1. ORGANIZATION: They address the administrative and programmatic requirements for disease management. 1.1 Medical Leadership The medical leadership group includes representatives from Primary care physicians, Specialty physicians as appropriate to the disease management program and Health plan or sponsoring organization medical leadership. Appropriate representatives of the health plan or sponsoring organization and the DMO support the medical leadership group. The selection of physicians to participate in the leadership group should include consideration of the following criteria- Experience with health care delivery within the local community, Board Certification, and active participating provider in the health plan's or sponsoring organization's network. 1.2 Coordination among Physicians and other practitioners The Disease Management organization promotes coordination and communication among practitioners, primary care physicians and specialty physicians to provide care for all identified health care needs of each patient. The primary care physicians or other practitioners manage a large percentage of the population with chronic diseases. It may be appropriate, at certain points, to refer to specialty physicians. When many physicians or other practitioners are involved with the care of a patient, they may not have all the important information necessary to manage the issues of health care at hand. The coordination of care and

communication between and among practitioners is critical, since the continuity of care is necessary to attain the best possible clinical outcomes. To achieve this, a list of specialty care physicians should be maintained. Important medical information should be shared between the practitioners, primary care physicians and specialty physicians. The consultation, referral and clinical practice guidelines specific to the disease must be established and approved by the Disease Management Organization and it should be distributed to all the network providers. 1.3 Roles and Responsibilities of the DMO care team The Disease Management Organization establishes responsibilities and promotes adherence to performance expectations for all staff members of the DMO. All the staff members of the DMO are provided with a written job description. They are also provided with a formal orientation program that provides initial training. The DMO also provides a performance management program to assess, and improve as necessary, adherence to job responsibilities and expectations for its members. To maintain and improve competency, knowledge and/or skills for all staff members, the DMO coordinates continuing education. The success of the DMO staff functioning depends on the depth of the initial orientation, understanding of roles and responsibilities, belief in the mission, and identification of opportunities for performance growth with appropriate education and training. 1.4 Integration with Health plan/ sponsoring organization The Disease Management Organization services are fully integrated with the health plan's or sponsoring organization's services. Delivery of a comprehensive disease management program requires successful performance of a myriad of different activities, many of which the health plan or sponsoring organization may already be performing effectively. Whenever appropriate, the disease management program should not replicate such services. In order to assure all services are being performed, effective integration of processes between the health plan and sponsoring organization and the DMO and clear pathways of communication are critical to maximize the results of the program. 1.5 Information System The Disease Management Organization provides and maintains an Information System (IS) capable of supporting data design, collection, analysis, storage, retrieval, dissemination, and reporting to facilitate timely use of both clinical and financial data information. 1.6 Communications The Disease Management Organization provides appropriate and timely communication with diagnosed patients, their physicians or responsible practitioners, the health plan or sponsoring organization, and other health care team members. The goals of the program for the patients are consistent and are communicated to the practitioner, patient and the DMO care team. All the communication between the DMO and other members of the health care team is documented and

maintained. The documentation reflects that communication among all health care team members is timely and appropriate to patient care needs. Feedback communication to physicians or practitioners is provided in a constructive and educational manner. 1.7 Patient care The Disease Management Organization supports the coordination and integration of all the health care needs of all diagnosed patients of the population whether or not their needs are related to the defined diagnosis. The DMO identifies and includes all patients within the chronic disease population being managed, regardless of overall health status. All newly identified health care needs of the chronic disease population are communicated by the DMO to the primary physician or practitioner. 1.8 Patient stratification The Disease Management Organization provides a formal stratification structure to assure appropriate interventions in accordance with each patient's health care needs. Patient stratification is based on pre-determined clinical classification models, which includes clinical, behavioral, utilization, and cost components and patient stratification/re-stratification occurs as new clinical information becomes available. Each stratification level is linked to program interventions. All patients are entitled to a minimum standard of care for most chronic disease programs. Some patients in the population will have progressed along the disease continuum and will require intensive and/or more frequent interventions. Programs that are built on the application of evidence-based standards and best practices reflect the ability of a DMO to apply appropriate resources at appropriate times as dictated by the needs of the population. 1.9 Outcomes The Disease Management Organization has developed a pre-determined set of performance measures for the diagnosed population to evaluate program outcomes. The DMO collects, analyzes and reports information/data consistent with those methodologies recommended by quality/regulatory organizations, and population based metrics defined by the DMO. Appropriate intervals for performance monitoring are set by the medical leadership group and reviewed in conjunction with the DMO and the health plan or sponsoring organization. A critical component of a disease management program is the ability to determine, measure, and report performance toward program goals. Effectiveness of care delivered can then be evaluated in a variety of ways, including improvement in overall health status, satisfaction, and total health care costs. 1.10 Complaint and Grievance Process The Disease Management Organization ensures that a "Complaint/Grievance Resolution Process" is in place to address issues raised by patients or providers.

The Complaint/Grievance Process is written. The Complaint/Grievance Process is approved by the medical leadership group, health plan or sponsoring organization and DMO and is reviewed on at least a semi-annual basis. The patients and providers are informed of the existence of the Complaint/Grievance Process and their ability to access the same in accordance with quality/regulatory oversight organizations. The Complaint/Grievance Process is consistent and coordinated with that of the health plan or sponsoring organization. Patient and provider satisfaction is essential to the success of the disease management program. Accordingly, the DMO considers the resolution of complaints to be a serious matter that calls for timely response. The Complaint/Grievance Process should be more substantive than a mere defense of current operations and services. Rather, they should provide opportunities to critically review program processes to determine if there are potential improvements to be made.

2. PERSONNEL COMPONENTS: These address the staffing and Human Resources issues associated with disease management. The Disease Management Organization provides sufficient and appropriately educated and clinical and administrative staff with credentials to meet program requirements. An adequate number of DMO staff is provided to accommodate the scope of services. Each member of the DMO staff has education/training appropriate to his/her role. Each professional member of the DMO staff is appropriately licensed and/or certified. Each member of the DMO staff performs responsibilities consistent with his/her education/training, licensure, certification, and within his or her state practice act. The DMO will assure that any subcontractor meets the appropriate standards with respect to education/training, licensure, certification, and responsibilities. The success of the disease management program is highly dependent on and directly related to the DMO's ability to provide qualified, knowledgeable, and competent staff that will be able to practice within their professional practice guidelines.

3. PHYSICIAN AND OTHER PRACTITIONER EDUCATION: They address the required provision of support to physicians and other practitioners. The Disease Management Organization provides education to physicians, other practitioners, and their support staff to facilitate successful management of the program population: The physicians, other practitioners, and their support staff are educated by the DMO regarding current adopted clinical practice guidelines for the program population. It also provides education to physicians, other practitioners, and their support staff regarding tools and processes available for meeting the objectives of the DMO program. It is essential that physicians, other

practitioners, and their support staff be fully informed regarding current clinical practice guidelines and evidence-based treatment modalities. The Disease Management Organization provides physicians and other practitioners data for their program patients: The DMO communicates program outcomes to be reported. It also provides periodic outcome reports to the practitioners regarding their clinical practices with respect to peer groups and target references, which include evidence-based best practices. There is evidence to suggest to that the provision of meaningful data and information can encourage physicians and other practitioners to adopt and or maintain best clinical practices; the provision of these data allows physicians and other practitioners to evaluate their own performances as compared to their peers.

4. OUTCOMES: These address metrics and measurement processes. The DMO establishes written, predetermined clinical, satisfaction, and financial outcome metrics for evaluation of program performance: The outcome metrics is established from clearly identified data sources. Established outcome targets are agreed upon and communicated by the medical leadership group, health plan or sponsoring organization, and the DMO. Clinical outcomes are based on evaluation of contemporary and generally accepted standards of care and best practices. The DMO conducts surveys at specified intervals regarding patient and responsible practitioner satisfaction with the disease management program. Outcome results are utilized to guide further continuous improvement in both patient care and program design. The methodology for data collection, analysis, and reporting of outcomes is specified and documented. Analyses are conducted as required to satisfy appropriate third-party reporting requirements. The DMO also conducts clinical, satisfaction, and financial outcome analysis in a manner that addresses its program's impact on all patients with the disease: The frequency and methodology for data collection, analysis, and reporting of outcomes is specified and documented. The base period for analysis and the time frame for documentation are defined prior to commencement of the DMO program. The denominator for all calculations should be the number of patients diagnosed with the disease, irrespective of whether or not those patients are participating in the DMO program. In financial analysis, the costs to be evaluated should include the total health care costs of the entire population of patients diagnosed with the disease, irrespective of whether or not those patients are participating in the DMO program. 5. CLINICAL PRACTICE GUIDELINES: They address adoption, dissemination, and utilization. The Disease management Organization communicates comprehensive clinical practice guidelines (CPG) that reflect recognized standards of care and current best practices: The medical leadership group adopts CPG reflecting the most current medical evidence available. The CPG and all subsequent updates are communicated to all physicians and other practitioners on a timely basis. The DMO provides a process to facilitate periodic review of CPG. The foundation for

an effective disease management program is the application of infrastructure, systems, and processes that support responsible practitioners and patients in adhering to evidence-based medical practices. 6. INTERACTION WITH PATIENTS: These address interactions with patients and their role in self-management and appropriate use of resources. The Disease Management Organization's interactions with patients are conducted in a professional, compassionate and supportive manner: The DMO supports patients' rights to services and treatments consistent with adopted clinical practice guidelines. The organization ensures patient confidentiality and rights to use the complaint/grievance process and supports the resolution of complaints. It also ensures that communications with the patient are conducted in a courteous and respectful manner. The DMO also supports patient's right to decline participation in all or part of the disease management program and the patient/practitioner relationship and encourages patients to make suggestions to improve the program. The DMO also coordinates the education program to assist the patient in selfmanagement and effective use of available resources: All the patients in the program are offered education, which is an ongoing process, and the information is disseminated. Educational materials approved by the medical leadership group are provided to the patients. These are contemporary and designed to empower them in self-management of their health and in appropriate utilization of resources. 7. CONTINUOUS QUALITY IMPROVEMENT-- PLAN, IMPLEMENTATION & EVALUATION: They address the Continuous Quality Improvement process, the quality improvement plan, measurement, and follow up for both clinical and financial aspects of disease management. The CQI plan description defines scope, content, roles/responsibilities, and activities of the overall quality improvement process. The CQI plan defines roles and responsibilities of all the involved parties and the activities of the overall quality improvement process. The medical leadership group, the health plan or sponsoring organization and the DMO approve the plan. The medical leadership group provides the clinical oversight for the CQI plan development and implementation. The DMO and the health plan or other sponsoring organization provides the business oversight. Review of the CQI plan is documented on an annual basis and is modified as necessary by the medical leadership group, the health plan and/or sponsoring organization, and the DMO. The organization defines the process of prioritization of opportunities for improvement. The CQI is an integrative process linking infrastructure, standards, and outcomes information, to assess and improve clinical and business processes, thus to improve overall quality of care and services provided.

Chronic Illness Management

Chronic Illness is an illness or disease that is long-term or permanent, as opposed to acute. These illnesses can include everything from a mild case of hypertension, to asthma, diabetes, some forms of cancer, cerebral palsy, blindness, deafness, emphysema, stroke, Parkinson's and different forms of arthritis. Some patients have a combination of several diseases all at once. This illness causes much disability in individual lives and needs to be managed well. It costs society and families a great deal of financial stress, loss of employment, and is dysfunctional in every aspect.

Helping Patients Take Charge of Their Chronic Illnesses

1. The patient is the solution The patient is at the center and is actively involved in his or her own health care

But why can't we stick with the old models? Why does the patient need to be so involved? There are several reasons Most chronic illness care does not even involve physicians and other health care professionals. As a family physician, you may know what's best for treating diabetes or asthma or congestive heart failure, but that does not mean you necessarily know what's best for an individual patient We know from several studies that when patients are encouraged to be more involved and when their physicians are less prescriptive, patients do have better outcomes. 2. Empowerment through education It's very difficult for patients to do what they don't understand, so the first step in equipping patients to take on a more active role in their health care is to educate them

Four of the most important lessons patients with chronic diseases need to understand are the following: 1. Their illness is serious. There are still patients out there who believe they have the not-so-serious kind of diabetes. If they don't believe it is a problem, they will never make changes to improve their health. 2. Their condition is essentially self-managed. Every decision patients make throughout the day, from what they eat to whether they walk or ride the bus, has an influence on their health. Communicate to patients that they are the most important individuals in managing their illnesses.

3. They have options. There is rarely one perfect way to treat a condition. In the case of diabetes, for example, patients can be treated through diet and exercise, oral medication, insulin and so on. Patients need to understand the different treatment options available and should be encouraged to look at the personal costs and benefits of each. Only the patient can decide if the benefits are greater than the costs. 4. They can change their behavior. Rarely do patients leave the doctor's office and immediately enact whatever change was recommended. The reality is that it often has to be spread out into a series of steps. Teach patients that significant behavioral changes can be made by setting goals, taking that first step and figuring out what you learn about yourself along the way. 3. Helping patients set goals In the patient-centered model of care, the driving force behind each patient visit is the patient's agenda or goals related to his or her condition

The process of setting self-management goals with the patient involves essentially two steps. 1. Start at the problem. Rather than beginning the patient encounter focused on lab values or weight or blood pressure readings, begin by saying, Tell me what concerns you most. Tell me what is hardest for you. Tell me what you're most distressed about and what you'd most like to change. You'll get to the lab values and other issues later, but it will be in the context of the patient's personal goal, which will make it more meaningful for the patient. As you begin to get a sense of the patient's concerns, explore those issues together. Ask, Is there an underlying problem? Do you really want this problem to be solved? What's the real issue? 2. Develop a collaborative goal. Once you have worked with the patient to identify the real problem, your instinct may be to try to solve it, but don't. Don't try to fix it. Don't just say, It will be OK. Instead, validate the patient's feelings and his or her capacity to deal with the problem, and continue asking questions that will lead the patient to his or her own solution. Ask, What do you think would work? What have you tried in the past? What would you like to try?

QUALITY ASSURANCE IN NURSING: STANDARDS

Standard is an acknowledged measure of comparison for quantitative or qualitative value, criterion, or norm. A standard is a practice that enjoys general recognition and conformity among professionals or an authoritative statement by which the quality of practice, service or education can be judged. It is also defined as a performance model that results from integrating criteria with norms and is used to judge quality of nursing objectives, orders and methods A standard is a means of determining what something should be. In the case of nursing practice standards are the established criteria for the practice of nursing. Standards are statements that are widely recognized as describing nursing practice and are seem as having permanent value. A nursing care standard is a descriptive statement of desired quality against which to evaluate nursing care. It is guideline. A guideline is a recommended path to safe conduct, an aid to professional performance. A nursing standard can be a target or a gauge. When used as a target, a standard is a planning tool. When used as a gauge against which to evaluate performance a standard is a control device. Characteristics of Standard

Standards statement must be broad enough to apply to a wide variety of settings. Standards must be realistic, acceptable, and attainable. Standards of nursing care must be developed by members of the nursing profession; preferable Nurses practicing at the direct care level with consultation of experts in the domain. Standards should be phrased in positive terms and indicate acceptable performance good, excellence etc. Standards of nursing care must express what desirable optional level is. Standards must be understandable and stated in unambiguous terms. Standards must be based on current knowledge and scientific practice. Standards must be reviewed and revised periodically. Standards may be directed towards an ideal,ie,optional standards or may only specify the minimal care that must be attained,ie, minimum standard. And one must remember that standards that work are objective, acceptable, achievable and flexible.

Purposes of Standards

Setting standard is the first step in structuring evaluation system. The following are some of the purposes of standards. Standards give direction and provide guidelines for performance of nursing staff. Standards provide a baseline for evaluating quality of nursing care

Standards help improve quality of nursing care, increase effectiveness of care and improve efficiency. Standards may help to improve documentation of nursing care provided. Standards may help to determine the degree to which standards of nursing care maintained and take necessary corrective action in time. Standards help supervisors to guide nursing staff to improve performance. Standards may help to improve basis for decision-making and devise alternative system for delivering nursing care. Standards may help justify demands for resources association. Standards my help clarify nurses area of accountability. Standards may help nursing to define clearly different levels of care.

Major objectives of publishing, circulating and enforcing nursing care standards are to: 1. Improve the quality of nursing care, 2. Decrease the cost of nursing, and 3. Determine the nursing negligence. Sources of Nursing Care Standards It is generally accepted that standards should be based on agreed up achievable level of performance considered proper and adequate for specific purposes. The standards can be established, developed, reviewed or enforced by variety of sources as follows:

Professional organization, e.g. Associations, TNAI, Licensing bodies, e.g. Statutory bodies, INC, Institutions/health care agencies, e.g. University Hospitals, Health Centers. Department of institutions, e.g. Department of Nursing. Patient care units, e.g. specific patients' unit. Government units at National, State and Local Government units. Individual e.g. personal standards

Classification of Standards There are different types of standards used to direct and control nursing actions. 1. Normative and Empirical Standards Standards can be normative or empirical. Normative standards describe practices considered 'good' or 'ideal' by some authoritative group. Empirical standards describe practices actually observed in a large number of patient care settings. Here the normative standards describe a higher quality of performance than empirical standards. Generally professional organizations (ANA/TNAI) promulgate normative standards where as low enforcement and regulatory bodies (INC/MCI) promulgate empirical standards.

2. Ends and Means Standards Nursing care standards can be divided into ends and means standards. The ends standards are patient-oriented; they describe the change as desired in a patient's physical status or behavior. The means standards are nursing oriented, they describe the activities and behavior designed to achieve the ends standards. Ends (or patient outcome) standards require information about the patients. A means standard calls for information about the nurses performance. 3. Structure, Process and Outcome Standards Standards can be classified and formulated according to frames of references (used for setting and evaluating nursing care services) relating to nursing structure, process and outcome, because standard is a descriptive statement of desired level of performance against which to evaluate the quality of service structure, process or outcomes. a. Structure Standard A structural standard involves the 'set-up' of the institution. The philosophy, goals and objectives, structure of the organization, facilities and equipment, and qualifications of employees are some of the components of the structure of the organization, e.g. recommended relationship between the nursing department and other departments in a health agency are structural standards, because they refer to the organizational structure in which nursing is implemented. It includes people money, equipment, staff and the evaluation of structure is designed to find out the effectiveness, degree to which goals are achieved and efficiency in terms of the amount of effort needed to achieve the goal. The structure is related to the framework, that is care providing system and resources that support for actual provision of care. Evaluation of care concerns nursing staff, setting and the care environment. The use of standards based on structure implies that if the structure is adequate, reliable and desirable, standard will be met or quality care will be given. b. Process Standard Process standards describe the behaviors of the nurse at the desired level of performance the criteria that specify desired method for specific nursing intervention are process standards. A process standard involves the activities concerned with delivering patient care. These standards measure nursing actions or lack of actions involving patient care. The standards are stated in action-verbs that are in observable and measurable terms.eg: the nurse assesses", "the patient demonstrates". The focus is on what was planned, what was done and what was communicated or recorded. Therefore, the process standards assist in measuring the degree of skill, with which technique or procedure was carried out, the degree of client participation or the nature of interaction between nurse and client. In process standard there is an element of professional judgment determining the quality or the degree of skill. It includes nursing care techniques, procedures, regimens and processes.

Outcome Standards Descriptive statements of desired patient care results are outcome standards because patients results are outcomes of nursing interventions. Here outcome as a frame of reference for setting of standards refers to description of the results of nursing activity in terms of the change that occurs in the patient. An outcome standard measures change in the patient health status. This change may be due to nursing care, medical care or as a result of variety of services offered to the patient. Outcome standards reflect the effectiveness and results rather than the process of giving care. Legal Significance of Standards Standards of care are guidelines by which nurses should practice. If nurses do not perform duties within accepted standards of care, they may place themselves in jeopardy of legal action. Malpractice suit against nurses are based on the charge that the patient was injured as a consequence of the nurses failure to meet the appropriate standards of care. To recover losses from a charge of malpractice, a patient must prove that: 1. A patient-nurse relationship existed such that the nurse owed to the patient a duty of due care, 2. The nurse deviated from the appropriate standard of care, 3. The patient suffered damages, 4. The patient's damages resulted from the nurses deviations from the standard of care. Conclusion Quality assurance is to provide a higher quality of care. It is necessary that nurses develop standards of patient care and appropriate evaluation tools, so that professional aspects of nursing involving intellectual and interpersonal activities. Quality will be ensured and attention will be given to the individual needs and responses to patients. The formulation of standards is the first step towards evaluating the nursing care delivery. The standards serve as a base by which the quality of care can be judged. This judgment may be according to a rating or other data that reflect the conformity of existing practice with the established standards. The standards must be written, regularly reviewed and well-known by the nursing staff.

HOSPITAL ACCREDITATION
Hospital accreditation has been defined as: A self-assessment and external peer assessment process used by health care organizations to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve Accreditation is not just about standard-setting: there are analytical, counseling and self-improvement dimensions to the process. Evidence-based medicine, quality assurance and medical ethics, and the reduction of medical error are a key role of the accreditation process. Hospital accreditation is therefore one component in the maintenance of patient safety.

Broadly speaking, there exist two types of hospital accreditation: 1. Hospital and healthcare accreditation which takes place within national borders. 2. International healthcare accreditation. Importance of accreditation in hospitals Accredited hospitals offer higher quality of care to their patients Accreditation also provides a competitive advantage in the health care industry and strengthens community confidence in the quality and safety of care, treatment, and services. It improves risk management and risk reduction and helps organize and strengthen patient safety efforts and creates a culture of patient safety. Not only does it enhance recruitment and staff education and development, it also assesses all aspects of management and provides education on good practices to improve business operations. The accreditation process: 1. Begin with accreditation process by education: Educate the leaders and the managers and explain the benefits, advantages, process, timeline, etc., of the accreditation. 2. Baseline assessment: Use knowledgeable and credible evaluators (either internal or external consultants) who will critically and objectively assess each area and conduct a detailed baseline assessment of the organizations current adherence to the standards and each measurable element. Score as Met, Partially Met, or Not Met and cite specific findings and recommendations. Also collect and analyze baseline quality data as required by the quality monitoring standards (e.g., medication errors, hospitalassociated infection rates, antibiotic usage, surgical complications, etc.) Establish an

ongoing monitoring system for data collection (e.g., monthly, with quarterly data analysis) to identify problem areas and track progress in improvement. 3. Action planning: Using the findings of the baseline assessment, develop a detailed project plan starting first with priority areas of the core standards. Responsibilities, deliverables, and time frames should be assigned (e.g., revise informed consent policy, develop a new informed consent statement, educate staff in the next two-month time period.) 4. Chapter assignment: Look for good people skills, time-management skills, and consensus-building skills, and assign oversight of each chapter of standards to a respected champion or leader who will identify team members from throughout the hospital and carry out the process. 5. Policies and procedures: In addition to an overall project plan, it is often helpful to compile a list of all required policies and procedures that will need development and revision. Continue to monitor your progress in meeting the standards, such as through a mini-evaluation of each chapter at regular intervals (e.g., quarterly). 6. Final mock survey: Plan for a final mock survey at least four to six months in advance of the target date of the actual accreditation survey. Use evaluators (internal or external consultants) who were not involved in the baseline assessment and preparation, who will look at the organization with a fresh and objective eye. Plan final revisions and corrections based on the findings of the final mock survey. Final survey The success of any quality assurance program depends almost entirely on the commitment and interest of the administrators, nurses, paramedical staff, and physicians. Leaders of quality assurance programs must be able to generate interest and commitment without burdening clinical and administrative staff with an activity they neither understand nor believe in. This will help move quality assurance out of its current paralysis in some hospitals. Quality assurance is to succeed in its goal to identify and correct problems and to improve the quality of patient care.