Which step of the nursing process involves checking the effectiveness of a nursing plan?

The fifth stage of nursing process: Evaluation. Documentation

EVALUATION

Evaluation is the fifth step in the nursing process and involves determining whether the client goals have been met, have been partially met, or have not been met. Even though it is the final phase of the nursing process, evaluation is an ongoing part of daily nursing activities that determines the effectiveness of those activities in helping clients achieve expected outcomes.

Evaluation is not only a part of the nursing process, but it is also an integral process in determining the quality of health care delivered. In addition to discussing evaluation as part of the nursing process, this chapter also describes the role of evaluation in delivering quality care.

This chapter discusses the purposes, components, and methods of evaluation. The relationship between evaluation and quality of care is described.

EVALUATION OF CLIENT CARE

Evaluation is the measurement of the degree to which objectives are achieved. Therefore, evaluating the care provided to clients is an essential part of professional nursing. “Evaluation is a planned, systematic process . . . [that] compares the client’s health status with the desired expected outcomes” (Kenney, 1995, p. 195).

The American Nurses Association (1998), in its Standards of Clinical Nursing Practice, designates evaluation as a fundamental component of the nursing process (see the accompanying display).

The purposes of evaluation include:

• To determine the client’s progress or lack of progress toward achievement of expected outcomes

• To determine the effectiveness of nursing care in helping clients achieve the expected outcomes

• To determine the overall quality of care provided

• To promote nursing accountability (discussed later in this chapter)

Evaluation is done primarily to determine whether a client is progressing—that is, experiencing an improvement in health status. Evaluation is not an end to the nursing process, but rather an ongoing mechanism that assures quality interventions. Effective evaluation is done periodically, not just prior to termination of care. Evaluation is closely related to each of the other stages of the nursing process. The plan of care may be modified during any phase of the nursing process when the need to do so is determined through evaluation. Client goals and expected outcomes provide the criteria for evaluation of care.

COMPONENTS OF EVALUATION

Evaluation is a fluid process that is dependent on all the other components of the nursing process. As shown in Figure 10-1, evaluation affects, and is affected by, assessment, diagnosis, outcome identification and planning, and implementation of nursing care. Table 10-1 shows how evaluation is woven into every phase of the nursing process.

Ongoing evaluation is essential if the nursing process is to be implemented appropriately. As Alfaro-LeFevre (1998) states: When we evaluate early, checking whether our information is accurate, complete, and up-to-date, we’re able to make corrections early. We avoid making decisions based on outdated, inaccurate, or incomplete information. Early evaluation enhances our ability to act safely and effectively. It improves our efficiency by helping us stay focused on priorities and avoid wasting time continuing useless actions. (p. 22)

There are specific criteria to be used in the process of evaluation. The evaluation criteria must be planned, goal-directed, objective, verifiable, and specific (that is, strengths, weaknesses, achievements, and deficits must be considered).

Techniques

Effective evaluation results primarily from the nurse’s accurate use of communication and observation skills.

Both verbal and nonverbal communication between the nurse and the client can yield important information about the accuracy of the goals and expected planned outcomes and the nursing interventions that have been executed for resolution of the client’s problems. The nurse needs to be sensitive to clients’ willingness or hesitation to discuss their responses to nursing actions and must use the techniques of therapeutic communication to collect all necessary data.

The nurse must be sensitive to changes in the client’s physiological condition, emotional status, and behavior.

Because these changes are often subtle, they require astute observational skills on the part of the nurse.

Observation occurs through use of the senses. In other words, what the nurse sees, hears, smells, and feels when touching the client all provide clues to the client’s current health status.

Sources of Data

Evaluation is a mutual process occurring among the nurse, client, family, and other health care providers.

Both subjective and objective data are used in evaluating the client’s status. Asking clients to describe how they feel results in subjective data. Objective data consist of observable facts, such as laboratory values and the client’s behavior. When a nurse communicates an assessment of a client’s response to an actual or potential health problem, clients and families are empowered to discuss their concerns and questions. When feedback is given, the nurse must avoid being defensive, because that attitude may cause clients or families to avoid being open and honest. As a result, they may only say what they think the nurse wants to hear or they may completely refuse to participate in the evaluation process.

The nurse’s verbal and nonverbal communication establishes the atmosphere in which clients and families freely share their comments, both positive and negative.

Goals and Expected Outcomes

The effectiveness of nursing interventions is evaluated by examination of goals and expected outcomes. Goals provide direction for the plan of care and serve as measurements for the client’s progress or lack of progress toward resolution of a problem.

Realistic goals are necessary for effective evaluation. These goals must take into consideration the client’s strengths, limitations, resources, and the time frame for achievement of the objectives. Examples of client strengths are educational background, family support, and financial resources (for instance, money to purchase medications and foods that support the prescribed interventions). Examples of client limitations are delayed developmental level, poverty, and unwillingness to change (lack of motivation).

METHODS OF EVALUATION

The nurse who successfully evaluates nursing care uses a systematic approach that ensures thorough, comprehensive collection of data. Evaluation is an orderly process consisting of seven steps, which are explained here.

Establishing Standards

Specific criteria are used to determine whether the demonstrated behavior indicates goal achievement.

Standards are established before nursing action is implemented. Evaluation of criteria examines the presence of any changes, direction of change (positive or negative), and whether the changes were expected or unexpected.

Collecting Data

Assessment skills are used to gather data pertinent to goals and expected outcomes. The nurse must be proficient in assessment skills for effective, comprehensive evaluation to occur. Evaluation data are collected to answer the following question: Were the treatment goals and expected outcomes achieved?

Determining Goal Achievement

Data are analyzed to determine whether client behaviors indicate goal achievement. This process is validated through analysis of the client’s response to the specific nursing interventions that are developed in the plan of care. For example, these data can take the form of either physiological responses (such as the client’s being able to cough productively in order to promote effective breathing patterns) or psychosocial responses (such as the client’s being able to verbalize concerns about an impending surgical procedure in order to alleviate anxiety).

Relating Nursing Actions to Client Status

Nursing interventions are examined to determine their relevance to the client’s needs and nursing diagnoses. Efficient nursing actions are those that address pertinent client needs and are proven to be primary factors in helping clients appropriately resolve actual or potential problems.

Judging the Value of Nursing Interventions

Critical-thinking skills are employed to determine the degree to which nursing actions have contributed to the client’s improved status. These skills enable the nurse to apply an analytical focus to the client’s responses to the nursing interventions and thus to evaluate the benefits of those actions and identify additional opportunities for change.

Reassessing the Client’s Status

The client’s health status is reevaluated through use of  assessment and observation skills. Evaluation focuses on the client’s health status and compares it with baseline data collected during the initial assessment. Omissions or incomplete data within the database are identified so that an accurate picture of the client’s health status is obtained.

Modifying the Plan of Care

If the evaluation data indicate a lack of progress toward goal achievement, the plan of care is modified. These revisions are developed through the following process: reassessment of the client; formulation of more appropriate nursing diagnoses; development of new or revised goals and expected outcomes; and implementation of different nursing actions or repetition of specific actions to maximize their effectiveness (for instance, client teaching). See the Nursing Checklist for guidelines for evaluating effective application of the nursing process to client care.

Evaluation is performed by every nurse, regardless of the practice setting. For example, the home health nurse evaluates the care provided regularly throughout the client’s relationship with the agency. Evaluation of the home care client is carried out in order to determine whether the care was delivered in an effective and efficient manner, to modify the plan of care as needed, and to decide when the client is ready for discontinuation of home care services. The accompanying display provides an example of evaluation performed by the home health care nurse.

Critical Thinking and Evaluation

Evaluation is a critical thinking activity. It is a deliberate mechanism used to analyze and make judgments.

Nurses need to remain objective when evaluating client care in order to modify care based on reason rather than emotion. One critical thinking strategy, juxtaposing, is described as “putting the present state condition next to the outcome state in a side-by-side contrast” (Pesut & Herman, 1999, p. 93). Nurses use juxtaposing throughout evaluative activities by comparing client responses to expected behaviors. They make conclusions about whether expected outcomes have been met.

In order to make such conclusions, assessment data is needed to determine client progress toward achievement of objectives. Evaluation involves analysis and is much more complex than merely answering questions.

EVALUATION AND QUALITY OF CARE

Evaluation is performed at the individual and institutional levels. For example, individual evaluation focuses on the client’s achievement of goals and also on the individual nurse’s delivery of care. Quality and evaluation are closely related. This section examines the role of evaluation in assuring the delivery of quality health care. Because it is the mechanism used by nurses in determining the need for improvement, evaluation assists in the provision of quality care. The aspects that need to be evaluated to determine the quality of health care are:

• Appropriateness (the care provided adhered to standards and resulted in achievement of goals)

• Clinical outcomes

• Client satisfaction

• Cost-effectiveness

• Access to care

• Availability of resources

Quality management involves constant, ongoing evaluation (monitoring of activities).

Elements in Evaluating the Quality of Care

Organizational evaluation examines the agency’s overall ability to deliver quality care. Evaluation can be classified according to what is being evaluated: the structure, the process, or the outcome. Table 10-2 provides an overview of the types of evaluation. Figure 10-2 illustrates the variables to be assessed in each type of evaluation.

Structure Evaluation

Structure evaluation is a determination of the health care agency’s ability to provide the services offered to its client population. This type of evaluation focuses on assessing the systems by which nursing care is delivered (Barnum & Kerfoot, 1995). Structure evaluation examines the physical facilities, resources, equipment, staffing patterns, organizational patterns, and the agency’s qualifications for staff. The majority of problems with providing effective health care stems from problems in the structural area. The purpose of structure evaluation is to identify any system errors, which can then be corrected.

Structure evaluation involves determining whether client care meets legal and professional standards. A frequently used method to evaluate whether the agency provides care within legal parameters is a review of policy and procedure manuals to check for compliance with regulations.

Process Evaluation

Process evaluation is the measurement of nursing actions by examination of each phase of the nursing process. This type of evaluation is done to determine whether nursing care was adequate, appropriate, effective, and efficient. Nursing interventions are judged to be effective when use of the action results in the desired outcome. A nursing intervention is determined to be efficient through analysis of the intervention’s cost–benefit ratio (Gillies, 1994). Process evaluation determines the nurse’s ability to establish an environment that promotes the client’s health. See Table 10-2 for sample questions used during process evaluation.

Outcome Evaluation

Outcome evaluation is the process of comparing the client’s current status with the expected outcomes. This type of evaluation examines all direct care activities that affect the client’s health status. According to Kenney (1995), “Outcome evaluation, though difficult, is the most meaningful way to judge the effectiveness of nursing interventions” (p. 200).

Outcome evaluation focuses on changes in the client’s health status. A basic question to ask when evaluating the outcome is: Has the expected change occurred? Such changes may include “modifications of symptoms; signs; knowledge; attitudes; satisfaction; skill; and compliance with treatment regimen” (Gillies, 1994, p. 517). Another variable assessed during outcome evaluation is the client’s self-care ability. Has the client demonstrated an improved ability to care for self? Does the client verbalize knowledge related to self-care needs? See Table 10-2 for suggested approaches to performing outcome evaluation.

Nursing Audit

A nursing audit is the process of collecting and analyzing data to evaluate the effectiveness of nursing interventions.

A nursing audit can focus on implementation of the nursing process, client outcomes, or both in order to evaluate the quality of care provided. Nursing audits examine data related to:

• Safety measures

• Treatment interventions and client responses to the interventions

• Preestablished outcomes used as basis for interventions

• Discharge planning

• Client teaching

• Adequacy of staffing patterns

Audits are based on components such as institutional policies; federal, state, and local regulations; accreditation standards; and professional standards (see Figure 10-3). Audits assist in identifying strengths and weaknesses that, in turn, provide direction for areas needing revision. Corrective action plans are developed in accordance with the audit results.

Peer Evaluation

Another method of evaluating quality of care is peer evaluation (also referred to as peer review), the process by which professionals provide to their peers critical performance appraisal and feedback that are geared toward corrective action. According to the ANA (1988): Peer review in nursing is the process by which practicing Registered Nurses systematically assess, monitor, and make judgments about the quality of nursing care provided by peers, as measured against professional standards of practice. (p. 3)

In 1984, Lucille Joel postulated that peer review is the basis of nursing’s autonomy and self-governance (Joel, 1984). This perspective is still very relevant in today’s health care climate. By evaluating itself, nursing is demonstrating an essential criterion by which professions are recognized. Peer evaluation promotes both professional and individual accountability.

The quality of nursing care is strongly evident to coworkers and nurses who are expected to assess the work of their peers. “Peer review is an essential mechanism for evaluating the judgment and performance of clinical providers” (Wakefield, Helms, & Helms, 1995, p. 11).

Such judgment may result in one of the following outcomes:

• Destructive: Complaints and attacks that undermine morale and cohesiveness

• Constructive: Positive feedback that improves the quality of care

Peer evaluation can be destructive if the parties involved begin to personalize the process, misunderstand the purpose, or deliver feedback in an unfeeling and nonobjective manner. Peer evaluation can be threatening when guidelines have not been established for the process and when the assessment focuses on emotions and personalities instead of on behaviors. Conversely, peer evaluation is constructive when the focus remains on quality improvement and encourages the continued growth and learning of all the parties involved. The accompanying display provides principles that promote the use of objective, nonbiased peer evaluation.

EVALUATION AND ACCOUNTABILITY

Accountability means assuming responsibility for one’s actions. Evaluation enhances nursing accountability by providing a mechanism for assisting the nurse to define, explain, and measure the results of nursing actions.

Accountability is increased by ongoing evaluation; nurses are continually checking their own progress against predetermined standards.

Accountability is an integral part of professional nursing practice and is an important method through which commitment to quality client care can be demonstrated.

“Nurses are accountable for designing effective care plans, implementing appropriate nursing actions, and judging the effectiveness of their nursing interventions” (Kenney, 1995, p. 195). In other words, nurses are accountable, for their judgments, decisions, and actions, to:

• Clients, families, and significant others

• Colleagues

• Employers

• The general public (society)

• The nursing profession

• Themselves

Nurses demonstrate their commitment in a variety of ways, including:

• Maintaining expertise in skills

• Participating in continuing education programs

• Achieving and maintaining certification

• Participating in peer evaluation

MULTIDISCIPLINARY COLLABORATION IN EVALUATION

Evaluating the quality of care provided is a responsibility shared among members of the health care team. In addition to those directly involved (the health care providers, clients, and families), others interested in the outcomes of evaluation include the community and third-party payers (both public and private reimbursement organizations).

An ongoing monitoring process is implemented to evaluate quality of care. Ideally, every discipline monitors its own quality efforts. No single discipline is responsible for all-inclusive evaluation of client care. However, in most health care agencies, nurses are actively involved in monitoring evaluation activities. Many agencies have nurses on staff who function either as quality management coordinators, utilization review evaluators, or both.

When health care providers from all the relevant disciplines are involved in evaluation, the result is decreased fragmentation of care. The team approach mandates active involvement of all care providers in the evaluation of quality care. Multidisciplinary evaluation helps promote a continuum of care for the client, from the preadmission phase to discharge planning and follow-up care.

KEY CONCEPTS

• Evaluation, the fifth step in the nursing process, involves determining whether the client goals have been met, have been partially met, or have not been met.

• The purposes of evaluation are to determine the client’s progress or lack of progress toward achievement of client objectives, to judge the value of nursing actions in helping clients to achieve objectives, to determine the health care agency’s overall ability to deliver care in an effective and efficient manner, and to promote nursing accountability.

• Evaluation is based primarily on the skills of communication and observation.

• Evaluation is a mutual, ongoing process occurring among the nurse, client, family, and other health care providers.

• The effectiveness of nursing interventions is evaluated by examination of goals and expected outcomes that provide direction for the plan of care and serve as standards by which the client’s progress is measured.

• Evaluation is an orderly process consisting of seven steps: establishing standards; collecting data related to the goals and expected outcomes; determining goal achievement; relating nursing actions to client status; judging the value of nursing interventions in assisting clients to achieve goals and objectives; reassessing the client’s status; and modifying the plan of care if necessary.

• There is a relationship between quality management and evaluation. Evaluation is necessary in the provision of quality care because it is the mechanism used by nurses in determining how to improve care.

• Structure evaluation judges a health care agency’s ability to provide the services offered to its client population.

• Process evaluation measures nursing actions by examining each phase of the nursing process to determine the effectiveness of the actions in helping clients  meet expected outcomes and goals.

• Outcome evaluation compares the client’s current status with the expected outcomes and examines all direct care activities that affect the client’s status.

• A nursing audit can focus on implementation of the nursing process, client outcomes, or both in order to evaluate the quality of care provided.

• Peer evaluation (peer review) is the process by which professionals provide to their peers performance appraisal feedback geared toward corrective action.

• Evaluation enhances professional nursing accountability by providing a mechanism for assisting the nurse to define, explain, and measure the results of nursing actions.

• Evaluating the quality of care is a shared responsibility among members of the health care team.

MANAGING NURSING CARE

As a result of a global economy, increased competition, and spiraling health care costs, health care organizations must work to continually improve and strive for higher performance. For health care organizations to operate successfully and instill the drive for excellence in each employee, structures must be in place to empower employees to take ownership in their work. A new style of leadership that can facilitate teamwork and process improvement must prevail.

Quality of care, cost, and access are dominant themes in health care delivery. Health care services must be delivered in a manner that increases the likelihood of desired health outcomes and they must be consistent with current knowledge (Joint Commission on Accreditation of Healthcare Organizations [JCAHO], 1999). Nurses, as well as all other health care providers, are accountable for quality care. The challenge for nursing has never been greater as political, economic, and regulatory requirements increase and the demand for quality care intensifies.

This chapter discusses the historical development of quality management in health care and describes the principles that form the basis of quality improvement. It also presents the structure on which quality management programs can be established and explains the mechanisms and tools by which process improvement can be introduced and maintained within health care organizations.

THE QUALITY MOVEMENT IN HEALTH CARE

A quality management system in health care is similar to quality management in other businesses. A brief overview of the development of the quality initiative as it relates to health care is discussed in the following sections.

Evolution

Table 25-1 provides a historical perspective on the development of the quality movement. The AmericanCollege of Surgeons, established in 1913, was the first organized effort to develop quality standards in health care. This body later established the Hospital Standardization Program, which evolved into today’s Joint Commission on the Accreditation of Healthcare Organizations (JCAHO).

Role of the JCAHO in the Quality Movement

Founded in 1951, JCAHO has become the largest accrediting organization in health care today. JCAHO provides standards for hospitals, mental health care facilities, ambulatory care facilities, home health care agencies, and long-term care facilities. Participation in the accreditation process is a voluntary process that is not a condition of licensure but is often a condition for reimbursement by many payers, such as the Federal Health Care Finance Administration (HCFA).

In the 1980s, quality assurance was introduced into JCAHO accreditation standards with emphasis on a problem-solving approach. Each department of an organization was monitored and evaluated for service delivery. The 1990s marked a significant change in quality management in health care. There was a shift from departmental review to interdisciplinary performance improvement. This subsequent transition from quality assurance to the current approach of continuous quality improvement was derived from quality management in industry. The section entitled Quality Improvement discusses the concepts of quality assurance and continuous quality improvement in more detail.

JCAHO has made the following modifications in their survey process (effective January 2000):

• Random unannounced surveys will be conducted.

• Health care organizations will no longer receive advance notification of impending random surveys.

• The focus and scope of the review during the survey will vary from agency to agency.

• On-site surveys will occur during evenings, nights, and weekends rather than be limited to weekdays (Gropper, 1999).

All of these changes have been made in an attempt to improve the quality of health care delivered in organizations participating in JCAHO’s accreditation process.

Defining Quality

Health care has struggled for many years to define and measure quality. Quality is defined as meeting or exceeding requirements of the customer/client. A customer is anyone who uses the products, services, or processes of an organization. Quality is measured in terms of customer perspective. Clients are concerned with the following:

• Accessibility and availability of service

• Timely and safe delivery of service

• Coordination and continuity of care between services

• Effectiveness of services, that is, the delivery and outcome of care

In its 1998 report, JCAHO identified nine dimensions of quality performance. These dimensions are described in the accompanying display. Basically, a health care organization must be concerned with doing the right thing (efficacy, appropriateness) and doing the right things well (availability, timeliness, effectiveness, continuity, safety, efficiency, and respect and caring).

Performance improvement consists of those activities and behaviors that each individual does to meet customers’ expectations. It is doing the right thing well and continually striving to do better (JCAHO, 1998).

In measuring quality, there are three domains to measure: structure, process, and outcome. Each of these components is interrelated. The American Nurses Association’s (ANA’s) Standards of Clinical Nursing Practice (1991) uses these three components of care to guide nursing practice within the framework of the nursing process.

Factors Influencing the Quality Movement in Health Care

Today there are many consumers of health care in addition to clients and their families. One major consumer of health care is third-party payers, such as insurance companies, managed care organizations, and federal and state governments. The diversity of needs represented by these consumers requires improvement in health care delivery systems. The major factors that have influenced the development of the quality movement in health care are consumer demands, financial viability, professional accountability, regulatory requirements, progress in quality improvement techniques, and changes in health care delivery.

Consumer Demands

Heath care consumers are sophisticated, knowledgeable, and selective. Clients no longer place blind trust in their physicians and realize that variables in practice and results occur. Today’s consumers negotiate services and compare health care costs among providers.

Financial Viability

Health care has entered an era of increased competitiveness for services, staff, and customers. There is a demand to reduce spending and contain costs. Budgetary constraints continue to increase in both the private and public health sectors. Health care organizations must strive to reduce professional liability, increase reimbursement eligibility, and promote cost effectiveness through increased efficiency.

Professional Accountability

Emphasis on clinician accountability and adherence to codes of ethical practice is increasing. Health care professionals must be dedicated to reducing practice variances to protect the public.

Regulatory Requirements

The Health Care Financing Administration (HCFA) standards, JCAHO standards, and numerous laws require quality improvement programs. HCFA is a subsidiary of the Department of Health and Human Services and is the federal agency responsible for administering the Medicare and Medical programs. The regulations established by these organizations for accreditation and reimbursement have facilitated the quality initiative in health care. Such externally mandated regulations have promoted the development of internal monitoring and evaluation systems within health care organizations.

Progress in Quality Improvement Techniques

During the past decade, health care providers have spent valuable resources on defining and measuring quality. As a result, evaluation methodologies have improved considerably. Information systems are available through which national and regional norms for comparative data can be obtained. Measurability methods have been upgraded and include a variety of process improvement models. Process improvement examines the flow of client care between departments to ensure that the processes work as they were designed and that acceptable levels of performance are achieved.

Seminars, workshops, videotape training programs, and educational consultants are now available to teach process improvement in health care. Overall quality improvement methodologies enhance performance and work processes.

Changes in Health Care Delivery

Significant changes in health care delivery have occurred and unprecedented change is anticipated in the future. Clients being admitted to hospitals today are sicker, yet are being discharged more quickly.

Alternative care options such as home health care, inhome intravenous therapy, and intermediate care facilities have proliferated, resulting in an even greater need to coordinate a continuum of services.

Factors that have influenced the quality movement in health care have also protected those populations most vulnerable to inadequate health care; for example, the uninsured, the elderly, and low-income families. The quality movement has promoted access to care, standards of care, cost-effective service, and a continuum of care. Thus, the quality movement in health care has served as an advocate for consumers.

Legal and Ethical Implications

Nurses, as well as other health care providers, must understand the roles that law, regulations, and ethics play in the quality movement. These aspects define professional practice. Laws define legal practice, regulations define guidelines for delivery of care, and ethics define personal performance.

Legal Considerations

Legal considerations have an impact on quality management in several ways:

• Laws and regulations create the external structure for quality management.

• Failure to provide quality health care can result in lawsuits.

• Institutions can face liability for action taken against a practitioner if objective measures are not applied to performance and due process is not provided.

Quality management programs must protect against substandard care and ultimately reduce litigation.

Organizations must have clearly defined processes for professional review. These responsibilities are based on case law and federal regulations.

Case Law

Case law refers to the legal opinion rendered in court cases. Numerous legal cases have resulted in rulings that affect quality management. Several landmark cases have established the following issues within the quality management movement:

• Hospitals are liable for the care provided to clients.

• Hospitals are responsible for a department’s practice.

• Limited immunity for peer review exists.

Federal Regulations

A number of federal agencies regulate health care standards; for example, HCFA, the Food and Drug Administration (FDA), and the Occupational Safety and Health Administration (OSHA). Specific regulations issued by these agencies that directly affect quality of care are shown in the accompanying display.

Failure to adhere to the guidelines in these legislative acts can result in sanctions for violation of standards.

Federal funding and payment for services can be denied for failure to provide quality care.

Ethical Considerations

Laws establish standards of acceptable conduct; however, they often represent only a minimum acceptable standard. For example, registered nurse licensure indicates that the nurse possesses the basic knowledge, skills, and abilities to safely practice general nursing.

Professionals are expected to adhere to a code of ethical practice that espouses a responsibility to self, profession, client, and society. Ultimately, nurses have an ethical responsibility to deliver the highest possible quality of health care. Nurses are obligated by licensure to be knowledgeable about the care they are providing and to practice according to an established code of ethics and standards of practice, as exemplified by the ANA’s Code for Nurses (1985). See Chapter 24 for a complete discussion about ethical responsibilities.

Laws provide guidelines, and ethics provide a sense of obligation. Individual practitioners and institutions have a legal and ethical requirement to deliver quality care.

Quality and Cost

Health care costs have skyrocketed in the past decade.

The primary source of health insurance in the United States is employer coverage. Payers are becoming increasingly concerned about health care costs, and the issue of health care expenditures is being debated furiously.

Delivery of poor quality care has a negative financial impact on health care organizations. Yet, management will often argue that the quality improvement initiative is costly because of staff time involved in such activities.

However, one must consider the cost of poor quality, which results in the following problems:

• Duplicated work between departments

• Loss of time due to inefficient task performance

• Loss of staff due to job dissatisfaction

• Recruitment and training of new employees

• Expenditure of energy and time in investigation of complaints and allegations

• Litigation and malpractice settlements

• Employees continually executing tasks incorrectly despite direction

• Reporting and correcting errors

• Expenses related to overutilization of diagnostic tests to avoid malpractice

Originally, the perception of quality was that of doing more, that is, the performance of more tasks that resulted in intensive intervention. Today, it is believed that efficiency can be improved without compromising quality.

Health care leaders must now look at individual and collective effectiveness of organizational management.

Organizations must also begin to examine the cumulative cost associated with a less-than-optimal ability to plan, delegate, communicate, and listen. The prevailing philosophy is to do more with less. Such an approach to health care management has resulted in downsizing, cross-training, and reduction of middle management staff.

The primary cost-containment measure in health care delivery has been the proliferation of managed care systems.

Ongoing debate over the effect of cost containment on quality of care continues. The Survey of Physicians and Nurses, a survey of 1,053 physicians and 768 nurses, was conducted by the Kaiser Family Foundation and the Harvard School of Public Health in 1999. The nurses in this survey (Kaiser Family Foundation, 1999) stated that managed care has led to the following:

• Decreased the amount of time they spend with clients

• Decreased clients’ ability to see medical specialists

• Decreased the quality of care for individuals who are ill

• Increased the likelihood that clients would receive preventive services

QUALITY IMPROVEMENT

Quality management has its own array of terminology.

Despite the similarities, there are differences in the concepts, as outlined below:

• Quality assurance (QA) is the traditional approach to quality management in which monitoring and evaluation focus on individual performance, deviation from standards, and problem solving.

• Continuous quality improvement (CQI) is the approach to quality management in which scientific, data-driven approaches are used to study work processes that lead to long-term system improvements.

This concept has evolved into systems such as process improvement or performance improvement.

• Total quality management (TQM) is the method of management and system operation used to achieve CQI. TQM promotes an organization culture that supports customer need, empowers employees to work as teams, emphasizes self-development, and requires a new leadership style in which employees are viewed as resources.

TQM is a system of operation, whereas CQI is the desired outcome of a quality management program. It is difficult to achieve performance improvement without a TQM culture. The goal of a quality management program is to focus on process improvement, which will ultimately improve the quality of care.

Principles

Because CQI examines ways in which the entire organization can improve, the involvement of everyone, especially administration is required. CQI is based on the following principles:

1. Quality is a central theme to the organization. It is part of the organization’s mission and the core of daily activities.

2. Leadership is committed to an involved in creating an organizational culture (commonly held beliefs, values, norms, and expectations that drive the work force) for process improvement.

3. All staff members are personally responsible for quality; therefore, decision making is done by the people doing the work.

4. Education and training must be continual to improve skills and promote self-development.

5. Processes and system operation, in addition to individual performance, are monitored.

6. Work processes that influence outcome are studied and improved, rather than relying solely on problem solving.

7. A scientific approach based on analysis of data is used.

8. Good information is available and must be used in decision making. Individuals and institutions can no longer use opinion and intuition; they must manage by facts.

Customer Perspective

Promoting customer satisfaction requires an organizational commitment from top to bottom with every employee, especially direct care workers, being sensitive to the needs, wants and expectations of customers. This commitment requires putting the customer first.

Customers include those internal and external to the organization, such as clients, suppliers, third-party payers, families, visitors, employees, and the community.

Managers must meet employee needs and service delivery demands. The direct care provider must meet client needs, coworker’s needs, and organizational needs.

Organizations rely on customer relations programs to develop strategies to keep their customers satisfied. A program of customer relations can be costly to operate. It involves staff education, cost of survey materials, public relations representation, administrative time for evaluation and follow-up, and expenses for corrective action.

Corrective action may involve equipment, staffing, education, structural renovations, or new procedures. Focusing on the customer can be both time consuming and stressful because it may require change, which may evoke resistance in both employees and managers.

The reality is that health care agencies do not have unlimited resources allocated solely to keeping customers happy. Therefore, the organization and each employee must understand the implications of customer dissatisfaction from a financial perspective. The loss of one admission is relatively insignificant to a multimillion dollar budget; however, multiple losses can have a substantial effect on a health care facility’s financial well-being.

There is additional potential revenue loss from related ancillary services following hospitalization, such as home health care, laboratory procedures, pharmaceutical supplies, and office follow-up. A customer’s dissatisfaction with one facet of service can be generalized to all related delivery systems.

Anderson and Zemke (1998) have identified the 10 leading causes of customer dissatisfaction. As you read the accompanying display, think of how these factors can adversely affect a client’s satisfaction with health care services.

Another effect of customer dissatisfaction is a tarnished community image. There is a multiplier effect in which one bad encounter can affect the attitude and opinion of many. An unhappy client may inform the immediate family, extended family, neighbors, friends, and coworkers. Seemingly simple acts, such as those listed below, can result in client dissatisfaction despite a positive health outcome:

• A cold food tray

• Failure to respond to a call light

• Waiting for tests

• Late treatment

• Unemptied bedpan

• Delayed pain medication

Health care organizations must have a strong dispute resolution program to mediate customer complaints. In addition, strong efforts must be made to solicit customer feedback about services. Satisfaction is a subjective perception; therefore, health care providers must listen to the customer constantly to determine satisfaction and dissatisfaction. Then, improvements can be initiated.

ORGANIZATIONAL STRUCTURE FOR QUALITY MANAGEMENT

Because quality has become a central issue in health care delivery, nurses must consider the impact of organizational structure on the quality of care provided.

Nurses are key in establishing a culture for excellence in most health care organizations.

Several factors within an organization affect quality management: organizational culture, work force diversity, empowerment, leadership, and teamwork. To improve the quality of care, the organization should be viewed as a system that is comprised of governance, management, clinical, and support devices. Many processes within the system involve more than one group. Therefore, a framework must be established to promote collaboration.

Organizational Culture

Organizations have both formal and informal cultures.

Incongruence between the formal operational style espoused by management in meetings and documents and the style demonstrated and felt by staff members may be evident. This can result in an ineffectual organization in which achieving continual improvement is difficult.

Thus, the culture of an organization can affect the quality of care. A positive culture promotes trust, information sharing, collaboration, and risk taking, whereas a negative culture produces divisiveness, resistance, and a desire to maintain the status quo. In a negative culture, inertia develops and there is a lack of creativity and self-direction by employees. Table 25-2 compares characteristics of organizational culture within traditional and high-performance organizations.

Work Force Diversity

Health care will be delivered by a more diverse work force throughout the 21st century. The organization, managers, and workers must be able to maximize diversity.

Tomorrow’s work force and population will consist of more women, older Americans, people of color, and collegeeducated individuals. Despite increases in these groups, the overall available work force will decrease due to declining population growth. Employees can become more selective in job placement and seek new employment opportunities if dissatisfied. Employees desire self-actualization; therefore, job satisfaction will become imperative.

The slower growth in the work force will result in fewer applicants and a shortage of technical and professional staff. Rapid advances in technology will increase complexity of jobs and lead to increased competition for skilled workers. A flatter organizational structure, in which middle management is reduced, will require increased interaction and ability to work together.

Groups must enhance ways of communicating to be more productive.

This change in the work force will affect methods of delivery; therefore, the organization must be able to maximize the potential of each employee. To achieve a work environment that capitalizes on diversity, the organization must implement a program that addresses individual, group, and organizational biases. Education must be provided to eliminate stereotyping. Such educational programs are aimed at:

• Identifying individual beliefs and values

• Discussing assumptions and biases based on gender, race, age, and religion

• Explaining cultural differences

• Identifying legal responsibilities

• Valuing differences of specific groups.

Management practices must build an organizational climate that values each individual’s contribution to group achievement, and the organization must develop policies to promote and support cultural needs and differences.

These actions are essential in reducing the costs of employee turnover and litigation from discrimination and sexual harassment suits. The outcome of such efforts can be an increase in retention, productivity, market share, creativity, flexibility, and optimism of staff while effecting a decrease in complaints, grievances, litigation, and cost. Specific advantages of having a culturally diverse work force in nursing are shown in the accompanying display. Health care providers must consider transcultural principles and human rights in managing the work force and delivering quality care.

Empowerment

For organizations to operate successfully and instill the drive for excellence in each employee, the staff must be empowered to take ownership of their jobs. Empowerment is the process of enabling others to do for themselves. Employees need responsibility and authority to solve problems and take action in their work group. Empowerment recognizes the uniqueness of employees and conveys a message of value. As a result of empowerment within a work group, an environment is created in which the collective creativity is more diverse than the ideas and knowledge of a single individual.

To survive in today’s health care environment, all providers must work together to accomplish the organization’s mission, vision, and goals to achieve a philosophy of continual improvement. Restructuring health care delivery requires each individual to improve work processes. Work redesign, downsizing, consortiums, managed care, and cross-functional task sharing are but a few of the many efforts underway to reorganize health care in order to reduce waste, duplication of work, and cost. All health care providers must be involved in the process of change to minimize fear, reduce resistance, promote accountability, add credibility, and produce lasting results. To accomplish change, health care organizations need to maximize employees’ capabilities and motivate them toward continual improvement.

Leadership

Leadership is the interpersonal process that involves motivating and guiding others to achieve goals. Leaders in a health care organization include the governing body, chief executive officer, senior managers, leaders of the medical staff, department heads, nurse executives, and senior nursing leaders.

Effective leadership works across departmental lines to address multidisciplinary work functions and processes.

Traditionally, territorial issues (the so-called turf battles) have produced divisiveness and competition among departments and disciplines. The tools for combating such divisiveness and building effective work groups are collaboration and facilitation.

Organizational leadership contributes to the creation of the culture based on CQI beliefs and practice. Leadership must create a people-oriented culture. In today’s fast-paced, high-tech, cost-driven health care environment, the human factor is frequently overlooked. Although staffing incurs the greatest expense and is a primary target for cost reduction, it is the people in the health care organization who are the greatest asset, and management must focus on ensuring a return on this important resource.

Empowering employees, valuing diversity, creating organizational change, and promoting process improvement requires a new style of leadership that shifts from high manager/low employee participation. The manager becomes a coach instead of a supervisor. In this role, the manager facilitates collaboration and advocacy, serves as a consultant, and provides support.

Teamwork

Human resource management has become an essential function of health care managers. Authoritarian, hierarchical, and traditional ways of management are no longer effective; therefore, health care organizations are turning to team-based strategies for organizing labor. Improving quality requires team effort.

A team is a group of individuals who work together to achieve a common goal. The dynamics of team interaction are important. Teams must demonstrate commitment, cooperation, and communication. The way the team communicates and solves problems has a significant impact on outcome and delivery of service. For quality care to occur, work groups must function as teams.

For quality improvement, teams are used to study processes. There are two types of process improvement teams: functional and cross-functional. A functional team is a departmental or unit-specific group whose scope is limited to departmental or work area processes. A crossfunctional team is an interdepartmental, multidisciplinary group that is assigned to study an organization-wide process (Figure 25-1). An effective team demonstrates mutual respect and trust, displays open communication, builds on skills of members, and seeks consensus.

The use of teams to restructure and improve work processes has many advantages, such as:

• Increased involvement and understanding

• More opportunities to share ideas

• Assistance in building relationships

• Involvement of staff in problem solving

The team approach is effective for coordinating and integrating interdepartmental work processes.

PROCESS IMPROVEMENT

For years, the focus of health care quality has been on performance improvement. It was eventually recognized that no individual’s performance really stands alone. Each person’s action in an organization is actually a performance step that is connected to the action of others. This series of interconnected steps is known as a process; processes interconnect to form a system.

Prioritization

Quality improvement focuses on processes or systems within organizations that significantly contribute to outcome. This requires refocusing from solely departmental issues to crossdepartmental lines. Prior to a process improvement philosophy, quality improvement efforts were performed within departments. However, processes operate between departments and require multidisciplinary involvement.

To continually improve, an organization must realize that it is a system of interdependent parts all with the same mission of meeting the needs and expectations of customers. Understanding interdepartmental processes is crucial to quality improvement.

In process improvement, the emphasis is on system variation, not performance of individuals. Process improvement does not just address problem solving; it also promotes ongoing improvement of stable processes and correct establishment of new systems. Process improvement is intended to reduce variability, improve efficiency, and reduce complexity in systems.

Process improvement efforts must be directed at analyzing systems that have significant impact on the organization of care delivery. Important aspects of care involve activities or processes that are:

• High volume: occur frequently or affect large numbers of clients

• High risk: place clients at risk of serious consequences if not provided or provided incorrectly

• Problem prone: tend to produce problems for clients or staff (JCAHO, 1998)

Organizations must effectively use resources by focusing on high-priority systems that affect client outcome.

Scientific Approach

Typically, problem solutions are generated without timely analysis. A “ready, fire, aim” approach to process analysis is frequently used, in which action is taken without first thoroughly evaluating the problem. To counter this haphazard method, a scientific approach to performance improvement must be undertaken. In the scientific approach, data are used to measure process.

Such an approach results in the following:

• Minimal use of intuition and opinion

• More accurate and effective problem identification

• Increased understanding of root causes of variation

• Improved evaluation of alternative solutions

• Ability to statistically measure improvement

The scientific approach to improving quality performance consists of the following steps:

1. Identify an important process to evaluate.

2. Measure the current process.

3. Assess variations.

4. Formulate improvements.

5. Implement change in the process.

Tools

A variety of tools are used to collect and analyze data so that decisions can be made about organizational performance.

The accompanying display describes mechanisms frequently used to obtain and measure data.

In addition to measuring processes, data can also be used in benchmarking (a process that evaluates products, services, and priorities against the performance of others). Comparative data can be obtained from the literature, practice guidelines, and an increasing number of external reference databases.

NURSING’S ROLE IN QUALITY MANAGEMENT

The primary purpose of nursing is to provide quality care to clients. To do so means always seeking to improve the care delivered. Nurses function as clinicians, team members, and managers. Each role has specific responsibilities for quality performance and requires certain skills to achieve the expected level of performance (Table 25-3).

There are several characteristics of quality nursing care, including the following:

• Maintenance of a current knowledge base and competencies

• Interpersonal skills (with clients and coworkers)

• Caring and compassion

• Mutual decision making with client and nurse

• Individualized treatment

Whether functioning as a clinician, team member, or manager, nurses continually strive for excellence in everything they do. By using a CQI approach, which examines structure and process instead of individual performance, nurses can move forward in the provision of quality care. Quality improvement identifies situations when nursing teams are more productive and functioning at a higher quality level.

KEY CONCEPTS

• The nine dimensions of quality performance as identified by JCAHO are efficacy, appropriateness, availability, timeliness, effectiveness, continuity, safety, efficiency, and respect and caring.

• The quality movement was initiated by consumer demands, financial viability, professional accountability, regulatory requirements, progress made in quality improvement techniques, and changes in health care delivery.

• Case law and federal regulations establish guidelines for quality management.

• Health care professionals adhere to ethical codes of practice that espouse a responsibility to self, profession, client, and society.

• Continuous quality improvement focuses on studying work processes that promote system improvements.

• Total quality management is a method of organizational operation that establishes a work environment to achieve continuous improvement.

• A customer is anyone who uses the products, services, or processes within an organization. Clients, families, visitors, employees, suppliers, and the community are all considered customers within the health care system.

• Customer dissatisfaction can have significant financial implications for health care organizations.

• Quality management requires positive organizational culture, work force diversity, empowerment, leadership, and teamwork.

• A variety of tools, such as audits, peer reviews, and benchmarking are available through which data about variations in process improvement can be collected and analyzed.

• The nurse is responsible for quality improvement as a clinician, team member, and manager.

Which step of the nursing process considers the effectiveness of nursing care?

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During which step of the nursing process would the nurse review the patient's plan of care and determine whether a goal was met?

Which step of the nursing process considers the effectiveness of nursing care quizlet?