With the economic prosperity, technology developed in recent years, in recent years, the promotion of medical reform, the people's demand for self interest is increasingly high, while the medical quality and quality of service are also expected to follow. High level of medical quality can not only promote the safety of patient care, improve medical efficiency and quality of care, but also let the hospital get public trust, to achieve the goal of sustainable development. Nurses are the largest number of medical system, but also the important role of first-line care patients, nursing quality is meeting people's expectations, will affect the overall level of medical care. This article aims to introduce the definition of nursing quality, how to develop the quality of nursing care, the use of scientific methods to collect information, measurement and analysis, in order to understand the quality of the cause of the ideal, to achieve the goal of continuous improvement.
1 the significance and evaluation method of nursing quality
Under the new situation, the emphasis on "quality is to meet the consumer's expectations" "quality is the pursuit of the best medical results", quality improvement has become the best tool for competitive strategy. Each patient can achieve the desired results, in addition to avoiding complications due to medical treatment, but also to the medical needs of patients and their families, and to take into account the cost effectiveness and appropriate instrument record [1]. so the definition of medical quality is not only available in the patient as the center, pay attention to the end result of medical care, so that patients and their families understand or satisfied with the care, but also in the cost and quality to seek balance. Medical quality must be evaluated, in order to further management. Quality of care is also with the requirements of medical quality, must be systematically evaluated, in order to show the effect of nursing and professional contribution.
1.1 definition of nursing quality
Nursing quality refers to the effect and degree of nursing care for patients. Namely, the effect of nursing, the performance of nursing work and the effect of service quality. Objective performance in the process of nursing. The factors that affect the quality of the pros and cons, including the quality of each person, each job quality and the quality of each link, and ultimately to the patient and family satisfaction, so it is a moving target. "Quality of each person" refers to the core competence of clinical nursing "quality of each job" refers to whether the implementation of the technology according to the standard operation specification, "the quality of each link" refers to the convergence of the work flow, such as whether the transfer of the patient is clear and correct.
In addition to professional quality, the general public does not necessarily understand the professional quality of medical care, but the quality of service expectations, including the reliability, responsiveness, contact channels, politeness, communication, trust, security, etc. to evaluate the quality of service. So nursing staff should pay attention to comply with the commitment and provide appropriate services, with a dedicated service attitude, proficiency in essential knowledge and skills, easy to get close, courteous, respect each other, listen carefully and explain in detail, understand the patient's needs.
1.2 nursing quality evaluation model
1.2.1 Du Naber Dean (Donabedian) structure, process and results of the evaluation model.
(1) the structure of nursing: including the organization structure, management level, management system, nursing manpower allocation, collocation, nursing staff quality, nursing training, nursing operation standard, nursing technical manual and instrument equipment and so on.
(2) nursing process: refers to the implementation of nursing staff in the implementation of nursing work, whether or not in accordance with the standard implementation of the nursing process, there is no monitoring mechanism to ensure that the implementation of nursing measures to achieve acceptable levels, for the implementation of the nursing process is not up to the ideal of analysis, identify the problems with the standards, in accordance with the process of continuous improvement.
(3) nursing results: the ultimate goal of nursing is to promote patients to restore health status or reduce pain, reduce anxiety, including patients with existing or potential health problems.
The evaluation of nursing outcomes also included patients with pain relief, health care knowledge, self care skills to improve, reduce the anxiety state, patient satisfaction with care and health related behavior change [2].
1.2.2 evaluation model of the American Nursing Association
The evaluation model of the development of [3] in the American Nursing Association is a process of cycling. The purpose, concept and value of the nursing department is to guide policy, and so on. The standard and evaluation criteria of nursing. The data are analyzed and judged by using the method of continuous monitoring.
Hoesing 1.2.3 and 3P Kirk evaluation model
The factors that affect the quality of care are divided into three aspects, including: 1. The results of the patients (Patient). The emphasis is on the final index (Outcome). The work performance of nursing staff (People): that is, the evaluation of the process index, which pays great attention to the nursing process, such as: the procedure of administration, the operation of sputum aspiration, the technique of intravenous infusion. Cost effectiveness (Profit): refers to the use of limited resources to take into account the cost control, to achieve the effectiveness of patient care. Furthermore, the performance and service effect of nursing staff will affect the results of patient care and satisfaction, but also affect the operation performance of the whole organization. The model emphasizes the three key points of quality management: patient care management system, nursing staff management system and financial management system [4].
Clinical, professional and administrative evaluation model of Katz 1.2.4 and Greend
This model covers three levels: Clinical level: indicators for patients receiving care, the health status of patients after nursing or health behavior change, that is, the evaluation of the results of the patient care issues. Professional level: refers to the nursing staff, that is, the core competence of the nursing staff, the implementation of the training system, the evaluation of the effectiveness of their learning, and other issues of cooperation with other professionals. (3) administration (Administration) level: index of management leadership and management, institutions establishment, organization system of operation, human resources allocation and performance assessment, cost benefit analysis.
Comprehensive evaluation of the above model, can be summarized from the three levels to develop indicators to evaluate: the clinical nursing level (Domain Clinical): medicine, patient safety, skin care, infection control, pain control, patient and family care guidance and nursing records, etc.. II professional member of layer surface (staff ProfessionalDomain): induction training, clinical teachers system, the clinical ladder system, a system of cross training, nursing practice standards and staff evaluation. (3) the level of Administration (administration domain): nursing human resource allocation, the quality of personnel, personnel recruitment and retention, scheduling, grading nursing, standardizing nursing records, budget management and so on.
2 the development of medical quality index
2.1 types of medical quality indicators
Indicators are generally divided into two types according to the severity of the incident and the extent of its prevention.
2.1.1 (Sentinel Event) event warning index
Sentinel event index is refers to the quality problems of warning, such events occur with low frequency, but patients, family members and medical personnel are subject to serious influence must be one by one review or root cause analysis, such as: transfusion errors, wrong site surgery, maternal death.
2.1.2 integrated data indicator (Aggregate-dataIndicator)
Integrated data metrics for the collection and integration of multiple event or phenomenon data performance measurement methods. The percentage of the event rate and the default threshold for the calculation, such as hospital infection rate, if the assessment results exceed the standard or the probability of occurrence of the event, compared with other organizations, it is necessary to further explore the [6].
2.2 methods of constructing nursing quality index
The course of the development of the nursing quality index of the American nursing society includes: 1. To find out the important nursing care, the definition and the reliability and validity of the index. After a review of the definition of indicators, data collection methods, guidelines and collection form. After the revised index definition, guidelines and forms, to investigate the views of clinical nursing experts to ensure the validity of the indicators and the feasibility of data collection. The combination of clinical experts, revised definitions, guidelines and indicators of the collection form. The development of indicators the data out in some units, to ensure the reliability of data. The last was completed. The training of relevant personnel to correctly implement data collection. The American Nursing Association began to explore the methods of nursing quality evaluation in 1994. The study focused on the quality of the patients' safety and the quality of nursing.
2.2.1 structural index
(1) per patient per day care number (NursingHours per patient day including number provided by the following: (1) a registered nurse (RN) RegisteredNurses: registered nurses is the main person in charge of the nursing process. From receiving the patient, we must use all kinds of nursing methods, collect all aspects of the patient data, and make a preliminary assessment, at the same time to analyze the collected data, and propose the correct diagnosis and appropriate nursing plan and the effect of nursing. Nurses LPN/LVN (LicensedPractical/Vocational): the professional nurse's duty is more emphasis on the technical level, such as: oral care, wound care, etc.. In the hospital, can not make care of their own assessment and analysis, can not give the patient to do intravenous injection, must pass a professional practice examination, after obtaining a license, in order to work in the medical unit. 3 no assistants (Unlicensed assistive personnel UAP): no assistants work according to more emphasis on the patient's personal and health care, for example help getting out of bed, assist a sponge bath, change the sheets and turning over. California laws and regulations, nurse assistant can not give medicine, injections, nor engage in aseptic technology. As a general labor workers, do not need to pass the professional nursing practice examination, as long as the simple health care knowledge test, you can get a certificate.
(2) nursing education / Certificate (Education/Certification RN).
(3) Skill of hours nursing Total (Mix:Percent): the staff are registered nurses, professional nurses, and no care assistants.
(4) Voluntary (NurseTurnover).
(5) vacancy rate (Vacancy Rate Nurse).
2.2.2 process and results
Including patients with falls, falls, injuries, pediatric pain assessment, pediatric peripheral venous invasion, incidence of pressure ulcers (in the community, in the hospital), mental health, physical injury, restraint, nurse satisfaction, hospital infection (urinary tract infection, central venous catheter infection, ventilator associated pneumonia). Formulation of nursing quality index according to the researchers, using the descriptive, cross-sectional study design, and focus group discussion (focus group and Delphi method (Delphi technique. To review the literature collected domestic and foreign medical quality indicators project, the selection and care than the related indicators of the project, invite specialized in quality management of academic and clinical field experts focus group discussion, complete the first draft of the project indicators, Delphi method is then used to send questionnaires to engage in nursing quality related senior nurses, a total of three questionnaires. Results a total of 29 belongs to the nursing quality indicators. Divided into the face of the structure: nursing staff with qualifications, new training, human advanced and manpower allocation, working specification and environmental safety etc.; surface process: To evaluate patients and their families need, conforms to the patient care plans, implementation of care plans, detailed process of nursing records; results: nosocomial infection, falls, pressure sores, abnormal events, patient of nursing satisfaction.
2.3 the contents of nursing quality index
2.3.1 index name: the general ward falls into the case (the first level indicator), the index for the convenience of in-depth analysis, can be subdivided into a variety of two indicators [8].
(1) the causes of falls are divided into two levels: the health status of the patients, the treatment / drug and the anesthetic response are caused by falls, the environmental risk factors cause falls, and other factors cause falls.
(2) the damage is divided into two levels according to the falls. The falls are caused by a falling injury, falling injury, falling injury, severe injury, and death.
(3) repeat fall rate of two indicators.
Introduction to 2.3.2
(1) the importance of describing the indicator, such as: Falls is the most common adverse event of the patient's hospitalization. Falls can cause physical damage, which will have different levels of damage, the impact of these injuries to patients, such as: severe fractures or head trauma, increase the prevalence and mortality.
(2) to explain the factors causing the sensitivity to support the classification of indicators, such as: lead to falls in patients, including the patient's health factors, the response to drugs, treatment or anesthesia, external environment or other factors, etc..
(3) the benefits of this indicator and how to use it: if you can let the hospital monitor the occurrence of falls and evaluate the impact of falls on the patient, and compare with other hospitals. The analysis and comparison of the data can be used as the basis for improving the safety and safety of the patients in the future.
2.3.3 definition and description
The definition of the index is clear to collect the right data, in addition to the first level indicators, the two indicators should be defined, such as the extent of damage to different levels, the level of judgment. Such as: general ward falls total incident refers to the total number of patients to monitor the occurrence of falls in the general ward; serious injury refers to the incident caused by the injury, in addition to additional visits, assessment or observation, but also need surgery, hospitalization or extended hospitalization (such as fracture or pneumothorax, etc. need to be extended hospitalization).
2.3.4 approaches or methods of data collection
Data collection period and method of standard, such as: "general ward fall rates" formula = general ward fall event total / general ward Germanic. The "general ward day" refers to the inpatients in the first day of the month, month plus daily daily inpatients. On the day of admission the patient should also be regarded as a day of hospitalization.
3 the design and application of nursing quality index
Nursing department is responsible for the general design, nursing index can be carried out according to the following steps.
3.1 to determine the common or specialist
Commonality is the indexes of the hospital should be monitored; specialist can according to the hospital unit or specialties division, including general ward, ICU, outpatient service, emergency, maternity and baby room and so on; or divided by the specialties, including the families of the patient population characteristics, as defined in the nursing such as orthopedics, cardiac division, operation room provide treatment or prevention of duty of care. To define the activities offered by clinical professionals, including assessment, administration, treatment, counseling and health education, etc..
3.2 to determine the most priority quality improvement objectives
Deciding which is to be a priority to monitor the important care, or the quality of the patient care the most important activities. Priorities are established and the monitoring frequency, the following principles for reference: high risk activities, most people need or high rate, tendencies in the activity or the high cost of activities. For example: oncology wards, most patients need for antitumor drug treatment is a high rate of nursing, infusion if the injection needle abscission or drug extravasation may cause serious injury the skin of a patient and extravasation after drug dose inaccurate or re injection, the drug loss cost high, in line with the principles of nursing activities can be classified to give priority to the development of indicators.
3.3 setting index
The formulation of the index may include the structure, process and result, according to the type and severity of the event, the principle is: the index must be clear, must be reliable and have high reliability, validity and can be measured. According to the important nursing is oncology ward of antitumor drugs in the treatment of nursing, so index may depend on the development of the hospital of vein transfusion criteria, into the face of the structure: such as PICC operation performed by nurses after PICC professional knowledge and skills training; surface: anti tumor drugs to drug technical accuracy (such as when dispensing operators should be wearing double gloves, the inner layer is a PVC, the outer layer is made of latex, administered by a double check), PICC nursing correctness (such as whether the correct use of pulse type flushing pipe, to saline sealed tube). Results: anti tumor drug leakage, catheter related infection index.
3.4 establish evaluation threshold
Threshold value (threshold) refers to the desire to achieve the goal, the formulation of the principles of can with reference to the recent literature, professional bodies and expert opinion, internal discussion the consensus of opinion, or according to the statistics or group discussion understand the numerical distribution of the past year, make annual threshold value standard, such as anti-tumor drug extravasation rate last year was 2% next year, reducing to <1%. threshold is one of the two sides of, between compliance (compliance) and does not follow the Noncompliance standard boundaries. Reaching the standard is positive, not reaching the standard is negative. The closer to 100%, the negative to the more close to 0%, such as "the patient to nursing satisfaction for the positive threshold of 90%", is the positive threshold; "the degree of satisfaction of patients to nursing can not be higher than 10%", that is, negative to the threshold. The negative threshold setting is an important event (events Sentinel), must set the absolute value, that is not allowed to happen, such as blood transfusion error event is 0. Some experts also suggested that involves danger layer value set 99 or zero adverse events as the executive is correct, such as blood transfusion technology, drug delivery technologies; non immediately affect patients life value set the execution correctness 91%~ 95% and catheterization techniques such as; records or attitude project level, not directly influence patient life project, can through re education to promote the correct cognition and attitude, such as health care plan, and nursing service satisfaction can be located in the 80% to 90%.
3.5 data collection and analysis
3.5.1 data collection
The source of data of nursing index is medical records, inspection reports, medication records, abnormal events report, review and inspection report and Research Report. Methods through medical check, observation of patients, patient and talk, and talk to the nurse, observation of nursing work and questionnaire survey and audit table etc.. How to sample, collect how much, how long the collection of a, the nature of the index, there is every month, every three months or every half year to monitor, the development of nursing quality index data collection plan, see Table 1
3.5.2 data analysis
Data to be sorted, statistics and analysis, analysis of the reasons for the failure to reach the threshold, there are usually two.
(1) general reasons: the ability of nursing staff is limited, the operation procedures are not clear or the equipment is limited, these factors are not easy to complete control in the short term.
(2) special reasons: the cause of the failure of an employee to a certain matter or equipment, etc., for special reasons shall be immediately discussed and improved. In order to continuously monitor the index results, the comparison of the data of the control chart is made. In the range of the change, the variation of the common cause should be stable, and the variation of the special reason should be discussed. In the case of the nosocomial infection rate in general are maintained at 3.5% to 3.8%, in a month suddenly up to 5.5 per 1000, need to find special causes; or applied science control method and tool for the explicit evaluation, defined causes and issues. The commonly used tools are fishbone diagram, flow chart, curve, Platon etc..
3.6 to take action to improve
When an indicator of data is presented with abnormal changes, the general reasons can be divided into: the system of the problem: such as drug errors due to the appearance of the drug and the packaging is similar or not clear, the lack of equipment or nursing patients too many. Problem of work behavior: there are standard operating rules, but not implemented. Lack of knowledge of the problem: the lack of understanding of certain nursing measures, training, etc.. In recent years, there are many methods and tools for quality improvement, such as quality control circle, quality improvement project, medical team resource management, etc..
3.7 evaluate and record results
After the improvement plan is taken, the responsible person shall be appointed to track the improvement effect and record. The whole problem is reviewed and analyzed, and the whole problem is to be improved. The monitoring, assessment, improvement and follow-up of all nursing quality indicators were discussed in the nursing quality management committee. Monthly overview of the implementation of monitoring indicators will be reported to the hospital "medical quality and patient safety committee".
To sum up, the index can be used to evaluate quality of care, and construction of index system including structure, process and results, the indicators need to have clearly defined, the methods of data collection with consistency, have good reliability and validity in order to truly reflect the pros and cons of nursing quality, in order to achieve the goal of continuous improvement.
Reference test
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