Quality Measures and their Documentation in Healthcare

 

Introduction

Provision of quality and adequate care to patients is a continuous process and measures are put in place to ensure that the care provided is of high quality and appropriate to the patient. Data about these measures are collected after a certain period to assess their effectiveness and the outcome to the patient care. Health care staff perform different roles in care provision, and they do this while ensuring that they meet their professional and ethical standards. Nurse leaders should, therefore, have the necessary skills to offer good leadership and ensure there is improved quality of care in the health facility.

Quality measures

            Patient safety can be a great consent to both the hospital and its staff in all health care; thus it matters in the quality of care provided by the hospital (DiCuccio, 2015). Some of the patient safety measures which have been put in place are the patient identification, to enhance safety and avoiding patient identification errors, it is essential to confirm the details of the patient before giving any service to the client, for example, verifying the name of the patient, their date of birth and verification of their medical record number.

            Other measures are infection control  which is also a critical measure to  prevent transmission of infections from one client to another through proper infection control practices such as hand hygiene before attending to the needs of any client, this also applies to patient visitors at convenient locations in the hospital, wearing of personal protective equipment is also important (Graban, 2016). Staff members should also practice sterile techniques at all time when delivering care to the clients

Data collection

            The health informatics play a vital role in the provision of data which can be used in the analysis of patient safety and thus help in quality improvement in health care (McGonigle, & Mastrian, 2015). Hand hygiene is a simple and effective way of preventing infections and can be performed with alcohol hand rubs or by hand washing, and other practices performed play a key role in ensuring patient safety in the health care set up.

            Before delivering care to any client it is essential to double check the client to reduces the incidences of giving out the wrong medication with the wrong dosage or performing procedures which were meant for another patient, these activities together with infection control are incorporated to the nursing and providers documentation by ensuring everything done to the client is documented. This will help improve the quality of care and will enable the facility to implement the risk reduction interventions and therefore reduce transmission of nosocomial infections. It’s always important to acknowledge that, documentation is the only evidence that care was provided or to show what has already been done to the patient and failure to do this might result to confusion and might thus limit effective care delivery to patients.

            The process of care measures usually reflect the health care facility ability to deliver and comply with recommended practice of proper patient care, and therefore it is very vital to collect information on the measures the health facility has put in place to ensure patient safety is not compromised while they receive treatment in the facility (Douglas et al., 2016). Data will be collected in all facility information systems including observation of activities of the health care as they deliver the services to the clients.

            Some of the critical information that should be collected include the prevalence of nosocomial infections. The source of disease which can be the person, the patients or even the inanimate environment. On the other hand, the route of transmission which can be by direct contact or indirect, in air or transmitted by vectors, incidences of giving wrong medications to wrong patients or performing wrong procedures to wrong patients, occurrences of providing false information about the client, frequencies of transmission of infections to staff and other health workers in the hospital.

            In the provision of the data, the presence of incidences will show there infection control measures are not being practiced adequately or the patient identification system is not followed correctly. The data from the informatics might show the incidences and the no of people who might have developed infections during their stay in the hospital; thus they play an important role in analyzing clinical statistics. This data will, therefore, be useful in judging the quality improvement in the hospital in care delivery, it will enable the facility to initiate other proper measures may be to meet requirements of the health regulators and to ensure that the gap that may be present has been fixed to endure quality and effective care delivery.

Roles of the advanced registered nurse in data collection

            Advanced practice nurses used to encompass the certified nurse-midwife, registered nurse anesthetist, the clinical nurse specialist, and also the nurse practitioner, they have a key role in ensuring the patient safety and improved quality care is delivered to the patients effectively (McDonnell et al., 2015). The advanced nurse practitioner also acts as a primary patient caregiver and thus will provide essential information on patient safety.

            Furthermore, most of the cases such as patient identification and proper use of infection controls are done by them. Thus data collection on the practices and incidences of providing care to the wrong patients is better known by them, and their role is to provide quality and accurate data concerning the safety of the patient on the keys measures, that is the infection control and patient identification. Other members who take part in providing care to the patient are also involved to ensure that enough information is gathered including the consumers of the health services in the hospital.

Professional, ethics and regulatory standards

            Provision of care in health in health involves ethics which are usually considered on all aspects of care provision. It is always necessary to ensure that the attention of all the individuals is viewed as a priority and respect of their dignity is also essential (Rowe, 2017). Confidentiality of the client is maintained at all the times by respecting their right, informing them about all the activities being done and seek consent before implementing the plan unless it is done in line with the law.

            Collaboration with those individuals and responding to their preference is also crucial in making the plan. Meet communication needs and sharing of information in a way they can understand. Working with others to protect clients is also of great importance to their safety for example sharing of crucial information with other colleagues will help in fostering better care. Staff members must also be willing to share their skills and experience to others as well as take advice from colleagues .it is also necessary to treat each member of the team fairly and with respect with no discrimination.

            However, it must be considered that patient autonomy is regarded, and the care or the result of the implementation should not breach the patient right to independence. Furthermore, all the care given to the patient or information provided must not bring harm of any kind to the patient. All individuals must be treated fairly (Harrison, 2018). It is also essential to act fast in the case where you consider that someone has been put on risk.

            It is also necessary to inform the manager of any experiences that might prevent you from working under the code or the agreed standards and providing high standards of practice and care all the time through ensuring you update knowledge and skills to ensure safe practice even if you are alone.

            Keeping of clear records and accurate records concerning the data collected or care provided, this can be done through recording as soon as you get the information or giving care, avoiding tampering with original records and clearly stating the date and signing in case you make any entries in the file (Rowe, 2017). All the activities done in the facility must be recorded including all assessments.

            Besides, be honest, open and act with integrity and maintain the reputation of the profession, stick to the laws of the country, avoiding false coursework or clinical assessments. Other people should also be protected from harm through seeking help from the authority when the need arises, also seek help when people complain that they are unhappy about the care and treatment they are being given

Means of communication

            Communication is very critical in health care in the provision of high quality and safe care to the patient. Any communications that might be needed can be done through verbal communication, through internal memos, written or even interpersonal communication, as long the relevant messages reach the intended persons (Fischer, 2016). This mainly depend on the agency of the plan changes, the time the message is intended to reach the stakeholders, availability of the means and the requirements of the facility itself or the methods the facility considered the most appropriate for communications.

Leadership skills and project management

            Collaborative management is vital in the provision of adequate care to patient and quality improvement in the health facility. First, it is indispensable to improve on information sharing, and this will foster knowledge and in the long run enhance delivery of care to the patients. Presence of enough knowledge boost the morale of the staff members and will minimize confusion that may arise when information sharing is minimal.

            Furthermore, making vision as a team is also important, this will act as a motivation of the staff as they are part of the creation, this will make delivery of care as a responsibility of each staff member and will thus provide high-quality care to the clients.Application of critical thinking in decision making, the nurse leaders, should guide in developing their ability to make decisions on complex factors (Roche et al., 2015). Therefore, this skill is of great importance in the health care environment which has multidisciplinary collaboration, this will enable the individuals to know the cons and pros, and they will, therefore, seek solutions that are the most appropriate before choosing to initiate the plan. Increase in nurses autonomy also makes critical thinking very valuable skill for practitioners.

             Proper communications skills are also required, with the current multidisciplinary treatment in the health care, nurses arrange to attend rounds and thus to engage with different medical professionals, this engagement needs communication (Fischer, 2016). Other forms of information for example for knowledge developments can be done through various channels such as the newsletters, emails, intranet, and team meetings.

            Proper coaching and quality management are also important in collaboration to ensure the right thing is being done at the right time; all the team members also should compromise because not all battles can be fought (Roche et al., 2015). The team members should accept each other because people have so many individual differences and thus it is imperative that the team puts their differences aside and agree to work together.

   

   

References

DiCuccio, M. H. (2015). The relationship between patient safety culture and patient outcomes: a systematic review. Journal of patient safety, 11(3), 135-142.

Douglas, C., Booker, C., Fox, R., Windsor, C., Osborne, S., & Gardner, G. (2016). Nursing physical assessment for patient safety in general wards: reaching consensus on core skills. Journal of clinical nursing, 25(13-14), 1890-1900.

Fischer, S. A. (2016). Transformational leadership in nursing: a concept analysis. Journal of Advanced Nursing, 72(11), 2644-2653.

Graban, M. (2016). Lean hospitals: improving quality, patient safety, and employee engagement. Productivity Press.

Harrison, P. (2018). NMC Code updated to cover delegation and associates. Gastrointestinal Nursing, 16(9), 50-50.

McGonigle, D., & Mastrian, K. G. (Eds.). (2015). Nursing informatics and the foundation of knowledge. Jones & Bartlett Publishers.

McDonnell, A., Goodwin, E., Kennedy, F., Hawley, K., Gerrish, K., & Smith, C. (2015). An evaluation of the implementation of Advanced Nurse Practitioner (ANP) roles in an acute hospital setting. Journal of advanced nursing, 71(4), 789-799.

Rowe, G. (2017). VALUES AND ETHICAL FRAMEWORKS IN HEALTH AND SOCIAL CARE. The Handbook for Nursing Associates and Assistant Practitioners, 20.

Roche, M. R., Duffield, C. M., Dimitrelis, S., & Frew, B. (2015). Leadership skills for nursing unit managers to decrease intention to leave.