QUALITY AND CARE GOVERNANCE
INTRODUCTION
The healthcare professions all involve life and death situations. In these situations, quality is crucial and quantity is irrelevant. In my place of employment, there is an increasing incidence of chest infection associated with the use of tracheostomy tubes. The blame is placed on the apparent lack of knowledge of the nursing staff regarding tracheostomy care. It is time to seriously rethink, redesign, redevelop and reinvigorate the way governance is practiced in my current place of employment. There is a need for better quality and care governance.
Clinical governance provides a framework for a coherent, local program of quality improvement and an opportunity to share best practice. For nurses, clinical governance will be about building upon and linking together many of the activities that they are already involved in, which help to promote and improve standards of patient care (2002).
This paper presents the problems of increasing incidence of chest infection in my current place of employment and how this problem can be solved by providing solutions designed for the apparent cause of the problem. These solutions will focus on quality and clinical governance. The tools to be used to explore the issue will include SWOT analysis. Theories to be used to resolve the issue will include shared governance and total quality management.
A personal analysis on the presented problem will also be presented and as well as recommendations on how the quality of care can be improved in my place of employment regarding the particular problem.
CONTEXT
Tracheostomy refers to an opening into the trachea where an artificial airway (the tracheostomy tube) is inserted. This is usually performed to protect the patient from accidentally inhaling food, fluid or saliva. Such an airway may be necessary for patients when prolonged ventilation is required, or when an extended coma is anticipated. It may also be placed surgically to maintain the structure of the trachea–when threatened by cancer, infection or trauma, Placement of a tracheostomy is mainly used during the acute phase of an illness and later removed (2005).
A client may have a tracheostomy to bypass an upper airway obstruction, prevent aspiration, manage tracheobronchial secretions, or allow for prolonged mechanical ventilation. Whatever the reason for tracheostomy, the client should be provided standardized care in tracheostomy management. Lately, the rising incidence of chest infections in patients undergoing tracheostomy in my place of employment had been largely blamed on the part of the nurses. Such poor quality of practice is a no-no in the healthcare field. If nurses are not aware of the recommended and safe procedure, then the lives of clients are in jeopardy.
Quality in healthcare service and practice provision is very important. The method of quality measurement used by health economists is the QALY. QALY stands for Quality Adjusted Life Year. It is a term developed by health economists for an approach that is concerned with evaluating both effectiveness of treatments and their cost-effectiveness. The outcomes are measured according to a generic scale whereby if a client’s treatment is felt to be effective and long-lasting as well as cost-effective, then the patient can increase his/her score on the quality-of-life measure. This technique supports treatments that show improved quality-of-life over a long time and for the least cost ( 2002).
Since the late 1980s, the topics of quality and performance measurement have become important reporting areas for governance. Various “report card” “scorecard,” or “dashboard” measurement sets have been developed for routine reporting to governance on selected important performance areas. These balanced reporting sets may cover, for example, key clinical performance measures, financial performance summaries, satisfaction surveys, and measures related to human resources (such as turnover, time to fill vacancies). Progressive organizations also make the summary level information available for their employees and release the information to the community (2000).
Clinical governance involves the development of a culture and ways of working that continually improve quality, allowing good practice to be shared, lessons to be learnt from mistakes, and encouraging patient participation. For many nurses, clinical governance will afford the opportunity to formally link together and enhance existing quality improvement activities such as implementing evidence-based practice and care pathway development (2002).
Clinical governance can be divided into four key components: clinical effectiveness, human resources, professional self-regulation and risk management (2002).
Clinical effectiveness is about doing the right thing at the right time for the right patient. It enables nurses to reflect on why they do what they do for patients and to systematically find and implement better ways of providing care. The activities involved in clinical effectiveness include finding out what is best known practice, appraising the available evidence, changing practice if necessary, and confirming through clinical audit that actual practice is consistent with best practice (2002).
The human resources component of the clinical governance framework is about ensuring that healthcare professionals have the right education, adequate training and development, skills and competencies to provide quality patient care. It is also about workforce planning and lifelong learning (2002).
Professional self-regulation protects the public as it requires registered practitioners to practice within a code of conduct and is supported by the promotion of good practice, prevention of poor practice, and intervention when practice is poor. Professional self-regulation supports the clinical governance framework by setting professional standards and guidelines that contribute to the creation of an environment in which clinical excellence will flourish (2002). In practice, many nurses have experienced real and substantial problems with regulation.
Risk management is about identifying, measuring and controlling those risks that threaten quality or performance in the delivery of patient care (2002). Every day, nurses help patients through education, empowerment and expertise to avoid the recognized complications associated with tracheostomy care. They give practical advice and support to people with who underwent tracheostomy to manage risky situations such as an episode of chest infections, encouraging the patient and the family to learn from the event and employ tactics to prevent recurrence. This is a proactive risk management strategy that involves the recognition and identification of things that can go wrong as part of a systematic approach to patient care. Patients are empowered to respond appropriately in a risky situation.
Implementation of shared governance initiatives or other structures that promote autonomy, control of practice, and empowerment of nurses have been identified as key strategies to continue to improve the work environment of nurses (2004). This could in turn improve how the nurse delivers care to the clients.
In a shared governance model, each person has an obligation to ensure that his or her skills and knowledge make a positive contribution and to work efficiently and effectively ( 2004). Shared governance is a collaborative team process in which team members share key leadership roles ( 2004). Shared leadership is empowering employees to act autonomously, be decisive at the point-of-service, and create a shared vision aligned with organizational goals. Shared leadership development and autonomously practicing nurses appear to be the equation for success in delivering quality patient outcomes in today’s organized health care delivery systems.
For a shared governance model to work, the nursing leaders must develop skills that go beyond facilitating team and group decision making and assume a transformational role of disrupting the status quo, particularly in situations where evidence-based practice clearly points to a need for rapid change and improvement. Nursing leaders must translate the demand for change into a clear, understandable plan, as well as help staff members handle the chaos and uncertainty that accompany rapid change ( 2004).
ANALYSIS
Strengths (internal)
Weaknesses (internal)
Competent staff
Good clinical facilities
Lack of education on tracheostomy care
Opportunities (external)
Threats (external)
Health authority support
Staff support
Shortage of staff
The SWOT analysis table shows that although the hospital is equipped with competent staff, there is still an increase in chest infection in tracheostomy care since majority of the nursing staff are unaware of the recommended practice regarding tracheostomy care resulting to unsafe practice. Good clinical facilities for the tracheostomy procedure are also present in my place of employment.
Coming up with recommendations and implementing them at the place of employment is the most logical thing to do. An improvement for tracheostomy care and a decrease in chest infection incidence is expected as health authorities and the staff supports the programs that are designed for improvement of nursing services and quality of patient care.
Hong Kong’s healthcare profession is challenged by the shortage of healthcare professionals. This presents a threat to many areas of nursing practice. Not only that, this is a threat to patient care. If there is a decrease in the number of nursing staff that are competent enough to handle tracheostomy care, the problem regarding the increase in chest infection associated with tracheostomy would not be solved.
It seems that there is also an apparent poor quality of management and leadership in this case resulting to the poor quality of service. To improve quality, organizations have to apply ‘Total Quality Management’ (TQM) to their organizations to help them plan their efforts. The promise of superior performance through continuous quality improvement has attracted a wide spectrum of business to TQM, with applications reported in many domains including healthcare ( 2002).
RECOMMENDATIONS
Since the problem in itself roots on the apparent lack of knowledge on the part of the nursing professionals regarding the recommended practice of tracheostomy care, solutions must be also directed on them. The proper ways of performing tracheostomy care as well as the rationale behind each step are found in various medical literatures which can be provided to the nursing staff through educational programs.
In order for each and every staff to be educated and aware of this proper procedure, training or educational programs must be made available. Every nurse must be required to attend such educational training program. It will be an objective for the hospital for all nurses to attend a workshop on providing quality tracheostomy care as well as governance by the end of June 2006.
Once all the nursing staff are thoroughly educated and properly equipped with the knowledge of the recommended practice regarding tracheostomy care, their performance has to be monitored every now and then. They will be assessed on how they perform such care and evaluated if there is a change on how they perform it. It is not enough that after the initial educating sessions they will then be left to do the procedure. Monitoring has to be done in order to ensure that there is a demonstration of safe and proper practice of tracheostomy care.
From these educational programs designed to improve the quality of nursing care that is being offered, it is expected that standards for tracheostomy care will improve by reducing the incidence of chest infections following tracheostomy by the end of 2006.
As already presented in the analysis, there is an all-out support for this endeavor on the part of healthcare authorities and staff. That in itself would help make this project a success. Since they support the project of decreasing the incidence of chest infection, it follows that they would also support this plan of educating the nurses on how to properly perform tracheostomy care.
A one month time frame for properly educating the nursing staff on tracheostomy care is recommended. Granting that the nurses have their hearts in the education process, they will easily learn the recommended practice for tracheostomy care. Standards and objectives have also to be set as this is very important.
The period of monitoring would be the longer period in my recommended strategy. I propose a six-month to one year monitoring period. This would include assessing how each nurse performs the tracheostomy care and also observations on the incidence of client’s admission to intensive care unit because of chest infections.
To effectively carry out all of these, strategic planning has to be developed. Strategic planning is crucial in the management of healthcare organizations, even when the characteristics of the healthcare systems vary (2003).
Shared governance should be used as the nursing practice model for this. Shared governance is a dynamic process that promotes collaboration, shared decision making, and accountability for practice through workforce empowerment (2004). Although the principles of shared governance are universal, structure and process generally follow the needs of an organization based on its core values, mission, vision, and philosophy.
In moving to a shared governance model in my place of employment, ownership becomes both individual and team ownership because optimal outcomes cannot be achieved without integrated team effort. This transition requires new knowledge and behaviors at each level and results in a paradox as team members have to perform efficiently while practicing new skills that are unfamiliar and uncomfortable ( 2004).
Nursing leaders are needed to guide the nursing staff in the education or training process. They must be able to translate the demand for change in the particular field of tracheostomy care into a clear, understandable plan, as well as help nursing staff members handle the chaos and uncertainty that accompany the rapid change.
In achieving what is needed to be able to provide quality of care to the clients, the nursing staff should also act as a team. If a nurse learns something that is proven to be beneficial in the client’s care, then it is encouraged that they will share this with the other members of the nursing staff or if applicable, to the whole healthcare profession with the area of employment.
Management also plays an integral part in all of these. The quality of care delivered after the education and monitoring period could be measured using QALY. Evaluations can be done after the proposed strategies have been implemented.
Applying the four key components of clinical governance to the problem is helpful. The activities involved in clinical effectiveness will include finding out what is the best known practice regarding tracheostomy care, appraising the available evidence, changing the practice by educating the nursing staff, and confirming through monitoring or clinical audit that actual practice is consistent with best practice.
The human resources component of the clinical governance framework would aim to ensure that the nursing staff has the right education, adequate training and development, skills and competencies to provide quality tracheostomy care to patients.
There will be an all-out support for the promotion of good practice, prevention of poor practice, and intervention when practice is poor in tracheostomy care. Professional standards and guidelines that contribute to the creation of an environment where there will be less incidence of chest infections after tracheostomy will be set.
To further improve quality care, nurses must help patients through education, empowerment and expertise to avoid the complications associated with tracheostomy care. The nurses must be able to recognize and identify the things that can go wrong as part of a systematic approach to patient care.
The expected outcome of the recommendations should be a decrease in the incidence of tracheostomy clients developing chest infections within a period of at least six months from the time the educational programs are offered to the nurses. As already pointed out in the first few paragraphs of this paper, the reason why there is an increase in the incidence of clients developing chest infections is because of improper tracheostomy management on the part of the nurses. Therefore, the recommendations are more aimed at the nursing staff with emphasis on quality and care governance.
CONCLUSION
In my place of employment, there is a growing problem regarding the development of infection in tracheostomy patients. It has been found out that the reason for this is the apparent lack of knowledge of the majority of our nursing staff regarding the recommended and safe practice for tracheostomy care.
As part of the large whole of the healthcare organization, and as nurses who are in the frontline of delivering care to clients, it is our duty and responsibility to provide the best quality of care to our clients. But this has not been the case in my place of employment.
To summarize, I have recommended a training or education program for the nursing staff. This program will educate the nurses on the recommended practice of tracheostomy care. Every procedure that is involved will be taught and the rationale behind the procedure will also be given. After the initial education program, the staff will be periodically monitored. The incidence of chest infection will likewise be monitored and observed if there is a significant decrease since implanting the recommended strategy. Monitoring the implementation of health policy and evaluating the impact of the outcome has to be well developed.
To effectively carry out the recommendations and in the process improve the quality of care in tracheostomy patients, there should be a collaboration and support of healthcare professionals within my place of employment. Strategic planning should also be employed. Effective teamwork and good communication are essential to the success of quality and care governance. Change can result if there is unity within the organization. Clinical governance is about linking together many activities that affect the delivery of patient care.
Credit:ivythesis.typepad.com
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