Quality improvement is defined as the combined and unceasing efforts of everyone;
healthcare professionals, patients and their families, researchers, payers, planners and educators, to make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development (learning) (Batalden and Davidoff, 2007:2). Improving quality is to ensure that everyone is doing their best to make healthcare safer, more effective, patient-centred, timely, efficient, equitable and sustainable (Atkinson et al., 2010).
According to Manghani (2011), leaders and managers need to ensure that systems of quality control and quality assurance are in place in the workforce, thus enabling health care providers to implement quality improvement activities. Concurrently, Booyens (1998) argued that the quality improvement activities should be organized in a systematic manner and make provision for risk management, an infection control programme, clinical quality improvement
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activities, and the monitoring, measurement and evaluation of quality health care within the organization. In similar vein, Atkinson et al. (2010) argued that it is not possible to talk about quality improvement without talking about change as well as action based on experience.
However, every change is not necessarily an improvement (Muntlin, 2009:14). This suggests that quality improvement as a science needs to be evidence-based and it is therefore important to improve quality of care based on sound interventions (Davidoff, Batalden, Stevens, Ogrinc and Mooney, 2008). To conclude, Leape et al. (2006) proposed that those who are responsible for quality improvement should not only be guided by the Plan-Do- Study-Act cycle model put forward by W Edwards Deming to make quality improvement activities sound, but should also be guided by the standards of practice.
2.6.1. Standards and criteria
Although the concepts standards and criteria have become blurred with respect to quality improvement to such an extent that they are used interchangeably, they may, however, be clearly clarified. Standards are statements of what good healthcare should be (Booyens, 2008). In other words, a healthcare standard is a description of the desired level of performance for judging the quality of healthcare. In nursing practice, standards are referred to with respect to the scope of nursing practice, and encompass both various aspects of the nurse’ role, such as assessment, planning and evaluation; and standards of professional performance, such as aspects of the nurse’s role in quality assurance and research (Arries, 2006). Arries goes on to state that standards are cardinal in the delivery of quality nursing care since within them emerge criteria against which various aspects in the delivery of care are measured for the purposes of quality improvement. According to Booyens (2008), criteria are defined as descriptive statements of performance, behaviour, circumstances or clinical status that represent a satisfactory, positive or excellent state of affairs. However, criteria are related to the standard in that they serve as detailed indicators of the standards and thus make the standard work. Therefore, criteria serve as a practical measurement scale to assess the quality of care (Booyens, 2008).
2.6.2. Nursing clinical indicators
Clinical indicators give an indication of the quality of the patient care that is being delivered.
They must comply with high-quality standards and should be constructed in a careful and transparent manner. Indicators must be relevant to the important aspects of quality of care and be sufficiently evidence-based so that the recommendations formulated lead to clinical
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effectiveness, safety and efficiency (Wollersheim, Hermens, Hulscher, Braspenning, Ouwens, Schouten et al., 2007). Curtis et al. (2006) suggested that those undertaking a quality improvement programme should adopt the use of Donabedian’s tripartite model, which is made up of three classic quality of care components: structure, process and outcome. This model further serves as a guide to the American Nurses Association (1996), where it has been used to identify nursing clinical indicators to inform nursing practice in an attempt to improve nursing quality care.
Firstly, the nursing clinical indicators falling under the structure standards are ratio of nursing staff per patients, RN and nursing staffing, RN staff qualifications, total nursing hours per provided per patient, staff continuity, RN overtime and nursing staff injury. Secondly, the nursing clinical indicators related to process standards involve nurse satisfaction, assessment and implementation of patient care requirements, pain management, discharge planning, assurance of patient safety and responsiveness to unplanned patient care needs. Finally, those related to outcomes include mortality rate, length of stay, adverse incidents, complications, patient/family satisfaction with nursing care and patient adherence to discharge plan (American Nurses Association, 1996).
2.6.3. Strategies for fostering nursing continuous quality improvement
Draper, Felland, Liebhaber and Melichar (2008) have documented the strategies that could be implemented by the health care settings as far as quality nursing improvement is concerned.
These strategies include supportive hospital leadership, which is actively engaged in the work; setting expectations for all staff, not just nurses, that quality is a shared responsibility;
holding staff accountable for individual roles; inspiring and using physicians and nurses to champion efforts; and providing ongoing, visible and useful feedback to engage staff effectively. These authors also suggest to tackle the challenges faced by nurses related to their active involvement in quality improvement involves having adequate nursing staff when resources are scarce; engaging nurses at all levels, from bedside to management; facing growing demands to participate in more, often duplicative, quality improvement activities;
dealing with the high level of administrative burden associated with these activities; and confronting traditional nursing education that does not always adequately prepare nurses for their evolving role in today’s contemporary hospital setting (Draper et al., 2008).
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The South African Department of Health (2008) has outlined some strategies to improve quality nursing care which involved appropriate workload, professional leadership and clinical support, ongoing professional education, career mobility and career ladders, and good wages. In Tanzania, Manongi, Marchant and Bygbjerg (2006) found that even although financial incentives are important, they are not sufficient to motivate health workers. They revealed that supportive supervision, performance appraisal, career development and transparent promotion are essential for continuous improvement of quality nursing care.
Along the same line of thought, Pomey, Lemieux-Charles, Champagne, Angus, Shabah, and Contandriopoulos (2010) suggest that accreditation is also necessary to improve quality and safety in health care system delivery. In Rwanda, Muller, Murenzi, Mathenge, Munana, and Courtright (2010) documented that emphasis is put on training nurses in good patient interaction skills and providing adequate material, monitoring and evaluation of health services. It is also imperative to empower nurses in decision-making in health service management (Meessen, Musango, Kashala and Lemlin, 2006) and adopt a performance-based financing (PBF) in health as a strategy to improve quality of care (Rusa, Ngirabega, Janssen, Bastelaere, Porignon and Vandenbulcke, 2009). Furthermore, the Ministry of Health of Rwanda is striving to increase the number of health care providers to such an extent that ten (10) physicians and twenty (20) nurses will take care for 10.000 inhabitants (Ministry of Health, 2011).
To sum up, quality improvement in nursing implies that nurses attend effectively and efficiently to patients’ needs and are aware of and take into consideration all factors influencing the patients’ satisfaction (Johansson, Oléni and Fridlund, 2002).