Clinical Audit – Can Quality Care Metrics empower

nurses to demonstrate quality care through documentation? Johanna Downey RGN, RM, RPHN, NMPD Officer.

Objectives:

• To Understand the What, Why, Who, When, Where and How of the Quality Care-Metrics (QCMs) Initiative

• To identify the importance of documenting care provided

• To identify the QCMs currently in operation in the Public Health Nursing Service

• To identify means of reaching quality documentation practices

• To identify the National Plan for the Quality Care-Metrics Initiative

What are Quality Care-Metrics?

….are measures of the quality of Nursing and Midwifery clinical care processes in healthcare settings in Ireland, aligned to evidenced-based standards and agreed through national consensus HSE (2016) What gets measured gets managed! (Peter Drucker)

METRICS IDENTIFIED-QCM Research Project 2017. PUBLIC HEALTH NURSING / COMMUNITY NURSING: 1. Pressure ulcer prevention and management 2. Care plan development 3. Wound care management 4. Professional and ethical demeanour 5. Patient / Family / Carer experience 6. Health Promotion 7. Medication therapy safety 8. Maternal surveillance 9. Infant nutrition 10. Healthcare associated infection and prevention 11. Continence assessment 12. Child & Family Needs Assessment 13. Child Development Surveillance 14. Child Protection 15. Safeguarding Vulnerable Adults and Older Persons

KPI’s versus QCMS... What’s the Difference

KPI’s measure outcomes (HIQA, 2013) Quality Care-Metrics measure process leading to outcomes ‘many outcomes, by their nature, are delayed, and if they occur after care is completed, information about them is not easy to obtain….it is not possible to say precisely what went wrong unless the antecedent process is scrutinized’ (Donabedian, 1988)

Where did QCMs Come From?

• Introduced by Chief Nursing Officer Mandie Sunderland (NHS) in the Heart of England Foundation Trust

• Aimed to increase patient safety and promote quality care following an increase in complaints, falls, pressure ulcers and medication errors.

• Results indicated a significant improvement in patient safety and a decrease in falls, pressure ulcers and medication errors.

Why Implement QCMs?

• Provides opportunities for nurses/midwives to deliver a standard of care that is safe, evidenced based and congruent with legislative and national policies

• Establishing good processes will improve the standard of care and create good outcomes for Service Users/patients/clients

• Metric data will identify areas of good practice which must be celebrated, it will also identify areas where improvement is required

HSE apologies over • Baby deaths. • Aras Attracta. • Maternity Services.

Why Implement QCMs?

Measurement Improves Quality Measurement of care practices has been identified as playing an integral role in quality improvement and helps to promote positive change in care delivery

(Donabedian, 1980, Campbell et al., 2002, HIQA, 2013). REMEMBER The standard of care you walk past is the standard of care you accept, and what you accept you promote

How to Report on QCMs

Agreed Standard Measurement Score

90%-100%= Green 80%-89% = Amber

79%-0% = Red

Aim to have all services green for each Metric

Summary Report

Importance of Documenting care provided

• Healthcare records provide evidence about care and treatment patients receive

• Health records are clinical tools enabling continuity of care and appropriate decision making about future care and treatment.

• If the quality of care provided is questioned, documentation is essential for any investigation or review.

• Health records provide evidence that care is meeting quality and safety standards.

(College of Registered Nurses of Nova Scotia, 2012, Oates, 2014, NMBI, 2015)

Nursing Documentation

• Assessments • Care Plans • Progress Notes • Letters/Referrals • Written Communication Between Colleagues about Patients

• ‘Recording of care is not a distinct activity from delivering care,

and time should be allocated for documentation as part of patient contact’ (Oates, 2014)

• Nurses/Midwives are constrained by the structures used within the organisation (Oates, 2014)

Care Plan and Progress Notes

• The aim of the care plan is to achieve the assessed needs or goals of the person receiving the care

• Care plans should be individualised, current, accurate and evidence based with specific, measurable, achievable, realistic and timed objectives.

• Progress notes identify the direct care provided, which reflect person centred care and explicitly linked to the individual’s care plan.

(College of Registered Nurses of Nova Scotia, 2012, Oates, 2014, NMBI,

2015)

PHN Service QCMs

Documentation QCM Developed combining evidence based literature and expert consensus

• Nursing Assessment • Nursing & Midwifery Care Plan • NMBI Guidance • Discharge Planning & Caseload Management (Documentation QCM approved by Ms. Mary Wynne ONMSD) Dec 2015

PHN Service QCMs

• A Quality Care Process Metric is a quantifiable measure that captures quality in terms of how (or to what extent) nursing care is being done in relation to an agreed standard.

• A Quality Care Process Indicator is a quantifiable

measure that captures what nurses are doing to provide that care in relation to a specific tool or method.

Nursing Assessment

Nursing Care Plan

NMBI Guidance

Discharge Planning

Principles of Good Record Keeping-Nursing Assessment

• Accuracy of patient identification • Date, Time (24hr clock), Sign • Reason for Admission and Source of Referral • Past History • Complete Clinically Indicated Assessments (i.e. MUST, Falls Risk,

Barthel) • Medication, Allergy Status, Up to date Prescriptions • Infection Status

(HSE, 2011, College of Registered Nurses of Nova Scotia, 2012, Oates, 2014,

HSE, 2015, NMBI, 2015)

Principles of Good Record Keeping- Nursing Care Plan

• Include Patient in Nursing Decisions • Document Refusal of Treatment or Service • Rationale for Nursing Interventions • Discharge Education and Preparation • Evaluation of Care Provided • Communication with Other Professionals • Never Presume Consent, Document Verbal Consent • Care Provided and Patient Condition is Up-to-Date

(HSE, 2011, College of Registered Nurses of Nova Scotia, 2012, Oates, 2014, HSE, 2015, NMBI, 2015)

Principles of Good Record Keeping- NMBI Guidance

• Legible, Factual and Concise Entries • Patient Record Belongs to the Patient and Should be Comprehensible • Black Permanent Ink • Chronological Order (like a book) • Late Entries are Dated, Timed and Signed • Approved Terminology and Abbreviations • Alterations or Corrections as per NMBI Guidance • All Student Entries Countersigned

(HSE, 2011, College of Registered Nurses of Nova Scotia, 2012, Oates, 2014, HSE, 2015, NMBI, 2015)

Principles of Good Record Keeping-Discharge Management & Caseload Management • Preparation of the Patient and/or Carer for Discharge • Communication between Providers about the Discharge

Assessment and Plan of Care • Achievement of Nursing Objectives • Accurate, Comprehensive Transfer of Information • Patient Education about Self-Management • Assessment of Patient Knowledge of Self-Management (Coleman & Boult , 2003, HSE, 2013, HSE, 2015)

Principles of Good Record Keeping-Discharge Management & Caseload Management • Preparation of the Patient and/or Carer for Discharge • Communication between Providers about the Discharge

Assessment and Plan of Care • Achievement of Nursing Objectives • Accurate, Comprehensive Transfer of Information • Patient Education about Self-Management • Assessment of Patient Knowledge of Self-Management (Coleman & Boult , 2003, HSE, 2013, HSE, 2015)

Nursing & Midwifery QCMs National Plan

• Ms. Anne Gallen anne.gallen@hse.ie Director NMPD North West • National Project Lead on behalf of the ONMSD • Working with Project Officers in each NMPDU Nationally (8). • National Implementation of QCMs • Development of New QCMs

Quality Care-Metrics Acronym

References • Campbell, S. M., Braspenning, J., Hutchinson, A. and Marshall, M.

(2002) 'Research methods used in developing and applying quality indicators in primary care', Quality and Safety in Health Care, 11(4), pp. 358-364.

• Coleman, E. Boult, C. (2003) Improving the quality of transitional care for persons with complex needs. J Am Geriatr Soc 51, 556-557.

• College of Registered Nurses of Nova Scotia (2012) Documentation Guidelines for Registered Nurses, Halifax: College of Registered Nurses of Nova Scotia.

• Donabedian, A. (1988) 'The quality of care: How can it be assessed?', Jama, 260(12), pp. 1743-1748.

• Donabedian A. (1980) Exploration in quality assessment and monitoring volume 1. The definition of quality and approaches to its assessment. Ann Arbor, MI: Health Administration Press.

• Health Information and Quality Authority, (2013) Guidance on Developing Key Performance Indicators and Minimum Data Sets to Monitor Healthcare Quality.

• Health Service Executive (2015a) Guiding Framework for the Implementation of Nursing and Midwifery Quality Care-Metrics in the Health Service Executive Ireland, Health Service Executive; Nursing and Midwifery Planning and Development.

• Health Service Executive (2013) Public Health Nursing Service Community and Continuing Care Service in Longford and Westmeath, HSE.

• Health Service Executive (2015b) Standard Operating Procedure for Nursing and Midwifery Quality Care-Metrics Data Collection in Public Health Nursing Services, Dublin: Office of Nursing and Midwifery Services Director.

• Health Service Executive (2011) Standards and Recommended Practices for Healthcare Records Management, Dublin: HSE.

• Nursing and Midwifery Board of Ireland (NMBI) (2015) Recording Clinical Practice, Professional Guidance, Dublin: NMBI.

• Oates, B.J. (2014) Maintaining best practice in record-keeping and documentation, Continuing Professional Development, Nursing Standard, 28(36), 45-50.

References