Organizing lquality Assurance in a Materna&C%iU Health Division

JOC as PRINCIPLES & PRACTICE SUSAN NINE, RNC, CCRN, BSN KIMBERLY BAYES, RN, CCRN SANDY CHRISTIAN, RNC, BSN BETTY DILLON, RNC Organizing lquality Assurance in a Materna&C%iU Health Division The 10-step monitoring and evaluation process is described and applied to a maternal-child health division of a 3 0 0- bed tertiary care hospital. Examples of specijc important aspects of care and indicators are given. The organized plan developed for this division is examined using the Joint Commission on Accreditation of Health ca re Organ iza tio n 's gu idelines. Accepted: June 1991 n January 1990, Cabell Huntington Hospital was charged with developing a plan for enhancing quality assurance (QA) in its maternal-child health division. The goal was twofold. The division had to meet the requirements of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) by implementing a 10-step monitoring and evaluation process. In addition, a plan was to be formulated that would meet the needs of all five areas in the division -a 30-bed pediatric unit, a 6-bed pediatric intensive care unit, a labor and delivery area that had 2,500 deliveries per year and included a high-risk obstetric service, a 36-bed maternity unit that recently had implemented mother-baby care, and a level I11 24-bed neonatal intensive care unit. The director of quality and resource management of our 300-bed tertiary care hospital set the stage. An all-day, out-of-the-hospital meeting was arranged. Representatives from the maternal-child health division included nine staff nurses, four head nurses, and the director of maternal-child health. We used the JCAHO manual, Examples of Monitoring and Evaluation in Special Care Units, as a guide in devising a plan. Each step of the 10-step process was examined and outlined. The steps of the monitoring and evaluation process are as follows: 1. Assign responsibility. 2. Delineate the scope of care. 3. Identify important aspects of care. 4. Identify indicators. 5. Establish thresholds for evaluation. 6. Collect and organize data. 7. Evaluate the care. 8. Take actions to solve problems. 9. Assess the problem-solving actions and document any improvement therefrom. 10. Communicate relevant information to the organizationwide QA program (Joint Commission on Accreditation of Healthcare Organizations [JCAHO], 1988). This article details the special considerations discussed as each step of the plan was written. Examples of parts of the actual plan are given. All attempts were made to apply the exact JCAHO recommendations when possible. Modifications were made when necessary to adapt the plan more readily to the hospital. The 10 steps Responsibility The director of maternal-child health is accountable to the vice president of patient services for the QA activities of the division. Each head nurse is responsible for 28 JOCNN Volume 21 Number 1

Quulity Assurance in Maternal-Child Health Care the coordination of the units QA activities, including the appointment of a two- to three-person unit committee. Head nurses and unit QA committee members perform monitoring and evaluation on the unit level. All of the head nurses and at least one committee member from each unit attend the monthly divisional QA meetings and quarterly hospitalwide QA meetings. All unit QA committee members are invited, and several often attend when schedules permit. In this section of the plan, JCAHO (1988) requires that the physician director have overall responsibility for QA in special care units. In the maternal-child health division, these units are the neonatal intensive care unit and the pediatric intensive care unit. The group chose to emphasize that responsibility for QA is jointly shared by staff and management. Scope of care The statement on the scope of care begins by asserting that the maternal-child health division provides quality patient care to mothers and children according to hospital and national standards. Each unit s scope of care is then defined individually and contains the following information: type of patients served, diagnoses and conditions treated, treatments or activities performed, types of practitioners providing care, and if appropriate, sites and times care is provided (JCAHO, 1988, p. 15). Table 1 shows a portion of the scope of care in the division s neonatal intensive care unit. Important aspects of care In the group meeting, eight important aspects of care were defined to serve as the basis for monitoring and Table 1. Scope of Care In the Neonatal Intensive care (Init The head nurse assists the medical director in the development and implementation of policies and procedures and directs a staff of 31 registered nurses and a licensed practical nurse. The following responsibilities are fulfilled by the neonatal intensive care unit s primary nursing team: Evaluate neonates initial needs, stabilize as far as possible those neonates with life-threatening conditions, and provide the care immediately indicated. Provide appropriate nursing interventions for neonates with medical and surgical illnesses. Respond to emergencies in the labor and delivery area and, on occasion, in the emergency room. Assure the availability of follow-up care to support home care of neonates. evaluation. In selecting these aspects, JCAHO (1988) guidelines were followed, and the group chose areas that were high volume, high risk, or problem prone. The main challenge was making the aspects general enough to cover the entire division, yet specific enough to meet the needs of individual units. Following is a list of aspects selected and an explanation of why each was chosen: 1. Safety and security (high volume, high risk, and problem prone). It is necessary to monitor security issues in the mother-baby and pediatric units, as well as safety issues such as the use of monitor alarms and side rails. 2. Documentation (high volume). Documentation is vital in the health-care industry for legal and financial purposes. Also, through documentation, it is possible to monitor how well nursing care is carried out. 3 Patient, parent, and staff education (high volume). Patient education and parent education are an integral part of the division s familycentered nursing care on all units. Staff education is essential in assuring the competency of all personnel. 4. Medication administration/intravenous therapy (high volume, high risk, and problem prone). The safe administration of medication and intravenous therapy is a priority in all hospitals, and the margin for error becomes extremely small when dealing with infants and children. 5 Infection control (high volume, high risk, and problem prone). All units must be diligent in the adherence to infection control policies to reduce nosocomial infection. Again, infants are particularly susceptible. 6. Transferring patients to and from the unit or to and from other facilities (high volume, high risk, and problem prone). Ensuring the safety of patients when transporting them, as well as providing proper communication and documentation between units, is vital. In a regional referral center for critically ill infants, children, and obstetric patients, interhospital transport is a high-volume issue. 7. Management of the high-risk patient (high risk and problem prone). Each unit must be able to identify high-risk patients for whom monitoring and evaluation will be performed. 8. Inuasiue/noninvasive monitoring (high volume, high risk, and problem prone). All units in the division perform either invasive or noninvasive monitoring. This aspect allows evaluation of various practices, from monitoring apnea in the Januury/February 1992 JOG 29

~~~ ~ P R I N C I P L E S A N D P R A C T I C E nursery to monitoring fetal heart rate in labor and delivery. Table 2. Indicators and Thresholds Identified by Labor and Delivery Unit Indicators Indicators are quality-related variables and can measure structure, process, or outcome (JCAHO, 1988). It is important that they can be easily, reliably, and objectively measured. Indicators were not selected in the group meeting. Rather, each unit was assigned the responsibility of selecting indicators for each of the eight important aspects of care. The selections were then submitted collectively to the director of maternal-child health and woven into the plan. Each unit attempted to obtain indicators from authoritative sources recommended by JCAHO (1988). Those indicators selected by the labor and delivery unit are shown in Table 2. Thresholds Thresholds for each indicator were determined by the individual units. The purpose of a threshold is simply to establish the point at which further examination must occur. Setting thresholds saves time by allowing a specific number of infractions before in-depth investigation is required. Of course, some areas of practice are life-and-death issues, and perfection is required. In that case, the threshold is set at 0% if the event should never occur, or if it should always occur. Table 2 shows thresholds for the indicators selected by the labor and delivery unit. Data The remainder of the plan was written during the group meeting. For the collection and organization of data, staff members are encouraged to look at existing sources, rather than developing new forms. Examples of existing sources recommended by JCAHO (1988) are patients records, autopsy reports, laboratory reports, medication sheets, incident reports, department logs, minutes or reports of committee meetings, infection control reports, patient satisfaction questionnaires, direct observation of patients or staff, and utilization review findings. At Cabell Huntington Hospital, we also use occurrences (forms employees may use to document quality issues), pharmacy inspections, patient acuity data, and preventive maintenance reports (forms from the biomedical department documenting safety checks). Aspects of care to be monitored are listed on a calendar according to the frequency of monitoring and the assigned dates of monitoring. Statistics and trends are then recorded and submitted for review. Important aspect of care Safety/security Education Documentation Administration of medication Infection control Patient transfer Invasive/ noninvasive monitoring Care of high-risk patient Indicator All staff will display name badge with photo. Discharge instructions will be documented. Nursing interventions and resolution of identified fetal heart rate problems will be documented. Effect of epidural medications will be noted in nurses notes. Staff will isolate body substances. Gloves will be worn when starting intravenous administration, as outlined in policy. A maternal transport nurse will be ready to depart within 30 minutes of receipt of a request for transport. All nurses will pass a written test on interpreting invasive and noninvasive fetal heart rate monitoring with a score of 85% or better. Observations of the patient receiving MgS04 (intravenously) for preeclampsia will be documented according to protocol: Documentation will include a reflex check, intake and output, proteinuria, and blood pressure every hour. Documentation of the rate of intravenous flow and dosage of MGS04 will be performed on an hourly basis. Threshold 80% 30 J O C N N Volume 21 Number 1

Quulity Assurance in Maternal-Child Health Care Evaluation When the data rea5h the predetermined threshold, each unit evaluates the care provided to ascertain whether a problem exists. Problems can be caused by many factors, such as a lack of knowledge or malfunction of equipment. Actions to solve problems If a problem is identified, the unit decides what corrective action is necessary. According to JCAHO (1988, p. 28), a plan of corrective action identifies who or what is expected to change, who is responsible for implementing action, what action is appropriate in view of the problem s cause, scope, and severity, and when change is expected to occur. Many possible corrective actions are defined by JCAHO, and they are included in the QA plan. The actions range from adjusting staffing to providing inservices. The plan specifies that any corrective action is to take place through existing channels and must be documented. Assessment of actions After an action has been taken to solve a problem, it is necessary to determine whether or not the action was successful. Each indicator is monitored on a continual or intermittent basis to see whether the thresholds established are met after corrective action is taken. If a threshold is not met twice, the reasons for the failure are examined, and a new action plan is formulated and implemented. Continued monitoring and evaluation of the new action is essential. Even when a threshold is met, monitoring and evaluation are used to determine how consistently it is met. The assessments are documented to provide a record of the efficiency of the actions. Documentation is accomplished by using a QA report that includes important aspects of care, indicators, thresholds, data collection methods, conclusions, recommendations, corrective actions (including what was done, when, and by whom), effectiveness of actions, resolutions, and to whom the information was reported. This report provides a summary of the 10-step process for each indicator (see Table 3). Communication A summary of findings, conclusions, recommendations, actions, and results is discussed at unit staff meetings, critical care committee meetings, pediatric and obstetric medical section meetings, and divisional and hospitalwide QA meetings. Information obtained through monitoring and evaluation is communicated to the director of maternal-child health, who then forwards the information to Table 3. Quality Assurance Report Unit/Dept. Labor and Deliverv Quarter 1 Important aspect of care: Administration of medication Indkator: Effect of epidural medications noted in nurses notes. Specifically, blood pressure checks three times within first 30 minutes, then at least once every 30 minutes. Data couection: Month of February, 20 inpatient charts reviewed. Concl~ons: 75% correct documentation. Recommendahns: Discuss with staff and continue quarterly monitoring. ZtWt?SbOId Actions taken: Wben By wbom Discuss and review at staff 04/01/90 Donna meetings. Edwards Eflectiveness of actions: To be determined by chart review, month of May. Resolutions: Pending. Refer to second- and third-quarter reports. Reports shared with: Head nurse, maternal-child health director, and director of quality and resource management. the vice president of patient services. The information is also communicated to the director of quality and resource management and the medical directors of the special care units. The director of quality and resource management reports to the hospital QA committee and the board of directors. Case Studies To illustrate different types of actions taken when thresholds were not met, we shall briefly examine two cases from the labor and delivery unit. In the first, Januury/Februury 1992 JOG 31

P R I N C I P L E S A N D P R A C T I C E illustrated in Table 3, documentation of the effect of epidural medication on blood pressure is described. Documentation was correct 75% of the time. Action taken after a review of the documentation was simply a discussion in staff meetings. By the second report, 3 months later, documentation was correct 87% of the time. Because the action was effective, it was repeated, and by the third and fourth reports, correctness increased to 88% and 93%, respectively. At the time of the second report, another, indicator was added: documentation of patient comfort after epidural medication. After staff meetings, correctness for this indicator increased from 78% to 80% and, finally, to. A second case involved documentation of discharge instructions. Initially, the documentation was correct nearlyat the threshold level, but with an action of revising discharge instruction forms and placing them in predrawn charts, correctness increased to and remained there for two more reviews. This brief example is included to emphasize that creative actions are at times beneficial (i.e., the action should not always be just a discussion of the problem). Nursing Implications Nursing directors, head nurses, and staff nurses can work in collaboration to maintain an effective QA program. A commitment to high-quality care by all levels of nursing staff and an understanding of the 10-step monitoring and evaluation process are the basis for an excellent program. Involvement at all staff levels is important to facilitate the selection of the important aspects to monitor. A central individual, whether the director or another designated individual, is necessary to organize the efforts of the various units and to ensure compliance with the steps. A smooth-running QA program can increase the nursing staffs pride in its contribution to high-quality patient care. Nursing is unique in that no other profession spends as much time with hospitalized patients. Therefore, nurses can assess, monitor, and evaluate care in a highly accurate manner on a day-to-day basis. By involving themselves in the procedure described, nurses realize that QA is not just another paperwork requirement. Like nursing per se, the procedure improves the quality of care that patients receive. Summary The JCAHO 10-step plan is practical and easy to apply to a maternal-child health division. A day away from the hospital is recommended to allow staff and managemen! time to become familiar with the process and to select the important aspects of care. Indicators and thresholds can be selected at a later time by individual units. The final step in planning is to compile the steps into a written plan, which can effectively be accomplished by the divisional nursing director. A QA program can thus be a useful, and even enjoyable, way to resolve issues and improve the care given to patients. At Cabell Huntington Hospital, the staff has found its own satisfaction increasing as it sees beneficial changes accomplished. Reference Joint Commission on Accreditation of Healthcare Organizations. (1988). Examples of monitoring and evaluation in special care units (pp. 13, 15, 19-20, 22,26,28). Chicago: Author. Address for correspondence: Susan Nine, RNC, CCRN, BSN, Director, Maternal Child Health, Cabell Huntington Hospital, 1340 Hal Greer Blvd., Huntington, WV 25701. Susan Nine is director of maternal-child health at Cabell Huntington Hospital in Huntington, West Virginia. Ms. Nine is a member of NAACOG. dmberly Bayes is head nurse in the Pediatric Intensive Care Unit at Cabell Huntington Hospital in Huntington, West Virginia. dndy Chrlsttan is a clinical educator of pediatrics at Cabell Hunttngton Hospital in Huntington, West Virginia. ltty Dillon is a clinical educator in the Neonatal Intensive Care Unit at Cabell Huntington Hospital in Huntington, West Virginia. 32 J O G N N Volume 21 Number 1