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Quality and Safety in Healthcare Management

Introduction

For a variety of reasons that include professionals, patients and policymakers, healthcare organizations nowadays seek to establish solid systems for managing quality and safety in the industry (Bowie & Bradley 2012). After the publishing of the Institute of Medicine (IOM) report, “To Err is Human: Building a Better Health System”, many attempts have been made to prevent errors in medical practice and to also improve the quality of healthcare provision. Healthcare organizations started to inculcate a culture of healthcare safety in their practice. They also began looking for ways to anticipate errors before they occur. In order to prevent medical errors and reduce harm, organizations need tools to detect these (Halbach & Sullivan 2003). The audit is one of the tools that provide health care professionals with the opportunity to detect errors in order to build a safer system. It is one of the key methods through which practitioners can identify opportunities for quality improvement.

In this assignment, the writer has selected decontamination in dental clinics as a critical issue for audit. Cross-contamination in dental clinics is an extremely important area in dental practice as patients and dental staff can be exposed to fetal transmitted diseases such as hepatitis B and HIV Aids virus. It is important therefore to be sure that the dental staff is following the best practice guidelines as regards infection control in their daily practice so as to build a safe and clean environment (Debattista, Zarb & Portelli 2007). In this regard, the writer has prepared an audit proposal to examine the level of compliance by the dental team with the best practice guidelines on infection control. The proposal also aims to detect errors in the system, in addition to also identifying opportunities for improvement.

The importance of evaluation, measurement and research in managing healthcare

To help healthcare organizations improve the quality and safety of the services they deliver, information gathering and analysis are required. Evaluation, measurement and research can help healthcare organizations to gain information required to improve quality and safety. Studies show that there is still a need for additional efforts to evaluate, measure, and research the healthcare sector in order to improve healthcare quality level and also help organizations to identify programs’ weaknesses and strengths (Smith et al. 2008). Evaluation is used to assess and examine a program in an organization and produce information that can be used to improve its quality and effectiveness (World Health Organization Europe n. d.). It attempts to find how a program is working so that it can be improved in addition to finding out if a program meets its stated objectives (eSource Behavioral & Social Sciences Research n.d.). There is a growing importance on the need to conduct an evaluation in the healthcare field. It is used to assess the effectiveness, efficiency, acceptability and equity in the healthcare system. It helps healthcare managers to assess costs and ensure that all patients’ demands are met (Loeb 2004). Moreover, evaluation helps patients to make an informed choice as regards the healthcare services and treatment that they receive. It also helps healthcare professionals to improve their practice and monitor the effectiveness of certain interventions on the quality of their services.

A measurement is a critical tool for improving quality and supplying the information consumers and purchasers need in healthcare systems. It tracks the healthcare organizations’ progress in reaching their aims and guiding public health planning and policymaking. A valid and stable quality measure is important in order to improve performance and encourages healthcare organizations to learn from each other through a benchmarking process (Government Information Library n.d.).

Research is another integral element for healthcare systems. It forms the foundation for program development and policies all over the world. Research helps health care organizations to identify the factors that are necessary for the successful implementation of healthcare projects (eSource Behavioral & Social Sciences Research n.d.). It provides decision-makers in the healthcare sector with the best available evidence for certain questions. Research is also used to evaluate the efficacy and effectiveness of different healthcare programs in a healthcare organization. It is also used to improve clinical practice and patient outcomes and evaluate the efficacy of diagnostic methods and treatment interventions. Research can provide healthcare organizations with quality improvement information and comparison of current practice to evidence-based standards (Steinwachs & Hughes 2008).

Evaluation, measurement and research agree on certain similarities and diverge in some differences. They use similar data collection and analyses methods. Evaluation and Measurement are similar in the systemic approach of data collection to understand and assess if an intervention meets certain standards. The main differences between evaluation and measurement are that evaluation seeks to show causality while measurement does not show causality (Council of Medical Specialty Societies n. d.). Evaluation and research share the objective of answering certain questions, but they differ in that evaluation aims to improve the existing program while research is intended to prove a theory or hypothesis (Levin-Rozalis 2003).

Rationale for the audit

Audit is an essential tool for Continuous Quality Improvement (CQI) (Johnston et al. 2000). It is considered a basic evaluation method (Arter n.d.). Many healthcare organizations use auditing to measure the level of quality they provide. It ensures that healthcare professionals deliver care of the highest standard to their patients (The Clinical Audit Criteria and Guidance Working Group 2008). The audit helps healthcare organizations to identify reasons why standards are not met and identify and implement changes to meet standards. There is extensive evidence from different regions that a gap exists between the health care that patients receive and the recommended practice. There are also many examples of how health care can cause patients avoidable risks (Flottrop et al. 2010). The Audit the writer selected to carry out is tracking the level of compliance regarding the protocols of decontamination in dental clinics located in his/her organization.The main purposes that informed the writer to select the subject of the audit are

  1. To ensure the safety of the patients and the staff members
    Safety is a major concern of healthcare organizations, patients and politicians (Flottrop et al. 2010). From studies, it was found that medical errors are the eighth leading cause of death in a country like the US (Ursprung et al. 2007). Studies show that auditing in the healthcare system help in detecting medical error. Errors detection is crucial to introduce interventions that would improve patient safety. Regarding the writer’s auditing topic it was found that cross-contamination by air-borne bacteria occurs as a result of routine dental activity (Debattista, Zarb & Portelli 2007). The dental staff is exposed to the risk of infection control through the exposure to blood and to mixtures of blood and saliva which may be contaminated with a wide variety of microorganisms including blood-borne viruses (The Dental Council of New Zealand Code of Practice 2002). A study published in the journal of the American Dental Association entitled the possibility of cross-contamination between patients by means of the saliva ejector made it very important to follow infection control guides to reduce it (Nord n. d.). According to the American Dental Association, microorganisms can spread by airborne transmission and be inhaled by dental staff including viral influenza. Also, the hepatitis B virus could be transmitted to the dental staff by contaminated penetrating injury. The chance of transmission of hepatitis C is one in 30 and HIV/AIDS is one to 300 (Schulke n. d.). Auditing decontamination in dental clinics following standards of best practice would ensure the safety of patients and the dental staff by detecting any error in the system.
  2. To improve the quality and patient care
    Through auditing, the healthcare providers can monitor the quality of services they deliver to patients and identify areas for improvement. Also, they can measure the extent to which standards are met (NHS Scotland 2007). Studies showed evidence of improving the quality of healthcare services by using Auditing (Yasmeen 2010). It improves patient centeredness and patient satisfaction (Johnston et al. 2000). It also develops and sustains a culture of best practice (Hughes 2005). Selecting the topic of decontamination in dental clinics for auditing would help the staff to determine if they are meeting the standards (Hughes 2008). Patients deserve to be treated in a clean environment with a consistent standard of care every time they are treated.
  3. To improve professional practice
    Audit when optimally designed could play an important role in improving professional practice (Ivers et al. 2012). It helps staff to measure what they do against systemic standards.The audit gives professionals an opportunity to detect areas that need to be corrected and follow preventive actions to prevent its occurrence in the future (Ivers et al. 2012). Studies showed that health professional may not always assess their work accurately and they need a tool to help them to do that to modify their practice (World Health Organization Europe n. d.). In contrast, some studies found that evidence of the benefits of clinical audit to patient care and quality improvement is limited (Bowie, Bradley & Rushmer 2012). Some people think that auditing is a criticizing tool and may show resistance to it (Yasmeen 2010). Some studies showed that the staff members want to satisfy their managers rather than achieve integrity of self-observation (Hughes 2005). Some staff members would feel that auditing creates a blame culture and they are afraid of punishment (Hughes 2005). Some studies showed that some clinicians believe that auditing is waste of time and resources.Work pressure and lack of protected time were considered as an auditing barrier (Bowie et al. 2012).To overcome the mentioned limitation a preparation of the organization’s environment to receive the change before introducing it is important. Educating the staff member about the use of auditing as a tool that could detect weakness to improve it (Renshaw & Ireland 2003). Building a systemic audit would help to prevent wasting time and resources are important. It is also important to support the audit process from higher management and ensure the staff that it is safe to make mistakes and learn from them (Smith et al. 2008).

Best practice in this area

The Writer’s auditing topic is adopted from guidelines listed by the British Dental Association BDA to control cross-infection in dentistry. It is originally adopted from guidelines listed by the Care Quality Commission in the UK. It is a commission that guides hospitals, dentists, ambulances and care homes to meet national standards in quality and safety. According to their regulation number 12 in 2010 focuses on dentists regarding cleanliness and infection control they designed an auditing system that detects the spread of infections (Somerset South & West Local Assessment Policy 2012). It helps dentists to raise standards of local decontamination. They divided the project into two stages

  • Stage one: the essential quality requirement that should be achieved in one year by self-auditing in which at the end of this year 100% compliance with guidance should occur.
  • Stage two: achieving the best practice implementation of the guidance occurs, this includes the provision of a safe and clean environment and appropriate decontamination of dental equipment. The audit tool will help the practice in monitoring both clinical practice and environment and allow the practice to assess their level of compliance with the guidance. It is spread into seven standards: (DH/IPS 2009).
    • prevention of blood-borne virus exposure
    • Decontamination
    • environmental designs and cleaning
    • hand hygiene
    • management of dental medical devices
    • personal protective equipment
    • waste control

The writer found that the audit system published by The BDA is a best practice in auditing of decontamination in the dental clinic because of the following: (National Institute for Clinical Excellence 2002).

  1. It is a structured program with a systemic method of auditing
  2. Adhere to principles of best practice in clinical audit at a national level
  3. Adequate time is provided for the project to ensure that the design of the national audit project is right.
  4. The design of the audit tool is straightforward and the amount of data collected is kept to minimum
  5. Detailed information is provided

Other factors that could help in the success of auditing in the dental clinic are:

  1. To create the environment that supports the introduction of audit to the organization system.
  2. To encourage a culture of creativity and openness, and errors and failure are reported and investigated without fear of blame.
  3. To involve the right people with the right skills
  4. To allow communication to take place to understand the role of staff responsibility in the project and change management

Overall aims and audit objectives

Aim of the audit

  • To Achieve 100% compliance of infection control guidance at the end of the 12 months

Objectives of the audit

To measure the level of compliance to the universal guidelines of infection control. By achieving these objectives the following will result:

  • Improve patient care
  • Identify whether standards are met
  • Reduce clinical risk
  • Encourage professional educating and training
  • Promote corrective actions that would improve the quality of services

Another way to present the objectives of the auditing project is using SMART objectives. This means that the goals of the project should be characterized by being Specific Measurable, Achievable, Relevant and Time bounded (Learn Marketing n. d.).

Specific

The objectives specifically state that the audit will show the level of compliance to infection control guidance.

Measurable

The objective specifically states that the first stage guidelines should be met 100% within 12 months to progress to the second stage “best practice”

Achievable

The objective would be achieved if the audit managers prepared the environment of the dental center to help achieve the auditing successfully.

Realistic

Before starting auditing the dental staff should review the availability of the required resources (for example staff, cost, machines, materials, and time). For now, the challenge is in funds because the dental center is governed by the ministry of health that would require a complicated procedure to cover the project financially.

Time-scaled

The auditing will take place continuously through 12 months to achieve the first stage “essential quality requirement”.

Action plan

The Dental center administration plans to undertake an audit project to ensure that the critical elements and methods of infection control and decontamination in the center’s clinics are compliant with recognized standards and best practices. The plan that will be designed for auditing will follow the guidelines of the British Dental Association (BDA) of infection control. The action plan will follow five stages according to the clinical audit cycle of the National Institute for Clinical Excellence (2002).

Stages Title Description
One Preparing for audit The audit preparation will go through the following:
  • Form the auditing team and conduct a meeting to decide the topic and the purpose of the audit. The team that will conduct the auditing will be made of: one infection control expert and one experienced general dentist. The writer’s organization selected the topic of decontamination in the dental clinic. The purpose of selecting this topic is that it is considered high cost, high volume, high risk to staff and users. The dental center administration received five complaints from patients about unclean dental clinics, units and instruments within the last six months, one of them was a complaint about blood droplets in the dental unit sink. It is highly dangerous to miss cleaning blood in dental practice because of the possibility of transmission of blood-borne viruses like Hepatitis and Aids.
  • Create the audit framework document: A structured audit tool based on the British Dental Association infection control standards will be followed. It is built on best practice standards.The audit included assessment of policies, procedures and practices followed by the dental staff regarding infection control.
  • Outline of audit procedure, audit time and funds: The funds should be supplied by the Ministry of Health and this procedure could be complicated and need a long time. The auditing will be done quarterly within 12 months period.It is an accepted timeline to collect , analyze data and to introduce any intervention for improvement between auditing cycles until the clinics reach the best practice stage.It is important to train the staff to ensure that the staff implements the measure required. Conducting lectures that provide an overview of decontamination guidance before auditing would be useful to ensure a common standard of interpretation.
Two Selecting the criteria The audit tool includes a criterion that determines whether the organization has comprehensive policies in infection control and that structures are in place to ensure compliance with such policies. All criteria should be marked either “Yes”,” No” or “Partial” according to the level of compliance. The main standards that will be Audited are
  1. Hand Hygiene: Hands will be decontaminated correctly and in a timely manner using a cleansing agent to reduce the risk of infection control (HSE Code of Practice for Decontamination of RIMD 2007).
  2. Environment: The environment will be maintained appropriately to reduce the risk of cross-infection.
  3. Disposable of wastes: Waste is disposed of safely without the risk of contamination or injury.
  4. Contamination with blood/bloody fluids: Body fluid contamination is dealt with in ways that reduce the risk of cross-infection.
  5. Personal protective equipment: Personal protective equipment is available and is used appropriately to reduce the risk of cross-infection.

The data collection will be collected by:

  1. interview
  2. observation

The auditor will use a checklist designed by the BDA to investigate compliance with the guidance of decontamination and select one of the appropriate answers regarding the compliance to the guideline: “Yes: Score 10”,” No: Score 0” or “Partial: Score 2-8”.The auditor can detail some comments to explain the reason for the relevant answer.

Three Measuring level of performance The audit will include all the ten dental clinics in the dental center.The audit will be conducted by a team composed of the following members: An infection control expert and an experienced dentist. The audit will be conducted quarterly in 12 months period to achieve an acceptable level of the first stage of the project “essential quality requirement” as the BDA guideline suggests. The type of data collection will be Qualitative through two methods:
  • Interview: to reveal information from dental staff about their understanding of infection control protocols and follow up if the staff has a good background about infection control
  • Observation: the auditor will use a checklist designed by the BDA and select one of the appropriate answers regarding the compliance to the guidelines, “Yes: Score 10”,” No: Score 0” or “Partial: Score 2-8”.The auditor can detail some supporting evidence or comments to explain the reason for the relevant answer.

The data analysis will be through calculating the criterion score as a percentage and comparing it with the project aim. The aim of the project is to achieve 100% compliance with infection control guidance at the end of the 12 months. After ending the audit project the data will be analyzed and feedback on the results is given.

Four Making improvements The main obstacles that would face the auditing project are:
  • lack of resources: The shortage in dental staff could make their time-limited to audit and cause conflicts between immediate demands of treating patients and the long time needed to audit.
  • Organizational problems such as lack of supportive relationship between the staff and the managers. In the past, the dental center administration had experiences with refusal by the managers to make quality improvement projects because on the ground of cost.
  • Poor cooperation from the staff: many staff members may feel that audit is a blame tool.

To overcome these obstacles the following is suggested:

  • Interview the staff being audited to understand their opinion and challenges about the auditing procedure
  • The need for a protected time to conduct the audit accurately.
  • Build a supportive organizational environment
Five Sustain improvement The topic will be re-audited every three months as the best practice guidelines suggested. This would ensure continuing compliance with the clinical audit standards and confirm that recommendations raised during the previous auditing have been implemented.

Conclusion

The writer’s auditing project would improve the safety of patients and dental staff. If the plan is followed by which auditing is done quarterly and interventions are introduced in each auditing cycle there is a prediction that all the dental clinics will reach the level of best practice in one year. Although the project could face some challenges like lack of resources or lack of cooperation from the working team, with the support from professionals and managers and with the preparation of the environment to receive the change, the project would overcome these obstacles and will guide the organization to an acceptable level of infection control within time.

References

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Smith, P C, Mossialos, E, Papanicolas, I & Leatherman, S 2008. Performance measurement for health system improvement: experiences, challenges and prospects. Web.

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Yasmeen S A 2010,’ Quality audit experience for excellence in healthcare’, Clinical Governance: An International Journal, Vol. 15, No 2, 113 – 127.

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