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chapter 10 | Quality and Safety 139 CikguOnline
surprises that may delay patient discharge and can ■ Preparing the patient for discharge
predict lengths of stay more effectively. ■ Telephoning the patient post discharge
Each of these processes can be evaluated in terms
Aspects of Health Care to Evaluate
of timeliness, appropriateness, accuracy, and com-
A CQI program can evaluate three aspects of
pleteness (Irvine, 1998). Process variables include
health care: the structure within which the care is
psychosocial interventions, such as teaching and
given, the process of giving care, and the outcome
counseling, and physical care measures. Process also
of that care. A comprehensive evaluation should
includes leadership activities, such as interdiscipli-
include all three aspects (Brook, Davis, &
nary team conferences. When process data are col-
Kamberg, 1980; Donabedian, 1969, 1977, 1987).
lected, a set of objectives, procedures, or guidelines
When evaluation focuses on nursing care, the inde-
is needed to serve as a standard or gauge against
pendent, dependent, and interdependent functions
which to compare the activities. This set can be
of nurses may be added to the model (Irvine,1998).
highly specific, such as listing all the steps in a
Each of these dimensions is described here, and
catheterization procedure, or it can be a list of
their interrelationship is illustrated in Table 10-3.
objectives, such as offering information on breast-
feeding to all expectant parents or conducting
Structure
weekly staff meetings.
Structure refers to the setting in which the care is The American Nurses Association (ANA)
given and to the resources (human, financial, Standards of Care are process standards that
and material) that are available. The following answer the question: What should the nurse be
structural aspects of a health-care organization can doing, and what process should the nurse follow to
be evaluated: ensure quality care?
■ Facilities. Comfort, convenience of layout, acces-
Outcome
sibility of support services, and safety
■ Equipment. Adequate supplies, state-of-the-art An outcome is the result of all the health-care
equipment, and staff ability to use equipment providers’ activities. Outcome measures evaluate
■ Staff. Credentials, experience, absenteeism, the effectiveness of nursing activities by answering
turnover rate, staff-patient ratios such questions as: Did the patient recover? Is the
■ Finances. Salaries, adequacy, sources family more independent now? Has team function-
ing improved? Outcome standards address indica-
Although none of these structural factors alone
tors such as physical and mental health; social and
can guarantee quality care, they make good care
physical function; health attitudes, knowledge,
more likely. A higher level of nurses each shift and
and behavior; utilization of services; and customer
a higher proportion of RNs are associated with
satisfaction (Huber, 2000).
shorter lengths of stay; higher proportions of RNs
The outcome questions asked during an evalua-
are also related to fewer adverse patient outcomes
tion should measure observable behavior, such as
(Lichtig, Knauf, & Milholland, 1999; Rogers
the following:
et al., 2004).
■ Patient: Wound healed; blood pressure within
Process normal limits; infection absent
Process refers to the activities carried out by the ■ Family: Increased time between visits to the
health-care providers and all the decisions made emergency department; applied for food stamps
while a patient is interacting with the organization ■ Team: Decisions reached by consensus; atten-
(Irvine, 1998). Examples include: dance at meetings by all team members
■ Setting an appointment Some of these outcomes, such as blood pressure or
■ Conducting a physical assessment time between emergency department visits, are eas-
■ Ordering a radiograph and magnetic resonance ier to measure than other, equally important out-
imaging scan comes, such as increased satisfaction or changes in
■ Administering a blood transfusion attitude. Although the latter cannot be measured as
■ Completing a home environment assessment precisely,it is important to include the full spectrum