Quality and Risk Management in Health Care - Essay Example

MODULE 10 ESSAY Quality and risk management in health care are essential and interrelated components of the health care delivery system. This essay aims at discussing various issues related to the quality and risk management within the health care context. While the essay defines and describes both independently, it also focuses on the interrelatedness between the two. The essay will describe the importance of quality in health care and measures taken to reduce risks or risk management that are currently being adapted. In risk management, the highlight will be on the professional, legal and ethical perspectives. To describe and discuss various issues related to quality and risk management in health care literature will be reviewed extensively. A simplistic definition of is given by the Concise English Dictionary (1994) as, "a grade of goodness or excellence." Donabedian (1980) defines quality in health care as "almost anything anyone wishes it to be". Though these two definitions are easy to understand, they do not suffice the need of defining quality in health care appropriately. The Institute of Medicine (2001) has defined quality as "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge." The St Mary's NHS Trust (2005) define quality as "meeting or exceeding standards, which reflect user needs and expectations and which conform to recognised best practise". These last two definitions of quality emphasise on two major areas of health care. One is meeting standards of health outcomes that are desired by the users and updating professional knowledge so that it can achieve the first goal of meeting expected standards. As stated earlier, risk management is an integral part of health care. It is a discipline designed to minimise the adverse effects of unwanted outcome in an organisation's users (St Mary's NHS Trust, 2005). Hinchliff et al (2003) defined risk management as safe practise, which aims to develop good practise and reduce the occurrence of harmful or adverse events. Nurses therefore need to assure patients/clients that they are delivering a high standard of quality nursing which aims to be in the best interest of the patients/clients. Clinical risk management is an approach to improving the quality and safe delivery of health care by placing special emphasis on identifying circumstances that put patients at risk of harm, and acting to prevent or control those risks.(Moulden). Jean Faugier (1997) in her research paper concludes that while Clinical Risk Management undoubtedly raises standards of patient care, the future implementation and direction of the strategy may be governed by both patient expectations and the changing nature of the 'new NHS'. Hichliff et al (2003) supports this by explaining that risk management should have a strategy in order to minimise risk to clients and staff and the strategy should include policies and procedures implementation. In clinical risk management, the risk assessment tool provides a framework for local risk assessments to be translated into local risk management action plans. This involves observing patients on admission through a nursing assessment process which provides and acknowledges that all patients are potential infection carriers. According to the DOH (1995), it is impossible to identify by merely looking at an individual if they are infected therefore observing universal precautions to maintain quality is of tremendous importance. As an example, Methycillin resistant staphylococcus aureus (MRSA) C-diff and other hospital acquired infection can be reduced, for these infections are spread by direct contact from patient to nurse or patient to patient if proper hand washing technique is not observed. Cross infection may occur if micro-organisms that cause an infection are acquired from hospital personnel and can be spread by incorrect disposal of contaminated material such as body fluids or blood. Bamigboye (2006) states that, "Universal precautions are intended to prevent parenteral, mucous membrane and non-intact skin exposures of health-care workers to blood borne pathogens. An important aspect of these precautions is the need to wash hands after touching patients or coming in contact with fomites as well as other fluids and secretions from patients especially in an hospital setting. Personal hygiene thus becomes a fundamental principle in observing universal precautions. " Health workers should practise proper universal precautions such as isolation, safe handling and disposal of clinical waste, use of protective clothing and hand washing to maintain good quality of care. High standards of cleaning or disinfection where appropriate reduce the risk of hospital acquired infections which according to the National Audit (2002) 1 000000 people a year become infected in hospital and 5 000 die as a result. To manage this risk and improve compliance there has been the introduction of bedside decontamination using hand rub gels that are alcohol based. Health professionals have a duty to control the spread of infectious diseases by practicing universal precautions and according to Jeanes (2003) the introduction of alcohol based rub helps care providers, patients and their relatives become compliant with hand hygiene. Personal hyegine is considered to be of fundamental importance in practice of universal precautions as a safeguard to reduce risks of routine infections. A systematic review of the study on alcohol based hand rub by Pincheansathian (2004) supported the research that alcohol hand rub removes micro organisms effectively, requiring less time and irritating hands less than antiseptic and soap. Hand hygiene is therefore a key factor in reducing clinical risks or hospital acquired infections and should be seriously considered in risk management since it has an impact on the achievement of high quality, effective and safe care for patients. The Department of Health (DOH 1995) requires health professionals to adopt universal precautions policy, which involves hand washing and wearing protective clothing when coming into contact with blood products and bodily fluids. Health professionals by adhering strictly to the universal precautions can facilitate the risk reduction process. Adhering to the universal precautions at all conditions can be an effective way to maintain the quality of health care. The quality of care therefore in risk management, sets standard which should be observed in order to minimise hospital acquired infections. The St Mary's NHS Trust (2005) has a duty to provide adequate training, information, instructions and supervision for employees while at work. Health professionals should always be aware of the need of implementing policies and procedures at their workplace. Thus the duty risk management in health care is multifold and involves the patients, their families, health care providers and policy makers. The joint efforts of all these can bring better results. Control of Substances Hazardous to Health (COSHH, 1999) is another regulation that governs the disposal of bio-hazardous substances such as blood products. According to Selwyn (1997) the regulation requires that all bio-hazardous substances be disposed of safety e.g. proper disposal of needles and sharps. Health and safety issues should always be at the forefront and thinking about safety as a form of quality needs to be a reflex action prior to any task being undertaken. The most common injury among nurse is needle stick injury and according to Dimond (2002) the manufacture of the needle can be liable for the nurse's injury should the health professional have observed protocols and procedures of the Trust. Clinical governance is a framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standard of patients care by creating an environment in which excellence in health care will flourish (DOH 1995). It encourages nursing professionals to evaluate their contribution to patient outcomes and effective monitoring of clinical care with high quality systems such as evidence based practice which is supported and applied routinely in everyday practices (Commission for Health Improvement 2000). Professional practice requires an awareness and alertness to identify risks e.g. MRSA screen on admission and once every week is carried out by St Mary's NHS Trust (2005) to minimise infections. Barrier nursing is also practiced to prevent cross infection and according to the Royal College of Nursing (RCN) (2000), barrier nursing signs should be displayed in isolation to maintain patient confidentiality. The key to reduce risks of infection and improve quality in health care delivery are awareness, commitment and involvement of the staff. The awareness and knowledge about professional code of conduct, ethical dilemmas that a professional might face while providing care and the legal implications of health care are considered pivotal in health care. While improving the safety and quality of care are major objective for all NHS care providers, confidentiality should be maintained at all times to avoid stigmatisation of infected patients. Gammon (1998) states that patients who are barrier nursed stay longer in hospital due to loss of control over their condition, anxiety and feeling like an outcast, therefore need to maintain patient confidentiality on the wards by not disclosing patients' diagnosis to other patients should be maintained at all times. In maintaining quality of care for patients/ clients the Trust has a responsibility of providing a systematic and focused mechanism to review and monitor risk and incidents, while the health professional has an obligation to possess knowledge and skills required for safe and effective practise without direct supervision. Health care practice associates itself with the service for human beings. The ethical issues that underline various health care practices needs to be taken notice of for the improvement of quality and even to understand the legal implications of the health care services. Legal issues influence health professionals in conducting their day-to-day duties. There is also a legal requirement for employers under the General Rules of Health and Safety at Work Regulations (1992) and the Control of Substances Hazardous to Health Regulations (1994) to safeguard employees and others against clinical and non-clinical risks. These include risks posed by blood borne infections and strategies should be put in place to reduce the risks (Alexander et al 2000). Health professionals have a duty of care, which means that one must not harm a patient, other service users therefore aim to avoid acts, and omissions that would injure patients thereby compromising quality of care. Patients have a right to be protected from preventable infections such as HAIs and nurses have a duty to safeguard the well being of their patients (Reeves et al 2002). Individual patient assessment on admission and before any procedure should therefore be carried out so nurses can tackle potential risks by predicting and planning (St Mary's NHS Trust 2005) According to Noddings (1984) an approach to ethics from caring is 'rooted in receptivity, relatedness and responsiveness. Ethical principles are based on morals and values and can help in developing a strong base in a nurse - patient relationship. While looking for the requirements of maintaining health care quality and risk reduction, the humane face of the health care delivery system should not be forgotten. Manning Rita (1998) describes five elements that constitute a care ethic: moral attention, sympathetic understanding, relationship awareness, accommodation and response. On the basis of these five components the health care professionals can be responsive to the needs and requirements of their profession and the health care users. Understanding the moral and ethical background of the profession helps the professionals in dealing with ethical dilemmas coming across in day to day practice. According to the Nursing and Midwifery Council (NMC 2002) Code of Professional Conduct, nurses must protect and support the health of individual patients and clients, protect and support the health of the wider community, act in such a way that justifies the trust and confidence the public have in him/her and uphold and enhance the good reputation of the professions. The Nursing and Midwifery Council (NMC 2004) Code of Professional Conduct also states that the nurses must act to identify and minimise risk to patients and clients in order to promote health. Working under this code helps nurses acknowledge their duty of care and accountability in protecting patients and clients from acquiring infections or preventing further deterioration. Health professionals should accept the idea that every person is of equal value and that they should be respected as persons whatever their culture and morals they might have (NMC 2002). When it comes to the spread of infection, nurses should not let moral values cloud their judgement. Hinchliff et al (2003) relates to virtue-based ethics, which look at generosity, kindness and comparison, which is often adopted in society when people want to be viewed as helpful. In clinical areas, nurses fulfil this theory often by offering personal care to patients without observing universal precautions. Some nurses according to Alexander et al (2000) argue against wearing gloves when delivering personal care because they want to be seen as compassionate and kind yet they do not realise that some patients do not observe proper genital hygiene of washing hands each time they visit the toilet. Bacteria breeds easily and not washing hands after contact with such patients can lead to cross infection. In order for quality standard of care to be maintained, it is the responsibility of the health professional to implement safe practise at all times to avoid risk of potentially infecting others. The three basic principles of bioethics are respect for autonomy, beneficence or non-malficence and justice. Principle of autonomy can be translated into various other terms such as respect for individual or individual freedom, because the differences in these terms are subtle. In health care decisions, our respect for the autonomy of the patient would, in common parlance, mean that the patient has the capacity to act intentionally, with understanding, and without controlling influences that would mitigate against a free and voluntary act. This principle is the basis for the practice of "informed consent" in the physician/patient transaction regarding health care. (University of Washigton School of Medicine) In many instances, in nursing and medicine non- malficenece is more applicable than beneficence. The principle of beneficence in relation to risk management is about doing good to the patient while making sure one ought to prevent harm. In relation to quality, it can be argued that the nurse's duty to care extends beyond the period of duty, in as much as they have a responsibility to ensure that those to whom they hand over the care are fully informed of the patients' needs hence the holistic assessment process for all patients admitted should be observed. According to Rumbold (1999) two criticisms of beneficence are that it may conflict with the principle of justice and that it implies paternalism, which is usually associated with doctor, patient relationship. While trying to maintain confidentiality at all times, the principle of justice cannot be achieved unless resources are unlimited. The compromise is to base resources on known demands e.g. at a macro level, we know the percentage of at risk population for a given condition actually contract it (Burnard et al 1993). This enables health personnel to come up with an action plan thus justice in the distribution of quality health care becomes a possibility given adequate resources. Often in practise areas, ward mangers want to remain within their budget through cutting costs in gloves, aprons and paper towels but this may result in compromising the patient's health as one pair of gloves may be used on different patients thereby spreading infection. This behaviour compromises the quality of care that patients receive, making the patients vulnerable to the risk of cross infection (Dimond 2002). The principle of justice in health care is usually defined as a form of fairness, or as Aristotle once said, "giving to each that which is his due." This implies the fair distribution of goods in society and requires that we look at the role of entitlement. (University of Washigton School of Medicine) For risk management to be successful clinical reviews and audits should exist within the Trust. Clinical Governance is about ensuring that all NHS organisations have in place proper processes for continuously monitoring and improving clinical quality and risk management. Being one of the seven pillars it enables Trusts to identify possible problems and responding by putting in place systems to prevent and learn from them, hence infection control audit is essential so progress can be noted and areas lacking improved. Audits on infection control measures such as the introduction of alcohol hand gels are essential in providing a clear picture on effectiveness and so protect Trust employees. This became a clinical governance issue after the National Audit Office (2002) reported that over a million people acquire infections in hospital each year. The health care profession is dynamic and still it stands on the firm foundation of its objectives of providing opportunities of better health to all. The quality and risk management in health care are is the core of sustainability of the profession. In the changing contexts of the society, requirements of the health care professionals also change. Nurses in any practice area have a duty of care professionally, legally or ethically. A professional is considered to be successful if s(he) acquires essential knowledge base, skills and qualities. These skills gradually help in transforming the health care. In this essay, an attempt has been made to understand quality and risk management and to analysis of risk management has been discussed in relation to quality. The integral components of nursing profession such as professional, ethical and legal perspectives have been discussed with relevant references. As a gist, the quality and risk management in health care is determined not only by a single component but by understanding the diverse nature of the profession. The goal of improving quality of health care and effective risk management can be achieved through a clear understanding of the different perspectives of the nursing profession. REFERENCES Alexander, M.F., Fawcett, J. N., Runchman, P. J. 2000, Nursing practice: hospital and home, the adult 2nd Ed. London Churchill Livingstone. Bamigboye, A. 2006, 'Knowledge and Practice of Universal Precautions among Qualifying Medical and Nursing Students: A Case of Obafemi Awolowo University Teaching Hospitals Complex', ILE-IFE. Research Journal of Medicine and Medical Sciences, 1(3): 112-116. Burnard, P. Chapman, C. M. 1993, Professional and ethical issues in nursing: the code of professional conduct 2nd Ed. London Scutari Press. Commission for Health Improvement. 2000, Assessment framework: Seven pillars of clinical governance. London CHI. Concise English Dictionary. 1994, Wordsworth Editions Ltd Great Britain Crossing the Quality Chasm: The IOM Health Care Quality Initiative. Available at: http://www.iom.edu/CMS/8089.aspx Department of Health. 1995, Hospital infection control: Guidance of the control of infections in hospital. London DOH. Dimond, B. 2002, Legal aspects of nursing 3rd Ed. Harlow Longman. Donabedian, A. 1980, Explorations in quality assessment and monitoring Vol. 1 Health Administration Press. Faugier, J. 1997, 'An exploration of clinical risk management from a nursing perspective', Nursing Times Research, Vol. 2, No. 2, 97-105. Gammon J. 1998, Analysis of the stressful effects of hospitalisation and source of isolation on coping and psychological construction Nursing Practice 4. 84 - 96. Hinchliff, S. Norman, S. Schober, J. 2003, Nursing practice and health care 4th Ed. London Arnold. Institute of Medicine Report. 2001, Crossing the Quality Chasm: A New Health System for the 21st Century. Jeanes, A. 2003, Best practice infection control improving hand hygiene. Nursing Times Vol 99 No 7. Manning, R. 1998, A care approach. In: Kuhse H, Singer P (eds). A companion to bioethics. Blackwell, Oxford, P 98-105. Moulden, A. Clinical Quality and Safety. Available at: http://www.rch.org.au/css/risk/index.cfmdoc_id=1469 National Audit Office. 2002, The management of infection control of hospital acquired infections in acute NHS Trusts in England Leeds. Stationary Office. Noddings, N. 1984, Caring- a feminine approach to ethics and moral education. Univesity of California Press, Berkley, CA. pp. 2. Nursing and Midwifery Council. 2002, Code of professional conduct London. NMC. Nursing and Midwifery Council. 2004, Code of professional conduct London. NMC. Pincheansathian, W. 2004, 'A systematic review on the effectiveness of alcohol based solutions for hand hygiene', International Journal of Nursing Practice, Vol 10, (1) pp. 3 - 9. Reeves, M. Orford, J. 2002, Fundamental aspects of legal, ethical and professional issues in nursing. Salisbury Mark Allen Publishing Ltd. Royal College of Nursing. 2000, Working well initiative: Methicillin resistant staphylococcus aureus. Guidance for nurses. London. RCN Rumbold, G. 1999, Ethics in nursing practice 3rd Ed. Edinburgh. Balliere Tindall. Selwyn, J. 1997, The law of health and safety at work. Health and safety in practice. Surrey. Corners. St Mary's NHS Trust. 2005, Clinical governance and risk management strategy 2003-2008. St Mary's NHS Trust. University of Washigton School of Medicine. Principles of bioethics. 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