1st THEME

QUALITY GUARANTEE IN HEALTH

A QUALITY GUARANTEE SERVICE COMPANY :

It is to ensure the quality of the service, so that the client can use it with
satisfaction and confidence.

IN A COMPANY FOR HEALTH :

Quality assurance is to ensure the quality of the service so that the
customer's full trust and complete satisfaction are earned.

 Quality improvement is built on the motivation and constant effort of the

entire human team.

 To maintain and improve the product or services, it is necessary to establish

a quality assurance system, as an initial stage in the process of progress
towards total quality.
TO REACH QUALITY GUARANTEE:

1. Quality planning.
2. Quality control.
3. Quality assurance
4. Quality improvement.
5. Quality assessment

1.- QUALITY PLANNING:

It is identified with the same strategic planning of the company as basic

pillars:

Vision : Results from the study and considerations on relevance,

opportunity, advantages, disadvantages, location, viability and
possibilities of the program.

Mission : It is the objective or goal of the program.

Formulation of strategies : Represents the set of measures or actions

that allow the fulfillment of the mission.

Service engineering : It is the provision of human resources and

material facilities for the fulfillment of the plan.

Implementation activity : Represents permanent compliance with the

standards for achieving the mission.
 Operation : It is the joint action of all the means available to obtain the
set goal.

Customer orientation: It represents one of the most important aspects

to achieve the success of the program.

2.- QUALITY CONTROL .

It is an effective system to integrate quality development and quality
improvement efforts.
In health institutions the maximum body for quality control is:
The health audit : It represents a scheme for permanent monitoring of standards
in all areas of the institution.

The only goal of the program is customer satisfaction.

Academic program that covers aspects of the institutional environment:

 Epidemiological research.
 The planning.
 Related to aspects of convenience and layout of physical structure.
 The aspects of acquisition, maintenance, replacement of machinery and
equipment.
 General aspects of the external and internal environment.
 What is pertinent to biosafety
 Staff ethics
 Legal aspects (civil, criminal and administrative liability)
 Aspects related to social well-being of internal and external clients
 The way the institution is articulated with the national health system.

Topics highlighted in the audit:

 Quality assurance.
 Improving quality.
 Quality manuals.
 The quality guarantee.
 The institutional audit
 The audit of medical records.
 The audit of results.
 The audit of education programs.

Topics related to administrative management:

 Aspects of inter-institutional competition.
 Impact on the market.
 Selection, management, preparation, evaluation of human resources.
 Administrative, economic and financial management.
 Supplies and supplies.
 Loss prevention.
 Computer management.
 Institutional security.
  Communications management.
 Development plans of the institution.

As the body with the greatest responsibility:

 Control compliance with standards
 Monitor resource management
 Prevents possible failures
 Alert about weaknesses
 makes recommendations to improve overall process
 Constantly evaluate.

3.- QUALITY ASSURANCE

It is a system that brings together all planned and systematic activities,
equipment, materials, processes, budget documentation, personnel
required so that tasks and operations are fulfilled, guaranteeing quality in
their results, minimizing sources of error.

It is the fundamental guarantee in the application of the quality manual,

integration of all standards, coordinated effort of the staff, appropriate use of
all resources and strategies.

The quality manual:

It identifies the policies and objectives of the institution and the actions of all
kinds, designed to achieve the desired quality goals.

4.- QUALITY IMPROVEMENT.

It represents the company's permanent commitment, and cannot be

achieved without the determined participation of the people.
Quality improvement depends on people's participation.
The long-term goal of a company is to survive and to achieve this the possible
mechanism is continuous quality improvement. The systematic approach to quality
management is the fundamental factor to access continuous improvement since it
provides specific opportunities to:
o Improvement in service provision.
o User satisfaction.
o Improve productivity and reduce costs.
o Greater market share
o Allows progressive balance.

5.- QUALITY EVALUATION:

 Factor that leads to quality assurance, it measures not only the impact but
the general development of the program that begins in planning.

2 evaluation models:
DOPRI

DOPRI MODEL
CONVENTIONS
D=Demand Pr=Product
O=Offer R=Result
E=Structure I=Impact
P=Process Ef.=Effect

1.- CONTEXT

Q
d O=I Pr= I=E

FEEDBACK

SWOT MATRIX
FUTURE
EXTERNAL
Q ANALYSIS OR ( OPPORTUNITIES) A ( THREATS )
R
A 1. _____________ 1.- ________________
N 2. _____________ 2.- ________________
D 3. _____________ 3.- ________________
Y
es INTERNAL ANALISIS
A
N F ( STRENGTHS) ( STRATEGIES) FO ( STRATEPHIES) FA
D 1.- _______________ 1.- _______________ 1.- ______________
N 2.- _______________ 2.- _______________ 2.- ______________
T 3.- _______________ 3.- _______________ 3.- ______________
A
N D (WEAKNESSES) (STRATEGIES ) DO (STRATEGIES) DA
D
1.- _______________ 1.- _______________ 1.- _______________
2.- _______________ 2.- _______________ 2.- _______________
3.- _______________ 3.- _______________ 3.- _______________

They propose to take 3 fundamental areas:

1.- Structure: The characteristics of the facilities and equipment, the technology
used, the general conditions of human resources, the financial part and everything
related to communications are analyzed.
2.- Processes: The characteristics of the services provided are measured.
3.- Results: the degree of user acceptance or satisfaction is evaluated.

Not to be confused:
- Health control or audit prevents errors.
- The evaluation measures the results.
- Leadership is a determining factor for guaranteeing service quality.
To achieve quality assurance, senior management must ensure:
 The vision: Results from the knowledge of the goals and projections towards
the future.
 The persistence of leadership: It is a natural condition of it.
 Expectations: They result from the reality of the vision and the power to
direct programs and strategies to high goals.
 Knowledge: Added to the skills and abilities of the leader.
 Empathy and power of persuasion: They reflect personal conviction of what
you are promoting or offering.
Leadership must be:
o Persistent.
o Efficient.
o Reiterative.
o Confidence generator.
o It adapts to the environment.
o It is transformative.
o It is causative.
o It's organizational.

The set of plans, programs, actions, strategies, circumstances and special

conditions to achieve user or client satisfaction, it is necessary to articulate the
fundamental tools in efficient management engineering to achieve quality
assurance.
2nd THEME
QUALITY GUARANTEE

Due to the growing complexity of health sciences and the constant increase in the
specialization of health professionals, the need arises to carry out rigorous controls
to guarantee that these health professionals have sufficient knowledge and skills to
provide safe and effective care. .

CLAIMS FOR A QUALITY GUARANTEE:

As a result of social pressure to improve the quality of healthcare and
reduce costs, federal, state, and local laws require healthcare institutions to
implement quality control measures.
The Joint Commission on Accreditation of Healthcare Organizations:
Requires institutions seeking recognition from this organization to coordinate all
quality assurance activities into an integrated institutional program that focuses on
identifying patient care problems.

PROFESSIONAL STANDARDS REVIEW ORGANIZATIONS:

The congress of E. OR. approved Public Law 92-603. In 1972. This law
establishes amendments to the Social Security Act. It gave rise to a system of
organizations for the review of professional standards, in which local physicians
were made responsible for the review and evaluation of the quality and adequacy
of health services financed by Medicare, Medicaid, and Maternal and Child Health
Programs.

JOINT COMMISSION QUALITY ASSURANCE PROGRAM:

The Joint Commission on Accreditation of Healthcare Organizations, an
independent organization, has required the continuity of an organized and well-
defined quality assurance program.
Mandatory quality assurance activities in nursing are described in nursing
standard 12.8 of the organization's 1986 accreditation manual.
Currently, the JCAH recommends that hospitals have an integrated and
comprehensive quality assurance program that includes continuous monitoring of
patient care in order to detect problems, analyze and correct them, and follow up to
ensure continuous control.

QUALITY ASSURANCE PROGRAMS OF THE AMERICAN

NURSES'ASSOCIATION:
The standards for professional nursing practice of the American Nurses'
Association were used as guidelines for the creation of various quality assurance
programs; facilitating a systematic analysis of nursing activities.

DEFINITIONS:
The nursing manager must be familiar with the following definitions:

PHILOSOPHY: It is a system of beliefs, concepts and motivating principles; The

philosophy of the nursing department determines the objectives of the work group.

RESPONSIBILITY: It is the obligation to render accounts, for the activities carried

out, to the people who have authority over these activities.

NURSING CARE OUTCOME: It is the final consequence of nursing activities.

CRITERION: It is the unquantified name of a variable, which is recognized as a

reliable indicator of quality.

STANDARD: It is the level of current compliance of a certain work group in relation

to a specific criterion.

OBJECTIVE: It is a goal or ultimate goal towards which activities are oriented.

MEASUREMENT: It is an objective process that is used to determine the capacity,

quantity or dimension of an object, manifestation, result or change.

EVALUATION: It is a subjective judgment based on objective measurements.

FEEDBACK: It is the information about the operation of a system that is reflected

therein as a basis for monitoring system operations.

QUALITY HEALTH CARE: It is the correct application of the essential principles of

medical sciences in patient care.

QUALITY ASSURANCE: It is the process of establishing an indicative degree of

excellence in relation to nursing activities and the implementation of strategies that
guarantee that patients receive the agreed level of care.

EFFECTIVENESS OF A SPECIFIC NURSING ACTIVITY: It can be determined by

the degree to which the objectives provided have been achieved through the
accomplishment of that activity.
COLLEAGUE: She is a co-worker, with a similar position and experience, who is
engaged in clinical practice in a similar unit within the same institution.
REVIEW AMONG NURSING COLLEAGUES: It is the evaluation carried out by a
group of practicing professional nurses on the quality of nursing care provided by
other nurses.
QUALITY ASSURANCE STRATEGIES:

There are 3 classic frames of reference from which nursing care can be
evaluated:
 - Elements of Structure : They include the physical structure, the material
and equipment resources, and the conditions in which nursing care is being
provided.
- Process Elements: They include the phases of the nursing care process
itself – Assessment, -planning, -execution, -evaluation and all the
subsystems included in the nursing care process.
- Result Elements : These are the changes in the health status of patients
that occur as a result of nursing interventions.

BASIC PRINCIPLES OF QUALITY ASSURANCE ACTIVITIES :

1.- All health professionals should collaborate in the activities of evaluating

and improving care
2.- Adequate coordination is required to ensure that the objectives and
activities of each profession reinforce and do not neutralize other professional
groups.
3.- Attention must be paid to confirm that the consumption of resources used
in quality assurance activities are appropriate.
4.- Researchers should focus their attention on monitoring critical
compliance factors.
5.- The key to ensuring quality in patient care is a rigorous evaluation of
patient care.
6.- The ability to achieve nursing objectives depends on the optimal
functioning of the entire nursing care process.
7.- The evaluation of care in itself does not improve care practice.
8.- Once the quality of care has been evaluated and the need for
improvements has been established, pressure from the staff can provide the
stimulus to make the changes established in professional practice.
9.- Units may demand changes in the formal structure of the organization.
10.- The collection and analysis of qualitative evaluation data must be
carried out by a person who has the power to make decisions.

IMPLEMENTATION OF A QUALITY ASSURANCE PROGRAM :

Detailed planning is needed by all managers of a healthcare institution to
implement a quality assurance program.
The program must include a wide variety of quality assurance activities:
 Auditoría asistencial
Formulación de
restrospectiva de lsa
estándares
historias clínicas de
profecionales
los pacientes

Auditoria asistencial
simultanea del
proceso del paciente

Circulos de Revisión entre

calidad colegas

Análisis del
perfil asistencial
de los pacientes

Quality Assurance Task Force:

The group must have representation of all clinical nursing specialties,

managers and staff nurses; They should meet to exchange opinions regarding
quality control, analyze differences in their nursing values through open
confrontation, and intensify the reinforcement points and institutional constraints
that must be taken into account when evaluating and improving the quality of care.
of nursing.

QUALITY ASSURANCE METHODS

The purpose of a nursing quality assurance program should be twofold:

1.- Measure.
2.- Improve the quality of nursing care provided in the institution.

The objective of the researchers should be aimed at discovering which

elements of care produce the best results in each type of patient treated at the
institution.

Formulation of quality assurance criteria:

A criterion must be a clear statement of the quality, quantity or characteristics

of a selected variable with which the adequacy of a specific nursing action can be
measured.

The expectations of the population require the use of criteria related to social,
economic and emotional aspects, as well as aspects based on the disease.

Reliability and validity of measurement instruments: Reliability refers to the

consistency with which a given instrument measures what it is supposed to
measure. Validity refers to the degree to which an instrument measures what it
purports to measure.

To guarantee the Reliability and Validity of a measurement, the formulation of

the criteria must be objective.

Analysis of quality assurance criteria

To be effective, criteria must be realistic, understandable, formulated in terms of

behavior, and achievable with reasonable effort.

Preparation of measuring instruments:

The quality assurance coordinator must structure the criteria into measurement
instruments and data collection forms.

Different types of instruments have been used. Some are based on the
standards of professional nursing practice formulated by the American Nurses'
Association or some specialized nursing organization.

Training of interviewers and motivation of nursing staff:

The training should include an explanation of the meaning and purpose of the
criteria, the type of evidence needed to demonstrate whether each criterion has
been met.

They must receive additional training on the purposes, methodology and time
scheduling in relation to quality assurance studies and improvement activities.
 Professional nurses express more positive attitudes toward quality assurance
programs when they place greater emphasis on direct patient care activities,
because these activities constitute the most important aspect of their professional
work.

TYPES OF PATIENT CARE AUDITS:

Patient care audits can be of various types:

- An audit can be focused on a specific diagnosis.

- In a diagnostic test.
- In a problem.
- In a procedure.

Patient care audits are of 2 types:

1.- A simultaneous audit: It is one in which patient care is evaluated.

2.- A retrospective audit: It is one in which patient care is evaluated after their
hospital discharge.

Conducting the audit:

The main function in this regard of the institution's multidisciplinary audit committee
is to decide the size of the patient sample for each audit and over what period of
time the sample data will be collected.

Analysis of medical history data:

After reviewing all of the records in the sample to determine which meet all of the
audit criteria and which do not, the clinical documentation technician will refer the
records that show deviations from the established criteria to a professional
advisory group of nurses or physicians, which must determine whether the
deviation is justified or corrective action is required.

Most often, deviations indicate the need for corrective action, such as a change
in standards, procedures, materials and equipment, or staffing models.

If the failure to meet a certain criterion is not due to a lack of knowledge or skills
of the staff, but is due to negligence in the work, stricter supervision will be
exercised to demonstrate management's commitment to the criteria in question.
question.
 It is evident that nurses must be informed of both the positive results of audits
and the negative results, in order to continue with professional activities that are
already carried out correctly and correct failures in professional practice.

REVIEW BETWEEN PROFESSIONALS:

1.- It is a process through which employees of the same profession, job

category and workplace evaluate each other's professional practice in relation to
previously recognized standards.

2.- With the intention of increasing the responsibility of nurses in the professional
decision-making process and effective nursing care.

3.- The criteria for the evaluation of professional practice are deduced from the list
of activities included in the official job description.

4.- The group representatives must decide which aspects of each nurse's activities
should be evaluated by their colleagues and what type of information about their
professional practice their colleagues should obtain to carry out the information.

QUALITY CIRCLE:

Health centers have established quality circles as a system to motivate

professionals to improve the quality of nursing care provided to patients.

A quality circle consists of a small group of 5 to 15 people who do similar jobs

and who meet 1 hour a week to try to solve problems related to their work,
including identifying problems related to their usual tasks, to determine the causes
of the problem, find a solution and propose it to management through a formal
presentation.

Quality circles use techniques such as brainstorming, cause-effect diagrams,

and Pareto analysis. If management accepts the group's proposal, the circle
implements its plan to solve the problem and evaluates its effectiveness.

In addition to patient care audits, peer review, and quality circles, medical
organizations have developed the following quality assurance measures:

- Profile analysis
- Protocols
- Criteria maps
- Profile analysis
Consisting of longitudinal or cross-sectional analysis of data collected about
patients presenting with a complete diagnosis or problem, it is effective in
identifying factors associated with complications and deaths in these patients.

Protocols can be used to identify care deficiencies, as well as to regulate care.

Staff feedback:

To create the relevant Feedback cycles in the quality assessment process, the
operating group must decide how much information should be provided to
healthcare professionals, how the information should be transmitted, to whom said
information should be directed, and how frequently. The data obtained on quality
estimation must be communicated.

The method of information transmission must be adapted to the message to be

communicated, the degree of staff resistance to quality assessment activities, and
the number of communication links that the message must travel through.

The quality assurance operational group must prepare the quality indices
monthly, so that they are disseminated in schematic form to all services and
departments of the institution. A summary report that lists the deficiencies in the
structure, process and results that have been detected by the people carrying out
the assessment; the causes of each deficiency, specified by the responsible
manager; the departments and services with the highest indexes, the departments
and services with the most score deviations, both positive and negative, since the
last review, and the recommendations of the quality operating group for the
correction of each of the errors.

Correction of deficiencies:

Many of the errors and omissions in nursing care that are discovered through
quality assessment studies are a consequence of a lack of skills and knowledge;
They can be corrected more easily when the quality assurance program is strongly
linked to the institution's continuing and in-service training problems. Assessment
data can be quickly communicated to caring nurses with the information needed to
correct detected problems.

Nurses who know how, when and why they have to perform basic care,
treatment and coordination activities for specific patients may stop doing so due to
disinterest, lack of time, emotional overload or simply obstinacy. When deficiencies
occur in practice such as disinterest or exhaustion, you can resort to advice or
enrichment of work content to regain motivation.
 The manager should readjust scheduling and staffing to balance the distribution
of work; when emotional overloads and human limitations are responsible for
errors and omissions, prospective computerized memos, protocols, and criteria
lists can be effective in improvement of care; In professional negligence,
disciplinary measures must be adopted.

PROBLEMS ASSOCIATED WITH QUALITY ASSURANCE:

The main problem associated with quality control in nursing is the risk of
focusing so much on quality assessment procedures that you lose sight of the
objective of the program:

- Improve nursing care.

Another problem is that there is hardly any evidence; It has not been demonstrated
that one quality validation system is superior to another, nor is there a single
nursing evaluation instrument that meets all the objectives and that can be applied
generally in all health institutions.

Quality assurance problems come from the impossibility of measuring each of

the variables that influence the quality of nursing care for a given patient.

Some of the factors known to influence the quality of nursing care cannot be
investigated due to the existence of ethical and legal barriers regarding the
imposition of experimental controls in social systems.

It is not only difficult to determine all the factors that influence nursing care, but
also to define the outcome criteria that are solely attributable to nursing care.
 3rd TOPIC: CONTROL PANEL
The objective of a scorecard is not to develop a new set of indicators: Indicators,
the way we describe results and goals, are truly powerful motivation and evaluation
tools: But the structure of the Balanced Scorecard should be used to develop a
new management system: This distinction between a measurement system and a
management system is subtle but crucial. The indicator system should be only a
means to achieve an even more important objective: a strategic management
system that helps executives implement and obtain feedback on their strategy.

 The strategy is the reference point for the entire management process.
 Shared vision is the basis for strategic formation.

Clarifying and
translating vision and
strategy

Communication Strategic feedback

and linking Balanced and training
Scorecard

Planning and goal

setting
The use of the Balanced Scorecard as a strategic structure for action.

When the Balanced Scorecard is used as the central organizational structure for
the new management system, all changes can be consistent and coherent. The
result can be spectacular.

Gain clarity and consensus on

strategy

Get focus

Develop leadership

Strategic intervention
Build a Build a new
Balanced managemen
Scorecard t system
Educate the organization

Set strategic goals

Align programs and

investments
Most companies introduce the scorecard to drive parts of the management
process.

The introduction of a Balanced Scorecard creates pressures to expand its role in

the management system. Once a scorecard has been designed and introduced,
concerns soon arise if the scorecard is not tied to other management programs
such as budgeting, aligning strategic initiatives, and setting personal goals. Without
these kinds of connections, the effort devoted to the balanced scorecard may not
provide tangible benefits.

The management calendar incorporates four essential characteristics of a strategic

management system:

1. Strategic formulation and updating of strategic themes: these are methods

for the heads of operational divisions.
2. The link with personal objectives and rewards: it is clear that incentive
compensation motivates performance.
3. The link with planning, resource allocation and annual budgets: this occurs
during the second half of the year.
4. Feedback and strategic training: This process links monthly operational
reviews, in which managers compare short-term performance with the goals
established in the annual budget, and quarterly strategic reviews that
examine longer-term trends in indicators. of the scorecard, to evaluate if the
strategy is working and to what degree.

Roles of utmost importance when building and implementing the Balanced

Scorecard:
 1. Architect: is responsible for the process that builds the initial Balanced
Scorecard and that introduces the scorecard into the management system.
2. Agent of change: it is critical because it acts as a substitute for the general
director, shaping the daily use of the new management system. The change
agent helps managers redefine their roles as required by the new system.
3. Communicator: The communicator must earn the understanding,
acceptance and support of all members of the organization, from the highest
levels to frontline teams and employees.

Companies adopt the Balanced Scorecard for a variety of reasons, including

clarifying and gaining consensus on strategies, focusing organizational change
initiatives, developing leadership capabilities in strategic business units, or
achieving coordination and savings across multiple business units. Organizations
can achieve these desired objectives with the development of the scorecard and
especially the process between top management to define the objectives,
indicators and goals for the scorecard, ultimately reveals an opportunity to use the
BSC in a much more exhaustive and generalized than had been thought.
4th TOPIC: PREREQUISITES FOR THE START OF AN INSTITUTIONAL
EVALUATION, ORGANIZATION AND CULTURE PROGRAM

Conditioning aspects for the design of a structured program for quality

management in an institution:
1.-Knowledge of the environment and the organization
 Point out the social function
 Define the general characteristics of users (user needs).
 Find out what are the available means
 Services provided by the institute
 Specify what functions that hospital is covering in relation to teaching and
health research and healthcare aspects.
2.-Explain the mission of the organization
The mission must guide us towards what the organization's objective should be,
it represents the formal commitment of the top managers, it must be stated in
easily understandable terms, it must be disseminated throughout the institution.
 What are we?
 Why are we in the sector?
 Who are our clients?
 What can we offer you?
 With what level of quality?

3.-Motivate the organization towards participation in quality evaluation and

improvement activities.
 Self evaluate your activity
 Collective responsibility in relation to deficient aspects
 The solution to the deficiencies
 Quality standards must be systematically improved

Improvement actions and elements of professional motivation:

Explicit mission of the organization
 Quality level that is expected to be achieved, with respect to its activities
 Actions that will be undertaken in the development of improvement activities
  Incentivizing the achievement of better quality standards
 Promote research work to improve care
 Basic and permanent staff training that responds to healthcare demands

The key to the success of an organization interested in improving its services lies
in continuous feedback in the search for shared values and the assumption of the
importance they have within the work team.

4.-Basic tools for nursing work, in the field of improving care

• The commitment to the project of all team members

• A cultural climate, focused on effort

• A personal commitment of professionals

• Continuous training oriented to the institution

• Establishing quality objectives

In quality policies the managerial functions are:

a. Plan the quality that you want to offer in the institution

b. Have adequate information systems that allow you to know the level of
quality that is being offered

c. Implement actions that allow increasing quality levels whenever necessary

How to Organize Quality Assessment Activities”

Those responsible for nursing management must establish planned and evaluable
activities that favor the achievement of institutional objectives in relation to the
Quality of Care offered to clients in each work center.

Quality Improvement Program

These activities are based on the description of the aspects that we want to
analyze, measuring them objectively and acting to introduce the actions that are
necessary to improve.
The Evaluation can be of a nature:
 INTERNAL AND EXTERNAL.

INTERNAL: It is when it is carried out by the health institutions themselves, to

recognize their level of quality of care or by professionals to assess their benefits, it
fundamentally addresses aspects of the process and result of the care.
EXTERNAL: When it is carried out by organizations outside the center that is
being evaluated, with a broad social, governmental, etc. purpose. His areas of
interest are basically focused on structural aspects
INTERNAL CHARACTER EVALUATION
It must be manifested by periodically reviewing, through specific committees,
expert evaluation personnel, those aspects selected as basic to control in each
specific period of activity.
Hospital Clinical Commissions
The mandatory nature of their existence is regulated by the Official State Gazette
of April 16, 1987, stating that they must exist at least to address issues related to:
 Pharmacy and therapeutics.
 Medical records.
 Infections.
 Mortality.
 Use of Diagnostic resources.
 Teaching and research.

The Clinical Commissions are made up of center staff who, voluntarily,

participate by working in groups and with a structured methodology regarding the
identification and proposal of solutions to the deficiencies detected in the quality of
care. They must issue written reports of their activities and their recommendations
so that they can be discussed within the management team.

Work Methodology
It meets as a group in a structured way, considering that it must be summoned with
adequate advance notice that allows each member to carry out the tasks entrusted
to him by the president of the group.

In a generic and group way:

• Selection of the topic to be discussed.
• Definition of the objective and approach method.
• Distribution of tasks among members
• Sharing of all data, statistical treatment and analysis thereof.
• Discussion of the results and conclusions.
• Improvement proposal by the group.
• Issuance of the written report to the corresponding address.
• Support for the implementation of accepted proposals.
• Reevaluation after the implementation of the planned actions.
Improvement Teams
Some centers have chosen to build these teams to improve those areas that the
workers themselves consider deficient or whose development is inappropriately
complex. They are usually made up of a small number of people who share as a
common goal the improvement of a specific aspect of their activity.
For its operation to be operational, the
must receive information on problem analysis and resolution methodology that
allows them to appropriately evaluate the situation and investigate the causes of
deficiencies
Monitoring of indicators
Monitoring is the systematic and planned measurement of quality indicators. This
activity aims to identify the existence of problematic situations that must be
evaluated or intervened on.
The monitoring of quality indicators serves as a complement to the evaluation of
common objectives.
• They measure aspects of healthcare with an impact on quality.
 • They allow results to be compared between different hospitals and between
different organizations.
These indicators have certain methodological limitations, which requires
responsible use of data, both at the local level and at the organizational level.
The phases to follow in the process of the data that constitute the indicator
are:
• Assign responsibilities both in the selection and planning, and in the
subsequent data collection.
• Define the scope of attention that you want to control.
• Define the criteria that will include the selection of the indicator.
• Indicator design.
• Collection and organization of the data obtained.
• System to follow for their assessment.
• Decision making to improve if necessary.

There are another series of indicators that cannot be obtained automatically

from information systems and that require specific studies in hospitals.
Some are clinical indicators and others evaluate the appropriateness of health
care.
These indicators are hospital infection, waiting times in the emergency room,
adequacy of stays, detection of patients with social problems, unnecessary
radiology, descheduling of outpatient clinics, descheduling of operating rooms, etc.

In general, we must try to use indicators that have easy clinical or management
interpretation, and are useful for professionals to improve their care practice.
For most of the monitored indicators there are still no accepted standards. Despite
this, they can be a tool that helps evaluate the quality of care and identify
opportunities for improvement.

The Quality Plan has been a useful tool to introduce the culture of quality in our
centers, involving managers and professionals.
 Despite its limitations, it can be considered a positive experience, useful to guide
the Institution towards clinical and health management based on evidence, and
concerned with the quality of care.

5th TOPIC: STRATEGIC MONITORING OF THE QUALITY OF CARE OF NURSING

SERVICES

The follow-up and monitoring system for nursing services is based on management
indicators, which allow the execution of activities to be periodically measured, in order
to adapt in a timely and anticipated manner to the changes and challenges generated
by the environment. This system is integrated into the evaluation and monitoring of
performance that is applied in a cascade manner for the different levels.

Monitoring must meet the following requirements:

 Design and plan measurement instruments for the coordination of nursing services.
 Define the periodicity to carry out the controls, according to the control points
established.
 Apply the indicators, based on facts and data that originate in the areas and services
where the personnel works.
 Promote commitment and discipline, both among management personnel and the
operational area.
 Carry out homologation of concepts.

The responsibility and discipline of each of the management levels of nursing

services make monitoring a fundamental and transcendental event.

Monitoring the quality and management of nursing services requires forming,

approving and supporting quality groups at the sectional and local level.

The corrective groups for the improvement of services are:

 Nursing quality and ethics group in hospital IPS.

 Advisory groups- Advisory committee and nursing coordinator.
 Groups of improvement or primary experts in all IPS.

QUALITY ASSURANCE SYSTEMS OF HEALTH SERVICES

It is the set of actions, processes and methods for an institution responsible for health
services, whose implementation within the framework of competence generates
evaluation, follow-up, monitoring and control mechanisms in a planned and
systematic manner.

1.- Quality assurance and nursing care system

Nursing quality assurance. It consists of ensuring the quality of the service in such a
way that the person can buy and use it with confidence and satisfaction. Quality
assurance in nursing intervention is framed in the principles of moral, ethical and legal
 responsibility, through the audit, evaluation and monitoring of the care procedures
and processes carried out.

OBJECTIVES OF THE QUALITY ASSURANCE SYSTEM

 Determine the level of quality of the care process in the IPS, based on procedure
manuals or intervention guides.
 Determine the training and updating needs of all staff.
 Determine the deficiencies in structure that directly affect the quality of the care
process.
 Provide decision-making levels with elements of judgment.
 Minimize the risks of care in the provision of nursing services.
 Evaluate the degree of satisfaction of the person who uses nursing services.

The components of quality assurance systems are:

 Verification of essential requirements: The Ministry of Health establishes technical,

scientific and administrative standards that a service-providing institution must have in
relation to the minimum conditions of personnel, physical infrastructure, equipment,
technical-administrative procedures, information systems, transportation,
communication. and service audit.
 Improvement plans: It is the change process, carried out by all the agents of the
organization, led by the nursing quality improvement group with the aim of carrying
out the change processes aimed at identifying, generating, applying and evaluate
options that allow achieving the objectives proposed by the institution.

Standard: Set of steps defined for the development of processes. It is a document

obtained by consensus for the performance, capacity, state, movement, sequence,
method, procedure, responsibility, duty, authority, way of thinking, concept, with the
objective of unifying and simplifying the processes, in such a way that honest,
convenient and beneficial.
 Standardization Stages

o Identify, through brainstorming or other related methodology, with the nursing

improvement group the main operational processes of the services.
o Survey the processes.
o Train all nursing staff on standardized processes.
o Evaluate and monitor standardized processes

The standardized format must contain

 Grass flow
 Responsible
 Dependence
 Observations
 Checkpoints
 Requirements
 Quality standard
 Information systems
 Service audit: Medical audit is understood as the systematic evaluation of health care,
with the fundamental objective of improving the quality of services. It means the
difference between the observed quality and the desired quality, in accordance with
the previously defined technical and administrative standards.

Donabedian suggests that quality can be evaluated in four aspects:

1. Structure evaluation is measured through physical structure, human resources and

organizational systems.
2. Process evaluation is based on the assessment of care activities, procedures and
treatments.
3. The evaluation of results evaluates the achievements obtained by performance,
recovery of the person, costs of care, compliance with protocols.
4. The impact evaluation evaluates the effects and changes in the target community in
the service.
 Customer satisfaction

Nursing evaluates quality through

Direct observation of the procedures, care and treatments carried out in the provision
of services.
The audit of your clinical records.
Direct or professional group interviews regarding the care to be evaluated.

The group of quality evaluators can be:

 From experts
 Of pairs

The procedure or standard is qualified according to its compliance with:

 Excellent
 Acceptable
 Not acceptable

STRATEGIES TO ACHIEVE QUALITY IN NURSING SERVICES

QUALITY
 Human talent management
 Improvement culture
 Health audit
 Formal education
 Committed management
 Quality process (clinical/technical/human)
 Indicator standards
 Continuous training

Plan for management implementation

1. Organization
2. Education
3. Communication
4. Team development
5. Recognition
6. Monitoring
7.
NURSING STANDARD
A standard is a descriptive statement of the degree of performance required, with
which the quality of the process structure and results can be quantified.
A standard of nursing care is a descriptive statement of the established quality, with
which the nursing care provided to a patient can be evaluated.

Objectives of nursing care standards

1. Improve the quality of nursing care

2. Reduce the cost of nursing care
3. Provide foundations that allow the delimitation of nursing negligence

6th TOPIC: “Building Bridges between Evidence and Practice:

Dissemination Strategies to Improve the Impact of Evidence in
Nursing Practice.”

Research and training are closely linked to the quality of care and professional
development and are what guarantee its permanence and growth. Initiatives aimed at
enhancing the nursing profession by providing it with greater autonomy and control
over its practice and the recognition of its role within the organization, benefit not only
it, but fundamentally the patient's health outcomes. We must all promote the
implementation of new tools that lead us to better clinical practice.

There is a growing interest on the part of governments and their health provider
systems, as well as citizens and professionals so that the care provided to citizens is
more effective every day.
Thus, it has been shown that adequate nursing practice can be effective in terms of
improving health outcomes (reducing morbidity and mortality of patients), containing
costs, or making health systems equitable and sustainable, that is, , that when a
practice is carried out based on scientific evidence, not only is professional variability
reduced, but high quality care is promoted and with better cost effectiveness and this
attracts nurses to work in these centers, they are called “Magnetic Hospitals” . ”.

A good tool to disseminate research among professionals can be the preparation of

systematic reviews, clinical practice guidelines or the development of procedures and
protocols that incorporate evidence while meeting the appropriate quality criteria in
their preparation.

The certainty that our action will influence the development process of the human
being energizes many nursing professionals to do their job well and have it
recognized, to be creative in developing skills, to investigate and to propose
innovations to achieve their goal. The definitive support for this professional evolution
has been established by Royal Decree 1231/2001 of November 9, 2001, in which the
healthcare, research, teaching and management functions are definitively recognized.

Nurses have achieved a high degree of professionalization and our knowledge and
skills have increased; But the development of knowledge and the increase in
research in all areas of health sciences, together with the development of new
technologies, mean that these do not last long over time and we must constantly
update them.

Research and training are closely linked to the quality of care and professional
development and are what guarantee its permanence and growth, the initiatives
aimed at enhancing the nursing profession by providing it with greater autonomy and
control over its practice and the recognition of its role within of the organization,
benefit not only the organization but fundamentally the patient's health results. We
must all promote the implementation of new tools that lead us to better clinical
practice. To the extent that organizations commit to undertaking the best proposals,
professionals also assume more responsibility and become more involved. In short,
quality care requires the development and recognition of our nursing profession if we
want to offer “the best” to our patients and their families.

"Adverse events".

Adverse Event: “Any clinical event that is harmful to a participant that does not
necessarily have a causal relationship with the research intervention.” (AE) can be
any unfavorable and unintended sign, symptom or disease temporarily associated
with the use of a medicinal product.

Serious Adverse Event: “Any harmful clinical event that causes death; constitutes a
danger of death; requires or prolongs hospitalization; causes persistent or significant
disability or disability; or it is a congenital anomaly or birth defect.”

Serious adverse events are classified as related or unrelated to the study

intervention. Those related to the study may require further investigation. Additionally,
many clinical procedures pose a known risk. In other words, the procedure is likely to
cause an expected serious adverse event. The investigator must be prepared for
unexpected serious adverse events.

“Adverse Events During the Care of the Critically Ill.”

Cleanliness is considered an essential part of nursing activities aimed at covering the

need for hygiene. Due to the frequency with which this technique is applied in any
hospitalization unit, a prospective cohort study was carried out which includes all
adult patients admitted to an ICU during a period of five months who met certain
severity parameters, which The most frequent events were: desaturation 18%,
maladjustment 11%, arterial hypertension 21% and arterial hypotension 11%.
Intracranial hypertension occurred in 42% of neurosurgical patients.

Therefore, the study demonstrates the high incidence of adverse events during
cleaning, some of them of prolonged duration and others that are difficult to avoid.

For all these reasons, the practice of cleaning, and the way it is carried out, should
be carefully evaluated and planned, just like the rest of the care applied to the
critically ill.

“Patient Safety”.

The adverse event can be defined as a damage or injury caused by the treatment of a
patient's disease or condition by health care professionals, and that is not due to the
underlying disease or conditions itself; human errors can sometimes give rise to To
serious failures, there are usually deeper systematic factors that, if addressed earlier,
would have prevented the errors. Hence, to increase patient safety, a broad series of
actions are required in the hiring, training and retention of health professionals, and it
is also necessary to improve results, environmental safety and risk management, as
well as such as infection control, safe use of medications, safety of equipment, safety
of clinical practice and the safety of the care environment.
There is increasing evidence that inadequate staffing levels in institutions are linked
to increases in adverse events such as patient falls, bed injuries, medication errors,
infections and readmission rates, which can lead to longer hospital stays and
increased mortality rates in hospitals. In conclusion, inadequate human resources are
a serious threat to the safety and quality of health care.
In developing countries, the probability of adverse events is much higher than in
industrialized countries, partly due to the poor state of infrastructure and equipment,
unreliable supply and quality of medicines, deficiencies in waste disposal and
infection control, low numbers and poor performance of staff due to low motivation or
insufficient technical skills, and serious underfunding of essential running costs of
health care services health.
Adverse health care events have a high financial cost. Approximately half of the costs
of avoidable errors occur in direct health care acts.
 7th TOPIC: CAREER DEVELOPMENT
For some nurses, nursing was an attractive occupation that offered a diversity
of employment, for others there was a strong motivation for long-term work in a
career. Each nurse responds uniquely to the values, goals, interests and
aspirations in the path of the work they choose to perform in adult life.

DEFINITIONS:

EMPLOYMENT: is a position that is offered, work that is done in exchange for

financial payment.

CAREER: is the chosen path or personal contract to satisfy a pattern of

professional contributions.

COMMITMENT: is the individual's attitude toward his or her profession and the
motivation to work in a previously chosen professional area.

BACKGROUND:

In a profession like nursing you can choose a succession of jobs that become a
career or deliberately build an academic career. Jobs and careers are best
understood in the context of the phases of adult life and are divided into eight
phases according to Henderson and McGettigan:

1.- Transition to adult life (18 to 22 years).

2.- Early adult life (23 to 30 years).

3.- Adult life (31 to 37 years).

4.- Transition to middle adult life (38 to 45 years).

5.- Average adult life (46 to 53 years).

6.- Transition to late adult life (54 to 61 years).

7.- Late adult life (62 to 69 years).

8.- Adult life of a gentleman (70 years or more).

For nurses, changes in growth and development impact the balance between
employment, personal and family functions and needs. They can explore and
analyze what phase of the project they are in and where they want to move
forward.
CAREER ANCHORS:

They can be used to explain individual values and motives when applied to career
decisions. The eight career anchors are (Friss, 1989):

1.- Service:

2.- Managerial competence:

3.- Autonomy:

4.- Functional technical competence:

5.- Security:

6.- Identity:

7.- Variety:

8.- Creativity:

Nurses can analyze career anchors and identify the most relevant one(s) for
themselves; they can benefit from periodic analysis.

Sovie's review identifies three anchors:

1.- Professional recognition

2.- career mobility

3.- opportunity for advancement

I show that nurses are primarily interested in, concerned with, and therefore
motivated by identity, security, and personal actualization needs.

NURSING AS A CAREER

It offers many interesting possibilities for nurses. It is useful to know certain

information to know how to plan a career.

1.- Choose self-confidence as a strategy for academic growth.

2.- The options and opportunities actually available will color the career.

3.- Trends and issues in health care and nursing can contribute to an academic
career.
4.- Nurses face issues of time distribution regarding family and career goals,
creating tension.

THE FIRST JOB:

The first professional job is believed to influence personal satisfaction with

nursing as a career and may influence future advancement.

A work environment that promotes growth can be as important as salary and

benefits to adapt and obtain satisfaction over a longer period of time.

CAREER PLANNING :

It is built on top-level skills Vogel identified 6 phases of career development:

1.- Self-analysis

2.- Analysis of the race.

3.- Integration

4.- Planning.

5.- Application.

6.- Evaluation.

There are some specific steps that can be taken when planning a race or
choosing a goal in it (Henderson and McGettigan).

- Test the goals.

- Weigh the results.
- Specify the actions.
- Write a plan.
- Apply the plan.
- Evaluate progress.

The influences of society:

- The explosion of knowledge.

- Demographic and economic factors.
- Consumer demands.
- The cost content.
- Changes in the health care system.
They can impact nurses' career planning by slowing down the trajectory,
accelerating it, or modifying it. Nurses must:
 - Observe the environment.
- Set goals for themselves.
- Plan the race.
- Anticipate the future and be alert to trends.

CAREER STYLES :

Careers are almost never static Friss identified the 5 career styles often found
in nursing:

1.- Stability.

2.- Linear.

3.- Business.

4.- Transitory.

5.- Spiral.

These career styles are reflections of patterns that emerge in nursing careers.
The leadership and management styles adopted by nurses incorporate a
recognition of nurses with diverse career orientations and styles.

The phase perspective suggests sequential growth in knowledge, experience,

and leadership ability over the course of a career. (McBride) identified 4 phases of
the race:

1.- Preparation.

2.- Contribution.

3.- Address.

4.- Advice.

Benner's classic work on skill growth in nursing uses the skill acquisition model
to outline 5 levels of efficiency:

1.- Newbie

2.- Advanced beginner.

3.- Competent.

4.- Efficient.

5.- Expert.
Skill gains in nursing are supported by education and experience. The result is
better utilization of skills and abilities, and greater job satisfaction. (Seyboldt)
pointed out 5 different categories:

1.- Home.

2.- Early.

3.- Medium.

4.- Advanced.

5.- Late.

In the nurse's career there are different phases; Priorities may vary depending
on career phase, situation and commitment factors. Intervention strategies must
also be adjusted to meet the different needs of nurses in different phases.

LEADERSHIP AND DIRECTION IMPLICATIONS:

Nurses and assistant managers understand and use academic concepts for
selection, recruitment, and retention of registered nurses. The nurse's personality
is diverse and multifactorial in relation to him:

- Education degree.
- Level of Experience.
- Skill acquisition level.
- Time in the profession.

Increases in skill level develop over time.

Academic engagement is one aspect of recruitment and retention in nursing. Staff

development and in-service instructors can use concepts of academic engagement
to promote professional loyalty and commitment, thereby reinforcing career plans
and goals. Interest in the concept of reality shock or the transition from school to
work arises from an in-depth study of the entry and early phases of a career.

Kramer's phases of the clash with reality are:

- Honeymoon.
- Shock.
- Recovery.
- Resolution of the conflict.

COMMON ASPECTS AND TRENDS:

Advanced practice

Nurses are confused about what options they can follow to develop
academically and what is better to choose to develop themselves.

The role of an advanced practice nurse is supported by clinical knowledge and

skill, in actual functions that vary in the context of the specific practice. Advanced
practice nurses have begun to serve in leadership roles in managed care settings
and on functional multidisciplinary teams.

Nursing certification is recognition of experience in a specialized area of

practice. It is a credential for professionals to assure the public that they are
qualified to offer specialized services to consumers. 3 ways have been described
to do it:

1.- Through professional organization.

2.- Through the individual states.

3.- Through individual institutions.

THE IMPORTANCE OF NURSING RECORDS IN THE

CLINICAL RECORD
MENDEZ C., GABRIELA MORALES C., MARLEN A. AND COLS.

The present research study is retrospective, cross-sectional, observational and

comparative, through the survey as a method and as an instrument, the purpose of
the observation record is to inform us of the importance that nursing records
currently have in the clinical record and that The nurse assesses the preparation of
these as well as the medical-legal repercussions for the misuse of the clinical
record.

The objectives are: Determine if nurses have full knowledge of the importance
of the nursing records that are made in the clinical record, verify if the content of a
nursing record has the characteristics and rules established for it and make known
to both the nurses and the corresponding authorities the results obtained from the
research.

PROBLEM STATEMENT:

Clinical records are documents that are prepared for every patient upon
entering a health institution and must contain:

- Patient diagnosis.
- Clinic history.
- Observations.
- Etc.

Therefore it is said to be a medico-legal instrument.

WORK HYPOTHESIS.

The importance that the nurse gives to the nursing records that he prepares in the
clinical record determines that the contents are institutionally regulated.

NULL HYPOTHESIS:

The importance that the nurse gives to the nursing records that he prepares in the
clinical record does not determine that the contents are institutionally regulated.

THEORETICAL FRAMEWORK:

The clinical record is used as a legal instrument, in which the nurse has an
important participation due to the experience of their records in it, writing with
greater precision each moment of the patient's evolution and thus determining the
needs and care that the patient manifests. Whether physical, social or moral, the
records in the clinical record are therefore vital to achieve adequate management.

The clinical record is the set of specific forms of paperwork that make up the
patient's medical history; The results of the medication and treatment are
accurately recorded, keeping the doctor informed of the patient's status. It is
reference material for research work on diagnostic and treatment methods. For
teaching doctors, nurses and other hospital personnel. It is important testimony in
legal matters.

The patient's record is useful to the community, as it highlights its own public
health problems and points out the way to solve them. The importance of
accounting, updating and accuracy of the records it contains is also mentioned.

For CONAMED, the clinical file must contain:

- Initial notes.
- Clinic history.
- Front sheet.
- Medical notes.
- Admission notes.
- Review Notes.
- Evaluation notes.
- Interconsultation notes.
- Preoperative notes
- Preanesthesia notes.
- Postoperative notes.
- Postanesthetic notes.
- Graduation notes.
- Nursing notes.
- Laboratory and office notes.

The Ministry of Health carries out an official project of the clinical file, it contains the
records of the essential technical elements for the rational study and solution of the
user's problems, involving preventive, curative and rehabilitative actions and which
is constituted as a tool mandatory for the public, social and private sectors of the
national health system.

They define the clinical record as the sets of written, graphic and imaging
documents in which health personnel must make the records, notes and
certifications corresponding to their intervention, in accordance with health
provisions. Containing the following:

- Type name and address of institution

- Reason and company name.
- Name, age, sex and address of user.
- The records are the property of the service provider and must be kept for 5
years from the last medical act.
- The others that are indicated by the health provisions.
 - The doctor and all technical and auxiliary professionals involved in care
must comply with ethical and professional guidelines.
- Service providers have the obligation to report clinical cases if requested.
- The file must be handled with discretion and confidence, taking into account
scientific and technical principles that are oriented towards medical practice
and are only made known to third parties through competent authorities.
- Notes, reports and procedures must adhere to official Mexican standards.
- The medical notes and reports referred to in this standard must contain
patient data.
- In the case of a contract signed by the institution, there must be a copy of
the file.

NURSING NOTES:

The observations made by the nurse and the way in which he or she provides
care to the patient are written down. 5 kinds of reports are recorded.

- Therapeutic measures applied.

- Ordered therapeutic measures.
- Planned measures.
- Measures executed.
- Other observations in relation to health status.

NURSING RECORDS:

The nurse's record must begin with the patient's admission to the hospital, with
legible handwriting using blue ink during the day and red ink at night, the method of
admission, objective and subjective signs and symptoms will be noted; treatment
and diet, notes will be made about the time the treatments were given, healing,
removal of sutures, anything related to any organ, breathing, blood pressure,
pulse, temperature, admissions and discharges.

NURSING CARE SHEET:

The comprehensive nursing care sheet is the result of the needs expressed by
the nursing staff in the existential, administrative and teaching areas. Its purpose is
to integrate the greatest number of patient data into a single document to carry out
a complete and accurate assessment. In this way, establish therapeutic measures
and specific care for the patient quickly and effectively.
INVESTIGATION METHODOLOGY :

 Study design
 Universe
 Sample
 Inclusion Criteria
 Exclusion criteria
 Variables .

PILOT TEST:

2 instruments were developed

1. An interview form
2. An observation card

RESULTS:

A prospective, cross-sectional, observational and comparative investigation was

carried out on the importance of nursing records in the clinical record.

CONLUSIONS AND SUGGESTIONS :

An important part has little experience in managing nursing records and does
not give due importance to them, completely ignoring the psycho-emotional, socio-
economic and spiritual aspects, the records being deficient, which is why it is
suggested to the corresponding authorities have greater control of the nursing
staff. Since the records are the identity that makes them present.
 NURSE ASSESSMENT
POTTER, PATRICIA ANN

A competent nurse must have adequate knowledge of physiology,

pathophysiology, psychopathology, social and behavioral sciences, and medical
treatment to safely carry out and provide care.

INTRUDUCTION TO THE NURSING PROCESS:

The nursing process allows the nurse to organize and provide nursing care,
integrates the elements of critical thinking, to make judgments and implement
actions based on reason. The nursing process is used to identify, identify and treat
human responses to health and illness, it includes 5 steps:

- Assessment
- Nursing diagnosis
- Planning
- Implementation
- Assessment
 It also involves scientific reasoning.

CRITICAL THINKING APPROACH TO VALUATION:

The nurse must be able to review information from various sources to form
critical judgments. During the nursing assessment, relevant data are systematically
collected, verified, analyzed, and communicated to the client. This phase of the
nursing process includes 2 steps:

1.- Collection and verification of data from a primary source.

2.- Data analysis as a basis for nursing diagnosis

The purpose of the assessment is to establish a database relating to the client's

perceived needs, health problems and responses to these problems, related
experiences, health practices, objectives, values, lifestyle and expectations of the
health service. When you assess the client, the nurse must assess principles of
critical thinking, and also contribute knowledge of the physical, biological and social
sciences to the assessment.

Carnevali and Thomas suggest 2 approaches to collecting data:

1.- A complete database format: It is oriented from the general to the specific.

2.- The problem-oriented approach: Starts with problem areas and extends to
relevant areas of the client's life.

TYPOLOGY OF GORDON'S 11 FUNCTIONAL MODELS

 Health knowledge-management
 Knowledge-care
 Nutritional-metabolic
 Activity-exercise
 Cognitive-perceptual
 Sleep-rest
 Self-perception-self-concept
 Role-relationships
 Sexuality-reproduction
 Adaptation-tolerance to stress
 Values-beliefs

The nurse should group the assessment data and begin to identify emerging
patterns and potential problems. The extent of a nurse's ability to understand the
meaning of all the data that is being collected and analyzed is related to the
knowledge and experience he or she possesses.

ORGANIZATION OF DATA COLLECTION:

Accurate assessment enables the formulation of appropriate nursing diagnoses

and the establishment of appropriate goals, expected outcomes, and strategies for
the client.

Data in the assessment phase are outlined to provide clear direction for how
nurses make decisions for client care.

METHODOLOGY FOR NURSING ASSESSMENT

 Nurse-client interaction
 Recording of nurse and client behavior
 Questions and inference
 Model identification
 Application of theories and concepts
 Validation.

DATA COLLECT:

The nurse collects descriptive, concise and complete data; This is achieved by
obtaining all information relevant to the actual or potential health problem.

TYPE OF DATA:

During the assessment, nurses obtain 2 types of data:

1.- Subjective data: These are the clients' repercussions on their health problem;
They can include feelings of anxiety, physical discomfort, and mental stress.

2.- Objective data: These are observations or measurements made by the person
obtaining the data.

DATA SOURCE:

Objective data is obtained from the client, family, loved ones, members of the
healthcare team, and notes from the histories.

Subjective data are obtained through physical examination, results of diagnostic

or laboratory tests, and relevant medical and nursing literature.

CUSTOMER : In most situations the customer is the best source of information

FAMILY AND RELATIVES : They can be questioned as a primary source of information
when dealing with infants or children and clients who are seriously ill, mentally ill,
disoriented or unconscious.

HEALTH CARE TEAM MEMBERS : The healthcare team consists of physicians,

nurses, allied healthcare professionals and non-professional employees who work in the
healthcare environment; They can provide information about how the client interacts with
and reacts to the healthcare environment.

MEDICAL RECORDS : May verify information regarding past health patterns and
treatments or may provide new information .

OTHER RECORDS : As educational, military or employment records may contain health

information in this regard, any information obtained is confidential and is treated as part of
the client's legal medical history.

LITERATURE REVIEW : Nursing, medical and pharmaceutical related to a disease

helps the nurse to complete the database .

NURSE EXPERIENCE : It is developed by verifying and perfecting propositions,

questions and expectations based on principles.

DATA COLLECTION METHODS:

INTERVIEW:

It is a communication model initiated for a specific purpose and focused on a

specific content area.

In nursing: The purposes of the interview are to obtain the nursing health history,
identify health needs and risk factors, and determine specific changes that have
occurred in well-being and lifestyle.

When conducting the interview, the nurse uses specific communication skills to
focus attention on the client's degrees of well-being; achieving several objectives:

- The nurse-client relationship.

- A relationship of interpersonal proximity that develops
- Favors research.
- Commenting on client responses to health and illness.
- Information is obtained about the physical, developmental, emotional,
intellectual, social and spiritual dimensions of the client.
- Provides the opportunity to observe the client.

TYPES OF INTERVIEW TECHNIQUES:

 The interview process is affected by the client's personality and care needs, the
environment where this care is provided, and the skill and experience of the nurse.

In a situation where the nurse is able to obtain a complete nursing history, it is

useful to begin to find out, in the client's own words, what the health problem is and
what its possible cause is.

- Use open-ended questions to get one- or two-word answers.

- You can use channeled response that includes active listening techniques
such as “okay” and “yes” indicate to the client that you have heard them.
- Closed questions require concise answers and are used to clarify prior
information or provide additional information.

PHASES OF THE INTERVIEW:

It involves orientation, work and completion of the phases.

Orientation phase:

The nurse reviews the purpose of the interview, the types of data that should be
obtained, and the most appropriate methods for conducting the interview. The
nurse must also be aware that the client is forming an opinion about the interview.

Establishment of the nurse-client relationship

It is an important time to establish a relationship that promotes trust and mutual

acceptance. An important objective is to establish the foundation for the nurse to
understand the client's needs and to begin the relationship that allows the client to
become an active partner in making decisions related to care; explaining the
purpose, the types of questions that will be asked, and the client's role in the
process.

Work phase:

The nurse asks questions to establish a database from which a nursing care
plan can be developed.

Completion phase:

Completion requires skill on the part of the interviewer to indicate that the interview
is over.

HEALTH NURSE STORIES:

It is made up of all the data obtained about the client's well-being, it is obtained
through the interview whose main component is carrying out an assessment, its
objective is to identify the models of health and illness, the risk factors for physical
and health disorders. of conduct; allowing the development of a complete care
plan.

Biographical information:

It is a set of relative demographic data of the customer.

Reason for requesting health care:

The nurse asks the client why he or she requested health care, given that the
information contained on the initial intake form may differ greatly from the client's
subjective reason for requesting care.

Customer expectations:

It is not the same as the reason for requesting medical attention to which they
are usually related; clients usually have expectations in the following areas:

- Information needed to independently manage your health conditions.

- Interest and compassion expressed by healthcare professionals.
- Quick response of professionals to client requests.
- Relief of pain and symptoms.
- Involvement in decision making.
- Cleaning the environment where care is provided

The initial interview can establish the client's expectations when entering the
environment dedicated to this purpose.

Current illness:

If there is an illness, the nurse gathers relevant and essential data regarding
the onset of symptoms. This determines when they started, whether the onset
was sudden or gradual, the nurse records specific information such as location,
intensity and quality of a symptom.

Previous health history:

The information collected in this regard provides data on the client's

experiences with healthcare. The nurse assesses whether you have been
hospitalized or have undergone surgery.

The nurse also identifies habits and lifestyles. When planning nursing care,
it is important to assess sleep, exercise, and nutrition patterns.

Family history:
 Its purpose is to obtain data on immediate family members and blood
relatives.

The objectives are to determine if the client presents a risk of suffering from a
disease of a genetic or family nature, identify areas for health improvement and
disease prevention, and also provide information about the family structure,
interaction and function that may be useful in the care plans.

Environmental history:

Provides data on the clients' home environment and any support system that
they or their family members may need.

Psycho-social history:

It will reveal the client's support system which may include a partner,
children or other family members and close friends. Includes information about
typical ways the client and family cope with stress.

Spiritual health:

The experiences and events of life are constituted according to one's own
spirituality, the spiritual dimension represents the totality of one's being and it is
difficult to assess it quickly.

Systems review:

It is a systematic method of all body systems. Depending on the client's

condition and the urgency in initiating care, Gordon's functional health models
serve as a way to focus or organize an approach to collecting nursing
assessment.

PHYSICAL EXPLORATION:

It involves obtaining observable, objective information not distorted by the

client's perceptions; it involves taking vital signs and other measurements and
examining all parts of the body using inspection, palpation, percussion,
auscultation, and olfaction techniques.

Scan order:

It is carried out in a systematic manner similar to the systems review of

nursing health history.

Physical examination techniques:

 Uses inspection, palpation, perception, auscultation and smell to thoroughly
examine the client.

Diagnostic and laboratory data:

It is the result of diagnostic and laboratory tests, it is important for the nurse
to review the results to verify the alterations identified in the nursing health
history and physical examination.

FORMULATION OF NURSING JUDGMENTS:

The nurse critically chooses the type of information to gather about the client,
interprets this information to determine abnormalities, makes additional
observations to clarify the information, and then lists the client's disorders in the
form of nursing diagnoses.

Data interpretation:

After collecting extensive information through a process of deductive reasoning

and judgment, he decides what information has meaning in relation to the client's
health status.

The assessment of a problem involves obtaining, estimating and judging the

value and meaning of the data. Assessment allows the nurse to better understand
the problems and look for relationships between them.

Data Grouping:

The nurse organizes the information into meaningful groups. During data
grouping, certain cues alert the nurse's grouping process more than others
because the nurse recognizes them and focuses attention on the client's functions
that require support or help for recovery.

DATA DOCUMENTATION:

It is the last part of the complete documentation. Thoroughness in data

documentation is essential for 2 reasons:

1.- Data related to client status is included.

2.- Observation and annotation is a professional and legal responsibility.

The basic rule is to write down all observations, the nurse must pay attention to
the facts and must make an effort to be as descriptive as possible.
TOPIC 8: NURSING RECORDS
Nursing documentation must be complete and flexible enough to retrieve critical
data, maintain quality and continuity of care, track client assessment, and reflect
current patterns.

MULTIDICIPLINARY COMMUNICATION WITHIN THE HEALTH CARE TEAM:

Client care requires effective communication between members of the

healthcare team, reporting includes oral and written exchanges of information
between caregivers.

A client record and chart is a permanent legal documentation of information

relevant to a client's health care management.

Consultations are another form of information according to which a health

professional issues a formal opinion about a client's care to another professional.
Referrals, consultations, meetings must be noted in the record.

DOCUMENTATION:

Anything written or printed that serves as a record of a test for authorized

persons, reflects the quality of care and provides evidence of the responsibility of
each member of the healthcare team; The logs contain the following information:

- ID
- History
- Diagnosis
- Care plans.
- Treatment record.
- Medical record.
- Medical Orders.
- Medical evolution notes.
- Physical examination report.
- Reports of diagnostic studies.
- Summary of operating procedures.
- Discharge plan.
PURPOSE OF RECORDS:

A registry is a valuable source of data that is used by all members of the

healthcare team. Its purposes include communication, economic billing, education,
valuation, research, audit and legal documentation.

COMMUNICATION:

The record is a means by which members of the healthcare team convey

contributions to client care, including individual treatments, content of important
discussions, client education, and use of referrals for discharge planning.

BILLING:

The customer care record is a document that shows the extent to which health
insurance companies must reimburse services.

Education:

Nursing students and health disciplines use the medical record as an

educational source. An effective way to learn the nature of the illness, and the
individual response to it, is to read the client's care records.

ASSESSMENT:

A nursing history and initial assessment are complete when a client enters the
nursing care unit; it usually includes biographical data. Detailed care notes and
physician findings at the time of assessment.

INVESTIGATION:

Statistical data can be extracted from the client record is a valuable resource for
describing the characteristics of client populations in a health care facility, the
record of a client during a research study to collect information on certain factors.

AUDIT:

A regular review of information in client records provides a basis for evaluating

the quality and education of care offered in an institution.

LEGAL DOCUMENTATION:
 Accurate documentation is one of the best defenses against legal claims
associated with nursing care. The law protects client information obtained through
examination, observation, conversation, or treatment.

GUIDELINES FOR QUALITY DOCUMENTATION AND REPORTING:

They are necessary to enhance efficient and individualized customer care, they
are distinguished by 5 characteristics that are real, accurate, complete and
organized:

REAL:

A record contains descriptive and objective information about what a nurse sees,
hears, feels, and smells.

An objective description : it is the result of observation and direct determination

A subjective description: The client's exact words should be noted “whenever

possible.”

EXACT:

The use of exact determinations ensures that a record is accurate. Correct

writing is important and demonstrates a degree of competence and attention to
detail.

COMPLETE:

The information is an entry or a report, it must be complete, containing concise,

appropriate and complete information about customer care.

CURRENT:

Time entries are essential in client care to increase accuracy and decrease
unnecessary duplication. Many health care institutions employ client bedside
records, which facilitates immediate documentation of a client's information. as it is
collected.

ORGANIZED:

The nurse transmits the information in logical order.

STANDARDS:
 Documentation needs to follow JCAHO criteria to maintain institutional
accreditation and reduce liability. The nurse management of each health care
institution selects the method used to document client care. The JCAHO requires
documentation in the nursing process context.

NARRATIVE DOCUMENT:

It is the traditional method of recording nursing care.

Problem-oriented medical records:

It is a documentation method that emphasizes the client's problems. It consists

of the following main sessions:

- Database : Contains all available valuation information belonging to the

client. The foundation for identifying client problems and planning care.
- Problem list: After analyzing the data, the problems are identified and a
unique list is made. They include the client's physiological, psychological,
social, cultural, spiritual, developmental, and environmental needs.
- Nursing care plan : A care plan was developed for each problem by the
disciplines involved in the client's care.
- Progress Notes: Members of the health care team monitor and record the
progress of a client's problems.
- Record according to origin: It is a record according to origin, the client's
graph is organized in such a way that each discipline has a separate section
in which they record the data. An advantage is that professionals can easily
locate the appropriate section in which they make entries; the notes session
is the section in which nurses enter a written description of nursing care and
the client's responses.

GRAPHICS IN CASE OF EXCEPTION:

Exception graphics are an innovative approach used to try to improve

documentation, reducing repetition and time spent on graphics. It is a shorthand
method for documenting normal findings and usual care based on clearly
defined graphic guidelines and predetermined criteria for nursing assessments
and interventions.
 The exception chart can pose legal risks if nurses are not disciplined to
document exceptions. About what happens to clients.

CRITICAL CASES AND PATHWAYS SECTION:

Incorporates a disciplinary approach to document client care, critical

pathways are disciplinary care plans that include key interventions and
expected evolutions in an established time frame, reduce duplication and the
amount of work in the chart, identify expected reactions for each care day.
Unexpected events, goals not met, and interventions not specified in the clinical
pathway timeline are called variations.

- A negative variance occurs when clinical guideline activities are not

completed as planned or the client does not follow the course
- A positive variance occurs when a customer evolves faster than expected.

COMMON FORMS OF REGISTRATION:

Various forms are available specially designed for the type of information that
nurses regularly document.

Nursing story:

The nursing history form is complete when a client enters a nursing care unit.
Each institution prepares a nursing design form in different ways, based on
practical standards and the philosophy of nursing care.

Graphics and algorithms:

Algorithms are printouts that allow nurses to assess the client and document
vital signs and routine repetitive care.

Kardex nurse:

It is a form that is kept on a card or portable notebook in the nursing control.

It has 2 parts:

- An activity and treatment section

- A nursing care plan section.

Acuity recording system:

Recording acuity requires staff to assign a numerical ratio scale to interventions,

thereby obtaining a numerical level of acuity for each client.
 Appropriate acuity categorizations are necessary to justify over time the
numbers and qualifications of staff needed to safely serve clients.

Standardized care plans:

They are pre-printed established recommendations that are used to serve

clients who have similar health problems.

Written modifications can be made to standardized plans to individualize

treatments.

An advantage is the establishment of clinical care guidelines for similar groups

of clients.

The main drawback is the risk that standardized plans inhibit nurses'
identification of clients' individualized and unique treatments.

Discharge preparation forms:

Much emphasis has been placed on preparing a client for efficient discharge at
the appropriate time from a health care institution.

Ideal discharge planning begins at admission. The JCAHO has established

client education criteria for quality discharge planning:

- Education on possible interactions of foods, drugs, nutritional intervention

and modified diets.
- Rehabilitation techniques to accompany adaptation and/or functional
independence in the environment.
- Access to available community resources.
- When and how to obtain treatment or follow-up later.
- The responsibilities of the client and family in caring for the client.
- Medication education including when to take each drug and why, the
dosage, route of administration, precautions and possible side effects, and
when and how to renew prescriptions.

Discharge summary forms make the summary concise and instructive

DOCUMENTATION IN HOME CARE:

The issue of home care continues to grow with shorter hospitalizations and
increased numbers of seniors requiring home care services.

Documentation in the home care system has different implications than in other
areas of nursing, a main difference being that most of the evolution of care is
witnessed by the client and family rather than the nurse. Nurses must have
important activity assessment skills to capture necessary information about
changes in the client's health status.

DOCUMENTATION IN LONG-TERM CARE:

An increasing number of seniors require long-term care services. Many

individuals will live in this situation for the rest of their lives, which is why they are
called residents rather than clients.

In long-term care, government residences are instrumental in determining

criteria and standards for documentation. Long-term care facilities are also
developing experienced care units for clients requiring higher-level care in
response to demands for shorter hospital stays. Fiscal support for long-term
residents depends on the justification of the nursing care as demonstrated in the
documentation from the services.

COMPUTERIZED DOCUMENTATION:

Nurses have been using computerized systems for supplies, equipment,

medication storage, and diagnostic tests for some time. Software programs allow
nurses to quickly enter specific assessment data and the information is
automatically transferred to different reports.

Computerized systems have not been limited to services with greater economic
resources, and they are changing enormously. There are legal risks associated
with computerized documentation anyone could theoretically access a terminal in a
hospital and obtain information on almost any client. Confidentiality of access to
computerized records is an issue.

The transition to computerized documentation presents opportunities and

challenges for nurses and nurse managers.

REPORT:

Nurses convey information about clients so that all team members can make
decisions about their care.

SHIFT CHANGE REPORTS:

The purpose of this report is to provide continuity of care among nurses who are
providing care to the client.

A shift change report can be given orally in person via voice recording or during
“call-ins” at each client's bedside. An advantage of oral reports is that it allows staff
members to ask questions or clarify explanations. A good report describes the
clients' health status and allows nurses on the next shift to know exactly what kind
of care they need. An organized report follows a logical sequence.

PHONE REPORTS:

Persons participating in a telephone report must provide clear, accurate and

concise information.

PHONE ORDERS:

Telephone orders involve a physician placing a therapeutic prescription to a

licensed nurse over the telephone. It is important to clarify messages when a nurse
accepts doctor's orders over the phone.

TRANSFER REPORTS:

Clients may be moved from one unit to another to receive different degrees of
care. The nurse includes the following information.

1.- Name and age of the client, main doctor and medical diagnosis.

2.- Summary of the evolution until the moment of transfer.

3.- Current health status.

4.- Current care plan.

5.- Any critical assessment or intervention.

6.- Any special consideration.

7.- Need for any special equipment.

INCIDENT REPORTS:

An incident is any event that is not consistent with the operation of a health care
unit or the usual care of a client.