ASSIGNMENT ON

QUALITY ASSURANCE, OBSTETRIC

AUDITING- RECORDS/REPORTS,
NORMS, POLICIES AND PROTOCOLS

Submitted To: Submitted By:

Madam. M. Samanta Ananya Sain
Senior Lecturer M.Sc. Nursing 2nd Year
Govt. CON. Burdwan Govt. CON. Burdwan
Introduction:
In the changing healthcare environment, quality of care is receiving greater attention than
ever before. As consumer become more knowledgeable as a result of increased information
available to them, much of the mystique surrounding healthcare is being dissipated. The
focus of efforts to measure quality has also expanded from inside the boundaries of hospital
to community and long term care setting.

Meaning of Quality:
The dictionary defines quality as "a degree of excellence; a peculiar and essential character."
Although individual writers suggest slightly different view about quality, several
communalities emerge when reviewing their approaches.
 Quality can be measured.
 Quality measures a standard or a degree of excellence.
 Excellence needs to be determined by validating standard of care or measuring
professional conduct when caring for patients.

Definition:
The British Standards Institute defines Quality as "the totality of features or characteristics of
a product or services that bears on its ability to satisfy a given needs."
It can be paraphrased into "quality is that which gives complete customer satisfaction.

Elements of quality:
Shaw (1998) approaches these dimensions similarly but describes them as elements of
quality. He sets out the following elements:
 Appropriateness: the service or procedure is what the population or individual actually
needs.
 Equity: a fair share is available for all the population.
 Accessibility: services are not compromised by undue limits of time and distance.
 Effectiveness: services are achieving the intended benefits for the individual and for the
population.
 Acceptability: services are provided such as to satisfy the work expectations of patients,
providers and the community.
 Efficiency: resources are not wasted on one services or patient to the determent of
another.
Definition of Quality Assurance:
“Quality assurance is a judgement concerning the process of care, based on the extents to
which that care contributes to valued outcomes”. –Donabedian, 1982
“Quality assurance as the monitoring of the activities of client care to determine the degree of
excellence attained to the implementation of the activities”. –Bull, 1985

Goals of Quality Assurance:

Maciorowski provides three major goals of an effective nursing quality assurance program.
These areas-
 Evidenced of nursing accountability for services rendered and compliances with
standards of practice.
 A defined mechanism to identify, measures and resolves, clinical issues related to
practice.
 A defined mechanism of evaluating quality indicators, collecting data, developing
corrective action and assessing outcomes.

Components of Quality Assurance Plan:

A quality assurance plan provides the foundation and framework of all quality control
activities. A quality assurance plan should include the following components.
 Clearly stated goals
 Measurable objectives of how the goals will be met
 Designated accountability for written objectives
 Delineated methods of QA activities
 Outlined responsibilities conducting QA activities
 Outlined mechanisms of reporting of reporting data
 Outlined mechanisms of corrective action
 Clear statement of confidentiality

The World Health Organization in their booklet ‘The principles of Quality Assurance' (1983)
set out four particular components that must be addressed in any quality assurance activities.
They are:
 Performance (technical quality)
 Resources use (efficiency )
 Risk management (the identification and avoidance of injury or illness associated with
service provided)
 Patient satisfaction with the services provided.

Measurement of Quality Care:

In 1988, at a meeting of the American Association of College of Nursing, Diers described a
model for quality care measurement. In this model services render in the health care delivery
system result in products such as, X-Ray, Lab-test results, hours of patient care delivered,
meals served etc. This products or intermediate outputs delivered over a given episode of
patient care result in a final output or outcome. When comparing the cost of producing
products to final outcomes, a measure of quality care can be determined based on cost. Diers
maintain the database arguments in nursing are necessary to relate efficiency to effectiveness
and that a comparison on these will be the basis for determining quality in the future.
This model views nursing services of a specific type (staff mix and model, i.e. case
management, primary care, modular care) as an input that results in a product. It provides a
means for analyzing the efficiency or productivity of nursing unit, for patients hospital stay.
But the question whether efficient utilization of services delivered according to standards
result in quality patient outcomes, remains unanswered. By focusing on outcomes as
compared to inputs, the questions become:
1. How effective is the utilization of services delivered according to standards?
2. Comparing the quality of outcomes, was the cost efficiency of services within an
acceptable range?

These issues and concerns are potentially addressed by a new integrated model, which
considers the new aspects of measurements like computers and cost accounting.
A Systematic Measure of Quality Nursing Care:
Professional nurses can provide more efficient and cost effective services to the consumer
with aid of advanced technologies viz. computers and cost accounting.
A systematic integrative model of quality care measurement, will determine quality of
outcomes based on antecedents (structure elements and process). In such model, structural
inputs into the nursing care system would include those elements in the settings in which
nursing care are given.
According to Donabedian, the culture within the organization is the most crucial factor
associated with quality care.
The process elements measured in such systematic approach would address the interaction
between the nurse, the patient/client, and the patient's / client's environment.

Components of Quality Assurance:

In the United Kingdom, British Standards 5750, and sets out how a quality system might be
set up within a company. There are 19 components that describe how the quality system is to
be applied to the design and manufacture of a product or services.
1. Documented quality system.
2. Organization
3. Review of quality system operation
4. Planning
5. Work instruction
6. Records
7. Corrective action
8. Control of design activities
9. Documentation and change control.
10. Control of inspection, measuring and test equipment
11. Control of purchased material.
12. Control of manufacture.
13. Purchaser supplied material.
14. Completed item inspection and test
15. Sampling procedure
16. Control of non conforming material
17. Indication of inspection status
18. Protection and preservation of product quality
19. Training.
The component of a nursing quality assurance program were originally developed by Lang
and adopted by the American Nurses' Association as a model for quality assurance in nursing.
The evaluation model is open and circular, indicating a cyclical process that can be entered at
any point.
The American Nurses Association model for quality assurance and implementation of
standards:
Identification of values emphasizes the need to clarify the social, institutional, professional
and individual values, along with the advances in scientific knowledge which influences
nursing practice.
The standards and criteria derived from the values describe the level of nursing care
considered acceptable. These standards may range from minimal to achievable, excellent, or
comprehensive. Standards represent the agreed-upon level of excellence, whereas criteria are
specific, measurable. Statements which reflects the intent of the standards and can be
compared to actual nursing practice.

The next component involves the measurement of current nursing practice against the
established standards criteria.
 Here process describe the nature and sequence of nursing activities (what nurses do, how
they do it and in what order)
 Standards refer to the level of nursing care that is to be provided.
 Criteria are the characteristics or behaviours used to measure the level of care.
 Outcome standards and criteria reveal the end result of nursing care.
 Fig 1: ANA Model of Quality Assurance

Quality circles: A quality control program, or simply quality circle (QC), is a group of
people from the same organizational area who meet regularly to solve problems they
experience at work. Members are trained in solving problems, in applying statistical quality
control, and in working groups. Usually a facilitator works with each group, which normally
consists of six to twelve members. The QC's may meet 4 hours a month. Although QC
members may receive recognition, they usually do not receive monetary rewards.
Quality circles evolve from suggestion programs. In both approaches, workers participate in
solving work related problems.
Factors influencing quality management:
 Good organization structure/function
 Good quality staff
 Continuing professional development
 Continuing structure/ functional performance evaluation
 Learning from failures and moving from low quality to high quality organization.

Guidelines for quality control:

While approaches to quality improvement depend on the situation criteria guidelines can be
helpful:-
1. Quality improvement must not be a fad; it must be a long- term continuous efforts. There
are always opportunities for improvement.
2. While top- management commitment is of vital importance, everybody in an organization,
from top to bottom, must be committed to quality.
3. Most quality problems require the cooperation and coordination of many functional
departments, production design testing, engineering, manufacturing, marketing, and so.
4. Ideas and suggestions for quality improvement can come from many, often unexpected,
sources.
5. Quality control should be done at crucial steps in the operations process.
6. A quality improvement plan is not enough. Provision must make for its implementation.

Implementation of quality assurance in nursing:

Quality improvement is the commitment and approach used to continuously improve every
process in every part of an organization, with in intent of meeting and exceeding customer
expectations and outcomes.
1. Policy and Planning
Most countries reported inadequate involvement of nurse/ midwives in policy and planning,
inadequate capacity and capability of nurses/ midwives to effectively contribute, and limited
strategies and opportunities to develop capacity and capability. In most countries with a
strategies plan for nursing and midwifery development, the implementation is poor or the
plan is not being implemented at all.
2. Education, Training and Development
In the majority of countries, linkages and interdependency between education and service
sectors are absent or weak. There are few problems with the numbers of students being
recruited, but there are issues in some countries in regard to the quality and potential of those
recruited. Achieving competency based education and modern some countries in regard to the
quality and potential of those recruited. Achieving competency based education and modern
teaching methodology and skills requires significant effort. There are few multidisciplinary
learning opportunities for nurses and midwives. Other than Thailand, all countries reported
difficulty in encouraging, promoting and achieving a culture of life on learning.
3. Development and Utilization
Very few initiatives have been taken to strengthen the flexibility of the nursing and
midwifery workforce. Rosters are no evidence based and in need of revision. Basic
equipment is lacking in many countries. Sustainable funding is problematic and inequitably
distributed, particularly between urban, rural and remote areas. Most countries report the
nursing/ midwifery professional associations were essential, but that they needed
strengthening, as did leadership and management of nursing/ midwifery. Working conditions
need improvement; salaries are low in the majority of countries; heal facilities are often poor
and unsafe for staff; there are inappropriate nurse/midwife patient ratios; nurses and
midwives at subjected to physical and verbal abuse; housing and transport are often
unsatisfactory; incentives are poor; mutual respect between nurses/ midwives and
nurses/midwives and other members of the health team needs strengthening. Technical
supervision is generally poor and there is an overall weak approach to continuous quality
improvement and encouraging motivation. There at few opportunities for nurses / midwifes
to improve their technical supervision skills.
4. Regulations
The enforcement of regulations for nurse/midwives is uneven across the Region despite the
extensive evidence base now available on the impact of strengthened regulations, and best
practice approaches to regulations.
5. Evidence Based Decision Making
The information systems available in the countries of the Region are limited. Opportunities
for local research and access to evidence bases being developed in other countries of the
region are limited with financial constraints cited as most common reason for the weakness.
The shortage of nurses and midwives to some extent is one of the causes of inequity in health
of the population in the region. The weaknesses in all components of the workforce
management mentioned above have contributed to this problem. Apparently, low pay, low
status and poor working conditions, together with completion from developed countries who
themselves suffer from strategies of nurses and midwives, among others, appear cause the
problem. In countries where nurses have a low social status and low pay, it is difficult to
attract qualified men and women into the profession.

AUDIT IN OBSTETRICS
Definition: Audit is defined as the systematic and critical analysis of the quality of medical
care.
Nursing Audit: It meant by which nurses themselves can define standards from their point of
view and describe the actual practice of nursing.
Objective:
Objective of carrying out an audit is to improve the quality of clinical care. It is done by
changing and strengthening many aspects of hospital, practice and administration.
Audit could be medical where scrutiny is done over the medical aspect of the work performed
by the doctors. It could be clinical, where scrutiny is done over the work done by all health
professionals including the doctors.
Structuring an audit:
Important aspect to organize an obstetric audit is motivation of all doctors, midwives, and
other health professionals. Proper documentation of facts and figure must be there. Audit
should be kept confidential and is considered as an educational tool.
When to audit
The audit should be done 3 to 6 months or 12 months after commencement, then:
1. At regular intervals such as annually, or
2. Immediately when a major incident or problem occurs or
3. As soon as feasible when there is a complaint by the midwifery- trained personnel that they
are unable to fulfill the standard, or a complaint is raised by the community about the quality
services,
4. When a new intervention related to the standard is implemented, such as the use of some
new technology or treatment/ drug. In this case there should be an interval of a minimum of
three months before the audit is conducted so that the full benefits/ effects of the new
treatment, equipment or drug can be seen.
How to conduct audit
Audit should be pre arranged with the midwifery trained personnel. The auditor should go to
the field/ unit where the midwifery trained personnel is working to observe the standard in
practice in the local situation. This should be done over 2-3 days so that the auditor can
observe the midwifery trained personnel in different situations.

Importance of carrying out an audit:

 A well structured and efficient audit is based on scientific evidences with facts and
figures.
 It can replace the out of date clinical practice with the better one.
 It can remove the disbelieving and agonistic attitudes between hospital management and
professionals and also amongst the professionals.
 It improves awareness between doctors and patients.
 It is an efficient educational tool.

Use of Audit Results:

After conducting the audit and depending on the results, the decision will be made either to:
 Continue with the standard since it is working effectively.
 Take further specific action to strengthen the standard or correct deficiencies
 Revise the standard.
From the result of the audit check list, it will be possible to develop an action plan to further
improve or strengthen the standard. It is important in action plan to set target dates for
completion of each task.
If the result shoes that the standard is operating correctly, then a date should be set for re-
audit of the standard annually, or as national policy states. It may be necessary to re audit
earlier if, there is any major change or any problem/ incident, or there is a complaint from
either the midwifery trained personnel that they cannot achieve the standard, or from the
community about the quality of care and performance.
Limitations
Unless the audit is simple one, it requires lot of time, staff commitment and technology.
Clinical Audit
Clinical audit is about improving practice and providing a better service for consumers.
Practitioners are expected to measure and demonstrate the effectiveness of the care they
provide and one way of assessing practice by clinical audit.
Clinical audit is a continuous process that involves identifying an area to be examined, the
collection of appropriate data and the introduction of changes in practice as a result of
analysis of the data. It is crucial that the effect of changes is monitored by repeating the audit
and introducing further changes, if indicated. Health care professionals are mainly concerned
with the outcome of clinical intervention, but there are other aspects of clinical practice that
may influence outcome. Audit may influence aspects of service structure and process as well
as the outcome of clinical care.
Process of Clinical Audit:
When embarking on a process of clinical audit for the first time, it is better to concentration a
small area of study, and one that is amenable to change. An example might be to improve
breast feeding rates. One must decide what it is necessary to know in order to achieve this. It
is extremely important to define objectives at the start of any process of audit and how the
results of the process might be used to influence practice.
When an area of study has been chosen, it is vital for there to be clinical consensus on what
constitutes good care, that is, what should be happening, a desired level of achievement, a
standard. It is likely to be easier to agree any changes as a result of the audit if clinical
consensus on good care has been obtained.
Example for audit check list:
Evaluation Proforma of procedure on Bed bath
Date of evaluation:
Name of the patient:
Hospital number:
Date of admission:
Name of student Nurse
Fundamental steps in Admission procedure:
1. Preparing the patient's unit
2. Explanation to the patient
3. Action of bed bath
4. Comfortable position to the patient
5. Termination of the articles
6. Recording and reporting

RECORDS/REPORTS
A record is a clinical, scientific, administrative and legal document relating to the nursing
care given to the individual, family or community.
Purpose of Recording:
The most common type of written communication in health care is the client record.
1. Communication.
2. Education.
3. Legal documentation
4. Quality assurance
5. Reimbursement.
6. Financial billing.
7. Research education.
8. Program planning and evaluation.
9. Indicates plan for future,
10. Improving nursing care.

Principles of Record Writing:

1. Written clearly, accurately, appropriately and legibly.
2. Nurses should develop their own method of writing instead of writing an imposition.
3. All entries should be signed by them who writes it.
4. Care should be taken not to make errors on the records,
5. All records should be written with black ink or typed for better legibility.
6. Records should contain true facts based on observation, conversation and action.
7. Printed records are always advisable, if not, the factors should be printed briefly and
clearly.
Records should be completed and should give accurate information.
8. Record should be completed and should give accurate information.
9. Records shouldn't be kept blank.
10. All the records should be filed in serial number and should be properly arranged.
11. While record writing, continuity should be maintained.
12. Record should be written immediately after the service.
13. Records should be brief and neat.
14. Records should be kept as confidential.
15. Records should be handled properly, carefully and safely.
16. Records are used as a basis for Research and Evaluation. Hence, records should have
completeness.
17. Records systems are essential for uniformity of service. Hence the efficiency and agency
should develop new or revise old forms to meet the needs.
18. Combined checking and narrative record form are useful and save time.
Rule 42 (UKCC 1993) requires the midwife to keep detailed records which
contemporaneously as is reasonable, in other words as must be made as near the event as
possible. Records must be in a form acceptable to the employer and approved by the local
supervising authority. A midwife in independent practice will discuss the format of her
records with her supervisor of midwives.
The midwife's record is distinct from that of the doctor although she may contribute to the
medical record, especially during pregnancy. She must keep records of the midwifery history,
and of all antenatal examinations which she makes. During labour, records of observations,
examinations and care are essential and it is particularly important to enter details promptly,
because events move on so rapidly. A register of controlled drugs is kept for the purpose of
monitoring the issue and use of drugs of addiction. The midwife's register of births is usually
kept communally by hospital midwives but individually by a community midwife.
Maternity units use a wide variety of records and notes, including those which are designed to
be entered into a computer and others which are appropriate to the midwifery process or to
varying styles of individualized care.

All records that are made by a midwife and must be preserved for a period of not less than 25
years. The reason for this is that the record may be needed for the midwife's protection in
case of litigation or allegations of professional misconduct.

Maintaining of records according to the different ward (obstetrical documentation)

1. Antenatal Period Antenatal examination and care a. Bio-demographic data b. Socio
economic History c. Personal History d. Dietary History e. Family History f. Medical and
Surgical History g. Menstrual History h. Previous Obstetrical History i. Physical
Examination j. Antenatal Abdominal Examination k. Present Obstetrics history/ complains or
condition
2. Intranatal Period a. History of the patients b. Previous obstetrical history c. Present
pregnancy history d. Investigation and examination e. Admission for labour f. General
conditions g. Record the following on the partograph ( ▪ Patient information ▪ Fetal heart rate
▪ Amniotic fluid ▪ Cervical Dilatation ▪ Descent of the head or station of the head ▪ Hours ▪
Time ▪ Contraction ▪ Oxytocin ▪ Drugs given ▪ Pulse ▪ Blood Pressure ▪ Temperature ▪
Protein, Acetone and volume of urine)
3. Postnatal period • Condition of mother on discharge • Health education
4 .Family planning Record
 No. of eligible couples who accepted permanent methods
 No. of eligible couples who accepted temporary methods
 No. of eligible couples who discontinued spacing methods.

5. New born records

 Demographic data
 Condition at birth
 Physical Assessment
 Immunization record
A report is the summary of the services of person or personnel and of the agency.
Purposes
 To show the kind and amount of service rendered over a specified period.
 To illustrate progress in teaching goals.
 It acts as an aid in studying health conditions.
 It acts as an aid in studying health conditions.
 It acts as an aid in planning.
 To interpret the services to the public and to the other interested agencies.

Value of Good Reports:

 Good reports are time savers.

 They prevent duplication of work.
 Direct influence on the progress and even life of the patients.
 Provide a sense of security and confidence to the nurse in doing her work. Giving a good
report is an art.

Elements of Report:
 Timing: Most pertinent time. An accident or change in person' conditions are examples
of reasons for immediate reporting.
 Organization: Important points are mentioned in a logical order and stand out from the
explanatory and supporting statements.
 Clarity: Leaving no doubt of what happened, what was done, or what remains to be
done.
 Brevity: Omit unnecessary words and statements for a clear, complete picture.
 Correctness: Of all information to prevent serious mistakes in giving continued nursing
care.
 Objectivity: Presentation of facts, not personal feelings, to give a true picture.

Reports Used In Hospital Setting:

a. Change of shift reports.
b. Transfer reports.
c. Incident reports.
d. Day, evening and night reports.
e. Legal reports.
f. Telephone reports.
g. Telephone order.
Nurses responsibility for record keeping and reporting:

 The patient has a right to inspect and copy the record after being discharged.
 Failure to record significant patient information on the medical record makes a nurse
guilty of negligence.
 Medical record must be accurate to provide a sound basis for care planning.
 Errors in nursing charting must be corrected promptly in a manner that leaves no doubts
about the facts.
 In reporting information about criminal acts obtained during patient care, the nurse must
reveal such information only to the police, because it is considered a privileged
communication.

Fact
Information about clients and their care must be functional. A record should contain
descriptive, objective information about what a nurse sees, hears, feels and smells.

Accuracy
A client record must be reliable. Information must be accurate so that health team members
have confidence in it.

Completeness
The information within a recorded entry or a report should be complete, containing concise
and thorough information about a client care or any event or happening taking place in the
jurisdiction of manger.

Currentness
Delays in recording or reporting can result in serious omissions and untimely delays for
medical care or action legally, a late entry in a chart may be interpreted on negligence.

Organization
The nurse or nurse manager communicates information in a logical format or order. Health
team members understand information better when it is given in the order in which it is
occurred.

Confidentiality
Nurses are legally and ethically obligated to keen information about client's illnesses and
treatments confidential.
Maintaining good quality records and reports has both immediate and long-term benefits for
staff. In the long term it protects individuals and teams from accusations of poor record-
keeping, and the resulting drop in morale. It also ensures that the professional and legal
standing of nurses are not undermined by absent or incomplete records, if they are called to
account at a hearing.
 NORMS
Norms are standards that guide, control, and regulate individuals and communities. For
planning nursing manpower we have to follow some norms. The nursing norms are
recommended by various committees, such as; the Nursing Man Power Committee, the High-
power Committee, Dr. Bajaj Committee, and the staff inspection committee, TNAI and INC.
The norms has been recommended taking into account the workload projected in the wards
and the other areas of the hospital.

POLICIES
Policies are general principles or directions, they are usually without the mandatory approach
for addressing an issue, but might be considered mandatory in some NHS Trusts. They are
often set at national level, such as the indications of success in the report changing Childbirth.
A policy is a general statement, which in line with the organizational objectives, intends to
provide guidelines for decision-making. In the words of Koontz and O' Donnell, "Policies are
plans in that they are general statements for understandings which guide or channel thinking
and action in decision- making. They limit an area within which a decision to be made and
assure that the decision will be consistent with and contribute to objectives." This definition
indicates that policies are standing plans that provide solutions to recurring problems by
setting boundaries or limits around the decisions, telling people within the organization what
can be done and what cannot be answers to the similar situations, which ensure the
uniformity in actions and thus make the decision more predictable and transparent.

According to Terry, “A policy is a verbal, written or implied overall guide setting up the
boundaries that supply the general limits and direction in which management action will take
place."
We hear about personnel policies, hiring and firing policies, purchasing policies,
advertisement policies, financial policies etc. in an enterprise. Policies on the basis of their
emergence are called originated, appealed, implied or imposed policies.
The policies that are formed at the initiative of top-level manager are called originated policy.
The policies that are formulated out of the appeal made by subordinates to their superior in
relation to the actions to be taken on a given situation are called appealed policies. Such
decisions made by the manager on the appeal become the precedent for future actions.
There are certain policies that are stated neither in writing nor verbally but believed to exist
are called implied policies. They actually develop out of actions of superiors that people see
about them and believe to exist as policy.
The policies that are externally imposed on an enterprise that it must follow are called
imposed policies. The Government, professional agencies are some of the examples of the
external sources of imposed policies.
Characteristics of Good Policies:
A good policy must have the following features.
 In order to help in achieving objectives, policy must be in line with organizational goals,
and it should reflect the needs of those who will be affected by it.
 It must be comprehensive enough to cover a wide range of actions and leave room for
judgment and interpretation as required by the specific situations (not too rigid).
 It order to avoid ambiguity, every policy should be expressed in definite and precise words
indicating as who is responsible for implementing it.
 It should be formulated by using a participative approach in order to ensure compliance by
the people.
 It should be periodically reviewed in order to bring about necessary change or to abandon
completely.
 It must maintain à reasonable balance between stability and flexibility, In other words,
policy must change with the change of conditions. However, some degree of stability must
also prevail in order to give the sense of order and direction.
In order that a good standard of nursing care be maintained, the nursing superintendent
should develop written policies and procedures to serve as guides for nurses of the various
units of the hospital. Important topics that should be incorporated are as follows:-
1. Organization
2. Status and Relationship
3. Responsibilities
4. Staffing pattern, shift pattern
S. Departmental functions
6. Requisitioning of supplies
7. Utilizations, care and maintenance of equipment
8. Patient admission procedures including communication with doctors.
9. Nursing procedures
10. Coordination and domestic services.
11. Handling of patients clothing and valuables.
12. Dealing with verbal or telephonic
13. Handling and control of narcotics and dangerous drugs
14. Isolation techniques and communicable diseases
15. Control/ prevention of hospital infection.
16. Safety- hospital hazards, accidents and fire
17. Care and maintenance of furnishings.
18. Standards of temperature, ventilation, lighting
19. Public relations, release of patient in formations to others.
20. Visiting hours, dealing with visitors
21. Health education of patients, briefing of visitors and relatives.
22. Transfer of patients
23. Records and reports
24. Private nurses
25. Use of restraints
26. Discharge procedures including communication to business office and others.
27. Procedure for patients leaving against medical advice (LAMA).
28. Procedure following death of patients.

PROTOCOLS
A protocol is a written system for managing care that should include a plan for audit of that
care. Most protocols are binding on employees as they usually relate to the management of
consumers with urgent, possibly life threatening conditions. A protocol may exist for the care
of the woman with ante partum hemorrhage but not for the care of women in labour without
complication.

Balliere's midwives dictionary (Tiran 1997) describes a protocol as a multidisciplinary

planned course of suggested action in relation to specific situations, Protocols determines
individual aspects of practice and should be researched using the latest evidence . Most
protocols are binding on employees as they usually relate to the management of consumers
with urgent, possibly life threatening conditions.

Emergency department Protocols:

When questions are asked about delays
 Listen and respond with empathy and concern.
 Acknowledge and apologize for the delay.
 Briefly explain the reason for the delay, communicate a realistic and liberal time frame
and do not blame other departments or colleagues for the delay.
 Confirm the patient understands of his or her plan of care.

When questions are asked about Treatment

 Listen and respond with empathy and concern.
 Clarify the questions. Answer and the question confirm the patient understands of
response.
If you do not know the answer, advise the patient that you will have to check on that
information or request that information or request and then follow up with the patient.
When patients verbalize that they are they are “Leaving Without Being Seen"
 Immediately communicate to the in charge nurse that the patient if going LWBS. Patient
leaves the emergency department.
 The charge nurse should evaluate the situation and intervene with the patient as
appropriate.
 Document the patient.
 Intervention and the results.

When patients verbalize that they are leaving against Medical Advice
 Immediately communicate to the in charge nurse and the physician that the patient is
going to AM.
 The physician should evaluate the situation and intervene with the patient as appropriate.
 Document the patient intervention and the results and complete the appropriate forms.
When patients Use Threats and it Profanity
 If the patient uses Profanity state the following: “In order for me to be able to help you
need to stop using profanity.
 Immediately notify the charge nurse of situation.
 Implement the security management plan as needed.

Identify patients who are at High Risk for Dissatisfaction

It is important to identify patients who may be high –risk for dissatisfaction in order to use
proactive behaviour to keep the patient's dissatisfaction from escalating to the point where the
patient goes LWBS on LAMA. Proactive behaviours on the part of emergency department
staff may also prevent profanity. Keep in mind that the following patients are a high risk for
dissatisfaction
 Patients who have waited over 45 minutes in the lobby.
 Patients who have waited over 30 minutes to see a doctor.
 Patients who have spent over 3 hours in the emergency room

Conclusion:
Continuous monitoring of quality assurance, auditing, records, reports, norms, policies and
protocols in maternity units raised the awareness of the quality of obstetric performance and
improved the quality of care provided, thereby improving MMR.
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