QUALITY AND CLINICAL GOVERNANCE
QUALITY AND CLINICAL GOVERNANCE
There is an increasing incidence of medication errors in our area of practice. This is due to incompetent staff and management. This is unavoidable yet it is important that health care organizations should focus on how to completely eliminate or decrease this incidence. Thus a plan is made up to further educate health care professionals within the organization regarding the correct administration of specific medications. Additionally, management has to adopt new techniques that will contribute to the decrease in medication errors. This change has to be completely supported by all health care staff and management in the health care organization so that there will be effective change that will take place.
The healthcare professions all involve life and death situations. In these situations, quality is crucial and quantity is irrelevant. In my place of employment, there are increasing medication errors happening in my hospital which may due to many possible causes. But as we know that patient safety and quality care is very important. The blame is placed on aspects of manpower (labor), management, money (finances), and materials. It is time to seriously rethink, redesign, redevelop and reinvigorate the way governance is practiced in my current place of employment. There is a need for better quality and care governance.
Clinical governance provides a framework for a coherent, local program of quality improvement and an opportunity to share best practice. For healthcare professionals, clinical governance will be about building upon and linking together many of the activities that they are already involved in, which help to promote and improve standards of patient care (2002).
Medication errors that occur in many healthcare organizations mirror the increasing problem worldwide of deterioration of health care. The deterioration of healthcare work and its environment is a major problem of concern to the healthcare leaders or managers. A healthy work environment is necessary to bring about quality healthcare service to the population. An unhealthy work environment would create a devastating impact not only to the healthcare professionals and the clients but most importantly on the effectiveness of the entire healthcare system.
The possible root causes for this apparent deterioration of healthcare work are outlined in the succeeding sentences. (1) Healthcare professionals are placed in leadership positions even if they are not adequately prepared and without adequate support for their roles. (2) Healthcare professionals, especially in the case of nurses are assigned to handle many clients than they can handle. (3) Decision-making within the work environment is done only by one department, without consultation of all the other parties that are involved.
Many medical-surgical nurses experience difficulty when calculating drug dosages. One study revealed that 56% of nurses could not calculate medication dosages to a 90% proficiency rate. In addition, nurses made significantly more errors in calculating intravenous drug dosages as compared to oral, intramuscular, or subcutaneous drug dosages (2004).
The nurse should double-check the six rights of safe medication administration and know the desired action and side effects ( 2004). If the medication has an antidote, it must be available during administration. When administering potent medications, the nurse must assess vital signs before, during, and after infusion.
The resulting environment created by these situations brings about many negative results in the working environment. When inadequate leaders are placed in positions, there will be dissatisfaction and high turnover for healthcare leaders and the staff as well. For example, when each nurse is assigned to handle many clients, this would result in confusion and the clients are placed at risk for errors and injury. The nurses are also frustrated, angry and stressed out. Decisions that are made without consulting all the parties involved places everyone involved – doctors, clients, nurses, managers and other staff - at risk. The overall quality of care offered by the healthcare service would be diminished.
Good clinical facilities
Lack of education and qualifications of some staff
Health authority support
Shortage of qualified staff
The SWOT analysis table shows that although the hospital is equipped with the most advanced materials and funded with more than enough financial resources, there is still an increase in medical errors resulting to unsafe practice. Hong Kong’s healthcare profession is challenged by the shortage of healthcare professionals. This presents a threat to many areas of health care practice. Not only that, this is a threat to patient care.
It seems that there is also an apparent poor quality of management and leadership in this case resulting to the poor quality of service. Management is necessary to make labor and capital productive and requires converting economic principles into rules of behavior that can be clearly communicated to employees, bosses, clients, and other partners. Management in health care is not simple. In management it is people, not things that have to be managed, and because decisions must be made under uncertainty, based on expectations, without ever really knowing the entire facts one would like to have, it makes it all the more complicated.
Applying the four key components of clinical governance to the problem is helpful. The activities involved in clinical effectiveness will include finding out what is the best known practice a specific medication administration, appraising the available evidence, changing the practice by educating the health care staff, and confirming through monitoring or clinical audit that actual practice is consistent with best practice.
The human resources component of the clinical governance framework would aim to ensure that the health care staff has the right education, adequate training and development, skills and competencies to provide quality care to patients which include the proper medication administration. The expected outcome of the recommendations should be a decrease in the incidence of medication errors.
Coming up with recommendations and implementing them at the place of employment is the most logical thing to do. An improvement for the increase in medication errors is expected as health authorities and the staff supports the programs that are designed for improvement of health care services and quality of patient care. Improvements are geared towards the management and individual health care staff.
To improve quality, organizations have to apply 'Total Quality Management' (TQM) to their organizations to help them plan their efforts. The promise of superior performance through continuous quality improvement has attracted a wide spectrum of business to TQM, with applications reported in many domains including healthcare ( 2002).
Total Quality Management or TQM is defined as an integrative management philosophy aimed at continuously improving the performance of products, processes and services to achieve and surpass customer or patients expectations (Tsang and Antony, 2001). Actually, it was a management approach originally developed for improving manufacturing. However, it has recently shown its significance in service industries like healthcare services for improving the quality of service and satisfaction which has resulted in increased competitive advantage (2001). One of the service industries for example that have already joined the TQM bandwagon is the clinical healthcare sector. The surveyed clinical healthcare sector already applied the principles of TQM in their operations. They have shifted from efficiency to quality in order to attain the needs of their patients. But the implementation of TQM is not as “easy as one two three”.
There are some advantages that clinical healthcare services sector guided by the principles of TQM. Basically, the Total Quality Management philosophy of management within clinical healthcare services sector is customer-oriented. All members of a total quality management (control) organization strive to systematically manage the improvement of the organization through the ongoing participation of all staff in problem solving efforts across functional and hierarchical boundaries. TQM incorporates the concepts of product quality, process control, quality assurance, and quality improvement. Consequently, it is the control of all transformation processes of an organization to better satisfy customer needs in the most economical way. Total quality management is based on internal or self-control, which is embedded in each unit of the work system (technology and people). Pushing problem solving and decision-making down in the organization allows people who do the work to both measure and take corrective action in order to deliver a service that meets the needs of their patients.
Healthcare providers are able to make the most of their participation in the quality movement because of the learning provided by the various patients training sessions, especially when these are relevant and highly accessible. As this survey revealed, most surveyed healthcare industries were doing a relatively good job in making sure that their healthcare staff were all keeping on improving their skills and knowledge through relevant and accessible training activities. However, the time needed to attend to these trainings seemed to be a problem for most healthcare workers. The feasibility and sustainability of these quality management movements were also sometimes being doubted by the healthcare workers. With these things under consideration, the government must be able to find ways to make these quality management movements even more advantageous and beneficial so workers and staff can do their jobs effectively.
The leadership training program in the health institution should be an innovative, team-based approach to learning which supports the institution’s mission of providing responsive and cost-effective services by developing a highly skilled work force. Additionally, the program should to support the organizational values. Its dual focus on process improvement and team development enables health staff to learn in an outcome-driven environment, where they can directly apply learned skills to improve a specific process. Moreover, leadership training interventions help cross-functional work teams analyze existing processes, identify possible improvements, implement changes, and evaluate results.
Sometimes, situations call for a time to shift the responsibility for leadership away from management and toward the employees. One way to do this is to allow each of the employees to run a weekly staff meeting--its structure, delineation of responsibilities to others and follow-up. Placing future leaders into management development roles is probably the most important benefit that management has to offer the people (2002). In addition, management should keep an eye out for other ways to give the employees more responsibility to test their leadership skills. Respect and recognition are two proven ways to retain employees.
The dramatic increase in the number of new medications, including biotechnology products, makes it difficult to keep current on their proper use, and can overwhelm the best intentions of all health care practitioners, including nurses. Administration of the wrong drug is the most common error that occurs. Factors that contribute to wrong drug error include similar labeling and packaging of products, medications with very similar names and storage of these similar products together. In addition, poor communication is a common cause of administering the wrong drug.
To administer medication safely to patients, certain cognitive skills are essential. The nurse accepts full responsibility and accountability for all actions that are taken; this includes the administration of medications, whether it is intravenous, oral, or something else. When a nurse administers an intravenous medication to a patient, the nurse accepts the responsibility that the medication or the nursing actions in administering it will not harm the patient in any way. The nurse does not assume that the medication that is ordered for the patient is the correct medication or the correct dose.
The nurse or any health care professional could be held accountable for administering an ordered intravenous medication that is knowingly inappropriate for the patient. Because of this, the nurse should be familiar with the therapeutic effect, usual dosage, laboratory interferences, and side effects of all medications that are administered (2004). Demonstrating accountability and acting responsibly in professional practice means that the nurse acknowledges when errors in professional practice occur. Most of the errors that are made by nurses are medication errors (2004), and this includes intravenous medication administration.
Once all the health care staff are thoroughly educated and properly equipped with the knowledge of the recommended practice regarding medication administration, their performance has to be monitored every now and then. They will be assessed on how they administer medications and evaluated if there is a change on how they perform it. It is not enough that after the initial educating sessions they will then be left to do the procedure. Monitoring has to be done in order to ensure that there is a demonstration of safe and proper practice of care.
The period of monitoring would be the longer period in my recommended strategy. This would include assessing how each health care professional performs medication administration and also observations on the incidence of patients’ reactions to administration. To effectively carry out all of these, strategic planning has to be developed. Strategic planning is crucial in the management of healthcare organizations, even when the characteristics of the healthcare systems vary (2003).
The health care professional is the essential link in the prevention of medication errors. Unfortunately, many medication errors are never identified. When an error occurs, it should be acknowledged immediately and reported to the appropriate hospital personnel. This is necessary since measures to counteract the effects of the error may be necessary.
There is no right way of effective change. According to (1996), there is “No Best way to manage change”. An organizational change comes in different shapes, sizes and forms. Thus it is difficult to establish an accurate picture of a successful change management (1996). However, According to(2002) there are three main components for organizational change that collectively lead to improve organizations performance: (1) creating a shared mindset; (2) building competencies and capabilities; and (3) changing organizational culture.
Moreover, change must be effectively managed to enable the competitive position of the organization to be refocused. At this instance, change becomes a fundamental need not an option (2002). Nevertheless, organizational change requires a clear vision of the clinical healthcare sector’s new strategy and the shared values needed to make it work by managing it from the top down. Leadership by example is combined with organizational adaptations and changes e.g. systems, structure etc.
Changes in medical care and management needed to be a representation of all affected by the healthcare. This would mean that an experts approach might not be as successful as a case conference approach which would involve physicians, mental health professionals (clinical and organizational psychologists, specialty and organizational psychiatrists), social workers, church leaders, family members, and family support system members. Although the process might seem unwieldy, the reality was that differing ways of knowing and differing world views would expand the options and capacities needed to craft strategies that fostered harmony, bonding, trusting, and honoring of the client and the healthcare system (2002).
Medication errors can be a source of significant morbidity and mortality in the health care setting. Thus in our health care setting, this problem is not being taken lightly. Providing care to a patient is a complex health care technology and patients are at risk of experiencing adverse events such as medication errors. Increasingly, human error theory is used to investigate adverse events such as these. In our health care area, medication errors could be largely attributed to lack of knowledge, skills, and education of the health care staff; and an incompetent management. A plan is therefore proposed to rectify this problem. It is important that medication errors be monitored so that similar incidents can be prevented in the future. Problems associated with devices that lead to medication errors should also be reported to health care authorities.
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