Quality Assurance in Mental Health and Psychiatric Nursing

INTRODUCTION:

Quality Assurance system motivates nurses to strive for excellence in

delivering quality care and to be more open and flexible in experimenting
with innovative ways to change outmoded systems

Florence Nightingale introduced the concept of quality in nursing care in

1855 while attending the soldiers in the hospital during the Crimean war .

Quality refers to excellence of a product or a service, including its

attractiveness, lack of defects, reliability, and long-term durability.

Quality assurance provides the mechanisms to effectively monitor patient

care provided by health care professionals using cost-effective resources.

Quality assurance is generally and defined as the process where the

performance of a system or service is assessed and evaluated to ensure
that a high quality, safe service is offered and delivered to those using it,
and that it complies with agreed standards, accreditation and any relevant
legislation and safety requirements. Quality assurance generally takes the
form of a range of activities, from the identification and monitoring of
appropriate standards (international, national, regional and local) including
clinical safety and clinical standards, to the formal and Informal monitoring
and inspection of services, to the lodging of, investigation into and reporting
of complaints and serious incidents to advocacy for those using the service.

The main objective of these activities is to ensure a good quality and safe
Service system for those using them, their families and carers and a level
of assurance for all the communities.

Meaning of Improved quality in mental health care

Preserve the dignity of people with mental disorders

 Provide accepted and relevant clinical and non-clinical care aimed at

reducing the impact of the disorder and improving the quality of life of
people with mental disorders.
  Use interventions which help people with mental disorders to cope by
themselves with their mental health disabilities.
 Make more efficient and effective use of scarce mental health
resources.
 Ensure that quality of care is improved in all areas, including mental
health promotion, prevention, treatment and rehabilitation in primary
health care, outpatient, inpatient and community residential facilities.

Quality comprises of

 Acceptability
 Affordability
 Effectiveness
 Comprehensiveness

Assurance refers to the process that includes

 the identification of values and standards
 Specification of criteria
 Measurement of observable aspect of care

Aim of QA in Psychiatric Nursing

- QA is an important aspect of psychiatric nursing

 Funds are available only after evidence is provided that

predetermined standards of care have been met.
 QA helps nurse monitor their own practices in a systematic way.
 QA ensures the public confidence in health care professionals
 QA is one way in which professional nurses regulate their profession
in order to maintain high level of nursing practice and at the same
time retain the confidence of the public.
How To Improve Quality Of Mental Health Care

The steps in improving quality are cyclical.

Step 1. Align policy for quality improvement

Policy-makers have a key role in the quest for quality. They are in a
position to establish the broad parameters of quality through consultation,
Partnerships, legislation, funding and planning.

Consultation (Functions):Obtaining input from various stakeholders,

sharing information across stakeholder groups and building a common
understanding. The development of such an understanding is an essential
task of policy-makers.

Partnerships (Functions):Partnerships with professional groups, academic

institutions, advocacy groups, Other health and social service sectors.

These partnerships form the backbone of the quality improvement process

and enable long-term sustainability. They build consensus and consistency
in messages related to the need for quality and can also serve to mobilize
resources and other necessary supports. Legislation: Policy-makers should
promote legislation that reflects concern for and emphasis on quality.

Funding: Financial systems for mental health care should be aligned so

that they maximize quality and do not become an obstacle to quality
improvement. Improved efficiency is an essential goal in relation to both
quality improvement and cost containment.

Planning : Quality processes can inform planning by providing a

knowledge base for evidence-based practice. In the course of planning,
several issues pertaining to resource allocation and priority-setting have a
bearing on quality.

Step 2. Design standards

Once policies have been aligned for quality the next essential step is to
develop a set of standards against which services can be measured.
Planners and managers should establish a working group Consult with
relevant stakeholders and draft a standards document.
The standards document should cover all aspects of a mental health
service.

 Criteria for each standard should be specified.

 These criteria should provide a means for rating existing services.
 The rating of services should be supplemented by observations on
the quality of all aspects of mental health care.

Step 3. Establish accreditation procedures

 Accreditation provides the opportunity to assess the quality of care

delivered by a mental health service and to provide the service with
the appropriate legal recognition.
 Accreditation is essential because it makes quality a cornerstone of
the official licensing of mental health services or facilities.
 Service planners should ascertain whether any accreditation
procedures already exist which can be used to assess current
services.
 Outdated procedures should be reformed in keeping with the
evidence for the most clinically effective and humane forms of mental
health care.
 Accreditation procedures should be developed if there are none.
 The standards document developed in step 2 can be used as a
structure to provide criteria and a rating system for assessing
services and conferring the appropriate legal status.

Step 4. Monitor the mental health service by using the quality

mechanisms

 Use standards to assess the service annually.

 Use of accreditation procedures to assess and accredit new service
developments and to review the ongoing functioning of services.
  Routine information-gathering through existing information systems,
particularly by means of performance and outcome indicators.
 Consultation with independent organizations for to assess people
with mental disorders and advocacy groups.
Step 5. Integrate quality improvement into the ongoing
management and delivery of services

 Managing annual service quality reviews; including quality checks in

service planning targets;
 Building quality improvement into clinical practice through evidence-
based practice, clinical practice guidelines, teamwork and continuing
professional development; audit.

Step 6. Consider systematic reform for the improvement of services

 An assessment of the quality of a mental health service may indicate

a need for systematic reform or improvement.
 This step may require concrete planning and coordination by various
sectors.

Step 7. Review the quality mechanisms

A review of quality mechanisms is necessary in order update them in

accordance with evidence on the most effective methods of quality
improvement.

Key components in quality assurance includes

 Standards of care
 Criteria specific to practice
 Protocols for nursing intervention
 Audits or review of care procedure
 Peer review
 Level of practice
 Professional development activities
  Credentials
 Licensure
 Certification

Standards of Care

Standards of care is drawn from available knowledge about human

being, the norms of group who care for patients and values of nurses.

  E.g. Rights of client

 To safeguard client
 To experience a sense of personal acceptance

Formation of Standards of Care

Involves a task forces or other committees and presentation of preliminary

statements of standard to the members of organization for criticism and
revision. Nurses who are most influential in development of standards are
those

 who have achieved a significant level of experience in a particular

functional area
 Higher education
 Recognized by the peers as being outstanding.

Criteria

Criteria are specific, predetermined rules or principles developed by health

care practices for a given setting and against which the health care
practices implemented in that setting are compared. Three types of criteria
are generally used: Structure criteria, Process criteria and Outcome criteria.

Structure criteria
It indicates the aim and purposes of institution or agency or program and
can be designed for the institution, or agency, the client or the nurse.
Statement may be made about the philosophy and objectives of the
institution, the facilities, administrative organization, regulations ,standards
and procedures. E.g. of structure criteria are

 The expectation that staff nurses have completed a course in group

therapy
 The requirement that each client in each unit has an attendant to
provide care.

Process Criteria

Process criteria are used in the evaluation of actions and the sequence of
behavior and events during the provision of client care.E.g documentation
of the therapeutic one to one relationship and progress notes

– Data to indicate whether or not the nursing care plan was developed

Benefits

To identify problems that occur while caring for clients and to take
immediate measures that can change or improve the final outcome of care.
Enables the nursing dept. to evaluate the extent to which care is
completed. The implementation of policy and procedures and the activities.

Outcome criteria

– Developed to evaluate the end result of the care and services provided to
the client E.g. client orientation about time, place, person and his
responsibility for activities of daily living when discharged from hospital.

Limitation of outcome criteria

When the outcome or effect of intervention are reviewed and it is found that
it is not reaching the standards or predetermined criteria then It is difficult to
determine whether

 it is due to faulty nursing process or

 due to uncooperative patient

Protocols

A protocol is an instrument that guides a practitioner in the collection of

data and recommends specific action based on that data.

 Written statement of specific interventions for certain signs and

symptoms
 Guidelines to be used in chronic illness.

In hospital quality assurance programs protocols may be defined as

statement of behaviors identified as discrete steps used by nurses in the
attainment of long and short-term goals

Aim

 To become more aware of the procedure.

 To identify specific stages in client care that have been accomplished
well or poorly.
 To direct nursing intervention.
 To intervene in client care when physicians are not available.
 To serve as specific statements of nursing behavior that can be
incorporated into quality assurance activities.

Development of Protocol 

Developed by multidisciplinary committee composed of professional health

providers who function within that setting. Members are physician often
because they are recognized as health team leader and have the right to
prescribe medication. Such committee also develop protocol after a review
of literature.

Audits : Auditing is the verification that the nursing care given to client is
appropriate and in accordance with the predetermined standards of nursing
care in a particular area. It is a mechanism used to asses and verifies the
quality of client care.

Methods of Nursing Audit are the Concurrent view and the

Retrospective view

Concurrent audit: It is a method of evaluating ongoing activities,

assessment at the time of review of one particular aspect of care.E.g
whether side rails are up on the beds of confused elderly client. Benefits
are:-

 Allows corrective actions to be taken immediately.

 Quickly improves the quality of care.
 Immediate feedback.
 Opportunity to develop greater capabilities in clinical role.

Retrospective audit : It was applied after services have been rendered.
Data one can get from records or interview

Peer review : It is the process by which the quality of nursing care
rendered by a nurse is evaluated by other psychiatric nurses actively
involved in clinical nursing practice.

Aim

 To improve overall client care.

 Allows the contribution of individual nurses to be appraised.
 Promote individual accountability and are often the primary way of
recognizing clinical expertise. It allows degree of consistency
between practice and predetermined standards.
Levels of Practice

Ranking or a degree of performance supported by a particular knowledge

base and development of required skill. The inclusion of the levels of
practice concept in a quality assurance provides a more precise description
of the unit being evaluated and the level of care being rendered: Psychiatric
Registered Nurses, Psychiatric Nurse Practitioners, psychiatric nurse
managers

Professional development : The term professionalism implies

 certain levels of competence in nursing practice and

 educational accomplishments
 that reflect breadth of knowledge, skill, and personal maturity.

Continuing education program: Includes short term planned programs of

courses under the direct direction of staff educators or academicians.
Learning experience are designed to enhance previously acquired
knowledge and skill. Post Basic and Post-graduate education: Includes
program of study under the direction of professional educators in college or
university. Function: To prepare nurse specialist with the additional
knowledge and skill necessary to exercise independent judgment.

Diploma in Psychiatric Nursing (DPN):Is a post basic mental health

psychiatric nursing programs, emphasis is usually placed on

 Assessment
 Awareness of the most frequently encountered emotional problems
and pathological conditions,
 Appropriate nursing intervention
 Modes of evaluation
Post Graduate in Psychiatric Nursing(MS Psychiatric Nursing.): Is a
post graduate mental health psychiatric nursing programs, emphasis is
usually placed on

 Clinical competences in assessment and psycho-pathology of various

conditions, diagnostic criteria, appropriate treatments, nursing
interventions and rehabilitation.
 Modes of promotion of mental health and prevention of mental
disorders.
 Teaching of mental health nursing.
 Research in the areas of Mental health. Credentials

A credentials attests the institution or a person to function in a function in a

particular area of expertise.

To acquire a credential, an institution or individual is identified by a

recognized authority as credentials are inherent in any quality assurance
program and the possession of appropriate credentials constitutes a part of
the audit process.

Four fundamental features are quality, identity, protection and control.

Nursing credentials include Licensure, certification and Accreditation

Licensure : They suggest that institutional licensure will costs and promote
efficiency by:

 Providing opportunity for evaluation of individual on site performance

 Allowing for innovative continuing education programme in hospitals
 Facilitating career mobility
Certification : It is the formal recognition of the specialized knowledge,
skills, and experience demonstrated by the achievement of standards
identified by a nursing specialty to promote optimal health outcomes.

Practice models : Practice models may be defined as various pattern in

delivery of nursing services by which health care is made available to
diverse groups of people in different settings.

Frame work for Quality Assurance

One suggested framework for quality assurance consists of two key

‘pillars’, each with a core set of interrelated functions:

1. Rights and protections

 Protecting the rights of involuntary users of services

 Protecting the rights voluntary users of services and their carers
/supporters
 Independent advocacy for users of services and their
carers/supporters
 A complaints procedure for users of services and their
carers/supporters

2. Quality management

 Setting standards and outcomes

 Independent inspection, monitoring and evaluation
 Pre-qualification and licensing of providers
 Reporting and monitoring of sentinel events

Professional Performance Standards

As the field of nursing grows and changes in defining the role of a nurse,
the central theme will always be that of caring. It can be said that, all other
duties and responsibilities of nurses have centered around, “caring”. With
the emergence of the, “caring”, theorists also came the emergence of
“Standards of Profession Performance”.

The American Nursing Association set forth the following requisites for
standards of professional performance

Standard I : Quality of care

Psychiatric mental health nurse systematically evaluates :

 Quality of care
 Effectiveness of mental health nursing practice.

Standard II: Performance appraisal

Mental health nurse evaluates

 One’s own mental health nursing practice standards

 In relation to national and state statutes and regulations.

Two ways of performance appraisals

1. Administrative performance appraisal: Involves review, management,

regulation of competent psychiatric nursing practice. Involves supervisory
relationship in which a nurse’s work performance is compared with the role
expectations. Helps in identify the competency area and areas of
improvement.

2. Clinical performance appraisal: Guidance provided through a

mentoring relationship and clinical supervision with a more experienced,
skilled and educated nurse.

Standard III: Education

Psychiatric nurse acquires and maintains current knowledge in nursing
practice.
Standards IV : Ethics

The psychiatric nurse’s assessments, actions & recommendation on behalf

of the patient are determined and implemented ethically.

Standard V : Research

The psychiatric nurse contributes to nursing & mental health through the
use of research methods and findings.

Role of psychiatric nurse in QA 

• Acute(Emergency ward)

1. Shorten duration of hospital stays

2. Prevention of re-hospitalization

3. Consideration of human rights

4. Family support

5. Careful nursing care of client

•Sub-acute(General ward)
1. Enhancement of intensive rehabilitation

2. Improvement of patient’s QOL

3. Enhancement of patient and family psycho-education

4. Improvement of adherence

• Recuperation(Convalescent ward)

1. Enhancement of rehabilitation by interdisciplinary team

•The roles of nursing administrators and managers in improving psychiatric care

services

Improvement of patient’s daily life skills and abilities Enhancement of patient mental
education Improvement of adherence and self-care

Conclusion

QA is the process by which the maintenance of excellence in the provision of health

care is ensured. Everyone in need should have access to basic mental health care, the
key principles are that care should be equitable and accessible.
To improve the quality of psychiatric services, the following matters require attention :

Clarifications of psychiatric service goals precise measurement of effects, shortened

hospitalizations. Implementation of patient-centered care includes establishment of trust
relationships with patients based on open communication and effective interdisciplinary
teamwork. In addition, nursing administrators and managers must judge the clinical
competency of nurses and assign them appropriately.

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