QUALI TY MANAGEMENT AT A HOSPI TAL’S NURSI NG SERVI CE
Ely r ose Sousa Br it o Rocha1
Mar ia Au x iliador a Tr ev izan2
Rocha ESB, Tr ev izan MA. Qualit y m anagem ent at a hospit al’s nur sing ser v ice. Rev Lat ino- am Enfer m agem 2009 m arço- abril; 17( 2) : 240- 5.
The st udy aim ed t o know t he opinion of nurses in relat ion t o t he Qualit y Managem ent im plem ent ed in a hospit al
ser v ice. Th is is an ex plor at or y an d descr ipt iv e st u dy car r ied ou t w it h a sam ple of 1 7 in div idu als. Th e m ain r esult s, am ong t he 14 pr inciples of qualit y , r ev eal t hat t he sev ent h pr inciple “ adopt and inst it ut e leader ship”
received t he highest score. On t he ot her hand, t he lowest scored principle was t he t hird: “ cease t he dependency
of m ass inspect ion” . The obt ained r esult s, coupled w it h t heor et ical know ledge on t he subj ect and pr ofessional
experience on t he m anagem ent of nursing services, lead us t o t he conclusion t hat nurses consider Tot al Qualit y a pract ical philosophy t o be im plem ent ed in t he services under t heir responsibilit y and accept t he challenge of
ov er com ing bar r ier s r elat ed t o t r adit ion, going fr om discour se t o pr act ice.
DESCRI PTORS: qualit y of healt h car e; nur sing ser v ices; t ot al qualit y ; qualit y m anagem ent
ADMI NI STRACI ÓN DE LA CALI DAD EN UN SERVI CI O DE ENFERMERÍ A EN UN HOSPI TAL
El obj et ivo de est e t rabaj o fue conocer la opinión del enferm ero en lo que se refiere a la Adm inist ración de la
Calidad im plant ada en un ser v icio hospit alar io. Se t r at a de un est udio de car áct er ex plor at or io y descr ipt iv o,
cu y a m u est r a se con st it u y ó de 1 7 su j et os y , com o pr in cipales r esu lt ados, se pu ede cit ar qu e, en t r e los 1 4 Pr in cipios de la Calidad, el qu e r ecibió m ás pu n t u ación de los en f er m er os f u e el sépt im o, qu e se r ef ier e a
“ adopt ar e inst it uir el lider azgo” . Por ot r o lado, el pr incipio m enos punt uado fue el t er cer o: “ t er m inar con la
depen den cia de la in spección en m asa” . Los r esu lt ados obt en idos, aliados al con ocim ien t o t eór ico sobr e el t em a y a la vivencia profesional en adm inist ración de servicios de enferm ería, lleva a sugerir que los enferm eros
consideran la filosofía de la Calidad Tot al com o siendo viable en los servicios baj o su responsabilidad y acept an
el desafío de r om per las bar r er as de la t r adición, pasando del discur so a la pr áct ica.
DESCRI PTORES: calidad de la at ención de salud; ser v icios de enfer m er ía; calidad t ot al; gest ión de calidad
GERENCI AMENTO DA QUALI DADE EM UM SERVI ÇO DE ENFERMAGEM HOSPI TALAR
O obj et iv o dest e t r abalh o f oi con h ecer a opin ião do en f er m eir o a r espeit o do Ger en ciam en t o da Qu alidade
im plant ado em um ser v iço hospit alar . Tr at a- se de est udo de car át er ex plor at ór io e descr it iv o, cuj a am ost r a const it uiu- se de 17 suj eit os e, com o principais result ados, pode–se cit ar que, dent re os 14 Princípios da Qualidade,
o m ais bem pont uado pelos enfer m eir os foi o sét im o, que diz r espeit o a “ adot ar e inst it uir a lider ança” . Por
ou t r o lad o, o p r in cíp io m en os p on t u ad o f oi o t er ceir o: “ cesse a d ep en d ên cia d a in sp eção em m assa” . Os r esu lt ados obt idos, aliados ao con h ecim en t o t eór ico sobr e o t em a e à v iv ên cia pr ofission al em ger ên cia de
ser v iços de enfer m agem , lev a a suger ir que os enfer m eir os consider am a filosofia da Qualidade Tot al com o
v iáv el aos ser v iços sob su a r esp on sab ilid ad e e aceit am o d esaf io p ar a r om p er as b ar r eir as d a t r ad ição,
passando do discur so à pr át ica.
DESCRI TORES: qualidade da assist ência à saúde; serviços de enferm agem ; qualidade t ot al; gest ão de qualidade
Escola de Enferm agem de Ribeirão Preto, da Universidade de São Paulo, WHO Collaborating Centre for Nursing Research Developm ent, Brazil: 1RN, Mast er’s
St udent , e- m ail: elysrocha@uol.com .br; 2Full Professor, e- m ail: trevizan@eerp.usp.br.
I NTRODUCTI ON
C
urrently, organizations in several sectors are increasingly concerned with the quality of their services or goods. I n this context, the health sector is certainly gr ow ing because of it s incr easing influence on t he econom y of sev er al count r ies and also because it s client ele has incr easingly dem anded qualit y in t he satisfaction of its health needs.The world has finally understood that, reined by t he law of supply and dem and, t hose who buy or use goods and services are the ones who really m atter. Organizations or institutions from the m ost varied health areas have begun to provide goods/ services that clients dem and and not what they want to supply, increasing com pet it iveness am ong t hem and consequent ly, t he excellence of each.
On e o f t h e p i o n e e r s i n To t a l Qu a l i t y Managem ent ( TQM) st resses t hat qualit y consist s of m eet in g t h e n eeds of clien t s f or a pr ice t h ey can affor d. He adds t h at all people in an or gan izat ion should do what t hey can, however, t hey should also know what to do( 1).
A cur r ent lit er at ur e r ev iew appoint ed som e r esult s achiev ed by Br azilian hospit als and nur sing ser v i ces t h at ad o p t ed TQM. Af t er r ep o r t i n g t h e experience of four hospitals that decided to im plem ent this philosophy, the study showed, am ong other aspects, satisfactory outcom es from the adoption of TQM in these health institutions. Gains in term s of hum an resources were perceived because em phasis on t he percept ion that m istakes are m ore related to the system than to individuals yields t he est ablishm ent of a new cult ural pat t er n of r elat ion sh ip, of r ecor ds an d an aly sis of adverse event s, verificat ion and checking of result s. Pat ient s’ sat isfact ion was anot her gain evidenced by the study, as well as society’s acknowledgm ent through awards, dissem ination in the local m edia and increased financial contributions from business and com m unity in general. Changes in the hospital’s statistical indicators were also highlighted, such as dim inished m ortality rates and average period of perm anence, with a concom itant increase in occupation rates(2).
Qu alit y m an ag em en t in v olv es q u est ion in g traditional values related to the m anagem ent of people and also to the function of clients because, according to this philosophy, knowing and “ enchanting” clients is a gam e ev er y one should get inv olv ed in. Facing t his challenge is necessary because it is about guaranteeing the institution’s survival(3).
I n this perspective, user satisfaction has been used as an instrum ent to evaluate the quality of health services as well as hospital accreditation(4-5).
To m anage a health service with a view to the qu alit y of h ealt h act ion s, it is n ecessar y t o adopt changes, transferring the focus of action from the disease to the production of health focused on the individual. Therefore, care cannot be fragm ent ed, individualized and hegem onic( 4).
Perhaps one of the aspects that m ight explain this fact is that custom ers are slowly getting interested in knowing healt h care and healt h prom ot ion. People are getting increasingly aware of their rights and duties and, in general, are starting to strongly considerer that h ealt h an d qu alit y h ealt h car e ar e basic r igh t s of everyone and not a privilege of few(6).
I n this perspective, the client is the one who really rules and people who deliver services to clients are t hose who hold t he great est power because t he r em ai n d er o f t h e o r g an i zat i o n seek s t o p r o v i d e resources and infrastructure to those in the front line so that clients get what they want(7).
I n a study on the nursing care delivered by the Pediatric unit at the William Beaum ont Hospital, Michigan, USA, groups of fam ilies with hospitalized children were inv est igat ed. One gr oup r eceiv ed special t r eat m ent com pared to the control group with regard to the nursing professionals’ attitudes when help was asked, am ount of attention given to patients’ personal needs and the degree to which nurses kept them inform ed about tests, t reat m ent s and equipm ent s( 8). The aut hors concluded that, am ong other aspects, sim ply offering “sym pathetic and understandable listening” as well as answering to patients’ and fam ilies’ questions had a salutary effect on their general satisfaction in relation to the nursing care delivered( 8).
Services that prim e for quality are constantly in direct contact with their custom ers, seeking to know, understand, define and value them(9). Nurses are leaders in the care delivered to clients and it is their m ain source o f co n t i n u ed co n t act , w h i ch i n cl u d es o r i en t at i o n regarding st andards and right s, as well as providing com plete, precise and truthful inform ation regarding the procedures perform ed by the nursing team and other professionals( 10).
On t h e o t h er h an d , t h er e ar e i n cr easi n g expect at ions in current healt h inst it ut ions for nurses to get involved with m anagem ent of their sector. Thus, in addit ion t o t heir role of being in const ant cont act wit h client s, t hese professionals also engage in care d e l i v e r y m a n a g e m e n t i n Br a zi l i a n h e a l t h ca r e inst it ut ions.
Ther efor e, a quest ion consider ed im por t ant is: What is t he nurses’ opinion regarding t he Qualit y Managem ent im plem ented in the nursing service they pr act ice in , based on t h e 1 4 Pr in ciples of Qu alit y proposed by Dem ing( 1)?
I t is im portant to highlight that, even though t he healt hcare indust ry has undergone changes t hat l e d t o i m p o r t a n t sci e n t i f i c a n d t e ch n o l o g i ca l ad v an cem en t s, it st ill ex p er ien ces sit u at ion s lik e inhum ane and delayed care, long queues, high rat es of hospital infection, ineffective cost m anagem ent, low level of t raining and lack of cont inued educat ion for people who deliver health care, inadequate personnel dim ension, am ong ot hers.
Th i s si t u a t i o n cl a i m s f o r a d e q u a t e m a n a g e m e n t m o d e l s t h a t o p t i m i ze r e so u r ce s, im pr ov ing pr oduct iv it y and sat isfact ion of bot h t he care recipient s and healt h service providers.
Despite the fact that not m any hospitals have opt ed for qualit y m anagem ent in Brazil, t he num ber of in st it u t ion s t h at m ak e t h is opt ion is in cr easin g b e ca u se m a n a g e r s p e r ce i v e t h a t cl i e n t s a r e increasingly dem anding quality care with lower costs, t hat em ployees need t o be valued and t hey have t o follow t he changes observed in recent years( 11).
For som e experts on the subj ect, the Principles o f Qu a l i t y p r o p o se d b y D e m i n g h a v e n o t b e e n efficient ly adapt ed t o healt h services. Alt hough t hey have been largely acknowledged in the service sector, indust ry and ot hers, t he healt h sect or has not been f u l l y ca p a b l e o f d e a l i n g w i t h p r o b l e m s l i k e l o w perform ance and qualit y in healt hcare in t he light of t hese principles.
Therefore, im plem ent ing Dem ing’s approach t o h ealt h car e ser v ices is on ly at t ain ab le if som e serious considerat ions are t aken int o account : t eam ev a l u a t i o n sh o u l d r ep l a ce i n d i v i d u a l ev a l u a t i o n , m easures of perform ance should be focused on quality an d t r ain in g p eop le sh ou ld p r eced e n u m b er s an d quotas. Additionally, the use of statistical data should base decision- m ak ing inst ead of per sonal opinions. All t hose inv olv ed in t he pr ocess should k now w ell the work system they are part of, including their own
and ot hers’ responsibilit ies. Mut ual coordinat ion and co o p e r a t i o n , i n st e a d o f co m p e t i t i o n , sh o u l d b e en co u r a g ed . Th e a u t h o r s b el i ev e t h a t D em i n g ’ s p r in cip les w ill r em ain a ch allen g e f or t h e cu r r en t m anagers of this sector until these tools of quality are specifically developed for t he m anagem ent of healt h services( 12).
An im por t an t st u dy pr esen t ed a h ist or ical over view on t he ear ly assessm ent of t he qualit y of h ea l t h ser v i ces i n Br a zi l w i t h t h e Ho sp i t a l Standardization Program , established by the Am erican College of Surgeons in m id-1924, until the creation of a Brazilian Accreditation Organization. This organization aim s t o im plem ent an ongoing process for im proving health care and encouraging services to achieve higher levels of quality. According to this study, data on the Evaluation Criteria for Nursing Services, which are used in processes of inst it ut ional accredit at ion, reveal t hat 36 out of 195 evaluat ed Brazilian healt h inst it ut ions w er e accr edit ed bet w een Oct ober 1999 and Mar ch 2002, from a total of 6,528 health institutions. Of the 36 accredited institutions, only 27 were able to m aintain t h e l e v e l o f co m p l i a n ce a n d , co n se q u e n t l y, t h e Cert ificat e of Accredit ed Hospit al( 13).
I t is necessary, however, to highlight that the assessm ent crit eria for nursing services ident ified in this study m ainly focus on structure and organizational processes instead of institutional results. The need was verified to change traditional m echanism s of evaluation focused on physical structure, billing service production an d h o t el ser v i ces, w i t h a v i ew t o v al u i n g car e outcom es originated in program s based on criteria that i n cl u d e e p i d e m i o l o g i ca l a n d q u a l i t y st a n d a r d s, co m p e t e n ce a n d p e r f o r m a n ce w i t h e x ce l l e n ce , elabor at ion of m or e qualit at iv ely and quant it at iv ely equit able st andards in t erm s of st ruct ure, processes and results( 13).
Based on t h e abov e, w e ack n ow ledge t h e im portance of this subject to im prove nursing services, which originally m ot ivat ed t his st udy. The t heoret ical r ef er en ce f r am ew or k w as b ased on Tot al Qu alit y Managem ent, m ore specifically on the 14 Principles of Quality(1).
OBJECTI VE
To know nurses’ opinion regarding the Quality Managem ent im plem ented in a hospital service in the light of the 14 Principles of Quality(1).
METHOD
This is an explorat ory and descript ive st udy, whose aim was t o know relevant aspect s relat ed t o nur ses’ opinion r egar ding t he Qualit y Managem ent im plem ented in the hospital service they worked in.
Exper t s use t his kind of r esear ch t o obt ain precise inform ation on the characteristics of individuals, groups, inst it ut ions or sit uat ions, or t he frequency a phenom enon occurs. The variables of int erest can be classified as opinions, attitudes or facts and data can be collected through questionnaires or interviews(17).
This st udy was carried out in a hospit al t hat has im plem ented Total Quality Managem ent in its nursing service, located in the interior of São Paulo, Brazil.
Th e r esear ch p r o j ect w as su b m i t t ed an d approved by the research institution and the Research Et hics Com m it t ee at t he Univer sit y of São Paulo at Ribeirão Pret o College of Nursing ( Prot ocol No 0734/ 2006) .
The study participants were nurses who agreed t o par t icipat e in t he st udy and had w or k ed in t he inst it ut ion for at least six m ont hs. The quest ionnaire used in this study was adapted from an instrum ent based on t h e 1 4 Pr in ciples of Qu alit y( 1 ), elab or at ed an d v alidat ed for nur sing ser v ice( 11 ). I t w as cr eat ed t o discover and know the opinion of nurses regarding the Quality Managem ent im plem ented in the hospital service they work for in the light of the 14 Principles of Quality proposed by Dem ing(1). I t is com posed of 14 item s that correspond to Dem ing’s(1) 14 principles and also presents it s definit ion, w hich Ant unes( 11) adapt ed t o nur sing ser vices.
Data collection was carried out at the hospital after nurses were inform ed about the study objectives and signed the free and inform ed consent. The study participants were personally asked to answer the first part of the instrum ent, which referred to the tim e they had worked at the hospital and the sector they practiced in. Then, they were asked to score, from one to four, each of the Principles of Quality based on the nursing service they worked for.
To proceed with data analysis, scores attributed by nurses were defined as follows:
1 – the principle never corresponds to the reality of our nursing service;
2 – the principle hardly corresponds to the reality of our nursing service;
3 – the principle frequently corresponds to the reality of our nursing service;
4 – the principle always corresponds to the reality of our nursing service.
Then, t he percent age of scores at t ribut ed t o each principle and average of these scores by principle was obt ained. Based on t hese result s and on t he 14 principles of Dem ing(1), we sought to know the opinions of nur ses w it h r espect t o t he Qualit y Managem ent im plem ented in the service they work for. We also aim ed to com pare data from this study to those from previous r esear ch.
RESULTS AND DI SCUSSI ON
The research inst it ut ion is a privat e hospit al l o ca t ed i n t h e i n t er i o r o f Sã o Pa u l o , SP, Br a zi l , inaugurat ed in 1969. The Tot al Qualit y Program was officially im plem ented in 1998 and, since then, it has developed its activities with well-defined objectives and guidelines ( verbal inform at ion)*.
One of the first item s in the instrum ent refers t o t he nurse’s t im e of work in t he inst it ut ion, which perm itt ed charact erizing the st udy sam ple. Of t he 27 nurses working at the hospital, eight were trainees and one was on vacat ion, rem aining 18 professionals. Of these, one did not m eet the inclusion criteria (at least six m ont hs of work at t he inst it ut ion) , which defined t he st udy sam ple: 17 int erviewed nurses.
Of t hese 17 individuals, 35% has worked at the hospital between six m onths and two years; another 35% between three and six years, 18% between seven
and t en y ear s and 12% bet w een 11 and 13 y ear s. Tim e on the j ob ranged from 11 m onths to 13 years. To achiev e qualit y goals, 14 pr inciples ar e p r o p o se d . Th e se ca n b e i m p l e m e n t e d i n a n y organizat ion, sm all or large, or yet in a single sect or of an or ganizat ion( 1). These pr inciples hav e alr eady been adapted to nursing services( 11) and are used here t o base t his research.
The nurses int erviewed were asked t o score, from one to four, the 14 Principles of Quality(1) adapt ed t o nursing( 11), wit h regard t o t he pract ice exist ent at t he hospit al t hey worked for.
Table 1 present s t he scores t he 17 ( 100% ) int er v iew ed nur ses at t r ibut ed t o t he 14 pr inciples, accor ding t o pr e- est ablished scor es, as w ell as t he average of t hese scores.
Table 1 – Num ber and average of scores at t ribut ed by nurses to the 14 Principles of Quality( 1)
s e l p i c n i r P f o r e b m u N g n i t u b i r t t a s t n a p i c i t r a p s e r o c
s Average
1 2 3 4
e s o p r u p f o y c n a t s n o C .
1 0 0 6 11 3.6
y h p o s o li h p w e n e h t t p o d A .
2 0 2 9 6 3.2
s s a m n o e c n e d n e p e d e s a e C . 3 n o it c e p s n
i 1 7 6 3 2.6
n o d e s a b s s e n i s u b d r a w a t o n o D . 4 e n o l a g a t e c i r
p 0 2 9 6 3.4
f o m e t s y s e h t y lt n a t s n o c e v o r p m I . 5 e c i v r e s d n a n o it c u d o r
p 0 0 8 9 3.5
g n i n i a r t e t u t it s n I .
6 0 2 3 12 3.6
p i h s r e d a e l e t u t it s n i d n a t p o d A .
7 0 0 3 14 3.8
r a e f t u o e v i r D .
8 0 0 7 10 3.6
s a e r a f f a t s g n o m a s r e i r r a b k a e r B .
9 0 0 11 6 3.4
s n o it a t r o h x e , s n a g o l s e t a n i m il E . 0 1 s t e g r a t d n
a 0 0 9 8 3.5
s a t o u q l a c i r e m u n e t a n i m il E . 1
1 0 4 8 5 3.1
e d e p m i t a h t s r e i r r a b e v o m e R . 2 1 r i e h t n i e d i r p e k a t o t e l p o e p p i h s n a m k r o w
0 0 7 10 3.6
n o it a c u d e f o m a r g o r p a e t u t it s n I . 3 1 t n e m e v o r p m i -fl e s d n
a 0 1 7 9 3.5
e h t h s il p m o c c a o t n o it c a e k a T . 4 1 n o it a m r o f s n a r
t 0 0 8 9 3.5
The principle m ost scored by the participants in t his st udy is t he sevent h. I t refers t o adopt an d institute leadership and 14 participants (82% ) attributed the highest score (four). The average score for principle seven was 3.8.
The leader of qualit y should encour age t he participation of everyone in the decision-m aking process, facilitate and participate with the staff in the process, help the group to define and achieve objectives, show
the im portance of each m em ber in the team because everyone can contribute, distribute tasks according to responsibilities and share the m erit of achievem ents(14). The philosophy of qualit y cert ainly requires a leader aware of what has to be done, com m itted to the service and sufficient ly m ot ivat ed t o inspire all t hose under lead er sh ip w it h a com m on sp ir it of coop er at ion , t eam work and cont inuous search for qualit y.
I n a st u d y w h o se a i m w a s t o e v a l u a t e D e m i n g ’ s m a n a g e m e n t m o d e l , t h e o m n i p r e se n t im port ance of leadership t o assure t he success of a qualit y im provem ent program is appoint ed as one of the m ain findings(18).
According to som e experts, Dem ing appointed an interesting scenario when he had to be hospitalized aft er an accident . He observed t hat nurses did t heir best and were polite, but were discouraged and puzzled between their real functions and functions the system required from t hem . I n addit ion, t here w ere delays and som e m inist ered t reat m ent s different from what had been prescribed. Dem ing acknowledged t hat t he healt hcar e sy st em w as deficient but did not blam e w or k er s f or t h at . For h im , am on g ot h er asp ect s, excellent leadership was in need( 12).
Another study, also based on the 14 Principles of Quality, carried out in a hospital located in the interior of São Paulo, SP, Brazil, shows that nurses attributed the lowest score to the seventh principle, which indicates that there are m any things to change in this institution so that the program is adequately im plem ented( 11).
The lowest score attributed in our study is the third one: cease dependence on m ass inspect ion. Only three participants (18% ) attributed the m axim um score (four) and it was also the only principle that received only one ( 6% ) at t ribut ion t o t he lowest score ( one) . The average score attributed to the third principle was 2.6.
Mass inspection is not reliable. I n addition, it is costly and inefficient because, when it is carried out, t he service or good has already been delivered( 1).
Another research, also carried out in a hospital service, reveals that this principle, as opposed to the reality in which data collection was perform ed, is often applied in nursing services( 11).
I t is im portant to stress that there will always be aspect s unique t o each service, which should be i m p r o v ed d u r i n g To t al Qu al i t y Man ag em en t i m p l em en t at i o n , m ai n t en an ce an d i m p r o v em en t processes. This is part icularly t rue if one t akes int o account aspect s lik e differ ent cult ur es, clim at e and socioeconom ic conditions existent in the diverse regions of Brazil.
CONCLUSI ONS
Based on t he obt ained result s and lit erat ure review on the topic, we believe that the initially proposed objective was achieved. The m ain results of this study, am ong the 14 Principles of Quality(1), appoint that the seventh principle, adopt and inst it ut e leadership, was the m ost scored by the interviewed nurses. The lowest scored principle was the third one: cease dependence on m ass inspect ion.
We expect to contribute to the im provem ent of nursing services through the availability of an additional
source of lit erat ure, so t hat researchers, nurses and m anagers and ot hers can count on a reference t hat relates theory and practice.
I t is also im portant to stress that experts believe that the im plem entation of Dem ing’s m anagem ent m odel to the service sector, including the healthcare industry, is possible if the nuances that characterize this specific sector are taken into account. They also suggest that researchers include variables from this m odel in their st udies on qualit y of ser v ices, such as: leader ship, co n t i n u o u s i m p r o v em en t , w o r k sat i sf act i o n an d com m itm ent, and clients’ satisfaction, am ong others(12,18). Results from this study and related discussion can also serve as a reference source for t he st udied hospital, as well as for other nursing services that aim to im plem ent the philosophy of Total Quality.
Finally, we suggest that nurses, especially those working with m anagem ent, consider the viability of the Tot al Qualit y Philosophy for bot h privat e and public nursing services, and accept the challenge of breaking wit h barriers of t radit ion, m oving from discourse t o pract ice.
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