The Quality of Nursing Service Management In South African Hospitals

The purpose of this study is to determine explore and describe the quality of nursing service management in South African hospitals. A combined qualitative and quantitative preand post-test research strategy, in accordance with the COHSASA programme, was utilised. The hospitals implement the national standards during the preparatory phase, after having entered into an agreement with COHSASA. They determine their baseline status by means of an assisted self-evaluation. This is fol­ lowed by an external survey phase where the hospital’s compliance with the stand­ ards is evaluated. The nursing service is one of the professional services included in the accreditation programme. Their performance is compared with selected other professional services and their compliance with the core elements is also evalu­ ated. The nursing services in South Africa are compliant with the national stand­ ards. The deficiencies are mainly within the quality improvement programmes that require further development and refinement.


Introduction
Quality refers to excellence within a given service and excellence is described by means of standards and criteria in ac cordance with the expectations of the different role-players -the patient, serv ice providers and funders.These stand ards can be structure, process or outcome-based.Compliance with stand ards can be evaluated by the service p ro vid e rs them selves in an inform al manner, or within a formalised accredi tation system.Accreditation is a proc ess whereby national standards are set and com pliance with them evaluated.Generic national standards are form u lated by the professions and services at large, and implemented by the specific health care institutions or services, fol lowed by an external evaluation by peers (Donahue & O'Leary, 1997:128-132).
There are many factors impacting on the quality of service delivery.Certain facili ties, equipment, structures and systems need to be in place to enable quality health care to be practised and deliv ered.The process of nursing service delivery is influenced by the nursing practitioners themselves and the way in which they practise health care which should be directed by clinical and mana gerial guidelines.There are several di mensions of quality which relate mainly to accessibility, equity, acceptability, ef ficiency, appropriateness/applicability, safety and professional/technical com-63 Curationis June 2000 petency.These factors and dimensions need to be considered when the quality of nursing service management is as sessed and evaluated.This article focuses on the quality of nurs ing service management as one of the professional services, in accordance with the national accreditation programme of the Council for Health Service Accredi tation of Southern Africa (COHSASA).The Council for Health Service accredi tation was initiated in 1993 with the for mulation of national standards by vari ous expert groups, the implementation of these standards in six pilot hospitals who agreed to participate on a voluntary basis.The assistance of an international consultant was utilised during this pe riod.COHSASA was registered as a notfor-gain organisation in October 1995.Towards the end of August 1998, 83 hos pitals (16 public and 67 private) had entered COHSASA's hospital accredita tion programme of which 45 have been awarded accreditation status and an other 30 are due for the external survey during 1999.COHSASA represents a national collaborative effort between the state, private industry, consumers and health professionals.The programme aims to assist participating hospitals to comply with professional organisational standards which define system s and processes that the various professional b o d ie s believe sh o u ld be in p lace (Whittaker, 1998:10-14).
The Nursing Service is one of the pro fessional services that are assessed w ithin the hospital accreditation pro gramm e.It appears as if the nursing services compare very favourably with the other professional services -but the question arises: what is the quality of nursing service management in South African hospitals?The purpose with this research is to evaluate the quality of nursing service management within the COHSASA programme.A total of 45 nursing services have been evaluated (by means of an external survey) within the accreditation programme of which most (N=38) are part of private hospi tals, three from the mine hospitals and the rest (N=4) within public hospitals.

Q uality
Quality refers to the features or charac teristics of excellence (stated in the form of standards and criteria) and the de gree of compliance with pre-determined standards.Quality in this article refers to compliance with nursing service stand ards within the COHSASA accreditation programme.

N ursing service management
A nursing service is one of the profes sional services within a hospital.Nurs ing service management is the compre hensive nursing care service for the hos pitalised patient consisting of the follow ing elements in the accreditation pro gramme: strategic planning, organisa tion, finance, human resource manage ment, policies and procedures, facilities and equipment, nursing care and qual ity improvement.

A ccreditation
Accreditation is a formalised process by which a government or non-government agency grants recognition to health care institutions which meet certain standards that require continuous improvement in structures, procedures and outcomes.It is usually voluntary, tim e-lim ited and based on periodic assessments by the accreditor and may, like certification, be used to achieve other desirable ends such as payment or funding (Donahue & O'Leary, 1997:130).In South Africa, accreditation is a form alised process whereby national standards are set and com pliance with them is evaluated by means of a sequential process compris ing of internal evaluation by the health care service staff themselves during the preparatory phase, followed by an ex ternal evaluation by peers during the survey phase.A computerised calcula tion of results is done, followed by the validation of these results by a Techni cal Committee.On compliance with the standards, the accreditation status is awarded to the health care service by the Accreditation Board of the Council for Health Service Accreditation of South ern Africa (COHSASA).Accreditation certificates are valid for one to three years (Whitakker, 1998).

Research Design
A combined quantitative and qualitative research strategy is followed in accord ance with the formalised accreditation process as developed and implemented by the Council for Health Service Ac c re d ita tio n o f S o u th e rn A fric a (COHSASA), consisting of an internal (pre-test) and external (post-test) evalu ation/quality survey (Whittaker & Muller, 1998).The trustworthiness of the evaluation survey is ensured by applying the prin ciples as described by Lincoln and Guba (1985).The truth value of the results (credibility, applicability, confirm ability and reliability) is increased by the fol lowing measures: * a formalised accreditation system and process; * prolonged engagement by the staff w here the p re p a ra to ry phase takes twelve to eighteen months and the nurs ing staff are continuously involved in the interpretation and implementation of the standards; * the surveyors are professional and credible nursing experts who are famil iar with the standards and spend at least three days in the hospital during a nurs ing service survey; * a combination of evaluation strategies are used by the surveyors to assess compliance with standards; * a structured verification process is fol lowed by the surveyors during the ex ternal survey whereby the non/partially compliant, as well as those standards exceeding compliance, are verified by a second surveyor; * a formalised process of internal and external validation of results is followed: a baseline assessment is conducted by the staff of the hospital, followed by a validation of these results by COHSASA staff, as well as continuous validation by the facilitator during the implementation (preparatory phase) of the standards; * the external survey results are vali dated by the hospital staff with the op portunity of challenging any results and motivations which could result in a fo cus survey by the same or other survey ors; * the external results are discussed and validated by the Technical Committee of COHSASA; * the final results are discussed and validated by the Board of Directors of COHSASA; * the standards are continuously up dated to make provision for content va lidity of standards (the sixth revision process is almost finalised); * a comprehensive computerised sys tem is used for the calculation of results to exclude human error in this regard; * international collaboration with the In ternational Society of Quality in Health Care during the annual international con ferences w here the a ccre d ita tio n of health services is one of the interest groups and the principles, processes/ methods and problem s related to ac creditation are discussed.The accreditation process follows a se quential and form alised process of a health service entering into a contractual agreement with COHSASA on a volun tary basis, a preparatory phase with a baseline self-evaluation, followed by the external survey phase.In the case of n on-conform ance with certain stand ards, a focus survey is conducted once the necessary rem edial actions have been taken by the hospital management to verify compliance with the standards (Whittaker & Muller, 1998).

Preparatory phase
After having entered into the form al 64 Curationis June 2000 agreement with COHSASA, a baseline survey is performed by the staff and vali dated by the COHSASA facilitator.The standards are then im p lem en te d in preparation for the external survey.A formalised process of facilitation is fol lowed whereby the hospital is assisted with the implem entation of the stand ards.The preparatory phase takes ap proximately twelve to eighteen months, depending on different factors impact ing on the process and the capacity of the health care service to implement the standards.Approxim ately six weeks prior to the external survey, another in ternal evaluation is conducted by the hospital staff to determine the progress.The results of both the baseline and pre external surveys are calculated and for warded to the team of external survey ors.

External survey phase
Peer group evaluation is done by a team of external surveyors, based on the na tional standards and guidelines provided in terms of the accreditation programme.The surveyors not only provide an ob jective, external opinion regarding com pliance with standards, but because of their experience they are also in a posi tion to compare a specific health care facility with the larger group of health care organisations w ho use a set of standards, thereby providing the facility with information about how it compares within its peer group.The surveyors may also provide advice to the health care organisation when poor compliance has been achieved, which adds an educa tional and capacity building dimension to the accreditation process.The sur veyors are trained in the principles of peer group evaluation and must com plete at least two surveyor training ses sions w h ich in c lu d e the b e g in n e rs course as well as the advanced training programme where moc surveys are con ducted.The surveyors also need to comply with the principles of credibility as experts in the particular fields being surveyed by them.
On completion of the external survey, a report is subm itted by the surveying team to COHSASA, who finalises the re port and calculation of results.A trans parent process of validation if followed whereby the health service management gets the opportunity to comment or re act to the report.The surveyors have to justify in writing any non/partial com pli ance, as well as those standards and criteria exceeding compliance.When there are d iscrepancies between the views of the surveyors and staff of the health care service on any ratings allo cated or motivations given, this is veri fied by the COHSASA facilitators and sur veyors.The report is then submitted to a T echnical C om m ittee w ho re c o m mends the status of accreditation to the COHSASA Board.When there are seri ous limitations impacting on the quality of health service delivery, that particular hospital or health service gets six months to address the problems after which a focus survey is conducted.On com pli ance with the standards the accredita tion status is awarded, which can range between one to three years.

Quantitative and qualitative analysis
The standards and criteria are set in the form of a standards manual/evaluation instrument.Compliance with the stand ards are evaluated and a rating is allo cated by the surveyor.This rating can be one of four: non-compliance, partial compliance, compliant and exceed com pliance.A further qualitative evaluation is conducted by the surveyor in the case of non/partial-com pliance with stand ards.The degree of seriousness is de termined, which could be very serious, serious, moderate or mild.The impact of the non/partial compliancy is also de termined by the surveyor which could be related to patient care, legality, staff and patient safety or efficiency.The surveyor therefore utilises both quantitative and qualitative methods of analysis.A com puterised calculation (a statistical pro gram m e developed by COHSASA) is conducted by the programme adminis trators of COHSASA and the final rating could range between 0-40 which is noncompliant, 41 -80 which is partially com pliant, and 81 -120 as compliant.A score obtained higher than 120 implies that the standard exceeds compliance.A com puterised weighting system is included in the statistical programme to ensure reliability of results.When the non/par tial compliancy with a criterion is rated as very serious impacting on patient care or legality, this will impact on the results of that standard by means of a weighted deduction and calculation.

Evaluation strategies
The surveyor utilises different evaluation strategies to assess compliance with the standards and criteria.These strategies include individual and/or group inter views with service providers and pa tients, direct and indirect observation where the surveyor also follows the route of the patient (eg.from admission to dis charge/transfer) involving the principle of a simulated patient experience.Docu ment analysis also form s a significant part of the evaluation.The surveyor has to validate or cross check the com pli ance with standards between the differ ent professional services (eg.whether the pharmaceutical drug control policies are implemented in the clinical units), as well as between the managerial, profes s io n a l and s u p p o rt s e rv ic e s (eg.whether the personnel policies are be ing implemented at operational or grass root levels).The external survey is con ducted by at least three surveyors and the average tim e spent is three days (which includes the evaluation of night duty services when applicable).

Core service elements
The COHSASA standards comprise of core elements that are assessed in every health care institution or service.These core service elements relate to the man agement of the service, health and safety in accordance with the related legisla tion, resuscitation services, infection con trol and sterile services, the food, domes tic, laundry and maintenance services, as well as the health record system.Na tional standards and criteria for these core service elements are formulated by national expert groups and these stand ards have been reviewed once and the sixth revised set of standards is in the final phase of completion.This article does not focus on the discussion of re sults related to the core service ele ments, but describes the results of the nursing services as one of the profes sional services in a hospital.

Professional service elements
Apart from the core service elements that are assessed, the different professional service are also assessed.These in clude in-patient clinical/medical services (both medical and surgical), the anaes thetic or theatre services, the nursing and pharmaceutical services, as well as ar eas such as infection control.The dif ferent specialities that are offered in that particular health care service are also assessed, which could be critical care service, obstetric/maternity, psychology, laboratory, p hysiothe ra py and many other services.National standards have been set by the national professional groups.The nursing service standards have been developed by a group of nurs ing service managers and experts.

Health service standards: common areas
There are certain common areas in all the services which are assessed based on the national standards.These com mon areas include the philosophy/objec tives of that service/speciality, the staff ing composition, as well as the manage ment and development of the staff, op erational policies and procedures re quired in that speciality, the patient in-

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te ra c tio n and la stly the quality improvem ent pro gramme.Although the fo cus o f the a ccre dita tion programme at this stage is therefore on structure and process standards, the as sessment of outcome will follow as soon as the differ ent clinical indicators have been developed.The qual ity im p ro v e m e n t p ro gramme does make provi sion, however, for that par ticular service to m onitor the outcome of service de livery.

Population, sampling and realisation
A total of 83 hospitals have entered the COHSASA ac creditation programme of w ho m 45 have been awarded accreditation sta tus fo r the period 1995-1998 and many are in the final post-survey process p rio r to a c c re d ita tio n (Whittaker, 1998)

Results
The results of the evaluation survey on the quality of nursing service manage ment in South African hospitals, are pre sented by means of an overall compara tive performance where the quality of nursing service m anagem ent is compared with other selected pro fessional services, being resusci tation/casualty services, infection control, critical care, anaesthetic (theatre), management, medical and surgical in-patient services, as well as the pharmaceutical serv ices.These professional services were selected from the 36 different professional services for which COHSASA has national standards, but based on the fact that they are as sessed in all the hospitals (due to the fact that a limited amount of public hos pitals have been evaluated, all the pos sible professional services are not in cluded in these results because the pri vate hospitals don't necessarily render all the services).The nursing service management is assessed in terms of the difference between the initial baseline assessments (pre-test) and the final external survey (post-test) results.This is followed by a general analysis of the quality of nursing service management in terms of their overall performance in the different standards applicable to the management of nursing services.

Overall comparative performance
The quality of nursing service manage ment compares favourably with the other professional services (see figure one  ices obtained the highest overall score of 99, followed by the infection control services with a score of 97 and the criti cal care services with an average score of 96,5.The overall average compliance score of management is 94 and the phar maceutical services obtained a disap pointing score of 86.The anaesthetic services obtained the same score as the nursing service and the M edical and Surgical In patient services scored an average of 92.These professional serv ices are all compliant with the standards (the average score should range be tween 80-100 to comply with the stand ards).

Nursing service management performance: comparison between baseline and external surveys
When the hospital has entered into a for mal c o n tra c tu a l a g re e m e n t w ith COHSASA, the sta nd ard s m anual is given to the management.A COHSASA facilitator assists the staff with the inter pretation of the standards and continu ous empowerment regarding the princi ples of quality improvement is done.A h osp ital-ba sed q u a lity im p rove m e nt committee is elected and one overall co ordinator for the programme is identified and authorised as such.A baseline in ternal assessment is conducted by the sta ff (p re -te s t), v a lid a te d by the COHSASA facilitator, follow ed by the external assessment and survey approxi mately 18 months later.
Only 18 nursing services were com pli ant (obtained an overall score of at least 80) during the baseline survey as op posed to the external survey score of com pliancy by all the nursing services (N =45).The baseline assessment re vealed an overall partial compliancy by 27 nursing services, with an average to tal score of 64,3 opposed to the exter nal average score of 95 (compliant) by the nursing services in the external survey.The range of scoring during the baseline survey of 42-92 in the different criteria has also improved significantly to 69-118 during the external survey (see table one).The statistical significance between the baseline and external sur vey assessments can not be accurately calculated due to the low frequency rate.The results do, however, show a remark able im provem ent confirm ing the em powerment or capacity building advan tage of the COHSASA programme.

Overall nursing service performance
The overall nursing service standard reads as follows: The nursing service m anagem ent provides goal directed leadership and facilitates dynamic man agem ent processes for an integrated, co-ordinated and participative approach to nursing which e n a b le s m a xi mum effectivity of nursing care and resources, which are re fle c te d th ro u g h o u t the hospital.This standard is sub-divided into ten different d i m ensions (see figure two) and the average compliance score of the sub division is given in brackets: stra te g ic p la n n in g (104) and man agement (107), organisation (103), fin a n c ia l management (89), nursing hu man re so u rce management (102), p o lic ie s and procedures (109), fa c ilitie s and e q u ip m e n t (109), nursing care (105) and quality improvement programmes (73).It is clear that the nursing services (N=45) are not com pliant with the quality im provement standards and that there are limitations/problems related to financial management.

a) Strategic plan
A written strategic plan is required, with the mission statement, objectives and actions to achieve these objectives, as well as proof of a participative manage ment approach being practised.The nursing services were mostly non-compliant with this standard during the base line survey (score of 45), as opposed to an average score of 104 obtained dur ing the external survey which reveals full compliance w ith this standard and re lated criteria.The principles of partici pative management are not always fully implemented though and it is also diffi cult for the external surveyor to assess this during the short survey period.The nursing service managers' participation in top management decision-making on strategic issues, also appear to be lim ited.

b) Management
This standard relates to the qualifications and experience of the nursing service manager, as well as her/his inputs and interaction with the top management of the hospital to ensure credible input by the nursing fraternity.The nursing serv ices are com pliant with this standard (average compliant score of 92 during 67 C urationis June 2000 the baseline survey and a score of 107 during the external survey), with highly professionally qualified nursing service managers in charge of the various nurs ing services.The quality of their input in top management decisions can, how ever, not be assessed through this ac creditation programme.

c) Organisation o f the nursing service
The nursing service is organised to en sure quality clinical nursing/m idwifery care and cost effective management of resources.This standard is measured by means of six criteria relating to the following: a written organogram, the in tegration of the nursing service with other systems and services of the hospital, a system to ensure patient-focused nurs ing care with app ro priate c o n tin u ity thereof, professional supervision of pa tient care at all times, appropriate sup port services to enable the nursing staff to focus on nursing responsibilities and duties, as well as the utilisation of appro priate statistics to optimise nursing care and the utilisation of resources.An av erage compliant score of 103 was ob tained for this standard during the exter nal survey as opposed to a score of 76 obtained (partially compliant) during the baseline survey.

d) Financial management
The nursing manager is accountable for the financial management of the nurs ing service, in accordance with the finan cial system of the health care organisa tion.This standard is m easured by means of four different criteria in relation to assessment and preparation of the nursing service budget, the monitoring of expenditure, a system of utilisation review and cost containment, as well as involvement in the overall financial man agement of the health care organisation as a member of top management

f) Policies and procedures
There are written policies and proce dures for the activities of the nursing serv ice, com piled within the professionalethical framework of the nursing profes sion, which reflect current standards of practice, regulations and the objectives of the health service.This standard re quires that policies and procedures for the nursing service are in place in ac cordance with 28 criteria.An average compliant score of 109 was obtained in the external survey as opposed to a par tially com pliant score of 52 during the baseline survey.It is common to find the absence of written policies and proce dures on commencement of the accredi tation programme.This results in a very labour intensive process by the nursing service to get all the policies and proce dures in place prior to the external sur vey.This also causes a lot of paper work for the service.

g) Facilities and equipm ent
A therapeutic environm ent is created and maintained in the nursing service to ensure safe nursing care in accordance with the legal requirements.

i) Q u a lity im provem ent
A quality improvement programme is a formalised comprehensive programme focusing on the monitoring and evalua tion of those interactions that impact on nursing care, based on written stand ards, with evidence of remedial action taking place to address deficiencies.A form alised q ua lity im provem ent p ro gramme is maintained in accordance with 15 different criteria.These criteria focus on the full quality cycle (formula tion of standards, monitoring/evaluation and remedial action) to be developed and implemented in the nursing service in a participatory and multi-disciplinary or collective manner.The total average partially compliant score for this stand ard during the external survey was only 73 -the lowest of all the scores.This does, however, show a remarkable im provement from a score of 42 which was obtained during the baseline surveys.
The nursing staff still find it difficult, time consuming and expensive to have for m a lise d q u a lity im p ro v e m e n t p ro grammes in place.These programmes have to be driven by a very committed person.

Conclusions
The following conclusions are relevant: * the external survey scores were sig nificantly higher than the baseline scores due to the process of facilitation during the preparatory phase, resulting in em powerment and capacity building; * the highest scores during the external surveys were obtained in the standards relating to policies/procedures and facili ties/equipment; 68 Curationis June 2000 * although compliant with a score of 89, financial managem ent by the nursing service managers is inadequate; * the principles of quality improvement have not yet been fully implemented with a partially compliant score of 73; * statistical analysis of the results (com parisons between the baseline and ex ternal survey results) is problematic due to the low frequency rate (N=45).

Concluding Remarks and Recommendations
The fo llo w in g re co m m e n d a tio n s are made: * statistical validation of the standards (content and construct validity); * reliability tests to determine the reli ability of the instrument and inter-rater reliability between surveyors; * the im pact of the COHSASA p ro gramme on the quality of nursing serv ice management should be determined; * the development of quality indicators to be utilised by the various nursing serv ices for comparative purposes; * continuous revision of the standards and related criteria; * continuous professional development of nursing service managers, unit man agers and clinical nurses/midwives with regard to the various quality im prove ment activities, including the principles of total quality management.
Determining the quality of nursing serv ice management is a lifelong process which requires comm itment, persever ance and lots o f e n e rg y by all the roleplayers.Once the health care or ganisation has com m itted itself to the accreditation process, the COHSASA facilitator has to manage the dynamicsboth the positive and negative dynam ics.But it always remains an exhilarat ing experience!

65 Curationis June 2000 F
ig u re 1 : O v e ra ll c o m p a ra tiv e p e rfo rm a n c e o f s e le c te d p ro fe s s io n a l s e rv ic e s during th e e x te r n a l s u rv e y s ( rn a l s u rveys : N u rsing S e rv ic e s (N = 4 5 )

Figure 2 :
Figure 2 : O v e ra ll N u rsing S e rv ic e P e rfo rm a n c e