Quality Assurance m Health Care, Vol. 4. No. 3, pp. 187-192, 1992 Printed in Great Britain
1040-6166/92 $5.00 + 0.00 © 1992 Pergamon Press Ltd
A PILOT PROJECT ON QUALITY ASSURANCE IN NURSING CARE IN THE STATE OF SCHLESWIG-HOLSTEIN, FEDERAL REPUBLIC OF GERMANY
Institute for Health Systems Research Kiel Weimarer StraBe 8 W-2300 Kiel-Wik Federal Republic of Germany (First received 30 May 1991; accepted 18 December 1991)
As a direct result of the law passed in Germany requiring the practice of quality assurance in health care which has been in effect since 1 January 1989, the Institute for Health Systems Research in Kiel piloted a project on quality assurance in medicine in 12 hospitals in Schleswig-Holstein from September 1989 to February 1991. Two procedures for measuring the quality of nursing care were also developed in two of these hospitals. These procedures were oral care aided by nursing staff and oral care carried out by nursing staff. The pilot project was then evaluated by the Institute. An extension of the medical side of the project to cover all 80 hospitals in SchleswigHolstein was planned to begin on 1 January 1992. As far as the nursing side is concerned, approximately 10 procedures will be developed and tested in eight hospitals. Key words: Quality assurance, nursing, Germany, pilot project in hospitals.
INTRODUCTION
The project on quality assurance in nursing care reported here is part of a larger project on quality assurance in hospitals which for the first time in the Federal Republic of Germany—from now on in this paper referred to as Germany— comprises more than one discipline including nursing. Our institute, the Institute for Health Systems Research in Kiel, was commissioned to evaluate this project. The institute is a multi-disciplinary institute, and physicians, nurses, statisticians and mathematicians as well as other professionals worked on this project. There is in Germany, as in many other countries in Europe, an increasing shortage of nurses. Some of the reasons are of a demographic nature: a diminishing, yet aging population with more people to be cared for and a shortage of school leavers because of a decrease in the birth rate. There are other reasons, e.g. the status of the nurse in First presented to the 8th Congress of ISQA, Washington, 29-31 May 1991. Reprint requests should be sent to Prof. F. Beske, at the above address.
187
Downloaded from https://academic.oup.com/intqhc/article-abstract/4/3/187/1797143 by guest on 25 October 2019
Fritz Beske, Petra Heinrichs, Fiona Short and Ingrid Thoben
188
F.Beskeetal.
QUALITY ASSURANCE IN GERMANY Quality assurance in hospitals is rather new in Germany and restricted to a few medical disciplines. It started in the 1980s in the field of perinatology. This is the only field of quality assurance in hospitals which is now established all over Germany. About 80% of ah1 births undergo a standardized quality assurance programme. In some states there are already quality assurance measures for certain surgical, gynaecological and paediatric diagnoses. Quality assurance in heart surgery will after a pilot study of about 4 years now be established in almost all departments of heart
Downloaded from https://academic.oup.com/intqhc/article-abstract/4/3/187/1797143 by guest on 25 October 2019
health care services and in society. Nurses themselves are struggling for a new identity. They are supported by those who realize that amongst other things a new identity for nurses is needed in order to make this profession attractive to enough people that all nursing tasks can be fulfilled. There is in Germany quite a lot of debate about the number of nurses needed in hospital care. In this respect we have a mixture of both a decentralized and a centralized system. The per diem for hospital care is negotiated between hospitals and sickness funds on a local or regional level. One of the largest items in hospital care is the personnel costs which amount to about 65% of the hospital expenditure. Nurses take up the largest share of the personnel costs. The number of nurses determined as being necessary in each individual hospital is therefore of great importance for those who deliver services, the hospital itself, and for those paying sickness funds. There is now a law in Germany which makes it the joint responsibility of hospitals and sickness funds on the federal level to decide on the methods to define the number of nurses needed in a German hospital. The German Hospital Federation has proposed a method, the so-called "analytical method", by which the required nursing care in any discipline and the time needed to fulfill this task determine the number of nurses needed. The sickness funds are against this method as they are afraid that it will lead to a much larger number of nurses with consequences for the per diem. Again according to law the Federal Ministry of Health has to determine the methods by which the number of nurses needed in hospitals will be defined if the parties concerned do not agree. This is the present situation. The Ministry is favouring a method which resembles the one proposed by the German Hospital Federation but the decision has not yet been made. Neither the German Hospital Federation nor the Ministry of Health include quality assurance in their respective methodologies. We, however, in our institute think that quality assurance must form part of any method designed to determine the number of nurses needed in hospitals. In addition, the introduction of quality assurance in nursing in hospitals will make everybody aware what nursing really means and what skills and what time is needed to deliver good nursing care. It will help to emancipate the nursing profession and nursing research, thereby making this profession more attractive. Quality assurance in nursing is therefore one of the tools that may help to overcome the shortage of nurses. It is in this sense a tool of health policy for securing the highest possible level of health care services; something that is impossible without qualified nursing care.
Nursing Care in Schlcswig-Holstcin
189
surgery. Quality assurance in nursing is almost non-existent in Germany, although some larger hospitals and some research institutes have developed standards for nursing care. The largest study was made by the German Hospital Institute in cooperation with the Dornier System. This study defines the development and evaluation of methods for quality assurance in nursing in hospitals [1] but no consequences were derived from this study. THE 1988 LAW
PILOT PROJECT IN THE STATE OF SCHLESWIG-HOLSTEIN
In order to develop methods for quality assurance in hospitals that could be used elsewhere, a pilot project was established in the State of Schleswig-Holstein, the most northern state of Germany. The pilot project was carried out in 12 general hospitals and ran from 1 September 1989 until 28 February 1991 followed by evaluation by our institute. It included surgery, internal medicine, gynaecology/ obstetrics, haemotherapy, nosocomial infections and nursing. As part of the project, the organization in hospitals for quality assurance, e.g. commissions for quality assurance, and the cost of quality assurance had to be assessed. In addition, two procedures for measuring the quality of nursing care in two hospitals had to be developed. For this purpose a concept including the methodology and a plan of work was worked out in our institute. This concept was then presented to the directors of nursing at the 12 participating hospitals in order to find two hospitals for this project. This was successful. It has to be mentioned that none of the hospitals or the nursing staff had any experience with quality assurance. Within these two hospitals four wards decided to participate in the pilot project. Two working groups were formed, one for organization and the other for problem finding and standards. Both working groups were composed of members of the nursing staff of the two hospitals and members from our institute. In addition a scientific advisory group was set up. In this advisory group nurses with special knowledge of work analysis, planning of nursing activities, documentation and
Downloaded from https://academic.oup.com/intqhc/article-abstract/4/3/187/1797143 by guest on 25 October 2019
All studies on and all methods of quality assurance in Germany used to be carried out on a voluntary basis. This situation has changed completely. In 1988 a federal law was passed called the "Law on the Reform of the Health Care System (Gesundheits-Reformgesetz)[2]. This law requires all hospitals to participate in quality assurance programmes, both internal and external. These programmes have to include the structure, the process and the outcome of medical care services. The purpose of quality assurance is stated as follows: "Quality and effectiveness of services have to be in accordance with the recognized standard of medical science including medical progress"[2]. In the law itself there is no special reference to quality assurance in nursing care. According to our interpretation of the law, and many others interprete the law in the same way, good quality of services is impossible without good quality of nursing care. Accepting this interpretation of the law, quality assurance in nursing care is now a legal requirement in all German hospitals.
190
F.Beskeetal.
Oral Care Aided by the Nursing Staff Nurse washes her/his hands There was a large number of "no" responses. The reasons for these answers can be retraced to one problem: although there was a wash-hand-basin in most of the patients' rooms there were no soap dispensers or disposable towels available. It was therefore not possible for the nursing staff to wash their hands in the patients' rooms. From both a hygienic and medical point of view, washing is often preferred to disinfecting the hands. The hospitals were therefore recommended to provide disposable towels, soap dispensers and litter bins in each of the patients' rooms. Nurse notes the condition of the oral cavity and appropriate measures are taken These two connected items were both hotly discussed during the development of the standards and the questionnaires. The necessity to observe the condition of the patient's oral cavity was generally accepted, but in practice these criteria should be judged relative to the patient's condition. Most nurses have inhibitions as far as looking inside a conscious patient's oral cavity is concerned, especially when there appears to be no particular reason for this measure. The following questions on this point were discussed in the working groups: — Do nurses have to inform themselves about the condition of every patient's oral cavity for preventative reasons? — How far does the nurse's own attitude to oral hygiene create inhibitions in dealing with the oral care of other people? Through these discussions it soon became clear that it is not the task of quality assurance to clarify these questions, but rather that of researchers into nursing care.
Downloaded from https://academic.oup.com/intqhc/article-abstract/4/3/187/1797143 by guest on 25 October 2019
nursing standards were represented as well as representatives from the National Organization for Quality Assurance in Hospitals (CBO), Utrecht, The Netherlands, and from the European Office of the World Health Organization in Copenhagen. As procedures for measuring the quality of nursing care, oral care aided by nursing staff and oral care carried out by nursing staff were chosen. The distinction between the two procedures of oral care depends upon the degree of the patient's handicap or the need for prophylaxis of stomatopathy. For example, a patient with both upper arms fractured requires oral care aided by nursing staff whereas a somnolent patient with hemiparesis requires oral care carried out by nursing staff. Due to the lack of generally accepted standards of nursing care procedures in Germany, criterias and standards for the two oral care procedures had to be defined by the working group. Questionnaires for quality audit could then be derived from these defined standards. After an informational meeting of the whole nursing staff of the participating hospitals the applicability of the formulated quality assurance questionnaires was tested during a 2-week pretest. Data was collected further using slightly modified questionnaires over a period of 8 weeks in autumn 1990. The collected data was evaluated and interpreted and conclusions drawn by the nursing staff of the hospitals, supported technically and advised by our institute. Some of the main results of the pilot project are described below.
Nursing Care in Schleswig-Holstein
191
Oral Care Carried Out by the Nursing Staff
Changes in the condition of the oral cavity are noted and measures appropriate to the changes taken Changes in the condition of the patient's oral cavity could only be determined when the condition of the oral cavity was documented on admission. It became evident during the ensuing discussions that theflowof information is hampered when there is no clearly defined and conscientious documentation. Without this it is not possible to achieve easily the desired level of quality of care. Documentation is therefore one topic for quality assurance in nursing care. In summary, the two procedures of quality assurance in oral care can be used in other hospitals for quality assurance in nursing care. It was possible to identify problems in the structure as well as in the procedure of oral care and recommendations derived from the project have led to changes in both of these areas. OUTLOOK It is expected that, as of 1992, gradually all 80 general hospitals in the State of Schleswig-Holstein and hospitals from neighbouring States, too, will start a quality assurance programme. Quality assurance in nursing care will perforce be included. As far as quality assurance in nursing care is concerned the two procedures of oral care will be used as a beginning. Our institute expects a grant from the.Federal
Downloaded from https://academic.oup.com/intqhc/article-abstract/4/3/187/1797143 by guest on 25 October 2019
Patient is informed The response "No communication possible" was frequent for this and for other items in the questionnaire. There were heated discussions within the working groups to define when communication with the patient is not possible and how great the nurse's attempt should be at making contact with the patient. Alternative possibilities of communicating with the patient are either little known or are rejected for taking up too much time. Fear of entering the room or dealing with moribund patients, overwork and other factors can all be reasons for unsatisfactory attempts at communication with the seriously ill. Communication is not only a problem for the nursing staff, rather it is a problem for society as a whole. Verbal and non-verbal communication difficulties, for example in the family, amongst friends and in teams, can often intensify the feeling of isolation and being misunderstood. Nurses who themselves have such communication difficulties naturally cannot overcome the same difficulties when dealing with patients. Virtually every director of nursing is confronted daily with communication problems between the different hospital staff groups and within the groups themselves. Communication is a multi-faceted problem whose roots are not to be found in nursing. It is for this very reason that the various education programmes solely aimed at improving non-verbal communication techniques between nurse and patient cannot be very effective. Communication between and within the different hospital groups must be improved parallel to these programmes. One possibility could be to introduce fully qualified supervisors into the wards. Just as promising could be the introduction of a concept designed by all those concerned which describes how the various dimensions of communication can be applied.
292
F.Beskeetal.
Ministry of Health in order to develop some 10 more procedures on quality assurance in nursing care. We hope that we can offer these new procedures to hospitals in about 2 years. REFERENCES
Downloaded from https://academic.oup.com/intqhc/article-abstract/4/3/187/1797143 by guest on 25 October 2019
1. Bundesministerium fur Albeit und SoziaJordnung, Qiinlilittssicherung pflegerischer Arbeit im Knotkenhaus. Fonchungsbericht Gesundheitsforschung; No. 128. Bundesministerium filr Albeit und Sozialordnung, Bonn, 1985. 2. Sozialgesetzbuch (SGB), FOnftes Buch (V) Gesetdiche Krankenversicherung of 20.12.1988. In: Verband da Angestellten-Knmkaikassat e. V.: Sozialgaetzbuch-SGB, pp. 36701-36900. CW Haarfeld GmbH & Co., Essen, 1992.
1040-6166/92 $5.00 + 0.00 © 1992 Pergamon Press Ltd
A PILOT PROJECT ON QUALITY ASSURANCE IN NURSING CARE IN THE STATE OF SCHLESWIG-HOLSTEIN, FEDERAL REPUBLIC OF GERMANY
Institute for Health Systems Research Kiel Weimarer StraBe 8 W-2300 Kiel-Wik Federal Republic of Germany (First received 30 May 1991; accepted 18 December 1991)
As a direct result of the law passed in Germany requiring the practice of quality assurance in health care which has been in effect since 1 January 1989, the Institute for Health Systems Research in Kiel piloted a project on quality assurance in medicine in 12 hospitals in Schleswig-Holstein from September 1989 to February 1991. Two procedures for measuring the quality of nursing care were also developed in two of these hospitals. These procedures were oral care aided by nursing staff and oral care carried out by nursing staff. The pilot project was then evaluated by the Institute. An extension of the medical side of the project to cover all 80 hospitals in SchleswigHolstein was planned to begin on 1 January 1992. As far as the nursing side is concerned, approximately 10 procedures will be developed and tested in eight hospitals. Key words: Quality assurance, nursing, Germany, pilot project in hospitals.
INTRODUCTION
The project on quality assurance in nursing care reported here is part of a larger project on quality assurance in hospitals which for the first time in the Federal Republic of Germany—from now on in this paper referred to as Germany— comprises more than one discipline including nursing. Our institute, the Institute for Health Systems Research in Kiel, was commissioned to evaluate this project. The institute is a multi-disciplinary institute, and physicians, nurses, statisticians and mathematicians as well as other professionals worked on this project. There is in Germany, as in many other countries in Europe, an increasing shortage of nurses. Some of the reasons are of a demographic nature: a diminishing, yet aging population with more people to be cared for and a shortage of school leavers because of a decrease in the birth rate. There are other reasons, e.g. the status of the nurse in First presented to the 8th Congress of ISQA, Washington, 29-31 May 1991. Reprint requests should be sent to Prof. F. Beske, at the above address.
187
Downloaded from https://academic.oup.com/intqhc/article-abstract/4/3/187/1797143 by guest on 25 October 2019
Fritz Beske, Petra Heinrichs, Fiona Short and Ingrid Thoben
188
F.Beskeetal.
QUALITY ASSURANCE IN GERMANY Quality assurance in hospitals is rather new in Germany and restricted to a few medical disciplines. It started in the 1980s in the field of perinatology. This is the only field of quality assurance in hospitals which is now established all over Germany. About 80% of ah1 births undergo a standardized quality assurance programme. In some states there are already quality assurance measures for certain surgical, gynaecological and paediatric diagnoses. Quality assurance in heart surgery will after a pilot study of about 4 years now be established in almost all departments of heart
Downloaded from https://academic.oup.com/intqhc/article-abstract/4/3/187/1797143 by guest on 25 October 2019
health care services and in society. Nurses themselves are struggling for a new identity. They are supported by those who realize that amongst other things a new identity for nurses is needed in order to make this profession attractive to enough people that all nursing tasks can be fulfilled. There is in Germany quite a lot of debate about the number of nurses needed in hospital care. In this respect we have a mixture of both a decentralized and a centralized system. The per diem for hospital care is negotiated between hospitals and sickness funds on a local or regional level. One of the largest items in hospital care is the personnel costs which amount to about 65% of the hospital expenditure. Nurses take up the largest share of the personnel costs. The number of nurses determined as being necessary in each individual hospital is therefore of great importance for those who deliver services, the hospital itself, and for those paying sickness funds. There is now a law in Germany which makes it the joint responsibility of hospitals and sickness funds on the federal level to decide on the methods to define the number of nurses needed in a German hospital. The German Hospital Federation has proposed a method, the so-called "analytical method", by which the required nursing care in any discipline and the time needed to fulfill this task determine the number of nurses needed. The sickness funds are against this method as they are afraid that it will lead to a much larger number of nurses with consequences for the per diem. Again according to law the Federal Ministry of Health has to determine the methods by which the number of nurses needed in hospitals will be defined if the parties concerned do not agree. This is the present situation. The Ministry is favouring a method which resembles the one proposed by the German Hospital Federation but the decision has not yet been made. Neither the German Hospital Federation nor the Ministry of Health include quality assurance in their respective methodologies. We, however, in our institute think that quality assurance must form part of any method designed to determine the number of nurses needed in hospitals. In addition, the introduction of quality assurance in nursing in hospitals will make everybody aware what nursing really means and what skills and what time is needed to deliver good nursing care. It will help to emancipate the nursing profession and nursing research, thereby making this profession more attractive. Quality assurance in nursing is therefore one of the tools that may help to overcome the shortage of nurses. It is in this sense a tool of health policy for securing the highest possible level of health care services; something that is impossible without qualified nursing care.
Nursing Care in Schlcswig-Holstcin
189
surgery. Quality assurance in nursing is almost non-existent in Germany, although some larger hospitals and some research institutes have developed standards for nursing care. The largest study was made by the German Hospital Institute in cooperation with the Dornier System. This study defines the development and evaluation of methods for quality assurance in nursing in hospitals [1] but no consequences were derived from this study. THE 1988 LAW
PILOT PROJECT IN THE STATE OF SCHLESWIG-HOLSTEIN
In order to develop methods for quality assurance in hospitals that could be used elsewhere, a pilot project was established in the State of Schleswig-Holstein, the most northern state of Germany. The pilot project was carried out in 12 general hospitals and ran from 1 September 1989 until 28 February 1991 followed by evaluation by our institute. It included surgery, internal medicine, gynaecology/ obstetrics, haemotherapy, nosocomial infections and nursing. As part of the project, the organization in hospitals for quality assurance, e.g. commissions for quality assurance, and the cost of quality assurance had to be assessed. In addition, two procedures for measuring the quality of nursing care in two hospitals had to be developed. For this purpose a concept including the methodology and a plan of work was worked out in our institute. This concept was then presented to the directors of nursing at the 12 participating hospitals in order to find two hospitals for this project. This was successful. It has to be mentioned that none of the hospitals or the nursing staff had any experience with quality assurance. Within these two hospitals four wards decided to participate in the pilot project. Two working groups were formed, one for organization and the other for problem finding and standards. Both working groups were composed of members of the nursing staff of the two hospitals and members from our institute. In addition a scientific advisory group was set up. In this advisory group nurses with special knowledge of work analysis, planning of nursing activities, documentation and
Downloaded from https://academic.oup.com/intqhc/article-abstract/4/3/187/1797143 by guest on 25 October 2019
All studies on and all methods of quality assurance in Germany used to be carried out on a voluntary basis. This situation has changed completely. In 1988 a federal law was passed called the "Law on the Reform of the Health Care System (Gesundheits-Reformgesetz)[2]. This law requires all hospitals to participate in quality assurance programmes, both internal and external. These programmes have to include the structure, the process and the outcome of medical care services. The purpose of quality assurance is stated as follows: "Quality and effectiveness of services have to be in accordance with the recognized standard of medical science including medical progress"[2]. In the law itself there is no special reference to quality assurance in nursing care. According to our interpretation of the law, and many others interprete the law in the same way, good quality of services is impossible without good quality of nursing care. Accepting this interpretation of the law, quality assurance in nursing care is now a legal requirement in all German hospitals.
190
F.Beskeetal.
Oral Care Aided by the Nursing Staff Nurse washes her/his hands There was a large number of "no" responses. The reasons for these answers can be retraced to one problem: although there was a wash-hand-basin in most of the patients' rooms there were no soap dispensers or disposable towels available. It was therefore not possible for the nursing staff to wash their hands in the patients' rooms. From both a hygienic and medical point of view, washing is often preferred to disinfecting the hands. The hospitals were therefore recommended to provide disposable towels, soap dispensers and litter bins in each of the patients' rooms. Nurse notes the condition of the oral cavity and appropriate measures are taken These two connected items were both hotly discussed during the development of the standards and the questionnaires. The necessity to observe the condition of the patient's oral cavity was generally accepted, but in practice these criteria should be judged relative to the patient's condition. Most nurses have inhibitions as far as looking inside a conscious patient's oral cavity is concerned, especially when there appears to be no particular reason for this measure. The following questions on this point were discussed in the working groups: — Do nurses have to inform themselves about the condition of every patient's oral cavity for preventative reasons? — How far does the nurse's own attitude to oral hygiene create inhibitions in dealing with the oral care of other people? Through these discussions it soon became clear that it is not the task of quality assurance to clarify these questions, but rather that of researchers into nursing care.
Downloaded from https://academic.oup.com/intqhc/article-abstract/4/3/187/1797143 by guest on 25 October 2019
nursing standards were represented as well as representatives from the National Organization for Quality Assurance in Hospitals (CBO), Utrecht, The Netherlands, and from the European Office of the World Health Organization in Copenhagen. As procedures for measuring the quality of nursing care, oral care aided by nursing staff and oral care carried out by nursing staff were chosen. The distinction between the two procedures of oral care depends upon the degree of the patient's handicap or the need for prophylaxis of stomatopathy. For example, a patient with both upper arms fractured requires oral care aided by nursing staff whereas a somnolent patient with hemiparesis requires oral care carried out by nursing staff. Due to the lack of generally accepted standards of nursing care procedures in Germany, criterias and standards for the two oral care procedures had to be defined by the working group. Questionnaires for quality audit could then be derived from these defined standards. After an informational meeting of the whole nursing staff of the participating hospitals the applicability of the formulated quality assurance questionnaires was tested during a 2-week pretest. Data was collected further using slightly modified questionnaires over a period of 8 weeks in autumn 1990. The collected data was evaluated and interpreted and conclusions drawn by the nursing staff of the hospitals, supported technically and advised by our institute. Some of the main results of the pilot project are described below.
Nursing Care in Schleswig-Holstein
191
Oral Care Carried Out by the Nursing Staff
Changes in the condition of the oral cavity are noted and measures appropriate to the changes taken Changes in the condition of the patient's oral cavity could only be determined when the condition of the oral cavity was documented on admission. It became evident during the ensuing discussions that theflowof information is hampered when there is no clearly defined and conscientious documentation. Without this it is not possible to achieve easily the desired level of quality of care. Documentation is therefore one topic for quality assurance in nursing care. In summary, the two procedures of quality assurance in oral care can be used in other hospitals for quality assurance in nursing care. It was possible to identify problems in the structure as well as in the procedure of oral care and recommendations derived from the project have led to changes in both of these areas. OUTLOOK It is expected that, as of 1992, gradually all 80 general hospitals in the State of Schleswig-Holstein and hospitals from neighbouring States, too, will start a quality assurance programme. Quality assurance in nursing care will perforce be included. As far as quality assurance in nursing care is concerned the two procedures of oral care will be used as a beginning. Our institute expects a grant from the.Federal
Downloaded from https://academic.oup.com/intqhc/article-abstract/4/3/187/1797143 by guest on 25 October 2019
Patient is informed The response "No communication possible" was frequent for this and for other items in the questionnaire. There were heated discussions within the working groups to define when communication with the patient is not possible and how great the nurse's attempt should be at making contact with the patient. Alternative possibilities of communicating with the patient are either little known or are rejected for taking up too much time. Fear of entering the room or dealing with moribund patients, overwork and other factors can all be reasons for unsatisfactory attempts at communication with the seriously ill. Communication is not only a problem for the nursing staff, rather it is a problem for society as a whole. Verbal and non-verbal communication difficulties, for example in the family, amongst friends and in teams, can often intensify the feeling of isolation and being misunderstood. Nurses who themselves have such communication difficulties naturally cannot overcome the same difficulties when dealing with patients. Virtually every director of nursing is confronted daily with communication problems between the different hospital staff groups and within the groups themselves. Communication is a multi-faceted problem whose roots are not to be found in nursing. It is for this very reason that the various education programmes solely aimed at improving non-verbal communication techniques between nurse and patient cannot be very effective. Communication between and within the different hospital groups must be improved parallel to these programmes. One possibility could be to introduce fully qualified supervisors into the wards. Just as promising could be the introduction of a concept designed by all those concerned which describes how the various dimensions of communication can be applied.
292
F.Beskeetal.
Ministry of Health in order to develop some 10 more procedures on quality assurance in nursing care. We hope that we can offer these new procedures to hospitals in about 2 years. REFERENCES
Downloaded from https://academic.oup.com/intqhc/article-abstract/4/3/187/1797143 by guest on 25 October 2019
1. Bundesministerium fur Albeit und SoziaJordnung, Qiinlilittssicherung pflegerischer Arbeit im Knotkenhaus. Fonchungsbericht Gesundheitsforschung; No. 128. Bundesministerium filr Albeit und Sozialordnung, Bonn, 1985. 2. Sozialgesetzbuch (SGB), FOnftes Buch (V) Gesetdiche Krankenversicherung of 20.12.1988. In: Verband da Angestellten-Knmkaikassat e. V.: Sozialgaetzbuch-SGB, pp. 36701-36900. CW Haarfeld GmbH & Co., Essen, 1992.
