Q uality:

Quality

is

defined as the
extent
of
resemblance
between
the
purpose
of
healthcare
and
the
truly
granted
care
(Donabedian
1986).

Q uality assurance
"Quality

assurance is the
monitoring of the activities of
client care to determine the
degree of excellence attained
to the implementation of the
activities". (Bull, 1985)

 Quality

assurance
is
the
defining of nursing practice
through well written nursing
standards and the use of those
standards as a basis for
evaluation on improvement of
client care (Maker 1998).

A PPR O A CH ES FO R A Q U A LITY A SSU R A N CE

PR O G R A M M E:

Two

major
categories
of
approaches exist in quality
assurance they are
General
Specific

G eneral A pproach:
It involves large governing of official
body's evaluation of a persons or
agency's ability to meet established
criteria or standards at a given time.
1) Credentialing:
2) Licensure:
3) Accreditation:
4) Certification:

1) C redentialing:
It is generally defined as the

formal
recognition
of
professional
or
technical
competence and attainment of
minimum standards by a
person or agency According to
Hinvasky (1981)

credentialing process has four

functional components
a) To produce a quality
product
b) To confer a unique identity
c) To protect provider and
public
d) To control the profession.

2) Licensure:
Individual

licensure
is
a
contract
between
the
profession and the state, in
which
the
profession
is
granted control over entry into
and exists from the profession
and
over
quality
of
professional practice.

 The licensing process requires

that regulations be written to

define the scopes and limits of
the professional's practice.
Licensure of nurses has been
mandated by law since 1903

3) A ccreditation:
National

league for nursing

(NLN) a voluntary organization
has established standards for
inspecting nursing education's
programs. In the part the
accreditation process primarily
evaluated
on
agency's
physical
structure,
organizational structure and

4) C ertif c
iation:
Certification

is
usually
a
voluntary process with in the
profession.
A
person's
educational
achievements,
experience and performance
on examination are used to
determine
the
person's
qualifications for functioning in
an identified specialty area.

Specif c
i approaches:
Quality assurances are methods
used to evaluate identified instances
of providers and client interaction.
1)Peer review:
2)Standard as a device for
quality assurance:
3)Audit as a tool for quality
assurance:

1)Peer review :
To maintain high standards, peer review

has been initiated to carefully review the

quality of practice demonstrated by
members of a professional group. Peer
review is divided in to two types. One
centers on the recipients of health
services by means of auditing the quality
of services rendered. The other centers
on the health professional by evaluating
the quality of individual performance.

2)Standard as a device for

quality assurance:
Standard is a pre-determined baseline

condition or level of excellence that

comprises a model to be followed and
practiced. The ANA standard for
practice include;
Standard 1: The collection of data
about health status of the patient is
systematic and continuous. The data
are accessible, communicative, and
recorded.

 Standard

2: Nursing diagnosis are

derived from health status data.
Standard 3: The plan of nursing care
includes goals derived from the nursing
diagnoses.
Standard 4: The plan of nursing care
includes priorities and the prescribed
nursing approaches or measures to
achieve the goals derived from the
nursing diagnoses.

 Standard 5: Nursing actions

provide for patient

participation in health
promotion, maintenance, and
restoration.
Standard 6: Nursing actions
assist the patient to maximize
his health capabilities.

 Standard 7: The patient's progress or

lack
of
progress
towards
goal
achievement is determined by the
patient and the nurse.
Standard 8: The patient's progress or
lack
of
progress
towards
goal
achievement directs re-assessment,
re-ordering of priorities, new goal
setting, and a revision of the plan of
nursing care.

 To

evaluate quality nursing

care regularly, many staff
nurses do indeed welcome
opportunity to develop criteria,
to
review
nursing
care
retrospectively
and
concurrently, and to discover
methods of achieving higher
levels of quality nursing care.

3)A udit as a tool for

quality assurance:
Nursing audit may be defined

as a detailed review and

evaluation of selected clinical
records in order to evaluate
the quality of nursing care and
performance by comparing it
with accepted standards

 To be effective a nursing audit

must be based on established

criteria
and
feedback
mechanism
that
provide
information to providers on the
quality of care delivered.

Q U A LITY A SSU R A N C E
M O D EL IN N U R SIN G
Quality assurance model in nursing is
the set of elements that are related to
each other and comprise of planning
for quality development of objectives
setting and actively communicating
standards
developing
indicators,
setting thresholds, collecting data to
monitor
compliance
with
set
standards for nursing practice and
apply solutions to improve care

P H ILO SO P H Y O F Q U A LITY
A SSU R A N C E M O D EL IN
nursing
council believes
NIndian
U R SI
NG
that nurse will

Do good for person /receiver of

care, do no harm, maintain respect

for life and human dignity, believe
in human justice and fairness to
individuals in terms of access to
resources and care and protect the
vulnerable

 Have moral obligation to provide

services as per the prescribed of

the regulatory body / health care
system/ organization /institution
even if it is in conflict with her
personal beliefs and values
Be responsible and accountable for
providing quality care in line with
set standards

 Be

committed to understanding of
dynamic nature of his / her role in
interdisciplinary health team
Be obliged to create public awareness
and consider social expectations before
making decisions for providing nursing
care
Be obliged to include receiver in making
choices in planning and implementation
of care

 Work in conjugation with

legislation, accreditation and

political system
Have obligation to promote
education of self and others
Be committed to advancement
of profession

P U R P O SE O F Q U A LITY
A SSU R A N C E M O D EL
To ensure quality nursing care

provided by nurses in order to

meet the expectations of the
receiver, management and
regulatory body
It also intends to increase the
commitment of the provider
and the management

G O A LS O F Q U A LITY
A SSU R A N C E M O D EL
Develop confidence of the receiver

that quality care is being rendered as

per assurance
Develop
commitment
of
the
management towards quality care
Increase commitment of providers to
adhere to set standards for nursing
practice and strive for excellence

M O D ELS O F Q U A LITY
A SSU R A N C E

1) System Model for

Quality assurance.
2) ANA Quality Assurance
Model
3)JCAHO Quality Assurance
Model
4)ISO Quality Assurance

A System M odelfor Q uality assurance.

The basic components of the system

are
Input
Throughput
Output
Feedback

i) Input:- Can be compared to the present state

of the system.

ii) Through put:- The through put to the

developmental process.

iii) Out put:- To the finished product.

iv) Feed Back:- It is the essential component of

the system because it maintains and nourish
growth.

AM ERICAN N URSES ASSO CIATIO N M O D EL FO R

Q UALITY ASSUREN CE

Identify values

Identify structure, process and outcome

standards and criteria

Select measurement
Make interpretation

Identify course of action

Choose action
Take action
Reevaluate

1) Identify Value:
In the ANA value identification

looks as such issue as

patient/client,
philosophy,
needs and rights from an
economic, social, psychology
and spiritual perspective and
values, philosophy of the
health care organization and
the
providers
of
nursing

2) Identify structure,
process and outcom e
standards and criteria:
Identification

of standards and
criteria for quality assurance
begins with writing of philosophy
and objective of organization. The
philosophy and objectives of an
agency serves to define the
structural standards of the agency.

 Standards of structure are defined

by licensing or accrediting agency.

Another
standard
of
structure
includes the organizational chart,
which shows supervisory methods,
communication
patterns,
staff
patterns
and
sometimes
staff
assignments. Evaluation of the
standards of structure is done by a
group internal or external to the

3) Select m easurem ent

needed to determ ine
degree of attainm ent of
criteria and standards:
Measurements are those tools used to

gather information or data, determined

by the selections of standards and
criteria. The approaches and techniques
used to evaluate structural standards
and
criteria
are,
nursing
audit,
utilization's reviews, review of agency
documents, self studies and review of

 The

approaches
and
techniques for the evaluation
of process standards and
criteria are peer review, client
satisfactions surveys, direct
observations, questionnaires,
interviews, written audits and
videotapes.

4) M ake interpretations
The

degree to which the

predetermined criteria are met
is the basis for interpretation
about
the
strengths
and
weaknesses of the program. The
rate of compliance is compared
against the expected level of
criteria accomplishment.

5) Identify C ourse of A ction

If the compliance level is above the

normal or the expected level, there is

great value in conveying positive
feedback and reinforcement. If the
compliance level is below the expected
level, it is essential to improve the
situations. It is necessary to identify
the cause of deficiency. Then, it is
important to identify various solutions
to the problems.

6) C hoose action
Usually various alternative course of

action are available to remedy a

deficiency. Thus it is vital to weigh the
pros and cons of each alternative while
considering the environmental context
and the availability of resources. In the
recent that more than one cause of the
deficiency has been identified; action
may be needed to deal with each
contributing factor.

7) Take A ction:
It is important to firmly establish

accountability for the action to

be taken. It is essential to
answer the questions of who will
do? What? By when?. This step
then concludes with the actual
implementation of the proposed
courses of action.

8) R eevaluate:
The final step of QA process

involves an evaluation of the

results of the action. The
reassessment is accomplished
in the same way as the
original
assessment
and
begins the QA cycle again.

 Careful

interpretation
is
essential to determine whether
the course of action has
improves
the
deficiency,
positive
reinforcement
is
offered
to
those
who
participated and the decision
is made about when to again
evaluate that aspect of care.

JCAHO

JCA H O Q U A LITY A SSU R EN CE M O D EL

ISO Q U A LITY A SSU R EN CE M O D EL

Q U A LITY A SSU R A N C E
P R O C ESS:
Establishment of standards or criteria
Identify the information relevant to criteria
Determine ways to collect information
Collect and analyze the information
Compare collected information with established

criteria
Make a judgment about quality
Provide information and if necessary, take
corrective action regarding findings of
appropriate sources
Determine ways to collect the information

FA C TO R S A FFEC TIN G
Q U A LITY A SSU R A N C E IN
N1)ULack
R SINofG Resources:
CA R E
2) Personnel problems:
3) Improper maintenance:
4) Unreasonable Patients and
Attendants
5) Absence of well informed
population.
6) Absence of accreditation
laws

7) Lack of incident review

procedures
8) Lack of good and hospital
information system
9 Absence of patient
satisfaction surveys
10) Lack of nursing care
records

1) Lack of Resources:
Insufficient

resources,
infrastructures,
equipment,
consumables,
money
for
recurring expenses and staff
make it possible for output of a
certain quality to be turned out
under
the
prevailing
circumstances.

2) Personnel problem s:
Lack of trained, skilled and

motivated employees, staff

indiscipline affects the quality
of care.

3) Im proper m aintenance:
Buildings

and
equipments
require proper maintenance
for efficient use. If not
maintained
properly
the
equipments cannot be used in
giving
nursing
care.
To
minimize
equipment
down
time it is necessary to ensure
adequate after sale service

4) U nreasonable Patients
and Attendants
Illness,

anxiety, absence of
immediate
response
to
treatment, unreasonable and
un co-operative attitude that
in turn affects the quality of
care in nursing.

5) A bsence of w ell
inform ed population.
To improve quality of nursing

care, it is necessary that the

people become knowledgeable
and assert their rights to
quality care. This can be
achieved through continuous
educational program.

6) A bsence of accreditation
law s
There

is
no
organization
empowered by legislation to lay
down standards in nursing and
medical care so as to regulate the
quality of care. It requires a
legislation that provides for setting
of a stationary accreditation /
vigilance authority to

a) Inspect hospitals and

ensures
that
basic
requirements are met.
b)
Enquire
into
major
incidence of negligence
c) Take actions against
health
professionals
involved in malpractice

7) Lack of incident review

procedures
During a patients

hospitalizations reveal incidents

may occur which have a
bearing on the treatment and
the patients final recovery.
These critical incidents may be
a) Delayed attendance by
nurses, surgeon, physician

b) Incorrect medication
c) Burns arising out of faulty
procedures

8) Lack of good and

hospital inform ation
A
good
management
system
information system is essential
for the appraisal of quality of
care.
a)
Workload,
admissions,
procedures and length of stay
b) Activity audit and scheduling
of procedures.

9 A bsence of patient
satisfaction surveys
Ascertainment

of
patient
satisfaction at fixed points on an
ongoing basis. Such surveys
carried
out
through
questionnaires, interviews to by
social worker, consultant groups,
and help to document patient
satisfaction
with
respect
to
variables that are

a) Delay in attendance by
nurses and doctors.
b)
Incidents
of
incorrect
treatment

10) Lack of nursing care

records
Nursing

care
records
are
perhaps the most useful source
of information on quality of care
rendered. The records.
a) Detail the patient condition
b)
Document
all
significant
interaction between patient and
the nursing personnel.

c) Contain information regarding

response to treatment
d) Have the dates in an easily
accessible form.

Thank you for your patient listening