Subject: Advanced Nursing Practice

Seminar on: Quality Assurance in Nursing &

Futuristic Nursing

Quality Assurance in Nursing

Introduction
The field of quality assurance is an old as modern nursing. Florence Nightingale introduced
the concept of quality in nursing care in 1855 while attending the soldiers in the hospital
during the Crimean war.

Concept of quality in health care

The expense of quality is an interactive process between customer and provider. The
customer does not receive anything tangible, mostly only a piece of paper with a promise for
a better future e.g. Doctors writing prescriptions.
Quality assurance usually focuses on material, good work and service provided effectively.
Any lack in service provided causes decrease in quality.

Quality
It is a degree to which health services for individual and population increase the likelihood of
desired health outcomes and are consistent with current professional knowledge.
-Joint commission on
Accreditition of health care organization,2002
(JCAHO)
“Quality is doing the right thing right the first time and doing it better the next time.”

Assurance
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 It is statement or indication that inspires confidence.

Quality Assurance
Quality assurance is a dynamic process through which nurses assume accountability for
quality of care they provide. It is a guarantee to the society that services provided by nurses
are being regulated by members of profession.

Quality assurance is an on-going, systematic, comprehensive evaluation of health care

services and impact of those services on health care services.
-Kozier

Nursing
“The unique function of the nurse is to assist the individual, sick or well, in the performance of those
activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if
he had the necessary strength, will or knowledge & to do this in such a way as to help him to gain
independence as rapidly as possible.”
-Virginia Henderson

Objectives
 To ensure the delivery of quality client care
 To formulate plan of care
 To demonstrate efforts of health care providers to providing good results
 To evaluate achievement of nursing care
 To support delivery of nursing care with administrative & managerial services
 To state code of ethics and professional conduct for nurses in India.
 Plan and conduct patient teaching sessions.

Principles
 Customer focus
 Leadership
 Involvement of people
 Process approach
 Factual approach to decision making

Quality Assurance Process

It is a systematic process of evaluating the quality of care given in a particular unit or
institution.
It includes:

 Setting standards
 Determining criteria to meet those standards
 Data collection
 Evaluating how well the criteria have been met
 Making plans for change based on the evaluation
 Implementation for change

The 10-step process in a Quality Assurance Program

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STEP-1 Assigning responsibility
STEP-2 Delineate scope of care and services
STEP-3 Identify important aspects of care and services
STEP-4 Identify indicators
STEP-5 Establish threshold for evaluation
STEP-6 Collect and Organize data
STEP-7 Evaluate care
STEP-8 Take actions to solve problems or otherwise improve
STEP-9 Assess the effectiveness of actions
STEP 10- Communicate relevant information to the organization- wide quality assurance
program.

Approaches for a Quality Assurance Programme:

Two major categories of approaches exist in quality assurance they are
1. General
2. Specific

General Approach:
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:
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 Hinsvark (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) Accreditation:
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 regency’s physical structure, organizational structure and personal

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qualification. In 1990 more emphasis was placed on evaluation of the outcomes of care end
on the educational. Qualifications of the person providing care.
4) Certification:
Certification is usually a voluntary process with in the professions. A persons educational
achievements, experience and performance on examination are used to determine the
persons qualifications for functioning is an identified specialty area.

Specific Approaches:
Quality assurances are methods used to evaluate identified instances of provides and client
interaction.
1. Peer review committee:
These are designed to monitor client specific aspects of care appropriate for certain levels of
care. The audit has been the major tool used by peer review committee to ascertain quality
of care.
2.The audit Process - (Stan hope Han Caster 2000)

 Follow up of problems Topic study selected

 Recommendations for collecting deficiencies Explicit criteria selected for quality care.
 Peer review of all cases not meeting criteria
 Records reviewed
3.Utilization Review (UR)
Utilization review activities are directed towards assuring that care is actually needed and
that the cost appropriate for the level of care provided.
3 types of U.R are there:
a) Prospective: It is an assessment of the necessity of care before giving service.
b) Concurrent: a review of the necessity of care while the care is being given.
c) Retrospective: in analysis of the necessity of the services received by the client after the
care has been given.
U.R has been used primarily in hospitals to establish need for client admission end the
length of hospital stay. The UR process includes the development of explicit criteria that
serves as indicators of the need for services and length of services.
4) Evaluation Studies:
Three major models have been used to evaluate quality they are:-
1. Donabedian’s structure- process-outcome model
2. The tracer model
3. The sentinel model
Donabedian introduced 3 major methods of evaluating quality care.
A) Structural evaluation:

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This method evaluates the setting and instruments used to provide care such as facilities
equipment’s, characteristics of the administrative organization and qualification of the health
providers. The data for structural evaluations can be obtained from the existing documents
of an agency or from an inspector of a facility.
B) Process evaluation:
This method evaluates activities as they relate to standards and expectations of health
provides is the management of client care, data for this can be collected through direct
observations of provider encounters and review of records, audit, check list approach and
the criteria mapping approach are used to establish the client encounter protocol.
C) Outcome Evaluation:
The net changes that occur as a result of health care or the net results of health care. The
data of this method can be collected from vital statistical records such as death certificates,
in person or telephone client interviews mailed questionnaire and client records.
The Tracer method: is a measure of both process and outcome of care. To use the tracer
method, one must identify a volume of client with a particular characteristic resuming specific
health care management. Physicians and nurse practitioners to identify persons with certain
illness such as HT, ulcers, UTI and to establish criteria for good medical and nursing
management of the illnesses have used the traced method. This method provides nurses
with data to show the differences in outcome as a result of nursing care standards.
The Sentinel method: It is an outcome measure for examining specific instances of client
care the characteristics of this method are,
a) Cases of unnecessary disease, disability deaths are counted.
b) The circumstances surrounding the unnecessary event or the sentinel are examined in
detail.
c) In review of morbidity and mortality are used as an index.
d) Health status indicator such as changes in social, economic, political and environmental
factors are reviewed which may have an effect on health outcomes.

Models of Quality Assurance

1) A System Model for implementation of unit Based Quality assurance:
The implementations of the unit-based quality assurance program, like that of any other
program, involves making changes in organizational structure and individual roles one
method of facilitating and structuring the change process is the system approach in which
the task is broken down into manageable components based on defined objectives.
The basic components of the system are
a. Input-can be compared to the present state of systems
b. Throughput-the throughput to the developmental process
c. Output-to the finished product
d. Feedback-is the essential component of the system because it maintains and nourishes
the growth.

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2) American Nurses Association Model :
The ANA has developed QA model in 1977 which has wide spread applicability in any
healthcare setting and can be used as guide to implement QA program.
The first step in developing QA program is continuing education. Many staff nurses and
supervisors have not been prepared in the academic setting to develop standards of practice
when a quality assurance program is implemented, the continuing education needs of all
staff should be ascertained. Quality is not assured if only a small committee evaluates care
and understands quality assurance program.
The basic components of the ANA model can be summarized as follows:
1) Identify values
2) Identify structure, process and outcome standards and criteria
3) Select measurement
4) Make interpretation
5) Identify course of action
6) Choose action
7) Take action
8) Reevaluate

Factors affecting Quality Assurance in Nursing Care

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 problems:
Lack of trained, skilled and motivated employees, staff indiscipline affects the quality of care.
3) Improper maintenance:
Buildings and equipment require proper maintenance for efficient use. If not maintained
properly the equipment cannot be used in giving nursing care. To minimize equipment down
time it is necessary to ensure adequate after sale service and service manuals.
4) Unreasonable Patients and Attendants
Illness, anxiety, absence of immediate response to treatment, unreasonable and
uncooperative attitude that in turn affects the quality of care in nursing.
5) Absence of well-informed 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) Absence of accreditation laws

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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 patient’s hospitalizations reveal incidents may occur which have a bearing on the
treatment and the patient’s final recovery. These critical incidents may be
a) Delayed attendance by nurses, surgeon, physician
b) Incorrect medication
c) Burns arising out of faulty procedures
d) Death in a corridor with no nurse / physician accompanying the patient etc.
8) Lack of good and hospital information system
A good management 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) Absence 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, 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.
11) Miscellaneous factors

 Lack of good supervision

 Absence of knowledge about philosophy of nursing care
 Lack of policy and administrative manuals.
 Substandard education and training

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 Lack of evaluation technique
 Lack of written job description and job specifications
 Lack of in-service and continuing educational program

Futuristic Nursing
Introduction

Nursing is a profession with good career opportunities that changes and reflect the society in
which nurse live.

Nurses should be concerned about future directions for nursing. Whether nursing will have a
bright, new professional image depends on how conscientious and industrious nurses are in
their efforts to achieve professionalism.

Definition

“We are in a new place, we are not in the edge of the old place. we are not pushing the
envelope, we are totally a new envelope. So the rule have changed, ever fundamental
premise old way of thinking is no longer applies.”
-Sister Elizabeth Davis

Vision of the future of Nursing

 New treatment and technologies
 Addition of new diseases and threat of bioterrorism

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 Growing specialization in medicine is resulting in a trend towards increased
specialization in nursing
 Developments are showing the need for a deeper therapeutic relationship between the
nurse and the patient.

Nursing in the 21st century

 For the nursing graduate, the future holds numerous social, political and technological
changes
 During the 21st century, societies will continue to move towards globalization
 The clients may be more likely to combine conventional therapies with complimentary
healing techniques, such as homeopathy, neuropathy, therapeutic touch, reflexology,
acupressure, aromatherapy and nutritional therapy.

Sibbold and other experts on nursing and health care also predict the following:-
- Neighbourhood will employ nurses who will work in 24 hours nurse managed clinics
- Nurse practitioners will cross medical threshold to provide services usually provided by
physicians
- Nurse therapist will provide numerous services to the clients and their families
- Hospital stays will be exceedingly short and early discharge will become more important
- Nurses will be strong and autonomous practitioners whose practice and care delivery
focuses much more on health than illness

Future trends in nursing

 Service(practice) education
 Practice (nursing care) Research Administration
 Clinical nurse specialist (CNS)
 Nurse Practitioner (NP)
 Adult nurse practitioner
 Family nurse practitioner
 Doctoral programs in nursing
 Geriatric nurse practitioner
 Bachelor of science in management/ Paediatric nurse practitioner health care
 Women’s health nurse practitioner certificate in forensic education
 Certificate in legal nurse consulting
 Certified nurse midwife
 Certified registered nurse anaesthetist (CRNA) administration
Other areas for practice in service:

 Mobile nursing/ health care education

 Space nursing certified nurse practitioner
 Licensed practical nurse
 Arrow nursing
 Masters of science in nursing/ Masters of Health administration

Developmental changes in the Nursing

1. Nursing Education
2. Nursing Service
3. Nursing Research

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Nursing Education
 Upgrading the profession
 Nursing education through teleconferencing
 Television nursing
 Internet
 Clinical practice nursing
 Standardized examinations

Nursing Practice
 The human genome project
 Robots
 Computer assistance
 Nurses enter private practice
 Space nursing society
 Remote care

Nursing Research
Profession and research: growing amounts of writing the researches have come as a result
of higher education for nurses.

 Significant factors that shape the future of nursing education and research:
 Theoretical clarity about the role or work of nurses
 Current atmosphere in institutions of higher education
 The need for reshaping nursing education to meet the changing features of health care
industry
 The changing face of the learner and learning
 Problems / hindrances for better future of nursing
 Expanding technology
 Influence of modern health technology on nursing education
 Development need of our country
 New threat to health
 New forms of health care

Changing roles of a nurse

 Educator
 Administrator
 Practitioner
 Researcher

References
 Shebeer. P. Basheer. S. Yasmeen khan advanced nursing practice 2nd edition 2017.
Page No. 59 to 63.
 Navdeep Kaur Brar. H C Rawat. Advanced nursing practice 1st edition page no. 945, 984,
961, 1010, 1026.

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The field of quality assurance
is an old as modern nursing.
Florence Nightingale
introduced the
concept of quality in nursing
care in 1855 while attending
the soldiers in the hospital
during the
Crimean war.
The field of quality assurance
is an old as modern nursing.
11
Florence Nightingale
introduced the
concept of quality in nursing
care in 1855 while attending
the soldiers in the hospital
during the
Crimean war.
The field of quality assurance
is an old as modern nursing.
Florence Nightingale
introduced the
concept of quality in nursing
care in 1855 while attending
the soldiers in the hospital
during the
Crimean war.
12
The field of quality assurance
is an old as modern nursing.
Florence Nightingale
introduced the
concept of quality in nursing
care in 1855 while attending
the soldiers in the hospital
during the
Crimean war.
he field of quality assurance is
an old as modern nursing.
Florence Nightingale
introduced the
concept of quality in nursing
care in 1855 while attending

13
the soldiers in the hospital
during the
Crimean war

14