Quality:

 Quality is defined as the extent of

resemblance between the purpose of
healthcare and the truly granted care
(Donabedian 1986).
Quality 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).
APPROACHES FOR A QUALITY ASSURANCE PROGRAMME:

 Two major categories of approaches

exist in quality assurance they are
 General
 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:
2) Licensure:
3) Accreditation:
4) Certification:
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 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) 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 agency's
physical structure, organizational
structure and personal qualification
4) Certification:

 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.
Specific 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) Audit 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.
QUALITY ASSURANCE MODEL IN
NURSING
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
PHILOSOPHY OF QUALITY
ASSURANCE MODEL IN NURSING
Indian nursing council believes 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
PURPOSE OF QUALITY ASSURANCE
MODEL
 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
GOALS OF QUALITY ASSURANCE
MODEL
 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
 MODELS OF QUALITY ASSURANCE

1) System Model for Quality

assurance.
2) ANA Quality Assurance Model
3) JCAHO Quality Assurance Model
4) ISO Quality Assurance Model
A System Model for Quality 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.
AMERICAN NURSES ASSOCIATION MODEL FOR
QUALITY ASSURENCE

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 services.
2) Identify structure,
process and outcome
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 agency.
 3) Select measurement needed
to determine degree of
attainment 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
physicals facilities.
 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) Make 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 Course of Action

 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) Choose 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 Action:

 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) Reevaluate:

 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
JCAHO QUALITY ASSURENCE MODEL
ISO QUALITY ASSURENCE MODEL
QUALITY ASSURANCE PROCESS:

 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
FACTORS AFFECTING QUALITY
ASSURANCE IN NURSING CARE
1) Lack of Resources:
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 problems:

 Lack of trained, skilled and motivated

employees, staff indiscipline affects
the quality of care.
3) Improper maintenance:

 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 and
service manuals.
4) Unreasonable 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) 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
 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
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, 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