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QUALITY ASSURANCE IN NURSING

1.INTRODUCTION

Quality assurance provides the mechanisms to effectively monitor

patient care provided by health care professionals using cost-effective
resources. 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. It is a
matter of pride for nurses that the nursing profession has attained a distinct
position in the search for quality in health care.

2.CONCEPT OF QUALITY IN HEALTH CARE: Defining quality is difficult.

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

1. Quality is defined as the extent of resemblance between the purpose of

healthcare and the truly granted care (Donabedian 1986).
2. In an economic dimension quality is the extent of accomplished relief
case with a justified use of means and services (Williamson 1999)
3. Government and those who pay of the care will see quality as a
weighing out between results and costs to fulfill certain expectations in
health care. t

3.CONCEPT OF QUALITY ASSURANCE: Quality assurance originated in

manufacturing industry. The idea was “to ensure that the product consistently
achieved customer satisfaction”.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.

4.MEANING OF QUALITY ASSURANCE

Nursing programmes of quality assurance are concerned with the quantitative

assessment of nursing care as measured by proven standards of nursing
practice. In addition, they motivate practitioners in nursing to strive for
excellence in delivering quality care and to be more open and flexible in
experimenting with innovative ways to change outmoded systems

5.DEFINITION OF QUALITY ASSURANCE

“Quality assurance is a judgment concerning the process of care, based on

the extent to which that cares contributes to valued outcomes”. (Donabedian
1982).

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“Quality assurance as 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).

6.APPROACHES FOR A QUALITY ASSURANCE PROGRAMME

Two major categories of approaches exist in quality assurance they are

1. General
2. Specific

A. 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 in US 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

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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.

B. Specific approaches:

Quality assurances are methods used to evaluate identified instances of

providers and client interaction.

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.

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 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.

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. 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.

7.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

1. Input

2. Throughput

3. Output

4. Feedback

The input can be compared to the present state of systems, the throughput to
the developmental process and output to the finished product. The feedback
is the essential component of the system because it maintains and nourishes
the growth. The boundaries of the system define its integration is the
environment is to the other tasks and goals of nursing department, to the
process of nursing science in relation to evaluation. Their boundaries should
be semi-permeable so that they allow necessary information and energy into
and out of the change process.

2) ANA Quality Assurance Model:

The basic components of the ANA model can be summarized as follows:

1) Identify values

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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

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 providres 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.

The evaluation of process standards is a more specific appraisal of the quality

of care being given by agency care providers. An agency can choose to use
the standards of care set forth by the providers professional organization such
as the ANA nursing standards or the agency can use the nursing process and
apply it to the activities of the nurses as the activities correspond to the
procedures of care defined by the agency. The primary approaches for
process evaluation include the peer review committee and the client
satisfaction survey. The techniques included are direct observation,
questionnaire, interview, written audit and videotape of client and provider
encounter

The evaluation of outcome standards reveals the end results of nursing care.
To be able to identify the net changes in the client’s health status as a result of
nursing care will give nursing profession data to show the contributors of
nursing to the health care delivery system. Research studies using the trace
method or the sentinel method to identify client outcomes and client
satisfaction surveys are approaches that may be used to evaluate outcome
standards. Technique used is client classification systems that are admission

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data on the clients’ level of dependence or problems and discharge data that
may show changes in the level of dependence.

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.
The evaluation approaches for outcome standards and criteria include
research studies, client satisfaction surveys, client classification, admission,
readmission, discharge data and morbidity data.

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:

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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.

8.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 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 unco-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

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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

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, 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.

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11) Miscellaneous factors

a. Lack of good supervision

b. Absence of knowledge about philosophy of nursing care

c. Lack of policy and administrative manuals.

d. Substandard education and training

e. Lack of evaluation technique

f. Lack of written job description and job specifications

g. Lack of in-service and continuing educational program

9.FRAMEWORKS FOR QUALITY ASSURANCE:

1. Maxwell (1984)

Maxwell recognized that, in a society where resources are limited, self

assessment by health care professionals is not satisfactory in demonstrating
the efficiency or effectiveness of a service. The dimensions of quality he
proposed are:

 Access to service
 Relevance to need
 Effectiveness
 Equity
 Social acceptance
 Efficiency and economy

2. Wilson (1987)

Wilson considers there to be four essential components to a QA programme.

These are:

 Setting objectives
 Quality promotion
 Activity monitoring
 Performance assessment

3. Lang (1976)

This framework has subsequently been adopted and developed by the ANA.
The stages includes;

 Identify and agree values

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 Review literature, Known QAP

 Analyze available programmes
 Determine most appropriate QAP
 Establish structure, plans, outcome criteria and standards
 Ratify standards and criteria
 Evaluate current levels of nursing practice against ratified structures
 Identify and analyze factors contributing to results
 Select appropriate actions to maintain or improve care
 Implement selected actions
 Evaluate

10.STAGES OF THE DEVELOPMENT OF INTERNATIONAL STANDARDS:

An International Standard is the result of an agreement between the member

bodies of ISO. It may be used as such, or may be implemented through
incorporation in national standards of different countries.

International Standards are developed by ISO technical committees (TC) and

subcommittees (SC) by a six-step process:

 Stage 1: Proposal stage

 Stage 2: Preparatory stage
 Stage 3: Committee stage
 Stage 4: Enquiry stage
 Stage 5: Approval stage
 Stage 6: Publication stage

The following is a summary of each of the six stages:

Stage 1: Proposal stage

The first step in the development of an International Standard is to confirm

that a particular International Standard is needed. A new work item proposal
(NP) is submitted for vote by the members of the relevant TC or SC to
determine the inclusion of the work item in the programme of work.

The proposal is accepted if a majority of the P-members of the TC/SC votes in

favour and if at least five P-members declare their commitment to participate
actively in the project. At this stage a project leader responsible for the work
item is normally appointed.

Stage 2: Preparatory stage

Usually, a working group of experts, the chairman (convener) of which is the

project leader, is set up by the TC/SC for the preparation of a working draft.
Successive working drafts may be considered until the working group is
satisfied that it has developed the best technical solution to the problem being
addressed. At this stage, the draft is forwarded to the working group's parent
committee for the consensus-building phase.

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Stage 3: Committee stage

As soon as a first committee draft is available, it is registered by the ISO

Central Secretariat. It is distributed for comment and, if required, voting, by
the P-members of the TC/SC. Successive committee drafts may be
considered until consensus is reached on the technical content. Once
consensus has been attained, the text is finalized for submission as a draft
International Standard (DIS).

Stage 4: Enquiry stage

The draft International Standard (DIS) is circulated to all ISO member bodies
by the ISO Central Secretariat for voting and comment within a period of five
months. It is approved for submission as a final draft International Standard
(FDIS) if a two-thirds majority of the P-members of the TC/SC are in favour
and not more than one-quarter of the total number of votes cast are negative.
If the approval criteria are not met, the text is returned to the originating
TC/SC for further study and a revised document will again be circulated for
voting and comment as a draft International Standard.

Stage 5: Approval stage

The final draft International Standard (FDIS) is circulated to all ISO member
bodies by the ISO Central Secretariat for a final Yes/No vote within a period of
two months. If technical comments are received during this period, they are
no longer considered at this stage, but registered for consideration during a
future revision of the International Standard. The text is approved as an
International Standard if a two-thirds majority of the P-members of the TC/SC
is in favour and not more than one-quarter of the total number of votes cast
are negative. If these approval criteria are not met, the standard is referred
back to the originating TC/SC for reconsideration in light of the technical
reasons submitted in support of the negative votes received.

Stage 6: Publication stage

Once a final draft International Standard has been approved, only minor
editorial changes, if and where necessary, are introduced into the final text.
The final text is sent to the ISO Central Secretariat which publishes the
International Standard.

IMPACT OF ISO IN A LOCAL HOSPITAL:

Positive impacts:

1. Nurses are accountable for their actions and, professionally, we have

responsibility to evaluate the effectiveness of our care
2. Nurses can deliver a high standard of care, and being empowered to
identify and resolve problems can add to personal satisfaction with
work

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3. Documents state clearly how the health service should perform and
what the patient can expect

4. Guaranteeing standards of care to the public must be a duty of all

those who work within the health service

5. Nurses are actively involve in audit, service reviews, standard-setting

and customer relations

6. Improves the overall quality of nursing care

7. Improves all types of documentation and communication

8. Helps in professional growth

Negative impacts:

1. Lack of adequate resources

2. Lack of trained, skilled and motivated employees, staff indiscipline
affects the quality of care.

3. ISO activities may overburden the nursing personnel

4. Nurses will not get adequate time to spent with the patient, most of the
time may be spending for recording and reporting

5. The hospital will be restricted only to ISO standards

6. Hospital has to provide special training for all the staffs those who are
involved in ISO inspection

IMPACT OF ISO IN A LOCAL NURSING EDUCATIONAL INSTITUTIONS:

Positive impacts:

1. Improves the quality of nursing education

2. improves the quality of nursing practice

3. Helps to maintain international standard

4. Helps to compare the standard with another institution

5. Helps in personnel development of teachers

6. Helps to maintain all the records in time

7. Avoids malpractice and bias

8. Encourages extra-curricular activities also

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9. Act as a control for all the activities

10. Improves professional growth

Negative impacts:

1. Gives more importance to documentation

2. Over-burden for the teachers

3. Teachers need to take special training in maintaining the standards

4. Not observing the actual practice

5. Organizational philosophy and policies has to be modified according to

the ISO standards

CRITICAL ANALYSIS:

 Strengths: ISO helps to improve and maintain the quality of

educational institutions and hospitals
 Weakness: Standards are set by the institution itself, it may be biased
 Opportunities: Helps in professional growth
 Threats: Organizational philosophy and policies may not be
considered

11.QUALITY ASSURANCE IN NURSING PRACTICE

Introduction

Standard is an acknowledged measure of comparison for quantitative or

qualitative value, criterion, or norm. A standard is a practice that enjoys
general recognition and conformity among professionals or an authoritative
statement by which the quality of practice, service or education can be
judged. It is also defined as a performance model that results from
integrating criteria with norms and is used to judge quality of nursing
objectives, orders and methods

A standard is a means of determining what something should be. In the case

of nursing practice standards are the established criteria for the practice of
nursing. Standards are statements that are widely recognised as describing
nursing practice and are seem as having permanent value.

A nursing care standard is a descriptive statement of desired quality against

which to evaluate nursing care. It is guideline. A guideline is a recommended

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path to safe conduct, an aid to professional performance.A nursing standard

can be a target or a gauge. When used as a target, a standard is a planning
tool. When used as a gauge against which to evaluate performance a
standard is a control device.

Characteristics of Standard

 Standards statement must be broad enough to apply to a wide variety

of settings.
 Standards must be realistic, acceptable, attainable.

 Standards of nursing care must be developed by members of the

nursing profession; preferable

 nurses practising at the direct care level with consultation of experts in

the domain.

 Standards should be phrased in positive terms and indicate acceptable

performance good, excellence etc.

 Standardsof nursing care must express what is desirable optional level.

 Standards must be understandable and stated in unambiguous terms.

 Standards must be based on current knowledge and scientific

practice.

 Standards must be reviewed and revised periodically.

 Standards may be directed towards an ideal ,ie,optional standards or

may only specify the minimal care that must be attained,ie, minimum
standard.

 And one must remember that standards that work are objective,
acceptable, achievable and flexible.

Purposes of Standards

 Setting standard is the first step in structuring evaluation system. The

following are some of the purposes of standards.
 Standards give direction and provide guidelines for performance of
nursing staff.

 Standards provide a baseline for evaluating quality of nursing care

 Standards help improve quality of nursing care, increase effectiveness

of care and improve efficiency.

 Standards may help to improve documentation of nursing care

provided.

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 Standards may help to determine the degree to which standards of

nursing care maintained and take necessary corrective action in time.

 Standards help supervisors to guide nursing staff to improve

performance.

 Standards may help to improve basis for decision-making and devise

alternative system for delivering nursing care.

 Standards may help justify demands for resources association.

 Standards my help clarify nurses area of accountability.

 Standards may help nursing to define clearly different levels of care.

Major objectives of publishing, circulating and enforcing nursing care

standards are to:

1. improve the quality of nursing care,

2. decrease the cost of nursing, and

3. determine the nursing negligence.

Sources of Nursing Care Standards

It is generally accepted that standards should be based on agreed up

achievable level of performance considered proper and adequate for specific
purposes. The standards can be established, developed, reviewed or
enforced by variety of sources as follows:

 Professional organisation, e.g. Associations, TNAI,

 Licensing bodies, e.g. Statutory bodies, INC,

 Institutions/health care agencies, e.g. University Hospitals, Health

Centres.

 Department of institutions, e.g. Department of Nursing.

 Patient care units, e.g. specific patients' unit.

 Government units at National, State and Local Government units.

 Individual e.g. personal standards

Classification of Standards

There are different types of standards used to direct and control nursing
actions.

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1. Normative and Empirical Standards

Standards can be normative or empirical. Normative standards describe

practices considered 'good' or 'ideal' by some authoritative group. Empirical
standards describe practices actually observed in a large number of patient
care settings. Here the normative standards describe a higher quality of
performance than empirical standards. Generally professional organisations
(ANA/TNAI) promulgate normative standards where as low enforcement and
regulatory bodies (INC/MCI) promulgate empirical standards.

2. Ends and Means Standards

Nursing care standards can be divided into ends and means standards. The
ends standards are patient-oriented; they describe the change as desired in a
patient's physical status or behaviour. The means standards are nursing
oriented, they describe the activities and behaviour designed to achieve the
ends standards. Ends (or patient outcome) standards require information
about the patients. A means standard calls for information about the nurses
performance.

3. Structure,Process and Outcome Standards

Standards can be classified and formulated according to frames of references

(used for setting and evaluating nursing care services) relating to nursing
structure, process and outcome, because standard is a descriptive statement
of desired level of performance against which to evaluate the quality of
service structure, process or outcomes.

a. Structure Standard

A structural standard involves the 'set-up' of the institution. The philosophy,

goals and objectives, structure of the organisation, facilities and equipment,
and qualifications of employees are some of the components of the structure
of the organisation, e.g. recommended relationship between the nursing
department and other departments in a health agency are structural
standards, because they refer to the organisational structure in which nursing
is implemented. It includes people money, equipment, staff and the evaluation
of structure is designed to find out the effectiveness ,degree to which goals
are achieved and efficiency in terms of the amount of effort needed to
achieve the goal.

The structure is related to the framework, that is care providing system and
resources that support for actual provision of care. Evaluation of care
concerns nursing staff, setting and the care environment. The use of
standards based on structure implies that if the structure is adequate, reliable
and desirable, standard will be met or quality care will be given.

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b. Process Standard

Process standards describe the behaviours of the nurse at the desired level of
performance The criteria that specify desired method for specific nursing
intervention are process standards. A process standard involves the activities
concerned with delivering patient care.These standards measure nursing
actions or lack of actions involving patient care.The standards are stated in
action-verbs, that is in observable and measurable terms.eg :the nurse
assesses", "the patient demonstrates". The focus is on what was planned,
what was done and what was communicated or recorded. Therefore, the
process standards assist in measuring the degree of skill, with which
technique or procedure was carried out, the degree of client participation or
the nature of interaction between nurse and client.In process standard there is
an element of professional judgement determining the quality or the degree of
skill. It includes nursing care techniques, procedures, regimens and
processes.

c.Outcome Standards

Descriptive statements of desired patient care results are outcome standards

because patient's results are outcomes of nursing interventions. Here
outcome as a frame of reference for setting of standards refers to description
of the results of nursing activity in terms of the change that occurs in the
patient. An outcome standard measures change in the patient health status.
This change may be due to nursing care, medical care or as a result of variety
of services offered to the patient. Outcome standards reflect the effectiveness
and results rather than the process of giving care.

12.LEGAL SIGNIFICANCE OF STANDARDs

Standards of care are guidelines by which nurses should practice.If nurses do

not perform duties within accepted standards of care,they may place
themselves in jeopardy of legal action.Malpractice suit against nurses are
based on the charge that the patient was injured as a consequence of the
nurses failure to meet the appropriate standards of care.

To recover losses from a charge of malpractice, a patient must prove that:

1. a patient-nurse relationship existed such that the nurse owed to the

patient a duty of due care,
2. the nurse deviated from the appropriate standard of care,

3. the patient suffered damages,

4. the patient's damages resulted from the nurses deviations from the
standard of care.

13.Quality Improvement:

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The JCAHO (JOINT COMMISSION ON ACCREDITATION OF HEALTH

CARE ORGANIZATION) defines quality improvement as a method for
continuously studying and improving the process related to the provision of
the healthcare services to meet the needs of clients and others. Quality
improvement focuses on improving organization performances related to
processes.
JCAHO identifies performance as what is done and how well it is done to
provide health care. Among the processes that most directly influence clients
are those that constitute nursing practice. The quality of nursing practice is a
principal responsibility of nursing managers and their staff.

 Professional Standards:

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Professional standards are authoritative statements used by the

profession in describing the responsibilities for which its practitioners are ac-
countable. Included are the policies and position descriptions that identify the
performance skills within an institution. Standards are an organization's in-
terpretation of the professional's competency. Whenever a work unit such as a
nursing staff attempts to define quality, professional performance is a critical
element.
 Care Guideline:
Care guidelines are systematically developed statements to assist in
determining how diseases, disorders, and other health conditions can be
most effectively and appropriately prevented, diagnosed, treated, and
clinically managed. It i`ncludes procedures ,care plans, protocols, and critical
pathways.
 Outcomes:
Outcomes are the conditions to be achieved as a result of care delivery. An
analysis of outcomes is a key component of quality improvement. An outcome
tells whether interventions are effective ,whether client progress, how well
standards are being met and whether changes are necessary. There are two
types of outcomes :

1. Professional outcomes: A measure of the professional caregivers

performance.
2. Client outcomes: A measure of the clients status after receiving care.
All clients have outcomes reflected in their nursing plan of care.

Developing Quality Improvement Teams:

It makes sense for health care providers who are most familiar with client
care activities to collaborate on QI efforts. · In many health care organization
there are organization-wide and unit—based QI teams or committies.” The
organization-wide teams are composed or staff from all departments within a
hospital. The prohlems these teams seek k to solve usually affect processes
that occur Ion all units within an organization., In contrast, unit-based Ql
teams identify clinical priorities for a work unit.
Components of a Ql Program. A well-organized QI program focuses on
processes or systems that significantly Contribute to outcomes.
Responsibility for a QI programme: Leadershi.p and planning are essential
components of quality improvement . I, Most organizations have a director
responsible for TQM. In nursing care areas, home I care sections, or clinics,
a nurse mamager is response.ble for supporting a unit-based program. ,
Individual staffs are responsible for monitoring practice, making decisions
about ways to improve practice, and evaluating results.

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Scope of Service:
Each nursing care area involved in the care of a select group of clients
provides a well defined set of services. A unit’s scope of service includes the
types of clients who receive nursing care and the types of processes involved
in delivering care. · An exam· ple might be a general medicine unit in a
hospital that cares for middle-age and older adult clients who have diabetes,
heart disease, and gastrointestinal disorders. Such a unit would be involved in
processes that include intravenous administration, diabetes education,
referrals for cardiac diagnostic testing, and endoscopy. An understanding of
the scope of service allows staff to focus on quality issues related to typical
client groups.
Developing quality indicators:
, A quality indicator is a quantitative measure of an important aspect of
service that determines whether the service conforms to established
standards or requirements. · There are three types of indicators: structure,
process, and outcome.
Structure indicators evaluate the structure or systems for delivering care; an
example is adherence in checking if emergency carts are adequately stocked
or if forms documenting restraint use are completed correctly.
Process .indicators evaluate the manner in which care is delivered (e.g., the
process of pain assessment, recovery of clients from sedation, and clients’
referral to community services). Outcome indicators, evaluate the end result
of care delivered (e.g., incidence of nosocomial infection and adherence to
medication therapy).
Establishing Thresholds for Evaluation;
After selecting a quality indicator,, staff members must determine ways to
quantitatively measure the indicator. The occurrence of an indicator, or the
percentage of times the indicator is observed (e.g., the number of clients
havi.ng surgery who can successfully explain their discharge instructions) is a
common measure. threshold is a standard for determining whether a
problem exists.
Data Collection and Analysis.
· The process of data collection and analysis can be simple or complex.
obtaining accurate results that help in making appropriate decisions regarding
quality care issue. Many organizations bave made QI so important that formal
research studies are conducted . When formal research l’: not conducted,
staff may be come involved in simple evaluation studies involving the
collection of data on frequencies and percentages for a · predetermined
number of clients or cases.Evaluation studies offer valuable information on
practice trends and whether problems are evident.
Evaluation of Care:
Monitoring of quality indicators Evaluation of Care. Monitoring of quality
indicat,ors desired Outcomes. This allow staff to find the aspect of the
process to improve, organize all expert team that knows the process, clarify
knowledge about the process, understand any sources of variation, and select
an improvement or solution.
Resolution of problems:

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· After evaluating quality problem, staff develop action plans to improve the
process and outcomes. It is important to establish actions that will be
successful. · An action plan should be more direct.
Evaluation of Improvement.
After implementing an action plan, the staff must reevaluate its success.· The
change may be positive or negative. The QI process is similar to the nursing
process in that when desired outcomes are not met, the staff reinstitutes the
QI process
Communication 0f results :
, The result s of QI active ties must be communicated to staff in all appropriate
organizational departments. If findings and results are not Communicated,
practice changes will likely not occur. Regular discussions of QI activities
through staff meetings newsletters, and rnemos are examples of
communication strategies. Often a QI study reveals information requiring
organization-wide change. To this case the organization must be responsible
for responding to the problem with the resources needed to make changes.
Revision of policies and procedure, modification of standards of care, and
implementation of system changes are examples of ways that an organization
may respond.
CONCLUSION

Quality assurance is to provide a higher quality of care. It is necessary that

nurses develop standards of patient care and appropriate evaluation tools, so
that professional aspects of nursing involving intellectual and interpersonal
activities. Quality will be ensured and attention will be given to the individual
needs and responses to patients.The formulation of standards is the first step
towards evaluating the nursing care delivery. The. standards serve as a base
by which the quality of care can be judged. This judgement may be according
to a rating or other data that reflect the conformity of existing practice with the
established standards. The standards must be written, regularly reviewed and
well-known by the nursing staff.

Journal abstracts

Design and Results of the Nursing Quality Assurance

Program in Hospital de la Santa Creu i Sant Pau: An
Integrated Effort
This paper aims to describe and evaluate the results of the Nursing Quality
Assurance (QA) Program in the Hospital de la Santa Creu i Sant Pau. The
program was designed in 1987 as part of a global QA program involving all
aspects of patients' care. The QA Program was organized at three levels:
hospital, ward and joint medicalnursing. During the first 3 years of the study
the following activities were carried out: (A) nursing process and results; (B)
risk management; (C) patients' opinion; (D) utilization review; (E) ward nursing
QA programs. Among other significant results, the program has detected that
only 55.6% patients manifest that they sleep well at hospital, hygiene of
dependent males (51%) is significantly worse than dependent females (81%)
and patients' falls are more prevalent among oriented patients (73%) than

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disoriented patients (27%). Also a significative improvement has been

demonstrated after implementing corrective measures in patients' information
(7.5/10–8.1/10) and patients without supervision in emergency areas became
from 35% to 0.02%. New nursing records were designed as a result of the QA
assessment. The most important conclusion is that the Nursing QA Program
is a valid instrument to evaluate general problems in the hospital and concrete
problems in each ward.
Patient education and quality assurance in nursing Vivien E.
Coates :
Changes in healthcare provision introduced in the early 1990s raised
awareness of the issue of quality in health care. Quality, currently a
fashionable topic, is an abstract concept and attempts to define and measure
its properties have proved controversial and challenging. An equally
challenging aspect of nursing care is the satisfactory delivery of health
education to patients. This paper focuses on patient education and quality
assurance in nursing. The results of a study concerning 20 young adults with
insulin-dependent diabetes mellitus (IDDM) are reported. The findings indicate
deficiencies in their experiences of patient education at initial diagnosis,
discharge home after first hospital admission and when needing further
information. It is contended that patient education is an area which requires
qualitative as well as quantitative measurements of quality in order to capture
the unique experience of information needs.

Bibliography

1. Barbara C.(2001)Contemporary nursing issues trends and

management, Mosby publication; St Louis:
2. Barbara kozier (2004) fundamemtals of nursing, first edition.pearson
publications .singapore.
3. Basavanthappa BT.(2000) Nursing administration. Jaypee brothers;
New Delhi:
4. Margaret MM.(1992) Professionalization of nursing; current issues and
trends. JB Lippincott company; Philadelphia:
5. Stanhope.(1988) Community Health Nursing Process and Practice for
promoting health. Mosby publication; St Louis:

Journals:

 Journal of Research in Nursing July 1996 vol. 1 no. 4 307-317

 International.Journal for Quality in Health Care Volume5, Issue3 April
17, 1992.

 Journal of Research in Nursing November 2000 vol. 5 no. 6 416-423

Net refference:
 http://onlinelibrary.wiley.2648.1992.tb01999.x/abstract

 intqhc.oxfordjournals.org/content/5/3/267.abstract

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 http://jrn.sagepub.com/content/1/4/307

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