INTRODUCTION

The field of Quality Assurance is as 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. Quality is rapidly becoming a
concern to both consumers and the providers of the services. In health care quality is being
demanded and providers are judged by the quality of services. And hence there is a need to
sensitize and train nursing personnel to provide quality care.
DEFINITIONS
Quality Assurance is the defined as a nursing practice through well written nursing standards and
the use of those standards as a basis for evaluation on improvement client care [Maker 1998]
Quality assurance is the monitoring of the activities of the client care, to determine the degree of
excellence attained to the implementation of the activities. (Bull 1985).
OBJECTIVES
 To ensure the delivery of quality client care
 To demonstrate the efforts of the health care providers
 To provide technical assistance in correcting systematic deficiencies
 To refine existing methods for ensuring optional quality health care.
 To provide the best possible results.
MEANING OF QUALITY
Quality is doing the right thing right the first time and doing it better the next time.
Quality is defined as the extent to resemblance between the purpose of health care and truly
granted care.
ELEMENTS OF QUALITY
 Appropriateness
The service or procedure is what the population or individual actually needs.
 Equity
A fair share is available for all the population.
 Accessibility
Services are not compromised by undue limits of time and distance.
 Effectiveness
Services are achieving the intended benefits for the individual and for the population.
 Acceptability
Services are provided such as to satisfy the work expectations of patients, providers and the
Community.
NEED FOR QUALITY ASSURANCE IN NURSING
 To ensure quality, nursing care provided by nurses in order to meet the expectations of
receiver , management and regulatory body.
 Improves and maintains the patients state of health.
 Improves and maintains the patients functional abilities.
 Develops the patient’s psychophysical condition.
 To refine existing methods for ensuring optimal quality health care
PRINCIPLES OF QUALITY ASSURANCE
There are five basic principles of quality assurance:
1. Quality assurance is oriented towards meeting the needs and expectations of our clients.
2. It focuses on systems and processes.
3. It uses data to analyze service delivery.
4. It encourages the use of teams in problem – solving and quality improvement.
5. It uses effective communication to improve service delivery.
FACTORS AFFECTING QUALITY ASSURANCE IN NURSING PRACTICE
 Lack of resources
 Personnel problem
 Improper maintenance
 Unreasonable patients and attendants
 Absence of well-informed population
 Absence of accreditation laws
 Lack of incident review procedure
 Lack of good hospital information system
 Absence of patient Satisfaction Surveys
 Lack of nursing care research
 Miscellaneous Factors
QUALITY ASSURANCE PROCESS
Quality assurance process is the 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

1. Setting standards
The nursing profession should have to design standards of nursing practice that are specific to the
patient population served. These standards could serve as the foundation upon which all other
measures of quality assurance are based. An example of a standard is: Every patient will have a
treatment chart.
2.Determining Criteria
After standards of performance are established, criteria must be determined that will indicate if the
standards are being met and to what degree they are met. Just as with standards of care, criteria
must be general as specific to the individual unit. One criterion to demonstrate that the standard
regarding care plans for every patient are being met would be: A nursing care plan is developed
and written by a nurse within 10 hours of admission. This criterion, then, provides a measurable
indicator to evaluate performance.
3.Data Collection
It is the 3rd step in quality assurance. Sufficient observations and random samples are necessary
for producing reliable and valid information. A useful rule is that 10% of the institutional patient
population per month should be sampled. The devised tool to collect data should leave as little
room for interpretation by the data collector as possible. Data collectors need to be taught the
purpose of quality assurance along with the principles of data collection.
Data collection methods include:
a. Patient observations and interviews
b. Nurse observations and interviews.
c. Review of charts.
A policy should outline guidelines of the reporting of quality assurance data so it is clear who in
the organization needs to receive quality assurance information. The policy should also states at
what level in the organization the analysis of the different criteria is to take place, to whom these
analyses and recommendations are to be reported, who is responsible for implementing the
recommendations, and who is responsible for follow-up. Unless definite policies are established,
the system may fail and changing in nursing practice are not likely to occur.
4.Evaluating Performance
Various methods can be used to evaluate performance.
1. Reviewing documented records
2. Observing activities as they take place
3. Examining patients
4. Interviewing patients, families and staff.
Records are the most commonly used source for evaluation because of the relative ease of their
use, but they are not as reliable as direct observations. It is quite possible to write in the patient’s
chart activities that were not done or not to record those things that were done. The chart only
indicates that care was provided, it does not demonstrate the quality of that care. For example,
care plan could be checked nursing diagnosis, interventions planned, and discharge planning.
5. Making plans for change based on the evaluation
It includes taking the actions for improving quality care by changing the present scenario and
incorporate new policies for the same.
THE 10-STEP PROCESS IN A QUALITY ASSURANCE PROGRAM
Step 1-Assign Responsibility
Nursing departments and services must assign overall responsibility for their monitoring and
evaluation activities.
Step 2-Delineate Scope of care and services
Intended to assure that all nursing activities are considered in monitoring and evaluation
Types of patients served
a. Types of patients served
b. Condition and diagnosis
c. Types of nursing staff providing care and services
d. All existing standards of patient care.
Step 3-Identify important Aspect of care and services
It is important for nursing staffs to remember that important aspect of care are activities of
department that will be continually monitored and periodically evaluated to determine if care can
be improved or if problems are present. Nursing staff should identify those aspects of care and
services that:
  Occur frequently or affect large numbers of patients.
 Place patient at high risk.
 Have intended in the past to produce problems.

Step 4-Identify Indicators

Indicators are measurable variables related to the structure. Process or outcomes of care:
 Structures – Elements that facilitate care (resources, equipment, numbers and qualification
of staff)
 Process – Functions carried out by practitioners (assessment, treatment, planning and
medication administration)
 Outcomes – Includes complications, adverse effects, short and long term results of
treatment)

Step 5-Establish Threshold for Evaluation

 Thresholds are accepted levels of compliance with any indicators being measured.
 Thresholds for evaluations are the level or point at which intensive evaluation is triggered.

Step 6-Collect and Organize Data

Some common date can be found in:
 Patients, records
 Medication sheets
 Infection control
 Meeting minutes
 Patient surveys
 Incident reports
 Department logs
 Laboratory reports
 Direct observation
 Formal evaluation

Step 7-Evaluate Care

Once threshold for an indicator is reached, the critical step of evaluation is initiated. The most
important purpose of monitoring and evaluation is to foster overall continuous improvement in the
level of performance. Some examples are;
 Lack of knowledge and skill
 Staff members knew what to do but did not do so
 Equipment deficiencies
 Deficiencies in medical record documentation
 Policy \ procedure violation
 Lack of adequate staffing
 Infection control violation
 Inappropriate therapy, diagnostics.

Evaluation must be designed to identify the opportunities for improvement by:

 Objectively examining the possible causes for the level of performance
  Recommending action pertinent to those causes to improve the performance.

Step 8-Take Actions to Solve Problems or Otherwise improve

Some possible actions if the problem involves deficiencies in systems, include:
 Changing communication channels
 Changing organizational structure
 Adjusting staffing or redistributing staff
 Revising job descriptions
 Reallocating resources
 Adding or revising policies and procedures
 Altering the use of equipment
 Purchasing and repairing equipment.

Some possible actions, if the problem involves deficiencies in staff knowledge, include:
 Modifying orientation procedures
 Providing focused in-service education
 Providing focused continuing education
 Circulating written policies and procedures or other informational material.

Some possible actions, if the problem involves behavior or performance deficiencies, include:
 Revising job descriptions
 Informal counseling
 Changing assignments
 Disciplinary sanctions
 Limiting staff prerogatives relating to patient care
 Transferring to another unit/Department.

Step 9- Assess the Effectiveness of Actions

Monitoring and evaluation does not end when actions are taken. Staff continues to monitor the
aspect of care future opportunities for improvement, but they must determine whether are taken
successfully in improving care or service.
Step 10- Communicate Relevant Information to the organization-Wide Quality Assurance
Program
It is essential that monitoring and evaluation information be communicated through established
channels. Appropriate; dissemination of information helps to assure that quality assurance
activities are coordinated and that knowledge regarding monitoring, evaluation and problem-
solving methods is Shared.
APPROACHES FOR A QUALITY ASSURANCE PROGRAM
Two major categories of approaches exist in quality assurance;
A. General
B. Specific

General Specific
Peer review
Approaches Approaches committee
s The Audit
processUtilizat
 Credentialing
Licensure
Accreditation
Certification

GENERAL APPROACH
It involves large governing of official body’s evaluation of a person’s or agency’s ability to meet
established criteria or standards at give time.
1) Credentialing;-
A person generally defines it as the formal recognition of personal or technical competence
and attainment of minimum standards by a person or agency. According to Hinsvark [ 1981]
credentialing process has four functional components;
 To provide a quality product
 To confer a unique identity
 To protect provider and public
 To control the profession.
2) Licensure;-
Individual licensure is a contract between the profession and the state, in which the is
granted control over entry into and exists from the profession and professional practice the
licensing process requires that regulations be written to define the scopes and limits of the
professionals practice. Law has mandated licensure of nurses 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.
In 1990,more emphasis was placed on evaluation of the outcomes of care and on the
educational qualifications of the person providing care.
4) Certification;-
Certification is usually a voluntary process within the profession. A person’s
educational achievement, 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 provider and client
interaction.
A. 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.

B. The Audit process-[Stan Hope Caster,2000]

 Follow-up of problem Topic study selected.
 Recommendations for correcting deficiencies, explicit criteria selected for quality
care.
 Peer review of all cases not meeting criteria.
 Records review
NURSING AUDIT
Nursing audit is evaluation of patient care through analysis of written records maintained by
nurses in patient’s treatment profile. - Avtar Brar
GOALS OF NURSING AUDIT
• To improve quality of health care.
• To promote improved communication among nurses & other health team members.
• To improve quality of nursing care.
• To detect & analyze problems & errors.
NURSING AUDIT PROCESS

ADVANTAGES OF NURSING AUDIT

 Provides quality of nursing
 A patient is assured of good services.
 It will give valuable and pertinent information for the staff.
 It will lead to between co-operation and communication among the nurse & health team.
 It will help each professional nurse for her self evaluation.
 It helps the administration as better planning.
 It will reduce the incidence of medical legal complication.
 It will broaden and strengthen nursing service.

C. 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 .
There are 3 types of Utilization Reviews. They are;
i. Prospective: It is an assessment of the necessity of care before giving service.
ii. Concurrent: It is a review of the necessity of care while the care is being given.
iii. Retrospective: It is an analysis of the necessity of the services received by the client
after the care has been given.

Utilization Review (UR) has been used primarily in hospitals to establish need for client
admission and 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.
Advantages of Utilization Review
 It is designed to assist to avoid unnecessary care.
 It may serve to encourage the consideration of care options by providers, such as home
health care than hospitalization.
 It can provide guidelines for staff of program development.
 It provides a measure of agency accountability to the consumer.

Disadvantage of Utilization Review

Not all clients are fit for the classic picture presented by the explicit criteria that serve as the basis
for approval or denial of care.
COMPONENTS OF QUALITY IMPROVEMENT PROGRAMS

 Establish responsibility & accountability.

 Define scope of service for clinical area.
 Define key aspects of service for clinical area
 Develop quality indicators to monitor outcomes & appropriateness of care delivered.
 Establish threshold for evaluation of indicators.
 Collect & analyze data from monitoring activity.
 Evaluate results of monitoring activities to determine the need for change in practice
 Resolve problems through development of action plans.
 Reevaluate to determine if plan was successful.
 Communicate quality improvement results to organization.
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’s structure - process- outcome model

Donabedian’s introduced 3 major methods of evaluating quality care.
1. Structural Evaluation

This method evaluates the setting and instruments used to provide care such as facilities,
equipments and characteristics of the administrative organization and qualification of the health
providers. The data for the structural evaluations can be obtained from the existing documents of
an agency or from an inspector of a faculty.
2. Process Evaluation

This method evaluates activities as they relate to standards and expectations of health provider in
the management of client care, data for this can be collected through direct observations of
provider encounters and review of records, audit, checklist approach and the criteria mapping
approach are used to establish the client encounter protocol.
3. Outer 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 or telephone
client interviews, mailed questionnaire and client records.
The Tracer Method
It 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 HTN, Ulcers,
and UTI and to establish criteria for good medical and nursing management of the illness have
used the tracer 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;
 Cases of unnecessary disease, disability deaths are counted.
 The circumstances surrounding the unnecessary event or the sentinel is examined in
detail.
 In review of morbidity and mortality are used as an index.
 Health status indicator such as changes in social, economic, political and
environmental factors are reviewed which may have an effect on health outcomes.

Quality Assurance in nursing according to the Norma Lang model

In literature, one can trace many models to evaluate the quality of nursing. Most models use as
their basis Norma Lang’s model from 1976, which has seven levels. The Norma Lang model has
seven levels that run through three phases.
i. Description:

In the first phase Description, we identify the values and attitudes that lead us to nursing. Then we
select criteria for excellent nursing in standards covering the structure, process and outcome.
ii. Measurement:

In the second phase Measurement, we choose the methodology that is used to determine what our
practice is like in comparison with standards and criteria for excellent nursing, which we have set
internally or we st externally. The resuls obtained are analysed and then we decide if and why we
need changes.
iii. Action:

In the third phase Action, we choose the changes and paths along which the changes will
run in our environment and finally introduce the changes in our routine work.
Frameworks for Quality Assurance
Maxwell(1984): Maxwell recognized that,in a society whole resources are limited, self-
assessment by health care professionals is not satisfactory in demonstrating the effiency of a
service .The diamensions of quality he proposed are
 Access to service
 Relevance to need
 Equity
 Social acceptance
 Efficiency and economy.

2.Wilson(1987): Wilson considers four essential components toa quality assurance program.
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
 Establish structure,plans,outcome criteria and standers
 Review literature
 Analyze available programs
 Determine most appropriate program
 Evaluate current levels of nursing practice
 Identify and analyze factors contributing to results
 Select appropriate actions to maintain or improve care
 Implement selected actions
 Evaluation

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 prescribed by the regulatory body / health
care system/ organization/ institution even if it is in conflict with her.
 Be committed to understanding of dynamic nature of his / her role in
interdisciplinary health team.
 Be obligated to create public awareness and consider social expectations before making
decisions for providing nursing care.
 Be obligated 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 committeed to advancement of profession.

Purposes of Quality Assurance model

 To ensure quality nursing care provided by nurses inorder 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.
 Strengthen documentation of nursing care.
 Promote optimum utilization of resources in providing cost effective nursing care.

Models of Quality Assurance

1.System Model for Quality Assurance
System model is used for implementation of unit based quality assurance program.It involves
making changes in organizational structure and individual roles.In system model, task is broken
down into manageable components based on defined objectives.
The basic components of the system are:
a. Input -- The input can be compared to the present state of systems.
b. Throughput -- It is developmental process.
c. Output -- It is finished product or result.
d. Feedback -- It is essential component of system because it maintains and nourishes
growth.
2. ANA Quality Assurance Model.
The basic components of the American Nurses Association Model
3. JCAHO(Joint Commission on Accrediation of Health Care rganization) Quality Assurance
Model
4. ISO (International Standards Organisation) Quality Assurance Model

Selecting a Nursing Quality Assurance Model

 Select or develop a structure that first with the organizational structure and the style
management practiced in the organization.
 Decide on the format that makes the best use of resources and manpower available
 Keep the format simple and streamlined
 Use a consistent model throughout the division of nursing
 In a skilled nursing facility, use a consistency model throughout the facility
 It is a tool for assuring and improving quality of care.
 Used to monitor and evaluate the quality and appropriateness of care.
 It is the ongoing process to examine care, to find potential problems and opportunities for
improvement and to do something about them.

BARRIERS OF QUALITY IMPROVEMENT EFFORTS

 The Nurse Manager might become pre occupied with quality assessment
 It is impossible to identify all factors that influence nursing care quality.
 Difficulty in defining outcome criteria that result solely from nursing intervention
  Nurse’s documentation of care measures is at times vague, incomplete and lacking in
objectivity
 There is still no single, all purpose, all site quality assessment tool that is universally
appropriate for all health agencies.
 High cost

ROLE OF NURSES IN QUALITY ASSURANCE

Nurses are the active participant of interdisciplinary quality improvement team.
Develop mechanism for continually monitoring the effectiveness of nursing care both a
collaborative and an individual professional activity.
Contribute innovations and improvement of patient care
Participating in improvement projects and patient safety initiatives
Participate continuing educational programs and in- service educational programs for continuing
professional development
Periodic and continuing appraisal and evaluation of health care situation of the patient
Participate research works related to quality assurance
Identify any area of needed improvement in delivery of care

CONCLUSION
From the foregoing, it can be clearly seen that professional nursing education can be
greatly enhanced by quality assurance . The importance of evaluation to ensure this can never be
overemphasized. This is because both nursing education and practice are practically oriented. In
the course of course of training student nurses, there are skills (both simple and complex),
concepts, values and concrete body of knowledge to be acquired by the students. When Quality
assurance is implemented as suggested above, the quality of product from nursing education is
sure to improve and their ability as care givers greatly enhanced. There can be no improvement
in nursing efficiency without adequate information about the structure , process and outcome of
quality nursing services rendered to the health needs of the 21st century society.
BIBLIOGRAPHY

BOOKS:
1. Soni Samta,2013, Text book of Advanced Nursing Practice, , Jaypee Brothers Publishers, New
Delhi, 2013 : 14 - 22
2. Brar Navdeep Kaur, Text Book of Advanced Nursing Practice, Jaypee Brothers, New Delhi ,
2015 : 76-91.
3. Shebeer.P.Basheer, Text Book of Advanced Nursing Practice,1st edition, Emmess Medical
Publishers, Bangalore, 2013 : 50-60.

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