NURSING FOUNDATION

UNIT – V QUALITY ASSURANCE

Ms.Jeyarani.K M.Sc.(N).,
Asst. Professor
 Learning Objectives
At the end of the class the students will be able to 
 understand the concept of quality assurance.
 enumerate the purposes and objectives of quality
assurance.
 identify the various approaches of quality assurance
program
 discuss the standards in quality assurance
 describe about nursing audit
 explain regarding total quality management
 recognize the factors affecting and the role of nurse in
quality assurance
 Quality Assurance
Introduction
 The field of quality assurance is an old as modern nursing.

 “FLORENCE NIGHTINGALE” introduced the concept of

quality nursing care in 1855.

 Quality assurance necessitates that institutions and

health professionals render care in a most efficient,

effective and economical manner.
 Definition – Quality assurance

• “Quality Assurance is an on-going, systematic

comprehensive evaluation of health care services and
the impact of those services on health care services.
-Kozier.

• Quality assurance is defined as all activities

undertaken to predate and prevent poor quality.
-Neetvert (1992)
 Purposes of Quality Assurance
 To ensure high quality patient care,

 To ensure medical surveillance

To ensure population health management
through continuous monitoring and evaluation of
the patient care
Objectives
According to Jonas (2000)
• To ensure the delivery of quality client care
• To demonstrate the efforts of the health care
providers to provide the best possible results
• Formulate plan of care
• Evaluate achievement of nursing care
• Support delivery of nursing care with
administrative and managerial services
 Principles of Quality Assurance

 Focus on client needs

 Focus on data as basis for decision
 Focus on systems and processes
 Focus on team approach to problem
solving and quality improvement
 Dimensions of Quality Assurance

 Efficacy  Continuity

 Appropriateness  Safety

 Availability  Efficiency

 Timeliness  respect and caring

 Effectiveness
 Process of Quality Assurance
• 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
Contd..

• Make a judgment about quality

• Provide information and if necessary, take
corrective action regarding findings of
appropriate sources
• Determine ways to collect the information
Approaches of Quality Assurance
Program
Two major categories of approaches
exist in quality assurance Program:
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

5. Charter
1. Credentialing
• Formal recognition of professional or technical
competence and attainment of minimum standards by a
person or agency
 Credentialing process has four functional components

To produce 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 profession
is granted control over entry into and exists from
the profession and over quality of professional
practice.
• Tamilnadu Nurses and Midwives council (TNMC)
is the governing body to regulate nursing
licensure
3. Accreditation
• Accreditation is the process by which authorized
body evaluates the quality of a higher education
institution as a whole or of a specific educational
program in order to formally recognize it as having
met certain predetermined minimal criteria or
standards.
• Joint Commission International (USA)
• National Accreditation Board for Hospitals &
Healthcare Providers (NABH)
4. Certification
Certification is usually a voluntary process
within 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.
5. Charter
• A charter is the grant of authority or rights,
stating that the granter formally recognizes the
rights of the recipient to exercise the rights
specified
B. Specific Approaches
1. Peer review

2. Nursing Audit

3. Utilization Review
Contd..
• Peer review

These are designed to monitor client specific aspects

of care appropriate for certain levels of care. The audit
is used by peer review committee to ascertain quality of
care.
• Nursing audit
It is an evaluation of patient care through analysis of
written records maintained by nurses in patient’s
treatment profile.
 Contd..
• Utilization review
Utilization review activities are directed towards
assuring that care actually needed and that the cost
appropriate for the levels of care provided

Prospective: It is an assessment of the necessary of

care before giving services.

Concurrent: A review of the necessity of care while the

care is being given.

Retrospective: It is analysis of the necessity of the

services received by the client after the care has being
given
 Standards
Itis a pre-determined baseline condition or level of
excellence that comprises a model to be followed
and practiced.

 Distinguishing characteristic of standard

 Predetermined
 Established by an authority
 Communicated to and accepted by the
individuals affected by standard
Characteristics of Nursing
Standards
• Standards of nursing care must be developed by
members of the nursing profession
• Nurses practicing 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.
Contd..

• Standards of nursing care must express what

desirable optional level is.
• 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
Purposes
• 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 determine the degree to
which standards of nursing care maintained and
take necessary corrective action in time.
 Sources of STANDARDS
• Professional organization e.g. TNAI,
• Licensing bodies e.g. Statutory bodies, INC
• Institutions/Health care agencies e.g.University.
Hospitals, Health Centers
• Department of institutions e.g. Department of
Nursing.
• Patient care units e.g. Specific patients' unit.
• Government units at National State and Local
level
• Individual e.g. personal standards
The ANA standards for Nursing
Practice
 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.
Contd..
 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

 Contd..
 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.
 Models of Quality Assurance
 System Model for Quality assurance

 ANA Quality Assurance Model

 JCAHO Quality Assurance Model

 ISO Quality Assurance Model

 PDCA

 Six Sigma
Itis a systematic and
official examination of
record, process or account
to evaluate performance.
Structureaudit
Process audit
Outcome audit
Nursing Audit
* Nursing audit refers to the assessment of the
quality of clinical nursing.
- Elison

* Nursing audit is the means by which nurses

themselves can define standards from their
point of view and describe the actual practice of
nursing.
-Goster Walfer
Objectives
• To evaluate the quality of nursing care given.
• To achieve thedesired and feasiblequality of
care.
• To provide a way for better records.
• To focus on care provided and care provider.
• To provide rationalized care thereby
maintaining uniform standards worldwide.
• To contribute to research.
Characteristics
• It improves the quality of nursing care.
• It compares actual practice with agreed
standards of practice.
• It is formal and systemic.
• It involves peer review.
• It requires the identification of variations
between practice and standards followed by the
analysis of causes of such variations.
Methods of Auditing
 A concurrent nursing audit

A retrospective nursing audit

A prospective nursing audit

1. Retrospective method
• It refers to the detailed quality care assessment
after the patient has been discharged.
• The records can be viewed for completeness of
records, diagnosis, treatment, lab investigations,
nursing care plan, complications and end results
2. Concurrent method
• It is achieved by reviewing patient care during
the time of hospital stay.
• It includes assessing the patient at the bedside.

• It involves direct and indirect observation,

interviewing the staff responsible for care and
reviewing the patients records and the care plan
 Nursing Audit Process
 Select topic
 Develop criteria
 Ratify the criteria
 Review charts
 Identify variations
 Analyze the problem
 Develop solution
 Implement solution
 Evaluate and re-audit
• According to Payne, the stepsin audit
include
1. Criteria development
2. Selection of cases
3. Work sheet preparation
4. Case evaluation
5. Tabulation of evaluation
6. Presentation of reports
Advantages
• Patient is assured of good service.
• Better planning of quality improvement can be
done.
• It develops openness to change.
• It provides assurance, by meeting evidence
based practice.
• It increases understanding of client‘s
expectations.
• It minimizes error or harm to patients.
• It reduces complaints or claims.
Disadvantages
• It may be considered as a punishment to
professional group.
• Many components may make analysis difficult.
• It is time consuming
• It requires a team of trained auditors.
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 evaluation technique
Contd..
• Lack of good hospital information system
• Absence of patient satisfaction surveys
• Lack of nursing care research
• Lack of written job description and job specifications
• Lack of in-service and continuing education and staff
development program
• Nurse prescription –no provision yet
• Absence of knowledge about philosophy of nursing
care
• Lack of policy and administrative manuals
Total Quality Management (TQM)
 Also referred to as continuous quality
improvement
 Philosophy developed by Dr. W. Edward
Deming
 First implemented in Japan
 Focus on satisfying customers‘ expectations,
identifying problems, building commitment,
and promoting open decision-making among
Components of Quality Management
Program
Statement of purpose, philosophy and objective
 Standards for measuring quality care
 Policies and procedure
 Analysis and reporting
 Use of results to prioritize
 Monitoring

 Evaluation
 Principles of TQM
 Create a constancy of purpose for improvement
of the products and service
 Focus on improving processes
 Adopt a philosophy of continual improvements
 Improve constantly every process of planning
producing and service
Contd..
 Institute job training and retraining
 Develop leadership in the organization

 Encourage employees to participate actively in

process
 Foster interdependent co-operation
 Focus on quality not on quantity
 Promote team work
 Educate to maximize personal development
Steps in Quality Improvement
Process
 Select a nursing activity for improvement
Assemble a multidisciplinary team to review and revise
the nursing activity
Describe all components of the activity using a flow
chart
 Collect data
 Discuss various plans to meet the standard
 Collect data to evaluate the implementation
Role of Nurse in Quality Assurance

Maintenance of a current knowledge base and

competencies
 Interpersonal skills

 Caring and compassion

 Mutual decision making with client and nurse
 Individualized treatment

Strive for excellence in everything

that is done
(Nurses, Nurse manager or clinician, team member )
 Contd..
 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
 Contd..
 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.
Reference
 Kozier (2006). Fundamental of nursing. Dorling
Kindersley pvt.ltd. second edition.
 F.A. Davis.(1994). Legal ethical and political issues
in nursing. Davis Company. Second edition.
 Carol Taylor(2005). Fundamental of nursing.
Lippincott publications. sixth edition.
 Potter and Perry (1997). Fundamental of nursing.
Mosby publications, fourth edition,