QUALITY ASSURANCE DEFNITION OF CONTINOUS QUALITY IMPROVEMENT
INTRODUCTION
Controlling is the function of management that involve setting standards,
measuring performance against those standards, reporting the results and tacking
action. Quality control is a specific type of controlling refers to activities that
evaluate monitor or regulate services rendered to consumer. Quality assurance is
the very essence of quality control. It means to assure quality in a product so that
the customer can buy it with confidence and satisfaction. Quality assurance is the
effective execution of all activities concerned in attaining the set goal
TERMINOLOGY
Controlling –process of monitoring performance and taking action to ensure
desired results
Audit- systematic and critical examination to examine or verify
Standards- determining what something should be
Quality- a judgment of what consists good or bad.
DEFNITION OF CONTROLLING
Control is the process that measures current performances and gives it
towards some predetermined goals-Joseph Marrie
DEFNITION OF QUALITY ASSURANCE
Quality assurance is defined as a planned and systematic evaluation of care
given to group of clients.
Quality assurance is the periodic evaluation of health care services by
examining the factors such as policies, producers, job descriptions, client care and
outcomes.
Continuous quality improvement is a process to ensure programs are
systematically and intentionally improving services and increasing positive
outcomes for the clients they serve.
CONCEPTS OF CONTINOUS QUALITY IMPROVEMENT
1) Quality is defined as meeting or exceeding the expectations of customers.
2) Success is achieved through meeting the needs of those who serve.
PRINCIPLES OF CONTINOUS QUALITY IMPROVEMENT
Nurse managers who have implemented quality improvement efforts have
identified underlying principles for this control measure.
1) Because both physicians and nurses contribute to patient care outcomes
neither physicians or nurses should unilaterally carry responsibility for quality
improvement. Rather all health care professionals should collaborate in projects
to measure and improve care.
2) In planning a comprehensive quality-improvement program for a health
agency, the activities of various health care professionals must be coordinated to
ensure that efforts of diverse care givers enhance those of others.
3) Managers should undertake cost-benefit studies to ensure that resource
expenditure for quality assurance activities is appropriate in amount.
4) To ensure that resources invented in improvement efforts yield significant
results, nurses should monitor only critical performance factors, that is those
activities that yield the greatest health and financial benefit.
5) The key to improving patient care quality is accurate evaluation of care
and key to successful evaluation of care is adequate documentation of care.
6) The ability to achieve nursing objectives depends on the optimal
functioning of every step in the nursing process and effective monitoring.
7) Evaluation of care alone will not improve nursing practice. Continuous
feedback of nursing outcomes is needed to perpetuate good practice and replace
unsatisfactory interventions with more effective methods. Profession
8) After nursing care quality is assed and needed improvements are al
identified, peer pressure can provide the impetus needed to effect the prescribed standards
Patient
practice changes.
setting
care
Peer review
9) If assessment reveals the need for a different pattern of care delivery retrospecti
ve chart Patient care
recognition of care at unit level may require changes in formal organization
audit concurrent
structure.
process
10)For quality improvement efforts to be effective, the collection and analysis audit Continuous
of quality assessment data must be performed by a nurse who has decision
monitoring
Quality of critical
making authority. circles clinical
METHODS OF CONTINOUS QUALITY MANAGEMENT indicatons

The primary purpose of nursing quality improvement program should be

the enhancement of patient outcomes. The thrust of nursing quality improvement PROFESSIONAL STANDARDS SETTING
should be two fold.
The American nurses association has been instrumental in developing
1) To measure professional standards for almost 80 years. A standard is a predetermined level of
2) To improve the quality of nursing interventions excellence that serves as a guide for practice. Standards have distinguishing
characteristics that are predetermined, established by an authority and
The methods used are
communicated to and accepted by people affected them. standards for practice
 Professional standards setting define the scope and dimensions of professional nursing.
 Peer review
CONTINOUS MONITORING OR CRITICAL CLINICAL INDICATIONS
 Continuous monitoring of critical clinical indicators.
 Quality circles A clinical indicator is a quantitative measure that serves as a guide to
 Patient care retrospective chart audit monitor and evaluate the quality of an important aspect of patient care. Data
 Patient care concurrent process audit relating to clinical indications are not direct.

Measures of care quality but flags that identify elements of patient care
that may require further evaluation. Indicators, like criteria, are of three types
structure, process and outcome. Care givers in each nursing unit should determine
the indications to be continuously monitored in that clinical setting. There are two
general types of indicators 1) sentinel event and rate based. A sentinel event
indicator such as medication error is a serious indicator. A rate based indicator
reflects the incidence or frequency of care process or patient care outcome that
varies from normal.
PATIENT CARE RETROSPECTIVE CHART AUDIT
In retrospective audit patient care is observed or evaluated only after the
patients discharge from the health facility. In retrospective audit, the patients
medical records is the sole source of information about care given during the
patient’s stay in the facility. The accuracy of an retrospective audit depends on
the accuracy and completeness of documentation by all of the patients care
givers.
PATIENT CARE CONCERRENT PROCESS AUDIT
In concurrent process audit the patient care is observed as it is given to the
patient. This is more satisfactory than retrospective audit.
PEER REVIEW
Peer review is the process by which employees of the same profession,
rank and setting evaluate one another’s job performance against accepted
standards. The peer group should develop a performance appraisal tool for
calculating the value of each aspect of the nurses performance to be evaluated by
peers. Peer review activities are
 Observe nurse giving care to one or two patients in careload.
 Review nurse’s records of history and physical examination findings
 Observe the nurse’s instructions of patients, families and other staff
members.
 Observe the nurse’s participation in multi-disciplinary patient care
conferences.
 Review the nurses documentation of care on medical records , cpr reports
 Review the nurses change of shift reports, care management reports.
 Review care plans, care studies, scholarly papers written by nurse.
QUALITY CIRCLES
Quality circles are introduced in Japan during 1960’s to improve quality
and productivity in various industries. A quality is a group of 5 to 15 employees
who perform similar work and meet for one hour each week to some work related
problems. The group activities begin by identifying problems associated with
their common task. Then the group concentrates on one problem at a time,
exploring problems, causes, identifying possible solutions, and proposing a
preferred solution to management through a formal presentation.When
management approves the groups proposal the circle implements its plan for
problem solution effectiveness.If the problem is resolved then group moves to
the next problem.
UALITY IMPROVEMENT CIRCLE:
PLAN DO
ACT STUDY

PLAN-Plan evidence based programs and practices that meet the needs and
desires of the patient.This include development of a logic model and training staff
that fit the requirements of the service model.Good planning means the clients are
involved in each step of process.
DO-Provide services as intended.Document activities.Monitor fi delity.Provide
ongoing staff supervision and support and collect data formally through
evaluation activities, focus groups, needs assessments,self assessment and peer
review.Informally through self reflection feedback from consumers, staff, funders
and other stakeholders.
STUDY-Learn the data.Review and analyze data formally through staff
supervision,full staff meetings,board meetings and informally through daily
discussions with staff and participants,self assessment of job
performance,observation of day-to-day participant progress and satisfaction.
and objectives, the health agency building,organization structure, financial
resources,equipment,agency licensure and attitudes of patients and employees.
Process elements include steps of nursing process.Assessing, planning,
implementing, and evaluating and all subsystems within the nursing process such
as the health history, performing a physical examination, making nursing
diagnosis, determining patient care goals, constructing a nursing careplan,
performing each prescribed care task, measuring patient outcomes and reporting
patients response to care.
Outcome elements are changes in patient health status that from nursing
interventions.These changes are the modifications of the symptoms,signs,
knowledge,attitudes, satisfaction, skill and compliance with treatment regimen.
Each of these three frameworks permits more than one approach to quality
improvement.

ACT-Adjust practices based on findings.Make decisions on how to improve

practices.Formally by adopting new practices,programs,policies and procedures
based on findings and informally by making personal adjustments to improve job
performance.Implement the decisions.Repeat teps 1-4.

APPROACHES TO QUALITY IMPROVEMENT:

There are three classic frameworks from which nursing can be evaluated.

 Structure
 Process
 Outcome

Structural elements include physical setting,instrumentalities and conditions

through which care is administered such as the nursing departments philosophy
 QUALITY IMPROVEMENT CIRCLES: a preferred solution to management through a formal presentation.While
identifying and analyzing work problems, the quality circle uses decision
Input output
techniques s brain storming.When management approves the groups proposal, the

Care circle implement

Output its plan for problem solution and evaluates solution
Complianc effectiveness.If the problem is resolved the quality circle group moves on to the
givers
activiti Survey e rate next problem that they have identified and the cycle begins new.When quality
es forms complicati circles were used in hospitals, the groups were most successful in solving
on rate problems when circle leaders and members were pecifically trained in problem
Patient Director observation
eruptions
s charts of care peer review solving techniques.
Director to
retrospective chart
observati standards Experts claim that the most common shortcoming of the older quality
audit
on of performa assurance programs was the failure to provide adequate and timely feedback of
Patient
care peer nce information about quality assessment data to care givers.This problem is
mortalit
y and review
Nursing evaluation associated somewhat when caregivers, rather than managers, monitor critical
morbidi retrospe
care indicators, establish structure, process and outcome criteria and measure the
ty ctive
standards achievement of selected criteria.
Length Feedback
MODELS OF QUALITY ASSURANCE:
of stay
statisti 1. ANA QUALITY ASSURANCE MODEL
cs
The ANA provides a quality improvement model based on standards

Since in 1970s the emphasis has shifted from presenting mistakes that lower of care and quality indicators within the Donabedian frame work of structure,

health care quality to ensuring the achievement of pre established standards of process and outcome.Adopted by the ANA in 1975, the model was developed by

care, to continuous improvement in care quality.With this shift, many health long to deficit the multiple components of evaluation of client care.The ANA

agencies instituted quality circles as means of motivating employees to improve model has changed as more information has been gathered through research and

patient care.Quality circles were introduced in Japan during the 1960s to improve as the profession of nursing has grown, however, it has proved beneficial

quality nd productivity in various industries.A quality circle is a group of 5-15 overtime.

employees who perform similar work and meet for one hour each week to solve
The ANA model has changed as more information has been gathered
work related problems.The group activities begin by identifying problems
through research and as the profession of nursing has grown, however, it has
associated with their common task.Then the group concentrates on one problem
proved beneficial overtime.This are includes the agencies philosophy or mission
at a time, exploring problem causes, identifying possible solutions and proposing
statement, which identifies the values of the agency and reflects in views of
clients nursing, the community and health. Defining the beliefs of the agency is c) Select Measurement
the first step in improving quality.The three components of structure, process, d) Make interpretation
outcome are depicted as pie shaped wedges located around to more close us e) Indentify course of action
interrelated each section and make the transition to the next section smoother. f) Choose action
g) Take action
Although each component is important, agencies rely on positive client
h) Reevaluate
outcomes as key indicators of success. Successful outcomes are the purpose of
the agencies existence and the key to positive evaluation by accrediting Identify Values:
bodies.Moreover, continued rembursement by third- party payers such as private
In the ANA value identification looks as such issue as patient/ client
insurance companies, medicare and medicaid depends successful outcome.
philosophy, needs and rights from an economic, social, psychology and spiritual;
purposive and values, philosophy of health care organization and the providers of
nursing services.

Structure Identify structure, process, outcome standards and criteria:

(Environment and resources)
1) Identification of standards and criteria for quality assurance begins with
writing of objectives of organization.
CORE 2) The philosophy and objectives of an agency serves to define the structural
standards of the agency.
Philosophy or Mission Statement
3) Standards of structure are defined by licensing or accrediting agency.
Agency values – views of clients,
4) Evaluation of the standards of structure is done by a group internal and
nursing, the community, and health
external to the agency.
Process Outcomes 5) The evaluation of process standards is a more specific appraisal of the
(Expected
(Activities result of the quality of care being given by agency care providers.
nurse nurse’s
engages in) activities) Select measurement needed to determine degree of attainment of criteria and
standards:

1) Measurements are those tools used to gather information or data,

The basic components of ANA model are determined by the selections of standards and criteria.
2) The approaches and techniques used to evaluate structural standards and
a) Identify values
criteria are nursing audit, utilization review of physical facilities.
b) Indentify structure, process, outcome standards and criteria
3) The approaches and techniques for the evaluation of process standards and 2) This step then concludes with the actual implementation of the proposed
criteria are peer review, client satisfactions surveys, direct observations, course of action.
questionnaires, interviews, written audits and videotapes.
Reevaluate:
4) The evaluation approaches for outcome standards and criteria include
research studies, client classification, admission, readmission, discharge data and 1) The final step of quality assurance process involves an evaluation of
mobility data. results of the action.
2) The reassessment is accomplished in the same way as the original
Make Interpretations:
assessment and begins the quality assurance cycle again.
1) The degree to which the predetermined criteria are met is the basis for 3) Careful interpretation is essential to determine whether the course of action
interpretation about strengths and weaknesses of the program. has improves the deficiency, the reinforcement is offered to those who participate
2) The rate of compliance is composed against the expected level of criteria and the decision is made about when to again evaluate that aspect of care.
accomplishment.
DONABEDIAN MODEL:
Identify course of action:
Donabedian, the country’s premier research on health care quality,
1) If the compliance level is above the normal or the expected level, there is proposed a model for the structure, process and outcome of quality that has been
great value in conveying positive feedback and reinforcement. widely used over the past 35 years as the framework for more elaborate
2) If the compliance level is below the expected level, it is essential to models.The care environment structure- from philosophy, to facility resources, to
improve the situations. personnel is the first component.
3) It is necessary to identify the cause of deficiency.Then it is important to
Next all the process responsible for improving or stabilizing the clients status
identify various solutions to the problems.
such as standards, attributes and effective news of holes used in care giving (eg:
Choose Action: nursing care plans). Finally the resultant outcomes are carefully linked indicators
of quality such as client health care goals and effectiveness of service. The
1) Usually various alternative course of action are available to remedy a
Donabedian model is recognized as a simplistic, process and outcome can be
deficiency.
depicted in a box shaped model.
2) Thus it is vital to weigh the pros and cons of each alternative while
considering the environmental context and the availability of resources.

Take Action:

1) It is important to firmly establish accountability for the action to be taken.

 System outcome
Process
Structure
 Standards
(Individual, organization,
 Facility resources  Attitudes
group)
 Personnel mix and  Nursing care
skills plans
Interventions
 Philosophy, policies  effectivenessss client

 Client mix

Outcomes (Individual, family, community)

 Client health care goals

met
 Efficiency and
effectiveness of services THE QUALITY PRACTICE SETTING ATTRIBUTES MODEL:
 Client satisfaction
This model, developed by the Nurses of Ontario in Canada, provides the
QUALITY HEALTH OUTCOMES MODEL: foundational framework for the unique quality improvement approach to creating
quality practice environment.The nurses of Ontario is the regulatory body for
Mitchell and colleagues (1998) took the time tested Donabedian model a
registered practical nurses in the province of Ontario, Canada. It has functions
step further.The quality health outcomes model includes the client in the model
similar to those of the Boards of Registered Nursing in each state in the United
and proposes a two dimensional relationship among component interventions
States.The quality practice setting attributes model is used as a tool to artist in
always act through the system and the client, creating a dynamic model.The
ensuring the quality of nursing practice and the nursing profession by promoting
uniqueness of this model is the prostulate that there are “dynamic relationship
continuing competence among nurses in Canada. The nurse entered model of
with various components.A master curriculum of other models is that they do not
quality improvement is designed to contribute to the best possible health outcome
lend themselves to the population focus of community health nursing.However,
for the client regardless of health care setting. The components of this quality
this model includes community as a client.
assurance program include reflective nursing practice review and practice setting
consultation.The first two components focus on the nurses individual
responsibility for maintaining competence throughout her careers, the practice
setting consultation focuses on the practice environment in which nursing care is
delivered.
 The governing body for nurses in Ontario Canada has relied on the quality c) Output
setting attributes model to improve nursing care quality in their province.The d) Feedback
model identifies seven key system attributes ion the work environment that create
The input can be compared to the present state of the systems and the
a quality practice setting.
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.

OMAHA SYSTEM:

STANDARDS OF QUALITY ASSURANCE:

DEFINITION:

Standard is an predetermined baseline condition or level of excellence

that comprises a model to be followed and practiced.

CHARACTERISTICS OF STANDARDS:

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

variety of settings.
 Standards must be realistic, acceptable, attainable.
SYSTEM MODEL:
 Standards of nursing care must be developed by members of the
The implementation of the unit based quality assurance programme like nursing profession; preferable
that of any other programme involves making changes in organizational structure  Nurses practising at the direct care level with consultation of
and individual roles one method of facilitating and structuring the change process experts in the domain.
in the system of approach in which the last is broken down into manageable  Standards should be phrased in positive terms and indicate
components bases on defined objectives. acceptable performance good, excellence etc.
 Standardsof nursing care must express what is desirable optional
The basic components of the system are
level.
a) Input  Standards must be understandable and stated in unambiguous
b) Throughput 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.
 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.
SOURCES OF NURSING CARE STANDARDS
 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:
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.
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.
NURSING CARE STANDARDS IN WARD MANAGEMENT:
The major functions of nurses are classified as
 Those dealing with organization and control of the patients environment
and to secure for him maximum mental and physical comfort
 Those concerned with him immediate personal care
 Those performed under the direction and in cooperation with the physician
 Administrative duties of ward management
RESPONSIBIITIES OF HEAD NURSE:
 Carrying out the instructions of medical officers regarding treatment of
patients
 General cleanliness and upkeep of ward and its surrounding areas to
provide neat and cheerful environments for patients
 Supervision of care and maintenance of buildings, furnitures, fittings and
arranging their reports through CNO or medical officer
 Keeping the ward equipment in optimum state of readiness by prompt
repairs and replacement through condemnation boards
 Assignment or duties for patient care to staff working
 Identifying the collection of various items of medical and other stores
 Ensuring that all specimens are sent to the laboratory in time and results
collected in due
 Maintaining strict control over accounting and distribution of controlled
and dangerous drugs
 Ensuring sufficient linen is available in the ward
 Training of nursing and other personnel working in the ward
 Maintenance of all the registers and documents required in the ward.
LEGAL SIGNIFICANCE OF STANDARDS: 3) Stimulant to better records
4) Contributes to research
Standards of care are guidelines by which nurses should practice.If nurses
do not perform duties within accepted standards of care,they may place METHODS OF NURSING AUDIT

themselves in jeopardy of legal action.Malpractice suit against nurses are based

There are two methods
on the charge that the patient was injured as a consequence of the nurses failure to
meet the appropriate standards of care. a) Retrospective view- this refers to indepth assessment of the quality after
the patient has been discharged have the patient’s chart to the source of data.
To recover losses from a charge of malpractice, a patient must prove that: b) The concurrent review- this refers to the evaluations conducted on behalf
of patients who are still undergoing care. It includes assessing the patients at the
1. a patient-nurse relationship existed such that the nurse owed to
bedside in relation to predetermined criteria, interviewing the staff responsible for
the patient a duty of due care,
his care and reviewing the patient’s record and care plan.
2. the nurse deviated from the appropriate standard of care,
3. the patient suffered damages, AUDIT CYCLE:
4. the patient's damages resulted from the nurses deviations from the
standard of care.
Set standards:
NURSING AUDIT
Establishing standards of care is the foundation of quality assurance.
DEFINITON OF NURSIG AUDIT Standards are predetermined baseline condition or level of excellence that
compromise a model to be practiced. Once the planning step is over the standards
1) According to Ellisson “nursing audit refers to assessment of the quality od
should be setup based on structure process, and outcome. The structure standards
the clinical nursing”.
are licensing physical facilities and staffing. Process standards are the a standards

2) Nursing audit is an exercise to find out whether good nursing practices are of nursing practice based on objectives of nursing formulated by individual health

followed care settings and outcome standards are prepared to evaluate quality of care
delivered, patient satisfaction, nurses work satisfaction and outcome of nursing
3) The audit is a means by which nurses themselves can define standards from care.
their point of view and describe the actual practice of nursing.
Observe practice:
PURPOSE OF NURSING AUDIT
The standards of care should be monitored periodically by the quality
1) Evaluating nursing care given control committee by assessing whether the clients expectations requiring care
2) Achieves deserved and feasible quality of nursing care are met by the health care workers.
 set standards
Before carrying out an audit, an audit committee should be formed,
comprising of a minimum of five members who are interested in quality
assurance, are clinically competent and able to work in a group. It is
recommended that each member should review not more than 10 patients each
implement observe
change practice month and that the auditor should have the ability to carry out an audit in 15
minutes.

STEPS TO PROBLEM SOLVING PROCESS IN PLANNING CARE

compare with
standards a) Collects patients data in a systematic manner
1) Includes description of patients prehospital routines
Compare with standards: 2) Has information about the severity of illness
3) Has information regarding lab tests
The practice performed by the health workers should be assessed by the
4) Has information regarding vital signs
quality control committee through the nursing audit by retrospective and
concurrent methods and compare the standard of care performed by the health 5) Has information from physical assessment
b) States nurses diagnosis
workers with the predetermined standards of care. The problem in rendering
c) Writes nursing orders
quality care to the clients should be defined clearly by the committee to made
d) Suggests long term and immediate goals
necessary changes in client care.
e) Implements the nursing care plan
Implement change: f) Plans health teaching for patients
g) Evaluates the plan of care
The audit committee will analyze the problem areas and plan with the
health care team members to solve the problem areas related to inadequate AUDIT AS A TOOL FOR QUALITY CONTROL:
staffing, equipments, quality improvement in rendering satisfactions care to the
The audits most frequently used in quality control include
clients. After interpretation by the audit committee on a particular problem, they
plan for the problem solving techniques by designing the solution plan. while outcome,process and structure audit.

planning the solution for problem the team should consider the standards stated
by institution. The final step is implementing the solution formulated by audit
committee for effective problem solving in rendering quality care to the client.
OUTCOME AUDIT-Outcome audits determine what results if any occurred as a
result of specific nursing intervention for clients.These audits assume the
outcome accurately and demonstrate the quality of care that was provided.

AUDIT COMMITTEE
PROCESS AUDIT-Process audit are used to measure the process of care or how Creates an awareness or sensitizes the nurses about the importance of quality
the care was carried out.Process audit as task oriented and focus on whether or assurance.
not practice standards are being fulfilled.
2) FACILITATOR
STRUCTURE AUDIT-Structure audit monitors the structure or setting in which
She facilitates to develop, implement, monitor and evaluate standards for
patient care occurs such as finances, nursing service, medical records and
nursing practice at all times.
environment.

3) COORDINATOR
ADVANTAGES OF NURSING AUDIT
She coordinates the different units of quality assurance progammes and
1) Can be used a method of measurement in all areas of nursing
coordinates the activities with the hospital quality assurance programme.
2) Seven functions are easily understood
3) Scoring system is fairly simple 4) EDUCATOR
4) Results easily understood
5) Assess the work of all those involved in recording care She gives orientation to nursing personnel regarding the need for

6) May be useful tool as part of a quality assurance program in areas where standards and auditing of nursing service.

accurate records of care are kept.

5) LEADER

DISADVANTAGES OF NURISNG AUDIT

She communicates the quality message to all the staff members.

1) Appraises the outcomes of nursing process, so it not so useful in areas

6) EVALUATOR
where nursing process has not been implemented
2) Many of the components overlap making analysis difficult She evaluates the implementation of standards for nursing practice.
3) It is time consuming
7) SUPERVISOR
4) Requires a team of trained auditors
5) Deals with a large amount of information She supervises the activities of different committees. She supervises the
6) Only evaluates record keeping. It only serves to improve documentation, nurses at first and second level leadership positions.
not nursing care.
OBJECTIVES OF NURSING AUDIT
ROLE OF NURSE ADMINISTRATOR IN QUALITY ASSURANCE:
 To justify the cost occurred on human and material resources
1) INITIATOR  To take remedial actions towards cost effectiveness
 To evaluate excellence of nursing practice
 To revise and plan standards of nursing care
 To avoid external audit being imposed on the profession from outside, it Debit system is negative in nature and emphasis is towards illness. Credit system
means to avoid anticipatory problems if external audit is done is positive in nature and emphasis is on health.
 To measure progress
MEMBERSHIP TO THE AUDITING COMMITTEE
 To promote the maintenance of medical research
 To increase medico-legal protection Membership of the audit committee should include representative of all levels of
professional nursing including
CONCEPT OF NURSING AUDIT
o Client care coordinators
The concept of nursing audit is based on debit and credit system
o Supervisors
Debit systems are o Head nurses
o Clinical specialists
o Death note of patient justifiable or otherwise could have been prevented
o Nurse clinician
o Complications due to neglect of nursing care affecting the integrity of the
o Licensed practice nurse
system
o Nursing assistants
o Complications leading to mortality
o Other client care personnel
o Hospital infection and nosocomial infection
o Medical records administrator
o Error in treatment
o Patient left against medical advice FUNCTIONS OF THE AUDIT COMMITTEE
o Lack of application of nursing process
During I phase
o Absence of total patient care
o Total nursing care provided in a hospital only by the learners. o Development of purposes and objectives
o Establishing standards and criteria
Credit items are
o Establishing guidelines for conducting audit
o Number of recovered patients o Deciding upon auditing forces
o Shorter stay in hospital o Initiating the auditing forces
o Expansion of health knowledge in patient population o Keeping up brief, pertinent minutes of all audit committee meetings
o Research or problem oriented care approach
During II phase
o Regular follow up in the community
o Improved image in public or clients It begins with actual implementation and maintenance of audit procedure.
o Accurate nursing documentation
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 given to the individual needs and responses to
patients.The standards must be written regularly, reviewed and well known by the
nursing staff.

JOURNAL ABSTRACT:

 NURSING ORIENTATION-A continuous quality improvement

An orientation on process utilizing a collaborative, multidisciplinary approach
and principles of continuous quality improvement.This process successfully
transtitioned 63 graduate nurses into three different practice specialities decreased
the vacancy rate, and eliminated the need for agency nurses at Georgia Baptist
Medical Center in Atlanta,CNS acting as educators, clinical experts and
consultants, plays a key role in developing ,implementing and evaluating the
programme.
 TOTAL QUALITY MANAGEMENT IN NURSING CARE

The different stages of implementation of quality assurance is part of

nursing care.The desired stages represent the first three steps of adapted model of
quality assurance by Lang (1976)-identification of values in nursing teams--
Establishment of standards including criteria for structure, process and outcome -
-Quality measurement (Self-review and peer review) The following actions are
considered important for a successful quality assurance programme: --
decentralized procedure (bottom-up approach) --quality assurance by professional
colleagues from within the hospital --peer reviewed quality assurance Although
the nurses find the establishment of standards very difficult and need expert
advice for this difficult task, the initiated programme can be considered