QUALITY ASSURANCE

IN NURSING

Presented By
Mr. Migron Rubin
M.Sc. Nursing Ist Year
Pragyan College of Nursing
• QUALITY
D

ASSURANCE
IN NURSING
 INTRODUCTION

THE EXPENSE OF QUALITY IS AN

INTERACTIVE PROCESS BETWEEN
CUSTOMER & PROVIDER. QUALITY
ASSURANCE USUALLY FOCUSES ON
MATERIAL, GOOD WORK & SERVICE
PROVIDED EFFECTIVELY. ANY LACK
IN SERVICE PROVIDED CAUSES
DECREASE IN QUALITY.
 QUALITY

It is degree to which health services for

individuals & population increase the likelihood
of desired health outcomes & are consistent with
current professional knowledge.

-Joint Commission on
Accreditition of health care organization ,2002
(JCAHO)
 ASSURANCE

It is statement or indication that inspires

confidence.
 QUALITY ASSURANCE
• Quality assurance is an on-going, systematic,
comprehensive evaluation of health care services
& impact of those services on health care
services.
-Kozier
• Quality assurance is defined as all activities
undertaken to predate & prevent poor quality.
-Neetvert
 NURSING

The unique function of nurse is to assist in

individual sick or well in performance of those
activities contributing to health or its recovery or
to a peaceful death that he would perform
unaided if he had necessary strength will or
knowledge & to do this in such a way as to help
him to gain independence as rapidly as possible.”
- Virginia Henderson
 OBJECTIVES

• To ensure the delivery of quality client care.

• To demonstrate efforts of health care providers

to provide good results.

• To formulate plan of care.

• To evaluate achievement of nursing care.

• To support delivery of nursing care with
administrative & managerial services.

• To explain quality assurance models as pre-

requisite for quality nursing care.

• To state code of ethics & professional conduct for

nurses in India.
• To appreciate importance of practicing standard
safety measures.

• Plan & conduct patient teaching sessions.

• To identify appropriate management techniques

to be used for managing resources in given
situation.
 PURPOSES
• It is required to introduce code of ethics &
professional conduct for nurses in India.

• To prepare staff nurse for implementation

quality assurance model in nursing.

• To provide best care to patients by maintaining

standards.
 PRINCIPLES
1. Customer focus- It focuses on patient’s care with
standard & recent medical knowledge.

2. Leadership – It helps to inculcate qualities of

leadership in staff.

3. Involvement of People- It should involve

maximum nursing staff so that standards can be
maintained.
4)Process approach- There should be a systematic &
planned approach to provide quality care.

5)Factual approach to decision making- There

should be fact or appropriate reason in taking certain
decision for quality assurance of patient.
 APPROACHES TO QUALITY
ASSURANCE

1. Methods for measuring performance:

As nursing care is delivered within a framework of
independent relationships with physicians and a
multiplicity of other health care personnel .The most
commonly used methods of nursing care are task
analysis and quality control.
2) Measuring actual performance:

It is an ongoing repetitive process with the actual

frequency dependant on the type of activity being
measured. It is better to clarify the purpose of the
measurement and to measure performance on a
continuous basis.
3) Comparing results of performance with
standards and objectives and identifying
strengths and areas for correction:

The standards and objectives and methods of

measurement have been set ,if performance matches
standards and objectives , managers may assume
that things are under control if performance is a
contrary to standards and objectives, action is
necessary.
4) Acting to reinforce strengths or success
and taking corrective action as necessary:

Positive aspects needed to be identified in order that

they may e translated into encouragement and
motivation for the nursing members involved in
achieving them.
VELOPMENT OF A QUALITY
ASSURANCE PROGRAM
• Foster Commitment of Quality
• Conduct a Preliminary Review of Quality-
Related Activities
• Develop the Purpose and Vision for the Quality
Assurance Effort
• Determine level and scope of initial Quality
Assurance Activities
• Assign responsibility for Quality Assurance
• Allocate resources for quality assurance

• Develop a written quality Assurance plan

• Critical Management System

• Disseminate Quality Assurance Experience

• Manage Change
 APPROACHES FOR QUALITY
ASSURANCE PROGRAM
Approaches of quality assurance are divided
into 2 types:

1. General Approach
2. Specific Approach
 GENERAL APPROACHES

It involves large governing of official body’s

evaluation of person’s or agency’s ability to meet
standard at a given time.

1. CREDENTIALING - It is process of
determining & maintaining nursing standards.
Functional Components Of Credentialing
Process

According to Hinsvark, credentialing process has 4

functional components:-

1. To produce a quality product.

2. To confer a unique identity.
3. To protect provider & public.
4. To control the profession
2. LICENSURE

Individual licensure is a contract between profession

& state in which profession is granted control over
entry into & exists from profession & over quality of
professional practice.
3. ACCREDITATION

Accreditation is the act of granting credit or

recognition especially to an educational institution
that maintains suitable standards.
4. CERTIFICATION
Certification is usually a voluntary process within the
professions. A person’s educational achievement,
experience & performance on examination are used
to determine person’s qualification for functioning
in an identified specialty area.
 SPECIFIC APPROACHES
Quality assurances are methods used to evaluate
identified instances of provider and client
interaction

1.Peer review committee- 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.
2. 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.

3.Utilization Review

Utilization review activities are directed towards

assuring that care actually needed and that the
cost appropriate for the levels of care provided
 TYPES OF UTILIZATION REVIEW

• 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
4.Evaluation Studies

Donabedian’s Structure-Process-Outcome model

Donabedian introduced 3 major method of evaluating

quality care:-
1. Structural evaluation

This method evaluates setting & instruments used to

provide care such as facilities, equipments &
characteristics of administrative organization &
qualification of health provider. The data can be
obtained from existing documents.
2. Process Evaluation

This method evaluates activities as they relate to

standards & expectations of health providers in
management of client care. Data is collected through
direct observations, review of records, audit etc.
3.Outcome Evaluation

The net changes that occur as a result of health care or

net results of health care. The data of this method
can be collected from vital statistics records such as
death certificate or telephone client interview,
mailed questionnaire & client records.
 MODELS OF QUALITY
ASSURANCE
System Model
System model is used for implementation of
unit based quality assurance program. It
involves making changes in organizational
structure & individual roles. In system model,
task is broken down into manageable
components based on defined objectives.
 Basic Components of System
Models

• Input- The input can be compared to

the present state of systems.
• Throughput- It is developmental process.
• Output- It is finished product or result.
• Feedback- It is essential component of
system because it maintains & nourishes
growth.
ANA Quality Assurance Model
Identify
Reevaluation
values

Take action Identify standards &

criteria

Choose action Secure measurement

Identify course of
action
 Make
measureme
nt
 PDCA CYCLE
PLAN

PDCA DO
ACT
CYCLE

CHECK
FACTORS AFFECTING
QUALITY ASSURANCE
IN NURSING CARE
 QUALITY IMPROVEMENT
• Quality improvement is defined as an approach
to the continuous study & improvement of
process of providing health care services to
meet the needs of clients & others.
-Joint commission on accreditation of
health care organization (JCAHO)
 PRINCIPLES
• It requires continuous quality improvement.
• Knowledge of customer expectation needs.
• Processes of customer supplier relationship.
• Belief in people.
• Statistical analysis.
• Costs of poor quality.
 CONDITIONS IN WORK
ENVIRONMENT
• Employer’s involvement.
• Improvement.
• An environment that support taking risk.
• Team work.
• Data collection & analysis skills.
• Group interaction skills.
• Structure & management to enable
improvement.
• Tools to facilitate improvement.
 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.
TOTAL QUALITY MANAGEMENT
• It focuses the production and service, i.e.:
the environment must be customer
responsive.

• It identifies and do the right things, the right

way, the first time and the prevent problems.
• In this, customer needs and experiences
with the end product are constantly
evaluated .
 STANDARDS

Standard is an established rule as basis of

comparison in measuring or finding capacity,
quality context & value of objects in same
category.
 Classification of nursing care
standards
1) Structure standards

• It involves setup of institution.

• The philosophy, goals & objectives, structure of

organization, facilities, equipment, qualification
of employees are some of components of
structure of organization.
2) Process standard

• It describes behavior of nurse at desired

level of performance.

• It involves activities concerned with delivering

patient care.
3)Outcome standard

• An outcome standard measures changes

in patient health status.

• This change may be due to nursing care,

medical care or as a result of variety of
services offered to patient.
 ROLE OF A NURSE

• Role of nurse is to participate in quality

improvement team.

• Properly supervises & check whether patient

is receiving proper care or not.
• Contribute innovation & improvement of
patient care.

• Participating in improvement projects

&patient safety initiatives.
• Participating in CNE programs
& in-service education programs.

• Periodic & continuing appraisal

& evaluation of health care
situation of patient.

• Participate in research works

related to quality assurance.
• Nurse identifies area where
need improvement in delivery of care
 RELATED RESEARCH
1) Development of an instructional
quality assurance model in nursing
science

• Result- The result of instructional quality in

nursing science program is in high level (level
4 & 5 according to rating scale). Generally all
standards are in good level.
2) Evaluation of quality assurance model
for Public Health Nursing.
• Project was conducted for one year period.
The project was based on ANA Model for
Quality Assurance & assessed standard for an
overall Quality Assurance Program.
• Purpose of the study- To analyze baseline
outcome criteria for a Quality Assurance
Program and to implement and interface
evaluation methodologies on Public Health
Nursing (PHN) services within the IHS to:
1) Identify the amount and kind of quality
services provided and the strengths and
barriers.

2) Provide recommendations for improvement

in the quality of service.

3) Provide an action plan for implementing

changes to improve the quality of PHN care
to recipients.
• STUDY FINDINGS- Outcome criteria standards
are being met in a high percentage of
instances
- in the 60 to 70 percentiles.
• This was considered outstanding.
• Patient Satisfaction Surveys indicated
extremely high satisfaction with public health
nursing services - in the 95 to 99
percentiles.
• Peer Review and Utilization Review standards
also showed a very high positive percentile
ranking.
 THEORY APPLICATION

• FLORENCE NIGHTINGALE ENVIRONMENT

THEORY

Florence Nightingale was the first person to

describe about standards of nursing (1859) in
“Notes of nursing, what it is & what it is not”. In
this, she wrote about change to achieve high
standards.
. LIGHT AIR
 HOUSING
FOOD

NOISE CCLLNI
IEENNN VARIETY
DTT

CLEANLINESS
HEALTH
OF HOUSE

BEDDING HOPES/EMOTIONS
MODEL APPLICATION

STRUCTURE

OUTCOME PROCESS
• SYSTEM- Diarrhoea control program

• STRUCTURE
• Trained community workers.
• ORS packets.
• Accessible health centres.
• PROCESS
• Education to mothers.
• Rehydration therapy.
• Diagnostic studies.
• OUTCOME
• Number of children treated.

• No. of complications arose.

• No. of deaths due to diarrhoea.

 STRUCTURE PROCESS OUTCOMES
(CAUSAL PAST) FUTURE
PARTICIPANTS (TERMINAL OUTCOMES)
A
CARING RELATIONSHIP

1. PROVIDER RELATIONSHIP
• PHENOMENAL FIELD CENTERED 1. PROVIDER
• DESCRIPTORS INDEPENDENT
• SATISFACTION
RELATIONSHIP
• LIFE EXPERIENCE • PERSONAL GROWTH
PT. /FAMILY- NURSE
2. PATIENT /FAMILY + 2. PATIENT
• PHENOMENAL FIELD • QUALITY OF LIFE
• DESCRIPTORS
COLLABORATIVE
• SAFETY
• LIFE EXPERIENCE RELATIONSHIP • SATISFACTION OF TREATMENT
WITH HEALTH
3. SYSTEM • KNOWLEDGE
CARE TEAM NURSE
• RESOURCES 3. UTILIZATION
• WORKLOAD • RESOURCE
• ENVIRONMENT OF PROFESSIONAL • CONSUMPTION
ORGANIZATION ENCOUNTERS • COST

IMMEDIATE OUTCOMES FEEL “CARED FOR”

Presenter’s view
 Point to be discussed

Current Scenario of Quality Assurance in

Government & Private Hospitals In Madhya
Pradesh.
Summary