Faculty Of Nursing

Zagazig University

Master Degree

Third Term

Quality Control & Quality

Improvement

Under supervision
Dr. Maha Abdeen Abdeen
Dr. Azza Abdeldayem Ata

Prepared by
Nora wageeh Abd elwahab

2020

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Out line:
1-Introduction

2- Quality

Definition of Quality

Component of quality

Purposes of quality:

Dimension of quality

Quality Principles

3- Quality control
Definition

Quality control Objectives

Who should be involved in quality control?

Quality Control Process

Roles of nurse Manager Associated with Quality Control

4- Quality Improvement

Definition

Six Aims for Improving Quality in Health-Care

Aspects of Health Care to Evaluate

Methodology of quality improvement

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Introduction:

Quality improvement and evidence-based care (EBC) have been shown to

be powerful tools to make health care organizations more effective.
Quality Improvement (QI) is a management philosophy to improve the
organizational structure and the level of performance of key processes in the
organization to achieve high quality outcomes.
Quality control ensures that an organization product or service is
consistent. It has four main components: quality planning, quality assurance,
control, and quality improvement. Quality management is focused not only on
product and service quality, but also on the means to achieve it.
As a professional nurse, you have a responsibility to acknowledge the
complexity and deficits of the health-care system. In managing patient care, you
must continually consider the impact of the system on the care you provide and
participate in the quality and safety initiatives at the bedside, in your unit, and
within your organization to promote quality and safety within the system.
Definition of Quality:
Quality is defined as “the degree to which health services for
individuals and populations increase the likelihood of desired
health outcomes and are consistent with current and professional
knowledge” (IOM, 2001, p. 232).

Quality management is defined as a planned, systematic, organized

approach to the monitoring, analysis, and improvement of organization
performance, thereby continually improving the quality of patient care and
services provided and the' likelihood desired patient outcomes (Webitbead et
al., 2010)
Quality of care: The degree to which health services for individuals and
populations are safe, timely, efficient, equitable, effective, and patient centered.
(Jones 2007)
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 Component or elements of quality

1- Structure
2-process
3-outcome
Structure
Structure refers to the setting in which the care is given and to the
resources (human, financial, and material) that are available.
Structural aspects of a health-care organization can be evaluated:
■ Facilities: Comfort, convenience of layout, accessibility of support services,
and safety
■ Equipment: Adequate supplies, state-of-the-art equipment, and staff ability to
use equipment
■ Staff: Credentials, experience, absenteeism, turnover rate,
■ Finances: Salaries, adequacy, sources
Process
Process refers to the activities carried out by the health-care providers and all the
decisions made while a patient is interacting with the organization
Outcome
An outcome is the result of all the health-care providers’ activities. Outcome
measures evaluate the effectiveness of nursing activities.
(webitbead,weiss,tappen 2010)
Purposes of quality:
1. Monitor and evaluating quality of nursing staff according to quality
standards
2. Help supervisors to guide nursing staff to improve performance.
3. Improve quality of nursing care, increase effectiveness of care and efficiency
4. Increase patient and employee satisfaction
5. Increase productivity of nursing.

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Dimension of quality:
Eight dimensions of quality, these dimensions are useful framework that
helps health team to define and analyze their problems and to measure the extent
to which they are meeting program standard. These are:
1. Technical competence: the skills, capability, actual performance of
health provider, manager and support staff.
2. Access to service: it means that health care services are unrestricted by
geographic, economic and organizational barriers.
3. Effectiveness: Providing services based on scientific knowledge to all
who could benefit and refraining from providing services to those not
likely to benefit (avoiding underuse and overuse).
4. Efficiency: delivering health care in a manner which maximizes resource
use and avoids waste, in particular that of equipment, supplies, ideas, and
energy.
5. Interpersonal relation: refers to interaction between providers and
clients, manager and health care providers the health team and
community.
6. Continuity: means that the patient received the complete range of health
services that he needs and Timely.
7. Safe: delivering health care which minimizes risks and harm to service
users, avoiding injuries to patients from the care that is intended to help
them.
8. Amenities: refers to the feature of health service that enhances patient's
satisfaction and willingness to return to the facility.
(webitbead,weiss,tappen 2010)

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 Total quality management:

Definition:
 Total quality management is abroad management philosophy, promoting
quality and leadership commitment, that provides the energy and the
rationale for implementation of process of continuous quality improvement
(CQI) within the organization wide quality strategy (Marquis, 2012)

Goals of total quality management:

TQM is the coordination of efforts directed at:
1. Increasing employee participation
2. Facilitating organization atmosphere of continuous quality improvement
3. Patient satisfaction
4. Improving all the process within the organization
5. Minimize the cost
6. Make the organization to the best in the field
7. Obtaining accurate patient care feedback.
8. Correcting the care deficits.
9. Motivating nursing staff to improve patient care
10. Verifying effectiveness of established nursing process.
11. Conducting nursing research related structure, process, and outcome
elements and seeking to identify effective nursing methods

Principles of TQM:
The key principles of TQM are as following:
1. Management commitment
2. Employee empowerment
3. Fact based decision making
4. Continuous improvement
5. Customer focus
A. Management commitment:
 Plan: In the planning phase, people define the problem to be addressed,
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 collect relevant data, and ascertain the problem's root cause.
 Do: In the doing phase people develop and implement a solution, and
decide upon a measurement to gauge its effectiveness
 Check: In the checking phase, people confirm the results through, before,
and after data comparison
 Act: In the acting phase; people document their results, inform others
about process changes, and make recommendations for the problem.
B. Employee empowerment:
 Training
 Suggestion system
 Measurement and recognition
 Excellence team
C. Fact based decision making
 Statistical process control
 Team oriented problem solving
D. Continuous improvement
 Excellence team
 Attain, maintain, and improve standards
E. Customer focus
 Supplies partnership
 Customer driven standards

Elements of TQM:
To be successful implementing TQM, an organization must concentrate
on the eight key elements:
1. Ethics
2. Integrity
3. Trust
4. Training
5. Teamwork

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 6. Leadership
7. Recognition
8. Communication
TQM requires the help of those eight key elements. These elements can
be divided into four groups according to their function, the groups are
 Foundation: it includes (Ethics – integrity – and Trust)
 Building bricks: it includes (Training – Teamwork – and leadership)
 Roof: it includes Recognition
 Binding mortar: it includes Communication
Foundation:
TQM is built on a foundation of ethics, integrity, and trust it fosters
openness, fairness and sincerity and allows involvement by everyone these three
elements move together however, each element offers something different to the
TQM concept
 Ethics: is the discipline concerned with good and bad in any situation
 Integrity: implies honestly, morals, values, fairness, and adherence to the all
characteristics is costumers internal and external expect to avoid duplicity
 Trust: Is a byproduct of integrity and ethical conduit, it fosters full participation of
all members. It encourages commitment, allows decision making at appropriate
levels in the organization and ensure customer satisfaction
Bricks:
Bricks are placed to reach includes:
 Training: it is very important for employee to be highly product
 Teamwork: To become successful in business, teamwork is also a key
element to TQM
Roof:
 Recognition: It is the last and final element in the entire system
Binding mortar:
 Communication: It acts as a vital link between all elements of means a
common understanding of ideas between the sender and the receiver.

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 Quality control
Definition:
 It's the process which involves the activities that are used to evaluate
monitor, or regulate services rendered to consumers, by used measurement
tools.
The process of inspection products to ensure that they meet the required
quality standards
Quality control objectives
1) Increase customer satisfaction
2) Increase knowledge of customers' requirements
3) Reduce rework
4) Reduce customer complaints
5) Reduce manufacturing costs
6) Reduce staff turnover
7) Reduce absenteeism
8) Includes staff training
9) Encourage personal control of quality
10) Introduce continuous improvement
11) Keep up with technology and increase profits.
Who should be involved in quality control?
Ideally, everyone in the organization should participate in quality control,
because each individual is a recipient of the benefits.
Quality control gives employees feedback about their current quality of
care and how the care they provide can be improved.
Patients should also be actively involved in the determination of an
organization’s quality of care.

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Quality control as a process:
Control process involves the following steps as shown in the figure.

Step 1 :Establishing standards

This means setting up of the target which needs to be achieved to meet
organizational goals eventually.
Standards indicate the criteria of performance
Control standards are categorized as quantitative and qualitative standards.
Quantitative standards are expressed in terms of money.
Qualitative standards, on the other hand, includes intangible items .
Step 2 : Measurement of actual performance
The actual performance of the employee is measured against the target. With
the increasing levels of management, the measurement of performance becomes
difficult.
Step 3 : Comparison of actual performance with the standard
This compares the degree of difference between the actual performance and the
.standard.
Step 4 : Taking corrective actions
If standards are consistently unmet or met only partially, frequent reevaluation is
indicated. Effective leaders ensure that quality control is proactive by pushing

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standards to maximal levels and by eliminating problems in the early stages
before productivity or quality is compromised.
Roles of nurse manager associated with quality control
1. Encourages followers to be actively involved in the quality control process
2. Clearly communicates expected standards of care to subordinates
3. Encourages the setting of high standards to maximize quality
4. Embraces and champions quality improvement as an ongoing process
5. Uses control as a method of determining why goals were not met
6. Is active in communicating quality control findings and their implications to
other health professionals and consumers
7. Acts as a role model for followers in accepting responsibility and
accountability for nursing actions
8. Ensuring that patients receive at least minimally acceptable levels of quality
care
9. Supports/actively participates in research efforts to identify and measure
nursing sensitive patient outcomes
10. Creates a work culture that deemphasizes blame for errors and focuses
instead on addressing factors that lead to and cause near misses, medical
errors

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 Quality assurance

Definition:

 Quality assurance is the process of measuring the actual level of the service
provided against the degree and defined standards and take positive action to
modify services when necessary
The purposes of quality assurance:

 To assure the consumer that specified degree of excellence is given.

 To use resources effectively.
 To ensure high quality service among health workers.
 To evaluate care delivered.
Quality assurance process (cycle):
Quality assurance is cyclical process; this process must be applied flexibly
according to needs. it may begin with a comprehensive effort to define standard
and norms as described in step (1-3) or may start with small scale quality
improvement activities (step 5-10 ) alternatively the process may begin with
monitoring (step 4).

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 Quality assurance cycle
Step1 : plan

Step10 : Implement Step2 : set standards

solution

Step9 : identity who will Step3 : Communicate

Work on problem standards

Step8 : Analyze
Step4 : monitor
and study problem

Step7 : identity who will Step5 : identity and prioritize

Work on problem for improvement

Step6 : Define problem

Step 1: Planning:
Planning begins with review activities and scope of care of the
organization and decides:
 Where to begin?
 What kind of quality assurance activities will be undertaken?
 Who is responsible?
Step 2: Setting standard and specification:
Definition of standard:

 It is an agreed level of performance and offers a measure against which

current practice can be compared
 It is a written statement that define a level of performance or a set of
conditions determined to be acceptable by some authority
Types of standard:
1- Structure standard: Focus on the delivery system by which nursing care is
implemented. It include evaluation of physical environment, policies,
procedures, job description, staff number and equipment

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2- Process standard: Focus in nursing activities performed by nursing
personal particularly nursing tasks. It includes evaluation of assessment,
techniques, procedures, methods of delivering nursing care, methods of
patient education and methods of documentation.
3- Outcome standard: Focus on results of care administered to the patient. It
includes:
 Recovery rate
 Mortality rate
 Patient’s satisfaction
 Patient’s behavior
 Patient’s knowledge
 Patient’s self-care
Importance of standard:
1- Standard can enhance the nurses' control over many aspect of clinical
practice.
2- To promote competency.
3- To assess in position development.
4- To provide basis for performance appraisal.
5- To assess quality.
Characteristics of standard: Standard should be
 Valid
 Reliable
 Clear
 Measurable
 Applicable, and
 Achievable

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Criteria:
 Are predetermined measurable elements that will indicate if the standard is
met and to what degree it is met.
Characteristics of good criteria:
1- Good criteria must describe observable behavior.
2- State desired behavior.
3- Free from irrelevant material.
4- Incorporate only one action.
5- Use commonly acceptable abbreviation.
6- Criteria must be detail indicator of standards specific to area and type of
patient and be measurable.
Three types of criteria:
(1) Structure, (2) Process, and (3) Outcome criteria.

Step 3: Communicate standard:

Once performance standard have been defined, it is essential that staff
members communicate and promote their use. This will ensure that each health
worker, mangers and support person understands what is expecting of him.

Step 4: Monitoring:
Monitoring is the continuous or regular repeated observation of important
parts of the service (structure, process, and outcome). This process should have
four stages
 Measurement observation,
 Feedback,
 Comparison, and
 Action.

Purpose of monitoring:

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 1- To identify problems.
2- To ensure that improvement are maintained.
3- To verify that desired impact are achieved.
Methods for monitor nursing care:
Nursing audit:
It is the method for evaluating quality of nursing care through appraisal of
the nursing process or outcome of care as it is reflected in the patient care
records.
Types of audit:
 Concurrent audit: it has been called the open chart too. Because it occurs
while the patient is receiving care in health care facility.
Advantage:
1- It is based on clinical decision.
2- Assess present care given.
Disadvantage: It is costly and takes more time.
 Retrospective audit: It is conducted after a patient discharge. It involves
examining records of a large number of cases.
Advantage:
1- Less costly and take less time.
2- It is most useful for the organization because it give global picture of
care given.

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 Quality improvement (Q.I)
Definition:
 Quality improvement is defined as the commitment and approach used to
improve every process in every part of an organization with the intent of
meeting and exceeding customer expectation and outcomes
 Quality improvement is a continuous process focused on maintaining
regulatory compliance and improving patient care processes and
outcomes.(KELLY2010)
 Quality improvement cycle: Begin from step (5-10)
Six aims for improving quality in health-care
Health care should be:
1. Safe: Avoiding injuries to patients from the care that is intended to help
them
2. Effective: Providing services based on scientific knowledge to all who could
benefit and refraining from providing services to those not likely to benefit
(avoiding underuse and overuse)
3. Patient-centered: Providing care that is respectful of and responsive to
individual patient preferences, needs, and values and ensuring that patient
values guide all clinical decisions
4. Timely: Reducing waits and sometimes harmful delays for those who
receive and those who give care
5. Efficient: Avoiding waste, in particular that of equipment, supplies, ideas,
and energy
6. Equitable: Providing care that does not vary in quality because of
characteristics such as gender, ethnicity, geographic location, and
socioeconomic status. (webitbead,weiss,tappen 2010)

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Aspects of Health Care to Evaluate
A CQI program can evaluate three aspects of health care: the structure
within which the care is given, the process of giving care, and the outcome of
that care. A comprehensive evaluation should include all three aspects :
Structure
Structure refers to the setting in which the care is given and to the
resources (human, financial, and material) that are available. The following
structural aspects of a health-care organization can be evaluated:

 Facilities. Comfort, convenience of layout, accessibility of support

services, and safety

 Equipment: Adequate supplies and staff ability to use equipment

 Staff: Experience, absenteeism, turnover rate, staff-patient ratios
 Finances: Salaries, adequacy, sources.
Process
Process refers to the activities carried out by the health-care providers and all the
decisions made while a patient is interacting with the organization).
Examples include:

 Setting an appointment.
 Conducting a physical assessment.
 Ordering a radiograph and magnetic resonance imaging scan.
 Administering a blood transfusion.
 Completing a home environment assessment.
 Preparing the patient for discharge.
 Telephoning the patient post discharge.

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Outcome
An outcome is the result of all the health-care providers’ activities.
Outcome measures evaluate the effectiveness of nursing activities
Patient: Wound healed; blood pressure within normal limits; infection absent
Family: Increased time between visits to the emergency department.
Team: Decisions reached by consensus; attendance at meetings by all team
members. (webitbead,weiss,tappen 2010)

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 Reference
-Jones,R.A.P(2007), Nursing leadership and management,ch15,
USA,FA.Davis Company,PP.240,245-248.

-Kelly,p,(2010), Essentials of Nursing leadership & management ,ch

13, 2nd, USA,Delmar,PP.301,303-305,315.

-Wbitebead, D.K.Weiss,S.A. Tappen,R.M.(2010),Essential Nursing

leadership and management,ch 10,USA, ,FA.Davis
Company,PP135,139.

-Peer,M.(2003),Why Total Quality aMnagement Do Not Persist:The

Role of Management Quality and Implication for leading a TQM
Transformation.decicion sciences.vol.34,no.4,p.623.

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