1. SeminarSeminar
OnOn
Quality Assurance inQuality Assurance in
NursingNursing

2. Introduction:Introduction:

3. TERMINOLOGIES:TERMINOLOGIES:
 QualityQuality : Its is a relative term that describes: Its is a relative term that describes
something with high merit or excellence which issomething with high merit or excellence which is
compared to an accepted standard (degree ofcompared to an accepted standard (degree of
excellence).excellence).
 Quality careQuality care : means that the services: means that the services
provided match the needs of the population areprovided match the needs of the population are
technically correct, achieve beneficial results.technically correct, achieve beneficial results.
 AssuranceAssurance : Those activities those make: Those activities those make
certain that services are actually providedcertain that services are actually provided
(formal guarantee, certainty)(formal guarantee, certainty)

4. Cont….Cont….
 Standards of care Standards of care : desired goals that: desired goals that
can help in planning and evaluation ofcan help in planning and evaluation of
nursing practicesnursing practices
 Quality assuranceQuality assurance : refers to process of: refers to process of
achieving excellence in the serviceachieving excellence in the service
rendered to every client. Its also calledrendered to every client. Its also called
quality control processquality control process

5. Cont….Cont….
 Quality improvementQuality improvement ; it’s a systematic; it’s a systematic
approach to control and improve quality form theapproach to control and improve quality form the
perspective of both professionals and clients. itsperspective of both professionals and clients. its
also called total quality improvement or totalalso called total quality improvement or total
quality management.quality management.
 Quality CircleQuality Circle: a participative management: a participative management
approach in which employees and managersapproach in which employees and managers
share the responsibility for decision making andshare the responsibility for decision making and
problem solving in client care.problem solving in client care.

6. Cont….Cont….
 Quality IndicatorsQuality Indicators : Quality focused objective used as: Quality focused objective used as
markers to determine whether a goal has been achievedmarkers to determine whether a goal has been achieved
and to measure client outcomes or process out comes.and to measure client outcomes or process out comes.
 Audit Audit : an organized effort where by practicing: an organized effort where by practicing
professional monitor , assess and make judgmentsprofessional monitor , assess and make judgments
about the quality and appropriateness of nursing careabout the quality and appropriateness of nursing care
provided by peers are measured against professionalprovided by peers are measured against professional
standards of practicestandards of practice
 Bench markingBench marking : studying another’s processes in order: studying another’s processes in order
to improve one’s own processesto improve one’s own processes

7. Cont….Cont….
 Peer review :Peer review : An organized system by which peerAn organized system by which peer
professionals assess the quality of care being delivered.professionals assess the quality of care being delivered.
 Credentiality:Credentiality: Formal recognition of a person as aFormal recognition of a person as a
professional with technical competence or of an agencyprofessional with technical competence or of an agency
that has met minimum standards of performance.that has met minimum standards of performance.
 Accreditation:Accreditation: process whereby a professionalprocess whereby a professional
association or non-governmental agency grantsassociation or non-governmental agency grants
recognition to a school or health care institution forrecognition to a school or health care institution for
demonstrated ability to meet predetermined criteria fordemonstrated ability to meet predetermined criteria for
established standards.established standards.

8. Historical dvpt :Historical dvpt :
 Quality assurance have been evident in nursingQuality assurance have been evident in nursing
since the days of Florence Nightingale she wassince the days of Florence Nightingale she was
a pioneer in setting standards for nursing care.a pioneer in setting standards for nursing care.
 In 1860 Nightingale called for theIn 1860 Nightingale called for the
development of a uniform method to collect anddevelopment of a uniform method to collect and
present hospital statistics to improve hospitalpresent hospital statistics to improve hospital
treatmenttreatment
 In later 1800s the impetus for establishingIn later 1800s the impetus for establishing
nursing schools in the U.S came from a desire tonursing schools in the U.S came from a desire to
set standards that would upgrade nursing careset standards that would upgrade nursing care

9. Cont….Cont….
 In 1900s efforts were begun to set similar standardsIn 1900s efforts were begun to set similar standards
for all nursing schools by various accreditingfor all nursing schools by various accrediting
organization , two of the most influential organizationsorganization , two of the most influential organizations
are ANA- American nurses association (1890) and NLN-are ANA- American nurses association (1890) and NLN-
National league for nursing (1952).National league for nursing (1952).
 From 1912-1939 the interest in quality nursing educationFrom 1912-1939 the interest in quality nursing education
led to the development of nursing organization involvedled to the development of nursing organization involved
in accrediting nursing programs.in accrediting nursing programs.
 In 1892 Licensure has been a major issue in nursing.In 1892 Licensure has been a major issue in nursing.

10. Cont….Cont….
 In 1923, all states has permissive / mandatoryIn 1923, all states has permissive / mandatory
laws directing nursing practice . laws directing nursing practice .
 After World War II the attention of theAfter World War II the attention of the
emerging nursing profession focused onemerging nursing profession focused on
establishing a scientific method of practice.establishing a scientific method of practice.
 In 1950s they brought the development ofIn 1950s they brought the development of
tools to reassure quality assurance. One of thetools to reassure quality assurance. One of the
first tool created was nursing audit .first tool created was nursing audit .

11. Cont….Cont….
 In 1972, the congress for nursing practiceIn 1972, the congress for nursing practice
was charged with developing standards to bewas charged with developing standards to be
used to institute quality assurance programs.used to institute quality assurance programs.
 In 1972, The Joint Commission onIn 1972, The Joint Commission on
Accreditation of hospitals (JCAH) clearly statedAccreditation of hospitals (JCAH) clearly stated
the responsibilities of nursing in its description ofthe responsibilities of nursing in its description of
standards for nursing services.standards for nursing services.
 The JCAH called on the nursing industry toThe JCAH called on the nursing industry to
clearly plan document and evaluate nursing careclearly plan document and evaluate nursing care
provided .provided .

12. Cont….Cont….
 In mid 1980s JCAH became the jointIn mid 1980s JCAH became the joint
commission on accreditation of healthcommission on accreditation of health
care organization (JCAHCO) and begancare organization (JCAHCO) and began
developing quality control standards fordeveloping quality control standards for
home health nursing and hospital nursing.home health nursing and hospital nursing.
 In 2007, it was renamed as The JointIn 2007, it was renamed as The Joint
Commission (TJC) .Commission (TJC) .

13. DEFINITION:DEFINITION:
 1. Definition of quality assurance1. Definition of quality assurance
Quality assurance means deliveryQuality assurance means delivery
of efficient and effective medical care inof efficient and effective medical care in
accordance with the professional standards.accordance with the professional standards.
 2. Definition of Quality Assurance in2. Definition of Quality Assurance in
Nursing:Nursing:
Quality Assurance is the defining of nursingQuality Assurance is the defining of nursing
practice through well written nursing standardspractice through well written nursing standards
and the use of those standards as a basis forand the use of those standards as a basis for
evaluation on improvement of client care (Makerevaluation on improvement of client care (Maker
1998).1998).

14. GOALS & PURPOSES:GOALS & PURPOSES:
i) Goals:i) Goals:
· To ensure the delivery of quality client care· To ensure the delivery of quality client care
· To demonstrate the efforts of the health provider to provide the· To demonstrate the efforts of the health provider to provide the
best possible resultsbest possible results
ii)ii) Purpose of Quality Assurance:Purpose of Quality Assurance:
 Sets standards for care.Sets standards for care.
 Help patients and potential patients by improving quality of care.Help patients and potential patients by improving quality of care.
 Assess competence of medical staff, serve as an impetus toAssess competence of medical staff, serve as an impetus to
 keep up to date and prevent future mistakes andkeep up to date and prevent future mistakes and
 Bring to notice of hospital administration the deficiencies and inBring to notice of hospital administration the deficiencies and in
correcting the causative factorscorrecting the causative factors
 Helps to exercise a regulatory function, restricting undesirableHelps to exercise a regulatory function, restricting undesirable
 ProceduresProcedures

15. Need for quality control:Need for quality control:
 Quality control is essential to make the efficiency of healthQuality control is essential to make the efficiency of health
institutions possible through.institutions possible through.
a) Improvement of existing obsolete processes and proceduresa) Improvement of existing obsolete processes and procedures
b) Improved layout of office and working environmentb) Improved layout of office and working environment
c) Economy in human effortc) Economy in human effort
d) Suggesting the best use of money and materiald) Suggesting the best use of money and material
e) Improved design of the goods or services provided by thee) Improved design of the goods or services provided by the
organizationorganization
f) Improved performancef) Improved performance
g) Job satisfactiong) Job satisfaction
h) Improved flow of workh) Improved flow of work
i) Standardization of processes and products.i) Standardization of processes and products.

16. V. Approaches/ Techniques forV. Approaches/ Techniques for
Quality assurance:Quality assurance:
Two major categories of approachesTwo major categories of approaches
exist in quality assurance they are:exist in quality assurance they are:
 A. GeneralA. General
 B. SpecificB. Specific

17. Cont…..Cont…..
1) Credentialing:1) Credentialing:
It is generally defined as the formalIt is generally defined as the formal
recognition of professional or technicalrecognition of professional or technical
competence and attainment of minimumcompetence and attainment of minimum
standards by a person or agency.standards by a person or agency.
Licensure:Licensure: It is a contract between theIt is a contract between the
profession and the state, in which the professionprofession and the state, in which the profession
is granted control over entry into and exists fromis granted control over entry into and exists from
the profession and over quality of professionalthe profession and over quality of professional
practice.practice.

18. Cont….Cont….
Accreditation:Accreditation:
National league for nursing (NLN) a voluntaryNational league for nursing (NLN) a voluntary
organization has established standards for inspectingorganization has established standards for inspecting
nursing education’s programs. In the part thenursing education’s programs. In the part the
accreditation process primarily evaluated on regency’saccreditation process primarily evaluated on regency’s
physical structure, organizational structure and personalphysical structure, organizational structure and personal
qualification. In 1990 more emphasis was placed onqualification. In 1990 more emphasis was placed on
evaluation of the outcomes of care and on theevaluation of the outcomes of care and on the
educational qualifications of the person providing care.educational qualifications of the person providing care.

19. Cont….Cont….
Certification:Certification:
Certification is usually a voluntary processCertification is usually a voluntary process
with in the professions. A person’s educationalwith in the professions. A person’s educational
achievements, experience and performance onachievements, experience and performance on
examination are used to determine the person’sexamination are used to determine the person’s
qualifications for functioning is an identified specialtyqualifications for functioning is an identified specialty
area.area.

20. Cont…….Cont…….
B. Specific Approach:B. Specific Approach:
1. 1. Peer Review Committee:Peer Review Committee:
These are designed to monitor clientThese are designed to monitor client
specific aspects of care appropriate forspecific aspects of care appropriate for
certain levels of care. The audit has beencertain levels of care. The audit has been
the major tool used by peer reviewthe major tool used by peer review
committee to ascertain quality of care.committee to ascertain quality of care.

21. Cont….Cont….
Nursing auditNursing audit::
An audit is an organized effort whereby practicingAn audit is an organized effort whereby practicing
professionals monitor, assess, and make judgmentsprofessionals monitor, assess, and make judgments
about the quality and appropriateness of nursing careabout the quality and appropriateness of nursing care
provided by peers as measured against professionalprovided by peers as measured against professional
standards of practicestandards of practice
The toolsThe tools include record reviews, checklist,include record reviews, checklist,
questionnaires, and surveys.questionnaires, and surveys.

22. Cont….Cont….
Auditing can occurAuditing can occur retrospectively,retrospectively,
concurrentlyconcurrently, or, or prospectively.prospectively.
 Retrospective audit are performed after theRetrospective audit are performed after the
patient receives the service.patient receives the service.
 Concurrent audits are performed while theConcurrent audits are performed while the
patient is receiving the service.patient is receiving the service.
 Prospective audits attempt to identify how futureProspective audits attempt to identify how future
performance will be affected by currentperformance will be affected by current
interventions.interventions.

23. Cont…..Cont…..
The audit includes outcome audit , process audit, andThe audit includes outcome audit , process audit, and
structure audits:structure audits:
 Outcome auditOutcome audit
It can be defined as the end result of care, or how theIt can be defined as the end result of care, or how the
patient’s health status changed as result of thepatient’s health status changed as result of the
interventionintervention
 Process auditProcess audit::
Process audits are used to measure the process ofProcess audits are used to measure the process of
care or how the care was carried out and assume that acare or how the care was carried out and assume that a
relationship exists between the process used by therelationship exists between the process used by the
nurse and the quality of care provided.nurse and the quality of care provided.e.g.e.g. a processa process
audit is used to establish whether fetal heart tones oraudit is used to establish whether fetal heart tones or
blood pressures were checked according to anblood pressures were checked according to an
established policyestablished policy

24. Cont….Cont….
 Structure auditStructure audit::
Structure audit assume that a relationshipStructure audit assume that a relationship
exists between quality care and appropriateexists between quality care and appropriate
structure.structure. E.g.E.g. staffing ratios, availability of firestaffing ratios, availability of fire
extinguishers in patient care areas would all beextinguishers in patient care areas would all be
structure measures of quality carestructure measures of quality care
 2. Utilization review:2. Utilization review:
Utilization review activities areUtilization review activities are
directed towards assuring that care is actuallydirected towards assuring that care is actually
needed and that the cost appropriate for theneeded and that the cost appropriate for the
level of care provided.level of care provided.

25. Cont….Cont….
 Types of Utilization review:Types of Utilization review:
i. Prospective:i. Prospective: It is an assessment of the necessity ofIt is an assessment of the necessity of
carecare
before giving servicebefore giving service
ii.Concurrentii.Concurrent:: A review of the necessity of care while the A review of the necessity of care while the
care is being givencare is being given
iii.Retrospective:iii.Retrospective: In analysis of the necessity of the servicesIn analysis of the necessity of the services
 Received by the client after the care has being given.Received by the client after the care has being given.
Utilization review has been used primarily in hospitals to establishUtilization review has been used primarily in hospitals to establish
need for client admission end the length of hospital stay. Theneed for client admission end the length of hospital stay. The
Utilization review process includes the development of explicitUtilization review process includes the development of explicit
criteria that serves as indicators of the need for services and lengthcriteria that serves as indicators of the need for services and length
of services.of services.

26. Advantages of UtilizationAdvantages of Utilization
Review:Review:
 · It is designed to assist clients to avoid· It is designed to assist clients to avoid
unnecessary careunnecessary care
 · It may serve to encourage the· It may serve to encourage the
consideration of care options by providers, suchconsideration of care options by providers, such
as home health care rather than hospitalization.as home health care rather than hospitalization.
 · It can provide guidelines for staff of· It can provide guidelines for staff of
program development.program development.
 · It provides a measure of agency· It provides a measure of agency
accountability to the consumeraccountability to the consumer

27. 3.Client Satisfaction:3.Client Satisfaction:
Client satisfaction can be assessed using person orClient satisfaction can be assessed using person or
telephone interviews and mailed questionnaire. Datatelephone interviews and mailed questionnaire. Data
from client satisfaction surveys are used to measurefrom client satisfaction surveys are used to measure
structure, process and outcome of care given.structure, process and outcome of care given.
4.Incident Review:4.Incident Review:
During a patient’s hospitalization several incidentsDuring a patient’s hospitalization several incidents
may occur which have a bearing on the treatment andmay occur which have a bearing on the treatment and
patients final recovery. The report should contain thepatients final recovery. The report should contain the
name, age, exact time and place, description of how itname, age, exact time and place, description of how it
occurred any precaution taken conditions of patientoccurred any precaution taken conditions of patient
before and after the incident etc. since these reports arebefore and after the incident etc. since these reports are
of legal value it should be written carefully givenof legal value it should be written carefully given
importance to all the details and should be filed safely.importance to all the details and should be filed safely.

28. 5.Risk Management:5.Risk Management:
It can be defined in a program that is developed for theIt can be defined in a program that is developed for the
purpose of eliminating or controlling health carepurpose of eliminating or controlling health care
situations that has the potential to endangers or createssituations that has the potential to endangers or creates
risk to clients. Risk management activities are directedrisk to clients. Risk management activities are directed
towards the identifications, analysis and evaluationtowards the identifications, analysis and evaluation ofof
situations to prevent injury and subsequent financial loss.situations to prevent injury and subsequent financial loss.
6.Malpractice litigation:6.Malpractice litigation:
It is a specific approach to be imposed on the healthIt is a specific approach to be imposed on the health
care delivery systems by the legal systems. Malpracticecare delivery systems by the legal systems. Malpractice
litigation results from client dissatisfaction with thelitigation results from client dissatisfaction with the
provider and with the content of care received.provider and with the content of care received.

29. VI. Quality Assurance CommitteeVI. Quality Assurance Committee
(QAC):(QAC):
 The committee should consist of the following:The committee should consist of the following:
 1. Medical administrator1. Medical administrator
 2. Two senior clinicians2. Two senior clinicians
 3. Pathologist3. Pathologist
 4. Radiologist4. Radiologist
 5. Nurse administrator5. Nurse administrator
 6. Medical records officer – secretary6. Medical records officer – secretary
 7. Additional personnel such as super-7. Additional personnel such as super-
specialists and consultants can be co-opted onspecialists and consultants can be co-opted on
the committee as and when required.the committee as and when required.

30. VII. Quality AssuranceVII. Quality Assurance
Committee in Nursing:Committee in Nursing:
 The members of the committee should includeThe members of the committee should include
representative of all levels of professional nursingrepresentative of all levels of professional nursing
includingincluding
 Client Care coordinatorsClient Care coordinators
 SupervisorsSupervisors
 Head NursesHead Nurses
 Clinical SpecialistsClinical Specialists
 Nurse CliniciansNurse Clinicians
 Licensed practical NursesLicensed practical Nurses
 Nursing AssistantsNursing Assistants
 Other client care personnelOther client care personnel
 Medical records AdministratorMedical records Administrator

31. vii.a) Functions of the Qualityvii.a) Functions of the Quality
assurance committee:assurance committee:
1. Coordination:1. Coordination:
Collecting informationCollecting information
Consider activities that should be related, e.g. qualityConsider activities that should be related, e.g. quality
appraisal and continuing educationappraisal and continuing education
Communicate across patient care disciplinesCommunicate across patient care disciplines
Coordinate actions of hospital authority groupsCoordinate actions of hospital authority groups
2. Information:2. Information:
Provide a centralized source of reports to the boardProvide a centralized source of reports to the board
Suggest need for intervention to hospital authoritySuggest need for intervention to hospital authority
groupsgroups

32. Cont….Cont….
3. Planning:3. Planning:
Establish prioritiesEstablish priorities
4. Prodding:4. Prodding:
Insist on effective, productive qualityInsist on effective, productive quality
appraisal efforts from all hospital componentsappraisal efforts from all hospital components
5. Consultation:5. Consultation:
Provide specific assistance, usually throughProvide specific assistance, usually through
the coordinatorthe coordinator

33. Cont….Cont….
 6. Response:6. Response:
Internally, acknowledge issues of importance toInternally, acknowledge issues of importance to
individual and departments when suggesting high-priorityindividual and departments when suggesting high-priority
areas for immediate attentionareas for immediate attention
Externally, provide the organizational home forExternally, provide the organizational home for
responding to quality requirements of external agencies,responding to quality requirements of external agencies,
if any, e.g. medical companies.if any, e.g. medical companies.
7. Search for expertise:7. Search for expertise:
Operate openly, not behind closed doors seek out theOperate openly, not behind closed doors seek out the
specific clinical and/or management expertise necessaryspecific clinical and/or management expertise necessary
to reach sound conclusionsto reach sound conclusions

34. Cont….Cont….
8. Follow-up:8. Follow-up:
Insists on reports of the impact of implementedInsists on reports of the impact of implemented
changes.if quality assurance is to be effective rather thanchanges.if quality assurance is to be effective rather than
threatening, controversial, and counterproductive.threatening, controversial, and counterproductive.
Committee members must recognize that their majorCommittee members must recognize that their major
functions are:functions are:
i. To coordinate, not to controli. To coordinate, not to control
ii. To inform, not to scoldii. To inform, not to scold
iii. To plan, prod, and suggest priorities, notiii. To plan, prod, and suggest priorities, not
to do detailed studies “in committee”, andto do detailed studies “in committee”, and
iv. To recommend and report, not toiv. To recommend and report, not to
intervene directly.intervene directly.

35. Factors affecting qualityFactors affecting quality
assurance in nursing care:assurance in nursing care:
1) Lack of Resources:1) Lack of Resources:
Insufficient resources, infrastructures, equipment,Insufficient resources, infrastructures, equipment,
consumables, money for recurring expenses andconsumables, money for recurring expenses and
staff make it possible for output of a certainstaff make it possible for output of a certain
quality to be turned out under the prevailingquality to be turned out under the prevailing
circumstances.circumstances.
2) Personnel problems:2) Personnel problems:
Lack of trained, skilled and motivated employees,Lack of trained, skilled and motivated employees,
staff indiscipline affects the quality of care.staff indiscipline affects the quality of care.

36. Cont….Cont….
3) Improper maintenance:3) Improper maintenance:
Buildings and equipments require proper maintenance for efficient use.Buildings and equipments require proper maintenance for efficient use.
If not maintained properly the equipments cannot be used in givingIf not maintained properly the equipments cannot be used in giving
nursing care. To minimize equipment down time it is necessary tonursing care. To minimize equipment down time it is necessary to
ensure adequate after sale service and service manuals.ensure adequate after sale service and service manuals.
4) Unreasonable Patients and Attendants:4) Unreasonable Patients and Attendants:
Illness, anxiety, absence of immediate response to treatment,Illness, anxiety, absence of immediate response to treatment,
unreasonable and unco-operative attitude that in turn affects theunreasonable and unco-operative attitude that in turn affects the
quality of care in nursing.quality of care in nursing.
5) Absence of well informed population.5) Absence of well informed population.
To improve quality of nursing care, it is necessary that the peopleTo improve quality of nursing care, it is necessary that the people
become knowledgeable and assert their rights to quality care. Thisbecome knowledgeable and assert their rights to quality care. This
can be achieved through continuous educational program.can be achieved through continuous educational program.

37. Cont….Cont….
5) Absence of well informed population:5) Absence of well informed population:
To improve quality of nursing care, it is necessary that the peopleTo improve quality of nursing care, it is necessary that the people
become knowledgeable and assert their rights to quality care. Thisbecome knowledgeable and assert their rights to quality care. This
can be achieved through continuous educational program.can be achieved through continuous educational program.
6) Absence of accreditation laws:6) Absence of accreditation laws:
There is no organization empowered by legislation to lay downThere is no organization empowered by legislation to lay down
standards in nursing and medical care so as to regulate the qualitystandards in nursing and medical care so as to regulate the quality
of care. It requires a legislation that provides for setting of aof care. It requires a legislation that provides for setting of a
stationary accreditation / vigilance authority to:stationary accreditation / vigilance authority to:
a) Inspect hospitals and ensures that basic requirements are met.a) Inspect hospitals and ensures that basic requirements are met.
b) Enquire into major incidence of negligenceb) Enquire into major incidence of negligence
c) Take actions against health professionals involved in malpracticec) Take actions against health professionals involved in malpractice

38. Cont….Cont….
7) Lack of incident review procedures7) Lack of incident review procedures
During a patients hospitalizations reveal incidentsDuring a patients hospitalizations reveal incidents
may occur which have a bearing on themay occur which have a bearing on the
treatment and the patients final recovery. Thesetreatment and the patients final recovery. These
critical incidents may be:critical incidents may be:
a) Delayed attendance by nurses, surgeon,a) Delayed attendance by nurses, surgeon,
physicianphysician
b) Incorrect medicationb) Incorrect medication
c) Burns arising out of faulty proceduresc) Burns arising out of faulty procedures
d) Death in a corridor with no nurse / physiciand) Death in a corridor with no nurse / physician
accompanying the patient etc.accompanying the patient etc.

39. CONT….CONT….
8) Lack of good and hospital information system8) Lack of good and hospital information system
A good management information system is essential for theA good management information system is essential for the
appraisal of quality of care.appraisal of quality of care.
a) Workload, admissions, procedures and length of staya) Workload, admissions, procedures and length of stay
b) Activity audit and scheduling of procedures.b) Activity audit and scheduling of procedures.
9) Absence of patient satisfaction surveys9) Absence of patient satisfaction surveys
Ascertainment of patient satisfaction at fixed points on anAscertainment of patient satisfaction at fixed points on an
ongoing basis. Such surveys carried out throughongoing basis. Such surveys carried out through
questionnaires, interviews to by social worker, consultantquestionnaires, interviews to by social worker, consultant
groups, and help to document patient satisfaction withgroups, and help to document patient satisfaction with
respect to variables that arerespect to variables that are
a) Delay in attendance by nurses and doctors.a) Delay in attendance by nurses and doctors.
b) Incidents of incorrect treatmentb) Incidents of incorrect treatment

40. Cont….Cont….
10) Lack of nursing care records10) Lack of nursing care records
Nursing care records are perhaps the most usefulNursing care records are perhaps the most useful
source of information on quality of caresource of information on quality of care
rendered. The records.rendered. The records.
a) Detail the patient conditiona) Detail the patient condition
b) Document all significant interaction betweenb) Document all significant interaction between
patient and the nursing personnel.patient and the nursing personnel.
c) Contain information regarding response toc) Contain information regarding response to
treatmenttreatment
d) Have the dates in an easily accessible form.d) Have the dates in an easily accessible form.

41. Cont….Cont….
11) Miscellaneous factors11) Miscellaneous factors
a. Lack of good supervisiona. Lack of good supervision
b. Absence of knowledge about philosophy ofb. Absence of knowledge about philosophy of
nursing carenursing care
c. Lack of policy and administrative manuals.c. Lack of policy and administrative manuals.
d. Substandard education and trainingd. Substandard education and training
e. Lack of evaluation techniquee. Lack of evaluation technique
f. Lack of written job description and jobf. Lack of written job description and job
specificationsspecifications
g. Lack of in-service and continuing educationalg. Lack of in-service and continuing educational
programprogram

42. DevelopmentDevelopment of standardsof standards
a. Definition of standard:a. Definition of standard:
 A standard is a predetermined level ofA standard is a predetermined level of
excellence that serves a guide for practice.excellence that serves a guide for practice.
b.Characters:b.Characters:
 PredeterminedPredetermined
 Established by an authorityEstablished by an authority
 Communicated to and accepted by theCommunicated to and accepted by the
people affected by thempeople affected by them
 They must be measurable, achievableThey must be measurable, achievable

43. Cont….Cont….
c. Typesc. Types
 Organizational standards:Organizational standards:
this outline levels of acceptable practice within the institutionthis outline levels of acceptable practice within the institution
for example: each organization develops a policy and proceduresfor example: each organization develops a policy and procedures
manual that outlines its specific standards. These standards may bemanual that outlines its specific standards. These standards may be
minimizing or maximizing in terms of the quality of service expected.minimizing or maximizing in terms of the quality of service expected.
Such standards of practice allow the organization to measure moreSuch standards of practice allow the organization to measure more
objectively unit and individual performance.objectively unit and individual performance.
 Standardized clinical guidelines:Standardized clinical guidelines:
provides diagnosis based, step by step interventions forprovides diagnosis based, step by step interventions for
providers to follow in an effort to promote high quality care whileproviders to follow in an effort to promote high quality care while
controlling resource utilization and costs. They are all developed bycontrolling resource utilization and costs. They are all developed by
Agency for Health care Research and Quality (AHRQ)Agency for Health care Research and Quality (AHRQ)

44. Cont….Cont….
 x.d. Sources of nursing care standards:x.d. Sources of nursing care standards:
1. Professional organization E.g. TNAI Associations1. Professional organization E.g. TNAI Associations
2. Licensing bodies E.g. INC,2. Licensing bodies E.g. INC,
3. Institutions/ health care agencies E.g. JIPMER3. Institutions/ health care agencies E.g. JIPMER
4. Department of institution E.g. department of nursing4. Department of institution E.g. department of nursing
5. Patient care units E.g. specific patient care unit5. Patient care units E.g. specific patient care unit
6. Individual E.g. personal standards6. Individual E.g. personal standards

45. Cont…Cont…
e. Professional standards review organization:e. Professional standards review organization:
a. PSRO- Professional standards review boarda. PSRO- Professional standards review board
legislation(1972)legislation(1972)
b. Prospective payment systemb. Prospective payment system
c. JCAHO- The Joint Commission for Accreditation ofc. JCAHO- The Joint Commission for Accreditation of
health care Organizationshealth care Organizations
d. Centers for Medicare and Medicaid services (CMS)d. Centers for Medicare and Medicaid services (CMS)
e. National committee for quality assurance(NCQA)e. National committee for quality assurance(NCQA)
f. Maryland hospital association quality indicatorf. Maryland hospital association quality indicator
projectproject

46. Cont….Cont….
f. Nursing scopes and standards of practicef. Nursing scopes and standards of practice
(ANA-2004) (ANA-2004)
 Since the 1930s the American nurses association hasSince the 1930s the American nurses association has
played a key role in developing standards for theplayed a key role in developing standards for the
profession. Currently there are more than 20 differentprofession. Currently there are more than 20 different
ANA standard for nursing practice that reflect differentANA standard for nursing practice that reflect different
areas of specialty nursing practice (ANA, 2001).theareas of specialty nursing practice (ANA, 2001).the
standards of clinical nursing practice , originallystandards of clinical nursing practice , originally
published by ANA in 1991 and subsequently revised inpublished by ANA in 1991 and subsequently revised in
both 1998, 2004 provides a foundation for all registeredboth 1998, 2004 provides a foundation for all registered
nurses in clinical practice.nurses in clinical practice.

47. Cont….Cont….
 Nursing scope and standards of practice:Nursing scope and standards of practice:
Standards of practice:Standards of practice:
1. Assessment: the registered nurse collects comprehensive data1. Assessment: the registered nurse collects comprehensive data
pertinent to the patient’s health or the situationpertinent to the patient’s health or the situation
2. 2. Diagnosis:Diagnosis: the registered nurse analyze the assessment datathe registered nurse analyze the assessment data
to determine the diagnoses or issuesto determine the diagnoses or issues
3. 3. Outcomes identificationOutcomes identification : the registered nurse identifies: the registered nurse identifies
expected outcomes for a plan individualized to the patient or theexpected outcomes for a plan individualized to the patient or the
situationsituation
4. 4. Planning:Planning: the registered nurse develops a plan that prescribesthe registered nurse develops a plan that prescribes
strategies and alternatives to attain expected outcomesstrategies and alternatives to attain expected outcomes
5. 5. Implementation:Implementation: the registered nurse implements thethe registered nurse implements the
identified planidentified plan
6. 6. Evaluation:Evaluation: the registered nurse evaluates progress towardthe registered nurse evaluates progress toward
attainment of outcomesattainment of outcomes

48. Cont….Cont….
 Standards of professional performance:Standards of professional performance:
 7. Quality of practice7. Quality of practice : the registered nurse: the registered nurse
systematically enhances the quality and effectiveness ofsystematically enhances the quality and effectiveness of
nursing practicenursing practice..
 8. 8. EducationEducation: the registered nurse attains knowledge: the registered nurse attains knowledge
and competency that reflects current nursing practiceand competency that reflects current nursing practice
 9.Professional practice evaluation9.Professional practice evaluation ; the registered; the registered
nurse evaluates own nursing practice in relation tonurse evaluates own nursing practice in relation to
professional practice standards and guidelines, relevantprofessional practice standards and guidelines, relevant
statutes, rules and regulationsstatutes, rules and regulations
 10.Collegiality:10.Collegiality: the registered nurse interacts with andthe registered nurse interacts with and
contributes to the professional development of peers andcontributes to the professional development of peers and
colleaguescolleagues

49. Cont….Cont….
 11.Collaboration11.Collaboration : the registered nurse collaborates with the: the registered nurse collaborates with the
patient, family, and others in the conduct of nursing practice.patient, family, and others in the conduct of nursing practice.
 12.Ethics;12.Ethics; the registered nurse integrates ethical provisions in allthe registered nurse integrates ethical provisions in all
areas of practice .areas of practice .
 13.Research:13.Research: the registered nurse integrates research findings inthe registered nurse integrates research findings in
practice.practice.
 14,Resource utilization14,Resource utilization : the registered nurse considers factors: the registered nurse considers factors
related to safety, effectiveness, cost, and impact on practice inrelated to safety, effectiveness, cost, and impact on practice in
planning and delivering nursing services.planning and delivering nursing services.
 15.Leadership15.Leadership : the registered nurse provides leadership in the : the registered nurse provides leadership in the
professional practice setting and the profession.professional practice setting and the profession.

50. XI. Total quality managementXI. Total quality management::
 xi.a. Definition :xi.a. Definition :
It’s a systematic approach toIt’s a systematic approach to
control and improve quality from thecontrol and improve quality from the
perspective of both professionals andperspective of both professionals and
clients. its also called continuous qualityclients. its also called continuous quality
improvementimprovement

51. Total Quality ManagementTotal Quality Management
Principles: (Deming)Principles: (Deming)
1. Create a constancy of purpose for the1. Create a constancy of purpose for the
improvement of serviceimprovement of service
2. Adopt a philosophy of continual improvement2. Adopt a philosophy of continual improvement
3. Focus on improving processes, not on3. Focus on improving processes, not on
inspection of services.inspection of services.
4. End the practice of awarding business on4. End the practice of awarding business on
price alone; instead minimize total cost by working with aprice alone; instead minimize total cost by working with a
simple supplier.simple supplier.
5. Improve constantly every process for5. Improve constantly every process for
planning, production and serviceplanning, production and service

52. Cont….Cont….
6. Institute job training and retraining.6. Institute job training and retraining.
7. Develop the leadership in the organization.7. Develop the leadership in the organization.
8. Drive out fear by encouraging employees to8. Drive out fear by encouraging employees to
participate actively in the process.participate actively in the process.
9. Foster interdepartmental cooperation and break down9. Foster interdepartmental cooperation and break down
barriers between departments.barriers between departments.
10. Eliminate slogans, exhortations, and targets for the10. Eliminate slogans, exhortations, and targets for the
work forcework force

53. Cont….Cont….
11. Focus on quality and not just quantity11. Focus on quality and not just quantity
12. Promote teamwork rather than individual12. Promote teamwork rather than individual
accomplishmentsaccomplishments
13. Educate/ train employees to maximize13. Educate/ train employees to maximize
personal developmentpersonal development
14. Charge all employees with carrying out the14. Charge all employees with carrying out the
total quality management packagetotal quality management package

54. JCAHO’s 10 steps for QualityJCAHO’s 10 steps for Quality
Improvement -process:Improvement -process:
1. Establish responsibility and accountability for a QI1. Establish responsibility and accountability for a QI
ProgramProgram
2. Define the scope of service for a chemical area2. Define the scope of service for a chemical area
3. Define the key aspects of service for the chemical area3. Define the key aspects of service for the chemical area
4. Develop quality indicators to monitor the outcomes and4. Develop quality indicators to monitor the outcomes and
appropriateness of care delivered.appropriateness of care delivered.
5. Establish thresholds for evaluation of indicators5. Establish thresholds for evaluation of indicators
6. Collect and analyze data from monitoring activities6. Collect and analyze data from monitoring activities
7. Evaluate results of monitoring activities to determine the7. Evaluate results of monitoring activities to determine the
need for change in practiceneed for change in practice
8. Resolve problems through development of action plans8. Resolve problems through development of action plans
9. Reevaluate to determine if the plan was successful9. Reevaluate to determine if the plan was successful
10. Communicate QI results to the organization..10. Communicate QI results to the organization..

55. Tools in Quality managementTools in Quality management
Statistical tools utilized in quality managementStatistical tools utilized in quality management
studies includestudies include
Tools for process description, for data collection andTools for process description, for data collection and
for data Analysis.for data Analysis.
1. Tools for data collection:1. Tools for data collection:
2. Tools for Data Analysis:2. Tools for Data Analysis:
3. Tools for process description:3. Tools for process description:

56. Thank youThank you