Quality : Its is a relative term that describes
something with high merit or excellence which is
compared to an accepted standard (degree of
Quality care : means that the services
provided match the needs of the population are
technically correct, achieve beneficial results.
Assurance : Those activities those make
certain that services are actually provided
(formal guarantee, certainty)
Standards of care : desired goals that
can help in planning and evaluation of
Quality assurance: refers to process of
achieving excellence in the service
rendered to every client. Its also called
quality control process
Quality improvement ; it’s a systematic
approach to control and improve quality form
the perspective of both professionals and clients.
its also called total quality improvement or total
Quality Circle: a participative management
approach in which employees and managers
share the responsibility for decision making and
problem solving in client care.
Quality Indicators: Quality focused objective used as
markers to determine whether a goal has been achieved
and to measure client outcomes or process out comes.
Audit : an organized effort where by practicing
professional monitor , assess and make judgments about
the quality and appropriateness of nursing care provided
by peers are measured against professional standards of
Bench marking: studying another’s processes in order
to improve one’s own processes
Peer review : An organized system by which peer
professionals assess the quality of care being delivered.
Credentiality: Formal recognition of a person as a
professional with technical competence or of an agency
that has met minimum standards of performance.
Accreditation: process whereby a professional
association or non-governmental agency grants
recognition to a school or health care institution for
demonstrated ability to meet predetermined criteria for
Historical dvpt :
Quality assurance have been evident in nursing
since the days of Florence Nightingale she was a
pioneer in setting standards for nursing care.
In 1860 Nightingale called for the
development of a uniform method to collect and
present hospital statistics to improve hospital
In later 1800s the impetus for establishing
nursing schools in the U.S came from a desire to
set standards that would upgrade nursing care
In 1900s efforts were begun to set similar
standards for all nursing schools by various accrediting
organization , two of the most influential organizations
are ANA- American nurses association (1890) and NLN-
National league for nursing (1952).
From 1912-1939 the interest in quality nursing education
led to the development of nursing organization involved
in accrediting nursing programs.
In 1892 Licensure has been a major issue in nursing.
In 1923, all states has permissive / mandatory
laws directing nursing practice .
After World War II the attention of the
emerging nursing profession focused on
establishing a scientific method of practice.
In 1950s they brought the development of
tools to reassure quality assurance. One of the
first tool created was nursing audit .
In 1972, the congress for nursing practice
was charged with developing standards to be
used to institute quality assurance programs.
In 1972, The Joint Commission on
Accreditation of hospitals (JCAH) clearly stated
the responsibilities of nursing in its description of
standards for nursing services.
The JCAH called on the nursing industry to
clearly plan document and evaluate nursing care
In mid 1980s JCAH became the joint
commission on accreditation of health care
organization (JCAHCO) and began
developing quality control standards for
home health nursing and hospital nursing.
In 2007, it was renamed as The Joint
Commission (TJC) .
1. Definition of quality assurance
Quality assurance means delivery of
efficient and effective medical care in
accordance with the professional standards.
2. Definition of Quality Assurance in
Quality Assurance is the defining of
nursing practice through well written nursing
standards and the use of those standards as a
basis for evaluation on improvement of client
care (Maker 1998).
GOALS & PURPOSES:
· To ensure the delivery of quality client care
· To demonstrate the efforts of the health provider to provide
the best possible results
ii) Purpose of Quality Assurance:
Sets standards for care.
Help patients and potential patients by improving quality of care.
Assess competence of medical staff, serve as an impetus to
keep up to date and prevent future mistakes and
Bring to notice of hospital administration the deficiencies and in
correcting the causative factors
Helps to exercise a regulatory function, restricting undesirable
Need for quality control:
Quality control is essential to make the efficiency of health
institutions possible through.
a) Improvement of existing obsolete processes and procedures
b) Improved layout of office and working environment
c) Economy in human effort
d) Suggesting the best use of money and material
e) Improved design of the goods or services provided by the
f) Improved performance
g) Job satisfaction
h) Improved flow of work
i) Standardization of processes and products.
V. Approaches/ Techniques for
Two major categories of approaches
exist in quality assurance they are:
It is generally defined as the formal
recognition of professional or technical
competence and attainment of minimum
standards by a person or agency.
Licensure: It is a contract between the
profession and the state, in which the profession
is granted control over entry into and exists
from the profession and over quality of
National league for nursing (NLN) a voluntary
organization has established standards for inspecting
nursing education’s programs. In the part the
accreditation process primarily evaluated on regency’s
physical structure, organizational structure and personal
qualification. In 1990 more emphasis was placed on
evaluation of the outcomes of care and on the
educational qualifications of the person providing care.
Certification is usually a voluntary process
with in the professions. A person’s educational
achievements, experience and performance on
examination are used to determine the person’s
qualifications for functioning is an identified specialty
B. Specific Approach:
1. Peer Review Committee:
These are designed to monitor
client specific aspects of care appropriate
for certain levels of care. The audit has
been the major tool used by peer review
committee to ascertain quality of care.
An audit is an organized effort whereby practicing
professionals monitor, assess, and make judgments
about the quality and appropriateness of nursing care
provided by peers as measured against professional
standards of practice
The tools include record reviews, checklist,
questionnaires, and surveys.
Auditing can occur retrospectively,
concurrently, or prospectively.
Retrospective audit are performed after the
patient receives the service.
Concurrent audits are performed while the
patient is receiving the service.
Prospective audits attempt to identify how future
performance will be affected by current
The audit includes outcome audit , process audit, and
It can be defined as the end result of care, or how
the patient’s health status changed as result of the
Process audits are used to measure the process of
care or how the care was carried out and assume that a
relationship exists between the process used by the
nurse and the quality of care provided.e.g. a process
audit is used to establish whether fetal heart tones or
blood pressures were checked according to an
Structure audit assume that a relationship
exists between quality care and appropriate
structure. E.g. staffing ratios, availability of fire
extinguishers in patient care areas would all be
structure measures of quality care
2. Utilization review:
Utilization review activities are
directed towards assuring that care is actually
needed and that the cost appropriate for the
level of care provided.
Types of Utilization review:
i. Prospective: It is an assessment of the necessity of care
before giving service
ii.Concurrent: A review of the necessity of care while the
care is being given
iii.Retrospective: In analysis of the necessity of the services
Received by the client after the care has being given.
Utilization review has been used primarily in hospitals to establish
need for client admission end the length of hospital stay. The
Utilization review process includes the development of explicit
criteria that serves as indicators of the need for services and length
Advantages of Utilization
· It is designed to assist clients to avoid
· It may serve to encourage the
consideration of care options by providers, such
as home health care rather than hospitalization.
· It can provide guidelines for staff of
· It provides a measure of agency
accountability to the consumer
Client satisfaction can be assessed using person or
telephone interviews and mailed questionnaire. Data
from client satisfaction surveys are used to measure
structure, process and outcome of care given.
During a patient’s hospitalization several incidents
may occur which have a bearing on the treatment and
patients final recovery. The report should contain the
name, age, exact time and place, description of how it
occurred any precaution taken conditions of patient
before and after the incident etc. since these reports are
of legal value it should be written carefully given
importance to all the details and should be filed safely.
It can be defined in a program that is developed for
the purpose of eliminating or controlling health care
situations that has the potential to endangers or creates
risk to clients. Risk management activities are directed
towards the identifications, analysis and evaluation of
situations to prevent injury and subsequent financial
It is a specific approach to be imposed on the health
care delivery systems by the legal systems. Malpractice
litigation results from client dissatisfaction with the
provider and with the content of care received.
VI. Quality Assurance Committee
The committee should consist of the following:
1. Medical administrator
2. Two senior clinicians
5. Nurse administrator
6. Medical records officer – secretary
7. Additional personnel such as super-
specialists and consultants can be co-opted on
the committee as and when required.
VII. Quality Assurance
Committee in Nursing:
The members of the committee should include
representative of all levels of professional nursing
Client Care coordinators
Licensed practical Nurses
Other client care personnel
Medical records Administrator
vii.a) Functions of the Quality
Consider activities that should be related, e.g.
quality appraisal and continuing education
Communicate across patient care disciplines
Coordinate actions of hospital authority groups
Provide a centralized source of reports to the board
Suggest need for intervention to hospital authority
Insist on effective, productive quality
appraisal efforts from all hospital components
Provide specific assistance, usually through
Internally, acknowledge issues of importance to
individual and departments when suggesting high-
priority areas for immediate attention
Externally, provide the organizational home for
responding to quality requirements of external agencies,
if any, e.g. medical companies.
7. Search for expertise:
Operate openly, not behind closed doors seek out the
specific clinical and/or management expertise necessary
to reach sound conclusions
Insists on reports of the impact of implemented
changes.if quality assurance is to be effective rather
than threatening, controversial, and counterproductive.
Committee members must recognize that their major
i. To coordinate, not to control
ii. To inform, not to scold
iii. To plan, prod, and suggest priorities,
not to do detailed studies “in committee”, and
iv. To recommend and report, not to
Factors affecting quality
assurance in nursing care:
1) Lack of Resources:
Insufficient resources, infrastructures, equipment,
consumables, money for recurring expenses and
staff make it possible for output of a certain
quality to be turned out under the prevailing
2) Personnel problems:
Lack of trained, skilled and motivated employees,
staff indiscipline affects the quality of care.
3) Improper maintenance:
Buildings and equipments require proper maintenance for efficient use.
If not maintained properly the equipments cannot be used in giving
nursing care. To minimize equipment down time it is necessary to
ensure adequate after sale service and service manuals.
4) Unreasonable Patients and Attendants:
Illness, anxiety, absence of immediate response to treatment,
unreasonable and unco-operative attitude that in turn affects the
quality of care in nursing.
5) Absence of well informed population.
To improve quality of nursing care, it is necessary that the people
become knowledgeable and assert their rights to quality care. This
can be achieved through continuous educational program.
5) Absence of well informed population:
To improve quality of nursing care, it is necessary that the people
become knowledgeable and assert their rights to quality care. This
can be achieved through continuous educational program.
6) Absence of accreditation laws:
There is no organization empowered by legislation to lay down
standards in nursing and medical care so as to regulate the quality
of care. It requires a legislation that provides for setting of a
stationary accreditation / vigilance authority to:
a) Inspect hospitals and ensures that basic requirements are met.
b) Enquire into major incidence of negligence
c) Take actions against health professionals involved in malpractice
7) Lack of incident review procedures
During a patients hospitalizations reveal incidents
may occur which have a bearing on the
treatment and the patients final recovery. These
critical incidents may be:
a) Delayed attendance by nurses, surgeon,
b) Incorrect medication
c) Burns arising out of faulty procedures
d) Death in a corridor with no nurse / physician
accompanying the patient etc.
8) Lack of good and hospital information system
A good management information system is essential for the
appraisal of quality of care.
a) Workload, admissions, procedures and length of stay
b) Activity audit and scheduling of procedures.
9) Absence of patient satisfaction surveys
Ascertainment of patient satisfaction at fixed points on an
ongoing basis. Such surveys carried out through
questionnaires, interviews to by social worker, consultant
groups, and help to document patient satisfaction with
respect to variables that are
a) Delay in attendance by nurses and doctors.
b) Incidents of incorrect treatment
10) Lack of nursing care records
Nursing care records are perhaps the most useful
source of information on quality of care
rendered. The records.
a) Detail the patient condition
b) Document all significant interaction between
patient and the nursing personnel.
c) Contain information regarding response to
d) Have the dates in an easily accessible form.
11) Miscellaneous factors
a. Lack of good supervision
b. Absence of knowledge about philosophy of
c. Lack of policy and administrative manuals.
d. Substandard education and training
e. Lack of evaluation technique
f. Lack of written job description and job
g. Lack of in-service and continuing educational
Development of standards
a. Definition of standard:
A standard is a predetermined level of
excellence that serves a guide for practice.
Established by an authority
Communicated to and accepted by the
people affected by them
They must be measurable, achievable
this outline levels of acceptable practice within the
institution for example: each organization develops a policy and
procedures manual that outlines its specific standards. These
standards may be minimizing or maximizing in terms of the quality
of service expected. Such standards of practice allow the
organization to measure more objectively unit and individual
Standardized clinical guidelines:
provides diagnosis based, step by step interventions for
providers to follow in an effort to promote high quality care while
controlling resource utilization and costs. They are all developed by
Agency for Health care Research and Quality (AHRQ)
x.d. Sources of nursing care standards:
1. Professional organization E.g. TNAI Associations
2. Licensing bodies E.g. INC,
3. Institutions/ health care agencies E.g. JIPMER
4. Department of institution E.g. department of nursing
5. Patient care units E.g. specific patient care unit
6. Individual E.g. personal standards
e. Professional standards review organization:
a. PSRO- Professional standards review board
b. Prospective payment system
c. JCAHO- The Joint Commission for Accreditation of
health care Organizations
d. Centers for Medicare and Medicaid services (CMS)
e. National committee for quality assurance(NCQA)
f. Maryland hospital association quality indicator
f. Nursing scopes and standards of practice (ANA-
Since the 1930s the American nurses association has
played a key role in developing standards for the
profession. Currently there are more than 20 different
ANA standard for nursing practice that reflect different
areas of specialty nursing practice (ANA, 2001).the
standards of clinical nursing practice , originally
published by ANA in 1991 and subsequently revised in
both 1998, 2004 provides a foundation for all registered
nurses in clinical practice.
Nursing scope and standards of practice:
Standards of practice:
1. Assessment: the registered nurse collects comprehensive data
pertinent to the patient’s health or the situation
2. Diagnosis: the registered nurse analyze the assessment data to
determine the diagnoses or issues
3. Outcomes identification: the registered nurse identifies
expected outcomes for a plan individualized to the patient or the
4. Planning: the registered nurse develops a plan that prescribes
strategies and alternatives to attain expected outcomes
5. Implementation: the registered nurse implements the
6. Evaluation: the registered nurse evaluates progress toward
attainment of outcomes
Standards of professional performance:
7. Quality of practice: the registered nurse
systematically enhances the quality and effectiveness of
8. Education: the registered nurse attains knowledge
and competency that reflects current nursing practice
9.Professional practice evaluation; the registered
nurse evaluates own nursing practice in relation to
professional practice standards and guidelines, relevant
statutes, rules and regulations
10.Collegiality: the registered nurse interacts with and
contributes to the professional development of peers and
11.Collaboration: the registered nurse collaborates with the
patient, family, and others in the conduct of nursing practice.
12.Ethics; the registered nurse integrates ethical provisions in all
areas of practice .
13.Research: the registered nurse integrates research findings in
14,Resource utilization: the registered nurse considers factors
related to safety, effectiveness, cost, and impact on practice in
planning and delivering nursing services.
15.Leadership: the registered nurse provides leadership in the
professional practice setting and the profession.
XI. Total quality management:
xi.a. Definition :
It’s a systematic approach to
control and improve quality from the
perspective of both professionals and
clients. its also called continuous quality
Total Quality Management
1. Create a constancy of purpose for the
improvement of service
2. Adopt a philosophy of continual
3. Focus on improving processes, not on
inspection of services.
4. End the practice of awarding business on
price alone; instead minimize total cost by working with
a simple supplier.
5. Improve constantly every process for
planning, production and service
6. Institute job training and retraining.
7. Develop the leadership in the organization.
8. Drive out fear by encouraging employees to
participate actively in the process.
9. Foster interdepartmental cooperation and break
down barriers between departments.
10. Eliminate slogans, exhortations, and targets for the
11. Focus on quality and not just quantity
12. Promote teamwork rather than individual
13. Educate/ train employees to maximize
14. Charge all employees with carrying out the
total quality management package
JCAHO’s 10 steps for Quality
1. Establish responsibility and accountability for a QI
2. Define the scope of service for a chemical area
3. Define the key aspects of service for the chemical area
4. Develop quality indicators to monitor the outcomes and
appropriateness of care delivered.
5. Establish thresholds for evaluation of indicators
6. Collect and analyze data from monitoring activities
7. Evaluate results of monitoring activities to determine
the need for change in practice
8. Resolve problems through development of action plans
9. Reevaluate to determine if the plan was successful
10. Communicate QI results to the organization..
Tools in Quality management
Statistical tools utilized in quality management
Tools for process description, for data collection and
for data Analysis.
1. Tools for data collection:
2. Tools for Data Analysis:
3. Tools for process description: