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
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.
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
It is statement or indication that inspires
• Quality assurance is an on-going, systematic,
comprehensive evaluation of health care services
& impact of those services on health care
• Quality assurance is defined as all activities
undertaken to predate & prevent poor quality.
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
• 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
• Plan & conduct patient teaching sessions.
• To identify appropriate management techniques
to be used for managing resources in given
• 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
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
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
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
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
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
DEVELOPMENT OF A QUALITY
• Foster Commitment of Quality
• Conduct a Preliminary Review of Quality-
• Develop the Purpose and Vision for the Quality
• Determine level and scope of initial Quality
• 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
Approaches of quality assurance are divided
into 2 types:
1. General Approach
2. Specific Approach
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
According to Hinsvark, credentialing process has 4
1. To produce a quality product.
2. To confer a unique identity.
3. To protect provider & public.
4. To control the profession
Individual licensure is a contract between profession
& state in which profession is granted control over
entry into & exists from profession & over quality of
Accreditation is the act of granting credit or
recognition especially to an educational
institution that maintains suitable standards.
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.
Quality assurances are methods used to evaluate
identified instances of provider and client
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.
ADVANTAGES OF NURSING
• Provides quality of nursing
• A patient is assured of good services.
• It will give valuable and pertinent information for
• It will lead to between co-operation and
communication among the nurse & health team.
• It will help each professional nurse for her self
• It helps the administration as better planning.
• It will reduce the incidence of medical legal
• It will broaden and strengthen nursing service.
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
Donabedian’s Structure-Process-Outcome model
Donabedian introduced 3 major method of evaluating
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.
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
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
• 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 standards &
IN NURSING CARE
• 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)
• 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
• Employer’s involvement.
• An environment that support taking risk.
• Team work.
• Data collection & analysis skills.
• Group interaction skills.
• Structure & management to enable
• Tools to facilitate improvement.
COMPONENTS OF QUALITY
• 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
• Reevaluate to determine if plan was successful.
• Communicate quality improvement results to
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 .
Standard is an established rule as basis of
comparison in measuring or finding capacity,
quality context & value of objects in same
Classification of nursing care
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
• It involves activities concerned with delivering
• 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
• Properly supervises & check whether patient is
receiving proper care or not.
• Contribute innovation & improvement of patient
• Participating in improvement projects &patient
• 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
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
• 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
• FLORENCE NIGHTINGALE ENVIRONMENT
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