This document discusses quality assurance in nursing services. It begins by defining quality and quality assurance, and outlines several models of quality assurance including the systems approach, ANA model, and Shewhart PDCA model. The document then discusses credentialing, licensure, accreditation and certification as general approaches to quality assurance. Specific approaches discussed include peer review, using standards, and auditing. Factors that can enhance or affect quality assurance in nursing care are also outlined. The roles of the quality assurance committee and nurse administrators in quality assurance are described.

1. Quality assurance in
nursing service
Dr.Prabhavathi.S
Principal
Revathi college of nursing
Thirupur, Tamilnadu, India.

2. Frequently seen…….

3. QUALITY
 The process of
 ensuring that the
degree of
excellence
 specified is achieved

4. QUALITY Meaning ……
1920-4
0
1940-196
0
1960 1970-80
Minimum
Standards
Absence of
Defects
Capacity to
Give
Good
Care
Adherence to
Standards

5. Quality in the 1990s
Meeting customers’ expectations;
“Doing the right thing and doing it
well” (JCAHO, 1994);

6. A NURSE IS A…..
 Patient care consultant
 Educator
 Manager
 Recruiter
 Therapist
 Researcher
 Administrator
 Case manager
 The list goes on…

7. A simple definition
FIVE RIGHTS
 THE RIGHT PATIENT,
 AT THE RIGHT TIME,
 IN THE RIGHT SETTING,
 RECEING THE RIGHT CARE
 AT THE RIGHTTIME
 IN THE RIGHTCOST.

8. Quality assurance
 “Quality assurance as the monitoring of the
activities of client care to determine the degree
of excellence attained to the implementation of
the activities”. (Bull, 1985)
 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).

9. Quality assurance
QA in nursing comprise of set of related elements
such as
 planning for quality,
 development of objectives setting and
 actively communicating standards,
 developing indicators,
 setting thresholds,
 collecting data to monitor compliance with set
standards for nursing practice
 and applying solutions to improve care
INC-QA MANUAL

10. history
 Unwritten -roman military hospitals
 18th century-john howard and Elizabeth fry
 1850S -florence nightingale
 1920-40-st.isabel stewart eight point list
 1936-G.B.Carter &H.balme book on care
evaluation
 1958-need for standard for insurance
companies-Dr.Faye Abdullah developed a rating
scale consisted of 50 items.

11.  1950s Frances reiter-categorised patients
based on nursing care and developed an
evaluation tool also
 1960-70s cost effectiveness and
accountability issues and introduction of
nursing process… more nursing research
works..
 1971-JCAHO-standards of nursing care.

12.  1985-87-Royal college of nursing –In
pursuit of excellence
 1990s-working for patients and WHO
health policy

13. MODELS OF QUALITY
ASSURANCE
1.The system approach in which the task is
broken down into manageable components
based on defined objectives.
The basic components of the system are
 1. Input
 2. Throughput
 3. Output
 4. Feedback

14. 2) ANA Quality Assurance Model
The basic components of the ANA model can be
summarized as follows:
 1) Identify values
 2) Identify structure, process and outcome standards
and criteria
 3) Select measurement
 4) Make interpretation
 5) Identify course of action
 6) Choose action
 7) Take action
 8) Reevaluate

16. 3.Maxwell (1984)
Maxwell recognized that, in a society where resources
are limited, self assessment by health care professionals
is not satisfactory in demonstrating the efficiency or
effectiveness of a service. The dimensions of quality he
proposed are:
 Access to service
 Relevance to need
 Effectiveness
 Equity
 Social acceptance
 Efficiency and economy

17. 4.Wilson (1987)
QUALITY
PROMOTION
PERFORMANCE
ASSESSMENT
SETTING
OBJECTIVES
ACTIVITY
MONITORING

18. 5.Lang (1976)
 This framework has subsequently been adopted and developed by
the ANA. The stages includes;
 Identify and agree values
 Review literature, Know QAP
 Analyze available programmes
 Determine most appropriate QAP
 Establish structure, plans, outcome criteria and standards
 Ratify standards and criteria
 Evaluate current levels of nursing practice against ratified structures
 Identify and analyze factors contributing to results
 Select appropriate actions to maintain or improve care
 Implement selected actions
 Evaluate QAP

19. 6.SHEWHART PDCA MODEL

20. QUALITY ASSURANCE
PROCESS:
 Establishment of standards or criteria
 Identify the information relevant to criteria
 Determine ways to collect information
 Collect and analyze the information
 Compare collected information with established
criteria
 Make a judgment about quality
 Provide information and if necessary, take
corrective action regarding findings of
appropriate sources
 Determine ways to communicate the information

21. QA PROCESS

22. QUALITY ASSURANCE
PROGRAMME
 A SET OF FUNCTIONALLY RELATED
ACTIVITIES (QUALITY CONTROL
ACTIVITIES) WHICH
EVALUATE,MONITOR AND REGULATE
THE QUALITY OF SERVICE RENDERED.
 General
 Specific

23. A. General Approach
 It involves large governing of official
body’s evaluation of a persons or agency’s
ability to meet established criteria or
standards at a given time.
 1) Credentialing:
 2) Licensure:
 3) Accreditation:
 3)CERTIFICATION

24. 1) Credentialing
It is the formal recognition of professional or
technical competence and attainment of
minimum standards by a person or agency.
According to Hinsvark (1981) credentialing
process has four functional components
 a) To produce a quality product
 b) To confer a unique identity
 c) To protect provider and public
 d) To control the profession.

25. 2) Licensure
 Individual licensure 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 professional practice. The
licensing process requires that regulations
be written to define the scopes and limits
of the professional’s practice.

26. 3) Accreditation:
 The indian nursing council has established
standards for inspecting nursing
education’s programs in india(NLN-US). In
the part the accreditation process
primarily evaluated on agency’s physical
structure, organizational structure and
personal qualification

27. 4. Certification
 Certification is usually a voluntary process
with in the profession. A person’s
educational achievements, experience and
performance on examination are used to
determine the person’s qualifications for
functioning in an identified specialty area.

28. B. Specific approaches:
 Quality assurances are methods used to
evaluate identified instances of providers
and client interaction.
1) Peer review
2) Standard as a device for quality
assurance.
3) Audit as a tool for quality assurance

29. 1).Peer review

30. Peer review…
 To maintain high standards, peer review has
been initiated to carefully review the quality of
practice demonstrated by members of a
professional group.
Peer review is divided in to two types.
1) One centers on the recipients of health services
by means of auditing the quality of services
rendered.
2)The other centers on the health professional by
evaluating the quality of individual performance.

31. 2) Standard as a device for
quality assurance
 Standard is a pre-determined baseline
condition or level of excellence that
comprises a model to be followed and
practiced

32. A nursing care standard
 is a descriptive statement of desired
quality against which to evaluate nursing
care.
 It is guideline. A guideline is a
recommended path to safe conduct, an
aid to professional performance.
 a standard is a planning tool also it can
be used as a control device to evaluate
the performance

33. SOURCES OF STANDARDS
 Professional organisation, e.g. Associations,
TNAI,
 Licensing bodies, e.g. Statutory bodies, INC,
 Institutions/health care agencies, e.g. University
Hospitals, Health Centres.
 Department of institutions, e.g. Department of
Nursing.
 Patient care units, e.g. specific patients' unit.
 Government units at National, State and Local
Government units.
 Individual e.g. personal standards

34. The ANA standards for practice
 Standard 1: The collection of data about health status of
the patient is systematic and continuous. The data are
accessible, communicative, and recorded.
 Standard 2: Nursing diagnosis are derived from health
status data.
 Standard 3: The plan of nursing care includes goals
derived from the nursing diagnoses.
 Standard 4: The plan of nursing care includes priorities
and the prescribed nursing approaches or measures to
achieve the goals derived from the nursing diagnoses.

35.  Standard 5: Nursing actions provide for patient
participation in health promotion, maintenance, and
restoration.
 Standard 6: Nursing actions assist the patient to
maximize his health capabilities.
 Standard 7: The patient’s progress or lack of progress
towards goal achievement is determined by the patient
and the nurse.
 Standard 8: The patient’s progress or lack of progress
towards goal achievement directs re-assessment, re-
ordering of priorities, new goal setting, and a revision of
the plan of nursing care.

36. Nine Patient Safety Solutions
April 2007
 1. Look-Alike, Sound-Alike Medication Names
2. Patient Identification
 3. Communication During Patient Hand-Overs
 4. Performance of Correct Procedure at Correct
Body Site
5. Control of Concentrated Electrolyte Solutions
 6. Assuring Medication Accuracy at Transitions in
Care
7. Avoiding Catheter and Tubing Mis-Connections
8. Single Use of Injection Devices
 9. Improved Hand Hygiene to Prevent Health
Care-Associated Infection (HAI)

37. STRCTURE STANDARDS
 These are institution oriented and related to
care providing system and resources that
support for actual provision of care.
 They include the Physical facilities, building, etc.
Policies, goals and objectives.
 Staffing members: training, qualification, job
responsibilities.
 Equipment and supplies.
 Administrative setup and channel of
communication. Recording system.
 Budgeting.

38. Process standards
 degree of skills with which the techniques are
performed, it implies professional judgment in
determining quality of nursing care/skills.
 These are nursing oriented and referred to the behavior
and actions which a nurse should carryout.
 Nurse prepares appropriate written nursing care plan
which includes identification of: Personal needs, disease
related needs and therapy needs. nurses interaction,
client’s participation, Implementation of actions
Evaluation of the results or effectiveness of nursing
actions.
 Professional Performance: Performance appraisal ,
Education , Ethics, Research .

39. Outcome Standards
1.patient centered or client centered.
2.the descriptive statement of result of care
3.qualitative and quantitative.
4.The results of outcome standards may be
positive or negative.
Eg.Self-care or disability. Morbidity or mortality
status. Non-occurrence of complication and
restoration of body functions, e.g. patients
developing infections postoperatively

40. STEPS OF STANDARD
FORMULATION
 Organize a quality circle
 Decide on the area of nursing practice for which you want to work
out standards.
 Review philosophy, purposes and objectives of institution.
 Review existing nursing care practices, nursing process
 identify client’s role and strategies for nursing care services.
 Write the statements considering all the frame of reference giving
rationale and criteria It may be through the use of criteria checklist
for – making observation of care given; examining records; self
evaluation checklist; patients’ opinion, etc.
 Determine validity by giving to the experts.
 Try out the standards to determine the feasibility. The standards are
put into practice and quality care is audited. Updating of standards
periodically with continuous renewal.

41. LEVELS OF STANDARD SETTING
6 levels of standard
setting
• national
• state
• community
• institution
• department
• individual

42. 3) Audit as a tool for quality
assurance
 Nursing audit may be
defined as a detailed
review and evaluation
of selected clinical
records in order to
evaluate the quality of
nursing care and
performance by
comparing it with
accepted standards.

44. FACTORS ENHANCING ….
 Quality of Nursing Leadership
 Organizational Structure
 Management Style
 Personnel Policies and Programs
 Professional Models of Care
 Quality of Care
 Quality Assurance

45.  Consultation and Resources
 Level of Autonomy
 Community and the Hospital
 Nurses as Teachers
 Image of Nursing
 Collegial Nurse-Physician
Relationships

46.  Orientation, inservice, continuing
education, formal education and
career development

47. FACTORS AFFECTING QUALITY
ASSURANCE IN NURSING CARE
1) Lack of Resources:
2) Personnel problems:
3) Improper maintenance:
4) Unreasonable Patients and Attendants
5) Absence of well informed population.
6) Absence of accreditation laws
7) Lack of incident review procedures
8) Lack of good and hospital information system
9) Absence of patient satisfaction surveys
10) Lack of nursing care records

48. FACTORS AFFECTING QUALITY
ASSURANCE IN NURSING CARE
11) Miscellaneous factors
a. Lack of good supervision
b. Absence of knowledge about philosophy of
nursing care
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
specifications
g. Lack of in-service and continuing educational
program

49. Qa vs qi
Inspection oriented
Reactive
Correction of special clauses
Responsibility of few
Narrow focus
Leadership may not be
vested
Problem solving by
authority
Planning oriented
Proactive
Correction of common
causes
Responsibility of all
Cross functional
Leadership actively leading
Problem solving by
employees at all levels

50. Quality assurance committee
The committee should meet periodically to carry
out the evaluation. The committee should
consist of:
medical administer
Two senior medical staff
Pathologist
Racliologist
Nurse administer/2 nursing senior staff
Medical records officer

51. Functions of quality assurance committee
→ Coordination
→ Information
→ Planning
→ Prodding
→ Consultation
→ Response
→ Search for expertise
→ Follow up

52. Quality assurance promotes
 Accessible , accredited , acceptable
 Relevant , reliable , resourced
 Efficient , equitable and effective care

53. Role of nurse administrators
 Initiator,
 facilitator,
 co-ordinator
 educator
 leader
 evaluator
 supervisor

54. FUNCTIONS OF NURSE
MANAGER
 Encourages followers to be actively involved in the
quality control process.
 Clearly communicates standards of care to subordinates.
Encourages the setting of high standards to maximize
quality instead of setting minimum safety standards.
 Implement quality control proactively instead reactively.
 Uses control as a method of detraining why goals were
not met.
 Is positively active in communicating quality control
finding.
 Acts as a role model for followers in accepting
responsibility and accountability for nursing actions.

55. FUNCTIONS…
 In conjunctions with other personnel in the organization establishes clear
cut, measurable standards of care and determines the most appropriate
method for measuring if those standards have been met.
 Selects and uses process, outcome and structure audits appropriately as
quality control tools.
 Assesses appropriate sources of information in data gathering for quality
control tools.
 Determines discrepancies between care provided and unit standards and
seeks further information regarding why standards were not met.
 Uses quality control findings as a measure of employee performance and
rewards, coaches, counsels, or disciplines employees accordingly.
 Keeps abreast of current government and licensing regulations that affect
quality control.

56. QA IN INDIA
The hospital nurses work in the ratio of 1:100 in most of
the hospitals and units as against the prescribed norms
i.e. 1:6 in general wards, 1:4 in special wards and 1:1 in
critical care units. These prescribed norms by Indian
Nursing Council and also endorsed by staff inspection
unit of Ministry of Finance, formed in 1992 by the Govt.
of India.
In the community one Auxiliary Nurse midwife looks after
15000-20000 population as against the prescribed norm
of 1:5000 in plain areas and 1:3000 in hilly areas
recommended by Bhore Committee (1946) and High
Power Committee (1987).
In schools at present the ratio of teacher to student is
1:25-30 as against the prescribed ratio of 1:10 (Indian
Nursing Council: 1987,2001).

57. D.B Gupta and Pushali Majumdar, National
Council of Applied Economic Research
(NCAER) in their report have projected
average number of nurses required by the year
2015 is 1,00,727 (on the basis of nurse to
doctor ratio - 1:3) as against the supply of
38012. Thus creating an imbalance of 62715.

58. HINDERENCES….to QA
Some of the major reasons for mismatched ratio
are, inadequate number of nurses being trained,
migration, non-filling up of the posts and non-
creation of posts .
The Indian nurse is efficient in her own motherland
but is not recognized for her services.
The nurses take care of the well being of others but
their own working environment is ‘sick’
To retain the faculty the single important factor is
to offer salary equivalent to UGC scales as is
being offered to faculties working in other
university programmes.

59. The Indian Nursing Council (INC)
The Indian Nursing Council (INC) prescribes the
syllabus, including detailed plan and hours of
each subject, scheme of examination and
admission criteria.
This ensures that the education offered in all
member nursing institutions is uniform.
Minimum standards are also set for the physical
facility, teaching facility and clinical facility to
start a nursing programme.
The INC conducts periodic inspections of the
institutions to ensure that the set standards are
implemented.

60. In order to improve the quality of nursing
care, INC initiated the project of quality
assurance by selecting one ward in Dr
RML Hospital in New Delhi and one ward
in PGI, Chandigarh; continuous &
continuing education were planned to all
category of nursing personnel for three
months in these wards.

61. 1. Syllabii of all nursing courses have been
revised, the concept of NRHM, SBA and IMNCI
has been integrated into the syllabus.
2. One-year post basic speciality course (Nurse
Midwifery Practitioner) has been developed
and some of the states have already started.
3. About 80 students have been enrolled under
National consortium for Ph.D in Nursing.

62. Plan of Action
1. A sum of the Rs. 1.25 lakh per continuing education
programme for 30 participants for 7 days to update
nursing personnel i.e. Nursing Education, Nursing
Administration and Staff Nurses.
2. In order to improve the quality of nursing
education, an increase from Rs. 10.00 lakh to Rs.
25.00 lakh per nursing education institution in
Government sector in a plan period towards a
capacity building of nursing schools/colleges has
been made.

63. 3. In order to train more graduate nurses in government sector, a scheme for
upgrading the school of nursing into college of nursing attached to medical
college has been initiated. An increased financial assistance from Rs. 1.5
crore to 6.00 crore has been made.
4. Opening of ANM and GNM School in high focused states.
5. Opening of 6 Colleges attached to 6 new AIIMS-like institution with a
cost of Rs. 20.00 crore per institution.
6. Scheme for Faculty Development Programme of M.Sc. (Nursing)
for high focused states has been initiated and necessary financial
assistance for training M.Sc. (Nursing) has been made for which an
additional capacity has been created.

64. 
7. Opening of Centre of Excellence at state level with an estimated
cost of Rs. 20.00 crore. This institution will act like a think tank for
nursing at the state level.
8. Opening of 4 Regional Institutes with an estimated cost of Rs.
50.00 crore will be developed. This institution will focus on faculty
development and research.
9. A sum of Rs. 1.00 crore has been sanctioned to each state
towards strengthening of State Nursing Council including developing
live register and also Rs. 1.00 crore towards capacity building of
State Nursing Cells attached to the Directorate.
10. Monitoring and Evaluation unit at National Level.

65. Bibliography
www.indiannursingcouncil.org
www.jointcommision.com
www.who.org.in
www.thai.in
www.currentnursing.com

66. Bibliography
 Swansburg .c russel and richard j.swansburg
introduction to management
and leadership for nurse managers 3rd edition
jones and bartlett publisher boston
 Hubber l. diane ,’’leadership and nursing care
management’’,saunders
 ;christine c.wright,dorothy,whittingtop quality
assurance – an introduction to health care
professionals churcchil livingstone