QUALITY ASSURANCE IN NURSING

1. QUALITY
ASSURANCE IN
NURSING
Presented by:-
SARAL KUMAR
M.Sc. NURSING
1ST YEAR

2. INTRODUCTION:
• Quality is rapidly becoming concern to both the
consumers and the providers of the services. In health
care, quality is being demanded and expected and
providers are judged by quality of services and hence,
there is a need to sensitize and train nursing Personnel
to provide quality care.

3. • Quality refers to excellence of a product or a service
including its attractiveness, lack of defects, reliability
and long term durability. Quality assurance provides
the mechanism to effectively monitor patient care
provided by health care professionals using cost
effective resources.

4. DEFINITION:
Quality assurance is a systemic, ongoing, comprehensive
evaluation of health care services and impact of those
services on health care services.
kozier
Quality assurance is defined as all activities undertaken to
predate and prevent poor quality
Neetvert
Quality assurance is a judgement concerning the process of
care, based on the extents to which that care contributes to
valued outcomes.

5. CONCEPT OF QUALITYASSURANCE:
• Quality is defined at the extent of resemblance
between the purpose of healthcare and the truly
granted care.
• Quality assurance originated in manufacturing
industry “to ensure that the product consistently
achieved customer satisfaction”.
• Quality assurance is a dynamic process through
which nurses assume accountability for quality of
care they provide.

6. • It is a guarantee to the society that services provided
by nurses are being regulated by members of
profession.
• “Quality assurance is a judgment concerning the
process of care based on the extent to which that care
contributes to valued outcomes”.
• “Quality assurance as the monitoring of the activities
of client care to the determine the degree of
excellence attained to the implementation of the
activities”.

7. BENEFITS AND PURPOSES OF QUALITY
ASSURANCE:
Quality assurance enables:
• Brings internal benefits to the
universities/faculty/department/school/program and
the staff,
• Bring external benefits to the students and the
reputation of the institution
• Continuously improve themselves, the students and
the work of the university. Continuous improvement
is both the medium and outcome of the quality
assurance,

8. CONT....
• Serve accountability the accreditation requirements,
• Enhance the reputation of the
faculty/department/school/university, and meet
external demands for demonstrating quality, Quality
Assurance and quality enhancement.

9. Principles:
• Managers need to be committed to quality
management
• All employees must be involved in quality
improvement
• The goal of quality management is to provide a
system in which workers can function effectively
• The focus quality management is on improving the
system
• Every agency has internal and external customers.
• Customers defines quality
• Decision must be based on facts.

10. Process of quality assurance
• Setting standards
• Determining criteria to meet those standards
• Data collection
• Evaluating how well the criteria have been met
• Making plan for change based on the evaluation
• Implementation for change.

11. 1). Setting standards: -
• The nursing profession should have to design
standards of nursing practice that are specific to the
patient population served. These standards could
serve as the foundation upon which all other measure
of quality assurance are based. An example of
standards is: every patient will have a treatment chart.

12. 2). Determining criteria:-
• After standards of performance are established,
criteria must be determined that will indicate if the
standards are being met and to what degree they are
met. Just as with standards of care, criteria must be
general as well as specific to the individual unit.

13. 3). Data collection
• it is the third step in quality assurance. Sufficient
samples and random samples are necessary for
producing reliable and valid information. A useful
rules is that 10 percent of the institutional patient
population per month should be sampled.
Data collection methods include:
• Patient observation and interviews
• Nurse observation and interviews
• Review of charts.

14. 4).Evaluating performance
Various methods can be used to evaluate performance.
• These include:
• Reviewing documented records
• Observation activities as they take place
• Examining patients
• Interviewing patients, families and staff.

15. APPROACHES FOR THE QUALITY
ASSURANCE PROGRAMME:
There are two major categories of approaches exist in
quality assurance they are
• General
• Specific

16. 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.

17. 1) Credentialing:
Formal recognition of professional or technical
competence and attainment of minimum standards by
a person or agency

18. 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

19. 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.

20. 3) Accreditation
• State legislative bodies have authority to enact laws
controlling occupational and professional groups.
Nursing is one of the groups operating under state
laws that promote the general welfare by determining
minimum standards of education through
accreditation of school of nursing.

21. CONT....
• ISO
• JCI
• NABH
• Accreditation Canada

22. 4) certification
• Where as licensure measures entry-level competence,
certification validates specialty knowledge,
experience and clinical judgement. Nursing
certification is offered by professional organization.

23. Specific approach:
• Quality assurances are methods to evaluate identifies
instance of providers and client interaction.

24. 1) Peer review
• It is an organized effort whereby practicing
professionals review the quality of appropriateness of
services ordered or performed by their professional
peers.
• Peer review in nursing is the process by which
practicing registered nurses systematically assess,
monitor and make judgment about the quality of
nursing care provided by peers, as measured against
professional standards of practices.
ANA, 1988

25. Peer review is divided into two types.
• The recipients of health services by means of auditing
the quality of services rendered.
• The health professional evaluating the quality of
individual performance.

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

27. 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.

28. Framework:
• 1).Lang (1976)
This framework has subsequently been adopted and
developed by the ANA. The stages include;
• Identify and agree values.
• Review literature, known QAP.
• Analyze available programmes.
• Determine most appropriate QAP.

29. • Establish structure, plan, 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 action.
• Evaluate QAP

30. 2). WILSON (1987)
Wilson considers there to be four essential components
to a QA programme. These are;

31. • Setting objectives
• Quality promotion
• Activity monitoring
• Performance assessment

32. 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 services. The
dimensions of quality he proposed are;

33. • Assess to service
• Relevance to need
• Effectiveness
• Equity
• Social acceptance
• Efficiency and economy

34. Models of quality assurance:
• 1) System model
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 Brocken down into
manageable components based on defined objectives.

36. Basic components of system models:
• Input- the input can be compared to the present state
of system.
• Output- it is finished product or result
• Throughput- it is developmental process.
• Feedback- it is essential component of system
because it maintains & nourishes growth.

37. ANA quality assurance model:
• The ANA developed QA model in 1997 which has
wide spread applicability in any healthcare setting
and can be used as a guide implement quality
assurance program.

39. The basic components of ANA model are:
• Identify values
• Identify structure, process, outcomes, and criteria
• Select measurement
• Make interpretation
• Identify course of action
• Take action
• Re-evaluate

40. • 1). Identify value- in the ANA value identification
looks as such issue as patient/client, philosophy,
needs and rights from an economic, social,
psychology and spiritual perspective and values,
philosophy of the health care organization and the
providers of nursing services.

41. 2). Identify structure , process, and
outcomes standards and criteria-
• Identification of standards and criteria for quality
assurance begins with writing of philosophy and
objective and organization.
• The philosophy and objectives of an agency serves to
define the structural standards of the agency.

42. • 3). Select measurement- measurement is those
tools used to gather information or data, determined
by the selections of standards and criteria.

43. • 4). Make interpretation-
The degree to which the predetermined criteria are
met is the basis for interpretation about the strengths
and weakness of the program.

44. • 5). Identify course of action- it is necessary to
identify the cause of deficiency. Then, it is important
to identify various solutions to the problems.

45. 6). Take action-
• It is important to firmly establish accountability for
the action to be taken.
• This step then concludes with the actual
implementation of the proposed course of action.

46. 7). Re-evaluate-
• The final step of QA process involves an evaluation of
the results of the action.
• The reassessment is accomplished in the same way as the
original assessment and begins the QA cycle again.
• Careful interpretation is essential to determine whether
the course of action has improves the deficiency,
positives reinforcement is offered to those who
participated and the decision is made about when to again
evaluate that aspect of care.

47. Donabedian model
The donabedian model is a conceptual model that
provides a framework for examining health services and
evaluating quality of health care. According to the
model, information about quality of care can be drawn
from three categories: “structure,” “ process,” and
“outcomes”.

48. Structure
• it includes all the factor that affect the context
in which care is delivered. This includes the
physical facilities, equipment, and human
resources, as well as organizational
characteristics such as staff training and
payment method.

49. Process
• process is the sum of all actions that make up
healthcare. This community include diagnosis,
treatment, preventive care, and patient
education but may be expanded to include
action taken by the patient or their families.
Process contains all acts of healthcare delivery.

50. Outcomes
• outcomes contains all the effects of healthcare
on patients or population, including changes to
health status, behaviour , or knowledge as well
as patient satisfaction and health-related
quality of life. Outcomes are sometimes seen
as the most important indicators of quality
because improving patient health status is the
primary goal of healthcare.

51. Structural elements Process elements
Characteristics of:
Community treatment process
Institution stages of treatment
Provider appropriateness
Patient services process
Examples Examples
Geographic location of facilities use of efficacious therapy
Nurse-to-patient ratio use of diagnostic tests
Availability of technologies use of procedures
Hospital size treatment delays
Physician training ( including wait times)
Outcomes
Death
Adverse event
Patient satisfaction with care
Quality of life
Patient ability to function in daily activities

52. JCAHO:-
• Hospitals are required by the Joint Commission on
Accreditation of Health Care Organizations
(JCAHO) to establish programs to improve
the quality and appropriateness of care. ... An
effective quality assurance (QA) system should
allow hospitals and individuals to determine the level
of quality of care they administer.

55. The quality cycle:
PLANNING
IMPLEMENTATION
EVALUTAION
REVIEW

56. Factor affecting quality assurance in nursing:
• Lack of resources
• Personnel problems
• Improper maintenance
• Unreasonable patients and attendants
• Absence of accreditation laws
• Lack of incident review procedures
• Lack of good and hospital information system
• Absence of patient satisfaction surveys
• Lack of nursing care records

57. IMPACT OF QUALITY ASSURANCE IN
NURSING:
• Nurses are accountable for their actions
• Nurses can deliver a high standard of care
• Guaranteeing standards of care to the public
• Nurses are actively involved in audit and
consumer reactions
• Improve the overall quality of nursing care
• Improves all type of documentation and
communication

58. • Helps in professional growth
• Helps to maintain international standard
• Helps to compare the standard with another
institution
• Avoids malpractice and bias

59. Conclusion:
• Quality assurance programme will help to improve
the quality of nursing care and professional
development. Individuals with the profession must
assume responsibility for their professional action and
be answerable to the recipients for their care.