MS. VINITA MASCARENHAS
F.Y. M.SC NURSING
S.N.D.T. WOMEN’S UNIVERSITY
L.T. COLLGE OF NURSING.
At the end of the seminar, the group is able to
identify and describe the quality assurance in
The group is able to define Quality, and certain other terms in relation
The group is able to understand the concept of quality in health care.
The group is able to enumerate the purposes of quality assurance.
The group is able to identify various approaches of quality assurance
The group is able to state the principles of quality assurance in
The group is able to outline the frameworks of quality assurance in
The group is able to explain in brief about JCAHO, and list down its
The group is able to illustrate the various models of Quality assurance.
The group is able to express on the ANA model of quality assurance.
The group is able to identify the various AHRQ quality indicators, and
interpret a few.
The group is able to recognize the factors affecting quality assurance in
The group is able to discuss about the quality assurance in nursing
The group is able to summarize on the topic of quality assurance in
Assessing the quality of university education has been presented as one of
the main issues on the agenda of education reforms worldwide.
Ensuring quality is a combination of planned and systematic actions that
are necessary to provide the adequate reliability that a product or service
meets the requirements given for quality, which should be supported in
meeting the expectations of customers.
Quality assurance is based on planning, production, presentation,
distribution, statistical techniques of control and staff training.
Quality Assurance: It is a systematic, ongoing and continuous
review, analysis and evaluation of the level of compliance with
the standards set at local, national and international level.
CONCEPT OF QUALITY ASSURANCE:
Quality is defined as the extent of resemblance between the purpose of
healthcare and the truly granted care (Donabedian 1986).
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.
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 cares contributes to valued outcomes”.
“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)
BENEFITS AND PURPOSES OF QUALITY
Quality assurance (QA) enables ..
•bring internal benefits to the
university/faculty/department/school/program and the staff;
•bring external benefits to the students and the reputation of the
•continuously improve themselves, the students and the work of the
university. Continuous improvement is both the medium and outcome of
•serve accountability and accreditation requirements;
•enhance the reputation of the faculty/department/school/university, and
meet external demands for demonstrating quality, quality assurance and
APPROACHES FOR A QUALITY
Two major categories of approaches exist in quality assurance they are
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.
formal recognition of professional or technical competence and attainment
of minimum standards by a person or agency
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.
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.
SPECIFIC APPROACHES :
1) Peer review
•Peer review is divided in to two types.
a. The recipients of health services by means of auditing the quality of services
b. The health professional evaluating the quality of individual performance.
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.
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.
PRINCIPLES OF QUALITY ASSURANCE:
•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 define quality.
•Decision must be based on facts.
FRAMEWORKS FOR QUALITY ASSURANCE:
1. 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
•Efficiency and economy
2. Wilson (1987)
Wilson considers there to be four essential components to a QA
programme. These are:
3. Lang (1976)
This framework has subsequently been adopted and developed by the ANA. The stages
•Identify and agree values
•Review literature, Known QAP
•Analyse 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 analyse factors contributing to results
•Select appropriate actions to maintain or improve care
•Implement selected actions
JCAHO is the nation’s predominant standards-setting and accrediting
body in health care.
Since 1951, The Joint Commission has maintained state-of-the-art
standards that focus on improving the quality and safety of care provided
by health care organizations.
The Joint Commission’s comprehensive accreditation process evaluates an
organization’s compliance with these standards and other accreditation
To earn and maintain The Joint Commission’s Gold Seal of Approval, an
organization must undergo an on-site survey by a JCAHO survey team at
least every three years. (Laboratories must be surveyed every two years.)
WHO IS ELIGIBLE?
The Joint Commission provides evaluation and accreditation services for the
following types of organizations:
•General, psychiatric, children’s and rehabilitation hospitals
•Critical access hospitals
•Medical equipment services, hospice services and other home care
•Nursing homes and other long term care facilities
•Behavioural health care organizations, addiction services
•Rehabilitation centres, group practices, office-based surgeries and other
ambulatory care providers
•Independent or freestanding laboratories
STANDARDS AND PERFORMANCE
JCAHO standards address the organization’s level of performance in key
functional areas, such as patient rights, patient treatment, and infection
The standards focus not simply on an organization’s ability to provide safe,
high quality care, but on its actual performance as well.
The Joint Commission develops its standards in consultation with health
care experts, providers, measurement experts, purchasers, and consumers.
MODELS OF QUALITY ASSURANCE:
1. System Model
•Tasks are broken down into manageable components based on defined
The basic components of the system are
The input can be compared to the present state of systems, the throughput to
the developmental process and output to the finished product. The feedback is
the essential component of the system because it maintains and nourishes the
2) ANA Quality Assurance Model
The basic components of the ANA model are:
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
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
2) Identify structure, process and outcome standards and criteria:
•Identification of standards and criteria for quality assurance begins with writing of
philosophy and objective of organization.
•The philosophy and objectives of an agency serves to define the structural
standards of the agency.
•Standards of structure are defined by licensing or accrediting agency.
•Evaluation of the standards of structure is done by a group internal or external to
•The evaluation of process standards is a more specific appraisal of the quality of
care being given by agency care providers.
3) Select measurement needed to determine degree of attainment of criteria and
•Measurements are those tools used to gather information or data, determined by the
selections of standards and criteria.
•The approaches and techniques used to evaluate structural standards and criteria are,
nursing audit, utilization’s reviews, review of agency documents, self-studies and review
of physicals facilities.
•The approaches and techniques for the evaluation of process standards and criteria
are peer review, client satisfactions surveys, direct observations, questionnaires,
interviews, written audits and videotapes.
•The evaluation approaches for outcome standards and criteria include research
studies, client satisfaction surveys, client classification, admission, readmission,
discharge data and morbidity data.
4) Make interpretations
•The degree to which the predetermined criteria are met is the basis for interpretation
about the strengths and weaknesses of the program.
•The rate of compliance is compared against the expected level of criteria
5) Identify Course of Action
•If the compliance level is above the normal or the expected level, there is
great value in conveying positive feedback and reinforcement
•If the compliance level is below the expected level, it is essential to improve
•It is necessary to identify the cause of deficiency. Then, it is important to
identify various solutions to the problems.
6) Choose action
•Usually various alternative course of action are available to remedy a
•Thus it is vital to weigh the pros and cons of each alternative while
considering the environmental context and the availability of resources.
7) 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
courses of action.
•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, positive reinforcement is offered to those who
participated and the decision is made about when to again evaluate that
aspect of care.
WHAT ARE THE AHRQ QUALITY
The Quality Indicators (QIs) developed and maintained by the Agency for
Healthcare Research and Quality (AHRQ) are one response to the need for
multidimensional, accessible quality measures that can be used to gage
performance in health care.
These measures are currently organized into four modules: the Prevention
Quality Indicators (PQIs), the Inpatient Quality Indicators (IQIs), the Patient
Safety Indicators (PSIs), and the Paediatric Quality Indicators (PDIs).
The AHRQ QI Modules:
The AHRQ PQIs are one set of quality measures that can be used to
identify potential problems; follow trends over time; and ascertain
disparities across regions, communities, and providers.
The PQIs help answer questions such as
•Does the admission rate for diabetes complications in my community
suggest a problem in the provision of appropriate outpatient care to this
•How does the admission rate for congestive heart failure vary over time
and from one region of the country to another?
THE INPATIENT QUALITY INDICATORS
The AHRQ IQIs provide information about the quality of medical care
delivered in a hospital.
The provider-level volume IQIs are:
•Oesophageal resection volume
•Pancreatic resection volume
•Abdominal aortic aneurysm (AAA) repair volume
•Coronary artery bypass graft (CABG) volume
•Percutaneous transluminal coronary angioplasty (PTCA) volume
THE PATIENT SAFETY INDICATORS
The PSIs are a set of quality measures that use hospital inpatient discharge
data to provide a perspective on patient safety.
•Postoperative pulmonary embolism or deep vein thrombosis
•Postoperative respiratory failure
•Postoperative physiologic and metabolic derangements
•Postoperative abdominopelvic wound dehiscence
THE PAEDIATRIC QUALITY
The AHRQ PDIs are a set of quality measures that use hospital
administrative data and involve many of the same challenges associated
with measure development for the adult population.
•Accidental puncture and laceration
•Foreign body left in during procedure
•Iatrogenic pneumothorax in neonates
•Iatrogenic pneumothorax in non-neonates
•Paediatric heart surgery mortality
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
11) Miscellaneous factors
QUALITY ASSURANCE IN NURSING:
A standard is a means of determining what something should be. In the
case of nursing practice standards are the established criteria for the
practice of nursing. Standards are statements that are widely recognised as
describing nursing practice and are seem as having permanent value.
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.
CHARACTERISTICS OF STANDARD:
•Standards statement must be broad enough to apply to a wide variety of
•Standards must be realistic, acceptable, and attainable.
• Standards of nursing care must be developed by members of the nursing
• Nurses practising at the direct care level with consultation of experts in the
• Standards should be phrased in positive terms and indicate acceptable
performance good, excellence etc.
• Standards of nursing care must express what desirable optional level is.
• Standards must be understandable and stated in unambiguous terms.
• Standards must be based on current knowledge and scientific practice.
• Standards must be reviewed and revised periodically.
•Standards may be directed towards an ideal, i.e., optional standards or may
only specify the minimal care that must be attained, i.e., minimum standard.
• And one must remember that standards that work are objective, acceptable,
achievable and flexible.
PURPOSES OF STANDARDS:
•Setting standard is the first step in structuring evaluation system. The
following are some of the purposes of standards.
•Standards give direction and provide guidelines for performance of nursing
• Standards provide a baseline for evaluating quality of nursing care
• Standards help improve quality of nursing care, increase effectiveness of care
and improve efficiency.
• Standards may help to improve documentation of nursing care provided.
• Standards may help to determine the degree to which standards of nursing
care maintained and take necessary corrective action in time.
• Standards help supervisors to guide nursing staff to improve performance.
• Standards may help to improve basis for decision-making and devise
alternative system for delivering nursing care.
• Standards may help justify demands for resources association.
•Standards my help clarify nurses area of accountability.
• Standards may help nursing to define clearly different levels of care.
MAJOR OBJECTIVES OF PUBLISHING,
CIRCULATING AND ENFORCING
NURSING CARE STANDARDS ARE TO:
1. Improve the quality of nursing care,
2. Decrease the cost of nursing, and
3. Determine the nursing negligence.
SOURCES OF NURSING CARE
• Professional organisation, e.g. Associations, TNAI,
• Licensing bodies, e.g. statutory bodies, INC,
• Institutions/health care agencies, e.g. University Hospitals, Health
• 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
A number of the AHRQ QIs have been used in health care research projects. On the
whole, researchers use the indicators because of the quality and level of detail of the
AHRQ documentation of the QIs as well as the fact that these measures capture
important aspects of clinical care. The AHRQ QIs, their documentation, and the
related software reside in the public domain and are downloadable from the AHRQ
Web site, free of charge. The QIs can be used with readily available administrative
data, which researchers have ready access to in the form of HCUP. Further,
researchers appreciate the fact that they can dissect indicator results and relate them
back to individual records, which helps to gain a better understanding of the logic
used in the measures, which, in turn, assists in distinguishing data quality issues from
actual quality problems .Topics of studies using the AHRQ QIs include an analysis
examining the association between the Joint Commission accreditation scores and
the AHRQ IQIs and PSIs, the effect of resident physician work hour limits on surgical
patient safety, and the determination of whether persons with Alzheimer’s disease
were at greater risk for in-hospital mortality than non-Alzheimer’s patients.
To ensure quality nursing care within the contemporary health care system,
mechanisms for monitoring and evaluating care are under scrutiny. As the
level of knowledge increases for a profession, the demand for
accountability for its services likewise increases. Individuals within the
profession must assume responsibility for their professional actions and be
answerable to the recipients for their care. As profession become more
interdependent, it appears that the power base will become more
balanced, allowing individual practitioners to demonstrate their
competence and expertise. Quality assurance programme will helps to
improve the quality of nursing care and professional development.