This document discusses quality assurance in nursing care. It introduces concepts of quality and quality assurance, and how they relate to health care. It describes general approaches to quality assurance like credentialing, licensure, accreditation and certification. Specific approaches discussed include peer review, using standards, and audits. Models of quality assurance and the ANA quality assurance model are presented. Factors affecting quality assurance in nursing care are outlined. Frameworks for quality assurance from various authors are summarized. Finally, the stages of developing international standards are described.

1. Quality
assurance
Mrs. Sneha Sahay Youtham

2. INTRODUCTION
• 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 mechanisms to
effectively monitor patient care provided by health care
professionals using cost-effective resources.
• Nursing programmes of quality assurance are concerned
with the quantitative assessment of nursing care as
measured by proven standards of nursing practice.

3. Cont…..
• Quality assurance system motivates nurses to strive for
excellence in delivering quality care and to be more open
and flexible in experimenting with innovative ways to
change outmoded systems.
• Florence Nightingale introduced the concept of quality in
nursing care in 1855 while attending the soldiers in the
hospital during the Crimean war.

4. CONCEPT OF QUALITY IN HEALTH CARE
• 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.

5. • “Quality assurance is a judgment concerning the
process of care, based on the extent to which that
cares contributes to valued outcomes”. (Donabedian
1982).
• “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).

6. APPROACHES FOR A QUALITY
ASSURANCE PROGRAMME
Two major categories of approaches exist in quality
assurance they are
• General
• Specific

7. • 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
• 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.

8. 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.
• Licensure of nurses has been mandated throuhout the
world by laws and regulations..

9. 3) Accreditation
• ISO
• JCI
• NABH
• Accrediation Canada
• NAAC

10. 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.

11. B. Specific approaches
1) Peer review
• Peer review is divided in to 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.

12. 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. The ANA standard for practice include:
• 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.

13. • 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.

14. 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.

15. MODELS OF QUALITY ASSURANCE
1. System Model
Tasks are broken down into manageable components
based on defined objectives.
The basic components of the system are
• 1. Input
• 2. Throughput
• 3. Output
• 4. Feedback
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 growth.

16. 2) ANA Quality Assurance Model
The basic components of the ANA model are:
• Identify values
• Identify structure, process and outcome standards and
criteria
• Select measurement
• Make interpretation
• Identify course of action
• Choose action
• Take action
• Reevaluate

17. 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 providres of nursing services.

18. 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 agency.
• The evaluation of process standards is a more specific
appraisal of the quality of care being given by agency
care providers.

19. 3) Select measurement needed to determine degree of
attainment of criteria and standards
• 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.

20. 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 accomplishment.

21. 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 the situations.
• It is necessary to identify the cause of deficiency. Then,
it is important to identify various solutions to the
problems

22. 6) Choose action
• Usually various alternative course of action are available
to remedy a deficiency.
• Thus it is vital to weigh the pros and cons of each
alternative while considering the environmental context
and the availability of resources.

23. 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.

24. 8) Reevaluate
• 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.

25. 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 collect the information

26. FACTORS
AFFECTING
QUALITY
ASSURANCE IN
NURSING CARE

27. 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 circumstances.
2) Personnel problems
• Lack of trained, skilled and motivated employees, staff
indiscipline affects the quality of care.

28. 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

29. 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

30. 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

31. 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, physician
• b) Incorrect medication
• c) Burns arising out of faulty procedures
• d) Death in a corridor with no nurse / physician
accompanying the patient etc.

32. 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.

33. 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

34. 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 treatment
• d) Have the dates in an easily accessible form.

35. 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

36. 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
• Effectiveness
• Equity
• Social acceptance
• Efficiency and economy

37. 2. Wilson (1987)
Wilson considers there to be four essential components to
a QA programme. These are:
• Setting objectives
• Quality promotion
• Activity monitoring
• Performance assessment

38. 3. Lang (1976)
This framework has subsequently been adopted and developed
by the ANA. The stages includes;
• Identify and agree values
• Review literature, Known 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 QAO

39. STAGES OF THE DEVELOPMENT
OF INTERNATIONAL
STANDARDS

40. An International Standard is the result of an agreement
between the member bodies of ISO. It may be used as
such, or may be implemented through incorporation in
national standards of different countries.
International Standards are developed by ISO
technical committees (TC) and subcommittees (SC) by a
six-step process:
• Stage 1: Proposal stage
• Stage 2: Preparatory stage
• Stage 3: Committee stage
• Stage 4: Enquiry stage
• Stage 5: Approval stage
• Stage 6: Publication stage

41. Stage 1: Proposal stage
• The first step in the development of an International
Standard is to confirm that a particular International
Standard is needed. A new work item proposal (NP) is
submitted for vote by the members of the relevant TC or
SC to determine the inclusion of the work item in the
programme of work.
• The proposal is accepted if a majority of the P-members
of the TC/SC votes in favour and if at least five P-
members declare their commitment to participate
actively in the project. At this stage a project leader
responsible for the work item is normally appointed.

42. Stage 2: Preparatory stage
• Usually, a working group of experts, the chairman
(convener) of which is the project leader, is set up by the
TC/SC for the preparation of a working draft. Successive
working drafts may be considered until the working
group is satisfied that it has developed the best technical
solution to the problem being addressed. At this stage,
the draft is forwarded to the working group's parent
committee for the consensus-building phase.

43. Stage 3: Committee stage
• As soon as a first committee draft is available, it is
registered by the ISO Central Secretariat. It is distributed
for comment and, if required, voting, by the P-members
of the TC/SC. Successive committee drafts may be
considered until consensus is reached on the technical
content. Once consensus has been attained, the text is
finalized for submission as a draft International Standard
(DIS).

44. Stage 4: Enquiry stage
• The draft International Standard (DIS) is circulated to all
ISO member bodies by the ISO Central Secretariat for
voting and comment within a period of five months. It is
approved for submission as a final draft International
Standard (FDIS) if a two-thirds majority of the P-
members of the TC/SC are in favour and not more than
one-quarter of the total number of votes cast are
negative. If the approval criteria are not met, the text is
returned to the originating TC/SC for further study and a
revised document will again be circulated for voting and
comment as a draft International Standard.

45. Stage 5: Approval stage
• The final draft International Standard (FDIS) is circulated
to all ISO member bodies by the ISO Central Secretariat
for a final Yes/No vote within a period of two months. If
technical comments are received during this period, they
are no longer considered at this stage, but registered for
consideration during a future revision of the International
Standard. The text is approved as an International
Standard if a two-thirds majority of the P-members of the
TC/SC is in favour and not more than one-quarter of the
total number of votes cast are negative. If these approval
criteria are not met, the standard is referred back to the
originating TC/SC for reconsideration in light of the
technical reasons submitted in support of the negative
votes received.

46. Stage 6: Publication stage
• Once a final draft International Standard has been
approved, only minor editorial changes, if and where
necessary, are introduced into the final text. The final
text is sent to the ISO Central Secretariat which
publishes the International Standard

47. IMPACT OF ISO IN A LOCAL HOSPITAL:
Positive impacts:
• Nurses are accountable for their actions and, professionally, we
have responsibility to evaluate the effectiveness of our care
• Nurses can deliver a high standard of care, and being empowered
to identify and resolve problems can add to personal satisfaction
with work
• Documents state clearly how the health service should perform
and what the patient can expect
• Guaranteeing standards of care to the public must be a duty of all
those who work within the health service
• Nurses are actively involve in audit, service reviews, standard-
setting and customer relations
• Improves the overall quality of nursing care
• Improves all types of documentation and communication
• Helps in professional growth

48. Negative impacts:
• Lack of adequate resources
• Lack of trained, skilled and motivated employees, staff
indiscipline affects the quality of care.
• ISO activities may overburden the nursing personnel
• Nurses will not get adequate time to spent with the
patient, most of the time may be spending for recording
and reporting
• The hospital will be restricted only to ISO standards
• Hospital has to provide special training for all the staffs
those who are involved in ISO inspection
• All types of services will be under the control of ISO

49. IMPACT OF ISO IN A LOCAL NURSING
EDUCATIONAL INSTITUTIONS:
Positive impacts:
• Improves the quality of nursing education
• improves the quality of nursing practice
• Helps to maintain international standard
• Helps to compare the standard with another institution
• Helps in personnel development of teachers
• Helps to maintain all the records in time
• Avoids malpractice and bias
• Encourages extra-curricular activities also
• Act as a control for all the activities
• Improves professional growth

50. Negative impacts:
• Gives more importance to documentation
• Over-burden for the teachers
• Teachers need to take special training in maintaining the
standards
• Not observing the actual practice
• Organizational philosophy and policies has to be
modified according to the ISO standards

51. CRITICAL ANALYSIS:
• Strengths: ISO helps to improve and maintain the quality
of educational institutions and hospitals
• Weakness: Standards are set by the institution itself, it
may be biased
• Opportunities: Helps in professional growth
• Threats: Organizational philosophy and policies may not
be considered

52. Thank You
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