The document discusses quality and quality assurance in healthcare. It defines quality as the degree to which health services increase desired health outcomes consistent with current knowledge. Quality assurance aims to promote the best possible patient care through ongoing evaluation. It ensures delivery of quality care and demonstrates efforts to provide the best results. Various methods are used to evaluate quality, including assessing structures, processes, and outcomes of care. Quality assurance is important to improve care, assess competence, and identify issues to correct.

1. Hareesh.S

2.  Quality means usually think in terms of an
excellent product or service that fulfills or
exceeds our expectations.
 Quality is defined “as the degree to which a
set of inherent characteristics fulfills
requirement”.

3. QUALITY
 “Quality is defined as the degree to which
health services for the individuals and
populations increase the likelihood of the
desired health outcomes and are consistent
with current professional knowledge”.
-Joint Commission on Accreditation of
Healthcare Organizations (2002)
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4.  Quality assurance is achievable through on
going evaluation of patient care which would
assure the hospital that all was done for the
patient.
 Quality Assurance is a program adopted by
an institution that is designed to promote the
best possible care.

5.  Quality care is the term used to describe care
and services that allow recipients to attain
and maintain their highest level of physical
and psychological health.

6. QUALITY ASSURANCE
 “Quality Assurance is an on-going,
systematic comprehensive evaluation of
health care services and the impact of those
services on outcome.
 Quality assurance incudes all activities
undertaken to prevent poor quality.
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7. 1. General Approaches
a) Credentialing
b) Licensure
c) Accreditation
d) Certification
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8. It involves large governing of official body’s
evaluation of a person’s or agency ability to
meet established criteria or standards at given
time.
a) Credentialing –A person generally defines it
as the formal recognition of professional or
technical competence and attainment of
minimum standards by a person or agency.

9. b) Licensure-Individual licensure is a conduct
between the profession and the state, in which
the profession is granted control over entry into
and exist from the profession and over quality of
profession practice . The licensing process
requires that regulations be written to define the
scopes and limits of the professional’s practice.

10. c) Accreditation- National League for Nursing
(NLN) a voluntary organization has established
standards for inspecting nursing education
programs. In the part the accreditation process
primarily evaluated on agency’s physical
structure, organizational structure and
personal qualification

11. d) Certification - Certification is usually a
voluntarily process with in the professions. A
person’s educational achievements ,
experience and performance on examination
are used to determine the person’s
qualification for functioning in an identified
specialty area

12. Quality assurance are methods used to
evaluate identified instances of provider and
client interaction.
a) Peer review committee- These are designed
to monitor client specific aspects of care
appropriate for certain levels of care. The audit
has been the major tool used by peer review
committee to ascertain quality of care.

13. b) The audit process –It includes
recommendations for correcting deficiencies,
explicit criteria selected for quality care. Peer
review of all cases not meeting criteria

14. Quality chain focuses that care should be:-
 C- Comprehensive, Cost-effective
 A-Accessible, accredited, acceptable
 R-Relevant,reliable,Resourse
 E-Efficient, Equitable,Effective

15. According to Jonas (2000), the two main objectives
are;
 To ensure the delivery of quality client care.
 To demonstrate the efforts of the health care
providers to provide the best possible results.
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16.  To improve quality of care.
 Assess competence of medical staff, serve as
an impetus to keep up to date and prevent
future mistakes.
 To identify hospital administration
deficiencies and correcting the causative
factors.
 Help to exercise a regulatory function.
 Restricting undesirable procedures.

17.  Utilization review activities are directed
towards assuring that care is actually needed
and that the cost appropriate for the level of
care provided.

18. 1. Prospective: It is an assessment of the
necessity of care before giving service.
2. Concurrent: A review of the necessity of care
while the care is given.

19. 3. Retrospective:
It is analysis of the necessity of the services
received by the client after the care has being
given . It has been used primarily in hospitals
to establish need for client admission and the
length of hospital stay . The UR process
includes the development of explicit criteria
that serves as indicators of the need for
services and length of services

20. 1. It is designed to assist client to avoid
unnecessary care.
2. It may serve to encourage the consideration of
care options by providers, such as home health
care rather than hospitalization.
3. It can provide guidelines for staff development
program.
4. It provides a measure of agency accountability
to consumer

21. Three major models have been used to
evaluate quality of care.
1. Donabedian Structure –Process -Outcome-
model
2. The tracer method
3. Sentinel method

22. 1.Donabedian's stucture-process -outcome model
a. Stuctural evaluation
b.Process evaluation
c.Outcome evaluation
2.The tracer method
3The sentinel method

23. a) Structure evaluation :This method evaluates
the setting and instruments used to provide
care such as facilities , equipments and
characteristics of the administrative
organization and qualification of health care
providers. The data can be collected from the
existing documents of an agency or from an
inpector of faculty.

24. b) Process evaluation: This method evaluates
the activities as they relate to standards and
expectations of health care provider in the
management of client care , data for this can
be collected through direct observation of
provider and review of records , audit, checklist
and mapping approach.

25. c) Outcome evaluation : It includes result of
health care. The data of this method can be
collected from vital statistical records such as
death certificates or telephone client
interviews, mailed questionnaire and client
records.

26. It is a method of both process and outcome of
care .while using the tracer method ,one must
identify a volume of client with a particular
characteristics and specific health care
management.

27.  Physicians and nurse practitioners, to identify
persons with certain illness such as HTN,
ulcers, UTI, and to establish criteria for good
medical and nursing management of the
illnesses have used the tracer method . This
method provides nurses with data to show
the differences in outcome as a result of
nursing care standards.

28. It is an outcome measure for examining specific
instances of care the characteristics of this method
are:
 Cases of unnecessary disease, disability deaths
are counted.
 The circumstances surrounding the unnecessary
event or the sentinel is examined in detail.
 In review of morbidity and mortality are used as
an index .
 Health status indicator such as changes in social ,
economic, political and environmental factors

29.  CLIENT SATISFACTION:-Client satisfaction can
be assessed using person or telephone
interviews and mailed questionnaire. Data
from client satisfaction surveys are used to
measure structure, process and outcome of
health care services.

30. INCIDENCE REVIEW:-
During a patient’s hospitalization several incidents
may occur which may affect the treatment and
patients final recovery. The critical incidents may
be:-
 Incorrect medications.
 Lack of cleanliness and asepsis leading to
infection.
 Carelessness in carrying out nursing procedures.

31.  The report should contain the name , age,
exact time , and place , description of how it
occurred any precaution taken , conditions of
patient before and after the incident etc. for
legal purpose. It should be written carefully
with all details and should be filed safely.

32.  RISK MANAGEMENT:- It can be defined in a
program that is developed for propose of
eliminating or controlling health care
situations that has the potential to create
risk for clients. The main aim is to administer
‘safe care’ ‘without harm’ to client. Risk
management activities are directed towards
the identification, analysis, and evaluation of
situations to prevent injury and subsequent
financial loss.

33.  MALPRACTICE LITIGATION:- It is a specific
approach to be imposed on health care
delivery systems by the legal system.
Malpractice litigation results from client
dissatisfaction with the provider and with the
content of care received.

34.  The Nurse Manager might become pre occupied
with quality assessment
 It is impossible to identify all factors that
influence nursing care quality.
 Difficulty in defining outcome criteria
 Vague and incomplete documents and lacking
in objectivity
 High cost
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35.  Customer focus
 Leadership
 Involvement of people
 Process approach
 System approach to management
 Continual improvement
 Factual approach to decision making
 Mutually beneficial supplier relationship
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36. If medical care leads to poor quality, its
effects may be immediately noticed e.g. Fall
from cot, wound infection, sudden death etc ,
poor quality care can effect:-
1. Patients
2. Family
3. Society
4. Hospitals
5. Staff

37. 1. Effects on patients:-
a. Physical discomfort: e.g.
 Disturbed sleep due to noise of staff talking loudly,
cleaning utensils etc.
 Wound infection
 poor quality of food causing abdominal pain.
 I V fluid going out vein causing swelling or
thrombophlebitis.
b. Mental stress
c. Rise in complication
d. Higher mortality rate
e. Loss of working days
f. Increased expenses

38. Effects on family
 Inconveniences
 Higher expenses
 Frequent changes
 Loss of trust
 Black mailing, particularly for iatrogenic
complications, refusing to pay the bills.

39. Effects on society:-
 Increased prevalence of certain disease
 Increased risk of certain infections
 Diminished productivity, unhealthy person is
medically more demanding and economically
less productive.
 Avoiding use of scientific hospital
management and taking treatment from other
places.

40. Effects on hospital:-
 Increased length of stay leading –
overcrowding in public hospitals, cross
infection, reduction in turnover leading to
longer waiting list for routine admissions,
higher expenses, and shortage of linen.
 Higher rate of complications leading to
additional investigations, additional
medications, need for revision surgery.
 Accidents and mishappenings
 Hospital image getting tarnished
 Adverse publicity by media which undermines
other good services.

41. Effects on staff:-
 Reduced motivation
 Indiscipline
 Risk of infection to staff
 Difficulty to attract good staff
 Fast turn over
 Frustration.

42. 1. External quality assurance:-
 Quality assurance can be evaluated by
independent assessors (or) people from
outside the institution/hospital.
2. Internal quality assurance:-
 Quality assurance can be evaluated by
local assessors (or) senior person from the
same institution/hospital.

43. The committee should consist of the following.
 Medical administrator
 Two senior clinicians
 Pathologist
 Radiologist
 Nurse administrator
 Medical records officer – secretary
 Additional personnel such as super specialist
and consultants can be

44. Coordination:-
 Collecting information
 Consider activities that should be related, e.g.
Quality appraisal and continuing education
 Communication across patient care disciplines
 Co –ordinate actions of hospital authority groups.
Information:-
 Provide a centralized source of reports to the
board.
 Suggest head for intervention to hospital
authority groups.
Planning:-
 Establish priorities

45. Consultation:-
 Provide specific assistance, usually
through the coordinator.
Response:-
 Internally, acknowledge issues of
importance to individuals and
departments when suggesting high
priority areas for immediate attention.
 Externally, provide the organization
home for responding to quality
requirement of external agencies of
any e.g. medical companies.

46. Search for expertise:-
 Operate openly, not behind closed doors, seek
out the specific clinical and or management
expertise necessary to reach sound
conclusions.
Follow up:-
 Committee members must recognize that their
major functions are
◦ To coordinate not to control
◦ To inform, not to scold
◦ To plan and suggests priorities not to do
detailed studies in committee and To
recommend report, not to intervene directly.

47. 1.Establishment of standards or criteria
2.Identify the information relevant to criteria
3.Collect and analyse the information
4. Compare collected information with
established criteria
5. Make a judgment about quality
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48.  Lack of resources
 Personnel problem
 Improper maintenance
 Unreasonable patients and attendants
 Absence of well-informed population
 Absence of accreditation laws
 Lack of incident review procedure
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49.  Lack of good hospital information system
 Absence of patient Satisfaction Surveys
 Lack of nursing care research & records
 Miscellaneous Factors like lack of good
supervision, Absence of knowledge about
philosophy of nursing care, substandard
education and training, lack of policy and
administrative manuals.
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50.  Nurses are the active participant of
interdisciplinary quality improvement team
 Develop mechanism for continually
monitoring the effectiveness of nursing care
 Contribute innovations and improvement of
patient care
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51.  Participating in improvement projects and
patient safety initiatives
 Participate in continuing educational programs
and in-service educational programs for
continuing professional development
 Periodic and continuing appraisal and evaluation
of health care situation of the patient
 Participate in research activities.
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52. MODELS OF QUALITY ASSURANCE
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54.  Quality assurance model is developed by
Lang and adapted by the American nurses
Association. The evaluation model is open
and circular, indicating a cyclical process that
can be entered at any point.

56.  Emphasizes the need to clarify the social,
institutional, professional and individual
values, along with the advances in scientific
knowledge which influence nursing practice.
Examination of these beliefs offers insight
into what clients, nurses and others think is
important in nursing care.

57.  The standards and criteria derived from the
values describe the level of nursing care
considered acceptable. Standards represent
the level of excellence, whereas criteria are
specific, measurable statements which reflect
the intent of the standard and can be
compared to actual nursing practice.

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59.  This involves the measurement of current
nursing practice against the established
standards and criteria. There are many methods
which could be used to perform the comparison
including concurrent and retrospective audit,
direct observation of nurse or patient
performance, questionnaire, patient or nurse
interview and knowledge testing.
 Strengths and weaknesses of nursing practice
should be revealed through this comparison.

60.  The purpose of analysis and interpretation is
identification of discrepancies between the
established criteria and current practice.
Judgments are made about strengths,
deficiencies and other problems in quality.

61.  Suitable courses of action is to be considered.
Alternatives intended to resolve discrepancies
are identified and examined. Decisions may
range from simple actions to complex plans
entailing many changes.

62.  The last two components of the model
consist of the selection and implementation
of the best actions. Judgments are made
about strengths, deficiencies and other
problems in quality; it may be positive or
negative

63.  Some actions may need to be performed
immediately while others take longer to
initiate. The decisions as to which action to
choose are influenced by the organization
context and available resources. At this point
the cycle is repeated and the actions are
reassessed to determine if the expected
improvements in practice actually occurred or
have been maintained.

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