This document discusses quality assurance in healthcare. It defines quality assurance and related terms like quality control, continuous quality improvement, and total quality management. It describes the key components of quality in healthcare as safety, effectiveness, patient-centeredness, and timeliness. The purposes of quality assurance are to meet customer needs, standardize care, minimize errors, and attain excellence. Nurses play an important role in quality assurance through activities like developing quality monitoring mechanisms, contributing innovations, and participating in improvement efforts.

1. Quality Assurance

2. DEFINITION
 Dictionary meaning: Character with respect to fineness, or
grade of excellence.
 ‘Quality is the degree to which a product confirms to
specification and workmanship standards.’- John D.
McClellan

3. QUALITY
‘Quality is defined as the capability of a product to
fulfill its intended purpose, produced with least
possible cost.’ –AV Flegen Baum
Quality is an achievable, measurable, profitable,
entity once you have commitment and
understanding and are prepared for hard work.

4. QUALITY IN HEALTH CARE SETTING
“Quality is described as levels of excellence
produced and documented in the process of
patient care, based on the best knowledge
available and achievable at a particular
facility.” –The National association of quality
assurance professionals.

5. “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)

6. PURPOSE OF QUALITY
To meet the needs and expectation of the
customers, both external and internal
To meet increased demand for effective and
appropriate care
Need for standardization and variance control
To minimize the errors and further eliminated
to attain excellence in care

7. Contd…
To minimize the errors and further eliminated
to attain excellence in care
To bring improvement in care and services
To bring efficiency in the use of health care
resources and effectiveness in the delivery of
care and services
To reduce the failure and appraisal costs

8. Contd… To fit into the pressure of competition and to
enhance marketing
 For accreditation, certification and regulation
 To fulfill the ethical code to provide the best and
most appropriate care accessible to the patient
 To fulfill the desire for recognition and to strive for
excellence
 To attract recognition in the field and will encourage
other individual, organizations or systems to emulate

9. COMPONENTS OF QUALITY IN HEALTH
CARE
1. Safety
2. Effectiveness
3. Patient centeredness
4. Timeliness

10. 1. SAFETY
Improving safety means designing and
implementing health care processes to avoid,
prevent and ameliorate adverse outcome or
injuries that stem from the process of health
care itself.
Safety is best understood in terms of injuries
that occur to the patient and the errors and
latent failures that lead to these injuries or

11. 2. EFFECTIVENESS
 Effectiveness is probably the component of health
care quality most readily identified because ultimately
it represents the ‘bottom’, that is whether care leads
to improved outcome in terms of health status and
quality of life for patients.
 Effectiveness should distinguish from efficiency. It
refers to avoiding waste, including waste of
equipment, supplies, ideas and energy.

12. 3. PATIENT CENTERDNESS
 It refers to the health care that establishes a partnership
among health workers, patients, and their families to ensure
that decision respect patient’s wants, need and preferences
and that patients have the education and support they need to
make decisions and participate in their own care.
 Patients of different races, cultures, genders and ages have
different preferences and beliefs that providers must take into
account in order to achieve patient centered care. Patient vary
in the degree of autonomy and involvement that they want in
health care decision making.

13. 4. TIMELINESS
It combines being able to obtain care and
getting it promptly. It includes both access to
care (people can get care when they need)
and coordination of care (once under care,
the system facilitates moving people across
providers and through the stage of care).

14. QUALITY ASSURANCE
 History suggests that the first person that started the
quality movement in health care was Florence
Nightingale back in the mid 1800’s. The nurse
Nightingale was instrumental in noticing that there is
a direct correlation between a good nursing care and
a quality outcome

15. DEFINITION
QUALITY ASSURANCE
• “Quality assurance is a judgment concerning the
process of care, based on the extents to which that care
contributes to valued outcomes”. – Donabedian, 1982
• “The set of activities that are carried out to set
standards and to monitor and improve performance so
that the care provided is as effective and as safe as
possible”. –Quality Assurance Project.

16. RELATED KEY TERMS
Quality Control
Quality
Improvement
Continuous Quality
Improvement
Quality
Management
Total Quality
Management
Institutionalization of
Quality Assurance
Quality Circle

17. Quality Control
It is defined as the process by which actual
performance is measured, the performance
is compared with goals, and the difference is
acted upon. The statistical methods are used
to measure the quality.

18. Quality Improvement
It is defined as the process and sub process of
reducing variation of performance or
variance from standard in order to achieve a
better outcome to the organization’s
customers.
Key issue involves ability of this process to
identify and act on variance.

19.  Continuous Quality Improvement
In 1980’s QA was replaced by continuous quality
improvement. It involves a coordinated and
integrated approach for improving processes that
affect patient outcome. Performance management
has replaced later CQI. This term is specific. It
encompasses three critical programs:
a) awareness b) measurement and c) improvement.

20.  Quality management
Quality management is a structural umbrella over all
processes and activities related to quality assurance
and quality improvement. Quality management is
responsible for the coordination and facilitation of
these activities in an organization. Specifically quality
management is involved in the selection of health care
quality personnel, the allocation of other resources,
the monitoring and evaluation of plans and the
launching of improvement teams.

21.  Total Quality Management
Total quality management is a management
approach of an organization centered on quality
based on the participation of all its members and
aiming at long-term success through customer
satisfaction, and benefits to all members of the
organization and to the society.

22.  Institutionalization of quality assurance
Every institution has their own style and system to
assure the quality of their product or service.
Support from the management to create the
environment is very challenging in the
institutionalization quality assurance

23.  Quality Circle
 Quality circle is a system where the employees are
identified, recognized and their participation is drawn
integrated with a system which satisfies their ‘ego’
needs so that they will be more motivated to work
effectively than only their participation. The philosophy
of quality circle is based on MASLOW Theory.
 Based on participative management style

24. ELEMENTS OF QUALITY CIRCLE
 Its people building philosophy
 Its voluntary
 Employees help others to develop
 Everyone participate
 Training is emphasized
 Creativity is encouraged
 Management has to be supportive

25. OBJECTIVES OF QUALITY ASSURANCE
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

26. Other specific objectives are:
 Formulate plan of care
 Attend the patients physical and non-physical needs
 Evaluate achievement of nursing care
 Support delivery of nursing care with administrative
and managerial services

27. PRINCIPLE OF QUALITY ASSURANCE
Four major principles include:
1. Focus on customer:
Satisfying need of the customers is the primary goal of quality
management. Customer may be internal (working within the
organization, e.g., CMA of PHC) or external.
2. Teamwork and employee participation:
Quality can only be delivered by healthy interpersonal
relationships and teamwork that is based on such relationship.

28. Contd…
3. Focus on systems:
All components of systems (structures, process and
outcomes) need to be assessed, evaluated and improved
collectively and individually. If we desire quality, each component
must be at the optimal level. No one part can be said to be more
important than the other. Quality of the health care system is
interdependent on its parts and elements.

29. Contd…
4. Data driven/based:
The process of quality improvement (QI), quality assurance
(QA) and quality management (QM) is based on documented and
calculated progress. Without data quality cannot be measured. And
if measurement is not possible, quality cannot be calculated, nor
improvements documented. QI training therefore requires a strong
component of the collection, appropriate data analysis, the sensible
use of tools and data management systems/methods, and effective
use of data.

30. Other Principles Include
 Leadership
 Commitment
 Process oriented
 Outcome driven
 Participative approach
 Individual responsibility
 Employee empowerment
 Continuous process

31. Contd…
 Interdisciplinary
 Education and re-training
 System of employee reward and recognition
 Preventive management
 Various control
 Benchmarking
 Mutually beneficial supplier relationship

32. WHY QUALITY ASSURANCE IN HEALTHCARE
 Increased consumer demand for effective and
appropriate care
 Need for standardization and variance control
 Necessity for cost saving measures
 Benchmarking
 Accreditation, certification, and regulation

33. contd…
 Assessment of provider performance
 Requirement to define and meet consumer needs and
expectations
 Need for continuous improvement in care and services
 Desire for recognition and strive for excellence
 Ethical and legal consideration

34. COMPONENTS OF QUALITY ASSURANCE
 STRUCTURE EVALUATION
 PROCESS EVALUATION
 OUTCOME EVALUATION

35. QUALITY ASSURANCE COMMITTEE AT
DIFFERENT LEVEL
 National quality assurance committee
 Central quality assurance committee
 Institutional quality assurance committee
 Specialize unit level quality assurance committee

36. QUALTY ERROR
 Quality improvement is essential to focus on systems,
policies, procedures and tools because there are
concepts that:
I. 85% = System error that includes policies,
procedures and tools.
II. 15% = Human/ Worker error

37. FACTORS AFFECTING QUALITY
ASSURANCE
 Patient’s values
 Social values
 Structural resources
 Accreditation bodies
 Legislature enactments
 Available resources
 Administrative values
 Nursing values
 Evaluation policy
 Job description
 In service
education program

38. QUALITY ASSURANCE PROCESS
4.Collect and analyze the information
3.Determine ways to collect information
2.Identify the information relevant to criteria
1.Establishment of standards or criteria

39. Contd…
8. Determine ways to collect the information
7. Provide information
6. Make a judgment about quality
5. Compare collected information with established criteria

40. IMPLEMENTATION OF QUALITY
ASSURANCE IN HEALTH CARE SETTING
The basic steps include:
a. Cultivate leadership commitment.
b. Support from national and international.
c. Re-organize.
d. Increase awareness.
e. Determine the intervention methodology and design.

41. Contd…
f. Allocate resources
g. Train
h. Experimental study
i. Assessments and intervention
j. Disseminate and evaluate

42. MODELS OF QUALITY ASSURANCE
System model
American nurses association
Donabedian model
Focus – PDCA model

43. System Model Of Quality Assurance
The basic components of the system are
 Input
 Throughput
 Output
 Feedback

44. i) Input:- Can be compared to the present state of the
system.
ii) Through put:- The through put to the developmental
process.
iii) Out put:- To the finished product.
iv) Feed Back:- It is the essential component of the system
because it maintains and nourish growth.

45. American Nurse Association Model
For Quality Assurance
Identify values
Identify structure, process and outcome standards
and criteria
Select measurement

46. Identify course of action
Choose action
Take action
Reevaluate

47. Donabedian Model
Facility, resources, personal mix
and skills, client mix
Standards, attitudes, nursing
care plan, effectiveness, client
satisfaction
Client’s health care, goals met,
efficiency and effectiveness of
services
structure process outcome

48. Plan, Do, Check, Act Model

49. APPROACHES OF QUALITY
IMPROVEMENT
General Approaches
 Credentialing
 Licensure
 Accreditation
 Certification
Specific Approaches
 Peer Review Committees (Staff
Review Committees)
 Standard as a device for quality
assurance
 Audit as a tool for quality assurance

50. 1) Credentialing:
 It is generally defined as the formal recognition of professional or technical
competence and attainment of minimum standards by a person or agency
According to Hinvasky (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.

51. 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 by law since 1903

52. 3.Accreditation:
 National league for nursing (NLN) a voluntary organization has
established standards for inspecting nursing education's programs. In
the part the accreditation process primarily evaluated on agency's
physical structure, organizational structure and personal qualification
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.

53. • Peer Review Committees
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. One centers on the recipients of health services by
means of auditing the quality of services rendered. The other
centers on the health professional by evaluating the quality of
individual performance

54. • Standard
Healthcare standards are statements or guidelines of
expectation for the input, process, behavior and outcomes
of the health care system. Standards in health care are used
to describe guidelines, protocols, standard operational
procedures and specifications for clinical and nonclinical
activities

55. • Audit
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. To be effective a nursing audit must be based on
established criteria and feedback mechanism that provide
information to providers on the quality of care delivered.

56. BARRIERS OF QUALITY
IMPROVEMENT EFFORT
 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 that result solely
from nursing intervention.

57. Contd…
 Nurse’s documentation of care measures is at times
vague, incomplete and lacking in objectivity.
 There is still no single, all purpose, all site quality
assessment tool that is universally appropriate for all
health agencies.
 High cost

58. ROLE OF NURSES IN QUALITY
ASSURANCE
 Nurses are the active participant of interdisciplinary quality improvement
team.
 Develop mechanism for continually monitoring the effectiveness of nursing
care both a collaborative and an individual professional activity.
 Contribute innovations and improvement of patient care.
 Participating in improvement projects and patient safety initiatives

59. Contd…
 Participate 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 research works related to quality assurance.
 Identify any area of needed improvement in delivery of care.

60. A study of quality management practices in nursing in
universities in Australia.
-Mary Cruickshank; Australian Health Review [Vol 26 • No 1] 2003
In Australia, the traditional Quality Assurance approach used in the
hospital setting has played an important role in nursing practice.
During the past decade, nurses have begun making a paradigm shift
from Quality Assurance to Total Quality Management but scant
attention has been paid to quality management practices in nursing
in the higher education sector. This paper reports on a quantitative
study examining the perceptions of nurse academics to the
applicability of TQM to nursing in universities.

61. The research study was undertaken in two stages over a period of 18
months. Sample taken were 25 nurse academics. The survey found that
only 44.5% of respondents indicated that the school of nursing where
they were currently employed had a formal Quality Assurance program
and the QA programs that did exist consisted of three major components.
They were course review, subject or unit review, and nurse academic staff
performance and peer review. Thus, the findings of this research strongly
suggest that the introduction of Total Quality Management into nursing
education is a challenge to nurse academics.

62. BIBLIOGRAPHY
1. Vati Jogindra, Principles and Practice of Nursing Management and
Administration, New Delhi, Jaypee Publishers, 2013. Pg no. 93-110
2. Mehta R.S., Tara Pokharel, Leadership and Management, Kathmandu, Makalu
Publishers, second edition, 2010. Pg no. 156-59
3. Dahal R. Achyut, A Textbook of Health Management, Kathmandu, Vidhyarthi
Pustak Bhandar, 2012. Pg no. 394-410.
4. Singh Indira, Leading and Managing in Health, Kathmandu, Hisi Offset Printers,
2006. Pg no. 254-62.