The document provides facts about patient safety. Some key points: - 20-40% of health spending is wasted due to poor quality care. - 98,000 Americans die each year from preventable medical errors. - Hospital errors are the 5th-8th leading cause of death in the US. - There is a 1 in 300 chance a patient will be harmed during healthcare.

2. Few Facts on Patients Safety
About 20%–40% of all health spending
is wasted due to poor-quality care
98,000 Americans die each year in U.S.
hospitals due to preventable medical
errors (Institute Of Medicine, 1999).
World Health Organization
2

3. Hospital errors rank between the 5th and 8th
leading cause of death in US (IOM, 2005)
There is a 1 in 1 000 000 chance of a traveler
being harmed while in an aircraft.
 In comparison, there is a 1 in 300 chance of a
patient being harmed during health care
Few Facts on Patients Safety…
3

4. 4

5. About 18 percent of patients were
harmed by medical care, some more
than once…2.4 percent caused or
contributed to a patient’s death
— this corresponds to 155,000 deaths
per year
New York Times, 2010
Few Facts on Patients Safety…
5

6. LACK OF
QUALITY
6

7. Quality Target Is 100 % ..............
(Institute Of Medicine, 1999)
……………Not Even 99%
7

8. If 99.9% were good enough a major
plane crash would occur every 3 days
There would be 30,000 ATM errors
every hours
There would be 500 incorrect surgical
operation each day
Even 99% might mean
(Institute Of Medicine, 1999)8

9. Even 99% might mean
At least 2 lakh wrong prescription each year
More than 2 lakh new born babies given to
wrong parent
2 to 3 rail accident every day
(Institute Of Medicine, 1999)
9

10. Quality Assurance
Moderator
Rajkumar Mehta
Associate Professor
CON, CMCTH
Speaker
Nirsuba Gurung
Roll no- 10
MN 1st year
Seminar
On
10

11. Highlights of session
Quality
History
Myths and truth about quality
Terminology
Principle of QA
Dimensions of quality assurance
QA model
Factors affecting quality assurance
QA approach
Legal and ethical implication
Role of nursing11

12. Quality
Quality is measured in terms of costumer
perspective
Performance improvement consists of those
activities and behaviors that each individual
does to meet customers expectation
Doing things right the first time and
continually striving to do better
12

13. A degree or grade of excellence.
Proper performance of interventions that are
known to be safe, that are affordable to the
society in question, and that have the ability
to produce an impact on mortality ,
morbidity , disability and malnutrition.
Quality…….
-Roemer, M.I. and C.Montoya Aguilar, WHO, 1988.
13

14. Effect of Poor Quality of Care
Patient
Physical discomfort
Mental stress
Increased length of stay
Complication development
Loss of working days
Increased expenses
14

15. Family
Inconvenient
Loss of trust
Higher expenses
Family disputes
Effect of Poor Quality of Care…..
15

16. Society
Increased prevalence of disease
Increased risk of certain infection
Diminished productivity, Unhealthy
people is medically more demanding
and economically less productive
Effect of Poor Quality of Care…
16

17. Hospital or institution
Increased length of stay, overcrowding,
further degradation of quality care
Higher rate of complication
 Increased risk of accidents and mishaps
Adverse publicity
Decreased outcome
Effect of Poor Quality of Care…
17

18. Care provider/staff
Reduced motivation
Risk of infection to staff
High turn over rate
Burn out / frustration
Effect of Poor Quality of Care…
18

19. Why Quality Assurance?
Insure the right of the people to assess to
quality health services
Improve the health status of the people
Meet costumers needs and expectation
Increased demand for efficient utilization of
limited resources
Increased demand for effective and appropriate
care
19

20. Minimize waste of limited resources
and reduce cost
Standardize care and control variation
Ensure safety and minimize risk
Fulfill the ethical duty of health
professional
Why Quality Assurance?.........
20

21. History of Quality Assurance
1800 B.C. - King Hammurabi of Babylon
Laws for monitoring and controlling
good and bad acts
21

22. 22

23. 1859 B.C. - Florence Nightingale
 During Crimean war she noticed direct
correlation between good nursing care to
wounded soldiers and their low mortality rate
- Developed standards for nursing practice
 Concept of different wards
 Concept of Intensive Care Unit
 Father of Hospital Administration
 Many more……………………...
History of Quality ……….
23

24. 1895 - Dr. Abraham Flexor -
Recommend a set of strict guidelines for
standard of medical education and adopted
by US Government.
1910 - Ernest Codman -
Suggested routine follow up to determine
the outcome of medical intervention
History of Quality ……….
24

25. 1916 - The American College of Surgeons
Developed the minimum standard for hospitals
1926 - In USA
First medical standard manual was printed
1952 - Joint Commission
Accreditation of Hospital
History of Quality ……….
25

26. 1966 - Dr. Avedis Donabedia
System model for evaluating health care
quality
1980 :WHO
Intiation in Europe to introduce QA program
1986: Edward Deming
The concept of TQM was developed
Introduced in health care from industry.
History of Quality ……….
26

27. Purposes of Quality
Increased demand for effective and
appropriate care
Need for standardization and variance
control
Benchmarking
Necessity for cost saving measures
Accreditation, certification and regulations
Performance appraisal of the provider
27

28. Need for improvement in care and services
Ethical considerations
Requirement to define and meet patient needs
and expectations.
Pressure of competition and to enhance
marketing
Desire for recognition and the strive for
excellence.
Purposes of Quality………
28

29. Myths Truth
 It leads to wasted time
and increase workload
 Quality means more
expensive service
 Quality means
goodness, luxury
,shininess or weight
 It build a system which
leads to less time and
effort
 It can be improved with
the same resources
 Quality is never
luxury,it is essential to
improve health service
and minimize waste
MYTHS AND TRUTH OF QUALITY
29

30. Myths
 Quality is intangible and
not measurable
 Quality problems are
originated by the
workers.
 Quality originates in the
quality department.
 It can be measured
 The majority of the problems
encountered are due to
inappropriate functioning of
health systems, and not
necessarily the result of
errors of individual workers
 Quality is everybody’s job
Truth
MYTHS AND TRUTH OF………..
30

31. Terminology
Quality
The degree of excellence
Assurance
A promise that you will definitely do the best
(provided formal guarantee)
Quality Assurance
Defines performance measurements and
compare actual processes and outcomes to
clinical and satisfaction indicators
31

32. Quality Assurance in Nursing
Quality assurance is a program for formal
guarantee for provision of quality nursing
care against set standards
Quality Control
Involves performance management and
maintenance and includes systemic methods
of ensuring conformance to a desired
standard or norm
Terminology……
32

33. Quality Care - right person (health worker
) doing:
The right thing (evidence based practice)
In the right way (skills and competence)
At the right time (providing treatment/
services when the patient needs them)
In the right place (location of treatment
/services)
With the right result (clinical effectiveness /
maximizing health gain).
Terminology……
33

34. Quality Circle
 A participative management approach in
which employees and manages share the
responsibility for decision making and
problem solving in client care
Terminology……
34

35. Quality Improvement (QI)
is concerned with performance improvement
and is ongoing, involved with fixing problems
now, costly mistakes in the future, and
fostering breakthroughs.
Standard
Predetermined level of excellence that serves
as a guide for perfect practice
Terminology……
35

36. Total Quality Management (TQM)
Also referred to as continuous quality
improvement
Philosophy developed by Dr. W. Edward
Deming
First implemented in Japan
Focus on satisfying customers' expectations,
identifying problems, building commitment,
and promoting open decision-making among
workers.
Terminology……
36

37. Purpose of QA
To ensure high quality patient care,
To ensure medical surveillance
To ensure population health management
through continuous monitoring and
evaluation of the patient care
37

38. Principles of Quality Assurance
Focus on client needs
Focus on data as basis for decision
Focus on systems and processes
Focus on team approach to problem solving
and quality improvement
38

39. Dimension of Quality Assurance
Efficacy
Degree to which the intervention has been
shown to accomplish the indented outcome
Appropriateness
Degree to which the intervention is relevant
to client needs
39

40. Availability
Degree to which appropriate interventions are
available to meet client needs
Timeliness
 Degree to which the intervention is provided at the
most beneficial time to the client
Dimension of Quality Assurance…
40

41. Effectiveness
 Degree to which the intervention is provided in the
correct manner to achieve the intended client
outcome
Continuity
Degree to which the interventions are
coordinated between organizations ,among
care providers and across time
Dimension of Quality Assurance…
41

42. Safety
Risk of an intervention and risk in the
environment are reduced for both client and
health care provider
Efficiency
Care has the desired effect with the minimum
of effort , waste and expenses
Dimension of Quality Assurance…
42

43. Respect and caring
Clients are involved in health care decisions
and are trusted with sensitivity and respect
for their individual needs, expectations and
differences by health care providers.
Dimension of Quality Assurance…
43

44. Factors Influencing Quality
Improvement
Customer demand
Financial viability
Professional accountability
Regulatory requirements
Progress in quality improvement technique
Change in health care delivery
44

45. Quality control
A specific type of controlling, refers to
activities that evaluate , monitor or regulate
service rendered to consumers
The criterion or standard is determined
Information is collected to determine if the
standard has been met
Education or corrective action is taken if the
criterion has not been met
45

46. Quality Control as a Process
Establish control criteria
Identify information relevant to criteria
Determine ways to collect information
Collect and analyze the information
Compare collected information with the
established criteria
46

47. Make a judgment about quality
Provide information and if necessary take
corrective action regarding findings to
appropriate sources
Quality Control as a Process…..
47

48. Components of Quality
Management Program
Statement of purpose, philosophy and
objective
Standards for measuring quality care
Policies and procedure
Analysis and reporting
Use of results to prioritize
Monitoring
Evaluation
48

49. Principle of TQM
Create a constancy of purpose for
improvement of the products and service
Adopt a philosophy of continual improvements
Focus on improving processes
End the practice of awarding business on price
alone, instead minimize total cost by working
with simple supplier
49

50. Improve constantly every process of planning
, producing and service
Institute job training and retraining
Develop leadership in the organization
Encourage employees to participate actively in
process
Principle of TQM……..
50

51. Foster interdependent co-operation
Focus on quality not on quantity
Promote team work
Eliminate slogans and targets for the
workplace.
Educate to maximize personal development
Principle of TQM……..
51

52. Comparison of QA and QI process
QAP QIP
Goal Improve quality Improve quality
Focus Discovery and
correction of errors
Prevention of
error
Major task Inspection of
nursing activities
and chart
Review of nursing
activities ,
innovation and
self development
Quality
team
QA personnel Multidisciplinary
Outcome Set by QA team Set by QI team52

53. Technique for Obtaining Quality of
Care
Observe the behavior of the client and family
Interview
Conduct focus group discussion
Analyze solicited comments or letters from
client
Survey
Front line people (organization)
53

54. Employee feed back
Customer care services
Conduct telephone survey
Toll free telephone numbers
Costumer visit
Mail survey to discharged patient if feasible
Technique for Obtaining Quality of
Care………..
54

55. Steps in Quality Improvement Process
Select a nursing activity for improvement
Assemble a multidisciplinary team to review
and revise the nursing activity
Describe all components of the activity using a
flow chart
Collect data
Discuss various plans to meet the standard
Collect data to evaluate the implementation
55

56. Component of Integrated Quality
Management
Quality assessment and improvement
Infection control
Utilization management
Risk and safety management
56

57. Standards
It is a pre-determined baseline condition or
level of excellence that comprises a model to
be followed and practiced.
Distinguishing characteristic of standard:
Predetermined
 Established by an authority
Communicated to and accepted by the
individuals affected by standard
57

58. Type of standard
Core standard
Clinical standard
58

59. Areas of standard
Clinical
Communication
Environment
59

60. Areas of standards
Structure
Physical
Personnel
organization
Process
What is done
Why is done
Outcome
Effect on the health of the patient
60

61. Steps in standard
Identify the system
Identify the expert
Identify the input, process and output
Develop standard
Chose format
Appropriate intervention
61

62. The ANA standards for Practice
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.
62

63. 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.
The ANA standards for Practice…
63

64. 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.
The ANA standards for Practice…
64

65. 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.
The ANA standards for Practice…
65

66. QA Model in Nursing
QAM in nursing is a set of elements that are
related to each other and comprise of planning
for quality , development of objectives, setting
and actively communicating standards ,
developing indicators , setting thresholds,
collecting data to monitor compliance with set
standards for nursing practice and applying
solution to improve care
66

67. Purpose of QAM
Develop confidence of receivers that quality
care is being rendered as per assurance
Ensure quality nursing care
To meet the expectation of receiver,
management and regulatory body
Intends to increase the commitment of
provider and management
67

68. Cycle of Quality Assurance
Define acceptable standards of service
Compare services of standard
Implement developments and changes as
needed
Monitor the effects of changes and
developlment
68

69. Models of Quality Assurance
 System Model for Quality assurance
 ANA Quality Assurance Model
 JCAHO Quality Assurance Model
 ISO Quality Assurance Model
 PDCA
 Six Sigma
 DMAIC
 DMADDV
69

70.  System Model
 Tasks are broken down into manageable
components based on defined objectives.
The basic components of the system are:
1. Input (Structure)
2. Throughput (Process)
3. Output (Outcome)
4. Feedback
Models of Quality Assurance
70

71. System Model
System
Environment
Environment
Transformation
Employee’s work
activities
Management
activities
Technology and
operations methods
OutputsInputs
Raw materials
Human resources
Capital
Technology
Information
Products and services
Financial results
Information
Human results
Feedback
71

72. Structural Elements…
Geographical location of facility
Beds
Personnel
Nurse to patient ratio
Equipments and supplies
Space
Rules and procedures
Technology
Finance
72

73. Process Elements…
Treatment process
Technical aspect of care
Appropriateness
Use of efficacious therapy
Use of diagnostic test
Use of procedure
Treatment delay(including waiting time)
IPR
Conflict/grievance /readdress procedure
Documentation73

74. Outcome Elements….
Death rate
Adverse event
Readmission
Length of hospital stay
Cost of service
Patient’s satisfaction
74

75. ANA Quality Assurance Model
This is also based on the system
model
75

76. Identify
value Identify
structure,
process,
outcome
standard and
criteriaObtain
measureme
nt to
determine
attainment
of standard
and criteria
Interpretati
on based
on
measureme
nt
Identify
possible
courses of
action
Choose course
of action
Take
action
Evaluate
Action
taken

77. JCAHCO QA Model
Enhance standard
Compare standard
Attained Not attained
Collect data
Establish standard for evaluation
Identify indicator
Identify important aspect of concerned
subject
Delineate scope
77

78. ISO QA Model
Planning
Implementation
Evaluation
Review
78

79. Plan Do Check Act (PDCA) Cycle
79

80. Six sigma
Given by Bill Smith while working
at Motorola
Six Sigma describes quantitatively how a
process is performing.
To achieve Six Sigma, a process must not
produce more than 3.4 defects per million
opportunities
80

81. DMAIC
Define
Measure process performance
Analyze the process
Improve process
Control the improved process
81

82. DMADDV
Define
Measure of quality
Analyze
Design
Detail
Verify the definition
82

83. Tools to Measure Quality
Audit
Client records are reviewed for compliance
to predetermined criteria that measure
process and outcome of care
Peer review
Care is evaluated based on the judgments of
a colleague with equal education and
experience
83

84. Benchmarking
Measuring service and practice against the
competition
Clinical pathway
Measuring the performance of care according
to critical outcomes and key incident that
must occur within the given time frame
Tools to Measure Quality…
84

85. Audit
It is a systematic and official
examination of record, process or
account to evaluate performance.
Structure audit
Process audit
Outcome audit
85

86. It is the process of collecting
information from nursing reports and
other documented evidence about patient
care and assessing the quality of care by
the use of quality assurance program.
Nursing Audit
86

87. Purposes of Nursing Audit
Evaluating nursing care given
Achieve desired and feasible quality of
nursing care
Stimulant to better records
Focuses on care provided and not on care
provider
Contribute to research
87

88. Nursing Audit Process
Select topic
Develop criteria
Ratify the criteria
Review charts
Identify variations
Analyze the problem
Develop solution
Implement solution
Evaluate and re-audit
88

89. Structure Audit
Physical facilities
Equipment
Caregiver
Organization
Policies, standard management protocol ,
procedure and clinical records
Checklist measures standard
Structure should include knowledge and
experience
89

90. Process Audit
Task oriented
Implement indicators for measuring
nursing care to determine whether
nursing standards are met
Retrospective, being applied to measure
the quality of nursing care received by
the client
The phaneuf audit seven subsection
90

91. Phaneuf Audit…
Application and execution of physician’s legal
instruction and advices
Observation of symptoms and reactions
Supervision of client
Supervision of those participating in care
Recording and reporting
Application and execution of nursing procedures and
techniques
Promotion of physical and emotional health
91

92. Outcome Audit
Evaluate by establishing client outcome
criteria
National centre for health services
developed an outcome criteria based on
Orem’s description-air, water, food,
elimination, rest, social interaction,
protection from hazards, normalcy and
health deviation
92

93. Outcome Audit…..
Morbidity, disability and mortality during and
after health care service
Nursing assessment and intervention
Grouping items for efficiency
When outcome are not satisfactorily met,
deficiencies are identified , corrected and
followed up
93

94. Evaluated in terms of……….
Requirement is met
Client has the necessary knowledge to
meet the requirement
Client has the necessary skill and
performance
Client has necessary motivation
94

95. Methods of Auditing
A concurrent nursing audit
A retrospective nursing audit
A prospective nursing auditing
95

96. Types of Auditing
Internal auditing
External auditing
96

97. Set standards
Observe practice
Compare with
standards
Implement Change
Audit cycle
97

98. Approaches For A Quality
Assurance Program
Two major categories of approaches
exist in quality assurance Program:
General
Specific
98

99. 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
2. Licensure
3. Accreditation
4. Certification
5. Charter
6. Academic degree
99

100. 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
 To produce a quality product
 To confer a unique identity
 To protect provider and public
 To control the profession.
100

101. 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.
101

102. Licensure of nurses has been mandated
throughout the world by laws and
regulations.
In Nepal : Nepal nursing council (NNC)
is the governing body to regulate
nursing licensure
 NNC is a member of International
Council of Nursing (ICN)
2. Licensure…………..
102

103. 3. Accreditation
Accreditation is the process by which
authorized body evaluates the quality
of a higher education institution as a
whole or of a specific educational
program in order to formally recognize it
as having met certain predetermined
minimal criteria or standards.
103

104. International Accreditation organization
Joint Commission International (USA)
United Kingdom Accreditation Forum
(UKAF)
Quality Health New Zealand (QHNZ)
National Accreditation Board for Hospitals &
Healthcare Providers (NABH)
Accreditation Canada International (ACI)
104

105. 4. Certification
Certification is usually a voluntary process
within 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.
105

106. ISO (International Organization for
Standardization )
Focus on good management practices
Ensures that the organization deliver the
product or services that meet the customer's
quality requirements and
Enhance customer satisfaction, and achieve
continual improvement of its performance in
pursuit of these objectives.
106

107. Standards in the ISO 9000 family
include:
ISO 9001:2015 - Sets out the requirements of a
quality management system
ISO 9001:2008: Quality management system
ISO 9000:2015 - Covers the basic concepts and
language
ISO 9004:2009 - Focuses on how to make a quality
management system more efficient and effective
ISO 19011:2011 - Sets out guidance on internal and
external audits of quality management systems.107

108. Charter
A charter is the grant of authority or
rights, stating that the granter formally
recognizes the rights of the recipient to
exercise the rights specified
108

109. B. Specific Approaches
 Peer review
 Standard as a device for quality
assurance
 Audit as a tool for quality assurance
109

110. Factors Affecting Quality Assurance
In Nursing Care
 Lack of resources
 Personnel problems
 Improper maintenance
 Unreasonable Patients and Attendants
 Absence of well informed population
 Absence of accreditation laws
110

111.  Lack of incident review procedures
 Lack of good and hospital information
system
 Absence of patient satisfaction surveys
 Lack of nursing care records
 Lack of good supervision
Factors Affecting Quality Assurance
In Nursing Care………………
111

112. Absence of knowledge about philosophy of
nursing care
Lack of policy and administrative manuals.
Substandard education and training
Lack of evaluation technique
Factors Affecting Quality Assurance
In Nursing Care………………
112

113. Lack of written job description and job
specifications
Lack of in-service and continuing
education and staff development program
Nurse prescription – No provision yet.
Factors Affecting Quality Assurance
In Nursing Care………………
113

114. Legal and Ethical Implication
Law , regulation and ethics play a major role
Define professional practice
Laws define legal practice, regulation define
guideline for delivery of care and ethics define
personal performance
Code of ethics and professional conduct for the
nurses must be there in any country
114

115. The code of ethics helps to protect the rights of
individuals, families, & community and also the
rights of the nurse.
Code can’t be broken – should follow at any
circumstances.
Failure to provide quality health care can result
in law suit
Legal and Ethical Implication…
115

116. Nursing practice standard
Professional responsibility and accountability
Nursing practice
Communication and interpersonal relationship
Valuing human beings
Management
Professional advancement
116

117. Professional Responsibility and
Accountability
Based on quality assurance model
Professionally managed and ethically justified
Provided within the legal frame work
Documented accurately and completely
Responsibility and accountability for own
actions
117

118. Nursing practice
Reflects adherence to practice standards
Reflects nursing process approach
Provided in a safe environment
118

119. Communication and interpersonal
relationships (IPR)
Fosters effective interpersonal relationship with
individuals and families
Initiates strategies to promote the learning of
individuals and groups
 Nurses at all levels must have Large open/
public area or Quadrant 1 in JOHARI Model -
Self awareness about the professional role.
119

120. Valuing Human Beings
Enhances the dignity, individuality and self
esteem of individuals and groups
Reflects active pursuit for rights of all
individuals and in particular the vulnerable
groups
Reflects gender sensitivity towards the needs of
women related to their health
120

121. Management
Reflects use of effective techniques
Reflects use of quality assurance model.
Organizes and utilizes resources
efficiently
Ensures disaster preparedness
121

122. Management…
Contributes to development and
implementation of institutional policies in
conformity with statutory regulations
Develops and implements staff development
and welfare programs.
122

123. Professional advancement
Reflects the commitment to ongoing education
and professional growth of self and others.
Includes activities which focus on the
advancement of profession
123

124. Nursing Theories and Quality
Theory development in 1950’s
 Hildegard E. Paplau: Interpersonal relationship
in nursing, 1952
 Virgenia A Henderson :Independence theory:1955
Theory in the 1960’s:
 Faye Glenn Abdellah: Patient centred approach
theory, 1960
 Ida Jean Orlando : Nursing Process Theory-1961
 Dorothy E Johnson : Behavioral system model for
nursing ,1968
124

125. Theory in the 1970’s
 Sister Callista Roy: Adaptation model ,1970
 Dorothea E Orem: Theory of self care deficit ,
1971
 Betty Neuman : Neuman system model ,1974
 M Jean Watson: Theory of human caring ,1979
Theory in the 1980’s
 Madeleine M Leininger : Culture care diversity
and universality , 1985 & so on……………..
Nursing Theories and Quality…..
125

126. Role of Nurse in Quality Assurance
Maintenance of a current knowledge base and
competencies
Interpersonal skills
Caring and compassion
Mutual decision making with client and nurse
Individualized treatment
Strive for excellence in everything that is done
(Nurses, Nurse manager or clinician, team
member )
126

127. Nurses role in legal complication
Review nursing practice periodically
Know their job description
Follow nursing standards
Follow …. Rights
Use professional judgment before
implementing
Do not attempt anything beyond level of
competence
127

128. Federal regulation (International )
Social security act (1965,1972)
Consolidated omnibus budget reconciliation
act(COBRA) 1985,1986
Health care quality care improvement (1986)
Clinical laboratory improvement amendment
(CLIA)
Patient self determination act(1990)
Safe medical device act (1990)
Occupational safety and health administration
(1991,1993)
128

129. Regulations in India –NABH standard
1992:Quality council of India
Establishment of national accreditation
board of hospital and health care
provider(NABH)
Access, assessment and continuity of care
(AAC)
Patient right and education(PRE)
Care of patient (COP)
129

130. Management of medication (MOM)
Hospital infection control (HIC)
Continuous quality improvement (CQI)
Responsibility of management (ROM)
Facility management and safety (FMS)
Human resource management (HRM)
Information management system (IMS)
NABH standard…………
130

131.  Constitution of Nepal: Mentioned about
Quality Care
 Ministry of Health
 Ministry of Education
 Nepal Nursing Council (NNC)
 Nursing Association of Nepal (NAN)
 Nepal Medical Council (NMC)
 Nepal Health Professional Council (NHPC)
 Nepal Pharmacy Council
QA in Nepal
131

132. QA in Nepal…..
1991 – Family planning services focused in
quality
In 1993 health institution and manpower
development division was created
1993/94 -National workshop on QA in health
service.
132

133. 1994-plan of action to strengthen QA activities
1994/95 – reviewed and developed standard
guideline for SHP ,HP and PHC level
1999- developed nursing procedure manual
90’s- workshop for awareness of QA in health
service in 5 developmental region
QA in Nepal…..
133

134. In 9th (1997-2002) health plan policy
“improving public health and related indicator
and providing quality health, service are the
long term objective
2009- Policy on quality health service,2064
2014-Minimum service standard ,2071
QA in Nepal…..
134

136. QA in CMCTH
QA committee
Infection prevention committee
Incidence report
Nursing manual -2014
136

137. 137

138. Journal of Taibah University Medical Sciences (2015) 10(4),
Implementation of total quality management in hospitals
Emad A.S
70% of variance in implementing TQM can be
achieved by following the principles of
TQM(continuous improvement, teamwork, training,
top management commitment and customer focus.)
 Continuous improvement was the most significant
factor in explaining variance in implementing TQM
principles
138

139. International journal for quality in health careVol 18 ,Issue 6 Pp. 414 -
421 (2006)
Towards patient-centered health services in India—a
scale to measure patient perceptions of quality
Rao K D.,PetersD H
Better staff and physician interpersonal skills,
facility infrastructure, and availability of drugs
have the largest effect in improving patient
satisfaction at public health facilities.
139

140. British Medical Journal 2012;344:e1717
Patient safety, satisfaction, and quality of hospital
care: cross sectional surveys of nurses and patients
Aiken L H et al
Nurse burnout (10% (Netherlands) to 78%
(Greece)
 Job dissatisfaction (11% -Netherlands) to 56%
(Greece), and
Intention to leave (14% (US) to 49% (Finland,
Greece)
140

141. Common wealth fund ,2004
Hospital quality: ingredients for success—
overview and lessons learned
Jack A. (2004)
Essential elements of a successful strategy,
according to the study, include
 Developing the right culture,
Attracting and retaining the right people,
Devising and updating the right in-house
processes, and
Giving staff the right tools to do the job.
141

142. Satisfaction with Health Care Services of Out Patient
Department at Chitwan Medical College Teaching
Hospital, Nepal
 Rajbanshi L et al. (2014)
 Total sample :776
 Satisfaction level was 75.9%
 Level of satisfaction
 Access to care: 98.5%
 quality of care : 91.5%
 physical facility: 56.3%
 cost of healthcare: 61.3%
 courtesy of healthcare provider:50.8%
142
Satisfaction with Health Care Services of Out Patient Department at
Chitwan Medical College Teaching Hospital, Nepal

143. Reasons for turn over among the
nurses working at BPKIHS
Mehta R S et al.
 Sample:150
 Reasons for leaving institution
 Higher education
 Negative attitude of nursing leader
 Inadequate salary
 Proper promotion opportunity
-Nursing and Midwifery Research Journal, April 2005, Vol-1, No. 2,
143

144. Stress Among Nurses Working In Critical
Care Areas At A Tertiary Care Teaching
Hospital Nepal
 Level of stress
Moderate stress: 56% had
Mild stress :34%,
Severe stress: 6%,
No stress :4%
144

145. The Internet Journal of Healthcare
Administration™ ISSN: 1531-2933
Effects Of Nurse Prescribing Of Medication:
A Systematic Review
Citation: L. M. Van Ruth, P. Mistiaen & A. L. Francke : Effects
Of Nurse Prescribing Of Medication: A Systematic Review . The
Internet Journal of Healthcare Administration. 2008 Volume 5
Number 2
145

146. Clinical outcomes of patients being prescribed by
Nurses or Physicians -
Most of the studies found no differences between
prescribing nurses and GPs and some found that the
patients who were given prescriptions by nurses had
better clinical parameters.
Satisfaction with care-
Most of the studies found that patients being treated
by nurses were just as satisfied or more satisfied
than patients being treated by physicians
146

147. Patient enablement-
Studies report that patient enablement, i.e. the
extent to which patients understand their illness
and are able to cope, is similar for nurse
practitioners and GPs
Quality of care –
Most of studies in primary care report that
quality of care provided by nurses is similar to
or better (in some cases) than that provided
by GPs.
147

148. Consultation time-
Most of studies reporting on consultation times
found that nurses generally spent more time
with patients.
Information and documentation-
Nurses were found to give more advice than
GPs about home remedies, self-medication and
general self-management.
Patients managed by nurse practitioners
reported receiving more information about
their illnesses and well documented.
148

149. Effects on costs and other characteristics of
health care system-
Netherlands showed that the costs incurred for
personnel were lower for the group of patients
being treated and prescribed for by the
specialist nurse.
149

150. Quality
History
Myths and truth
about quality
Terminology
Principle of QA
Dimensions of
quality assurance
QA model
Factors affecting
quality assurance
QA approach
Legal and ethical
implication
Role of nursing
Winding Up
150

151. Take home message
TQM is a new wave of nursing management
Customer is anyone who uses the products,
services or process within an organization
Quality management programs make certain
that the patient care delivered meets established
standards
Doing things right the first time and every
time.
151

152. 152

153. 153

154. 154

155. 155

156. Reference
Singh, I. (2012). Leading and Managing in Health (5th
ed.). J.B. Singh Publication: Kathmandu.
Kelly, P. (2008). Leadership and Management in
Nursing (1st ed.). Cengage Learning India Pvt. Ltd.:
India.
Meheta, R.S., & Pokheral, T. (2012). Leadership and
Management (3rd ed.). Makalu Publication:
Kathmandu.
Wolper,L. (2004). Health Care Administration (3rd ed.).
Jones and Bartlett Publication: Masschesetts.
156

157. Sakharkar,B.M. (2008). Principles of Hospital
Administration and Planning (5th ed.). Jaypee
Publication: New Delhi, India.
Sah, A.P. (2011). Essential of Health
Management (1st ed.) Vidyarthi Pustak
Bhandar: Kathmandu.
Peter, R.K. (2007). Essential Managed Health
Care (5th ed.). Jones Barllett Publishers
sudbury: Massachusetts.
Reference….
157

158. Dill, D.D. (2000) Designing Academic Audit:
lessons learned in Europe and Asia, Quality
in HigherEducation, Vol. 6, No. 3
Askling, B. (1997) Quality Monitoring as an
Institutional Enterprise, Quality in Higher
Education, Vol. 3,No. 1
Harvey, L. (2002) The End of Quality?, Quality
in Higher Education, Vol. 8, No. 1
Reference….
158

159. Rasmussen, P. (1997) A Danish Approach to
Quality in Higher Education, The Case of
Aalborg
University, in Brennan, J. de Vries, P. and
Williams, R. (eds.) Standards and Quality in
Higher Education, Higher Education
Policy Series, Vol. 37, Jessica Kingsley
Reference….
159

160. Kelvin B. H., Singhal V.R. (1997)Does
Implementing an Effective TQM Program Actually
Improve Operating Performance? Empirical
Evidence from Firms That Have Won Quality
Awards.pubsonline. Volume 43, Issue
9( September 1, 1997)
http://pubsonline.informs.org/doi/abs/10.1287/mnsc.
43.9.1258
Reference….
160

161. Schouten L M T(2008) Evidence for the impact of
quality improvement collaboratives: systematic
review.The BMJ
http://www.bmj.com/content/336/7659/1491.short
Rao K D.,PetersD H (2006),Towards patient-centered
health services in India—a scale to measure patient
perceptions of quality. International journal for
quality in health care .Volume 18, Issue 6. Pp. 414 -
421
Reference….
161

162. Aiken L H et al (2012). Patient safety, satisfaction, and
quality of hospital care: cross sectional surveys of
nurses and patients in 12 countries in Europe and
the United States. BMJ 2012;344:e1717
http://www.bmj.com/content/344/bmj.e1717
R AN, M KK, P RM, Akanksha J, S BB. Patients’ Waiting
Time and Their Satisfaction of Health Care Services
Provided at Outpatient Department of Government
Medical College, Nanded (Maharashtra, India). . IJHSR.
2014; 4(4): 21-27
http://www.scopemed.org/?jft=107&ft=107-1398677084
Reference….
162

163. Derek Milne, Bob Drummond, (1990) "Quality
Assurance: Implementation in Nursing
Practice", International Journal of Health Care
Quality Assurance, Vol. 3 Iss: 5
http://www.slideshare.net/HareeshSasidharan/qua
lity-assurance-26354281
Reference….
163

164. 164