Quality assurance

1. QUALITY ASSURANCE TRIANGLE
QUALITY ASSURANCE
ISO 9000 defines Quality Assurance as "part of quality management focused on providing
confidence that quality requirements will be fulfilled"
QUALITY ASSURANCE TRIANGLE
The Quality Assurance (QA) approach to addressing quality of care issues incorporates three
core quality assurance functions: defining quality, measuring quality, and improving) which
work synergistically to ensure quality care as an outcome of the system. The QA triangle
effectively illustrates the synergy between these three QA functions. The triangle shape indicates
that rather than a unique sequence of steps that initiate QA activities, all core functions need to
take place in a balanced manner for a QA strategy to be effective. It is the heart of any effort to
institutionalize quality care.
They together encompass the range of mutually supportive QA methodologies and techniques,
no core activity is sufficient on its own to maintain and improve quality; it is the interaction and
synergy of all three that facilitate sustainable improvements. Each core activity encompasses a
group of interrelated activities. The greatest impact on quality of care results only when all three
functions are implemented in a coordinated fashion.
Defining Quality
It means developing expectations or standards of quality as well as designing systems for quality.
Standards can be developed for inputs, processes, or outcomes (expected outputs, results or

2. impact on health status); they can be clinical or administrative. Standards state the expected level
of performance for an individual, a facility, or an entire health care system. A good standard is
reliable, realistic, valid, clear, and measurable. Standards of quality can be developed for each of
the nine dimensions of quality shown below, which cover widely recognized attributes of quality
of care.
Dimension Definition
Technical Performance Compliance with technical standards
Access to Services Removal of geographic, economic, social,
organizational or linguistic barriers to care.
Effectiveness of Care Degree to which desired health results are achieved.
Efficiency of Care Extent to which minimal resources are used to achieve
desired results.
Interpersonal Relations Effective listening and communication, establishment
of trust, respect, responsiveness, and confidentiality
Continuity of Services Consistency of provider where feasible and
appropriate, as well as timely and appropriate
referrals.
Safety Degree to which risk of injury, infection, or side
effects is minimized
Physical Infrastructure/
Comfort
Amenities of care such as physical appearance,
cleanliness, comfort and privacy
Choice Choice of provider, treatment, or insurance plan, as
appropriate and feasible. Access to information that
allows client to exercise autonomy
Means to define quality: - Quality can be defined using various means:
1. Structural reorganization: - In terms of health care system structural measures gives
consumers a sense of health care provider’s capacity, systems and processes. The main
reason for restructuring an organization is to execute a new strategy. A strategy sets out a
plan that determines how an organization will use its major resources to meet its strategic
objectives. It is a response to changes in product or service demand.
2. Incentives: - Incentive is “a thing that motivates or encourages someone to do
something”. There is no evidence for a clinically significant effect of financial incentives
on performance of preventive care in community health centers. Rather, Incentives have
been used widely in ambulatory medical care to increase visit productivity. In recent
years, there has been growing interest in applying this methodology to increase
performance of physicians in achievement of specific quality targets, most often in
preventive care and chronic disease management.

3. 3. Motivation: - Different studies indicate that employee motivation have greater impact on
product quality and service delivery. Motivation actually describes the level of desire
employees feel to perform, regardless of the level of happiness. Employees who are
adequately motivated to perform will be more productive, more engaged and feel more
invested in their work. When employees feel these things, it helps them, and thereby their
managers, be more successful. It is a manager's job to motivate employees to do their
jobs well.
4. Standards setting: - Standard setting is the methodology used to define levels of
achievement or proficiency. Standards define how your company acts, which, in turn,
builds trust in your brand. They can be guidelines that describe quality, performance,
safety, terminology, testing, or management systems, to name a few. They can comply
with authoritative agencies or professional organizations and be enforceable by law, such
as required medical degrees for doctors or credentials for financial planners. Or they can
be voluntary rules you establish to create confidence among your clients that your
business operates at a high and consistent quality level.
5. Monitoring systems: - In a organization, monitoring a system determines whether the
organization is using its resources efficiently and effectively. Many of the quality
monitoring activities are organized within hospitals or provider groups, usually in an
effort to demonstrate value to the insurers and managed care organizations purchasing
their services. Other quality monitoring activities are externally driven and have an
accountability function—the government may want to ensure that publicly funded
healthcare programs are adhering to best practices, or professional societies may want to
demonstrate to the public that their care meets or exceeds accepted standards of care. The
better you’re monitoring and evaluation system, the more effective and competitive your
organization can become. Having a good monitoring and evaluation system starts with
developing the system that's most appropriate for your organization.
6. Supervision: - It involves stimulating the right people to perform the right activities with
the right information at the right moment in order to achieve the right result.
Measuring quality
It consists of quantifying the current level of performance or compliance with expected standards
including patient satisfaction. This process requires identifying indicators of performance,
collecting data, and analyzing information. Measuring quality is inextricably linked with
defining quality because the indicators for measuring quality are related to the specific definition
or standard of quality under study. When standards define quality, measuring quality requires
assessing the level of compliance with standards. Hence, measuring quality is easier with a clear
definition or standard, because the indicators are directly derived from the expression of the
standards. Likewise, measuring quality leads directly to identifying areas for improvement or
enhancement - the first step in quality improvement. A few key points in the measurement
deserve highlighting; the details appear in different publications:
 If one starts the QA approach with measuring quality, the scope of measurement should be
limited to what the system is able/willing to improve (i.e., a quality improvement objective
must be defined).

4.  The QA team must be realistic about what data the team can readily collect at the facility level
or across the system. A simple performance monitoring system with a limited number of
indicators related to the improvement goal is usually very effective.
 Measurement strategies, such as special surveys, self-assessment, audits, and supervision visits,
must be carefully designed so that those stakeholders ultimately controlling the quality of care
(usually the providers) take full ownership of the quality improvement process. The team in
charge of making improvements should fully participate in defining standards, identifying
indicators, and developing a measurement strategy.
The indicators used to measure quality will vary in each setting, based on the particular standards
used and the level of the system (facility, district, regional, or national) on which measurement
focuses. With regard to maternal health, indicators are based on existing Neonatal and
Emergency Obstetrical Care (EmOC) standards relating to newborns and safe motherhood.
However, even when well-defined national standards exist, defining new standards (and
indicators) specific to the needs of the facility and community served may be necessary.
Means to measure the quality :-
1. Quality evaluation:- Evaluation is an integral component of quality improvement and
there is much to be learned from the evaluation of small scale quality improvement
initiatives at a local level. This type of evaluation is useful for a number of different
reasons including monitoring the impact of local projects, identifying and dealing with
issues as they arise within a project, comparing local projects to draw lessons, and
collecting more detailed information as part of a bigger evaluation project. Focused
audits and developmental studies can be used for evaluation within projects, while
methods such as multiple case studies and process evaluations can be used to draw
generalized lessons from local experiences and to provide examples of successful
projects. Evaluations of small scale quality improvement projects help those involved in
improvement initiatives to optimize their choice of interventions and use of resources.
2. Regulation :- Safety and efficacy are in the focus of this phase to aim population safety.
Key elements are performing testing, safety assessment & post-market reporting using
criteria of safety and quality standards.
3. Accreditation :- Accreditation has been a voluntary process through which the
organization is able to measure the quality of its services and performance against
nationally or internationally recognized standards. Within the organization seeking
accreditation, there must be a system in place to assure qualified health care providers
and support personnel: that they adequately meet the needs of the patients; and that they
have been granted privileges to work within the organization. This system must not only
ensure such personnel is painstakingly selected, their education and experience
thoroughly verified, but also that their performance is regularly evaluated by superiors
and/or peers.
4. Audit: - Audit in healthcare is a process used by health professionals to assess, evaluate
and improve care of patients in a systematic way. Audit measures current practice against

5. a defined (desired) standard. It forms part of clinical governance, which aims to
safeguard a high quality of clinical care for patients
Improving Quality
It refers to the application of quality improvement methods (problem solving, process re/design
or re-engineering) to close the gap between the current and the expected level of quality (defined
by the standards)by understanding and addressing system deficiencies(as well as enhancing
strengths)in order to improve or in some cases re-design health care processes . A variety of
quality improvement approaches exists from individual problem solving to redesign of
systems/processes to organizational restructuring /reengineering. This core function applies
quality management tools and principles to:
1. identify/determine what one wants to improve;
2. analyze the system of care/problem;
3. develop a hypothesis on which changes (solutions) might improve quality;
4. test/implement the changes to see if they really yield improvement; and
5. based on the results of testing, decide whether to abandon, modify, or implement the
solutions .
Means to measure the quality :-
1. Policy making:- A policy is a deliberate system of principles to guide decisions and
achieve rational outcomes. Policy or policy study may also refer to the process of making
important organizational decisions, including the identification of different alternatives
such as programs or spending priorities, and choosing among them on the basis of the
impact they will have.
2. Quality re-designing:- Health care/system redesign involves making systematic changes
to primary care practices and health systems to improve the quality, efficiency and
effectiveness of patient care.
3. Benchmarking:- Benchmarking is a term used to describe a rule or guideline by which
others can be measured or judged. The purpose of benchmarking in healthcare is to
improve efficiency, quality of care, patient safety and patient satisfaction. The process
involves looking at standards, best practices, and evidence-based practices and then
identifying potential areas of improvement. Employees may be given individual goals
that will assist in achieving an area or organizational goal.
4. Problem solving:- Problem solving is very much a human activity, for which perception,
reasoning, technical knowledge of the application area, and creativity are needed.
Reasoning has a prominent role in problem solving
5. Management actions:- At each level of management, leaders help to create their own
standard work. Middle managers, for instance, make the rounds of their direct reports
every morning, asking specific — often scripted — questions about the day’s challenges.
One example is a “status sheet” discussion. The status sheet contains questions that
managers and executives ask when they go to a place of work (the intensive-care unit, the

6. emergency room, etc.) The aim of the questions is to understand the status of the work.
On the Medical-Surgical floor, the status-sheet discussion between a manager and a nurse
lead might include a conversation about which patients are at risk for falls today, or
whether there is adequate staffing to handle patients’ requirements (patient acuity). Then
the manager meets with a frontline team to coordinate problem solving and improvement
activities before meeting with her own superior to discuss the day’s observations, update
improvement activities, etc.