This document discusses quality assurance in nursing. It begins by defining key terms like quality, assurance, and quality assurance. It then discusses the need for quality assurance in nursing to ensure quality patient care. The objectives of quality assurance in nursing are outlined. A 10 step quality assurance process is described involving setting standards, data collection, evaluation, and taking corrective actions. Different approaches to quality assurance like general approaches of credentialing, licensure, accreditation and certification as well as specific approaches like peer review, nursing audit, and utilization review are explained. Models for quality assurance evaluation like Donabedian's structure-process-outcome model and tracer and sentinel methods are also summarized.

1. QUALITY ASSURANCE IN
NURSING

2. Mr.Vinayak Gunjal
Assistant Professor
MVP’s INE Nashik.
QUALITY ASSURANCE
IN
NURSING

3. INTRODUCTION
The expense of quality is an interactive
process between customer & provider. Quality
assurance usually focuses on material, good work
& service provided effectively. Any lack in service
provided causes decrease in quality.

4. QUALITY
It is degree to which health services for
individuals & population increase the likelihood
of desired health outcomes & are consistent with
current professional knowledge.
(JCAHO) 2002

5. ASSURANCE
It is statement or indication that inspires
confidence.

6. QUALITY ASSURANCE
• Quality assurance is an on-going, systematic,
comprehensive evaluation of health care services
& impact of those services on health care services.
-Kozier
• Quality assurance is defined as all activities
undertaken to predate & prevent poor quality.
-Neetvert

7. NURSING
The unique function of nurse is to assist in individual sick or
well in performance of those activities contributing to
health or its recovery or to a peaceful death that he would
perform unaided if he had necessary strength will or
knowledge & to do this in such a way as to help him to
gain independence as rapidly as possible.”
- Virginia Henderson

8. OBJECTIVES
• To ensure the delivery of quality client care.
• To demonstrate efforts of health care providers to
provide good results.
• To formulate plan of care.
• To evaluate achievement of nursing care.

9. • To support delivery of nursing care with
administrative & managerial services.
• To explain quality assurance models as pre-
requisite for quality nursing care.
• To state code of ethics & professional conduct for
nurses in India.

10. • To appreciate importance of practicing standard
safety measures.
• Plan & conduct patient teaching sessions.
• To identify appropriate management techniques to
be used for managing resources in given situation.

11. Quality Assurance Three Basic steps Break Down
1. Criterion or standard is determined.
2. Information is collected to determined if the
standard has not been met.
3. Educational or corrective action is taken if the
criterion has not been mate.

12. NEED FOE QUALITY ASSURANCE IN
NURISNG
• To ensure quality nursing care provided by nurses in
order to meet the expectation of receiver, management
and regulatory body.
• It also intends to increase the commitment of provider
and the management.
• Improves and maintain the patients state of health.

13. NEED FOE QUALITY ASSURANCE IN
NURISNG
• Improves and maintains patients functional ability.
• Develop patients psychophysical condition or well
being.
• Refine existing method for ensuring optimal quality
health care.
• Provide technical assistance in correcting systemic
deficiencies.

14. PURPOSES
• It is required to introduce code of ethics &
professional conduct for nurses in India.
• To prepare staff nurse for implementation
quality assurance model in nursing.
• To provide best care to patients by maintaining
standards.

15. PRINCIPLES
1. It is oriented towards meeting the needs and expectations of
our clients.
2. It focuses on systems and processes.
3. It uses the data to analyze service delivery.
4. It encourage the use of teams in problem-solving and quality
improvement.
5. It uses effective communications to improve service
delivery.

16. PRINCIPLES
1. Customer focus- It focuses on patient’s care with
standard & recent medical knowledge.
2. Leadership – It helps to inculcate qualities of
leadership in staff.
3. Involvement of People- It should involve
maximum nursing staff so that standards can be
maintained.

17. 4)Process approach- There should be a systematic &
planned approach to provide quality care.
5)Factual approach to decision making- There should
be fact or appropriate reason in taking certain
decision for quality assurance of patient.

18. QUALITY ASSURNACE PROCESS
It is the systemic process of evaluating the quality
of care given in a particular unit or institutions.
1. Setting standards.
2. Determining criteria to meet those needs.
3. Data Collection.
4. Evaluation how well criteria have been met.
5. Making plans for change based on the evaluation.
6. Implementation for change.

19. 10 STEP PROCESS OF QUALITY ASSURNACE
PROGRAM
Step 1 : Assigning Responsibility
 Nursing departments and services must assign
overall responsibility for their monitoring and
evaluation activities.
 The person oversees all aspects of nursing
monitoring and evaluating, assuring that the
act9ivities are comprehensive, effective, uniform
and coordinated.

20. 10 STEP PROCESS OF QUALITY ASSURNACE
PROGRAM
Step 2: Delineate the scope of care and services:
It intended to assure that all nursing activities
are considered in monitoring and evaluation:
1. Types of patients served.
2. Condition and diagnosis
3. Types of nursing staff providing care and services
4. All existing standards of patient care.

21. 10 STEP PROCESS OF QUALITY ASSURNACE PROGRAM
Step 3: Identify important aspects of care and services:
Nursing staff to remember that important aspect of
care are activities of the department that will be
continually monitored and periodically evaluated to
determined if care can be improved or if problems are
present. Nursing staff should identify those aspects of
care and services that:
1. Occurs frequently or affect large number of the patients.
2. Place patients at serious risk.
3. Have intended in the past to produce problems.

22. 10 STEP PROCESS OF QUALITY ASSURNACE PROGRAM
Step 4: Identify Indicators:
Indicators are measurable variables related to the
structures, process and outcome of care:
1. Structures: Elements that facilitates care (Resources,
Equipments, numbers and qualification of staff).
2. Process: Functions carried out by the practitioners
(Assessment, treatment, planning and qualification of
staff).
3. Outcomes: Includes complication, adverse effects, short
and long term results of treatment.

23. 10 STEP PROCESS OF QUALITY ASSURNACE PROGRAM
Step 5: Established threshold for evaluation:
 Thresholds are accepted levels of compliance with any
indicators being measured.
 Thresholds for evaluations are the level or point at which
intensive evaluation is triggered.

24. 10 STEP PROCESS OF QUALITY ASSURNACE PROGRAM
Step 6: Collect and Organized Data :
Some common dates can be found in
1.Patients, records
2.Incidents reports
3.Medication Sheets
4.Infection Control
5.Meeting Minutes
6.Patients Surveys
7.Department Logs
8.Laboratory reports
9.Direct Observation
10.Formal Evaluation.

25. 10 STEP PROCESS OF QUALITY ASSURNACE PROGRAM
Step 7: Evaluate Care:
Once threshold of an indicator is reached the critical
step of evaluation is initiated.
1. Lack of knowledge or skill
2. Staff knew what to do but
didn’t do
3. Equipment Deficiencies.
4. Policy/ Procedure violation.
5. Lack of adequate staffing.
6. Infection control violation
7. Inappropriate therapy,
diagnostics.
8. Deficiencies in MRD

26. 10 STEP PROCESS OF QUALITY ASSURNACE PROGRAM
Step 7: Evaluate Care:
Evaluation must be designed to identify the opportunities for
improvement by:
1. Objectively examining the possible causes for the level of
performance.
2. Recommending action pertinent to those causes to
improve the performance.

27. 10 STEP PROCESS OF QUALITY ASSURNACE PROGRAM
Step 8: Take actions to solve problems or Improve:
Some possible actions if the problems involves
deficiencies in the system includes:
1. Changing communication channels.
2. Changing organizational structures.
3. Adjusting or redistributing staff.
4. Revising job descriptions.
5. Reallocation resources.
6. Altering the use of equipments.
7. Purchasing and repairing equipments.
8. Adding or revising policies and procedures.

28. 10 STEP PROCESS OF QUALITY ASSURNACE PROGRAM
Step 8: Take actions to solve problems or Improve:
Some possible actions if the problems involves
deficiencies in the staff knowledge includes:
1. Modifying orientations procedures.
2. Providing Focused In-service Education.
3. Providing focused continuing education.
4. Circulating written policies and procedures or other
informational materials.

29. 10 STEP PROCESS OF QUALITY ASSURNACE PROGRAM
Step 8: Take actions to solve problems or Improve:
Some possible actions if the problems involves
behavior or performance deficiencies includes:
1. Revising Job descriptions.
2. Informal Counseling.
3. Formal Counseling.
4. Changing assignments.
5. Disciplinary sanctions.
6. Limiting staff prerogatives relating to patient care.
7. Transferring to another unit or department.

30. 10 STEP PROCESS OF QUALITY ASSURNACE PROGRAM
Step 9: Assess the effectiveness of actions:
 Monitoring and evaluation does not end when actions
are taken. Staff continues to monitor the aspects of care
for the future opportunities for improvement, but they
must determined whether actions are taken successfully
in improving care of services.
 If care does not improve within the expected time, staff
should re-examine the aspect of care and take further
actions.

31. 10 STEP PROCESS OF QUALITY ASSURNACE PROGRAM
Step 10: Communicate relevant information to the
organization- Wide Quality assurance program:
 It is essential to be communicated the monitored and
evaluated information through established channels.
 Appropriate dissemination of information helps to assure
the quality assurance activities are coordinated and that
knowledge regarding monitoring, evaluation and problem
Solving methods is shared.

32. APPROACHES TO QUALITY ASSURANCE
1. Methods for measuring performance:
As nursing care is delivered within a framework
of independent relationships with physicians and a
multiplicity of other health care personnel .The most
commonly used methods of nursing care are task
analysis and quality control.

33. 2) Measuring actual performance:
It is an ongoing repetitive process with the actual
frequency dependant on the type of activity being
measured. It is better to clarify the purpose of the
measurement and to measure performance on a
continuous basis.

34. 3) Comparing results of performance with
standards and objectives and identifying
strengths and areas for correction:
The standards and objectives and methods of
measurement have been set ,if performance matches
standards and objectives , managers may assume
that things are under control if performance is a
contrary to standards and objectives, action is
necessary.

35. 4) Acting to reinforce strengths or success
and taking corrective action as necessary:
Positive aspects needed to be identified in
order that they may e translated into
encouragement and motivation for the nursing
members involved in achieving them.

36. DEVELOPMENT OF A QUALITY
ASSURANCE PROGRAM
• Foster Commitment of Quality
• Conduct a Preliminary Review of Quality-Related
Activities
• Develop the Purpose and Vision for the Quality Assurance Effort
• Determine level and scope of initial Quality Assurance
Activities
• Assign responsibility for Quality Assurance

37. • Allocate resources for quality assurance
• Develop a written quality Assurance plan
• Critical Management System
• Disseminate Quality Assurance Experience
• Manage Change

38. APPROACHES FOR QUALITY
ASSURANCE PROGRAM
Two major categories of approaches exist in
Quality Assurance
1. General Approach
2. Specific Approach

39. GENERAL APPROACHES
It involves large governing of official body’s evaluation
of person’s or agency’s ability to meet standard at a given
time.
1. Credentialing:
A person generally define it as the formal
recognition of professional or technical competence and
attainment of minimum standards by a person or agency.
According to Hinsvark (1981) credentialing has four
functional components:
 To produce a quality product.
 To confer unique identity.
 To protect provider and public.
 To control the profession.

40. LICENSURE:
Individual licensure is a
contract between profession &
state in which profession is
granted control over entry into &
exists from profession & over
quality of professional practice.
Principles of Credentialing

41. Accreditation
Accreditation is the act
of granting credit or
recognition especially to
an educational institution
that maintains suitable
standards.

42. CERTIFICATION:
Certification is
usually a voluntary process
within the professions. A
person’s educational
achievement, experience &
performance on examination
are used to determine person’s
qualification for functioning
in an identified specialty area.

43. SPECIFIC APPROACHES
Quality assurances are methods used to
evaluate identified instances of provider and
client interaction.
Peer review committee:
These are designed to monitor client
specific aspects of care appropriate for certain
levels of care. The audit is used by peer review
committee to ascertain quality of care.

44. Nursing audit
Nursing audit is
evaluation of patient
care through analysis
of written records
maintained by nurses
in patient’s treatment
profile.
- Avtar Brar

45. GOALS OF NURSING AUDIT
• To improve quality of health care.
• To promote improved communication among
nurses & other health team members.
• To improve quality of nursing care.
• To detect & analyze problems & errors.

46. NURSING AUDIT PROCESS

47. ADVANTAGES OF NURSING AUDIT
• Provides quality of nursing
• A patient is assured of good services.
• It will give valuable and pertinent information for
the staff.
• It will lead to between co-operation and
communication among the nurse & health team.

48. • It will help each professional nurse for her self
evaluation.
• It helps the administration as better planning.
• It will reduce the incidence of medical legal
complication.
• It will broaden and strengthen nursing service.

49. Utilization Review
Utilization review activities are directed towards
assuring that care actually needed and that the cost
appropriate for the levels of care provided

50. TYPES OF UTILIZATION REVIEW
• Prospective:
It is an assessment of the necessary of care before
giving services.
• Concurrent:
A review of the necessity of care while the care is
being given.
• Retrospective:
It is analysis of the necessity of the services received by
the client after the care has being given.

51. Evaluation Studies
Three major models have been used to evaluate
quality care:
1. Donabedians structures-process0outcome model.
2. The Tracer Model
3. The sentinel Model

52. Donabedian’s Structure-Process-Outcome model
Donabedian introduced 3 major method of
evaluating quality care:-
Structural Evaluation:
This method evaluates setting & instruments
used to provide care such as facilities, equipments
& characteristics of administrative organization &
qualification of health provider. The data can be
obtained from existing documents.

53. Process Evaluation:
This method evaluates activities as they relate
to standards & expectations of health providers in
management of client care.
Data is collected through direct observations,
review of records, audit, checklist approach and
criteria mapping approach are used to established
the client encounter protocol. etc.

54. Outcome Evaluation:
The net changes that occur as a result of
health care or net results of health care.
The data of this method can be collected from
vital statistics records such as death certificate or
telephone client interview, mailed questionnaire
& client records.

55. STRUCTURE
(CAUSAL PAST)
PARTICIPANTS
PROCESS
CARING RELATIONSHIPS
OUTCOMES
FUTURE
(TERMINAL OUTCOMES)
1. PROVIDER
• PHENOMENALFIELD
• DESCRIPTORS
• LIFE EXPERIENCE
2. PATIENT/FAMILY
• PHENOMENALFIELD
• DESCRIPTORS
• LIFE EXPERIENCE
3. SYSTEM
• RESOURCES
• WORKLOAD
• ENVIRONMENTOF
ORGANIZATION
1. PROVIDER
• SATISFACTION
• PERSONALGROWTH
2. PATIENT
• QUALITY OFLIFE
• SAFETY
• SATISFACTION OFTREATMENT
• KNOWLEDGE
3. SYSTEM
• UTILIZATION
• RESOURCE
• CONSUMPTION
• COST
RELATIONSHIP
CENTERED
INDEPENDENT
RELATIONSHIP
PT. /FAMILY- NURSE
+
COLLABORATIVE
RELATIONSHIP
WITH HEALTH
CARE TEAM NURSE
PROFESSIONAL
ENCOUNTERS
IMMEDIATE OUTCOMES FEEL“CARED FOR”
Example of Donabedians Model of Evaluation

56. Two Examples OF Donabedians Model of
Evaluation

57. Tracer Method:
It is a measure of both process and outcome of care. To use tracer
method one must be identify a volume of client with a particular
characteristics resuming specific health care management.
 Physicians and nurse practitioners to identify person with certain
illness such as HTN, Ulcers, UTI and to established a criteria for
good medical and nursing management of the illness have used the
tracer method.
This method provides nurses with data to show the differences in
outcome as a result of nursing care standards.

58. The Sentinel Method:
It is an outcome measure for examining specific instances of
client care. The characteristics of this methods are:
Cases of unnecessary diseases, disability deaths are countered.
The circumstances surrounding the unnecessary events 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 are reviews which may have an
effect on health outcomes.

59. Models of Quality Assurance:
Mostly model used as their basis Norma
Lange’s model of Quality Assurance of 197 which
has seven levels that run through three phases.
Description.
Measurement
Action.

60. Norma Lange’s Quality Assurance Model

61. Models of Quality Assurance
System Model
System model is used for implementation of unit
based quality assurance program.
It involves making changes in organizational
structure & individual roles.
In system model, task is broken down into
manageable components based on defined objectives.

62. Basic Components of the system
models are
• Input- The input can be compared to the
present state of systems.
• Throughput- It is developmental process.
• Output- It is finished product or result.
• Feedback- It is essential component of system
because it maintains & nourishes growth.

63. System Model for Quality Assurance

64. American Nurses Association Model (1977)
The ANA developed QA model in 1977 which has wide
spread applicability in health care settings and can be used as a
guide to implement QA program. The basic components of ANA
models are:
Identify Values.
Identify structure, process,
outcomes standards and criteria.
Select Measurements.
Make interpretation.
Identify course of actions.
Chose actions.
Take actions.
Re-evaluate

65. ANA Quality Assurance Model
Identify
values
Identify standards &
criteria
Secure measurement
Make
measurement
Identify
course of
action
Choose action
Take action
Reevaluation

66. ANA Quality Assurance Model

67. Factors affecting quality assurance in Nursing
1. Lack of resources.
2. Personnel Problems.
3. Improper Maintenance.
4. Unreasonable patients and attendants.
5. Absence of well informed populations.
6. Absence of accreditation laws.
7. Lack of good hospital Information System.
8. Absence of patients satisfaction surveys.
9. Lack of Nursing care Records.

68. Factors affecting quality assurance in Nursing
Miscellaneous Factors includes :
1. Lack of good supervision.
2. Absence of knowledge about philosophy of nursing care.
3. Lack of policy and administrative manuals.
4. Substandard education and training.
5. Lack of evaluation technique.
6. Lack of written job description and job specification.
7. Lack of in-service and continuing education program.

69. Quality improvement
Quality improvement is defined as an
approach to the continuous study &
improvement of process of providing health
care services to meet the needs of clients &
others.
-Joint commission on accreditation of
health care organization (JCAHO)

72. Role of Nurse in Quality Assurance in Nursing
1. Role of nurse is to participate in quality improvement
team.
2. Properly supervises & check whether patient is
receiving proper care or not.
3. Contribute innovation & improvement of patient care.
4. Participating in improvement projects &patient safety
initiatives.
5. Participating in CNE programs and In-service Education
Programs

73. Role of Nurse in Quality Assurance in Nursing
1. Periodic & continuing appraisal & evaluation of
health care situation of patient
2. Participate in research works related to quality
assurance.
3. Nurses identifies the areas where need improvement in
delivering care.

74. Summary