QUALITY ASSURANCE

1. QUALITY ASSURANCE IN COMMUNITY
HEALTH NURSING
PRESENTED BY :MS ANMOL

3. INTRODUCTION
As a result of advancement in healthcare technology,
increased competition, privatization and awareness
among the clients, healthcare system has become well
aware of the need to ensure quality.
The main aim of quality assurance us to achieved
desired outcomes. As now a days we are giving more
importance to achieve health for all so quality standard
is not only applied to tertiary level of hospital but also in
primary care setting like PHC and CHC, etc

4. CONCEPT OF QUALITY

5. THREE-PART (TRILOGY) APPROACH TO QUALITY:

6. DEFINITION OF QUALITY
•'The quality is described as levels of excellence
produced and document 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

7. CONCEPT OF QUALITY ASSURANCE
Quality assurance (QA) is the process of
assuring compliance to specification,
requirements or standards and
implementing methods for conformance.
It includes planning and design for quality,
setting and communicating indications for
performance monitoring and compliance of
standards.

8. CONCEPT OF QUALITY ASSURANCE
•QA may also viewed as a measure of competence
demonstrated by efficiency in performance. It also
includes evaluation of process, outcome.
•In nursing, quality assurance has focused on nursing care
delivery structure, process and outcomes. Problem
identification, analysis and corrective action has gradually
evolved to systematic monitoring of nursing services.

9. DEFINITION OF 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
• Quality assurance as the monitoring of the activities of client care to
determine the degree of excellence attained to the implementation of
the activities.
-Bull, 1985

10. To provide technical assistance in designing
and implementing effective strategies for
monitoring quality and correcting systemic
deficiencies
To refine existing methods for ensuring optimal
quality health care through an applied research
program.
OBJECTIVES

11. Purpose of Quality Assurance
1.Help patients and potential patients by improving quality of care.
1.Assess competence of medical staff, serve as an impetus to keep up to date and prevent
future mistakes.
Bring to notice of hospital administration the deficiencies and in correcting the causative
factors
1.Help to exercise a regulatory function.
1.Restricting undesirable procedures.

12. AREAS OF IMPROVEMENT IN QUALITY
ASSURANCE
QUALITY
ASSURANCE
PROFESSIONAL
Codes of conduct
Autonomy
Accountablity
Interprofessionalism
Moral issues
ECONOMIC
Demographic changes.
Resource distribution
SOCIAL/POLITICAL
Public awareness
Social expectation

13. PRINCIPLES OF QUALITY ASSURANCE
• Quality assurance is a never-ending process of creative destruction,
with rapid advances in science and technology and reduced half life of
medical knowledge continuous updating is essential.
• The emphasis is on establishing professional excellence patient
satisfaction at a reasonable cost.
• Quality is not proportionate to the use of sophisticated technology or to
be expense incurred.
• Motto of fees for service should not be pregnant with the comedy of
needless services for a fee and tragedy of no services if no fee.

14. PRINCIPLES OF QUALITY ASSURANCE
• Technical imperative should not insist on prolonging life at any lost with no
consideration to quality of life.
• Managers need to be committed to quality management and all employees must be
involved in quality improvement.
• The goal of quality management is to provide a system in which workers can function
effectively.
• The focus of quality management is on improving the system, not on assigning
blame.
• Every agency has internal and external customers and customers will define quality
of the products.

15. METHODS OF QUALITY ASSURANCE
Concurrent
Quality
Assurance
Retrospective
Quality
Assurance

16. TYPES OF QUALITY ASSURANCE

17. Process of Quality Assurance
SET
STANDARDS
APPRAISE
PLAN
ACT

18. MODELS OF QUALITY ASSURANCE AND QUALITY
MANAGEMENT
American Nurses' Association (ANA) Model:

19. MODELS OF QUALITY ASSURANCE AND QUALITY
MANAGEMENT
Donabedian Model

20. MODELS OF QUALITY ASSURANCE AND QUALITY
MANAGEMENT
• Quality Health Outcome Model

21. Joint Commission 10-Step Process:
• 1. Assign responsibilities.
• 2. Delineate scope of care/service.
• 3. Prioritize aspects of care/service. Categorize as high volume, high risk, problem
prone, or high cost of poor quality.
• 4. Identify at least two projects to address.
• 5. Flowchart the process.
• 6. Establish indicators for identified projects.
• 7. Establish thresholds for evaluation based on customer expectations
• 8. Collect and analyze data.
• 9. Evaluate effectiveness of care and document the level of improvement and
determine and implement appropriate actions.
• 10.Evaluate effectiveness of action and document the level of improvement
communicate results.

22. QUALITY EVALUATION SYSTEM IN HEALTH
CARE
The following are the examples of different
approaches to quality evaluation that are
used in different countries:
GENERAL APPROACH
SPECIFIC APPROACH

23. GENERAL APPROACH
LICENSURE
ACCREDITATION
CERTIFICATION
CREDENTIALING- It is a process of maintaining and determining nursing
standard.
It have 3 principles:

24. SPECIFIC APPROACH
•Peer review committee-
These are designed to monitor client-
specific aspects of care appropriate for
certain levels of care. The audit has been
the major tool used by peer review
committee to ascertain quality of care.

25. SPECIFIC APPROACH
The audit process-(stan hope han caster 2000)
•Follow-up of problem topic study selected.
•Recommendations for correcting deficiencies,
explicit criteria selected for quality care.
•Peer review of all cases not meeting criteria.
•Records reviewed.

26. SPECIFIC APPROACH
Utilization review-
Utilization review activities are directed towards assuring
that care is actually needed and that the cost appropriate
for the level of care provided.
Evaluation study
• Donabedian structure- process-outcome model
• Tracer method
•Sentinel method

27. Constraints in Rendering Quality Care
INADEQUATE RESOURCES
POOR MAINTENANCE
MEDICAL SUPPLY-INADEQUATE.
DELAYS
POOR WORK CULTURE
ATTITUDES OF PATIENTS AND PUBLIC.

29. STANDARD
•Standard can be defined as a benchmark of achievement,
which is based on desired level of excellence. As such standards
become model to be initiated and may serve, in turn, as basis
of comparisons.
-The Oxford Dictionary, 1964
• Nursing Standard
It is descriptive statement of desired quality against which to
evaluate nursing care.

30. PURPOSE OF STANDARD
Give direction and provide guidelines for performance of nursing staff.
Provide a base for evaluating quality of nursing care, ranging from excellent care of usage care.
Help to improve quality of nursing care increases effectiveness of care and improves efficiency.
Help to improve documentation and record of care.
Help supervisor to guide nursing staff to improve performance.
Help to improve basis for decision making and desire alternative system for delivering nursing care.

31. Characteristics of Standards
Statement must be broad enough to apply to a wide variety of setting.
Must be realistic, acceptable and attainable.
Standards of nursing care must be developed by member of nursing profession.
Should be phased in positive terms and indicated, acceptable performance that in good excellent etc.
It must express what is desirable.
It must be understandable and stated in unambiguous terms.
It is based on current knowledge on scientific practice.
It must be reviewed and revised periodically.

32. SOURCES
The standard can be established, developed, reviewed or enforced by variety
of sources as follows:
• Professional organization, e.g., TNAI
• Licensing bodies, e.g., INC, MCI and DCI etc.
• Institution/healthcare agencies, e.g., university Hospital, Health centers.
• Department of institution, e.g., Department of nursing.
• Patient care unit, e.g., Specific patient unit.
• Government unit at national, state local units.
• Individual, e.g., personal standard.

33. STANDARD FOR COMMUNITY HEALTH
NURSING PRACTICE:

34. INDIAN PUBLIC HEALTH
STANDARDS
Indian Public Health Standards are a set of
standards envisaged to improve the quality
of health care delivery in the country
under the National Rural Health Mission.

35. Need for IPHS
The health care system in India has expanded
considerably over the last few decades. However, the
quality of services is not uniform due to various
reasons like non-availability of manpower, problem
of access, acceptability, lack of community
involvement, etc.
Hence, standards are being introduced in order to
improve the quality of public health level.

36. RECOMMENDATION OF THESE
STANDARDS
A Task Group under the Director
General of Health Services was
constituted to recommend the
Standards.
The IPHS is based on its
recommendation.

37. Who will it be applicable to?
•The NRHM aims at strengthening hospital care, for rural
areas. At present these standards are being applied only
to the Community Health Centres (CHCs). As a first steps
requirements for a Minimum Functional Grade of a CHC
are being prescribed.
•Further upgradation will be proposed after these
minimum requirements have been met. Subsequently,
standards for PHC and SC shall also be developed.

38. Various recommendations under IPHS:
• Improvement in the availability of specialist services in the CHCs by
ensuring availability of all the sanctioned specialists. Additional
sanction of the post of Anaesthetist and Public Health Manager is
also envisaged.
• Strengthening support staff, by recommending a Public Health Nurse
and an ANM in all these Centres, in addition to the existing staff.
• Norms for infrastructure, equipment, laboratory, blood storage
facilities, and drugs have been formulated.
• Guidelines for management of routine and emergency cases under
National Health Programmes are being provided to all CHCs, to
maintain uniformity and optimum standardised treatment.

39. How will compliance to these
standards be ensured?

40. •Monitoring and evaluation would be both internal as
well as external.
•Training of medical as well as para medical staff.
•Charter of Patients 'Rights would be' prominently
displayed in all these centres.
•Rogi Kalyan Sanitis would be formed to improve
accountability.
•The District Health Mission would monitor the progress
for maintenance of standards at facility level.

42. INTRODUCTION
• Quality:
A judgment of what constitutes good or bad.
• Audit :
A systematic and critical examination to examine or verify.
• Nursing audit
a. It is the assessment of the quality of nursing care.
b. Uses a record as an aid in evaluating the quality of patient care.

43. DEFINITION
According to Elison
"Nursing audit refers to assessment of the quality of clinical
nursing’’.
According to Goster Walfer:
• Nursing audit is an exercise to find out whether good nursing
practices are followed.
• The audit is a means by which nurses themselves can define
standards from their point of view and describe the actual practice
of nursing

44. PURPOSE
Evaluating nursing care given
Achieves deserved quality of nursing care
Stimulates to better health.
Contribute to research
Focuses on care provides.

45. History of Nursing Audit
Nursing audit is an evaluation of
nursing service before 1995, very
little was known about the
concept.
It was introduced by the
industrial concern and the year
was the beginning of medical
audit.

46. Essential Characteristics of
Nursing Audit
Written standards of care against which to evaluate
nursing care Evidence that actual practice was
measured against such standards.
Examination and analysis of findings.
Evidence of corrective action being taken.
Evidence of effectiveness of corrective action.
Appropriate recording of the audit program.

47. CONCEPT OF NURSING
AUDIT
•A nursing audit is a thorough investigation made to
evaluate the overall nursing care received by a
patient. An audit is generally done by experienced
nurses and audit committee who do not actually
work in the ward where the audit is being carried out.
•The concept of nursing audit is based on debit and
credit system.

48. DEBIT SYSTEM
• Death of the patient which have been prevented.
• Complication of disease due to neglect of nursing care.
• Left against medical advice.
• Hospital born infection.
• Error in treatment
• Absence of total patient care
• Lack of application of nursing process.
• Nursing care learners.

49. CREDIT SYSTEM
•Number of recovered patient.
•Expansion of health knowledge in patient's
population.
•Short stay in the hospital
•Regular follow-up in the community
•Research or problem oriented care approach
•Measures for improving public image
•Good nurses record.

50. Debit system is negative in nature. Its emphases on
illness where as credit system is positive in nature and
it emphases on health.

51. Guideline for Nursing Audit
• Objective or aim: Involvement of the health care and fact-
finding mission.
• Standards: Should be set by participating clinicians.
• Control: Should be by participating clinicians and by voluntary
participation.
• Method: Should be no threatening interesting objective and
repeatable.
• Records: Should have adequate clinical materials.

52. TYPES OF AUDIT:
There are two types:
•Internal audit: It is carried out continuously by hospital
staff and which consists of process of separating and
classifying clinical records and evaluating the nursing
care given.
• External audit: An outside agency periodically tests the
completeness and accuracy of internal audit.

53. METHODS OF NURSING AUDIT
• Retrospective audit is method for
evaluating the quality of nursing care by
examining the nursing care as it is
reflected in the patient care records for
discharged patients.
Retrospectives
view:
• It includes assessing the patient at the
bedside in relation to predetermined
criteria, interviewing the staff responsible
for his care and reviewing the patient
records and care plan.
Concurrent
view:

54. AUDIT COMMITTEE
• Before carrying out an audit, on audit committee should be
found.
• Comprising of a minimum of five members, who are interested
in quality assurance, are clinically competent and able to work
together in a group.
• It is recommended that each member should review not more
than 10 patients each month and that the auditor should have
the ability to carry out an audit in about 15 minutes.
• If there are less than 50 discharges per month, then all the
records may be audited. If there are large numbers of records to
be audited, then an auditor may select 10% discharge.

55. NURSING AUDITORS
INTERNAL
AUDITORS:
• The nursing experts from
within the hospital are
deputed for internal audit
and the auditing is done
within agency or hospital.
EXTERNAL
AUDITORS
• The nursing and medical
administration from the
ministry, other agency or
professional association
like TNAI undertake the
nursing audit in desired
agency of a hospital.

56. AUDIT CYCLE
SET STANDARDS
OBSERVE
PRACTICE
COMPARE WITH
STANDARDS
IMPLEMENT
CHANGE

57. ADVANTAGES
 Can be used as a method of
measurement in all areas of
nursing.
 Scoring system is fairly simple.
 Results easily understand.
 Assess the work of all those
involved in recording care.
 May be useful tool as a part of
a quality assurance program in
areas where accurate records
of care are kept.
DISADVANTAGES
 Appraises the outcomes of the
nursing process. So, it is not
useful in areas where the nursing
process has not been
implemented.
 Many of the components overlap
making analysis difficult.
 It is time consuming.
 Requires a team of trained
auditors.
 Deals with a large amount of
information.

58. Hospital Accreditation
System of India
Indian Hospitals Association-IHA, 1993.
Bureau of Indian Standards-BIS, 1988.
 National Accreditation Board for Hospitals
and Healthcare Providers-ΝΑΒΗ.

59. CONCLUSION
In conclusion, quality assurance in community health nursing is
paramount for ensuring the delivery of effective, safe, and
patient-centered care.
Continuous monitoring, evaluation, and improvement of
processes contribute to enhanced healthcare outcomes and the
overall well-being of the community.
Adherence to standards, collaboration among healthcare
professionals, and a focus on preventive measures are integral
components of successful quality assurance in community
health nursing.

60. ANY DOUBTS

61. WHAT IS QUALITY
ASSURANCE ?
Quality assurance as the monitoring of the activities
of client care to determine the degree of excellence
attained to the implementation of the activities.

62. Promoting health.
a) Health promotion.
b) Prevention and health protection.
c) Health maintenance, restoration and palliation.
Building individual and community capacity.
Building relationships.
Facilitating access and equity.
Demonstrating professional responsibility and
accountability
WHAR ARE THE STANDARDS FOR COMMUNITY
HEALTH NURSING PRACTICE?