1. QUALITY ASSURANCE
BY : AYUSHI RANA
M.SC. NURSING STUDENT ,
HOLY FAMILY COLLEGE OF NURSING , DELHI UNIVERSITY

2. DEFINITION OF QUALITY ASSURANCE
• According to WHO (1992) quality assurance is defined as making sure that the
services provided by the hospitals are the best possible in the given existing
resources and current medical knowledge.
• According to the joint commission, quality assurance was initially defined as “the
process of objectively and systematically monitoring and evaluating the quality and
appropriateness of Patient care for resolving identified problems.

3. NEED FOR QUALITY ASSURANCE
• Improve the health status of the population
• Insure the right of people to access to quality health services
• Meet customers needs and expectations
• Minimize waste of limited resources and reduce cost
• Increase demand for effective and appropriate care
• Increased demand for efficient utilization of limited resources
• Standardise care and minimize risk
• Fulfil the ethical duty of health professionals

4. CONCEPT OF QUALITY ASSURANCE IN HEALTH CARE
• Quality assurance is a judgement concerning the process of care, based on the
context to which that cares and contributes to the valued outcome
• Quality is defined as the extent of resemblance between the purpose of health care
and truly granted care.
• A quality assurance is a dynamic process through nurses assume accountability for
quality of care they provide.
• Quality assurance is the monitoring of all activities of the client care to determine
the degree of excellence attained to the implementation of the activities
• It is the guarantee to the society that services provided by
• The nurses are being regulated by member of profession

5. FACTORS INFLUENCING QUALITY
ASSURANCE
• The various factors which influence the quality assurance programme are:
• Lack of resources: infrastructure, equipment, and supplies etc.
• Personnel problem: lack of trained, skilled and motivated employees.
• Unreasonable patients and their attendants
• Absence of well informed populace
• Absence of accreditation laws
• Lack of incident review procedures
• Lack of good hospital information systems
• Absence of conducting patient- satisfaction surveys
• Lack of proper maintenance of nursing care records
• Miscellaneous factors: lack of good supervision, policy and administrative manuals, procedure
manuals, evaluation tools and techniques, written job-description, continuing educational
programmes, etc.

6. PRINCIPLES OF QUALITY ASSURANCE
• THEFOUR PRINCIPLESOF QUALITY ASSURANCE:-
• Quality Assurance is oriented toward meeting the needs and expectations of the patient and the
community.
• Quality assurance focuses on systems and processes.
• Quality assurance uses data to analyse service delivery processes.
• Quality assurance encourages a team approach to problem solving and quality improvement.

7. APPROACHES FOR QUALITY ASSURANCE PROGRAMME
GENERALAPPRAOCHES
It involves large governing of official body’s evaluation of person’s or agency’s ability to
meet established criteria or standards at a given time
1. CREDENTIALING: A person generally defines 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 process has four
functional components
• To produce a quality product
• To confer a unique identity
• To protect provider and public
• To control the profession

8. 2. LICENSURE: individual licensure is the contract between the profession and the
state in which the profession is granted control over the entry into and exists from
the profession and over quality of professional practice, the licensing process
requires the regulation be written to define the scopes and limits of the
professional practice.
3. ACCREDITATION: national league for nursing a voluntary organisation has
established standards for inspecting nursing education programmes. In 1990 more
emphasis was placed on evaluation of the outcome of care and on the educational
qualification of the person providing care.
4. CERTIFICATION- It is a voluntary process with the professions. A person’s
educational achievements, experience and performance on examination are used
to determine the person’s qualification for functioning in the identified speciality
area.

9. SPECIFICAPPROACHES
Quality assurances are methods used to evaluate identified Instances of provider and client interaction.
• PEERREVIEWCOMMITTEE: 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.
• THE AUDITPROCESS: follow up of problem. Topic study selected. Recommendations for correcting
deficiencies, explicit criteria for selecting quality care. Peer review for all cases not meeting criteria. Records
reviewed.
• UTILISATION REVIEW: utilisation reviews activities are directed towards assuring that care is actually
needed and that the cost appropriate for the level of care provided
• EVALUATION STUDIES: three major models have been used to evaluate quality they are-:
• Donabedianstructure-process-outcome model
• The tracer model
• The sentinel model

10. DONABEDIAN MODEL
• According to model, ‘structures’ include the adequacy of health care facilities, the
qualifications of practitioner and the financial aspect of care. The “processes” were
the aspects of care. And outcomes are the precise and concrete measurements of
effectiveness of care. Donabedian breaks down the delivery of health care into three
interlinking elements:-
• Structure
• Process
• Outcome

11. THE TRACER METHOD
• It is the measure of both process and outcome care. To use the tracer method, one
should identify a volume of client with a particular characteristic resuming specific
health care management. This method has provided the nurse with data to Show
the differences in outcome as a result of nursing care standards.

12. THE SENTINEL MODEL
• It is the outcome measure for examining specific instances of client care the
characteristics of this method are :
• Cases of unnecessary disease, disability deaths are counted
• The circumstances surrounding the unnecessary events or the sentinel is examined
in details
• 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 reviewed which my have an effect on health outcome

13. THE QUALITY ASSURANCE CYCLE
• The quality assurance process is simple, logical and cyclic process for planning and
implementing quality assurance activities.
• Quality assurance is a continuous process. It is never ending improvement in the
quality of care. At the basic level quality insurance includes the following stages
(Lang1984).
• Setting standards
• Appraising actual achievement
• Planning for improvement
• Taking actions when required

15. COMPONENTS OF QUALITY ASSURANCE PROGRAMMES
JACHO’S (Joint Commission on Accreditation of Health Care Organisation) established 10 steps
for quality assurance.
THE PROCESSON QUALITYASSURANCE PROGRAME
STEP1. ASSIGN RESPONSIBILTY
• Nursing departments and services must assign overall responsibility for their monitoring and
evaluating activities
• This person overseas all aspects of nursing monitoring and evaluating, assuring that the
activities are comprehensive, effective, uniform and coordinated
STEP2. DELINIATE SCOPE OF CARE AND SERVICES
• Intended to ensure that all nursing activities and considered in monitoring and evaluation:
• Types of patient served
• Condition and diagnosis
• Types of nursing staff providing care and services
• All existing standards of patient care

16. STEP3. IDENTIFY IMPORTANT ASPECTS OF CARE AN SERVICES
• It is important for staff to remember that important aspects of care are activities of the
department that will be continually monitored and periodically evaluated to determine if
care can be improved or if problem are present
• Occur frequently or affect large number of patients
• Place patient at serious risk
STEP4. IDENTIFY INDICATOR
• Indicators are measurable variables related to the structure, process or outcome of care.
• Process- functions carried out by practitioners (assessment, treatment, planning and
medication administration)
• Outcome- includes complications, adverse effects, short and long-term results of
treatment

17. STEP5. ESTABLISHM ENT OF Threshold are expected levels of compliance with any Indicator being
measured
• Thresholds for evaluation are the level or point at which intensive evaluation is triggered
STEP6. COLLECT AND ORGANISE DATA
• Some common data can be found in:
• Patient’s record
• Medication sheets
• Infection control
• Meeting minutes
• Patient’s surveys
• Incident report
• Department logs
• Laboratory report
• Direct observation
• Formal evaluation

18. STEP7. EVALUATE CARE
• The most important purpose of monitoring and evaluation is to foster overall
continuous improvement in the level of performance.
• Evaluation must be designed to identify the opportunities for improvement by:
• Objectively examining the possible cases for the level of performance
• Recommending action pertinent to those causes to improve the performance
STEP8. TAKE ACTIONS TO SOLVE PROBLEM OR OTHERWISE IMPROVE
• Some problem action, if the problem involves deficiencies in system include
• Changing communication channel
• Changing organisational structure
• Adjusting staffing or redistributing staff
• Revising job description

19.  Reallocating resources
 Adding or revising policies and procedures
 Altering the use of equipment
 Purchasing and repairing equipment
Some possible action, if the problem involves deficiencies in staff knowledge, include:
 Modifying orientation procedure
 Providing focussed in-service education
 Providing focussed continuing education
 Circulating written policies and procedures or other informal material

20. STEP9. ASSESS THE EFFECTIVENESS OF ACTION
Staff continues to monitor the aspect of care for future opportunities for improvement, but they
must determine whether actions are taken successfully in improving care or service. If care does
not improve within the expected time, staff should re-examine the aspect of care and take further
action.
STEP10. COMMUNICATE RELEVANT INFORMATION TO THE ORGANISTAION-WIDE
QUALITY ASSURANCE PROGRAMME
It is essential that monitoring and evaluation information helps to assure that quality assurance
activities are coordinated and that knowledge regarding monitoring, evaluation and problem-
solving methods are shared.

21. MODELS OF QUALITY ASSURANCE
• A System Model for Implementation of Unit Based Quality Assurance
• American Nurses Association Model
• ANA Quality Assurance Model
• Donabedian Model
• JCAHO Quality Assurance Model

22. A SYSTEM MODEL FOR IMPLEMENTATION OF UNIT
BASED QUALITY ASSURANCE

24. SELECTING A NURSING QUALITY ASSURANCE MODEL
• Select or develop a structure that fits with the organisational structure and the cycle
management practiced in the organisation
• Decide on the format that makes the best use of resource and the manpower available
• Keep the format simple and streamlined
• Use a consistent model throughout the division of nursing
• In a skilled nursing facility, use a consistency model throughout the facility
• It is a tool for assuring and improving quality of care
• Used to monitor and evaluate the quality and appropriateness of care
• It is the ongoing process to examine care, to find potential problems and opportunities
for improvement and to do something about them.

25. FACTORS AFFECTING QUALITY ASSURANCE IN
NURSING CARE
• Lack of resources
• Personal problems
• Improper maintenance
• Absence of well-formed population
• Unreasonable patient and attendants
• Absence of accreditation laws
• Lack of good hospital system
• Absence of patient satisfaction surveys
• Lack of nursing care records
• Miscellaneous factors

26. IMPROTANCE OF QUALITY ASSURANCE IN
COMMUNITY HEALTH NURSING
•Faced with limited resources available and escalating cost of care, health
care agencies must be to identify services and programs the best serve
needs of the community. The methods of quality assurance enhance the
quality of care delivered by the home care organisations. When the various
nursing intervention with in a group are proven to be highly satisfactory
and cost efficient, these are interventions should be consequently chosen
over those that fails such test. There are many areas in community health
in which the current system of services does not meet the need of large
segments of the population.

27. ROLE OF NURSE IN QUALITY ASSURANCE
IN COMMUNITY
• Although nurse who deliver care directly to client are not managers as such improving or
assuring quality is largely a management activity. Community health nurse may not be
responsible for a staff or agency budget and functioning, they are responsible for
managing a caseload of client with needs of varying degree of agency.
• Using the resources available, they must provide priority services that will promote the
highest level possible and group functioning and health.
• Role of nursing administration is to develop a formalised quality management program
that includes a three focus-:
• Review organisational structure, personnel and environment
• Focus on standard of nursing care, method of delivering Nursing care and
• Focus on the outcome of that care

28. RESEARCH REFERENCES
1. Quality Assurance In Nursing Education: An Absolute Necessity By Mgbekem,
M.A. And Samson-Akpan, Department Of Nursing Science. University of
Nigeria
• Quality assurance is now a major consideration for providers of goods and
services in the society especially in-service industries of higher education and
health services. This study looked at quality assurance in nursing education and
how this important process cab be evaluated in a three-dimensional focus viz:
structure evaluation, process evaluation, and outcome evaluation. The research
seeks to show how quality assurance can provide holistic health care service in
this technologically advanced age of the 21th century.

29. •Conclusion- from the fore going, it can be clearly seen that professional
education can be greatly enhanced by quality assurance. Both nursing
education and practice are practically oriented. When the quality
assurance model was implemented, the quality of product from the
nursing education is sure to improve and their ability as care givers
greatly enhanced. There can be no improvement in nursing efficiency
without adequate information about the structure; process and outcome
of quality nursing service rendered to the health needs of the 21th century
society.

30. 2. Development of an instructional quality assurance model in nursing science
• Result- the result instructional quality in nursing science programme is in high level
(level 4 and 5 according to rating scale) generally all standards are in good level.
• Evaluation of quality assurance model for public health nursing
3. Project was conducted for one-year period. The project was based on ANA model for
quality assurance and assessed standards for an overall quality assurance programme.
• Result- the outcome criteria standards are being met in high percentage of instances in
the 60-70 percentiles. This was considered outstanding. Patient satisfaction surveys
revealed high Satisfaction with public health services in the 90-95 percentiles.
• Peer review and utilisation review standards also showed a very high positive percentile
ranking.