nursing

1. GUIDED BY, PRESENDED BY,
Dr.Nalini J.Lissa
Principal II yrs Msc Nsg,
S H N C S H N C
Madurai Madurai

2. INTRODUCTION:
The term quality assurance comes from
industry. Quality assurance in nursing is a
process of establishing a target degree of
excellence (standard) for nursing intervention
and then taking step to ensure that each
client receive the agreed upon level of care

3. Quality:
 A product / service have a good quality if it is
meeting the standards that have been set before
the evaluation took place (Vanmaren 1979)
 Quality refers to characteristics of persist and
excellence.
Quality Care:
 According to Institute of Medicino’s definition is
“The degree to which health services for individual
and populations increase the like hood of desired
health outcomes and are consistent with current
professional knowledge.

4. Quality Assurance (QA):
 A System for evaluating performance, as in the
delivery of services or the quality of products
provided to consumers, customers or patient.
 The degree to which patient care service increase
the probability of desired patient outcomes and
reduce the probability of and desired outcomes,
give the current state knowledge.

5. There are many reasons, the incentives for quality assurance in
health care
Professional Factors Economic Factor
Social /
Political factors
- Codes of conduct - Demographic change - Public
awareness
 - Growth of autonomy - Resource distribution - Social
expectations
 - Accountability
- Legislation
 - Inter professionalism - International
pressure
 - Moral issues

6. HISTORY OF QUALITY ASSURANCE
The need for quality consideration was highlighted
during WORLD WAR I
From 1850 on words there had been a significant change
in the scale and diversity of industry. Mass production
evolved, this was moved to individual skilled to team un
skilled work and no one person had control or
responsibility over the end product .this led to the
development of inspection techniques .
Change of quality focus from inspection to the more
efficient and cost effective approach of structuring and
managing a system for product quality took decades.
During 1930s and 1940s some companies developed and
used statistical technique to monitor the quality of
produced goods.
Throughout the 1950s and 1960s British manufacturer is
general saw said no reason to change either their product
,which were geared to quantity not a quality, or the
management philosophy.

7. In 1970 the manufacturer recognized that need to
change .costumer becoming increasingly interested in
quality .
1970s and 1980s in order to contain cost and compete
with import . statistical technique were developed.
Slowly technique such as statistical process control
,quality circle ,quality assurance system and philosophy
such as statistical process control,and total quality
management were implemented .

8. Goals of Quality Assurance:
 To identify areas where standards have not been
met and correct them
 To ensure the delivery of quality care
 To evaluate the efforts of the health care provider
to provide best possible result

9. Quality Assurance Process:
 Setting Standard
 Establishing criteria of achievement
 Determining of criteria have been met
 Implementing action plan for improvement
 Re evaluating standards

10. Structure process outcome
Assessment of
resoures
Assessment of
content
Assess
Process
Assess out
come

11. Elements that Contribute towards QA:
 Commitment from top level management
 Commitment from all personal of the
organizational institution
 Setting clear responsibility for quality activities.
 Willingness to change
 Accurate documentation
 Effective communication at all levels.
 On going training programme in quality.

12. Access to healthcare
Acceptability
Appropriateness and relevance to need
Effectiveness
Efficiency
Equity

13. NEED FOR QA IN HEALTH CARE
It is a important managerial function which assure
confidence among customer.
Involves evaluation in order to serve improvement
and development on continuous basis
It is needed to indicate standard of agency

14. PRINCIPLES OF QA:
 Customer focused
 Use of quality tools and statistic
 Involve all people in quality improvement (team
approach)
 Every agency has internal and external customers
focus on fact
 Identify key process to increase quality.

15. Approaches
General approach
Specific approach
General approach: - It involves large governing or official bodies
evaluating a person or agencies‘ ability to meet established
criteria or standard during a given time.
a) Credentialing- It is the formal recognition of professional or
technical competence and attainment of minimum standards by a
person and agency. Credentialing process has 4 functional
components
To produce a quality product
To confirm a unique identity
To protect the provider and public
To control the profession

16. b) Licensure- It is a contract between the profession and the state in
which the profession is granted control over entry into an exit from the
profession and over quality of professional practice.
c) Accreditation- It is a process in which certification of competency,
authority, or credibility is presented to an organization with necessary
standards.
d) Certification
e) Charter- It is a mechanism by which a state government agency under
state law grants corporate state to institutions with or without right to
award degrees.
f) Recognition- It is defined as a process whereby one agency accepts the
credentialing states of and the credential confined by another.
g) Academic degree

17. a) Audit- It is an independent review conducted to compare some
aspect of quality performance, with a standard for that performance.
b) Direct observation- Structured or unstructured based on presence
of set criteria.
c) Appropriateness evaluation- The extent to which the managed care
organization provides timely, necessary care at right levels of
service.
d) Peer review- Comparison of individual provider‘s practice either
with practice by the provider‘s peer or with an acceptable standard
of care.
e) Bench marking- A process used in performance improvement to
compare oneself with best practice.
f) Supervisory evaluation

18. g) Self-evaluation
h) Client satisfaction
i) Control committees
j) Services- Evaluates care delivered by an institution rather than by
an individual provider.
k) Trajectory- It begins with the cohort of a person who shares
distinguishing characteristics and then follows the group going
through the healthcare system noting what outcomes are
achieved by the end of a particular period
l) Staging- It is the measurement of adverse outcomes and the
investigation of its antecedence.
m) Sentinel- It involves maintaining of factors that may result in
disease, disability or complications such as;
Review of accident reports
Risk management
Utilization review

19. TOOLS FOR QUALITY ASSURANCE
Setting standard for organization
Staff development
Personal orientation
Physical standard
Cost standard
Capital standard
Revenue standard
Program standard
Tangible standard
Goal standard
Strategy standard

20. Strategies for Quality Assurance
Setting Standards
Planning for
improvement
Appraising actual
achivement

21. What is JCAHO?
The Joint Commission on Accreditation Of Health Care Organization set
a standard for health care organization and issue accreditation to
organization that meet those standards.
History of health care quality review
As early as 1916 Dr.E.A.Codman expressed the need of review the
medical practice of that time . He is know for a spearhead of peer
review at general hospital with systemic audit of medical record .
The American college surgeon was formed in 1918 and required
peer review of physician ,as well as hospital department .
1951 the Joint Commission for the Accreditations of hospital (JCAH)
took over the responsibility
The Medicare regulation were initiated in 1965 with JCAH
1980 change gave force to addressing Q A in hospital
The JCAH changed direction in1984
Dr.Denne`s took the responsibility for standard revision and update
to meet the health care delivery .
In 1986 name of the agency changed to JCAHO

22. Quality Assurance and JCAHO problem Areas:
Complaints from clients and families
Reports of conflicts among professional staff members.
Unplanned returns to the operating room.
Unplanned transfers to other hospitals.
Unplanned admission to the critical care units
Mishandling the emergency situation eg. CPR
Problematic situation in house emergency
Clients leaving against medical advice
Cancelled surgeries, repeated X-rays and lab test.
Injuries accidents or incidence

23. JCAHO’S 10 STEPS OF QA:
1. Clear assignment of responsibility
2. Declination of the scope of care for each practioner.
3. An identification of the important aspects of care
4. Specific indicators of care
5. Establishment of thresholds for evaluation.
6. Collect and organize data to monitor important aspect
of care.
7. Evaluation of care
8. Actions takes to solve problem and improve the care.
9. Assessment of those actions and documenting the
improvement.
10. Communication of relevant information to the
organization

24. 1.ASSIGN RESPONSIBILITY
The governing body has a ultimate responsibility of patient / client care
.
According to JCAHO model’ the organizational leader should include
leader of the governing body ,medical staff ,managerial staff, nurse
executive .
2. Delineate of the scope of care for each practioner.
The scope of care is delineate using one of two method
Method of identifying activities
Identifying key function
Using Method of identifying activities method
Who
What
When
Where relates the care provided determine the scope of
care

25. The following should be included
Type of patient served
Service
Treatment and activities performed
Type of practioner providing care
Sites of service
Time of service delivery
This provides a comprehensive inventory of facility
The second method is the organization key
Governance
Managerial
Clinical
Support function
The process involve all the department
JCAHO will stress using this method in future

26. 3 .Identify important aspect of care
Aspect of care are determined by the degree of importance.
Because of limited resource , the review must focus on area that have
greatest impact on patient care. According to JCAHO model ,priority
of review should be assigned to aspect of care in which one or more
of the following true ;
High volume
High risk
Problem prone
4 .identify the indicator
For each important aspect of care ,at least one indicator should be
identified. An indicator is a quantitative measure that can be used as
guide to monitor and evaluate the patient care .
The indicator should be
well defined
comprehensive
Relevant
Efficient and
Clinically valid
Structure process outcome

27. 5. Establishment of thresholds for evaluation
Establishment of thresholds for evaluation or an acceptability level.
The threshold for evaluation is predetermined level or point in
cumulative data analysis that triggers the need for further
evaluation.
6 .collect and organize the data
This step is by far the most time consuming for nurse ,
Identified indicator
Data source method
Sampling technique
Frequency of collection
Responsibility of collection and organization data identified
7.Evaluate the care
Interpretation of data is the key to developing an effectives action plan
.
The data is evaluated for pattern or trends as it relate to problem or
opportunities to improve care .
The evaluation can be performed by individual in peer review setting or
by a team .

28. Many tools can be used to help the team understanding cause of
indicator result
Flow chart
Cause and effect chart
Run chart
Histogram
Control chart
Scatter diagram
8.Action improve care
The action plan is initiated if a problem or opportunity's to improve the
care was identified during the evaluation process . An underlying
philosophy to effect change is to approach the areas of concern in
positive , punitive way .
The written plan must
1. identify who or what is expected to change
2. who is responsible for implementing action
3. when the change is expected occur

29. 9.Assess actions and document improvement
The only way to assess the effectiveness of an action plan is to
continue to monitor and evaluate the result by using the original
indicator and data collection tools .
ongoing monitoring should continue until improvement has
been for a substantial time.
10. Communicate Information
Documenting and communicating findings to nursing staff and other
team

30. Dimension of Quality Performance:
Efficiency
Appropriateness
Caring
Respect
Efficiency
Safety
Continuity
Effectiveness
Timeliness
Availability

31. VARIOUS ASPECTS OF QUALITY
Quality Circle
TQM
implementation
Quality control Quality assurance
Total Quality
control
TQM

32. Quality control cycle
PLAN
DO
ACT
CHECK
Take the
Appropriate
action
Determine
Goal and
target
Determine method
Of reaching the
goal
Engage in
Education and
training
Implement
work
Check the
Effect of
implementation

33. Factors hindering QA
Avoiding responsibility
Few nurses feel every thing is all right
People are egoistic self before the organization
Some people do not seek help and reply on their
own shallow experiences
Have no ears others opinions
Despair ,jealousy

34. Dimension of Quality Performance:
Efficiency
Appropriateness
Caring
Respect
Efficiency
Safety
Continuity
Effectiveness
Timeliness
Availability

35. COMPONENTS OF QUALITY ASSURANCE:
Professional regulation
Competent practice
Socio-economic Welfare of the health care
workers.
UALITY ASSURANCE PROGRAMME:
 According to Dr. Rurles and Frank, it is a
systematic process for closing the gap between
actual performance and desirable outcome.

36. QUALITY ASSURANCE PROGRAMME IN NURSING:
Set of criteria for a specific patient population
presenting specific problems.
Set of criteria for nursing performance
Set of criteria for utilization of resources
Set of criteria indicating acceptable

37. QUALITY ASSURANCE METHODOLOGY:
Credentialing
Licensure
Accreditation
Standard
Clinical rounds
Quality circle

38. Quality Assurance Cycle:
Nsg
development
Suspected problem
area
Hospital QA
Nsg
committees
Standard of
Care
1
Recommendation
For
Change 5
Documented
Problem
4
Measurement
Of
Criteria
2
Assessment
3
Quality care
wheel

39. FACTORS AFFECTING QUALITY ASSURANCE IN NURSING
CARE:
Lack of resources
Lack of qualified nursing personnel
Unreasonable patient and relatives
Improper maintenance
Absence of well informed public
Absence of accreditation laws
Enquiring of negligence
Inspecting hospitals ensuring basic needs are met
Taking action against health profession involved in
malpractice.
Legal Problem
Laws less applicable for the nursing profession lack of
incidental review procedures.
Barrier assisting out of faculty procedure
Delayed attendance by physician, surgeon, nurses
Death in corridors with no physician / nurses
accompanying the patient

40. Lack of good hospital information system about
workload, statistic, admission, bed, occupancy,
procedure, length of stay, activity, audit,
scheduling of procedure, cost list / procedure in
critical area.
Absence of conducting patient satisfaction
surveys
Lack of nursing care records
Miscellaneous factors
◦ Lacks of good supervision
◦ Substandard education and training
◦ Lack of policy and administrated manuals.

41. DEFINITION OF QUALITY IMPROVEMENT:
 Quality improvement (QI) is known as continuous
quality improvement (CQI), total quality management
(TQM), performance quality improvement (PQI).
 According to Schroeder, QI is “The commitment and
approach used to continuously improve every process in
every part of an organization, with the intent of meeting
and exceeding customer expectation and outcomes.
APPROACHES TO QUALITY IMPROVEMENT:
Structural elements
Process elements
Outcome elements

42. PRINCIPLES OF QUALITY IMPROVEMENT:
All health care professionals should collaborate in projects
to measure and improve care.
In planning a comprehensive quality improvement
program for a health agency, the activities of various
health professional must be coordinated to ensure that
efforts of diverse care givers enhance those of others.
Managers should undertake cost benefit studies to ensure
that resource expenditure for quality assurance activities
in appropriate in amount.
To ensure that resources invested in improvement efforts
yield significant results, nurse should monitor

43. The key to improving patient care quality is accurate evaluation of
care and evaluation of care is a adequate documentation of care.
The ability to achieve nursing objective depends on the optimal
functioning of every step in the nursing process and effective
monitoring of nursing system is based on feed back.
Evaluation of care alone will not improve nursing practice.
Continuous feedback of nursing outcomes needed to perpetuate
good practice and replace unsatisfactory interventions with more
effective methods.
After nursing care quality is assessed and needed improvements
are identified, peer pressure can provide the impetus needed to
effect the prescribed practice changes.

44. reorganization of care at unit level may require changes in formal
organization structure.
For quality improvement efforts to be effective, the collection and
analysis of quality assessment data must be performed by a nurse
who has decision If assessment reveals the need for a different
pattern of care delivery, making authority. Data related to structural
inadequate outcomes are without value unless they are used by a
change agent to motivate remedial action.
QUALITY IMPROVEMENT ACTIVITIES:
Patient care concurrent process audit
Professional standards setting
Peer review
Continuous monitoring of critical clinical indicator
Quality circles
Patient care retrospective chart audit.

45. IMPROVEMENT (CONCEPT OF QI):
They are focus on
Organizational mission
Continuous improvement
Customer orientation
Leadership commitment
Empowerment
Collaboration / crossing boundaries
Focus on processes
Focus on data and statistical thinking.

46. Quality Assurance
•Externally driven
•Follows organizational
structure
•Delegated to a few
•Focuses on individuals
Works toward end points
•“Assures” quality
•Divided analysis of
effectiveness and efficiency
cost and quality.
Quality Improvement
•Internally driver
•Follows patient care
•Embraced by all
•Focus on process
•Has no end points
•“Improves” quality
•Integrated analysis

47. INC IN QUALITY ASSURANCE:
Strengthen involvement of nurses in health and nursing
policy formulations and planning
Empower nurse leaders
Establish quality assurance system for the nursing service.
Ensure nursing workforce management as an integrated
part of human, resource planning and health system
development.
Enhance nursing autonomy in practice.
Enforce implementation of recommended norms on nurse
to practice.
Create posts for professional nurses at the unity level and
strengthen the competency of the auxiliary nursing
midwife.

48. Produce advanced practice nurses.
Ensure appropriate facilitating and adequate medical
equipment and supplies.
Promote nursing research and evidence based practice.
Establishing a contuning nursing education system
Strengthen payment scales incentive system and working
conditions.
Ensure quality of nursing education by strengthening
nursing programme, increasing qualified nurse educations
and allocating appropriate resources to maximize
efficiency and effectiveness.
Expand the role and authority of the INC on nursing
development by revision of the act, restricting and
networking

49. Barriers of Quality Assurance:
High cost
Resistance to change
Authoritative leadership do not value innovators
Lack of awareness about change
Lack of evidenced based practice.
Role of Nurses in Quality Assurance:
Consumer centered service
Provide quality care with desired outcome
Function as leaders and managers to provide quality care
Evidenced based practice.
Responsible to promote standard measurement and
involve in continuous quality improvement.
Focuses on fact
Care consistent with current professional knowledge.

50. Role of Nurse Administrator in Implementing Quality
Assurance:
Initiator
Facilitator
Coordinator
Educator
Leader
Communication
Evaluator
Supervisor
Issues in Quality Assurance in Nursing:
Mushrooming of nursing colleges without essential
infrastructure e.g. ANM, diploma, graduate.
Numerous categories of the nurses
Improper job description of the nurse.
Lack of adequate nurse administrator
Shortage of trained nurses.
Lack of supplies and equipment in hospital.

51. The Quality Assurance Activities in a Hospital are
 Client care audits
 Peer review
 Client’s satisfaction studies / client’s opinion
studies.
 Control committees
 Review of accident report.
FACTORS AFFECTING Q.A. IN NURSING CARE:
ACHIEVING QUALITY CARE:
CLIENT;
 Families and friends
 Individual
 Community health care units
 Pressure group
 Media

52. PROFESSIONAL:
 International health care organization
 Other health care professionals
 Colleagues
 Specialist interact group
 Professional bodies
 Educationalist
 Individual quality
MANAGEMENT:
 Trade unions
 Family health services committee
 Government
 Manager
 District regional health authorities
OTHERS:
 Administrative and clinical staff
 Building and state staff
 Supplies of technical goods
 Axcillary staff

53. QUALITY ASSURANCE IN HEALTH CARE:
PROFESSIONAL FACTORS:
Codes of conduct
Growth of autonomy
Accountability
Inter professionalism
More issues
ECONOMICAL FACTORS:
Demographic change
Resource
Distribution
SOCIAL AND POLITICAL FACTORS:
Public awareness
Social expectation
Legislation
Accreditation
An international pressure

54. MODELS OF QUALITY ASSURANCE
I. JCAHO TEN STEP MODEL
II. A SYSTEM MODEL
The basic component of the system are
Input
Throughput
Output
Feedback
Input throughput output
feedback

55. III. AMERICAN NURSES ASSOCIATION MODEL:
Identify the
value
Take
action
Identify posible
Course of
action
Identify standard
value
Secure
measurement
Make
interpretation
ANA
Model
1975

56. IV. DONABEDIANS MODEL:
Structure standards
Process standards
Outcome standards
Structure process outcome
Fescility,resoure
personal., skill,
philosophy
Student attitude’
Nursing care plan,
Client satisfaction
Client health care
Goal, & efficiency
Of service