QUALITY ASSURANCE IN NURSING

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.

DEFINITION OF QUALITY :-
It is degree to which health services for individuals & population increase the likelihood of
desired health outcomes & are consistent with current professional knowledge.

-Joint Commission on Accreditition of health care organization ,2002 (JCAHO)

ASSURANCE
It is statement or indication that inspires confidence.

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

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

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.

• 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.

• 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

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.

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.

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.
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.

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.

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.

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.

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

• Allocate resources for quality assurance

• Develop a written quality Assurance plan

• Critical Management System

• Disseminate Quality Assurance Experience

• Manage Change
APPROACHES FOR QUALITY ASSURANCE PROGRAM
Approaches of quality assurance are divided into 2 types:

A) General Approach

B) Specific Approach

A) 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 - It is process of determining & maintaining nursing standards.

Functional Components Of Credentialing Process

According to Hinsvark, credentialing process has 4 functional components:-

a) To produce a quality product.

b) To confer a unique identity.

c) To protect provider & public.

d) To control the profession

2. 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.

3. ACCREDITATION - Accreditation is the act of granting credit or recognition especially to an

educational institution that maintains suitable standards.

4. 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.
B) SPECIFIC APPROACHES

Quality assurances are methods used to evaluate identified instances of provider and client
interaction

1. 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.

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

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.

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.

• 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.

3. UTILIZATION REVIEW

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

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.

4. EVALUATION STUDIES

Donabedian’s Structure-Process-Outcome model

Donabedian introduced 3 major method of evaluating quality care:-

1. 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.

2. 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 etc.

3. 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.
 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.

Basic Components of System Models

• 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.

ANA Quality Assurance Model

Reevaluation identity values

Take action identity standards and criteria

Choose action secure measurement

Identity course of action make measurement

PDCA CYCLE

PLAN

ACT
PDCA DO
CYCLE
CHECK
FACTORS AFFECTING QUALITY ASSURANCE IN NURSING CARE
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)

PRINCIPLES

• It requires continuous quality improvement.

• Knowledge of customer expectation needs.

• Processes of customer supplier relationship.

• Belief in people.

• Statistical analysis.

• Costs of poor quality.

CONDITIONS IN WORK ENVIRONMENT

• Employer’s involvement.

• Improvement.

• An environment that support taking risk.

• Team work.

• Data collection & analysis skills.

• Group interaction skills.

• Structure & management to enable improvement.

• Tools to facilitate improvement.

COMPONENTS OF QUALITY IMPROVEMENT PROGRAMS

• Establish responsibility & accountability.

• Define scope of service for clinical area.

• Define key aspects of service for clinical area

• Develop quality indicators to monitor outcomes & appropriateness of care delivered.

• Establish threshold for evaluation of indicators.

• Collect & analyze data from monitoring activity.

• Evaluate results of monitoring activities to determine the need for change in practice.

• Resolve problems through development of action plans.

• Reevaluate to determine if plan was successful.

• Communicate quality improvement results to organization.

TOTAL QUALITY MANAGEMENT

• It focuses the production and service, i.e.: the environment must be customer responsive.

• It identifies and do the right things, the right way, the first time and the prevent problems.

• In this, customer needs and experiences with the end product are constantly evaluated .

STANDARDS

Standard is an established rule as basis of comparison in measuring or finding capacity, quality

context & value of objects in same category.
Classification of nursing care standards

1) Structure standards

• It involves setup of institution.

• The philosophy, goals & objectives, structure of organization, facilities, equipment,

qualification of employees are some of components of structure of organization.

2) Process standard

• It describes behavior of nurse at desired level of performance.

• It involves activities concerned with delivering patient care.

3) Outcome standard

• An outcome standard measures changes in patient health status.

• This change may be due to nursing care, medical care or as a result of variety of services
offered to patient.

ROLE OF A NURSE
• Role of nurse is to participate in quality improvement team.

• Properly supervises & check whether patient is receiving proper care or not.

• Contribute innovation & improvement of patient care.

• Participating in improvement projects &patient safety initiatives.

• Participating in CNE programs & in-service education programs.

• Periodic & continuing appraisal & evaluation of health care situation of patient.

• Participate in research works related to quality assurance.

• Nurse identifies area where need improvement in delivery of care

RELATED RESEARCH
1) Development of an instructional quality assurance model in nursing science

• Result- The result of instructional quality in nursing science program is in high level (level 4 &
5 according to rating scale). Generally all standards are in good level.

2) Evaluation of quality assurance model for Public Health Nursing.

• Project was conducted for one year period. The project was based on ANA Model for Quality
Assurance & assessed standard for an overall Quality Assurance Program.

• Purpose of the study- To analyze baseline outcome criteria for a Quality Assurance Program
and to implement and interface evaluation methodologies on Public Health Nursing (PHN)
services within the IHS to:

1) Identify the amount and kind of quality services provided and the
strengths and barriers.

2) Provide recommendations for improvement in the quality of service.

3) Provide an action plan for implementing changes to improve the quality

of PHN care to recipients.

• STUDY FINDINGS - Outcome criteria standards are being met in a high percentage of
instances - in the 60 to 70 percentiles.

• This was considered outstanding.

• Patient Satisfaction Surveys indicated extremely high satisfaction with public health nursing
services - in the 95 to 99 percentiles.

• Peer Review and Utilization Review standards also showed a very high positive percentile
ranking.
 THEORY APPLICATION
• FLORENCE NIGHTINGALE ENVIRONMENT THEORY

Florence Nightingale was the first person to describe about standards of nursing (1859) in
“Notes of nursing, what it is & what it is not”. In this, she wrote about change to achieve high
standards.

NURSE

CLIENT
N N
N
NNNNNNNNNNNNNNNN
ENVIRONMENT
N
CE
CC
MODEL APPLICATION STRUCTURE PROCESS OUTCOME

• SYSTEM- Diarrhoea control program

• STRUCTURE

• Trained community workers.

• ORS packets.

• Accessible health centres.

• PROCESS

• Education to mothers.

• Re hydration therapy.

• Diagnostic studies.

• OUTCOME

• Number of children treated.

• No. of complications arose.

• No. of deaths due to diarrhoea.

 SUMMARY
Quality assurance is the monitoring of the activities of client care to determine the degree of
excellence attained to the implementation of the activities. There are general and specific
approach to assure quality. ANA quality assurance model and systematic models are the models
of quality assurance. In this assignment I discussed about the introduction, definition,
objectives, purposes, approaches, factors affecting quality assurance, model,total quality
management and role of nurse.

CONCLUSION
Quality assurance is monitoring the activities of client care to determine the degree of
excellence attained to the implementation of the activities and it is very essential to optional
quality health care.
 BIBLIOGRAPHY
 Basher shebeer.p, khan S.yaseen. A concise textbook of advanced nursing practice. 1st ed.
Banglore: Emmess medical publishers; p.50-55.

 Soni Samta. Textbook of advance nursing practice.1st ed. New delhi:

Jaypee brothers medical publishers; p.14-22.