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.
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
dependent 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 be 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:
1. General Approach
2. Specific Approach
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:-
1. To produce a quality product.
2. To confer a unique identity.
3. To protect provider & public.
4. 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.
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
Sentinal method
Tracer method
Measure both process and outcome of care.  Provides nurses with data to show the differences
in outcomes as a result of nursing care standards.
It is an outcome measure for examining specific instances of client care . Eg. cases of disability,
deaths, morbidity mortality etc.
It can be assessed using person or telephone interviews and mailed questionnaire.
The critical incidents may be delayed attendance, incorrect medications, lack of cleanliness, lack
of asespsis leading to infection, carelessness in carrying out nursing procedures.
Donabedian introduced 3 major method of evaluating quality care:-
1. Structural evaluation: This method evaluates setting & instruments used to provide care such
as facilities, equipment & 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
1) Identify values
2) Identify structure, process and outcome standards and criteria
3) Select measurement
4) Make interpretation
5) Identify course of action
6) Choose action
7) Take action
8) Reevaluate
Plan, Do, Study, Act cycle
FACTORS AFFECTING QUALITY ASSURANCE IN NURSING PRACTICE
• Lack of resources
• Personnel problem
• Improper maintenance
• Unreasonable patients and attendants
• Absence of well-informed population
• Absence of accreditation laws
• Lack of incident review procedure 19
• Lack of good hospital information system
• Absence of patient Satisfaction Surveys
• Lack of nursing care research
BARRIERS OF QUALITY IMPROVEMENT EFFORTS
• The Nurse Manager might become pre occupied with quality assessment
• It is impossible to identify all factors that influence nursing care quality.
• Difficulty in defining outcome criteria that result solely from nursing intervention
• Nurse’s documentation of care measures is at times vague, incomplete and lacking in
objectivity
• There is still no single, all purpose, all site quality assessment tool that is universally
appropriate for all health agencies.
• High cost
ROLE OF NURSES IN QUALITY ASSURANCE
• Nurses are the active participant of interdisciplinary quality improvement team
• Develop mechanism for continually monitoring the effectiveness of nursing care both a
collaborative and an individual professional activity.
• Contribute innovations and improvement of patient care • Participating in improvement
projects and patient safety initiatives
• Participate continuing educational programs and in- service educational programs for
continuing professional development
• Periodic and continuing appraisal and evaluation of health care situation of the patient
• Participate research works related to quality assurance
• Identify any area of needed improvement in delivery of care.
CONCLUSION
Quality is defined as the degree to which health services for the individuals and populations
increase the likelihood of the desired health outcomes and are consistent with current
professional knowledge. Quality Assurance is an on-going, systematic comprehensive evaluation
of health care services and the impact of those services on health care services
BIBLIOGRAPHY
• B T Basavanthappa. Textbook of nursing administration.1st edition. Jaype brothers
medical publishers. Newdelhi
• Jogeendra vati. Textbook of nursing management.1st edition. Jaype brothers medical
publishers. Newdelhi