Total Quality Management in

Nursing Care
What is TQM?
TQM is a set of management practices
throughout the organization, geared to ensure
the organization consistently meets or exceeds
customer requirements. TQM places strong focus
on process measurement and controls as means
of continuous improvement.
Total Quality Management (TQM) is an approach
that organizations use to improve their internal
processes and increase customer satisfaction.
 History of TQM
Lang (1976)
This framework has subsequently been adopted and developed by
the ANA. The stages includes;
Identify and agree values
Review literature, Known QAP
Analyze available programmes
Determine most appropriate QAP
Establish structure, plans, outcome criteria and standards
Ratify standards and criteria
Evaluate current levels of nursing practice against ratified
structures
Identify and analyze factors contributing to results
Select appropriate actions to maintain or improve care
Implement selected actions
Evaluate QAO
 Maxwell (1984)
Maxwell recognized that, in a society where
resources are limited, self assessment by health
care professionals is not satisfactory in
demonstrating the efficiency or effectiveness of
a service. The dimensions of quality he
proposed are:
Access to service
Relevance to need
Effectiveness
Equity
Social acceptance
Efficiency and economy
 Wilson (1987)
Wilson considers there to be four essential
components to a QA programme. These are:
Setting objectives
Quality promotion
Activity monitoring
Performance assessment
 Quality refers to excellence of a product or a
service, including its attractiveness, lack of
defects, reliability, and long-term durability.
Quality assurance provides the mechanisms to
effectively monitor patient care provided by
health care professionals using cost-effective
resources.
Quality assurance system motivates nurses to
strive for excellence in delivering quality care
and to be more open and flexible in
experimenting with innovative ways to change
outmoded systems.
 APPROACHES FOR A QUALITY
ASSURANCE PROGRAMME
Two major categories of approaches exist in
quality assurance they are
General
Specific
General Approach
It involves large governing of official bodys evaluation
of a persons or agencys ability to meet established
criteria or standards at a given time.
1) Credentialing
formal recognition of professional or technical
competence and attainment of minimum standards by
a person or agency
Credentialing process has four functional components
a) To produce a quality product
b) To confer a unique identity
c) To protect provider and public
d) To control the profession.
2) Licensure
Individual licensure is a contract between the profession and the state, in
which the profession is granted control over entry into and exists from the
profession and over quality of professional practice.
The licensing process requires that regulations be written to define the
scopes and limits of the professionals practice.
Licensure of nurses has been mandated throughout the world by laws and
regulations..
3) Accreditation
ISO
JCI
NABH
Accreditation Canada
NAAC
4) Certification
Certification is usually a voluntary process with in the profession.
A persons educational achievements, experience and performance on
examination are used to determine the persons qualifications for
functioning in an identified specialty area.
B. Specific approaches
1) Peer review
Peer review is divided in to two types.
The recipients of health services by means of auditing the quality of
services rendered.
The health professional evaluating the quality of individual
performance.
2) Standard as a device for quality assurance
Standard is a pre-determined baseline condition or level of
excellence that comprises a model to be followed and practiced.
The ANA standard for practice include:
Standard 1: The collection of data about health status of the
patient is systematic and continuous. The data are accessible,
communicative, and recorded.
Standard 2: Nursing diagnosis are derived from health status data.
Standard 3: The plan of nursing care includes goals derived from
the nursing diagnoses.
 Standard 4: The plan of nursing care includes priorities
and the prescribed nursing approaches or measures to
achieve the goals derived from the nursing diagnoses.
Standard 5: Nursing actions provide for patient
participation in health promotion, maintenance, and
restoration.
Standard 6: Nursing actions assist the patient to
maximize his health capabilities.
Standard 7: The patients progress or lack of progress
towards goal achievement is determined by the patient
and the nurse.
Standard 8: The patients progress or lack of progress
towards goal achievement directs re-assessment, re-
ordering of priorities, new goal setting, and a revision
of the plan of nursing care.
3) Audit as a tool for quality assurance
Nursing audit may be defined as a detailed
review and evaluation of selected clinical
records in order to evaluate the quality of
nursing care and performance by comparing it
with accepted standards.
MODELS OF QUALITY ASSURANCE
1. System Model
Tasks are broken down into manageable components based
on defined objectives.
The basic components of the system are
1. Input
2. Throughput
3. Output
4. Feedback
The input can be compared to the present state of systems,
the throughput to the developmental process and output
to the finished product. The feedback is the essential
component of the system because it maintains and
nourishes the growth.
ANA Quality Assurance Model
The basic components of the ANA model are:
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
1) Identify Value
In the ANA value identification looks as such
issue as patient/client, philosophy, needs and
rights from an economic, social, psychology
and spiritual perspective and values,
philosophy of the health care organization and
the providers of nursing services.
2) Identify structure, process and outcome
standards and criteria:
Identification of standards and criteria for
quality assurance begins with writing of
philosophy and objective of organization.
Evaluation of the standards of structure is
done by a group internal or external to the
agency.
The evaluation of process standards is a more
specific appraisal of the quality of care being
given by agency care providers.
3) Select measurement needed to determine
degree of attainment of criteria and
standards
Measurements are those tools used to gather
information or data, determined by the
selections of standards and criteria.
The approaches and techniques used to
evaluate structural standards and criteria are,
nursing audit, utilizations reviews, review of
agency documents, self studies and review of
physicals facilities.
4) Make interpretations
The degree to which the predetermined criteria
are met is the basis for interpretation about the
strengths and weaknesses of the program.
The rate of compliance is compared against the
expected level of criteria accomplishment.
5) Identify Course of Action
If the compliance level is above the normal or the
expected level, there is great value in conveying
positive feedback and reinforcement
If the compliance level is below the expected
level, it is essential to improve the situations.
6) Choose action
Usually various alternative course of action are
available to remedy a deficiency.
Thus it is vital to weigh the pros and cons of each
alternative while considering the environmental
context and the availability of resources.
7) Take Action
It is important to firmly establish accountability
for the action to be taken.
This step then concludes with the actual
implementation of the proposed courses of
action.
8) Reevaluate
The final step of QA process involves an
evaluation of the results of the action.
The reassessment is accomplished in the same
way as the original assessment and begins the
QA cycle again.
Careful interpretation is essential to
determine whether the course of action has
improves the deficiency, positive
reinforcement is offered to those who
participated and the decision is made about
when to again evaluate that aspect of care.