Quality Assurance in Nursing

Quality Assurance
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 Accreditation 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
CONCEPT
A quality assurance is an ongoing systematic process designed to
evaluate and [promote excellence in the health care provided to the
client. It provides documentation for outside organization and for
internal measures for improvement and refinement of policies and
procedures.quality assurance involves evaluation of three components:
STRUCTURAL EVALUATION
Focuses on the settings in which care is given.Structural standards
describe desirable environment and organizational characteristics that
influence here such as equipments and staffing.
PROCESS EVALUATION
Focuses on how the care is given. Process standards focus on the
manner in which the nurse uses the nursing process example check
clients identification band before giving medication.
OUTCOME EVALUATION
Focuses on demonstrable changes in the client health status as a result
of nursing care.Outcome criteria is written in terms of client responses
or status just as they are for evaluation within the nursing process.
OBJECTIVES
o To ensure the delivery of quality client care.
o To demonstrate efforts of health care providers to provide good results.
o To formulate plan of care.
o To evaluate achievement of nursing care.
o To support delivery of nursing care with administrative & managerial services.
o To explain quality assurance models as pre- requisite for quality nursing care.
o To state code of ethics & professional conduct for nurses in India.
o To appreciate importance of practicing standard safety measures.
o Plan & conduct patient teaching sessions.
PURPOSES
 To provide best care to patients by maintaining standards.
 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.
PRINCIPLES
• Customer focus- It focuses on patient’s care with standard & recent medical knowledge.
• Leadership – It helps to inculcate qualities of leadership in staff.
• Involvement of People- It should involve maximum nursing staff so that standards can
be maintained.
• Process approach- There should be a systematic & planned approach to provide quality
care.
• Factual approach to decision making- There should be fact or appropriate reason in
taking certain decision for quality assurance of patient.
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
APPROACHES FOR QUALITY ASSURANCE PROGRAM
Approaches of quality assurance are divided into 2 types:
1. GENERAL APPROACHES
2. SPECIFIC APPROACHES
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:-
• To produce a quality product.

• To confer a unique identity.
• To protect provider & public.
• 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.
NURSING AUDIT PROCESS
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
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

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Quality Assurance

DEVELOPMENT OF A QUALITY ASSURANCE PROGRAM

• Foster Commitment of Quality.

APPROACHES FOR QUALITY ASSURANCE PROGRAM

Approaches of quality assurance are divided into 2 types:

1. CREDENTIALING - It is process of determining & maintaining nursing standards.

Functional Components Of Credentialing Process According to Hinsvark, credentialing process has 4

• To produce a quality product.

GOALS OF NURSING AUDIT

• To improve quality of health care.

NURSING AUDIT PROCESS

ADVANTAGES OF NURSING AUDIT

• Provides quality of nursing

TYPES OF UTILIZATION REVIEW

• Prospective: It is an assessment of the necessary of care before giving services.

Studies Donabedian’s Structure-Process-Outcome model

MODELS OF QUALITY ASSURANCE System

FACTORS AFFECTING QUALITY ASSURANCE IN NURSING CARE

• It requires continuous quality improvement.

CONDITIONS IN WORK ENVIRONMENT

COMPONENTS OF QUALITY IMPROVEMENT PROGRAMS

• Establish responsibility & accountability.

TOTAL QUALITY MANAGEMENT

Classification of nursing care standards

• An outcome standard measures changes in patient health status.

• Role of nurse is to participate in quality improvement team.

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