QUALITY

ASSURANCE
BY:
K.Hema anandhy
Lecturer in Nursing,
SMVNC.

MASTER PLAN ON QUALITY ASSURANCE

Introduction
Definition of Quality Assurance
Objectives of Quality Assurance
Purposes of Quality Assurance
Principles of Quality Assurance
Approaches of Quality Assurance
General Approach
Credentialing
Licensure
Accrediation
Certification
Specific Approach
Peer Review
Standards as a device
Audit as a tool
Elements of Quality Assurance
Donabedian
Manwell, shaw
Models of Quality Assurance
System Model
ANA Model
Donabedian Model
Quality Health Outcome Model
Areas of Quality Assurance
OPD
Emergency Medical Services
IP
Speciality Services
Training
Quality Assurance Process
Standards as a device for quality assurance
JCI Standards
ANA Standards
JCAHO Standards
AACN Standards
APIE Standards
Factors Affecting Quality Assurance in Nursing Care

 Lack of Resources
Personnel Problems
Improper Maintenance
Unreasonable Patients and attendants
Absence of well informed population
Absence of accreditation laws
Lack of incidence review procedures
Summary & Conclusion
Journal Abstract
Bibliography

QUALITY ASSURANCE
INTRODUCTION
Quality assurance provides the mechanisms to effectively monitor patient care
provided by health care professionals using cost-effective resources. Nursing
programmes of quality assurance are concerned with the quantitative assessment of
nursing care as measured by proven standards of nursing practice. In addition, they
motivate practitioners in nursing to strive for excellence in delivering quality care and
to be more open and flexible in experimenting with innovative ways to change
outmoded systems
DEFINITION:
Quality assurance is a judgment concerning the process of care, based on the
extent to which that cares contributes to valued outcomes.
-

Donabedian (1982)

Quality assurance as the monitoring of the activities of client care to determine

the degree of excellence attained to the implementation of the activities.
-

Bull (1985)

Quality assurance is the defining of nursing practice through well written nursing
standards and the use of those standards as a basis for evaluation on improvement of
client care.

Maker (1998)

OBJECTIVES OF QUALITY ASSURANCE:

To successfully achieve sustained improvement in health care, clinics need to

design processes to meet the needs of patients.

To design processes well and systematically monitor, analyze and improve their

performance to improve patient outcomes.

A designed system should include standardized processes based on practices.

PURPOSES OF QUALITY ASSURANCE:

Rising expectations of consumer of services.

Increasing pressure from national, international government and other
professional bodies to demonstrate that the allocation of funds produces

satisfactory results in terms of patient care.

The increasing complexity of health care organizations.
Improvement of job satisfaction.
Highly informed consumer.
To prevent rising medical errors.
Rise in health insurance industry.
Accreditation bodies.
Reducing global boundaries.

PRINCIPLES OF QUALITY ASSURANCE:

It operates most effectively within a flat, democratic and organizational

structure.
Managers and workers must be committed to quality improvement.
The goal is to improve systems and processes and not to assign blame.
Customers define quality.
Quality improvement focuses on outcome.
Decisions must be based on data.

APPROACHES OF QUALITY ASSURANCE:

Two major categories of approaches exist in quality assurance they are
1. General

2. Specific
A. 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: It is generally defined as the formal recognition of
professional or technical competence and attainment of minimum standards by a
person or agency According to Hinsvark (1981) 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 by law since 1903.
3) Accreditation: National league for nursing (NLN) a voluntary organization
in US has established standards for inspecting nursing educations programs. In the
part the accreditation process primarily evaluated on agencys physical structure,
organizational structure and personal qualification
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 approachesQuality assurances are methods used to evaluate identified
instances of providers and client interaction.

1) Peer Review: To maintain high standards, peer review has been initiated to
carefully review the quality of practice demonstrated by members of a professional
group. Peer review is divided in to two types. One centers on the recipients of health
services by means of auditing the quality of services rendered. The other centers on
the health professional by 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 standards for practice includes:

Standard 1: The collection of data about health status of the patient is

systematic and continuous.

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.

3) Audit as a tool for quality assurance:To be effective a nursing audit must be

based on established criteria and feedback mechanism that provide information to
providers on the quality of care delivered. To evaluate quality nursing care regularly,
many staff nurses do indeed welcome opportunity to develop criteria, to review

nursing care retrospectively and concurrently, and to discover methods of achieving

higher levels of quality nursing care.

ELEMENTS OF QUALITY ASSURANCE:

According to Donabedian:
Structural Element The physical, financial and organizational resources
provided for health care.
Process Element The activities of a health system or health care personnel in
the provision of care.
Outcome Element A Change in the patients current or future health that
results from nursing interventions.
According to Manwell, Shaw &Beurri:

Access to healthcare.
Acceptability.
Appropriateness.
Effectiveness.
Efficiency.
Equity.

MODELS OF QUALITY ASSURANCE

1) A System Model:The implementations of the unit based quality assurance
program, like that of any other program, involves making changes in
organizational structure and individual roles. One method of facilitating and
structuring the change process is the system approach in which the task is 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. The
boundaries of the system define its integration is the environment is to the other tasks
and goals of nursing department, to the process of nursing science in relation to
evaluation. Their boundaries should be semi-permeable so that they allow necessary
information and energy into and out of the change process.
2) ANA Model: ANA quality Assurance Model was given by long and black in the
year of 1975. This helps in the self-determination of patient and family, nursing
health orientation, patients right to quality care and nursing contributors.The basic
components of the ANA model can be summarized as follows:

3) Donabedian Model: It is a model proposed for the structure, process and outcome
of quality. This linear model has been widely accepted as the fundamental structure
to develop many other models.

4) Quality Health Outcome Model: This uniqueness of this model proposed by

Mitchell & Co is the point that there are dynamic relationships with indicators that
not only act upon, but also reciprocally affect the various components.
System

Intervention

Outcome

Client
AREAS OF QUALITY ASSURANCE:
Outpatient Department: Courteous behaviour must be extended by all, trained or
untrained personnel. Provision of polyclinic concept to give all speciality services
under one roof.

In-Patient Department: Provide a pleasant hospital stay to the patient through

provision of a safe, homely atmosphere, a listening ear, human approach and well
behaved, courteous staff.
Emergency Medical Services: Services must be provided by well trained and
dedicated staff and they should have access to the most sophisticated life saving
equipment and materials.
Speciality Services: A high tech hospital with all types of speciality and superspeciality services will increase the image of the hospital.
Training: A continuous training programme should be present consisting of on the
job training, skill training workshops, seminars, conferences and case presentations.
QUALITY ASSURANCE PROCESS

a) Establishment of standards or criteria: It is process with the formation of new

standards and criteria for the hospitals and the quality of nursing care which
promotes to the patients.

b) Identify the information relevant to criteria: Gather the relevant information

which is needed for the formation of standards and it should be identified
appropriately.
c) Determine ways to collect Information: This includes the selection method for
gathering the needed information which is essential to the formation standards.
d) Collect and analyze the information: Gather all the information which is
needed and the collected information should be analyzed in a sequenced
manner.
e) Compare collected information with established criteria: Once the data was
analyzed it should be compared with the collected information under the
established criteria protocol.
f) Make a judgement about quality: Through the well framed information under
the criteria then the decision should be made on the basis of quality.
g) Provide Information: The finalized information is then communicated to the
needed areas to follow up the practice and maintain the standards of nursing
care in rendering a good quality of care.
h) Determine ways to collect the information: After the implementation of all the
information into the practice again determine the right ways to collect the
information regarding the performance and practice.
STANDARDS AS A DEVICE FOR QUALITY ASSURANCE:
JCI STANDARDS: Joint Commission International (JCI), as a global leader in
providing technical assistance, education, and quality evaluation services. As the
international aim of The Joint Commission based in the United States, we bring
highly-skilled consultants to hospitals, health care organizations, and ministries of
health, multinational companies, and government agencies on six continents.
JCI provide accreditation and certification preparation assistance to the following
types of health care organizations and programs:
Hospitals
Medical transport and ambulance services
Clinical laboratories

 Health care providers across the care continuum, including home care, hospice,
long term care, and rehabilitation services
Organizations providing care in ambulatory settings
Disease- or condition-specific care programs
Requirement 1: The hospital meets all requirements for timely submissions of
data and information to Joint Commission International (JCI).
Requirement 2: The hospital provides JCI with accurate and complete
information through all phases of the accreditation process.
Requirement 3: The hospital reports within 15 days any changes in the hospitals
profile (electronic database) or information provided to JCI via the E-App before
and between surveys.
Requirement 4: The hospital permits on-site evaluations of standards and policy
compliance or verification of quality and safety concerns, reports, or regulatory
authority sanctions at the discretion of JCI.
Requirement 5: The hospital allows JCI to request (from the hospital or outside
agency) and review an original or authenticated copy of the results and reports of
external evaluations from publicly recognized bodies.
Requirement 6 :The hospital allows JCI Accreditation Program staff and members
of JCIs Board of Directors to observe the on-site survey.
Requirement 7: The hospital participates in the Joint Commission International
Library of Measures quality improvement measurement system.
Requirement 8: The hospital accurately represents its accreditation status and the
programs and services to which JCI accreditation applies.

Requirement 9: Any individual hospital staff member (clinical or administrative)

can report concerns about patient safety and quality of care to JCI without
retaliatory action from the hospital.
Requirement 10: The hospital notifies the public it serves about how to contact its
hospital management and JCI to report concerns about patient safety and quality of
care.
ANA STANDARDS: As defined by the American Nurses (ANA), standards of nursing
consist of three components.
Professional standards of care define diagnostic, intervention, and evaluation
competencies.
Professional performance standards identify role functions in direct care,
consultation, and quality assurance.
Specialty practice guidelines are protocols of care for specific populations.
JCAHO STANDARDS: JCAHO defines practice guidelines, or standards of care, as
descriptive tools or standardized specifications of care of the typical individual in the
typical situation, developed through a formal process that incorporates the best
scientific evidence of effectiveness with expert opinion.
AACN STANDARDS:In 1998, the American association of Critical Care Nurses
[AACN] Board of Directors formed Practice Standard task Force to evaluate and
revise the current standards. The standards for Acute and Critical Care Nursing
Practice describe the practice of the nurse who cares for an acutely or critically ill
patient no matter where that patient is cared for within the health care environment.
APIE STANDARDS: In the April 2002 edition of Nursing Spectrum magazine, Judith
Brumm, RN writes about the APIE method to guide nursing practice.
Assess and analyze: Collect and organize data form a statement of the actual or
potential needs

 Plan and prioritize: Formulate your plan. This involves devising goals and
expected outcomes, setting priorities, and identifying interventions to help
reach the goals.
Implement and intervene: Put your plan into action
Evaluate: Assess your outcomes and see how they measure against the goals.

FACTORS AFFECTING QUALITY ASSURANCE IN NURSING CARE

1)

Lack

of

Resources:

Insufficient

resources,

infrastructures,

equipment,

consumables, money for recurring expenses and staff make it possible for output of a
certain quality to be turned out under the prevailing circumstances.
2) Personnel problems: Lack of trained, skilled and motivated employees, staff
indiscipline affects the quality of care.
3) Improper maintenance: Buildings and equipments require proper maintenance for
efficient use. If not maintained properly the equipments cannot be used in giving
nursing care. To minimize equipment down time it is necessary to ensure adequate
after sale service and service manuals.
4) Unreasonable Patients and Attendants: Illness, anxiety, absence of immediate
response to treatment, unreasonable and unco-operative attitude that in turn affects the
quality of care in nursing.
5) Absence of well informed population: To improve quality of nursing care, it is
necessary that the people become knowledgeable and assert their rights to quality
care. This can be achieved through continuous educational program.
6) Absence of accreditation laws: There is no organization empowered by legislation
to lay down standards in nursing and medical care so as to regulate the quality of care.
It requires a legislation that provides for setting of a stationary accreditation /
vigilance authority to:

a) Inspect hospitals and ensures that basic requirements are met.

b) Enquire into major incidence of negligence
c) Take actions against health professionals involved in malpractice
7) Lack of incident review procedures: During a patients hospitalizations reveal
incidents may occur which have a bearing on the treatment and the patients final
recovery. These critical incidents may be:
a) Delayed attendance by nurses, surgeon, physician
b) Incorrect medication
c) Burns arising out of faulty procedures
d) Death in a corridor with no nurse / physician accompanying the patient etc.
CONCLUSION
To ensure quality nursing care within the contemporary health care system,
mechanisms for monitoring and evaluating care are under scrutiny. As the level of
knowledge increases for a profession, the demand for accountability for its services
likewise increases. Individuals within the profession must assume responsibility for
their professional actions and be answerable to the recipients for their care. As
profession become more interdependent, it appears that the power base will become
more balanced, allowing individual practitioners to demonstrate their competence and
expertise. Quality assurance programme will helps to improve the quality of nursing
care and professional development.

JOURNAL ABSTRACT:
QUALITY ASSURANCE: IMPORTANCE OF SYSTEMS AND STANDARD
OPERATING PROCEDURES
KishuManghani
It is mandatory for sponsors of clinical trials and contract research organizations alike
to establish, manage and monitor their quality control and quality assurance systems
and their integral standard operating procedures and other quality documents to
provide high-quality products and services to fully satisfy customer needs and
expectations. Quality control and quality assurance systems together constitute the key
quality systems. Quality control and quality assurance are parts of quality
management. Quality control is focused on fulfilling quality requirements, whereas
quality assurance is focused on providing confidence that quality requirements are
fulfilled. The quality systems must be commensurate with the Company business
objectives and business model. Top management commitment and its active
involvement are critical in order to ensure at all times the adequacy, suitability,
effectiveness and efficiency of the quality systems. Effective and efficient quality
systems can promote timely registration of drugs by eliminating waste and the need
for rework with overall financial and social benefits to the Company.

PRIVATE SECTOR DELIVERY OF HEALTH SERVICES IN

DEVELOPING COUNTRIES: A MIXED-METHODS STUDY ON
QUALITY ASSURANCE IN SOCIAL FRANCHISES
Karen
Across the developing world health care services are most often delivered in the
private sector and social franchising has emerged, over the past decade, as an
increasingly popular method of private sector health care delivery. Social
franchising aims to strengthen business practices through economies of scale:
branding clinics and purchasing drugs in bulk at wholesale prices. While quality
is one of the established goals of social franchising, there is no published
documentation of how quality levels might be set in the context of franchised
private providers, nor what quality assurance measures can or should exist
within social franchises. The aim of this study was to better understand the
quality assurance systems currently utilized in social franchises, and to
determine if there are shared standards for practice or quality outcomes that
exist across programs.
The study included three data sources and levels of investigation: 1) Selfreported program data; 2) Scoping telephone interviews; and 3) In-depth field
interviews and clinic visits.

Social Franchises conceive of quality assurance not as an independent

activity, but rather as a goal that is incorporated into all areas of franchise
operations, including recruitment, training, monitoring of provider performance,
monitoring of client experience and the provision of feedback.

BIBLIOGRAPHY
BOOK REFERENCES:
Francic.C.M, Mario.C. Desouza, Hospital Administration, 3 rd Edition, Jaypee
Brothers Publishers, New Delhi.
Tattersall.E.R, Nursing Management In Practic, 1st Edition, English
Language Book Society[ELBS] Publishers.
Michael.P.Bowman, Nursing Management And Education-A Conceptual
Approach To Change, 1st Edition, Croom Helm Publishers.
Deepak .K, A Comprehensive textbook on Nursing Management, First
Edition 2013, Emmess publishers.
Basvanthappa B.T (200 4 ) 1st edition, Nursing administration,published by
jaypee brothers.
INTERNET REFERENCES:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3088954/
http://onlinelibrary.wiley.com/journal/10.1002/(ISSN)1099-1786
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3560158/