1

GRACIOUS COLLEGE OF NURSING

ABHANPUR RAIPUR (C.G.)

NURSING EDUCTION

SEMINAR
ON
Quality Assurance in Nursing

SUBMITTED TO:- SUBMITTED BY:-

MRS.ASHA CHATTERJI MR.ABHISHEK SAMSON
MSC NURSING LECTURER (MSN) MSC NURSING 1ST YEAR[MHN]
GRACIOUS COLLEGE OF NURSING GRACIOUS COLLEGE OF NURSING
 2

INDEX

S.NO. CONTENT PAGE NO.

1. Introduction of Quality Assurance in Nursing 3

2. Definition of Quality Assurance in Nursing 3

3. Principles of Quality assurance in Nursing 4

4. Purpose of Quality Assurance in Nursing 4

5. Needs of Quality Assurance in Nursing 4

6. Quality Assurance Process 4-5

7. Approaches of a Quality assurance Programme 5-7

8. Models Of Quality Assurance 8-9

9. Areas Of Quality Assurance 10

10. Factors affecting quality assurance in nursing 10-11

11. Summary 12

12. Bibliography 13

QUALITY ASSURANCE IN NURSING

 3

INTRODUCTION:-Quality refers to excellence or standards of a product or a service

including its attractiveness, lack of defect, reliability and long-term durability. Quality
assurance provides the mechanism of effectively monitor patient care provided by the health
care professionals using cost-effective resources. Florence Nightingale introduced the
concept of quality in nursing care in 1855 while attending the soldiers in the hospital during
the Crimean war.

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.

DEFINITION:-
1. “Quality assurance in nursing is the monitoring of the activities of client care to determine the
degree of excellence attained to the implementation of the activities.
:According to Bull, (1985)

2. “Quality assurance in nursing is a process of establishing a target degree of excellence

(Standards) for nursing intervention and then taking steps to ensure that each client receives the
agreed upon level of care.”
:According to Gillies, (1994)

3. “Quality assurance includes all activities related to establishing, maintaining and assuring high
quality care for patients.”
:According to Textbook of Navdeep Kaur

4. Quality assurance is an on-going, systematic, comprehensive evaluation of health care services

& impact of those services on health care services.
:According to Kozier

5. Quality assurance is defined as all activities undertaken to predate & prevent poor quality.
:According to Neetvert

PRINCIPLES OF QUALITY ASSURANCE:-

 4

There are five basic principles of quality assurance:-

 Quality assurance is oriented towards meeting the needs and expectations of our client.
 It focuses on system and processes.
 It uses data to analyse service delivery.
 It encourages the use of teams in problem solving and quality improvement.
 It uses effective communication to improve service delivery.

PURPOSES / OBJECTIVES OF QUALITY ASSURANCE:-

 To describe practice standards for nurses and the irrational.
 To identify the legal boundaries for nursing practice.
 To prepare nursing care plan following nursing process approach.
 To appreciate the importance of practicing standard safety measures.
 To identify appropriate communication techniques to be used in given interpersonal
situation.
 To plan and conduct patient teaching session.
 To identify appropriate management techniques to be used for managing resources in given
situation.
 To appreciate the importance of continuing education and research for development of self,
others and of the profession.

NEED FOR QUALITY ASSURANCE IN NURSING:-

 Improves and maintains the patient’s state of health.
 Improves and maintains the patient’s functional abilities.
 Develops the patient’s psychological condition or well-being.
 To refine existing methods for ensuring optimal quality health care.
 To provide technical assistance in correcting systemic deficiencies.
 To ensure quality nursing care provided by nurses in order to meet the expectations of
receiver, management and regulatory body.

QUALITY ASSURANCE PROCESS:- Quality assurance process is the systematic

process of evaluating the quality of care given in a particular unit or institution. It includes:-

1) Setting standards:- The nursing profession should have to design standards of nursing
practice that are specific to the patient population served. These standards could serve as the
foundation upon which all other measures of quality assurance are based.
Ex:- Every patient will have a treatment chart.
2) Determining criteria to meet those standards:- After standards of performance are
established, criteria must be determined that will indicate if the standards are being met and to
what degree they are met. Criteria must be general as well as specific to the individual unit.A
nursing care plan is developed and written by a nurse within 10 hours of admission.

3) Data Collection:- Sufficient observation and random samples are necessary for producing
reliable and valid information. A useful rule is that 10% of the institutional patient population
per month should be sampled.
 5

4) Evaluating Performance:- Various methods can be used to evaluate performance. It

includes:-
 Reviewing the documented records
 Observing activities as they takes place
 Examining patients
 Interviewing patients, families and staff
Records are most commonly used sources for evaluation because of the relative ease of their
use, but they are not as reliable as direct observation.
5) Making plans for change based on the evaluations:- It includes making the plans for
improving quality care by changing the present scenario and incorporate new policies for the
same.

6) Implementation for change:- It is the final step which includes taking the actions or
implementing the plans for improving quality care.

Approaches for A Quality assurance Programme:-

Two major categories of approaches exist in the quality assurance. They are:-
 General Approach
 Specific Approach

1. General Approach:- It involves large governing of official body’s evaluation of a person’s or

agency’s abilities to meet established criteria or standards at a given time.

a) Credentialing:- A person generally defines it as the formal recognition of professional or

technical competence and attainment of minimum standards by a person or agency. According
to Hinsverk (1981) credentialing process has four functional components:-
 To produce a quality product
 To confer a unique identity
 To protect provider and public
 To control the profession

b) Licensure:- Individual licensure is a contract between the profession and the state, in which
the state is granted control over entry into and exist 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 professional’s practice.

c) Accreditation:- National League for Nursing (NLN), a voluntary organization has established
standards for inspecting nursing education’s programmes. In the part the accreditation process
primarily evaluated on agency’s physical structure, organizational structure personal
qualifications.
 6

d) Certification:- Certification is usually a voluntary process within the profession. A person’s

educational achievement, experience and performance on examination are used to determine
the person’s qualifications for functioning in an identified specialty area.

2. Specific Approach:- Quality assurance are methods used to evaluate identified instance of
provider and client interaction.

a) Peer Review Committee:- These are designed to monitor client-specific aspects of care
appropriate for certain levels of care. The audit has been the major tool used by peer review
committee to ascertain quality of care.

b) The Audit Process:- Audit is a process of systematic and critical examination to examine or
verify.
 Follow up of problem
 Topic study selected
 Recommendations for correcting deficiencies, explicit criteria selected for quality care
 Peer review of all cases not meeting criteria
 Records reviewed.

c) Utilization Review:- Utilization review activities are directed towards assuring that care is
actually needed and that the cost appropriate for the level of care provider. There are three
types of utilization review. They are:-

 Prospective:- It is an assessment of the necessity of care before giving services.

 Concurrent:- It is a review of the necessity of care while the care is being given.

 Retrospective:- It is an analysis of the necessity of the services received by the client after the
care has been given.

d) Evaluation Studies:- Three major models have been used to evaluate. They are:-

1) Donabedian’s Structure-Process-Outcome Model

2) The Tracer Model
3) The Sentinel Model

1) Donabedian’s Structure – Process - Outcome Model:- Donabedian introduced 3 major

methods of evaluating quality care.
 7

A. Structural Evaluation:- This method evaluates the setting and instruments used to provide
care such as facilities, equipments and characteristics of the administrative organization and
qualifications of the health provider. The data for structural evaluations can be obtained from
the existing documents of an agency or from an inspector of a faculty.

B. Process Evaluation:- This method evaluates activities as they related to standards and
expectations of health providers in the management of client care, data for this can be collected
through direct observations of provider encounter and review of records, audit, checklist
approach and the criteria mapping approach is used to establish the client encounter protocol.

C. Outcome Evaluation:- The net changes that occur as a result of health care or the net results
of health care. The data of this method can be collected from vital statistical records such as
death certificates or telephone client interview, mailed questionnaire and client records.

2) The Tracer Model:-It is measure of both process and outcome of care. To use the tracer
method, one must identify a volume of clients with a particular characteristics resuming
specific healthcare management. Physicians and nurse practitioners, to identify persons with
certain illness such as HTN, ulcers, UTI and to establish criteria for good medical and nursing
management of the illness have use the Tracer Method. This method provides nurses with data
to show the differences in outcome as a result of nursing care standards.

3) The Sentinel Method:- It is an outcome measure for examining specific instances of client
care. The characteristics of this method are:-

 Cases of unnecessary disease, disability deaths are counted.

 The circumstances surrounding the unnecessary event or the sentinel is examined in detail.
 In review of morbidity and mortality are used as an index.
 Health status indicators such as changes in social, economic, political and environmental
factors are reviewed which may have an effect on health outcomes.
m
S
l
p
M
h
C
s
r
y
f
d
I
v
R
k
T
n
o
i
c
e
t
a
u MODELS OF QUALITY ASSURANCE

 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
a) Input
b) Throughput
c) Output
d) 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
8

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.

1) 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:
 9

2) 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.

3) 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
 10

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 super-speciality
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.

FACTORS AFFECTING QUALITY ASSSURANCE IN NURSING:-

 Lack of resources:- Insufficient resources, infrastructure, 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.

 Personnel Problem:- Lack of trained, skilled and motivated employees, staff indiscipline
affect the quality of care.

 Improper maintenance:- Buildings and equipment require proper maintenance for the
efficient use. If not maintained properly, the equipment’s can’t be used in giving nursing care.

 Unreasonable Patients And Attendants:- Illness, anxiety, absence of immediate response to

treatment, unreasonable and uncooperative attitudes, in turn, affect the quality of care in
nursing.

 Absence of well-informed Populations:- 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 programme.

 Lack of good Hospital Information System:- A good management information system is

essential for the appraisal of quality care:
 Workload, admission, procedure and length of stay
 Activity audit and scheduling of procedures

 Absence of Patient Satisfaction Surveys:-

 11

 Delay in attendance by nurses and doctors

 Incident of incorrect treatment

 Lack of nursing care records:-Nursing care records are perhaps the most useful source of
information on quality of care rendered. The records:-
 Detail of the patient condition.
 Document all significant interaction between patient and nursing personnel.
 Have the data in an easily accessible form.

 Miscellaneous Factors:-

 Lack of good supervision

 Absence of knowledge about philosophy of nursing care
 Lack of policy and administrative manuals
 Substandard education and training
 Lack of evaluation technique
 Lack of written job description and job specification
 Lack of in-service and continuing education programme

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.

SUMMARY
 12

 Introduction
 Definition
 Principles
 Purposes / Objectives
 Needs
 Quality Assurance Process
 Approach of Quality Assurance Programme
 Factors affecting Quality Assurance In Nursing
 13

BIBLIOGRAPHY
 Shebeer p basheer ; Text Book Of Advanced Nursing Practice ;
Second edition ; emmess medical publishers ; page no.-536-539.

 S yaseen khan ; Text Book Of Advanced Nursing Practice ;

Second edition ; emmess medical publishers ; page no. 530-532.

 Agrawal ,a.k. ; Text Book Of Nursing Practice ; sixth edition ;publishers

Pvt . Ltd, new delhi. Page no. 30-32.

 Choudhary ,s. K ; Text Book Of Nursing Practice ; second edition ; published by pvt . Ltd.
New delhi . Page no. 21-22.

 Deka ,p.k & longkumar, s.r. Text Book Of Nursing Advance Practice ;
2009 edition ; adhyayan publisher & distributors ; new delhi ;

 Dhingra ,i.c. ; Text Book Of Nursing Advance Practice ; 2007 edition ;

emmess medical publishers ; page no.16-18.

 Barman k. K. (1985) ; Text Book Of Advance Practice Nursing ; publishers

adhyanayan distributors new delhi ;

 Machenzie ,a. ; Text Book Of Nursing Advance Practice ;

published by emmess medical publishers ; tenth edition ;

 Indarjit walia ; Text Book Of Nursing Advance Practice ; fourth editon

cbs publishers & distributors pvt ltd ; page no.-712.

 Francic.c.m, mario.c. Desouza, “hospital administration”, 3rd edition,

Jaypee brothers publishers, new delhi.

 Tattersall.e.r, “nursing management in practic”, 1st edition, english language book society[elbs]
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.