Quality:

Quality is defined as the extent of

resemblance between the purpose of healthcare and the truly granted care (Donabedian 1986).

Quality assurance
"Quality assurance is 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).

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 body's evaluation of a persons or agency's ability to meet established criteria or standards at a given time. 1) Credentialing: 2) Licensure: 3) Accreditation: 4) Certification:

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 Hinvasky (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 professional's practice. Licensure of nurses has been mandated by law since 1903

3) Accreditation:
National league for nursing (NLN) a

voluntary organization has established standards for inspecting nursing education's programs. In the part the accreditation process primarily evaluated on agency's physical structure, organizational structure and personal qualification

4) Certification:
Certification is usually a voluntary

process with in the profession. A person's educational achievements, experience and performance on examination are used to determine the person's qualifications for functioning in an identified specialty area.

Specific approaches:
Quality assurances are methods used to evaluate identified instances of providers and client interaction. 1) Peer review: 2) Standard as a device for quality assurance: 3)Audit as a tool for quality assurance:

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 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 patient's progress or lack

of progress towards goal achievement is determined by the patient and the nurse. Standard 8: The patient's 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.

 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.

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

 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.

QUALITY ASSURANCE MODEL IN NURSING

Quality assurance model in nursing is the set of elements that are related to each other and comprise of planning for quality development of objectives setting and actively communicating standards developing indicators, setting thresholds, collecting data to monitor compliance with set standards for nursing practice and apply solutions to improve care

PHILOSOPHY OF QUALITY ASSURANCE MODEL IN NURSING Indian nursing council believes that nurse will
Do good for person /receiver of care,

do no harm, maintain respect for life and human dignity, believe in human justice and fairness to individuals in terms of access to resources and care and protect the vulnerable

 Have moral obligation to provide services

as per the prescribed of the regulatory body / health care system/ organization /institution even if it is in conflict with her personal beliefs and values Be responsible and accountable for providing quality care in line with set standards

 Be committed to understanding of

dynamic nature of his / her role in interdisciplinary health team Be obliged to create public awareness and consider social expectations before making decisions for providing nursing care Be obliged to include receiver in making choices in planning and implementation of care

 Work in conjugation with legislation,

accreditation and political system Have obligation to promote education of self and others Be committed to advancement of profession

PURPOSE OF QUALITY ASSURANCE MODEL

To

ensure quality nursing care provided by nurses in order to meet the expectations of the receiver, management and regulatory body It also intends to increase the commitment of the provider and the management

GOALS OF QUALITY ASSURANCE MODEL

Develop confidence of the receiver

that quality care is being rendered as per assurance Develop commitment of the management towards quality care Increase commitment of providers to adhere to set standards for nursing practice and strive for excellence

MODELS OF QUALITY ASSURANCE

1) System Model for Quality

assurance. 2) ANA Quality Assurance Model 3) JCAHO Quality Assurance Model 4) ISO Quality Assurance Model

A System Model for Quality assurance.

The basic components of the system are Input Throughput Output Feedback

i) Input:- Can be compared to the present state of the system. ii) Through put:- The through put to the developmental process.

iii) Out put:- To the finished product.

iv) Feed Back:- It is the essential component of the system because it maintains and nourish growth.

AMERICAN NURSES ASSOCIATION MODEL FOR QUALITY ASSURENCE

Identify values Identify structure, process and Select measurement Make interpretation

outcome standards and criteria

 Identify course of action Choose action Take action

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. The philosophy and objectives of an agency serves to define the structural standards of the agency.

 Standards of structure are defined by

licensing or accrediting agency. Another standard of structure includes the organizational chart, which shows supervisory methods, communication patterns, staff patterns and sometimes staff assignments. Evaluation of the standards of structure is done by a group internal or external to the agency.

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, utilization's reviews, review of agency documents, self studies and review of physicals facilities.

 The approaches and techniques for

the evaluation of process standards and criteria are peer review, client satisfactions surveys, direct observations, questionnaires, interviews, written audits and videotapes.

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. It is necessary to identify the cause of deficiency. Then, it is important to identify various solutions to the problems.

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. In the recent that more than one cause of the deficiency has been identified; action may be needed to deal with each contributing factor.

7) Take Action:
It is important to firmly establish

accountability for the action to be taken. It is essential to answer the questions of who will do? What? By when?. 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.

JCAHO

JCAHO QUALITY ASSURENCE MODEL

ISO QUALITY ASSURENCE MODEL

QUALITY ASSURANCE PROCESS:

Establishment of standards or criteria Identify the information relevant to criteria Determine ways to collect information Collect and analyze the information Compare collected information with established criteria Make a judgment about quality Provide information and if necessary, take corrective action regarding findings of appropriate sources Determine ways to collect the information

FACTORS AFFECTING QUALITY ASSURANCE IN NURSING CARE 1) Lack of Resources: 2) Personnel problems: 3) Improper maintenance: 4) Unreasonable Patients and Attendants 5) Absence of well informed population. 6) Absence of accreditation laws

7) Lack of incident review procedures 8) Lack of good and hospital information system 9 Absence of patient satisfaction surveys 10) Lack of nursing care records

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 un co-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

8) Lack of good and hospital information system

A good management information

system is essential for the appraisal of quality of care. a) Workload, admissions, procedures and length of stay b) Activity audit and scheduling of procedures.

9 Absence of patient satisfaction surveys

Ascertainment of patient satisfaction

at fixed points on an ongoing basis. Such surveys carried out through questionnaires, interviews to by social worker, consultant groups, and help to document patient satisfaction with respect to variables that are

a) Delay in attendance by nurses and doctors. b) Incidents of incorrect treatment

10) Lack of nursing care records

Nursing care records are perhaps the

most useful source of information on quality of care rendered. The records. a) Detail the patient condition b) Document all significant interaction between patient and the nursing personnel.

c)

Contain information regarding response to treatment d) Have the dates in an easily accessible form.

Thank you for your patient listening