QUALITY ASSURANCE IN NURSING

PREPARED BY: MR MARUDHAR, ASST. PROFESSOR, NIMS UNIVERSITY

Introduction
The field of quality assurance is an old as modern nursing. Florence Nightingale introduced the
concept of quality in nursing care in 1855 while attending the soldiers in the hospital during the
Crimean war. It is a matter of pride for nurses that the nursing profession has attained a distinct
position in the search for quality in health care.

CONCEPT OF QUALITY IN HEALTH CARE

Defining quality is difficult. The expense of quality is an interactive process between customer
and provider. The customer does not receive anything tangible, mostly only a piece of paper with
a promise for a better future e.g. Doctors writing prescriptions.

Quality:

Quality is defined as the extent of resemblance between the purpose of healthcare and the truly
granted care (Donabedian 1986).

In an economic dimension quality is the extent of accomplished relief case with a justified use of
means and services (Williamson 1999)

Government and those who pay of the care will see quality as a weighing out between results and
costs to fulfill certain expectations in health care.

CONCEPT OF QUALITY ASSURANCE:

Quality assurance is a dynamic process through which nurses assume accountability for quality
of care they provide. It is a guarantee to the society that services provided by nurses are being
regulated by members of profession.

“Quality assurance is a judgment concerning the process of care, based on the extent to which
that care contributes to valued outcomes”. (Donabedian 1982).

Bull 1985 defined “quality assurance as the monitoring of the activities of client care to
determine the degree of excellence attained to the implementation of the activities”.

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

1. General

2. 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:

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 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 regency’s physical structure, organizational structure and personal qualification. In
1990 more emphasis was placed on evaluation of the outcomes of care end on the educational.
Qualifications of the person providing care.

4) Certification:

Certification is usually a voluntary process with in the professions. A persons educational

achievements, experience and performance on examination are used to determine the persons
qualifications for functioning is an identified specialty area.
SPECIFIC APPROACHES:

Quality assurances are methods used to evaluate identified instances of provides 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 has been the major tool used by peer review committee to ascertain quality of
care.

The audit Process - (Stan hope Han Caster 2000)

Follow up of problems Topic study selected

Recommendations for collecting deficiencies Explicit criteria selected for quality care.

Peer review of all cases not meeting criteria Records reviewed

Utilization Review (UR)

Utilization review activities are directed towards assuring that care is actually needed and that
the cost appropriate for the level of care provided.

3 type of U.R are there:

1) Prospective: It is am assessment of the necessity of care before giving service.

2) Concurrent: a review of the necessity of care while the care is being given.

3) Retrospective: in analysis of the necessity of the services received by the client after the care
has being given.

U.R has been used primarily in hospitals to establish need for client admission end the length of
hospital stay. The UR process includes the development of explicit criteria that serves as
indicators of the need for services and length of services.

Advantages of Utilization Review:

1. It is designed to assist clients to avoid unnecessary care.

2. It may serve to encourage the consideration of care options by providers, such as home health
care rather than hospitalization

3. It can provide guidelines for staff of program development.

4. It provides a measure of agency accountability to the consumer.

The major disadvantage to UR is that hot all client fit for the classic picture presented by the
explicit criteria that serves as the basis for approval or dermal of care.

4) Evaluation Studies:
Three major models have been used to evaluate quality they are:-

1. Donabedian’s structure- process-outcome model

2. The tracer model

3. The sentinel model

Donabedian introduced 3 major method of evaluating quality care.

A) Structural evaluation:

This method evaluates the setting and instruments used to provide care such as facilities
equipment’s, characteristics of the administrative organization and qualification of the health
providers. The data for structural evaluations can be obtained from the existing documents of an
agency or from an inspector of a facility.

B) Process evaluation:

This method evaluates activities as they relate to standards and expectations of health provides is
the management of client care, data for this can be collected through direct observations of
provider encounters and review of records, audit, check list approach and the criteria mapping
approach are 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, in person or
telephone client interviews mailed questionnaire and client records.

The Tracer method: is a measure of both process and outcome of care. To use the tracer
method, one must identify a volume of client with a particular characteristic resuming specific
health care management. Physicians and nurse practitioners to identify persons with certain
illness such as HT, ulcers, UTI and to establish criteria for good medical and nursing
management of the illnesses have used the traced method. This method provides nurses with data
to show the differences in outcome as a result of nursing care standards.

The Sentinel method: It is an outcome measure for examining specific instances of client care
the characteristics of this method are,

a) Cases of unnecessary disease, disability deaths are counted.

b) The circumstances surrounding the unnecessary event or the sentinel are examined in detail.

c) In review of morbidity and mortality are used as an index.

d) Health status indicator such as changes in social, economic, political and environmental
factors are reviewed which may have an effect on health outcomes.

Client satisfaction:

Client satisfaction can be assessed using person or telephone interviews and mailed
questionnaire. Data from client satisfaction surveys are used to measure structure, process and
outcome of care gives.

Incident review:

During a patient’s hospitalization several incidents may occur which have a bearing on the
treatment and patients final recovery. The critical incidents may be,

- Delayed attendance by a physician /nurse

- In correct medications

- Lack of cleanliness and asepsis leading to infection

- Carelessness in carrying out nursing procedures eg. Hot and cold applications.

The report should contain the name, age exact time and place, description of how it occurred any
precaution taken conditions of patient before and after the incident etc since these reports are of
legal value it should be written carefully given importance to all the details and should be filed
safely.

Risk management:
It can be defined in a program that is developed for the propose of eliminating or controlling
health care situations that has the potential to inure endangers or create risk to clients. The
philosophical intent of such a program would be to “do the client no harm” that is to administer
safe care of whichever clients, groups or populations are being served. Risk management
activities are directed towards the identifications, analysis and evaluation of situations to prevent
injury and subsequent financial loss.

Malpractice litigation

It is a specific approach to be imposed on the health care delivery systems by the legal systems.
Malpractice litigation results from client dissatisfaction with the provider and with the content of
care received.
Approaches to Quality Improvement
 Credentialing
 Licensure
 Academic degrees
 Accreditation
 Certification
 Charter
 Recognition

Health care delivery system

- Utilization review
o Evaluative studies
o Incident review
o Peer review committee
o Audit process
o Client satisfaction

Principles and Conditions for total Quality Management

Principles

 Continuous quality improvement

 Knowledge of customer expedition needs
 Processes of customer supplier relationship
 Belief in people
 Statistical analysis
 Costs of poor quality
 Conditions in the work environment:
 Employer involvement
 Improvement
 An environment that supports risk taking
 Team work
 Data collection and analysis skills
 Group interaction skills
 Structure and management to enable improvement
 Tools to facilitate the improvement.
Framework for quality

Quality in Nursing Practice:

The point commission on Accreditation of health care organizations (JCAHO) 1997 defines
quality improvement (QI) as in approach to the continuous study and improvement of the process
of providing health care services to meet the needs of clients and others.

Steps in quality improvement:

Quality defined:

Before the nurse manager and staff can measure trends in nursing practice, they first must know
the standards or guidelines that define quality.

Professional standards:

They are authoritative statements used by the profession in describing the responsibilities for
which its practitioners are accountable (Peters 1995)

A) Policies: Policies are non negotiable aspects of practice that allow for no professional
judgment or interpretation is their implementation (Peters 1995)

E.g.. Professional dress policy, informed consent advanced directives.

B) Job descriptions: defined as the qualifications and responsibilities for individuals within a
position or job category.

E.g.. Clinical director, staff nurse etc.

Outcomes

Outcomes are the conditions to be achieved as a result of care delivery. An outcome tells
whether interventions are effectiveness, whether clients progress, how well standards are being
met, and whether changes are necessary,.

a) Professional outcome: a measure of the professional caregivers performance.

b) Client outcome: a measure of chant status after receiving care.

c) Developing quality improvement term:

This team composed of staff from all departments with in a hospital.

Components of Q.I programs.

JCAHO’s 10 steps for Q I

1. Establish responsibility and accountability for a G.I program.

2. Define the scope of service for a chemical area

3. Define the key aspects of service for the chemical area.

4. Develop quality indicators to monitor the outcomes and appropriateness of care delivered.

5. Establish thresholds for evaluation of indicators

6. Collect and analyze data from monitoring activities.

7. Evaluate results of monitoring activities to determine the need for change in practice.

8. Resolve problems through development of action plans.

9. Reevaluate to determine if the plan was successful

10. Communicate Q.I results to the organization

MODELS OF QUALITY ASSURANCE

1) A System Model for implementation of unit Based Quality assurance:

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

System model for unit based quality assurance (from Waynes P.I Quality Assurance Unit based
approach 1984, Pg 51).

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) American Nurses Association Model :

The ANA has developed QA model in 1977 which has wide spread applicability in any
healthcare setting and can be used as guide to implement QA program.

The first step in developing QA program is continuing education. Many staff nurses and
supervisors have not been prepared in the academic setting to develop standards of practice when
a quality assurance program is implemented, the continuing education needs of all staff should
be ascertained. Quality is not assured if only a small committee evaluates care and understands
quality assurance program.

3) ANA Quality Assurance Model:

ANA quality Assurance Model (from Susan Clemene, Diana Geeber: Comprehensive, family
and community health nursing, 3rd edition Pg 851)

The basic components of the ANA model can be summarized as follows:

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 provides 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 an 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.

The evaluation of process standards is a more specific appraisal of the quality of care being given
by agency care provides. An agency can choose to use the standards of care set forth by the
provides professional organization such as the ANA nursing standards or the agency can use the
nursing process and apply it to the activities of the nurses ass the activities correspond to the
procedures of care defined by the agency. The primary approaches for process evaluation include
the peer review committee and the client satisfaction survey. The techniques included are direct
observation, questionnaire, interview, written audit and videotape of client and provide
encounter.

The evaluation of outcome standards reveals the end results of nursing care. To be able to
identify the net changes in the client’s health status as a result of nursing care will give nursing
profession data to show the contributors of nursing to the health care delivery system. Research
studies using the trace method or the sentinel method to identify client outcomes and client
satisfaction surveys are approaches that may be used to evaluate outcome standards. Technique
used is client classification systems that are admission data on the clients’ level of dependence or
problems and discharge data that may show changes in the level of dependence.

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.

The evaluation approaches for outcome standards and criteria include research studies, client
satisfaction surveys, client classification, admission, readmission, discharge data and morbidity
data.

4) Make interpretations

The degree to which the predetermined criteria are met is the basis for interpolation 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 accomplishment in the say 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 of the deficiency was remedied, positive reinforcement is offered to those who
participated and the decision is made about when to again evaluate that aspect of care.

If the deficiency is not remedied, the problem solving process is repeated

Developing quality indicators:

A quality indicator is a quantitative measure of an important aspect of service that determines

whether the service conforms to established standards or requirements. The quality indicator is
the focus for the quality improvement program, with the staff monitoring criteria that will show
whether indicator standards have been met. There are three types of indicators- Structure,
process and outcome.

Structure Indicators:

Evaluate the structure or systems for delivering care an example is adherence in checking if
emergency casts are adequately stocked or if forms documenting restraint use are completed
correctly.
Process Indicators:

Evaluate the manner in which care is delivered (Eg. the process of pain assessment, recovery of
clients from sedation and clients referral to community services).

Outcome indicators:

Evaluate the end result of care delivered Eg: incidence of nosocomial infection and adherence to
medication therapy.

Outcomes are the most important in any quality improvement program, but structural and
process indicators cannot be ignored.

Processes of care are obviously closely related to outcomes and the structure in which a process
of call occurs, enhances or hinders the effectiveness of care (Donabedian 1988). When a unit-
based team selects a quality improvement indicator, it is important that the indicator be relevant.
It is often appropriate to measure a process as well as the expected outcome, to know if standards
of care are being met. Eg: In a medicine unit, staff may choose to measure their success in
implementing the process of diabetes Instructions early while also measuring the outcome of
whether clients learn to administer insulin correctly. When a unit based team sits-together to
select quality indicators for a quality project, it helps to ask what processes and related outcomes
are in need of improvement and are most likely to make a significant contribution to how nursing
care is being practiced processes to improve may include the following.

A weak process that is causing problems (Eg: poor pain management for clients with sickle cell
anemia).

A stable process that is adequate, but that can benefit for improvement (E: calculating time for
ambulatory surgery clients).

A process linked to negative outcome (Eg: care of intravenous access sets with the occurrence of
phlebitis.

Establishing Thresholds for Evaluation:

After selecting a quality indicator, staff members, must determine ways to quantitatively measure
the indicator. The occurrence of an indicator or the percentages of times the indicator is observed
(Eg: the number of clients having surgery who can successfully explain their discharge
instructions) is a common measure. A threshold is a standard for determining whether a problem
exists. A measurement that falls below the threshold indicates problems. Staff will then
thoroughly review the factor interfering with successful client education and adherence. When
quality is an ongoing process staff continuously work to improve outcomes or performance by
raising thresholds.
It is important to understand that almost all processes have variation. For eg; consider the process
of diabetic instruction and the associated outcome of clients administering insulin. Possible
variations in the process might include the time when teaching begins, materials used in
instruction and learner motivation.

Outcome variations might include accuracy in injections site selection and proficiency in
preparing the insulin in a syringe. Setting specific thresholds may not always be achievable. The
intent in any quality improvement program is to seek ways to continuously improve. This
includes defining the acceptable level of performance and allowing for normal variability.

Data collection and Analysis:

The process of data collection and analysis can be simple or complex. The importance however
is in obtaining accurate results that help in making appropriate decisions regarding quality can
issues. Many organizations have made quality improvement so important that formal research
studies are conducted. In this case the process of data collection and analysis is very formal and
well designed. Statistical techniques are used to determine if problems that have been identified
are significant. Similarly if a quality improvement project involves the introduction of a new
practice or procedure, statistics can show whether the improvement made a significant difference
in outcomes.

When formal research is not conducted, staff may become involved in simple evaluation studies
involving the collection of data on frequencies and percentages for a predetermined number of
clients or cases. Evaluation studies offer valuable information on practice trends and whether
problems are evident. What is important in data collection is to collect data on the right criteria
and to then have adequate data from which to make decision. Quality improvement teams
usually have access to resources within three organizations that can help determine how much
information is needed for Q1 analysis.

Evaluation of Care:

Monitoring of quality indicators evaluates whether a specifically defined process reaches desired
outcomes. If results exceed or meet a threshold or if performance is within controls out for a
process, no problem has been identified and process is performing well. When thresholds for
satisfactory care are not met or when performance is below the control limits set, staff must try to
find the cause of problems.

When a process is not working well, one of the models for Q1 (Eg. FOCUS – PDCA) may be
used. This allows the staff to find the aspect of process to improve, organize an expert team who
knows the process, clarify knowledge about the process, understand any sources of variation and
select an improvement or solution. The process may take several team meetings before the group
can agree on the actions to take. In the case of diabetic instruction, it would be important to have
staff nurses, dieticians, diabetes nurse specialists and pharmacists involved as a part of Q1 team.
Once the problem is identified, additional team members may be needed. The team collaborates
to discover what are the factors associated with a practice problems. Eventually the team
recommends approaches for improving the process with the goal of achieving desired outcomes.

Resolution of Problems:

After evaluating quality problems, staff develop action plans to improve the process and
outcomes. It is important to establish actions that will be successful. Eg. The action of merely
notifying staff that a problem exists is unlikely to change practice or improve outcomes. An
action plan should be more direct. In FOCUS – PDCA, staff plan the action or improvement to
make, do or implement the change, check or analyze results of change and then act on the
findings.

Eg. The Q1 team may discover that clients are not administrating insulin correctly because they
do not have all of the necessary information (Staff are not beginning teaching as soon as clients
learn that insulin will be a form of therapy. Staff are also found to have trouble acquiring
necessary teaching materials for instruction). In this case the team may recommend having the
pharmacy send instructional materials when insulin is sent to the unit and having a clinical
pharmacist assist with instruction on insulin therapy. The staff nurses and nurse specialist may
develop a practice protocols that outlines specific content to leach until the client learns to
administer infections. Collectively the team may develop innovational approach that is designed
to get appropriate information to clients more quickly and efficiently so that learning can take
place.

Evaluation of Improvement:

After implementing an action plan, the staff must reevaluate its success. In the E.g. Staff
members may repeat monitoring of the teaching process and the results of client testing to see if
improvement has been made. The change may be positive or negative.

Communication of Results :

The results of Q1 activities must be communicated to staff in all appropriate organizational

departments. If findings and results are not communicated, practice changes will likely not occur.
Regular discussions of Q1 activities through staff meetings, news letters and memos are eg. of
communication strategies. Often a Q1 study reveals information requiring organization wide
change. In this case the organization must be responsible for responding to problem with the
resources needed to make changes. Revision of policies and procedures, modification of
standards of care and implementation of system changes are examples of ways that an
organization may respond.
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 uncooperative

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.

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, 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.

11) 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 specifications
 Lack of in-service and continuing educational program