Quality Assurance in nursing

NURSE’S ROLE IN
QUALITY ASSURANCE
PRESENTED BY:-
Ms. Ann Joseph
M.Sc. Nursing I year
111/28/2018 Nurse's role in quality insurance

Need of Quality?

How Quality Assurance began?
• In 1842, Dr. Edwin Chadwick, published a
report describing the unacceptable sanitary
conditions associated with urban and rural
communities in Britain and recommended the
structural elements of public health ‘sanitary
police’ to monitor sanitary changes.

• In 1854, Florence Nightingale, was the first to
notice the positive correlation between the
introduction of adequate nursing care to
wounded soldiers and decrease in mortality
rate among the group.

• Emery Grove surveyed all hospitals with more
than 200 Beds regarding mortality as a
postoperative complication and compared one
hospital with another using the same criteria
and recommended the development of
standardized classification of disease and
establishes a follow up system.

• In 1918, the American college of surgeon to
create the hospital standardization programme
that provide the criteria and standards for
accreditation of which were later adopted by the
joint commission on accreditation of hospitals
(JCAH).
• In 1952, JCAH later changed to Joint Commission
on accreditation of health care organization
(JCAHO) published its first list of accreditation
standard with which hospitals, had to comply in
order to receive their accreditation certificate.

• In 1966, Dr.Avedes Donabedian, Introduced
his famous three measure of quality:
structure, process and outcome.
• He described ‘structure’ as the input to the
health care system to include both human and
physical resources ‘process’ include all
procedure and activity required to deliver care
by providers and support system ‘outcome’
included results and outputs of the care
process.

• In India, a consumer protection act was
implemented in 1986.
• US Agency for International Development
(USAID) funded a multi-million Dollar, the
quality assurance project in 1990, to introduce
quality assurance in developing countries.
• In New Millennium, for accreditation of health
care organization WHO has taken the lead.

What is Quality?
11/28/2018 Nurse's role in quality insurance 9

What is Quality?
• Quality is a matter of perception, like
beauty, lies in the eyes of the beholders -
Ellie Green.
• Quality is the degree to which a product
confirms to specification and
workmanships standards-John D.
Mcclellan

Quality in Health Care:
• The quality is defined as ‘the degree to which
the patient care service increases the
probability of desired outcome given the
current state of knowledge’. - Joint
Commission for Accreditation of health care
organization.

Quality Assurance:
• “Quality Assurance is a judgement concerning
the process of care, based on the events to
which that care contributes to valued
outcomes”. - Donabedian 1982
• Quality Assurance is defined as making sure
that the services provide by the hospital are
the best possible in a given existing resources
and current medical knowledge - WHO 1992.

OBJECTIVES OF QUALITY ASSURANCE
• To ensure the delivery of quality client care.
• To demonstrate efforts of heath care providers
to provide good results.
• To formulate plan of care.
• To evaluate achievement of nursing care.
• To support delivery of nursing care with
administrative and managerial services.

CONT..
• To explain quality assurance models as
prerequisite for quality nursing care.
• To start code of ethics and professional
conduct for nurses in India.
• To appreciate importance of practicing
standard safety measures.
• Plan and conduct patient teaching sessions.
• To identify appropriate management
techniques to be used for managing resources
in given situation.

IMPORTANCE OF QA

• It helps meet client’s demands and
expectations.
• It is effective in cost saving.
• It will meet the increased demand for
effective and appropriate care.
• It will minimize the errors to attain
excellence in care.
• It will bring improvement in care and
services.

CONT.
• It will reduce the failure.
• It is important for accreditation
certification and regulation.
• It will help in attracting recognition in the
field.
• It will help to strive for excellence.
• It helps in efficient use of hospital
resources.

QUALITY INDICATORS
• The Quality Indicators are measures of
health care quality that makes use of
readily available hospital data.

QI IN HEALTH CARE SETTING:
• Waiting time for OPD and Emergency patients.
• Waiting time for the lab reports
• Number of reported errors/1000 Investigations in laboratory.
• Percentage of reports co-relating with clinical diagnosis.
• Percentage of Re-Dos (Laboratory).
• Percentage of adherence to safety precaution.
• In operation theatre: percentage of rescheduling surgeries.
• Percentage of OT utilization.
• Percentage of adverse reaction of anaesthesia.
• Urinary Tract infection rate.
• Respiratory Tract infection rate.
• Intravascular device infection rate.
• Surgical site infection rate.

CONT..
• Percentage of unplanned ventilation after
anaesthesia.
• Employee satisfaction index.
• Employee absenteeism rate.
• Employee attention rate.
• Percentage of employee who are aware of
employee right’s $ responsibilities and welfare
scheme.
• Re-exploration rate for all invasive procedure in
OT.
• Percentage of modification of anaesthesia.

QUALITY IN HEALTH CARE
• Right care at the right time in right setting.
• Meeting or exceeding customer expectation.
• Striving for and reaching excellent care
standards.
• Patient’s perception:
-Short waiting time in hospital
-Polite and Caring behaviour
-Time devoted by doctor

AIMS OF QUALITY

CUSTOMER BENEFITS
HOSPITAL BENEFITS
EMPLOYEE BENEFITS

INDICATORS SHOULD BE:
• Based on agreed definition and described
exhaustively and exclusively.
• Highly or optimally specific and sensitive
• Valid and reliable.
• Evidence based
• Defined in detail, with explicit data specification
in order to be specific and sensitive.

PRINCIPLES
CONSUMER FOCUS
LEADERSHIP
INVOLVEMENT OF
PEOPLE

CONT.
PROCESS APPROACH
FACTUAL APPROACH
TO DECISION MAKING

QUALITY CONTROL
• It is defined as the process by which actual
performance is measure; the performance is
compared with goals and the difference in
acted upon. The statistical methods are used
to measure the quality care.

QUALITY IMPROVEMENT
• The process or processes of reducing variance
is quality improvement. It is the process of
attaining a new level of performance or
quality that is superior to any previous level of
quality.

PLANNING
SETTING
STANDARD
COMMUNICATING
MONITORING
IDENTIFICATION
AND PRIORTIZING
DEFINING
ORGANIZING THE
TEAM
ANALYSING FOR
ROOT CAUSE
DEVELOPING
SOLUTION
IMPLEMENTING
AND EVAULATING
S
T
E
P
S

Basic Tenets of Quality Improvement
According to JCAHO, the following are the seven
basic tenets of quality improvement:
1. Organization is commitment from the leadership
to set quality priorities, re orient the
organization to customer focus, as functions as
role models.
2. Leaders must define quality in their organization
and incorporate it into mission statement and
planning document.
3. Need and Expectations of customer both
internal and external to organization must be
explored with corresponding organization
changes to meet those needs.

4. Employees must be involved with quality
improvement, with the focus on quality driven
daily activities.
5. The focus of improved quality must be directed
towards work processes instead of individuals.
6. Quality improvement must emphasize
prevention with quality with design rather than
quality by inspection.
7. Quality improvement is based on the use of
formal problems solving method and statistical
tools, with all the processes and decisions being
data driven.

Tools for Quality Improvement
• A critical component of QI process is data
analysis. According to Deming, statistical
method are essential for understanding
processes, bringing them under control and
improving them.

Flow chart:
START
PROCESS STEP
DECISION
STOP

FishBone Diagram:
POLICIES PEOPLE
CAUSE
PROCEDURES EQUIPMENT
EFFECT

Histogram
• It is a graph of frequency distribution of a set
of data it is useful in data analysis phase of
quality improvement. It provides a visual
summary of data and is constructed by
graphing frequencies value on the vertical axis
and categorised evenly spaced on horizontal
axis in logical order.

Continuous quality improvement
• In 1980s QA was replaced by Continuous
Quality Improvement, it involves a
coordinated and integrated approach for
improving processes that affects the patient
outcome.

• Performance Management system provides the
framework within which the performance
awareness, measurement and improvement
programs can be developed. Performance
Management had replaced later CQI.
• It encompasses three critical program (a)
Awareness (b) Measurement (c) Improvement.
• The Joint Commission on accreditation of health
care organizations (JCAHO) incorporated the CQI
philosophy into health care accreditation policy
and focused on quality paradigm shift from
quality assurance to quality improvement.

QUALITY MANAGEMENT
• It is defined as the “the process by which people
are mobilised to achieve quality goals”
• Quality Management is becoming integral to the
delivery of health care.Nursing is also benefited
from this approach because strategic planning
takes place into account what is needed to
deliver the service. Education of staff,
recruitment and retention of qualified staff and
similar issues becomes the defined target in
management of quality. Here changes in any
aspect of service design must be considered from
the whole.

TOTAL QUALITY MANAGEMENT
(TQM)
• In 1985, Nancy Warren, a behavioural scientist in US
Navy, first suggested ‘Total Quality Management’
thereafter number of TQM gurus have made their
significant contribution in the industrial management.
• Deming, Juran and Crosby are the main pioneers of the
area of Total Quality Management their contribution to
TQM are regarded as three paths, one journey and are
compared. In the health sector also, it is considered
more organised a coordinated and integrated approach
to manage/improve processes that affects patient
outcomes.

OBJECTIVES OF TQM
According to Slee and Slee, 1991; Gillen 1988, the
objectives of TQM are as follows:
• To establish specific quality goals.
• To incorporate the improvement of quality as a
responsibility shared by all employees.
• To educate and train the employees.
• To formally recognize efforts to improve quality.
• To identify specific project that promise to improve
quality.
• To provide necessary resource both real and financial.
• To focus continually on method of improving the
quality of care.

According to Mclanghin and Kalizncy
1994:
The primary objective of TQM is not only to
focus on the needs of clients, a concepts that
includes employees and patients but also to
lower costs by improving quality and
reducing waste.

Key principle TQM
• The principle of TQM are focussed on work
processes, customer orientation and statistical
data analysis are as follows:
• Management Accountability
• Teamwork
• Continuous Improvements

Tools and Technique for TQM
Total Quality Management is an overall approach to
management, it needs system tools and
techniques that can convert this approach into
realities. These tools are as follows:
• Creating Client Focus
• Long Range Plan
• Continuous Improvement
• Daily Process Management
• Employees Involvement

TQM is the most successful when it functions in
four gear or focuses as described by Oriikoff:
• Fixing an existing problem
• Preventing Problem
• Changing systems to address the root cause of
problems
• Managing Innovations.

MODELS
AMERICAN NURSE’S ASSOCIATION (ANA) MODEL
• This model is given by long and black in 1975.
This it the first proposed and accepted model
of quality assurance, which was meant for
the nursing profession but was used by
various other professional in health care. This
is cyclic model. It helps in self determination
of patient, and family, nursing health
orientation, patient’s rights to quality care
and nursing contributions

DONABEDIAN MODEL
• Donabedian Model framework is recognised
as the method of measuring quality as
structure process and outcome in the mid of
1960s.

WILSON’S MODEL
• Wilson (1987) in the late 1980s tried to
operationalise Donabedian into a tangible and
practical form. He redefined input as people,
equipment and environment i.e. the resource
needs to attain a defined level of care
‘methods’ or procedures becomes the
everyday practice that is required. ‘Outcome’
are the target of care or services as measured
by productivity, quality and client satisfaction.

QUALITY MANAGEMENT MODEL
• This model was given by OBRA (Ommibus
Budget Reconciliation Act 1987).
• This model is based on two fundamental
ideas about cause and effect in long term
care;
• (a) the higher the quality of care received by
patients, the higher his or her level of
functioning (b) the higher the level of quality
of life experienced by the patient, the higher
his or her level of experiences.

FOCUS -PDCA MODEL (Quality
Management Model)
Find, organize, clarify, understand, select,
plan, Do, Check, Act’ Model was devised in
1930, has the following concepts:
• Find a process to improve
• Organize a team that knows the process
• Clarify current knowledge of process
• Understand causes of variation.

PDCA (Plan Do Check Act)
• A four step problem solving process. It is
used in quality control, it is also known as
Shewart Cycle, Deming Cycle, Deming Wheel,
or Plan do study Act.
• Dr. W. Edwards Demings, later modified PDCA
Plan, Do, Study and Act (PDSA), so as to
better describe his recommendation in six-
sigma. PDSA cycle is called ‘define, measure,
analyse, improve and control’ (DMAIC).

JOINT COMMISSION 10-STEP PROCESS MODEL
• This Model includes 10 steps for quality
assessment/assurance/ and quality
management. These steps provide a
systematic methodology for quality
management. This model is used for
monitoring and evaluation of services.

Joint Commission 10 Step
process
Suggested TQM Tools
Assign responsibility
Delineate Scope of care/
services.
Brainstorming affinity
diagram
Prioritize aspects of
care/services
Pareto chart
Establish indicators for
identified projects
Affinity diagram, flow
chart analysis
Establish threshold for
evaluation based on
customer expectation
Return on control chart
Collect and analyse data Tally sheet

Joint Commission 10 Step
process
Suggested TQM Tools
Evaluate Effectiveness of
care and document the
level of improvement
Pareto or scatter diagram,
histogram, Fishbone
Diagram
Determine and implement
appropriate actions
Evaluate effectiveness of
action and document the
level of improvement
Tally/Check sheet, pareto
Communicate result Flowchart, histogram,
Display Matrix
Continuous Monitoring Run chart, Control Chart

PERFORMANCE MANAGEMENT
SYSTEM PARADIGM
AWARENESS
MEASUREMENT
IMPROVEMENT
PERFORMANCE
MANAGEMENT SYSTEM
PARADIGM

Quality Caring Model:
• It reflects the trends towards evidence- based practice
while simultaneously representing unique contribution
of Nursing to quality of health care.
• The Model integrates Biomedical and Psychological-
spiritual factor associated with quality health care, this
model is grounded in the works of Donabedian and
Watson and influenced by contribution from King,
Mitchell and Iruine. the overriding structure-process-
outcomes components are blended with major
constructs in human caring model and provide the
central components of the Model

Marker’s Umbrella Model:
The Marker Model is a system for providing
continuity, consistency and competency in
clinical patient care. The goal is to provide
the above the developing a structure to
standardize professional nursing clinical
practice, while maximizing patient outcomes,
preventing untoward occurrences, and
controlling healthcare costs.

The characteristics of:
• Standard development
• Continuous advanced training
• Confirmation of technical authority
• Evaluation of execution of cares measures
• Examination
• Parallel examination
• Risk Management
• Control of the demand resources
• Active problem identification
the main focus here is maintain current competence
creating new competency, or responding to a quality
assurance corrective action.

QUALITY CIRCLE
Quality circle is a system where the
employees are identified, recognized and
their participation is drawn integrated with a
system satisfies their ‘ego’ needs so that they
will be more motivated to work effectively
than only their participation. The philosophy
of quality circle is based MASLOW Theory.

PRINCIPLES OF QC:
The following are the basic principles of QC:
• Understanding to improve work life.
• There is general disposition towards active
cooperation.
• Mutual trust should be developed to make
participation meaningful.
• Even lower-level employees can make useful
contribution to achieve overall objective of the
organization.
• Human development is made possible

ELEMENTS OF QUALITY CIRCLE
ITS BUILDING PHILOSOPHY
IT IS VOLUNTARY
IT HELPS OTHERS

EVERYONE PARTICIPATES
TRAINING IS EMPHASIZED
CREATIVITY IS ENCOURAGED

There are five golden rules for a successful
quality circle program
• These are:
• Organizational preparedness
• Professional commitment
• Selection of objectives
• Voluntary participation and training
• Flexibility

Factors that influence quality
measurement and improvement
• Patient’s value
• Societal value
• Structural resources
• Accreditation board
• Legislature enactment
• Legal interpretation
• Available resources
• Administrative values
• Nursing values

Importance of QC
• Improves personal capabilities
• Induces self confidence
• Participative style emerges
• Every employee gets training
• Helps in initiating changes
• Improves quality of work
• Lower cost outcome of organization
• Involves everyone in problem solving
• Develops personal stake in well being of organization
• Managerial personel gets training.

APPROACHES
APPROACHES
GENERAL
SPECIFIC

GENERAL APPROACH
• It involves large governing of official body’s
evaluation of person’s or agency’s ability to
meet standard at a given time.
 Credentialing:
• It is the process of determining and
maintaining nursing standards. It is generally
defined as the formal recognition of
professional or technical competence and
attainment of minimum standards

According to Hinsvark, Credentialing process
has 4 functional components:
• To produce a quality product
• To confer a unique identity
• To protect provider and public
• To control the profession

Licensure:
• Licensure is an approach to ensure that
individual and organizations meet minimum
standards to protect the health and well being
of the public. It is usually a
government/council approach

Accreditation:
• It is usually a voluntary, non governmental
approach to grant recognition to those
organization that meet quality standards
related to essential health care structure
process and outcome.

Certification:
• It is also a voluntary governmental or non-
governmental approach to grant recognition
to individual and organization that have met
high standards in specialized area.

SPECIFIC APPROACH
• Specific approaches are methods used to
evaluate identified instances of providers and
client interaction.
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.

NURSING AUDIT
• It is the evaluation of patient care through
analysis of written record’s maintained by
nurse’s in patient’s treatment profile.
-Avatar Brar.

Goals of Nursing Audit
• To improve quality of health care
• To promote improved communication among
nurses and other health team members
• To improve quality of nursing
• To detect and analyse problems and errors

Essential Characteristics of Nursing
Audit:
• Written standards of care should be there
against which to evaluate nursing care
• Evidence that actual practice was measured
against such standards
• Examination and analysis of findings
• Evidence of corrective action being taken
• Evidence of effectiveness of correction action
• Appropriate reporting of the audit process

PURPOSE OF NURSING AUDIT
• Encourages to be actively involved
• Clearly communicates standards
• Identifies why goals were not met
• Facilitates use of health resources
• Monitor quality of services
• Monitor improvement of services
• Opens new avenue in nursing research
• Improves quality of care
• Encourages high standards
• Maximizes quality

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 cooperation and communication
among the nurse and health team
• It will help for each professional nurse for her self
evaluation
• It will reduce medico legal complication
• It will broaden and strengthen nursing services

UTILIZATION REVIEW
• These activities are directed towards assuring the
care actually needed and the cost appropriate for
the levels of care provided.
Types of Utilization review
• Prospective: it is an assessment of the necessary
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
been given

EVALUATION STUDIES
Donabedian’s structure-process-outcome Model
• Donabedian quality framework is recognized as a
method of measuring quality as structure,
process and outcome in Mid of 1960s.
• According to model, ’structures’ include the
adequacy of health care facilities, qualification of
practioners and financial aspect of care the
‘processes’ are the aspects of care and
‘outcomes’ are the process and concrete
measurement of effectiveness of care.

Growing complexity in the health care system
has become prove to high risk so the quality
of our current care delivery system is
dependent on complex internal systems
working smoothly and efficiently together,
for the last few years the concepts of six
sigma has also entered in health care system.
SIX SIGMA IN HEALTH CARE

• Goals of Six Sigma
The primary goal of six sigma is to improve
customer/client satisfaction and thereby
profitability, by reducing and eliminating defects
• Benefits of Six Sigma
• Increased cost savings
• Decreased level of variations
• Improved service quality
• Maintain consistent quality of output
• Better customer/client services
• Enhanced employees moral and satisfaction

METHODOLOGIES
DMAIC:
• It defines opportunity, measure performance,
analyse opportunity, improve performance,
control performance is a rigorous data driven
quality problem solving approach. It is an
improvement system for existing services
falling below specifications/standards and
looking for incremental improvement. It
consist of the following five steps:
• Define-Measure-Analyse-Improve-Control

• DMADV:
• Process (define, measure, analyse, design,
verify) is an improvement system, used to
develop new processes or services/product at
six sigma level.
• Define-Measure-Analyse-Design-Verify

• The Six Sigma Model:
• It has been developed by Beth Lanham and
Pamela Manson Cooper in 2003, is based on
steps of DMAIC. This model has a great
practibility into the health care setting due to
practical approach to standardizing process
and use of its statistical method. It focuses on
process/service improvement efforts to
reduce the chance of errors occurring to 3.4
errors per million.

Steps involved in implementing six sigma in a hospital
• Identification of the customer expectations
• Identification of various processes involved in the
system
• Develop a quality function deployment for a hospital
• Identification of processes critical to quality (CTQ)
• Develop project definition along with the time frame
and expected outcome as per the customer
expectation
• Follow DMAIC process of the project
• Complete the project, record findings and explicit
benefits
• Choose another project.

• STANDARD NURING CARE
WHAT IS STANDARD?
• It is a benchmark of achievements which is
based on a desired level of excellence.
Nursing Service Standard:
• Focuses on the provision, management, and
monitoring of hospital based care
Standards of Nursing care practice:
• It describes what nurse does and how does
she provides nursing care

 Standard of governance:
• The nursing department is required to monitor or
evaluate both quality as well as appropriateness of
Nursing Care.
 Steps for Development of Nursing Standards
• Identify a function or system that requires standards
• Identify a team or panel of expert to address standard
• Identify inputs, processes and outcomes of function or
system.
• Define quality characteristics
• Develop standards
• Gather Background information
• Draft standard
• Develop indicators for standards
• Assess appropriateness of standard and indicators.

ROLE OF NURSE IN QA
• Participate in quality improvement team
• Properly supervise and check whether patient is receiving
proper care or not.
• Contribute innovation and improvement of patient care
• Participating in improvement projects and patient safety
initiatives
• Participates in CNE programs
• Periodic and continuing appraisal
• Participate in research work
• Identify area where needs improvement
• Help in professional growth
• Maintain international standard.

Quality Assurance in nursing

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