Mr. Harsh Raman

TERMINOLOGIES
• Quality: It is the degree to which a product
confirms to specification and workmanship
standards. (John D. McClellan)
• Quality Management: It refers to a philosophy
that defines a corporate culture emphasizing
customer satisfaction, innovation and employee
involvement.

TERMINOLOGIES
• Continuous Quality Improvement: It is an ongoing
process of innovation, prevention of error, and staff
development that is used by corporations and
institutions that adopt the quality management
philosophy.
 Quality Assurance: Means of delivering relevant and
effective product (medical care) in accordance with the
standards.
 Accreditation: The process of providing an official
approval to an organization stating that it has achieved
a required standard.

 JCAHO: Joint Commission on Accreditation of Health
care Organization is the primary accrediting organizing for
health care institutions.
 Standards: These are formal statements about how patients
should be managed or services be delivered.
 Audit: An independent review conducted to compare some
aspect of quality performance with a standard for that
performance.

DEFINITION
*“Quality assurance is defined as making sure that the
services provided by hospital are the best possible in a
given existing resources and current medical
knowledge.”-WHO (1992)
*“Quality assurance is a judgment concerning the
process of care based on the extent to which that care
contributes to valued outcomes.”
-Donabedian 1982

*“Quality assurance is a management system designed to give
maximum guarantee and ensure confidence that the service
provided is up to the given accepted level of quality, the
standards prescribed for that service which is being achieved
with a minimum of total expenditure.”
-British Standards Institute
* “CQI is an ongoing quality improvement measure using
management and scientific methods of quality assurance
involving data collection, its analysis, and formulating ways to
improve performance outcome according to proposed
standards.”

OBJECTIVES
 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,
predictable processes based on best practices.
 Set Incremental goals as needed.
NASA Ames Research Center Health Unit

To provide technical assistance
in designing and implementing
effective strategies for
monitoring quality
To refine existing methods
for ensuring optimal
quality health care through
an applied research
programme
(Decker, 1985 and Schroeder, 1984).

PURPOSES/ NEED
 Rising expectations of consumer of services.
 Increasing pressure on allocation of funds.
 The increasing complexity of health care organizations.
 Improvement of job satisfaction.
 Highly informed consumer
 To prevent rising medical errors
 Accreditation bodies
 Reducing global boundaries.

IMPORTANCE
To prepare
nursing
personnel for
implementing of
quality
assurance model
in nursing.
Introduce code
of ethics and
professional
conduct for
nurses in
India.

PRINCIPLES
 QM operates most effectively within a flat, democratic and
organizational structure.
 Managers and workers must be committed to quality
improvement.
 The goal of QM 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.

TYPES OF QUALITY ASSURANCE:-
*External Quality Assurance:- Quality
assurance can be evaluated by independent
assessors or people from outside the
institution/hospital.
*Internal Quality Assurance:- Quality
assurance can be evaluated by local assessors
or senior person from the same
institution/hospital.

BARRIERS OF CONTINUOUS QUALITY
IMPROVEMENT:
1. Difficult to foster collaboration between multiple
stakeholders.
2. Difficult to identify which processes to prioritize
improvement efforts.
3. Ill suited process management tooling.
4. Governing/controlling change
5. Lack of employee engagement

SOLUTIONS OF THE QUALITY IMPROVEMENT:
Individual
problem
solving
Rapid team
problem
solving
Systematic
team problem
solving
Process
improvement
solving

General approach
• Credentialing
• Licensure
• Accreditation
• Certification
• Charter
• Recognition
• Academic degree
Specific approach
• Audit
• Direct observation
• Appropriateness evaluation
• Peer review
• Bench marking
• Supervisory evaluation
• Self-evaluation
• Client satisfaction
• Control committees
• Services
• Trajectory
• Staging
• Sentinel

ELEMENTS/ COMPONENTS
 According to Donabedian;
Structure Element- The physical, financial and
organizational resources provided for health care.
Process Element- The activities of a health system or
healthcare personnel in the provision of care.
Outcome Element- A change in the patient’s current or
future health that results from nursing interventions.

 According to Manwell, Shaw, and Beurri, there are 3A’s
and 3E’s;
Access to healthcare
Acceptability
Appropriateness and relevance to need
Effectiveness
Efficiency
Equity

STANDARDS
‘Standards are written formal statements to describe
how an organization or professional should deliver health
service and are guidelines against which services can be
assessed.’
Kirk and Hoesing (1991) stated that standards are
needed to;
 Provide direction
 Reach agreement on expectations
 Monitor and evaluate results
 Guide organizations, people and patients to obtain optimal
results.

 AHRQ –Agency for Healthcare Research and
Quality
 IHI –Institute for Healthcare Improvement
 JCAHO –Joint Commission on Accreditation of
Healthcare Organizations
 NAHQ –National Association for Healthcare
Quality
 IOM –Institute of Medicine
 NCQA –National Committee for Quality Assurance

Sources of Nursing Care Standards
*Professional organisation, e.g. Associations, TNAI,
*Licensing bodies, e.g. Statutory bodies, INC,
* Institutions/health care agencies, e.g. University
Hospitals, Health Centres.
*Department of institutions, e.g. Department of
Nursing.
* Patient care units, e.g. specific patients' unit.
*Government units at National, State and Local
Government units.
* Individual e.g. personal standards

LIST OF NURSING STANDARDS:-
Normative and
Empirical
Ends and Means
Structure,Process and
Outcome

LIST OF NURSING STANDARDS (Acc to ANA):-
Quality of Practice
Education
Professional Practice
evaluation
Collegiality
Ethics
Collaboration
Research
Resource utilization
Leadership

Areas
of QA
Outpatient
department
Emergency
medical
services
In- patient
services
Specialty
services
Training

MODELS
1. Donabedian Model (1985):

2. ANA Model: This first proposed and accepted model of quality
assurance was given by Long & Black in 1975. This helps in the
self- determination of patient and family, nursing health
orientation, patient’s right to quality care and nursing
contributions.
Identify
structure ,
standard and
criteria
Apply the process,
standards and
criteria
Evaluate
outcome of
standards
and criteriaoutcome
structure
process

3. Quality Health Outcome Model: The 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
(Individual,
Group/ organization)
Intervention Outcome
Client
(Individual, Family & Community)

4. Plan, Do, Study, Act cycle: It is an improvement model
advocated by Dr. Deming.
A Plan is developed to test one of the improvement changes.
During the Do phase, the change is made, and data are
collected to evaluate the results.
Study involves analysis of the data collected in the previous
step. Data are evaluated for evidence that an improvement has
been made.
The Act step involves taking actions that will ‘hardwire’ the
change so that the gains made by the improvement are
sustained over time.

5. Six Sigma: It refers to six standard deviations from the mean
and is generally used in quality improvement to define the number
of acceptable defects or errors produced by a process.
*It consists of 5 steps: define, measure, analyze, improve and
control (DMAIC).
Define: Questions are asked about key customer requirements
and key processes to support those requirements.
Measure: Key processes are identified and data are collected.
Analyze: Data are converted to information; Causes of process
variation are identified.
Improve: This stage generates solutions and make and measures
process changes.
Control: Processes that are performing in a predictable way at a
desirable level are in control.

*WILSON’S MODEL:- Wilson 1987 in the late
1980’s tried to operationalize Donabedian model
into a tangible and practical form. He redefined it
as inputs, methods or procedures and outcomes.
He described inputs as personnel, equipment and
environment. Methods as procedures became the
everyday practice and the outcome are the targets
of care or services as measured by productivity,
quality and client satisfaction.

MARKER’S UMBRELLA MODEL:- This is a system for
providing continuity, consistency and competency in clinical
patient care. The goal is to provide the above by developing a
structure to standardize professional nursing clinical practice. The
model describes connecting the characteristics for a
comprehensive quality assurance model are:
*Standard development.
*Continuous advanced training.
*Confirmation of technical authority.
*Evaluation of execution of cares measures
*Examination
*Risk management
*Control of demand resources
*Active problem identification.

QUALITY TOOLS UDSED FOR CQI
chart audits
failure mode and effect analysis: prospective view
root cause analysis: retrospective view
flow diagrams
pareto diagram
histograms
run charts
control charts

INDICATORS OF QUALITY ASSURANCE
Waiting time for different services in the hospital
Medical errors in judgment, diagnosis, laboratory
reporting, medical treatment or surgical procedures, etc.
Hospital infections including hospital- acquired
infections, cross infections.
Quality of services in key areas like blood bank,
laboratories, X- ray department, central sterilization
services, pharmacy and nursing.

Identify needs.
Assemble a
multidisciplinary
team.
Collect data.
Establish measurable
outcomes and quality
indicators.
Select and
implement a
plan.
Evaluate implementation
of plan and achievement
of outcomes.
QUALITY IMPROVEMENT
PROCESS- STEPS

JCAHO quality assurance guidelines/steps:
1. Assign responsibility
2. Delineate scope of care and services
3. Identify important aspects of care and services
4. Identify indicators of outcome (no less than 2; no more than 4)
5. Establish thresholds for evaluation
6. Collect data
7. Evaluate data
8. Take action
9. Assess action taken
10. Communicate

FACTORS AFFECTING QUALITY ASSURANCE IN NURING
CARE
-Lack of resources
Personnel problems
Unreasonable Patients and attendants
Improper maintenance
Absence of well informed populance
Absence of accreditation laws
Inspect hospitals and ensure that basic requirements are met.
Lack of incident review procedures
Delayed attendance by physician/nurse
Lack of good hospital information system
Absence of conducting patient satisfaction surveys
Lack of nursing care records
Miscellaneous

FUNCTIONS OF NURSE IN QUALITY ASSURANCE
*Encourage team member to be actively involved in quality
process.
*Implement quality control and improvement
*Communicates standards of care too team members
*Assess appropriate source of information
*Evaluate quality and activity
*Assist in the planning and organization of quality assurance
program
*Assist in developing annual auditing scheduled
*Attend and participate in workshop and seminar
*Develop and implement plan and action to correct
deficiencies.

NEW TRENDS IN QUALITY ASSURANCE PROGRAME
Quality
Council
Standard
of care
Concurrent
monitoring
Interdisci-
plinary
quality
assurance
Performan-
ce
appraisal
Performa-
nce
appraisal

*Quality assurance practices in Europe: a survey of molecular
genetic testing laboratories.
*In the 2000s, a number of initiatives were taken internationally to
improve quality in genetic testing services. To contribute to and
update the limited literature available related to this topic, we
surveyed 910 human molecular genetic testing laboratories,of which
291 (32%) from 29 European countries responded. The majority of
laboratories were in the public sector (81%),affiliated with a
university hospital (60%). Only a minority of laboratories was
accredited (23%), and 26% was certified. A total of 22% of
laboratories did not participate in external quality assessment
(EQA) and 28% did not use reference materials (RMs). The main
motivations given for accreditation were to improve laboratory
profile (85%) and national recognition (84%).

*Quality assurance practices in Europe: a survey of molecular
genetic testing laboratories.
*Nearly all respondents (95%) would prefer working in an accredited
laboratory. In accredited laboratories, participation in EQA
(Po0.0001), use of RMs (P¼0.0014) and availability of continuous
education (CE) on medical/scientific subjects (P¼0.023), specific
tasks (P¼0.0018), and quality assurance (Po0.0001) were
significantly higher than in non-accredited laboratories.
*we showed that accredited laboratories (average score 92) comply
better than certified laboratories (average score 69, Po0.001), and
certified laboratories better than other laboratories (average score
44, Po0.001), with regard to the implementation of quality
indicators.
*We conclude that quality practices vary widely in European genetic
testing laboratories. This leads to a potentially dangerous situation
in which the quality of genetic testing is not consistently assured.

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