• 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
• 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
Quality Assurance: Means of delivering relevant and
effective product (medical care) in accordance with the
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
*“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
*“Quality assurance is a judgment concerning the
process of care based on the extent to which that care
contributes to valued outcomes.”
*“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
To successfully achieve sustained improvement in health
care, clinics need to design processes to meet the needs of
To design processes well, and systematically monitor,
analyze, and improve their performance to improve
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
To refine existing methods
for ensuring optimal
quality health care through
an applied research
(Decker, 1985 and Schroeder, 1984).
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
Reducing global boundaries.
QM operates most effectively within a flat, democratic and
Managers and workers must be committed to quality
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
*Internal Quality Assurance:- Quality
assurance can be evaluated by local assessors
or senior person from the same
BARRIERS OF CONTINUOUS QUALITY
1. Difficult to foster collaboration between multiple
2. Difficult to identify which processes to prioritize
3. Ill suited process management tooling.
4. Governing/controlling change
5. Lack of employee engagement
SOLUTIONS OF THE QUALITY IMPROVEMENT:
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
Access to healthcare
Appropriateness and relevance to need
‘Standards are written formal statements to describe
how an organization or professional should deliver health
service and are guidelines against which services can be
Kirk and Hoesing (1991) stated that standards are
Reach agreement on expectations
Monitor and evaluate results
Guide organizations, people and patients to obtain optimal
AHRQ –Agency for Healthcare Research and
IHI –Institute for Healthcare Improvement
JCAHO –Joint Commission on Accreditation of
NAHQ –National Association for Healthcare
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
* Patient care units, e.g. specific patients' unit.
*Government units at National, State and Local
* Individual e.g. personal standards
LIST OF NURSING STANDARDS:-
Ends and Means
LIST OF NURSING STANDARDS (Acc to ANA):-
Quality of Practice
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
Apply the 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.
(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
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
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
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:
*Continuous advanced training.
*Confirmation of technical authority.
*Evaluation of execution of cares measures
*Control of demand resources
*Active problem identification.
QUALITY TOOLS UDSED FOR CQI
failure mode and effect analysis: prospective view
root cause analysis: retrospective view
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.
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
FACTORS AFFECTING QUALITY ASSURANCE IN NURING
-Lack of resources
Unreasonable Patients and attendants
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
FUNCTIONS OF NURSE IN QUALITY ASSURANCE
*Encourage team member to be actively involved in quality
*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
*Assist in developing annual auditing scheduled
*Attend and participate in workshop and seminar
*Develop and implement plan and action to correct
NEW TRENDS IN QUALITY ASSURANCE PROGRAME
*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
*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.