UNIT 1 QUALITY ASSURANCE IN

NURSING SERVICES
Structure
1.0 Objectives
1.1 Introduction
1.2 DefEnition of Common Terms
1.3 Importance of Quality Assurance
1.3.1 Concept of Quality Assurance
1.3.2 Factors Influencing Quality Assurance
1.3.3 Professional Factors
1.3.4 Economic Factors
1.3.5 Social/Political Factors
1.3.6 Principles of ~;alityAssurance
1.3.7 Impact of Quality Assurance on Patient Care
1.4 Quality Assurance Cycle
1.5 Selected Models for Quality Assurance
1.6 Quality Assurance Programme
1.6.1 Steps in Organizing Quality Assurance Programme in a Hospital
1.6.2 Role of a Nurse Administrator in Organizing Quality Assurance Programme
1.7 Let Us Sum Up
1% Key Words
1.9 Answers to Check Your Progress
1.10 Further Readings

1.0 OBJECTIVES
A& going through this.mit, you should be able to:
W i d e quality, quality assurance;
explain the concept of quality assurance;
e state the importance of quality assurance in nursing services;
enumerata the factors influencing quality assurance;
explain the principles of quality assurance;
discuss the impact of quality assurance on patient care;
describe the quality assurance cycle;
Explain the selected models for quality assurance;
8 describe the steps in organizing quality assurance programme; and
8 discuss the role of a nurse administrator in organizing quality assurance programme.

1.1 INTRODUCTION
The assurance of quality is fundamental to the delivery of health care. All countries
regardless of their economic status share a major common concern to ensure that their
health care system and its services meet the requirements of their population. ~ e a l t care
h
professiopak, individually and collectively, should always place great importance on the
provision of high quality care to their clients. It is now recognized that the assurance of
quality requires a systematised explicit management strategy which is being constantly ,
'

. . . -- . . "" .. C .. .
evaluated and refined. An important role of any health care syskm is to ensure quality of its
... . * .. . ..
Quality Patient Care and levels. Nursing, being the integral and indispensible part of health services, should be
Quality Assurance directing its members towards providing quality services at primary, secondary and tertiary
level health care institutions.

In this unit you will be acquainted with definition, concepts and need for quality assurance.
Principles and factors influencing quality assurance and how to set up quality assurance
programme has also been included. All this will help you as nurse administrator to plan a
programme of quality assurance to evaluate nursing care at your institution.

Let us now learn the definition of common terms that will be used in this unit frequently.

Quality of care must be defined in the light of the provider's technical standards and patient
expectations, while no single definitionof health services quality applies in all situations,
the following definitions are helpful guides:
Quality is never an accident; it is always the result of high intention, sincere effort,
intelligent direction, skillful execution; it is the wise choice of many alternatives.
Quality means proper performance (according to standards) of interventions that are
known to be safe, that are affordable to the society in question, and that have the ability
to produce an impact on mortality, morbidity, disability and malnutrition (Reomer, M.I.
and C. Montoya Aguilar, W.H.O., 1988).
The quality of technical care consists in the application of medical science and
technology in a way that maximizes its benefits to health without correspondingly
increasing its risks. The degree of quality is, therefore. the extent to which the care
provided is expected to achieve most favourable balance'of risks and benefits (Dr.
Avedis Donabedian, 1980).
Quality health care is care @at is needed and delivered in a manner that is competent,
caring,cost-effective and timely and minimizes risk and achieve desirable benefits.

Some have detined quality in terms of key features of service e.g. accessibility. relevance to
need, equity, social r'equirements at the lowest cost and is stated to involve three elements:
1) Customer Quality: Wether the service gives customers what they want, as
measured by customer satisfaction and complaints.
2) Professional Quality: Whether the service meets customer needs as defined by
professionals and whether the professional procedures and standards, believed to
produce the required outcomes are observed.
.3) Personnel Quality: The design and operation of the service process to use
resources in the most efficient way to meet customer requirements.

There are different perspectives of quality in health care. The perspectives of quality in
health care are sumrnarisedin Table 1.l.

Table 1.1: Perspectives of Quality in Ilealth Care

4hwkkr's PerqpWives : Quality means providing the best possible care

available to the patient.

: Providng effective,care in a cost-conscious

environment that may include the rationing of healtp
care especially when resources are iimited.

se to cwe my symptoms in

Quality Assurance
Quality assurance refers to a system for monitoring outcomes of professional
interventions and departmental activities compared with estublished standards to
 Quality assurance encompasses necessary changes or improvements to ensure survival. Quallty Assurarice i n
It mvclves ident~fylr:g 2tandards for excel!ance, evaluating care against those standards Nursing Services
ar~dthen taking aciioii to mrxeci deficiencies and ach~evethe standards (Zimmer, 1974).

Now that we have leami what quality assuraoce is, let us proceed with the discussion on
needimportance of' quality acsurance.

1.3 I M P ~ % ? % % F QUALITY ASSURANCE

1.3.1 Concept of Quality Assurance
We have dicned tl:: lerins q:uI~tyar,d quality assurance, we have also got an idea of
various perspecti\ es of q:la!itj in health cate.

Now let us trace the developinent of quality assurance in industry and subsequently its
development irr health care prcfession.

Quality and quality assurance are not new concepts, but their formalised adoption has been
a slow process both 111 industry and in the health service sectors.

Quality Assurance has had a high profile in health care since the late 1980s. Many of hte
concepts and compo-nentsin indusnial quality assurance system had parallels in health care
setting.

However, concern for the quality of care is as old as medicine itself. Individual practitioners
from Hippocrates to Florence Nightingale have recorded their observations of poor quality
care and made recommendations for Improvement. The first formal systems for the
assurance of quality care, however, developed alongside the gradual professionalisation of
medicme, nursing and other health professions. As early as the 16th century, the Royal
College of Physicians made reference in its found~ngcharter to the need to 'uphold
standards for publ~cbenefit'. In moat cases, the colleges and other professional
associations took their respons~b~l~ty
for 'upholding standards' to include regulation of

.
education and naining, control of admission, and development of powers of dismissal from
the profession on grounds of malpractice.

Formal standards and inspection and monitoring procedures have been developed for
various aspects of practice. The Royal Ccllege of General Practitioners launched a 'quality
--
initiative' in 1985, and as early as 1965 the Koyal College of Nursing set up its 'Standards of
Care' project which has now developed into a major programme of research, development
and education. Guidelines and standards have been produced by various professional
bodies. Various Governniefit reports and documents have drawn the attention to the need
for a service, which provicled high quality care within available resources-in other words
value for the taxpayer's nloney. Both government and the professions have now recognized
the iniportance of quality assurancl: in health care. There is considerable activity
throughout rhe National Iieaitli Cars Services and in private practice in discussing, piloting
and setting up quality assurance procedures. All health professionals are going to be
involved in some such system.

1.3.2 Factors Influenci~gQuality Assurance

You have leanit nboalt thr tmp~~rtance of quality assurance in health care setting. A list of
various factors \vhich :nay adlversely influence quality assurance is presented. Read them
and include additional points relevant to nursing education. adminisnation and practice.

Various facthrs which map adversely influence the quality assurance programme are:
Lack of resources -- infrastructure, equipment and supplies, etc.
Personnel problem --lack of trainedl skilled and motivated employees.
Uareasonable expectations of patiei~tsand their attendants.
@ Absence of well informed populace.
Absence of' accreditation i w s .
Quallty Patient Care and W Lack of good hospital information system.
Quallty Assurance ,

W .Absence of conducting patient-satisfaction surveys.

W Lack of proper maintenance of nursing care records.
W Miscellaneous factors-lack of good supervision, policy and administrative manuals,
prqcedure manuals, evaluation tools, and techniques, written job descriptions,
continuing educational programmes etc.

1.3.3 Professiond Factors

Codes of Conduct
Each profession has a code of conduct or a statement about professional behaviour which
outlines professional rules. Boundaries are set for acceptable practice. If you, as a
practitioner, operate outside your code of conduct, your licence'topractise may be
'
withdrawn. Quality assurance sets the codes of conduct into a broader framework.
Professional bodies a~ also responsible for standards of training and qualification for
practice.
Growth of Autonomy and Acmuntab'fty
In recent years professionals have taken increasing responsibility for their own practice.
This has highlighted commitment to a consistent and accountable service-+ major aim of a
quality assurance sys&.

A quality service to clients often demands an inter-professional approach. This means that
communication between the professions must be effective and efficient. Such
communication is an integral part of quality assurance. Hence quality assurance has an
important role to play in promoting and maintaining inter-professional relationships.
Moral Issues
There is a moral obligation on everyone working in health care to provide a responsible and
caring service to everyclient. Moral dilemmas can arise where a few people benefit from a
very expensive care programme. The same expenditure in a low technology area could
benefit many more clients. Further, the moral beliefs of individual health care professionals
may affect the type of service they feel are able to provide.

Quality assurance activities encourage open debate about the nature and extent of
provision. They oherefore help to ensure that moral judgements ate only made after carefui
scrutiny of all the possible options.

13.4 Economic Factors

Changing demography compels the adoption of quality assurance in health care. Far
example, existing population changes will lead to a society with an increasing number of
dependent people whose health care must be paid for by the economically active.
Therefore, there is a growing need for an efficient and economically run health care service.
This is now becoming a sensitive political issue as choices are made and priorities
established.
Resource Distribution
Quality assurance provides objective evidence for the accountability. It esablishes that the
service delivered is appropriate and meets clients' needs at an acceptable cost. It also
-
supports individual accountability as demanded by general management, and is an
essential element in the evolution of service contacts. Finally, it provides a basis on which ,/

clients could choose between different suppliem of care.

1.3rR SociaVPolitical Factors

Public Awareness
Pressure from society is creating the need for a more efficient health servlce. 'me public
nnnatn1l.r arm b t t n t ;nfnrmnrl ahnnnt hnalth earn anrl their Anhtc tn hnnlth 0s- T k p r r arm mn-
 service is received. More and more, the client's voice is being heard in respect of health care Quality Assurance i o
issues. In the past, clients have felt excluded from the professional decision-making process Nursing Scrvlccs
and were poorly informed about their treatment. A quality assurance system should ensure
that the client's opinion is taken into account and that the client is consulted about
treatment. Such consultation can even be regarded as the client's moral right.

Social Expectations
Changing social expectations are another reason for quality assurance in health care. There
is a growing number of consumer bodies which campaign for the rights of individuals or
groups. Some of these have drawn up quality standards for use in client care settings. The .

media are often keen to take up such issues and to campaign for improved service.

s a voice in maintaining standards in health care. Many minimal standards

for practic&re already agreed in law and form part of the quality assurance programmes of
health c& personnel.
Accreditation
Accreditation of hospitals is very important for maintenance of quality care to clients and it
is being considered by many countries. Private nursing homes need a licence to operate and
are inspected by officers of the local Health Authority, e.g. in USA, there is a statutory
requirement for hospitals to be audited and accreditated if they are to receive public
funding.
International Pressure
The international political forum also has its effect on the health service. As a member of the
World Health Organization, countries are committed to the development of quality
assurance systems in health care. Several United Nations 6-ganisations also comment on
health care standards.

1.3.6 Principles of Quality Assurance

You have gathered information pertaining to the factors influencing quality assurance. To
ensure quality assurance in patient care it is essential to comprehend the underlying
principles.

Let us therefore look at the certain principles which can be followed in initiating a quality
assurance programme. . .These are:
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.l) It must be facused on client peed. ', ..
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the community and the health team.

2) It requirts a collaborative effort amcng all health professioals to measure and improve t

care..
3) During planning a co-ordination is needed to ensure that objectives and activities of
each health professional enhance rather than conceal those of other professionals.
4) Care should be taken to ensure that resource expenditure for quality assurance activities
is appropriate in amount.
5) Key to ensure quality in patient care is accurate assessment of patient care, the key to
successful auditing of care is adequate documentation of care.
6) Effective monitoring of the nursing system operations depend upon receiving feedpck
from all parts of the nursing system or process. .'
7) Evaluation of care will not by itself improve practice rather feedback to practitioner is
required both to perpetuate good practice and to replace unsatisfactory fhtervention
with more effective method.
..
8) For an cffec:ive quality assurance collective analysis of quai*assessment data must be
linked to the decision-making. Foms on data based for decision-making. Decisions
shnut nrnhlern areas and im~rovementsshould be based 6n accurate and timely data
Quallty Patient Care and (simple quantitative) and not on guesses. For example, instead of assuming what the
Quality Assurance
client thinks, feels, and needs, the quality assurance team collects information on client's
needs and level of satisfaction by interview or questionnaire. Further the nurse manager
who processes quality assessment data must be free to manipulate input variables in
order to improve nursing quality i.e, the nurse manager must have authority to change
staffing formulas or hiring policies.
9) Focus on Systems and hocesses: By focusing on the analysis of service de:ivery
processes, inputs, and outcomes, quality assurance approaches allow health team to
develop an in-depth understanding of a problem and provide them with the means to
address its root causes. Later on they can even analyze processes to prevent problems
before they occur.
10) Focus on team approach to problem-solving and quality improvement: Wcipatory
approach (team) offers high quality technical product. Involving employees in problem-
solving and opportunity improvements brings unique expertise and insight to the
quality improvement efforts. This leads to a thorough problem-analysis and makes
development of a feasible solation that is more likely tn be accepted and supported and
reduces the possibility sf resistance in implementation.

1.3.7 Impact sf ,QualityAssurance: on Patient Care

By end of the sub-section you will be able to justify the need of 4.4programme in health
care. Health care quality is system oriented. Since systems are comprised of structure,
processes and outcomes, health care quality focuseS on studying the elementes of each of
these components and finding ways to improve their status collectively. One basic principle
of health care quality is that the health care system is interdependent on its parts and
elements, no part is more important than the other in order to achieve a better outcome to
the patient. Therefore, d l of the system elements need to he taken into considera5on when
improvements are sought through quality assurance.

There are many incentives for Quality Assurance in health care that have an impact on
patient care as shown in Fig. 1.1.

Professional Factors Economic Factors SociaWolitical Factors

Codes of conduct Demographic change 0 Public awareness
Growth of autonomy @ Resource distribution 0 Social expectations
Accountability Legislation
Interprofessional3sm
Moral issues II I Accreditation
International pressure

Fig. 1.1: The incentives for quality assurance in health care

Having undergone the discussion on concept, factors influencing. principles and impact of
quality of assurance on patient care. let us now go on to section 1.4 to determine the steps
of quality assurance activities termed as quality asswance cycie.
 -
Quality Assurance in
1.4 QUALITY ASSURANCE CYCLE Nursing Services

The Quality Assurance process is a simple, logical, and cyclical process for planning and
implementing quality assuraqce activities as shown in Fig. 1.2.

It must be applied flexibly to meet the needs of a specific programme. The process may start
with a comprehensive effort to define standards and norms as described in Steps 1-3, or it
may start with small-scale quality improvement activities in Steps 5-10 or start. with
comprehensive monitoring in Step 4.

Fig. 3.2: Quality Assurance Cycle

Quality assurance is a continuous process, Comparison is made periodically which enables

the effects of changes to be monitored. In order to be silccessful, it is obvious that quality
assurance must be organised and managed through a structured systeaa. At a basic level,
the quality assurance incorporates the following stages (Lang, 1984):
Setting standards;
Appraising actual achievements:
Planning for improvement;
Taking action when required.

These basic steps are repeated in cyclical nature as shown in Fig. 1..3.

This is commonly referred to as the.quality wheel.

Quality Patient Care and Quality assurance is a never-ending improvement in the quality of care. If provision is level
Quality Assurance with or above expectation, then the standard may be changed to specify an improved level
of practice.

Check Y ~ u rProgress 1
1) Define the terms;
a) Quality

b) Professional Quality

C) Quality A s s ~ a n c e
....".......*"................................................................................................................................

tors influencing quality assurance.

..............................................................................................................................................

............................................................................................................................................................
3) Match the Statementsof Column 'A' with those of Column 'R'.
A B
a) Provider's perspective i) is that needed and delivered in a
manner that is competent, caring and
cost effective.
b) Key to suc~essfulauditing j$ requires a colIaborative effort among all
health professionals to measure and
impiove care.
c) ~ u a l i t yh i l t h care iii) is adequate documentation of care.
d) Quality whkel comprisesof iv) providing the best possible available
care to the patient.
nce V) setting standards, appraising planning
for improvement and acting.
vij problem-solving and quality
improvement.

Let us now go on to the next section where we shall discuss about the selected models for
quality assurance. ,

Standards for nursing practice help to fulfil the pr~fession'sobligation to provide quality
nursing services to the clients. The standards must be implemented in daily practice to .-
assure quality nursing care. Thus, the basic premise is thai'it is possible to implement
standards via a quality assurance programme.

Followi~gmodel adapted from Norma, M. Lang is proposed to assist the Individual &rse
practitioner or a EXDUD of nurse ~ractitionersta irn~lerenta r?roerarnmeof assuring aualitv
The model is openand circular indicating the components in the implementation process Quality Assurance in
cycle proceed ad-infinitum. The process of evaluation logically begins with the value Nursing Services
identification, standards and criteria established will reflect the values held. The general
logic
- of the model is that actions are evaluated to influence decisions, decisions in turn
influence actions, and again, actions are evaluated ad-infinitum. Each component is in a
constant state of change.

Fig. 1.4: A model of quality assurance proposed by Nonna, M. Lang (1975)

The function of the model is to provide a mechanism into which one may feed specific data.
As this tool stands, data can be fed into any component. One can enter or begin at any
component because of the ongoing nature of the nursing process.

The model can also accommodate the variety of practice situation. It may be used in
reference to individual nurses performance, to a patient and his care, and to an institutional
or organizational setting. It can be utilized in nursing service or nursing education.

Components of the model are identified in the following steps:

1) Identify Values: Quality impiies a group of properties characterized as "gipod". The
major sources of values are societal. professional, and scientific. Many variables
including human, organizational, academic, and civic influence health and/or nursing
practice. As society and its values change, the characteristics of quality must also
change.
When applied to nursing, this means that standards and criteria reflecting societal
and profehsional values must be established and that these nursing standards and
criteria must be dynamic and subject to change in light of new knowledge and
experience.
2) Identify Structure, Process, Otitconle Standards and Criteria: The second component
of the model necessitates making values explicit. This component is the identification of
standards and criteria (outcome, process and structwe) for nursing care. Statements
about quality nursing care can be expressed in terms of structure, process and outcomes
of nursing practice.
Nurses planning a quality assurance programme must decide which type of criteria they
will use depending on the purpose and target of the programme.
-
3) Secure MeasurementsNeeded to Determine Degree of Attainment of Standardsand
Criteria: This third component of the model is the determination of degree of -
'
- ,

attainment between the established standards and criteria and the current level of
nursing practice. There are many methods ihat can be used to measure the'current level
of nursing practice according to established criteria. Existing methods include direct
patient observation. external and internal peer review, concurrent and retrospective
audit, self-assessment. For example, outcomes of patient care couldbe measured by
- - . - ..
Quality Patient Care and The method selected will be dependent upon the purpose of the measure the tools
Quality Assurance available, and the human and fiscal resources of the institution.
4) ,Make Interpretations about Strengths and Weaknesses Based on Measurement: The
measuiement of the degree of attainment between the identified standards and criteria
and the current level of nursing practice serves as the data base for interpretations
about the strengths and weaknesses of nursing practice. It is, therefore, important to
examine the strengths as well as the weaknesses of practice and to provide
documentation.
5) Identify Possible Courses of Action: Action should be taken to reinforce the strengths
and to change the weaknesses of the nursing practice. Some of the more commonly
proposed actions are: continuing education, in-service education, peer pressure,
research. punitive or reward action, and self-initiated change. Each alternative action has
advantages and disadvantages depending u p n the organization.
6) Choose the Course of Action: After several alternative actions have been proposed and
examined, the best action is selected for impleme,ntation.The important element here is
that plan for changeis made.
7) W e Action: To gain improvement implies altered actions, and this in turn implies a
choice by the decision-maker. The action selected in the previous component is
implemented and documented.

The identification of outcome, process, structure standards, and criteria based upon current
values and knowledge; the measurement of the current level of nursing practice in terms of
these criteria; and the selection and implementation of actions for change in nursing
practice- a dynamic model of these components -- offers a systematic approach to
quality assurance, the implementation of standards.

1.6 OUALITY ASSURANCE PROGRAMME

We have explained the selected model(&)of quality assurance in nursing in the preceding
section. We shall now be acquainted with the steps in organizing quality assurance
programme in a hospital and the role of a nurse administrator in organising quality
assurance programme.

Considerable deliberation and planning are needed by all nurse managers in a health facility
in order to institute a quality assurance programme. The most successful nursing quality
assurance programmes are simple, inexpensive and non-threatening to staff members. A
long range plan with intermediate target dates for completion of each element of the
programme should be established.

1.6.1 Steps in Or~anizingQuality Assurance Programme in a Hospital

Quality assurance is a cyclic process of setting standards of care, measuring care according
to these standards, evaluating clata from chart review, observation and interview and
making recokmendations for improvement, (Fig. 1.5)

\ Setting and agreeing standards

I Selecting and using

measurement techniques

Comparing observed practice

with standards
 The following steps may be followed in organizing quality assurance programme in a Quailty Assurance in
hospital: Nursing Scrvlces

i) Approval of the progrzmme fiom appropriate administrative authority.

ii) Task force of committee group to be appointed. A quality assurance group is a team
of people who meet together to undertake quality assurance activities.
iii) Orientation programme to be arrznged for quality assurance comnlittee or group to
sensitize them with the purpose, principles, methods, etc.
iv) Exaniine the beliefs and behaviour of the group members concerning quality control
through workshop.
v) Explore the difference in nursing value through openlface-to-face confrontation.
vi) Identify institution21supports and constraints to be dealt with in measuring and
improving nursing quality.

A quality assurance programme consists of different methodologies, which focus on:

Planning of actions to be developed.
Communicating the standards to those who will use them.
Developing indicators and threshholds to continuously monitor these standards.
Problem-solving and process-improvement.

1.6.2 Role of a Nurse Administrator in Organizing Quality Assurance

Programme
In this sub-section, you will identify the role of a nurse administrator in organizing quality
assurance programme in a hospital. You will also expiore how you might take part in quality
assurance within your own professional practice. With the present day focus on
productivity, it is necessary that although appropriate and full utilization of personnel is
important, it is equally irriportant that a high quality nursing care is provided in our
hospitals. In health care, quality assurance often begins with practit~onerswho are cIose to
day-to-day process of care. The success or failure of quality initiative will obviously be
influenceci by the quality system or quality culture within which it takes place. On the other
hand, a successful quality icitiative might help to change a previously unsupportive
organizational setting.

Quality assurance programmes are based on the belief that quality is what the customer
says it is 2nd that a belief must be thoroughly integrated into the organization. It is visally
important to secure a genuine commitment to quality improvement from senior managers
and policy makers. Ideally, such commitment and universal involvement is expressed by top
management in a quality policy, which is realized through the implenlentation and . , '

maintenance of a quality system. Through development of quality assurance programme,

the nursing profession assumes responsibility of self-evaluation and self-reguIation. Such
I professional acco~i~itability can only lead to hprovement in patient care and validation of

i
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nursing contributions. within the institutio~~.

ru'ursing is continuous action a d interactiofi with the patient and h a family members. It is
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the activities rendered in cooperation and coordinatbn with other health team members. So
I
i organizational c!imate is essentia! for this. Nurse administrator plays a vital role in
developing a quality assurance programme in herhis hospital. A quality group is
established which sets standards, selects appropriate measurement techniques to evaluate
what is happening in practice, and then compares observed practice with the agreed
standards as shown in Fig. 1.6.

A quality assurance group is a team of people, who meet together to understand quality
assurance activities.
I
During early discussions, the group identifies a focus for quality assurance initiative and
clarifies beliefs and values zbibout practice. This is important. For example, some
professionals n a y believe that old people have poor recovery ability. Other professionals
I rnay believe that. with acive rehabilitation, old people can return to active participation in
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Quality Patient Care and
Quality Assurance

Implementing the action plan(s)

Selecting the best action plan(s)

Identifying possible action plan(s)

Identifying reasons for

differences (between observed
practice and standard@)

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F
ig.1.6: Quality Action
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A sequence of &-ps 1s suggested for ensuring quality of nursing care. They are:
1) Decide upon the phivsophy.
2) Make certain that you'as well as your nurses know what you wish to evaluate and why.
3) F o d a t e objective# ',
,
4) Set standards.
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5) Enlist expert guidancei ?': .
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6) Plan carefully and select' the evaluation tools suitable to the unit.
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7) Work cooperatively. 9

8) Publish the report of the reklts of evaluation of care.

t
Each agencyhospital needs a group to establish criteria and a process
for quality assurance and to recommendations, and do follow-up work.
A chairperson with details helps ensure a successful
programme. in quality assurance and knowledgeable
patient population and nursing
insehice instructors from various
nursing units help to develop and impkment a quglity assurance programme effectively.

To attain the of providing optimum hality c&e nurses themselves should make them
m d y by critical thinking and by devel@p&fpnd implementing a quality assurance
programme in their hospital so as to prd~i'd~asc~entific,
care which is combined with
humanitarian approach. i,h {,
 Quality Assurance in
Nursing Services

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3) Fill in the blanks:
......................for nursing practice help to provide quali
ursing audit cm be concurrentand ..................................
c) Quality assurance is a ................................. process of measuring
set standards.
d) Through Quality Assurance Programme, the nursing
................................ ., which leads to validation of nursing
hospital.
e) A quality assurance programmeaims to provide an ................ ,............... and
................................. services to the client.

7--

1.7 LE-S SUM UP

In this unit, we have discussed about concept of quality assurance and defined variGs
terms in relation to quality assurance i.e. quality. quality assurance. We discussed the
factors influencing quality assurance and principles to be cc - sidered when p!anning quality
assurance programme for the hospital nursing sewlce. We further discussed the impact of
quality assurance on patient care. Selected model(&)for quality assurance were described
and explained with the help of diagrammes.

In the section on Development of Quality Assurance Prograrme, we discuswd the steps to

be followed and highlighted the role of a nurse administrator in programme in a hospital. We
hope you enjoyed reading and have had a gainful learning through this unit, which would
enable you to integrate your understai~dingof the next unit i.e. Evaluation of hursifig Care,
where you would be learning the tools and techniques utilized for e\aluation of nursing care
including nursing audit. These in turn lead to maintenance of quality nursing care in the
hospital.

1.8 KEY WORDS

Acceptable : a service provision that satisfies the reasonable expectations of
tlie patientlclient, providers and society.
Accessible : a service provision not compromised by undue limits of time,
distance or cost.
Accountability : the state of being answerable for one's decisions and acticns.
Accountability cannot be delegated.
Assurance : a statement or assertion intended to inspire confidence. pledge
or promise of support. freedom from doubt, rnaking sure.
Audit : a methodical review or investigation of resources or actions.
Autonomy : the right to self-directed professional judgement acd treatment
planning.
C o m W r allegiance lo giver, prcfessiona! values and standards of care
and savirc.
Competence : presence of nccessar; knowledge. skill and personal attitudes to
allr?w for thc performance of professional tasks.
Quality Patient Care and Cost-effective : able to achieve intended objective with the optimum use of
Quality Assurance resources.
Evaluation : the systematic and scientific process of determining the extent to
which an action or set of actions were successful in the
achievement of predetermined objectives.
Philosophy : a set of values and beliefs which guides thoughts and actions.
Relevance : services provided are applicable to the needs of the client.
Standard : an acceptable or approved statement against which the
measurement and/or judgement takes place.
Valid : of measurement-measuring what is intended should be measured.

1.9 ANSWERS TO CHECK YOUR PROGRESS

Check Your Progress 1

1) a) Quality health care is care that is needed and delivered in a manner that is
competent, caring, cost-effectiveand timely and minimizes risk and achieves
achievable benefits.
b) Professional quality means whether the nursing care meets customer/clients' need
as defined by professionals and whether the professional procedures and
standards, believed to produce the required outcomes are observed.
c) Quality assurance refers to a system for monitoring outcomes of professional
interventions compared with established standards to evaluate and document
appropriateness and effectiveness of nursing practice.
2) Resources - infrastructure, equipment and supplies etc.
Personnel - lack of trained, skilled and motivated employees.
Unreasonable patients and their attendants.
Population not well informed.
Lack of good hospital information system.
Lack of proper maintenance of nursing care records.
Other factors: lack of good supervision, policy and administrative manuals, procedure
manuals, evaluation tools and techniques, written job-descriptions, continuing
educational programmes etc.
3) a) iv
b) iii
c) i
d) v
e) ii
Check Your Progress 2

1) Decide upon the philosophy.

Approval of quality assurance programme from appropriate administrative authofity.
Appoint quality assurance task force group.
Orient the quality assurance task force group and nurses to sensitise them with the
purpose, principles and methods etc.
Formulate objectives.
Set standards for nursing practice.
Plan and select carefully the evaluation tools to measure the set standards.
Work cooperatively.
ldentifv the hosuital suu~ortsand constraints to be dealt with in measuring and
 Quality Assurance in
Nursing Services

strengths and weaknesses

3) a) Standards
b) retrospective
c) cyclic
d) accountability
e) efficient,effective

1.10 FURTHER READINGS

Assaf, A1 Schmele, Total Quality in Health Care, Florida: St. Louis Press, 1993.

Berger, et al., Management for Nursing, St. Louis: The C.V. Mosby Co., 1980.

Blancy, Doris, R. and Charles, J. Hobson, Cost-Effective Nursing Practice: Guidelines for
Nurse Managers, Philadelphia: J.B. Lippincott Co., 1988.

Denovan, Helen M., Nursing Service Administration: Managing the Enterprise, St. Louis:
The C.V. Mosby Company, 1995.

Hogstan, R., Quality Nursing Care: A Qualitative Enquiry, Journal of Advanced Nursing,
1995,21(1),116-124.

Imin, Penny and Jan, F., Evaluating the Quality of Care, NY Churchill Livingstone, 1995.

Khan, Yasmeen, Factors Affecting Quality Assurance in Nursing, The Nursing Journal of
India, 1999,90(8), 173-174.

Marriner, Ann, Guide to Nursing Management, St. Louis: The C.V. Mosby Co., 1992.

S h k a r , B. M., Principles of Hospital Administration and P h n i n g , New Delhi: Jaypee

Brothers Medical Publishers, 1998.

Sridhar, S. S., Quality Assurance in Nursing, The Indian Journal of Nursing and Midwifery,
1998,1(2),5-12.

&3& Y., Lading and Managing in Nursing. St. Louis: The C.V. Mosby Company, 1995.

Wright, Christine C. and Dorothy, Whittington, Quaiity Assurance: An Introductionfor

Health Care Pr~fessionuls,U.K. Churchill Livingstone, 1992.

Zimmer, Marie, J., Quality Assurance, Philadelphia: W.B. Saunders Company, Nursing
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