Quality Assurance

Standards unit 6
H. Williams & J. Braham
Department of Nursing
NCU

 Quality Assurance (QA) is a management

method that is defined as all those planned
and systematic actions needed to provide
adequate confidence that a product, service
or result will satisfy given requirements for
quality and be fit for use.
A Quality Assurance programme is defined as
the sum total of the activities aimed at
achieving that required standard (ISO, 1994).
ISO 1994 Quality Management and Quality Assurance - a Vocabulary.
International
Organization for Standardization, Geneva.

Total Quality Assurance

Quality refers to excellence of a product or a
service, including its attractiveness, lack of
defects, reliability, and long-term durability.
Quality assurance provides the mechanisms to
effectively monitor patient care provided by health
care professionals using cost-effective resources.
Nursing programmes of quality assurance are
concerned with the quantitative assessment of
nursing care as measured by proven standards of
nursing practice.
(Ellis, 1995)

 Quality assurance system motivates

nurses to strive for excellence in delivering
quality care and to be more open and
flexible in experimenting with innovative
ways to change outmoded systems.
Florence Nightingale introduced the
concept of quality in nursing care in 1855
while attending the soldiers in the hospital
during the Crimean war.

CONCEPT OF QUALITY IN HEALTH CARE

Quality is defined as the extent of
resemblance between the purpose of
healthcare and the care duly given (Donabedian
1997).

Quality assurance originated in

manufacturing industry to ensure that the
product consistently achieved customer
satisfaction.
Quality assurance is a dynamic process
through which nurses assume accountability
for quality of care they provide (Ellis, 1995).

 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 cares contributes to valued
outcomes. (Donabedian 1997).
Quality assurance as the monitoring of the
activities of client care to determine the
degree of excellence attained to the
implementation of the activities (Bull, 1985).

 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).

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 professionals practice.
Licensure of nurses has been mandated
throughout the world by laws and regulations.

Approaches for a quality

assurance programmes
Two major categories of approaches that
exist in quality assurance:
1.General
2.Specific

A. General Approach
It involves large governing of official bodys
evaluation of a persons or agencys ability to
meet established criteria or standards at a
given time.
1) Credentialing
formal recognition of professional or technical
competence and attainment of minimum
standards by a person or agency
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

3) Accreditation
AAA (Adventist Accreditation Association)
UCJ (University & Colleges of Jamaica)
NCJ (Nursing Council of Jamaica)
4) Certification
Certification is usually a voluntary process
with in the profession.

 A persons educational
achievements, experience and
performance on examination are
used to determine the persons
qualifications for functioning in an
identified specialty area.

B. Specific approaches
1) Peer review
Peer review is divided in to two types.
The recipients of health services by means of
auditing the quality of services rendered.
The health professional evaluating the quality of
individual performance.

2) Audit as a tool for quality assurance

Nursing audit may be defined as a detailed
review and evaluation of selected clinical records
in order to evaluate the quality of nursing care
and performance by comparing it with accepted
standards.

3) Standard as a device for quality

assurance
Standard is pre-determined baseline
condition or level of excellence that
comprises a model to be followed and
practiced.

Standards
Standard is an acknowledged measure of
comparison for quantitative or qualitative value,
criterion, or norm.
A standard is a practice that enjoys general
recognition and conformity among professionals or
an authoritative statement by which the quality of
practice, service or education can be judged.
It is also defined as a performance model that
results from integrating criteria with norms and is
used to judge quality of nursing objectives, orders
and methods.
(Marquis & Huston, 2013)

 A standard is a means of determining what

something should be.
In the case of nursing practice standards
are the established criteria for the practice
of nursing.
Standards are statements that are widely
recognized as describing nursing practice
and are seem as having permanent value.

Nursing Care Standard

Is a descriptive statement of desired quality against
which to evaluate nursing care.
It is guideline. A guideline is a recommended path
to safe conduct, an aid to professional performance.
A nursing standard can be a target or a gauge.
When used as a target, a standard is a planning
tool.
When used as a gauge against which to evaluate
performance a standard is a control device.
(Marquis & Huston, 2013)

Characteristics of Standards
Standards statement must be broad enough
to apply to a wide variety of settings.
Standards must be realistic, acceptable,
attainable.
Standards of nursing care must be
developed by members of the nursing
profession; preferable nurses practicing at
the direct care level with consultation of
experts in the domain.

 Standards should be phrased in positive

terms and indicate acceptable performance
good, excellence and so on
Standards of nursing care must express
what is desirable optional level.
Standards must be understandable and
stated in unambiguous terms.
Standards must be based on current
knowledge and scientific practice.
(Marquis & Huston, 2013)

 Standards must be reviewed and revised

periodically.
Standards may be directed towards an
ideal for example optional standards or
may only specify the minimal care that
must be attained, for example minimum
standard.
must remember that standards that work
are objective, acceptable, achievable and
flexible.
(Marquis & Huston, 2013)

Purposes of Standards
Setting standard is the first step in
structuring evaluation system.
The following are some of the purposes of
standards
Standards give direction and provide
guidelines for performance of nursing staff.
Standards provide a baseline for evaluating
quality of nursing care

 Standards help improve quality of nursing

care, increase effectiveness of care and
improve efficiency.
Standards may help to improve documentation
of nursing care provided.
Standards may help to determine the degree
to which standards of nursing care maintained
and take necessary corrective action in time.
Standards help supervisors to guide nursing
staff to improve performance.
(Marquis & Huston, 2013)

 Standards may help to improve basis for

decision-making and devise alternative
system for delivering nursing care.
Standards may help justify demands for
resources association.
Standards my help clarify nurses area of
accountability.
Standards may help nursing to define clearly
different levels of care.

Classification of Standards
There are different types of standards used
to direct and control nursing actions.

Normative and Empirical Standards

Standards can be normative or empirical.
Normative standards describe practices
considered 'good' or 'ideal' by some
authoritative group.
Empirical standards describe practices
actually observed in a large number of
patient care settings.
(Marquis & Huston, 2013)

 Here the normative (written) standards

describe a higher quality of performance
than empirical standards (generally
accepted).
Generally professional organizations
(Nursing Council) promulgate normative
standards whereas low enforcement and
regulatory bodies (KPH) promulgate
empirical standards.

(Marquis & Huston, 2013)

Ends and Means Standards

Nursing care standards can be divided into
ends and means standards.
The ends standards are patient-oriented;
they describe the change as desired in a
patient's physical status or behaviour.
The means standards are nursing oriented,
they describe the activities and behaviour
designed to achieve the ends standards.

 Ends (or patient outcome) standards

require information about the patients.
A means standard calls for information
about the nurses performance.

(Marquis & Huston, 2013)

Structure, Process and Outcome

Standards
Standards can be classified and formulated
according to frames of references (used for
setting and evaluating nursing care
services) relating to nursing structure,
process and outcome, because standard is a
descriptive statement of desired level of
performance against which to evaluate the
quality of service structure, process or
outcomes.
(Marquis & Huston, 2013)

Structure Standard
A structural standard involves the 'set-up' of the
institution.
The philosophy, goals and objectives, structure of
the organization, facilities and equipment, and
qualifications of employees are some of the
components of the structure of the organization.
For example, recommended relationship between
the nursing department and other departments
in a health agency are structural standards,
because they refer to the organizational
structure in which nursing is implemented.

 It includes people money, equipment, staff

and the evaluation of structure is designed
to find out the effectiveness ,degree to
which goals are achieved and efficiency in
terms of the amount of effort needed to
achieve the goal.
The structure is related to the framework,
that is care providing system and resources
that support for actual provision of care.

(Marquis & Huston, 2013)

 Evaluation of care concerns nursing staff,

setting and the care environment.
The use of standards based on structure
implies that if the structure is adequate,
reliable and desirable, standard will be
met or quality care will be given.

Process Standard
Process standards describe the behaviours
of the nurse at the desired level of
performance
The criteria that specify desired method
for specific nursing intervention are
process standards.
A process standard involves the activities
concerned with delivering patient care.
(Marquis & Huston, 2013)

 These standards measure nursing actions

or lack of actions involving patient care.
The standards are stated in action-verbs,
that is in observable and measurable
terms for example: the nurse assesses",
"the patient demonstrates
The focus is on what was planned, what
was done and what was communicated or
recorded.

 Therefore, the process standards assist in

measuring the degree of skill, with which
technique or procedure was carried out, the
degree of client participation or the nature
of interaction between nurse and client.
In process standard there is an element of
professional judgement determining the
quality or the degree of skill.
It includes nursing care techniques,
procedures, regimens and processes
(Marquis & Huston, 2013)

Outcome Standards
Descriptive statements of desired patient
care results are outcome standards because
patient's results are outcomes of nursing
interventions.
Here outcome as a frame of reference for
setting of standards refers to description of
the results of nursing activity in terms of the
change that occurs in the patient.
(Marquis & Huston, 2013)

 An outcome standard measures change in

the patient health status.
This change may be due to nursing care,
medical care or as a result of variety of
services offered to the patient.
Outcome standards reflect the
effectiveness and results rather than the
process of giving care

LEGAL SIGNIFICANCE OF
STANDARDS
Standards of care are guidelines by which
nurses should practice.
If nurses do not perform duties within
accepted standards of care, they may place
themselves in jeopardy of legal action.
Malpractice suit against nurses are based on
the charge that the patient was injured as a
consequence of the nurses failure to meet
the appropriate standards of care.

To recover losses from a charge of

malpractice, a patient must prove that:
a patient-nurse relationship existed such
that the nurse owed to the patient a duty of
due care
the nurse deviated from the appropriate
standard of care
the patient suffered damages
the patient's damages resulted from the
nurses deviations from the standard of care.

CONCLUSION
Quality assurance is to provide a higher
quality of care.
It is necessary that nurses develop
standards of patient care and appropriate
evaluation tools, so that professional
aspects of nursing involving intellectual
and interpersonal activities.
Quality will be ensured and attention will
be given to the individual needs and
responses to patients.

 The formulation of standards is the first step

towards evaluating the nursing care delivery.
The standards serve as a base by which the
quality of care can be judged.
This judgement may be according to a rating
or other data that reflect the conformity of
existing practice with the established
standards.
The standards must be written, regularly
reviewed and well-known by the nursing staff.

MODELS OF
QUALITY
ASSURANCE

Systems Model
Tasks are broken down into manageable
components based on defined objectives.

The basic components of the system are

Input
Throughput
Output
Feedback

(Ellis, 1995)

 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.

Quality Assurance Process

Establishment of standards or criteria for
evaluating process - benchmarking is the
process of measuring products, practices,
and services against best-performing
organizations.
Identify the information relevant to the
criteria
Determine ways to collect information
Collect and analyze the information

 Compare collected information with

established criteria
Make a judgment about the quality of the
service or product
Provide information and if necessary, take
corrective action regarding findings of
appropriate sources
Determine ways to collect the information
(Ellis, 1993; Marquis & Huston, 2013)

FACTORS
AFFECTING
QUALITY
ASSURANCE IN
NURSING CARE

1) Material 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 Resources
) Lack of trained, skilled and motivated
employees and staff indiscipline affects the
quality of care.
(Marquis & Huston, 2013)

3) Improper maintenance
Buildings and equipment require proper
maintenance for efficient use.
If not maintained properly the equipment
cannot be used in giving nursing care.
To minimize equipment down time it is
necessary to ensure adequate after sale
service and service manuals
(Ellis, 1995)

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) Lack of good hospital information

system
A good management information system is
essential for the appraisal of quality of care.
a) Workload,
length of stay

admissions,

procedures

and

b) Activity audit and scheduling of procedures .

(Ellis, 1993)

7) Absence of patient satisfaction

surveys
Ascertainment of patient satisfaction at fixed
points on an ongoing basis.
Such
surveys
carried
out
through
questionnaires,
interviews
by
social
worker, consultant groups, and help to
document patient satisfaction with respect
to variables that are
a) Delayed in attendance by nurses and
doctors

8) 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 patients 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.

9) 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
educational programmes

continuing

 Donabedian A. The quality of care:

How can it be assessed? Journal of
the American Medical Association.
1988; 260 (12): 1743-1748.

Ellis, Roger. (1995). Quality

Assurance for University Teaching.
Society for Research into Higher
Education. London:

 The quality of care: How can it be

assessed?
Avedis Donabedian
Archives of Pathology & Laboratory
Medicine; Nov 1997; 121, 11;
ProQuest Nursing Journals
pg. 1145