QUALITY ASSURANCE- CONTINUOUS QUALITY IMPROVEMENT

INTRODUCTION
In the changing health care environment, concerns over quality of care are receiving greater attention
than ever before. As consumer become more knowledgeable as a result of increased information
available to them, much of the mystique surrounding health care is being dissipated. Quality
management (QM) and quality improvement (QI) are the basic concepts derived from the philosophy
of total quality management (TQM). Now it is preferred to use the term Continuous Quality
Improvement (CQI) since TQM can never be achieved. And the method of monitoring of healthcare
for CQI is done with Quality Assurance (QA).
DEFINITION
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 the measurement of provision against expectations with declared intention and
ability to correct any demonstrated weakness. ( Shaw)

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)
Quality assurance vs. Continuous quality improvement (Koch, 1993)
Quality improvement is not necessarily a replacement for existing quality assurance activities, but
rather an approach that broadens the perspectives on quality
Quality assurance (QA) Quality Improvement (QI)
 Inspection oriented (detection)  Planning oriented
 Reaction  Proactive
 Correction of special causes  Correction of common causes
 Responsibility of few people  Responsibility of all people involved
with the work
 Narrow focus  Cross- functional
 Leadership may not be vested  Leadership actively leading
 Problem solving by authority  Problem solving by employees at all
levels

OBJECTIVES
 To successfully achieve sustained improvement in health care, clinics need to design
processes to meet the needs of patients.
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  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 American Research Center Health Unit)
 Public accountability- It provides evidence that the funds are being spend both effectively
resulting in optimum utilization of the resource resulting in operational efficiency and
efficiency of services provided.

 Management improvement- This is to provide quality assurance programme as a tool for

managerial problem solving. It includes identification of the problem in areas of technical
quality, efficiency, risk and patient satisfaction to assess its nature, causes and taking effective
actions to reduce or eliminate the identified problems.

 Facilitation of adoption of innovations- It includes evaluation of performance of individuals

professionals, preparation of appropriate criteria for assessment of processes and outcome,
exchange of information within and outside the organization, and introduction of innovations
with assessment of their impact on patient care outcome, risk and satisfaction by using the
patient as a unit for analysis.

Quality assurance whether in health or education had two main objectives:

 To provide technical assistance in designing and implementing effective strategies for

monitoring quality and correcting systemic deficiencies and

 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 from national, international, government and other professional
bodies to demonstrate that the allocation of funds produces satisfactory results in terms
of patient care.
 The increasing complexity of health care organizations.
 Improvement of job satisfaction.
 Highly informed consumer
 To prevent rising medical errors
 Rise in health insurance industry
 Accreditation bodies
 Reducing global boundaries.

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 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.
According to W Edward Deming; (Deming’s 14 points)
 Crete consistency of purpose for improvement of product and service.
 Adopt the new philosophy
 Cease dependence on inspection to achieve quality.
 End the practice of awarding business on the basis of price tag.
 Improve constantly and forever the systems of production and service.
 Institute training on the job.
 Institute leadership.
 Drive out fear.
 Break down barriers between departments.
 Eliminate slogans, exhortations, and target for the workforce.
 Eliminate numerous quotas for the workforce and numerical goals of management.
 Remove barriers that rob people of pride and workmanship.
 Institute a vigorous programme of education and self-improvement for everyone.
 Put everyone in the company to work to accomplish the transformation.

APPROACHES
 General approach
 Specific approach
General approach: - It involves large governing or official bodies evaluating a person or
agencies‘ ability to meet established criteria or standard during a given time
. a) Credentialing- It is the formal recognition of professional or technical competence and
attainment of minimum standards by a person and agency.
Credentialing process has 4 functional components
 To produce a quality product
 To confirm a unique identity
 To protect the provider and public
 To control the profession
b) Licensure- It is a contract between the profession and the state in which the profession is
granted control over entry into an exit from the profession and over quality of professional
practice.
c) Accreditation- It is a process in which certification of competency, authority, or credibility
is presented to an organization with necessary standards.
d) Certification

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 e) Charter- It is a mechanism by which a state government agency under state law grants
corporate state to institutions with or without right to award degrees.
f) Recognition- It is defined as a process whereby one agency accepts the credentialing states
of and the credential confined by another.
g) Academic degree

Specific approach: -
These are methods used to evaluate identified instances of provider and client interactions.
a) Audit- It is an independent review conducted to compare some aspect of quality
performance, with a standard for that performance.
b) Direct observation- Structured or unstructured based on presence of set criteria.
c) Appropriateness evaluation- The extent to which the managed care organization provides
timely, necessary care at right levels of service.
d) Peer review- Comparison of individual provider‘s practice either with practice by the
provider‘s peer or with an acceptable standard of care.
e) Bench marking- A process used in performance improvement to compare oneself with
best practice.
f) Supervisory evaluation
g) Self-evaluation
h) Client satisfaction
i) Control committees
j) Services- Evaluates care delivered by an institution rather than by an individual provider.
k) Trajectory- It begins with the cohort of a person who shares distinguishing characteristics
and then follows the group going through the healthcare system noting what outcomes are
achieved by the end of a particular period
l) Staging- It is the measurement of adverse outcomes and the investigation of its
antecedence.
m) Sentinel- It involves maintaining of factors that may result in disease, disability or
complications such as;
 Review of accident reports
 Risk management
 Utilization review
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

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 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.
Standards are directed at structure, process, and outcome issues and guide the review of systems
function, staff performance, and client care. The organizations providing quality indexes are;
•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
Areas of QA
The assurance in various key areas are
Outpatient department- The points to be remembered are;
 Courteous behavior must be extended by all, trained or untrained personnel.
 Reduction of waiting time in the OPD and for lab investigations by creating more service
outlets.
 Provide basic amenities like toilets, telephone, and drinking water etc.
 Provision of polyclinic concept to give all specialty services under one roof.
 Providing ambulatory services or running day care centers.
Emergency medical services
Services must be provided by well trained and dedicated staff, and they should have access to the
most sophisticated life- saving equipment and materials, and also have the facility of rendering pre-
hospital emergency medical aid through a quick reaction trauma care team provided with a trauma
care emergency van.
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 In- patient services
Provide a pleasant hospital stay to the patient through provision of a safe, homely atmosphere, a
listening ear, humane approach and well behaved, courteous staff.
Specialty services A high tech hospital with all types of specialty and super- specialty
services will increase the image of the hospital.
Training A continuous training programme should be present consisting of ‗on the job
training‘, skill training workshops, seminars, conferences, and case presentations.
MODELS OF QUALITY ASSURANCE
1. Donabedian Model (1985):
It is a model proposed for the structure, process and outcome of quality. This linear model
has been widely accepted as the fundamental structure to develop many other models in QA.

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.

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 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

Intervention outcome

Client
(Individual, Family & Community)

3.Plan, Do, and Study, Act cycle:

It is an improvement model advocated by Dr. Deming which is still practiced widely that contains a distinct
improvement phase. Use of PDSA model assumes that a problem has been identified and analyzed for its most
likely causes and that changes have been recommended for eliminating the likely causes. Once the initial
problem analysis is completed, 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.
4.Six Sigma: It refers to six standard deviations from the mean and is generally used in quality

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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.

6. Achieving Quality Care:

This shows a complex and interactive framework. It illustrates the idea of that quality of care that is
important to clients, practitioners, management and health organizations, and to society as a whole.
These groups may be interested in quality for different reasons, will have different perspectives on
quality and consequently have different priorities. Their interests may be purely client-centered or
influenced by external pressures such as government policy, scarcity of resources or changing
technology.

 At an individual level, everyone affects quality of care-receptionists, telephones, building

maintenance staff, managers, clerical staff, caterers, and professional staff. Quality is everyone‘s
business. There is a potential problem here- since quality is everyone‘s business it can become no
one‘s business. In any organization someone needs to take the responsibility for quality.
Quality tools

 Chart audits It is the most common method of collecting quality data using charts as quality
assessment tool.
 Failure mode and effect analysis: prospective view It is a tool that takes leaders through
evaluation of design weaknesses within their process, enable them to prioritize weaknesses that
might be more likely to result in failure (errors) and, based on priorities decide where to focus on
process redesign aimed at improving patient safety.
 Root- cause analysis: retrospective view It is sometimes called a fishbone diagram, used to
retrospectively analyze potential causes of a problem or sources of variation of a process. Possible
causes are generally grouped under 4 categories: people, materials, policies and procedures, and
equipment.
 Flow charts These are diagrams that represent the steps in a process.
 Pareto diagrams It is used to illustrate 80/ 20 rule, which states that 80% of all process variation
is produced by 20% of items.
 Histograms It uses a graph rather than a table of numbers to illustrate the frequency of different
categories of errors.

 Run charts These are graphical displays of data over time. The vertical axis depicts the key
quality characteristic, or process variable. The horizontal axis represents time. Run charts should
also contain a center line called median.
 Control charts
These are graphical representations of all work as processes, knowing that all work exhibit
variation; and recognizing, appropriately responding to, and taking steps to reduce unnecessary
variation.

Indicators of quality assurance

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  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.
Quality improvement process-
Steps QI process steps include;
 Identify needs most important to the consumer of health care services.
 Assemble a multidisciplinary team to review the identified consumer needs and services.
 Collect data to measure the current status of these services.
 Establish measurable outcomes and quality indicators.
 Select and implement a plan to meet the outcomes.
 Collect data to evaluate the implementation of the plan and achievement of outcomes.

Quality assurance cycle:

In practice, QA is a cyclical, iterative process that must be applied flexibly to meet the needs of a
specific program. The process may begin 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
(Steps 5-10). Alternatively, the process may begin with monitoring (Step 4). The ten steps in the
QA process are discussed.

1. Planning for Quality Assurance

This first step prepares an organization to carry out QA activities. Planning begins with a review of the
organizations scope of care to determine which services should be addressed.

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 2.Setting Standards and Specifications To provide consistently high-quality services, an organization
must translate its programmatic goals and
objectives into operational procedures. In its widest sense, a standard is a statement of the quality that is
expected. Under the broad rubric of standards there are practice guidelines or clinical protocols, administrative
procedures or standard operating procedures, product specifications, and performance standards.
2. Communicating Guidelines and Standards
Once practice guidelines, standard operating procedures, and performance standards have been
defined, it is essential that staff members communicate and promote their use. This will ensure that
each health worker, supervisor, manager, and support person understands what is expected of him or
her. This is particularly important if ongoing training and supervision have been weak or if guidelines
and procedures have recently changed. Assessing quality before communicating expectations can lead
to erroneously blaming individuals for poor performance when fault actually lies with systemic
deficiencies.
3. Monitoring Quality
Monitoring is the routine collection and review of data that helps to assess whether program norms are
being followed or whether outcomes are improved. By monitoring key indicators, managers and
supervisors can determine whether the services delivered follow the prescribed practices and achieve
the desired results.
4. Identifying Problems and Selecting Opportunities for Improvement
Program managers can identify quality improvement opportunities by monitoring and evaluating
activities. Other means include soliciting suggestions from health workers, performing system process
analyses, reviewing patient feedback or complaints, and generating ideas through brainstorming or
other group techniques. Once a health facility team has identified several problems, it should set
quality improvement priorities by choosing one or two problem areas on which to focus. Selection
criteria will vary from program to program.
5. Defining the Problem
Having selected a problem, the team must define it operationally-as a gap between actual performance
and performance as prescribed by guidelines and standards. The problem statement should identify the
problem and how it manifests itself. It should clearly state where the problem begins and ends, and
how to recognize when the problem is solved.
6. Choosing a Team
Once a health facility staff has employed a participatory approach to selecting and defining a problem,
it should assign a small team to address the specific problem. The team will analyze the problem,
develop a quality improvement plan, and implement and evaluate the quality improvement effort. The
team should comprise those who are involved with, contribute inputs or resources to, and/or benefit
from the activity or activities in which the problem occurs.
7. Analyzing and Studying the Problem to Identify the Root Cause
Achieving a meaningful and sustainable quality improvement effort depends on understanding the
problem and its root causes. Given the complexity of health service delivery, clearly identifying root
causes requires systematic, in-depth analysis. Analytical tools such as system modeling, flow charting,
and cause-and-effect diagrams can be used to analyze a process or problem. Such studies can be based
on clinical record reviews, health center register data, staff or patient interviews, service delivery
observations.
8. Developing Solutions and Actions for Quality Improvement
The problem-solving team should now be ready to develop and evaluate potential solutions. Unless the
procedure in question is the sole responsibility of an individual, developing solutions should be a team
effort. It may be necessary to involve personnel responsible for processes related to the root cause.
Implementing and Evaluating Quality Improvement Efforts

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 The team must determine the necessary resources and time frame and decide who will be responsible
for implementation. It must also decide whether implementation should begin with a pilot test
inlimited

area or should be launched on a larger scale. The team should select indicators to evaluate whether the
solution was implemented correctly and whether it resolved the problem it was designed to address.
In-depth monitoring should begin when the quality improvement plan is implemented. It should
continue until either the solution is proven effective and sustainable, or the solution is proven
ineffective and is abandoned or modified. When a solution is effective, the teams should continue
limited monitoring.

JCAHO quality assurance guidelines/steps:

1. Assign responsibility:
According to the Joint Commission, ―The nurse administrator is ultimately responsible for the
implementation of a quality assurance program. Completing step one of the Joint Commission‘s
ten step process require writing a statement that described who is responsible for making certain
that QA activities are carried out in the facility. Assigning responsibility should not be confused
with assuming responsibility.
2. Delineate scope of care and services:
Scope of care refers to the range of services provided to patients by a unit or department. To
delineate the scope of care for a given department personnel should ask themselves,‘ what is done
in the department?‘
3. Identify important aspects of care and services:
Important aspects of nursing care can best be described as some of the fundamental contribution
made by nurses while caring for patients. They are the most significant or essential categories of
care practiced in a given setting. There is no prescribed list of important aspects of care that every
organization must monitor.
4. Identify indicators of outcome (no less than two; no more than four):
A clinical indicator is a quantitative measure that can be used as a guide to monitor and evaluate
the quality of important patient care and support service activities. Indicators are currently
considered as being of two general types i.e. sentinel events and rate-based. Indicators also differ
according to the type of event they usually measures (structure, process or outcome).
5. Establish thresholds for evaluation:
Thresholds are accepted levels of compliance with any indicators being measured. Thresholds for
evaluation are the level of or point at which intensive evaluation is triggered. A threshold can be
viewed as a stimulus for action.
6. Collect data:
Once indicators have been identified, a method of collecting data about the indicators must be
selected. Among the many methods of data collection is interviewing patient/family, distributing
questionnaires, reviewing charts, making direct observation etc.
7. Evaluate data:
When data gathering is completed in the process of planning patients care, nurses make
assessments based on the findings. In the QA process as a whole, when data collection has been
completed and summarized, a group of nurses makes an assessment of the quality of care.

8. Take action:
Nurses are action-oriented professionals. For many nurses, the greater portion of every day is
spent on patient‘s intervention. These actions and interventions conducted by nurses promote
health and wellness for patients. Converting nursing energy into the QA process requires
formulating an action plan to address identified problems.

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 9. Assess action taken:
Continuous and sustained improvement in care requires constant surveillance by nurses of the
intervention initiated to improve care.

10. Communicate:
Written and verbal messages about the results of QA activities must be shared with other
disciplines throughout the facility.
APPROACHES FOR MEASURING THE QUALITY OF NURSING PRACTICE:
The VNA [visiting nurse association] measurement approaches are identified

THE ESSENCE OF HEALTH CARE QUALITY ASSURANCE: -

The essential parameters of health care quality assurances are -
1) Concern for Excellence and Standards:-
All quality assurance initiatives whether implicit or explicit, focusing on individual care or
population services, undertaken by professionals, managers or consumers, must reflect an abiding
interest in the provision of the highest possible quality care. If such concern is not given primary
quality assurance cannot take place, it should extend to all aspects of care including the technical, the
interpersonal and moral.

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 2) Specificity and explicitness:- Despite the many difficulties health care quality assurance is, in
aspiration at least, a rational, explicit and practically based exercise. Standards are specified and
operationalised and measurement tools are developed for their appraisal. Respect for their

professional judgment and careful analysis of social and ethical dilemmas provide essential context
but the operation itself remains an attempt at developing empirically rigorous procedures for the
observation, analysis and review of care and indeed , reflexively, for the observation, analysis and
review of techniques for appraising and improving quality.
3) Adaptation of a cyclical model: All quality assurance systems involve appraisal of
quality standards followed by action for quality improvement. The American Nurses
Association cycle of quality assurance is an elaboration of the sequence. At each stage in the
cycle the observations and events of the previous stage influence the decisions to be made and
action to be undertaken in the next. If any one stage is missed or inadequately carried out the
others will suffer and the ultimate aim of quality maintenance or improvement will not be
achieved. The cycle is what is known as an open system that is one in which direction is
determined but actual destination may not be. This openness is necessary to allow for the idea
of continual quality improvement. Today‘s highest possible standards may not satisfy the
consumers and professionals of tomorrow.
4) Commitment: Both individuals and organizations must be positively motivated to
implement quality assurance. Concern for quality and even compliance in the implementation
of quality assurance procedures are necessary but not sufficient. At the individual level time
and energy must be devoted to the exercise and persistence displayed in the face of
opposition. At the organizational level there must be recognition that quality assurance does
not just happen. it must be managed. That implies commitment of time, energy and resources
not just to the quality assurance system itself but to designing and modifying it to match and
complement the organizational climate in which it operates.

Factors affecting quality assurance in nursing care:-

Quality assurance necessitates that institutions and health professionals render care in a most
efficient, effective and economical manner, there are some factors which are affecting quality
assurance in nursing care. They are as follows.

1. lack of Resources
2. personal problems
3. unreasonable patients and attendants
4. improper maintenance
5. absence of well-informed populace
6. absence of accreditation laws
7. legal redress
8. lack of incident review procedures
9. lack of good hospital information system
10. absence of conducting patient satisfaction surveys
11. lack of nursing care records

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 12. Miscellaneous factors like lack of good supervision, Absence of knowledge about
philosophy of nursing care, substandard education and training, lack of policy and
administrative manuals.

TOOLS OF THE CQI:

 Pareto Charts
 Fishbone Diagram
 Histograms
 Run Charts
 check sheets
 Flowchart
 Control Charts

Pareto Charts:
Tools define the source of variation in a process, allowing planning to decrease
inappropriate variation and improve quality. In order to validate the problems identified.
Examples of these cause and effect tools are the Pareto chart and analysis and the
Fishbone diagrams. The Pareto chart and analysis is used when dealing with chronic
problems and helps one identify which of the many chronic problems to attack first. The
chronic problem with the highest number of events will show up on the Pareto chart with
the tallest bar, which represents the most frequent occurring problem. The idea behind
Pareto analysis is the 20/80 rule in that 20% of your errors / customers / input accounts
for 80% of your complications / income/ output.
Fishbone Diagram:
One analysis tool is the Cause-and-Effect or Fishbone diagram. These are also
called Ishikawa diagrams because Kaoru Ishikawa developed them in 1943. They are
called fishbone diagrams since they resemble one with the long spine and various
connecting branches.

Cause and effect chart:

The fishbone diagram organizes and displays the relationships between different causes
for the effect that is being examined. This chart helps organize the brainstorming process.

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 The major categories of causes are put on major branches connecting to the backbone,
and various sub-causes are attached to the branches.
Histogram:
This is a vertical bar chart which depicts the distribution of a data set at a single
point in time. A histogram facilitates the display of a large set of measurements presented

in a table, showing where the majority of values fall in a measurement scale and the
amount of variation. The histogram is used in the following situations:
1. To graphically represent a large data set by adding specification limits one can
compare;
2. 2. To process results and readily determine if a current process was able to produce
Run chart:
Most basic tool to show how a process performs over time. Data points are plotted in
temporal order on a line graph. Run charts are most effectively used to assess and
achieve process stability by graphically depicting signals of variation. A run chart can
help to determine whether or not a process is stable, consistent and predictable. Simple
statistics such as median and range may also be displayed.The run chart is most helpful
in:
1. Understanding variation in process performance
2. Monitoring process performance over time to detect signals of change
3. Depicting how a process performed over time, including variation.

Allow the team to see changes in performance over time. The diagram can include a
trend line to identify possible changes in performance.
DATA COLLECTION:
Check sheets:
Check sheets are simply charts for gathering data. When check sheets are designed
clearly and cleanly, they assist in gathering accurate and pertinent data, and allow the data
to be easily read and used. The design should make use of input from those who will
actually be using the check sheets. This input can help make sure accurate data is
collected and invites positive involvement from those who will be recording the data.
Flowcharts :
A flow chart of the process is particularly helpful in obtaining an understanding of how
the process works. It provides a visual picture.
There are two types of flow charts that are particularly useful.
• Top Down Flow Chart and
• Deployment Matrix Flow Chart.
A Top Down Flow Chart shows only the essential steps in a process without detail. It
focuses on the steps that provide real value. It is particularly useful in helping the team to
focus their minds on those steps that must be performed in the final improved‘ process.
A Top Down Flow Chart is constructed as follows: -

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  by first listing the main steps across the top of the page and then listing the subsidiary steps
from the top down, below the main steps. The details are not recorded. For example, rework,
inspection, and typing are omitted.
 The flow chart provides a picture of the process that the team can work on and simplify. It
allows people to focus on what should happen instead of what does happen.

 Usually, most processes have evolved in an ad hoc manner. When problems occur, the process
is fixed. The end result is that a simple process has evolved into something complex. A flow
chart is a first step to simplification.
A Deployment Matrix Chart is another type of flow chart.
This is useful because it shows who is responsible for each activity, how they fit into the
flow of work and how they relate to others in accomplishing the overall job.
To construct a Deployment Matrix Flow Chart, the major steps in the process are:
• listed vertically down the left hand side of the page and the people or work groups are
listed across the top.
• The process is then charted to show who does what

CONTROL CHART:
A control chart is a statistical tool used to distinguish between variation in a process resulting
from common causes and variation resulting from special causes. It is noted that there is variation in
every p
rocess, some the result of causes not normally present in the process (special cause variation).
Common cause variation is variation that results simply from the numerous, ever-present differences
in the process. Control charts can help to
maintain stability in a process by depicting when a process may be affected by special causes. The
consistency of a process is usually characterized by showing if data fall within control limits based on
plus or minus specific standard deviations from the center line. Control charts are used to:
1. Monitor process variation over time
2. Help to differentiate between special and common cause variation
3. Assess the effectiveness of change on a process
4. Illustrate how a process performed during a specific period.

Using upper control limits (UCLs) and lower control limits (LCLs) that are statistically computed,
the team can identify statistically significant changes in performance. This information can be used to
identify opportunities to improve performance or measure the effectiveness of a change in a process,
procedure, or system.

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CONTINUOUS QUALITY IMPROVEMENT TECHNIQUES:
Some of the continuous quality improvement techniques:
 Improving quality by removing the causes of problems in the system inevitably leads to
improved productivity.
 The person doing the job is most knowledgeable about that job.
 This people want to be involved and do their jobs well. Every person wants to feel like a
valued contributor.

 More can be accomplished working together to improve the system than having individual
contributors working around the system.
 A structured problem solving process using graphical techniques produces better solutions
than in ',an unstructured process.
 Graphical problem solving techniques will let you know where you are, where the
variations lie, the relative importance of problems to be solved .

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BARRIERS OF CONTINUOUS QUALITY IMPROVEMENT:
Responsibility Barriers
Company‘s Directing Board  Because it‘s a general trend
 Immediate results
 Lack of a clear definition of the
organizational and the quality goals.
Operation Strategy  Lack of conformity between the
quality goals and the operation‘s
specificities
 Great amount of exceptions in order
to serve a determined number of
client
 Lack of actions that contribute to
the continuous improvement
Indicators  Lack of financial indicators
 Don‘t represent the reality of the
operations.
Cost strategy  Lack of true analyzes concerning
the cost of bad
 Quality
 Lack of analyzes of the financial
gains obtain with quality
management
 Lack of a parameter for the
investment feedback.

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SOLUTIONS OF THE QUALITY IMPROVEMENT:
Some of the solutions of quality improvement are:
 Individual problem solving
 Rapid team problem solving
 Systematic team problem solving Process improvement solving
Individual Problem Solving

The simplest solution for quality improvement is the traditional focus on an individual
problem. If based on the discussions of your initial quality audit review you decide that you have only

one problem area to address, you can develop an individual problem solution. For example, if your
quality audit shows that you should concentrate on improving the safety ranking of your line staff on
one production line, you can work with those staff members to develop improved safety protocols
and implement a tracking system to document your progress.
Rapid Team Problem Solving

If you have a more complex system to improve, you may want to try a rapid team solution. In
this model, you will implement small step-by-step changes and test those changes as they are
implemented. If the first step of your changes shows improvement in the quality measures you are
tracking, you will move on to the next step. Rapid team problem solving is a less rigorous, more
spontaneous approach to quality improvement and can be a good choice for faster paced businesses.
Systematic Team Problem Solving

If your business needs indicate that you should undertake a more extensive quality
improvement goal, you may want to implement systemic team problem solutions. These solutions
require a more detailed analysis of the problem using sophisticated data collection and evaluation. For
example, if you want to concentrate on improving the level of customer satisfaction with your
product, you will want to do extensive surveys or focus groups of current and potential customers.
Based on this data, you can design solutions that address the public perception of your entire business
and improve your brand. But you will need to constantly research and reassess your data to ensure
that your systematic team solution is effective.

Process Improvement Solving

Process improvement is the most complex of the quality improvement solutions. If your
business wants to make a full-time commitment to continuous quality improvement, then process
improvement is the solution for you. This solution involves setting up a permanent quality
improvement team to continually assess and amend your quality interventions to ensure that
improvement standards are met. Process monitoring solutions are often used in health care or other
settings where accreditation standards must be maintained.

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NURSING AUDIT

INTRODUCTION
Nursing services are necessary for every client seeking care of any type, including health promotion,
diagnosis and treatment. With the changing trends in the health care delivery, the role of the nurse
manager is becoming largely devoted to the holistic care of client which can only achieved through
the careful appraisal of the services in order to make further reforms.
Audit
A systematic and critical examination to examine or verify.
Systematic review and evaluation of records and other data to determine the quality of the services or
products provided in a given situation.
Nursing Audit
Nursing audit is defined as the evaluation of nursing care in retrospect through analysis of nursing
records. It is a systemic format and written appraisal by nurses of the quality of content and the
process of nursing service from the nursing records of the discharged patient.
Definition
A review of the patient record designed to identify, examine, or verify the performance of certain
specified aspects of nursing care by using established criteria. Often a nursing audit and a medical
audit are performed collaboratively, resulting in a joint audit
(Mosby’s Medical Dictionary, 8th edition.2009,
Elsevier)
“Nursing audit refers to assessment of the quality of clinical nursing”
(Elison)
“Nursing audit is an exercise to find out whether good nursing practices are followed”
(Goster Walfer)
The audit is a means by which nurses can define standards from their point of view and describe the
actual practice of nursing.

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 PURPOSES OF NURSING AUDIT
 Evaluation: Evaluating the nursing care given. Achieve deserved and feasible quality of nursing
care.
 Verification: Stimulant to better records. Focuses on care provided and not on care provider.
 Contributes to research. Review of professional work or in other words the quality of nursing
care i.e. we try to see how far the nurses have confirmed to the norms and standards of nursing
practice while taking care of patients.
 It encourages followers to be actively involved in the quality control process and better records.
 It clearly communicates standards of care to subordinates.
 Facilitates more efficient use of health resources.
 Helps in designing response orientation and in-service education programme.

METHODS OF NURSING AUDIT

There are two methods:
 Retrospective View: This refers to an in-depth assessment of quality after the patient has been
discharged, and uses the patient’s chart as the source of data.
 Concurrent Review: This refers to the evaluations conducted on behalf of patients who are still
undergoing care. It includes assessment the patient at bedside in relation to pre-determined criteria,
interviewing the staff responsible for his care and reviewing the patient record and care plan.

ESSENTIAL CHARACTERISTICS OF NURSING AUDIT

There should be:
 Written standards of care against which to evaluate nursing care
 Evidence that actual practice was measured against such standards, sharing a percent conformance
rate.
 Examination & analysis of findings.
 Evidence of corrective action being taken.
 Evidence of effectiveness of corrective action.
 Appropriate reporting of the audit programme.

PROCESS OF NURSING AUDIT

1. Set the key criteria (item): It should be measurable against identified values, set standard & in
terms of desired patient outcome.
Methods to develop criteria are:
 Define patient population.
 Identify a time framework for measuring outcomes of care.
 Identify commonly recurring problems presented by the defined patient population.
 State patient outcome criteria.
 State acceptable degree of goal achievement.
 Specify the source of information
2. Prepare Audit Protocol keeping in mind Audit Objectives, Target groups, Method of information
gathering (by asking, observing, checking records), Criterion you are measuring, identify the time

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 framework for measuring outcome of care, identify commonly recurring nursing problems, State
acceptable of goal achievement.
3. Design the type of tool: Quality assurance must be a priority. Those responsible must implement
a program not only a tool. A co-coordinator should develop and evaluate quality assurance
activities. Roles and responsibilities must be delivered. Nurses must be informed about the process
and the results of the program. Data must be reliable. Adequate orientation of data collection is
essential. Quality data should be analyzed and used by nursing personnel at all levels.
4. Plan and implement the tool: What is to be evaluated? Who is going to collect the information?
How many sample in the target group? Time period
5. Recording/Analysis, Concluding: Record the information, Analyze the information, Make a
summary, Compare with set standard, Conclusion.
6. Using results : The results aid to modify nursing care plans & the nursing care process, including
discharge planning, for selected patient outcome, implementing a program for improving
documentation of nursing care through improved charting policies, methodologies & forms,
focusing of nursing rounds & team conferences. Focusing supervisory attention upon areas of
weakness identified, such as one particular nursing unit or specific employees. Designing
responsive orientation & in-service education programs. Gaining administrative support for
making changes in resources, including personnel.

PREREQUISITES OF NURSING AUDIT

 Audit Committee: Before carrying out an audit, an audit committee should be formed which
consists of fair and impartial members including senior nurses as members to do nursing audit.
This committee should comprise of minimum five members who are interested in quality
assurance, are clinically competent and able to work together in a group.
 It is recommended that each member should review not more than 10 patients each month and that
the auditor should have the ability to carry out an audit in about 15 minutes.
If there are less than 50 discharges per month, all the records may be audited. If there are large
numbers of records to be audited, an auditor may select 10 per cent of discharges. The impetus must
come from the nursing staff themselves, realizing the benefits to the patients and themselves. A good
system of nursing record keeping
ADVANTAGES OF NURSING AUDIT

 Can be used as a method of measurement in all areas of nursing.

 Seven functions are easily understood.
 Scoring system is fairly simple.
 Results easily understood.
 Assesses the work of all those involved in recording care.
 May be a useful tool as part of a quality assurance programmed in areas where accurate records of
care are kept.
 Enables the professional group to highlight the deficiencies and how good they are in giving care.
 Better planning can be done.
 Helps in re-allocation of resources.
 Administrators are also sure that patients are getting quality care
DISADVANTAGES OF NURSING AUDIT

 Appraises the outcomes of the nursing process, so it is not so useful in areas where the nursing
process has not been implemented.
 Many of the components overlap making analysis difficult.

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 It time consuming.
 Requires a team of trained auditors.
 Only evaluates record keeping.
 It only serves to improve documentation, not nursing care.\ Medical legal importance. The
professionals feel that they will be used in court of law as any document can be called for in court
of law.
 Deals with a large amount of information.

ROLES AND FUNCTIONS OF NURSE MANAGER FOR EFFECTIVE QUALITY CARE
ROLES
 Encourages followers to be actively involved in the quality control process.
 Clearly communicates standards of care to subordinates.
 Encourages the setting of high standards to maximize quality instead of setting minimum safety
standards.
 Implement quality control proactively instead reactively.
 Uses control as a method of detraining why goals were not met.
 Is positively active in communicating quality control finding.
 Acts as a role model for followers in accepting responsibility and accountability for nursing
actions.
FUNCTIONS
 In conjunctions with other personnel in the organization establishes clear cut, measurable
standards of care and determines the most appropriate method for measuring if those standards
have been met.
 Selects and uses process, outcome and structure audits appropriately as quality control tools.
 Assesses appropriate sources of information in data gathering for quality control tools.
 Determines discrepancies between care provided and unit standards and seeks further information
regarding why standards were not met.
 Uses quality control findings as a measure of employee performance and rewards, coaches,
counsels, or disciplines employees accordingly.
 Keeps abreast of current government and licensing regulations that affect quality control.

CONCULSION:-

Quality assurance is the responsibility of the hospital management and (workers) health personnel to
assure a higher quality of care. The administrators generally have to face the consequences in terms
of poor reputation of the hospital, legal expenses and higher hospital cost.

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 REFERENCES:-
1. SHABEER P BASHEER, 1ST EDITION, 2013, ADVANCED NURSING PRACTICE,
EMMEESS PUBLICATIONS, PAGE. NO: 50-60
2. NAVDEEP KAUR BRAR, 1ST EDITION, 2015, TEXT BOOK OF ADVANCED NURSING
PRACTICE, JAYPEE PUBLISHERS, PAGE.NO:- 76-91
3. ANNE M BARKER, 1ST EDITION, 2010, ADVANCED PRACTICE NURSING, JONES AND
BARTLETT PUBLISHERS, PAGE. NO:-324.
4. I CLEMENT, 2011, MANAGEMENT OF NURSING SERVICES AND EDUCATION,
ELSEVIER, 280-286.
NET REFERENCES:-
1. QUALITY ASSURANCE IN NURSING, STANDARDS CURRENT
NURSING.COM/NURSING-MANAGEMENT/QUALITY STANDARDS.
2. QUALITY ASSURANCE IN NURSING/ HUB PAGES hub pages.com/health/deepthi piyush.
JOURNEL REFERENCES:-
1. AORN JOURNEL- QUALITY ASSURANCE IN NURSING-AUGUST 1975 VOLUME 22,
ISSUE-
2. THE JOURNEL OF NURSING ADMINISTRATION-NURSES CRITICAL TO QUALITY,
SAFETY AND NOW FINANCIAL PERFORMANCE.
3. CREATING QUALITY EVIDENCE SUMMARIES ON A CLINICIAN’S SCHEDULE.

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 NURSING MANAGEMENT
SEMINAR ON
NATIONAL HEALTH POLICY,STATE HEALTH
POLICY,NATIONAL POPULATION POLICY,NATIONAL
POLICY ON AYUSH

SUBMITTED TO, SUBMITTED BY,

Mrs.Nidhi Alex Mrs. Selja Elsa Saji
Asso Professor 2nd Msc.(N)

25
T.M.M. College of Nursing T.M.M. college of
Kaviyoor Nursing,Kaviyoor

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