QUALITY ASSURANCE IN OBSTETRICAL AND GYNAECOLOGICAL UNIT

INTRODUCTION

In the changing healthcare environment, quality of care is receiving greater attention than ever
before. A consumer become more knowledgeable as a result of increased information available
to them, much of surrounding healthcare is being dissipated. The focus of efforts to measure
quality has also expanded from inside the boundaries of hospital to community and long term
care setting.

MEANING OF QUALITY

The dictionary defines quality as "a degree of excellence; a peculiar and essential
character."Although individual writers suggest slightly different view about quality, several
communalities emerge when reviewing their approaches.
1. Quality can be measured
2. Quality measures a standard or a degree of excellence
3. Excellence needs to be determined by validating standard of care or measuring professional
conduct when caring for patients.

DEFINITION:

The British Standards Institute defines Quality as "the totality of features or characteristics of a
product or services that bears on its ability to satisfy a given needs." It can be paraphrased into
"quality is that which gives complete customer satisfaction.

DEFINITION OF QUALITY ASSURANCE :

Quality assurance is a process in which achievable and desirable levels of quality are described,
the extent to which there level are achieved is measured, and action to enable them to be reached
is taken.

Quality assurance is "an assessment of the effectiveness of health care provision, the efforts
made to improve care as a result of assessment, combined with an assurance that quality care
will be maintained."

ELEMENTS OF QUALITY

Shaw (1998) approaches these dimensions similarly but describes them as elements of quality.
He sets out the following elements:
Appropriateness: The service or procedure is what the population or individual actually needs.
Equity: A fair share is available for all the population
Accessibility: Services are not compromised by undue limits of time and distance.
Effectiveness: Services are achieving the intended benefits for the individual and for the
population.

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Acceptability: services are provided such as to satisfy the work expectations of patients,
providers and the community.
Efficiency: resources are not wasted on one services or patient to the determent of another.

COMPONENTS OF QUALITY ASSURANCE PLAN

A quality assurance plan provides the foundation and framework of all quality control activities.
A quality assurance plan should include the following components.

 Clearly stated goals

 Measurable objectives of how the goals will be met
 Designated accountability for written objectives
 Delineated methods of QA activities
 Outlined responsibilities conducting QA activities
 Outlined mechanisms of reporting of reporting dat
 Outlined mechanisms of corrective action
 Clear statement of confidentiality
A SYSTEMATIC MEASURE OF QUALITY NURSING CARE:

Professional nurses can provide more efficient and cost effective services to the consumer with
aid of advanced technologies. Computers and cost accounting. A systematic integrative model of
quality care measurement, will determine quality of outcomes based onantecedents (structure
elements and process). In such model, structural inputs into the nursing care system would
include those elements in the settings in which nursing care are given.

COMPONENTS OF QUALITY ASSURANCE

In the United Kingdom, British Standards 5750, and sets out how a quality system might be set
up within an company. There are 19 components that describe how the quality system is to be
applied to the design and manufacture of a product or services.
1. Documented quality system.
2. Organization
3. Review of quality system operation
4. Planning
5. Work instruction
6. Records
7. Corrective action
8. Control of design activities
9. Documentation and change control.
10. Control of inspection, measuring and test equipment.
11. Control of purchased material.
12. Control of manufacture.
13. Purchaser supplied material.
14. Completed item inspection and test
15. Sampling procedure
16. Control of non conforming material
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17. Indication of inspection status
18. Protection and preservation of product quality
19. Training.
The component of a nursing quality assurance program were originally developed by Lang and
adopted by the American Nurses' Association as a model for quality assurance in nursing. The
evaluation model is open and circular, indicating a cyclical process that can be entered at any
point.

FACTORS INFLUENCING QUALITY MANAGEMENT

 Good organization structure/ function
 Good quality staff
 Continuing professional development
 Continuing structure/ functional performance evaluation
 Learning from failures and moving from low quality to high quality organization.

GUIDELINES FOR QUALITY CONTROL

While approaches to quality improvement depend on the situation criteria guidelines can be
helpful:-
 Quality improvement must not be a fad; it must be a long- term continuous efforts. There
are always opportunities for improvement.
 While top- management commitment is of vital importance, everybody in an
organization, from top to bottom, must be committed to quality.
 Most quality problems require the cooperation and coordination of many functional
departments, production design testing, engineering, manufacturing, marketing, and so.
 Ideas and suggestions for quality improvement can come from many, often unexpected,
sources.
 Quality control should be done at crucial steps in the operations process.
 A quality improvement plan is not enough. Provision must make for its implementation

I. ESTABLISH STANDARDS

All standards of practice provide a guide to the knowledge, skills, judgment & attitudes that are
needed to practice safely. A nursing care standard is "a descriptive statement of desired quality
against which to evaluate nursing care given to a patient". Gillis(1989)

PURPOSE OF STANDARDS.

 To give direction and provide guidelines for performance of nursing care.

 To provide a baseline for evaluating quality of nursing care, ranging from excellent care
to unsafe care.
 To help to improve quality of nursing care, increase effectiveness of care and improve
efficiency.(Quality assurance)
 To improve documentation of nursing care provided i. e maintain record of care.

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  Help to determine the degree to which standards of nursing care maintained and take
necessary action time.
 To help supervisors to guide nursing staff to improve performance.
 To help to improve the decision making and devise alternative system for delivering
nursing care.
 It may help justify demands for resources association or improvement.
 To help to clarify nurses area of accountability.
 To help nursing to define clearly different levels of care.
 Help to decrease the costs of nursing care of eliminating nonessential nursing tasks.
 Be used as a framework or basis for determining nursing negligence.
 Motivate nurses to achieve excellence.

USES AND ADVANTAGES OF STANDARD:

 They establish norms and allow community members and individuals to know what level
of service to expect/ demand. Because they are written down they can be made public.
 They demonstrate quality provision and act as a bench mark to monitor quality
performance.
 They focus on the core and critical tasks that must be performed in the actual situation
and can be tailored to meet specific and local situation.
 They improve efficiency and lead to better utilization of resources.
 They improve staff utilization and staff motivation.
 They can be used to access the practical aspects of both basic and post basic education
and training.

APPROACHES:

A frame work for implementing the standards considers three possible approaches:
1. Centralized/ National approach
2. Decentralized/ Local approach
3. Combined approach

1. Centralized/ National approach:

It relies on the centre taking a lead, making all the decisions and initiating all the activities. For
this approach to be effective there should be an effective management system. This approach
has not been successful because it relies on decisions made at levels away from where the
activities will eventually take place. Sometimes local level difficulties arise which cannot be
foreseen at the national level at the time when the plan is being developed.

2. Decentralized/ Local approach: This approach is when the centre takes the lead in making
the policy decision to use midwifery standards as major component of quality assurance.
However the planning of activities and adaptations of the midwifery standards are left to the
local districts.
Disadvantages:
Lack of expertise in the local level.

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It does not ensure the use of national norms and consistency, as each site may make their own
adaptations and decisions.

3. Combined approach:
The centre at the National level remains responsible for the overall implementation of the
midwifery standards; but uses local demonstration sites to try them out, to learn lessons on how
they can be implemented elsewhere, and what adaptations are required to make them specific to
the country situation. The centre must therefore work closely and takes action with the local
demonstration sites at all stages, right from the initial decision making and planning stages to the
evaluation stage.

II. IMPLEMENTATION OF STANDARDS

Each employees of the institution should follow the standards developed by the organization.

III. MONITOR COMPLIANCE ON STRUCTURE STANDARDS AND PROCESS

STANDARDS
Compliance monitoring is done by survey and auditing

STANDARDS FOR NURSING PRACTICE:

The standards for nursing practice are interrelated and all equally important.-
Standard 1: Accountability
The registered nurse is accountable to the public for competent, safe and ethical nursing
practice.-
Standard 2: continuing competence-
The registered nurse attains and maintains competencies relevant to own scope of nursing
practice.-
Standard 3: application of knowledge, skills and judgment-
The registered nurse demonstrates competencies relevant to own scope of nursing practice.-
Standard 4: professional relationships an advocacy-
The registered nurse establishes professional therapeutic relationships with clients and advocates
for clients in their relationships with the health system.-
Standard 5: professional leadership
The registered nurse demonstrates professional leadership in the delivery of quality nursing and
health care services to the public-
Standard 6: self regulation
The registered nurse assumes personal accountability to practice nursing competently and
ethically.

THE IMPORTANCE OF STANDARDS FOR QUALITY MATERNITY AND

MIDWIFERY CARE

A standard serves to establish norms and states what level of performance is required to obtain a
specific desire to do outcome. In doing so, it provides protection to the public by having criteria

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against which products and the performance of practitioners can be assessed. Standard
statements are usually expressed in behavioral and measurable terms. They will say precisely
what the workers will do and how they will carry out the task. It is also important that standards
are realistic, desirable and achievable. Standards of practice can help identify the actual
competencies required by a midwifery trained personnel in routine normal practice.

Abdominal palpation:
 Aim: To estimate gestational age, monitor fetal growth and accurately identify lie,
presentation and position of the fetus. Pregnant women attend ANC
 Midwifery- trained personnel have been trained in the correct procedure for conducting
abdominal palpation
 Essential equipment such as tailor's measure tape and fetal stethoscope is available and in
good working condition.
 A culturally appropriate place is available which allows privacy to conduct the abdominal
palpation.
 Pregnancy records are in use

PROCESS:

Midwifery trained personnel must:

 Carry out abdominal palpation at every antenatal visit
 Ask the pregnant women prior to the palpation how she feels, if the baby is moving and
when her last menstrual cycle occur or the date she felt the baby first moved.
 Ensure the place for conducting palpation provides the pregnant women with privacy
 Prior to an abdominal palpation ask the pregnant women to empty her bladder
 Lay the pregnant women on her back with upper part of her body supported with
cushions. Never lie a pregnant women flat on her back as the heavy uterus may compress
the main blood vessels returning to the heart and cause fainting (supine hypotension)
 Inspect the abdomen for scar, previous stretch mark, signs of over distension/ other signs
of multiple pregnancy such as fetal parts felt to fetal heads palpated, excessive or reduced
amount of amniotic fluid. Record findings and refer for institutional deliveries. If the
women had a previous caesarean section or there are signs of excessive or reduced
amniotic fluid or multiple pregnancy.
 Estimate gestational age and assess the fetal growth. After 24 weeks of pregnancy the
most effective way to estimate gestational age is to use a tailor's tape measure.
 Using the measuring tape, measure from the upper border of the symphysis pubis to the
top of the fundus. Record the measurement in centimeters. If measurement is different
from calculated weeks by more than 3c.m or there is no growth or poor growth from the
last examination, refer for further investigation.
 Gently palpate the abdomen to assess the lie of the fetus
 Using two hands palpate the abdomen and pelvic area to identify the presenting part
 After 37 weeks especially in primi gravida assess the fetal head is engaged. If not, ask the
pregnant women to sit/ stand up and see if the head can be made to fit in to the pelvis. If
the head will not going to the pelvis refer to the first referral unit/ hospital.
 Identify where the fetal back is and listen to the fetal heart sound

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  Discuss all findings with the pregnant women, her husband/ accompanying family
members
 Record all findings accurately. Reveal all findings and if any deviations are found refer to
the first referral unit/ hospital for most specialized investigation as appropriate.

AUDIT IN OBSTETRICS:

DEFINITION:

Audit
Is defined as the systematic and critical analysis of the quality of medical care.

Nursing Audit:
Is a means by which nurses themselves can define standards from their point of view and
describe the actual practice of nursing.

Structuring an audit:
Important aspect to organize an obstetric audit is motivation of all doctors, midwives, and other
health professionals. Proper documentation of facts and figures must be there. Audit should be
kept confidential and is considered as an educational tool.

When to audit:
The audit should be done 3 to 6 months or 12 months after commencement, then:
1. at regular intervals such as annually
2. Immediately when a major incident or problem occurs, or
3. As soon as feasible when there is a complaint by the midwifery- trained personnel that they
are unable to fulfill the standard, or a complaint is raised by the community about the quality
services,
4. When a new intervention related to the standard is implemented, such as the use of some new
technology or treatment/ drug. In this case there should be an interval of a minimum of three
months before the audit is conducted so that the full benefits/ effects of the new treatment,
equipment or drug can be seen.

How to conduct audit:

Audit should be pre arranged with the midwifery trained personnel. The auditor should go to
the field/ unit where the midwifery trained personnel is working to observe the standard in
practice in the local situation. This should be done over 2-3 days so that the auditor can observe
the midwifery trained personnel in different situations.

Importance of carrying out an audit:

1. A well structured and efficient audit is based on scientific evidences with facts and figures.
2. It can replace the out of date clinical practice with the better one
3. It can remove the disbelieving and agonistic attitudes between hospital management and
professionals and also amongst the professionals.
4. It improves awareness between doctors and patients
5. It is an efficient educational tool

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Use of audit results:
After conducting the audit and depending on the results, the decision will be made either to:
1. Continue with the standard since it is working effectively.
2. Take further specific action to strengthen the standard or correct deficiencies
3. Revise the standard. From the result of the audit check list, it will be possible to develop an
action plan to further improve or strengthen the standard. It is important in action plan to set
target dates for completion of each task

Clinical audit:
Clinical audit is about improving practice and providing a better service for consumers.
Practitioners are expected to measure and demonstrate the effectiveness of the care they
provide and one way of assessing practice by clinical audit. Clinical audit is a continuous process
that involves identifying an area to be examined, the collection of appropriate data and the
introduction of changes in practice as a result of analysis of the data. It is crucial that the effect of
changes is monitored by repeating the audit and introducing further changes, if indicated. Health
care professionals are mainly concerned with the outcome of clinical intervention, but there are
other aspects of clinical practice that may influence outcome. Audit may influence aspects of
service structure and process as well as the outcome of clinical care.

Process of clinical audit:

When embarking on a process of clinical audit for the first time, it is better to concentration
a small area of study, and one that is amenable to change. An example might be to improve
breast feeding rates. One must decide what it is necessary to know in order to achieve this. It is
extremely important to define objectives at the start of any process of audit and how the results
of the process might be used to influence practice. When an area of study has been chosen, it is
vital for there to be clinical consensus on what constitutes good care, that is, what should be
happening, a desired level of achievement, and a standard. It is likely to be easier to agree any
changes as a result of the audit if clinical consensus on good care has been obtained.

Protocols, guidelines and procedures:

A protocol is a written system for managing care that should include a plan for audit of that care.
Most protocols are binding on employees as they usually relate to the management of consumers
with urgent, possibly life threatening conditions. A protocol may exist for the care of the woman
with ante partum hemorrhage but not for the care of women in labour without complication.
Guidelines or procedures are usually less specific than protocols and may be described as
suggestions for criteria or levels of performance which are provided to implement agreed
standards.

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JOURNAL STUDY

Objective:
To assess hospital practices in obstetric quality management activities and identify institutional
characteristics associated with utilization of evidence-supported practices.
Methods:
Data for this study came from a statewide survey of obstetric hospitals in California regarding
their organization and delivery of perinatal care. We analyzed responses from 185 hospitals that
completed quality assurance sections of the survey to assess their practices in a broad spectrum
of quality enhancement activities. Association between institutional characteristics and adoption
of evidence-supported practices (i.e., those supported by prior literature or recommended by
professional organizations as beneficial for improving birth outcome or patient safety) was
examined using bivariate analysis and appropriate statistical tests.
Results:
Most hospitals regularly audited adherence to written protocols regarding critical areas of care;
however, 77.7% and 16.8% reported not having written guidelines on diagnosis of labor arrest
and management of abnormal fetal heart rate, respectively. Private non-profit hospitals were
more likely to have written protocol for management of abnormal fetal heart rate (p=0.002). One
in ten hospitals (9.7%) did not regularly review cases with significant morbidity or mortality,
while only 69.0% regularly tracked indications for cesarean delivery. Moreover, 26.3%, 14.3%
and 8.7% of the hospitals reported never performing interprofessional simulations for eclampsia,
shoulder dystocia, and postpartum hemorrhage, respectively. Teaching status was associated
with more frequent simulations in these three areas (p≤0.04 for all); while larger volume was
associated with more frequent simulations for eclampsia (p=0.04).
Conclusion:
Hospitals in California engage in a wide range of practices to assure or improve quality of
obstetric care, but substantial variation in practice exists among hospitals. There is opportunity
for improvement in adoption of evidence-supported practices.

Quality Assurance Practices in Obstetric Care: A Survey of Hospitals in California

Lisbet S. Lundsberg1.Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale

School of Medicine, New Haven, CT;

Henry C. Lee2.Department of Pediatrics, Division of Neonatal & Developmental Medicine,

Stanford University School of Medicine, Stanford, CA;

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Published in final edited form as:
Obstet Gynecol. 2018 Feb; 131(2): 214–223.
doi: 10.1097/AOG.0000000000002437

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