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The hospital must have adequate numbers of qualified professional and supportive staff to evaluate
patients, formulate written, individualized comprehensive treatment plans, provide active treatment
measures, and engage in discharge planning.
(a) Standard: Personnel. The hospital must employ or undertake to provide adequate numbers of
qualified professional, technical, and consultative personnel to:
(1) Evaluate patients;
(2) Formulate written individualized, comprehensive treatment plans;
(3) Provide active treatment measures; and
(4) Engage in discharge planning.

(b) Standard: Director of inpatient psychiatric services; medical staff. Inpatient psychiatric services
must be under the supervision of a clinical director, service chief, or equivalent who is qualified to
provide the leadership required for an intensive treatment program. The number and qualifications of
doctors of medicine and osteopathy must be adequate to provide essential psychiatric services.
(1) The clinical director, service chief, or equivalent must meet the training and experience
requirements for examination by the American Board of Psychiatry and Neurology or the American
Osteopathic Board of Neurology and Psychiatry.
(2) The director must monitor and evaluate the quality and appropriateness of services and treatment
provided by the medical staff.

(c) Standard: Availability of medical personnel. Doctors of medicine or osteopathy and other
appropriate professional personnel must be available to provide necessary medical and surgical
diagnostic and treatment services. If medical and surgical diagnostic and treatment services are not
available within the institution, the institution must have an agreement with an outside source of these
services to ensure that they are immediately available or a satisfactory agreement must be established
for transferring patients to a general hospital that participates in the Medicare program.

(d) Standard: Nursing services. The hospital must have a qualified director of psychiatric nursing
services. In addition to the director of nursing, there must be adequate numbers of registered nurses,
licensed practical nurses, and mental health workers to provide nursing care necessary under each
patient's active treatment program and to maintain progress notes on each patient.
(1) The director of psychiatric nursing services must be a registered nurse who has a master's degree in
psychiatric or mental health nursing, or its equivalent from a school of nursing accredited by the
National League for Nursing, or be qualified by education and experience in the care of the mentally
ill. The director must demonstrate competence to participate in interdisciplinary formulation of
individual treatment plans; to give skilled nursing care and therapy; and to direct, monitor, and evaluate
the nursing care furnished.
(2) The staffing pattern must insure the availability of a registered professional nurse 24 hours each
day. There must be adequate numbers of registered nurses, licensed practical nurses, and mental health
workers to provide the nursing care necessary under each patient's active treatment program.

(e) Standard: Psychological services. The hospital must provide or have available psychological
services to meet the needs of the patients.

(f) Standard: Social services. There must be a director of social services who monitors and evaluates
the quality and appropriateness of social services furnished. The services must be furnished in
accordance with accepted standards of practice and established policies and procedures.
(1) The director of the social work department or service must have a master's degree from an
accredited school of social work or must be qualified by education and experience in the social services
needs of the mentally ill. If the director does not hold a masters degree in social work, at least one staff
member must have this qualification.
(2) Social service staff responsibilities must include, but are not limited to, participating in discharge
planning, arranging for follow-up care, and developing mechanisms for exchange of appropriate,
information with sources outside the hospital.

(g) Standard: Therapeutic activities. The hospital must provide a therapeutic activities program.
(1) The program must be appropriate to the needs and interests of patients and be directed toward
restoring and maintaining optimal levels of physical and psychosocial functioning.
(2) The number of qualified therapists, support personnel, and consultants must be adequate to provide
comprehensive therapeutic activities consistent with each patient's active treatment program.

Model for Minimum Staffing Patterns for Hospitals Providing Acute Inpatient Treatment for
Children and Adolescents with Psychiatric Illnesses.

Acute psychiatric treatment for children and adolescents requires the use of intensive and complex
resources. We have the responsibility to our patients to ensure the quality and effectiveness of this
treatment. The standards are designed to be a minimum in terms of both staffing structure and numbers
of staff.
Various factors of patient selection and program objectives require increased staffing. Training ad
research programs are examples. It should be noted that the requirements for psychiatrists are for
diagnostic and psychiatric management only. Individual and family psychiatrists are for diagnostic and
psychiatric management only. Individual and family psychotherapy, done by the attending
psychiatrists, are considered to require additional time commitment.
The availability of a sufficient number of high quality staff is an absolute necessity to qualify a
program to provide acute psychiatric hospital treatment. While there are many appropriate variations in
programs and staffing, it is important that a model be established for minimum patterns of staffing.
Team and Authority
Staffing for an inpatient program depends on the mission of the program, severity of the illness, the
degree of impairment, and the complexity of the situation. Program focus and physical design interact
with program staffing. The responsibility for balancing these interactive factors rests with the program
administrative team.
At a minimum, the program administrative team with the responsibility for the entire treatment
program must include a qualified child and adolescent psychiatrist, and a qualified psychiatric nurse.
The program must be consistent with a hospital administration as conveyed by an appropriate
representative of the administration.
The program is developed by the administrative team and approved by the medical staff and hospital
Staffing and program organization and other ancillary services such as psychology, education, social
work, pediatric medicine and occupational therapy, need to be professionals in those disciplines.
It is the responsibility of the child and adolescent psychiatrists to maintain the integrity of professional
judgements and behaviors independent of influence of the source of compensation (Principles of
Practice of the American Academy of Child and Adolescent Psychiatry).
The staff of various disciplines must meet the facility's specific written criteria for credentials and
clinical privileges.
The administrative team has the responsibility for a program of continuous quality improvement.

Attending Psychiatrist
A licensed physician who has completed an approved program in child and adolescent psychiatry. For
patients 14 years of age and older, a general psychiatrist with documented specialized training,
supervised experience and demonstrated competence in work with adolescents and their families, may
be considered a qualified attending psychiatrist. Continuing medical education is essential.

There will be a sufficient number of qualified attending psychiatrists to prove the basic functions of
evaluations, admissions, diagnoses, prescribing of treatment, and discharging patients, and to supervise
the clinical treatment team.
Basic Functions:
At a minimum, functions must be performed as outlined at the frequency prescribed in the
Documentation of Medical Necessity of Child and Adolescent Psychiatric Treatment: Guidelines for
Use in Managed Care, Third-Party Coverage and Peer Review (AACAP, October 1990).

At a minimum, the attending psychiatrists must document psychiatric management with progress notes
every three days.

At a minimum and not including individual, group or family psychotherapy, the attending psychiatrist
must spend sufficient hours per week in the patient's psychiatric management and treatment to properly
provide for admission, discharge, treatment team, family and staff conferences, ordering and
supervising treatment, communication with parents, ongoing psychiatric assessment, and
documentation. Week-by-week the time will increase or decrease according to the number of
admissions, initial evaluations, basic evaluations or comprehensive examinations. Ordinarily it would
be expected that these responsibilities would require no less than 2.5 hours per week.

This minimum number of hours will need to be increased to account for additional medical factors,
training and research.

Social Worker or Other Professional Responsible for Family Contacts
Mental health professional who has a master's degree in social work or related field. A mental health
professional with a bachelor's degree supervised by a master's-level social worker is also considered
qualified. Continuing education and in-service training is essential.
The staff must include at least one social worker who has experience in child and adolescent inpatient

The number of social workers, or another discipline charged with family assessment and family
contacts per week, should be at least one-full time equivalent to 10 patients. The number of staff may
need to increase if extensive supplementary functions are included.

Basic Functions:
A basic family assessment within three days of admission.
A comprehensive social assessment within 14 days.
A weekly family and/or agency contact and progress note documenting the staff's active involvement in
the implementation of treatment plan goals.
Coordination of discharge planning.
Participation in at least one treatment team meeting a week.

Supplemental Functions:
Family therapy and group therapy.
Family, parent and patient education.

Psychiatric Nurses
Registered nurse with appropriate state license supervised by a qualified psychiatric nurse, i.e., a
bachelor's - or - master's - level nurse with experience in child and adolescent psychiatric inpatient
nursing. Continuing education and in-service training is essential.

A program requires one psychiatric nurse per shift for each 12 patients. An additional group of 10
patients. This number also needs to be adjusted according to the acuity, medical treatment, medication
and extensive functions.

Basic Functions:
Initial assessment of patient's nursing needs and documentation of nursing needs and documentation of
nursing components of an initial treatment plan.
A daily assessment and documentation of the patient, the patient's treatment and response to treatment.
Supervision of assessments done by psychiatric technicians and countersigning of their documentation.
Provision and documentation of medical treatment and medication as needed.
Development of the appropriate psychiatric nursing components of the treatment plan.
Implementation of the interventions in the treatment plan that are designated for psychiatric nurses.
Implement milieu management.
Health teaching.

Supplemental Functions:
Primary nursing.
Individual milieu interventions (individualized behavioral management).
Group therapy.
Specialized treatment for high-acuity patients, e.g., suicidal, assaultive, severely disorganized,
elopement risk, acute medical distress (unstable diabetes or asthma).

Child and Adolescent Psychiatric Technician
Also known as a child care worker, mental health specialist, child care specialist, mental health
Educational credentials vary. Extensive pre-service and ongoing in service training is essential. The
assignment of clinical responsibilities must consider careful evaluation of the combination of training,
experience and personal characteristics such as maturity, empathy and objectivity.

This is determined by considering general/generic supervision in the treatment milieu. (See final
section on generic staffing).

Basic Functions:
Establish and maintain behavioral supervision of children.
Maintain implementation of safe, therapeutic milieu.
Implement specific assigned aspects of the treatment plan.
Observe, assess, and document the patient's status.
Assist in planning and supervision of leisure activities.
Participate in the observation and documentation of the patient's treatment.

Functions Shared By Nurse and Psychiatric Technician:
Certain functions are done by the nurse and/or psychiatric technician.
Observation, assessment and documentation of the patient's condition on each shift. Where the
observation and documentation is done by the psychiatric technician, the note is countersigned by the
nurse responsible for the patient on that shift.
Supervision of the patients and maintaining the safety and therapeutic quality of the milieu. (Both have
responsibility for this).
Assisting, as necessary, the children in their daily activities, including leisure activities, transportation,
activities related to personal hygiene.

Shared Supplemental Functions:
Individual patient discussions.
Assisting in group therapy.
Leading various therapeutic activities.
Mental health education with parents and patients.
Behavioral management classes.

Ratio for General Staffing/Generic Supervision
In these parameters, units are considered to be from 9 to 24 child or adolescent patients.
When the children are occupied primarily in the program unit during the day and evening, the
minimum number is three staff to nine patients, proceedings in a three-to-one ratio.
With this staffing pattern staff can accomplish their basic responsibilities. Supplemental complex or
intensive interventions will require additional staffing.
When 18 or fewer patients located on one program unit are asleep, the minimum number of staff is
two. With over 18 patients asleep, the minimum level is three staff. In either case, there must be an
additional person available to help with sudden change in acuity. This should not reduce the basic
staffing on another unit.
At night, when the patients are asleep there should be one nurse to 50 patients per shift with an on-call
nurse who can come on site.
Ratios are dependent on such variables as the number of children in the living unit, the physical
configuration of the facilities, the acuity including developmental levels, the frequency of turnover and
length of stay, and the availability of off-unit activities, e.g., specialized recreational activities.
Other Staffing Requirements:
Children and adolescents treated in acute psychiatric hospital programs require additional special staff.
Due to the variability in program structure and patient characteristics, the number of staff is not
specified. Staff must be available to meet the following program and supervisory functions:
Psychological Services:
Sufficient licensed psychologist to provide relevant and appropriate psychological testing. Cognitive
evaluation is particularly important. In some programs, psychologists may be involved in treatment
plan development, individual, group and family psychotherapy and other types of therapeutic
Educational Services:
Educators to assess academic achievement and needs, maintain educational progress and accomplish
transfer into an appropriate post-hospital educational program. Patients need an educational program 5
days per week under the direction of a special educator.
Therapeutic Recreation Services:
A therapeutic recreation program provided 7 days per week under the direction of a certified recreation
Relevant and Appropriate Consultation in the Following Areas:
Medical specialties
Speech and hearing evaluation
Occupational therapy
The Council of the American Academy of Child and Adolescent Psychiatry accepted these Guidelines
for Minimum Staffing in 1990. The Academy has led in the development of policies, position
statements and review standards. These labor-intensive efforts are fueled by the Academy's pledge to
assure our patients and their families an adequate quality of medically necessary psychiatric treatment.
Functional, accurate and safe clinical equipments is an essential requirements in the provision of health
services. Well maintained equipments will give nurses greater confidence in the reliability of its
performance and contribute to a high standard of client care . Equipment management is an important
issue for cost and safety in hospitals operations. Planning of equipment and supplies recommends that
at the outset of each project,; identify project goals, including clinical priorities, budget, schedule and
Medical equipment and supplies:
Equipments are defined as those items necessary for the functioning of all services of the facility such
as accounting and records, maintenance of buildings and grounds, laundry, public waiting rooms,
public health and related services.
The term equipment is used for more permanent type of article and may be classified as fixed and
movables. Fixed equipment is not a structure of the building, but it is attached to the walls or floors
(egg; steriliser,) Movable equipment includes furniture, instruments etc.
Supplies are those items that are used up or consumed; hence the term consumable is used for supplies.
The supplies in hospital include drugs, surgical goods (disposables, glass wares), chemicals,
antiseptics, food materials, stationeries, the linen supply etc.
Definition of planning equipments and supplies:
Planning of equipments and supplies is defined as process of selection and organization of the articles
or items used in the diagnosis, treatment, and monitoring of patients in order to ensure that they are
safe, available, accurate, and affordable.
Need of planning equipments and suppplies:
Medical equipment and supplies planning includes all the related policies and procedure govern
activities from selection and acquisition through to the incoming inspection, acceptance, maintenance
and eventual retirement and disposal of medical equipment.Planning and management of all
equipments and supplies used in hospital is need to be done to ;
ensure that equipment and supplies used in patients care are operational, safe, and properly configured
to meet the mission of the medical treatment facility.
manage safety and cost of articles.
overcome the problems in nursing care or other patient related activities due to inadequacy in
equipments and supplies.
stabilize fluctuations in consumptions.
provide reasonable level of client services.
satisfy the demands during the period of replenishment.
cross bureaucratic hurdles in case of imported equipments.
know about possible legal or licensure issues.
Phases of equipment management:
A typical life cycle of medical equipment has the following phases:
1. Planning phase:
The following conditions that should be met to help the decision process in planning phase:
Demonstrated clinical needs.
Availability qualified users.
Aproved and reassured source of recurrent operating budget.
confirmed maintenance services and support.
Adequate environment support.
A clear cut policy should be there on acquisition, utilization and maintenance of equipment need to be
established.This will help to reduce any future problems arising out of contracts, spare parts and
maintenance of equipment acquired locally, internationally.


2. Procurement phase:
Standardize on models or manufacturers of equipment.
Specify the conditions and special requirements in the purtchase order to specify the supplier withhold
payment if specified conditions are not met.

3. Incoming inspections:
Incoming inspections should be carefully checked for possible damages; compliance with
specifications in the purchase ordere; and delivery of accessories, spare parts and operating and service

4. Equipment inventory and documentation system:
It provides information to support different aspects of medical equipment management;
Inventory entries should includes accessories, spare parts and operating and service manuals.
Make copies of the manuals for distribution to the users, while the originals of the manuals should be
kept at the technical document library for safekeeping.

5. Commissioning and acceptance:
Commissioning can be carried out by hospital technical staff.if they are familiar with that item of
equipment. If commissioning by the suppliers is needed , the process should be monitored by hospital
technical staff so that any technical matters can be noted and recorded.

6. Monitoring of use and performance:
A link should be maintained between user and supplier and observe any suppliers technical services.

7. Maintenance:
Proper maintenance of equipment is essential to obtain sustained benefits and to preserve capital
investment . Equipment must be maintained in working order and periodically calibrated for
effectiveness and accuracy. Proper maintenance has a direct impact on the quality of care.

8. De-commissioning:
Repair existing old equipments.
Dismantle old units if required.
De-Commisioned equipment must be deleted to keep the inventory current.
Factors affecting selection and planning of equipment
1. Type of service provided by the hospital: A maternity hospital requires more equipment related to
gynaecologic procedures than a cardiac hospital.
2. Age of patients: children need different type and amount of equipments than adults.
3. Sex- Men and women sometime require different type of equipment.
4. Degree and type of illness- neurologic patients sometimes require more bedsides, rubber mattress and
linen than patients with other type of illness.
5. Cost of items- cost of items will limit the purchase of number of equipment.
General utility services in the hospital
1. Electric supply and installations : A hospital must have a steady electrical supply at a stable voltage.
Voltage fluctuations play havoc with sophisticated electronic equipment, endoscope, sterilisers, X-ray
equipments etc. While planning hospital departments, provision should be made for voltage
stabilisation in areas with heavy concentration of electrical and electronic equipment. This is preferred
over using voltage stabilisers with individual equipment. There should be an emergency generator
capable of supplying power to all emergency areas of the hospital. This generator should be of right
capacity and kept in working order by periodic test runs.
2. Water supply : Since safe water supply is not always assured, hospitals must have their own
purification system. Also there should be plumbing system.
3. Disposal of wasteliquids and solids: Disposal of waste both solid and liquid is a totally neglected
area. A hospital incinarator good for the waste management.
4. Refrigeration, air conditioning, ventilation and environment control: Air conditioning is required
for protection of sophisticated electronic equipment, X ray, machines etc.
5. Transport : Lifts are needed for vertical transport. There should be separate lifts for patients, visitors,
staff and supply. Patients lift should accommodate a standard hospital bed. Sides of the lift must be
protected to prevent damage by trolleys. Lift surfaces and flooring should be capable of easy cleaning
and disinfection. Ventilation, communication and emergency escape system should be provided on all
lifts. As for horizontal transport also trolleys and ramps with gentle gradient are useful.
6. Supply of medical gases , compressed air, hot water, vacuum suction and gas plants: Piped supply
of medical gases , compressed air, vacuum suction , hot water, steam, necessitates thoughtful planning
at all stages to consider problems of
Easy uninterrupted safe supply
Fire and explosion hazards
Easy of servicing and maintenance without disrupting hospital services.
7. Laundry: A hospital laundry has 2 separate areas, with provision for decontamination and sterilising
of soiled linen.
8. Fire hazard: There should be consideration of ventilation, exhaust systems and adequate earthing of
all electrical installation.
9. Communication-:Public telephone and internal telephones are required in each hospital.
10. Repairs workshop :There should be provision for repair and maintenance of necessary equipments
used in the hospital .
Materials used in hospitals
Hospital material medical side Hospital material management side
Perfusion materials
Surgical disposables
Drugs, medicine, oxygen, linen
Biomedical equipment
Disinfecting items
Computers, telephone and fax
Food and beverage materials
Anaesthetic equipment
Electro medical equipment
Glass ware, dental machines
Surgical dressing utensils
Artificial limbs ,bandages, cots for patient,
Engineering items and many others
Computer, fax, telephone, stationary items
Public address items overhead projector
Audiovisual systems
Essential equipments for a 50 bedded district hospital (who)
1) Scope of services
Essential clinical services- medicine, surgery, paediatrics., OBG, and acute psychiatry (when
Optional clinical services oral surgery, orthopaedic surgery, otolaryngology, neurology and
Essential clinical support- anaesthesia, radiology and clinical laboratory
Optional clinical support services- pathology and rehabilitation including physiotherapy.
2) Essential medical equipment
Diagnostic imaging equipment it include x-ray and ultrasound equipment. X-ray equipment can be
stationary in one room or mobile
laboratory equipment
o microscope
o blood counter
o analytical balance
o calorimeter( spectrophotometer)
o Centrifuge a small centrifuge that can accommodate six 15ml tubes should be available.
o Water bath used for stabilising temperature at 25, 37, 42, or 56degree Celsius.
o Incubator/oven- a small hot air oven to carry out standard cultivations and sensitisations.
Refrigeratoran ordinary household refrigerator with a freezer unit, for storing preparations, vaccines,
blood etc.
Distillation and purification apparatus - it should be made of metal that resists acid, and alkali and
should be free standing.
3) Electrical medical equipment.
Portable electrocardiograph
Defibrillator( external)
Portable anaesthetic unit 2 small aesthetic units should be obtained, complete with a range of masks.
Respirator it should be applicable for prolonged administration during post operative care.
Dental chair unit- a complete unit should be available to carry out standard dental operations.
Suction pump one portable and one other suction pump are required.
Operating theatre lamp- one main lamp with at least 8 shadows lamp and an auxiliary of 4 lamp units.
Delivery table- it should be standard and manually operated.
Diathermy unit a standard coagulating unit which is operated by hand or foot switch, with variable
poor control.
4) Other equipment
autoclave for general stabilisation
Small sterilisers- for specific services- eg. Stabiliser
cold chain and other preventive medical equipment
5) Small , inexpensive equipment and instruments
Equipment and instrument, such as BP apparatus, oxygen manifolds, stethoscope, diagnostic sets and
Equipment and supplies required during emergency
The World Health Organization (WHO), in consultation with other international organizations, has adopted a
standard classification that places humanitarian supplies in 10 different categories. This form of identification is
particularly useful for the sorting and recording of supplies during emergency or disaster: The categories are
the following:


Water and environmental health,

Health supplies/Kits,




Personal needs/Education,

Human resources,



Role of nursing managers in maintaining equipment and supply:
The nurse manager should apply system approach for maintaining equipment and supply in nursing unit.
The main objective of input component is to ensure adequate supply of equipment ad supplies of nursing unit.
The nurse managers need to:
Take active part in estimating the demand of equipment and supply.
Be aware of hospital policy for requirement , indenting, stock etc.
Nursing norms for equipment and supply as per nursing council.
Develop ward policy as per requirement.
Communicate higher authority about the gap between demand and supply.
Conduct meetings with superiors and subordinates for requirement .
Prepare guidelines for handling and taking over for the staff.
To maximize the proper utilization of available equipment and supply by the staff and proper
maintenance of equipment and supplies.
Mainten current inventory of functional/in working order equipment and supplies.
Send requisition monthly, weekly, daily as per the policy developed.
Have inventory control, maintain buffer stock for emergency.
Do proper distribution for evening , night shift.
Conduct supervisory round.
Check daily and periodically the functioning of emergency and general equipment andlife saving
Assign and delegate the work to junior staff.
Make them accountable for any loss and misuse of equipment and supplies.
Ask them to use the articles for rendering patient care.
Communicate all the team members about the out of stock and non functioning of equipment.
Develop orientation plan for the patient and their relatives about the availability and non availability of
particular article, equipment and supplies and ward policy.
Maintain record and report of equipment and supplies.
Regularly maintain the equipment and supply.
Condemn the non functioning and outdated equipment as per policy.
Check all the work has been done.
To render quality patient care;
All the staff should be aware of policy: hospital, ward related to equipment and supply.
There should be adequate supply of equipment and supplies without any interruption.
Equipment s should be in working order.


(1) The governing body must ensure that a written policies and procedures manual is maintained. In
addition to meeting the requirements of rule. Policies and Procedures for all facilities, themanual must
include the following elements:

(a) A quality assurance procedure for the assessment of the quality of care. This procedure must
ensure appropriate treatment has been delivered according to acceptable clinical practice;

(b) A written program description which must be available to staff, patients and members of the
public. The description must include, but need not be limited to, the following:

1. Characteristics of the persons to be served,
2. Referral process,
3. Program rules for patients, and
4. Referral mechanisms for services outside the facility (both medical and non-medical);

(c) Procedures to ensure how the patients parents, guardian, members of the immediate family or
other responsible adult are to be notified in the case of any unusual occurrence including
serious illness, accidents or death.

Quality assurance:-
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 "Quality assurance is 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 a judgment concerning the process of care, based on the extent to which that cares
contributes to valued outcomes. (Donabedian 1982)
Quality Assurance is the definition of nursing practice through well written Nursing standards and the
use of those standards as a basis for evaluation on improvement of client care. (Marker 1998)
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.
According to Jonas (2002), the two main objectives are:-
To ensure the delivery of quality client care
To demonstrate the efforts of the health care providers to provide the best possible results.
Formulate plan of care
Attend to the patients physical and non physical needs
Evaluate achievement of nursing care
Support delivery of nursing care with administrative and managerial services
NURSI NG EDUCATI ON: - (Decker, 1985 and Schroeder, 1984)
To provide technical assistance in designing and implementing effective strategies for monitoring
quality and correcting systemic deficiencies.
To refine existing methods for ensuring optimal quality health care through an applied research
The main 8 Principles of Quality Assurance. Quality Assurance principles are based on the ISO 9001
standard and are intended to be used by senior Quality Managers to run a business based on continual
improvement and quality assurance
1. Customer focus: - The customer is always the most important factor for any business, which is why
organisations need to understand current and future customer needs and aim to surpass expectations.
Quality assurance relies on researching and understanding the customers needs and ensuring that the
organisations objectives are in line with those expectations. A quality management system needs to be
in place to manage customer relationships and communicate those needs across the organisation.
2. Leadership:- Quality assurance principles also suggest that an organisation needs leadership in order
to have purpose and direction. Quality assurance relies on a business having a clear vision of the future
a vision which should consider the needs of all relevant parties including customers, directions,
employees, local community etc. Good leadership within an organisation should establish trust and
remove fear, whilst encouraging and recognising employees contributions
3. Involvement of people: - An organisation needs to be able to put quality management training into
practice. People at all levels of the business need to be motivated, committed and fully involved in the
organisation. This principle of quality assurance involves people evaluating their own performance and
identifying their constraints, as well as actively seeking opportunities
4. Process approach: - ISO 9001 training encourages that in order to achieve a desired result, resources
and activities should be managed as a process. The process should focus on resources, methods and
materials which affect the key activities within a business. In order to maintain quality assurance within
a service or product, risks, consequences, the impaction customers and suppliers and other relevant
parties should be continuously evaluated
5. System approach to management:- Quality assurance training demonstrates how to create a structure
system which is designed to achieve the organisations aims and objectives using the most effective and
efficient methods. Quality management system training should provide a better understanding of the
roles and responsibilities necessary for achieving those objectives and should be continually improved
by evaluating and measuring its performance
6. Continual improvement:- Another quality assurance principle is that continual improvement should
always be an objective for any business. To maintain quality assurance, it is essential to provide people
with the necessary tools and knowledge for continual improvement. Continual improvement of
products, processes and systems should be promoted as an objective for every employee throughout all
levels in the organisation.
7. Factual approach to decision making:- This quality assurance principle simply ensures that decisions
are based on analysed data and information. To comply with this quality management standard, data
and information should be accurate and reliable, accessible to those who need it and analysed using
valid methods
8. Mutually beneficial supplier relationships:- The Quality management standard ISO 9001 encourages
organisations to create mutually beneficial relationships with its suppliers. These mutually beneficial
relationships allow the organisation to benefit from optimised costs and resources, clear and open
communication and being able to share knowledge and plans on market changes and consumer
QUALITY ASSURANCE CYCLE:- 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
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.
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.
3. 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

4. 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.
5. 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.
6. 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.
7. 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.
8. 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
9. 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.
10. Implementing and Evaluating Quality Improvement Efforts:-
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 in a
limited 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.
I. General approach
II. Specific approach
I. 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. According to Hinvasky, 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. National league for nursing (NLN) a voluntary
organization has established standards for inspecting nursing education's programs. In the part the
accreditation process primarily evaluated on agency's physical structure, organizational structure and
personal qualification.
d) Certification:- Certification is usually a voluntary process with in the profession. A person's
educational achievements, experience and performance on examination are used to determine the
person's qualifications for functioning in an identified specialty area.
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
II) 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. 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
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 providers practice either with practice by the providers
peer or with an acceptable standard of care. To maintain high standards, peer review has been initiated
to carefully review the quality of practice demonstrated by members of a professional group. Peer
review is divided in to two types. One centers on the recipients of health services by means of auditing
the quality of services rendered. The other centers on the health professional by evaluating the quality
of individual performance.
e) Bench marking- A process used in performance improvement to compare oneself with best
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
1) Lack of 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 problems: Lack of trained, skilled and motivated employees, staff indiscipline affects
the quality of care.
3) Improper maintenance: Buildings and equipments require proper maintenance for efficient use. If
not maintained properly the equipments cannot be used in giving nursing care. To minimize equipment
down time it is necessary to ensure adequate after sale service and service manuals.
4) Unreasonable Patients and Attendants Illness, anxiety, absence of immediate response to treatment,
unreasonable and un co-operative 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) Absence of accreditation laws: There is no organization empowered by legislation to lay down
standards in nursing and medical care so as to regulate the quality of care. It requires a legislation that
provides for setting of a stationary accreditation / vigilance authority to:
8) Lack of good and hospital information system: A good management information system is
essential for the appraisal of quality of care.
9) Absence of patient satisfaction surveys: Ascertainment of patient satisfaction at fixed points on an
ongoing basis. Such surveys carried out through questionnaires, interviews to by social worker,
consultant groups, and help to document patient satisfaction
10) Lack of nursing care records: Nursing care records are perhaps the most useful source of
information on quality of care render.
Quality assurance follows client care rather than organizational structure, focus on process rather than
individuals and uses a systematic approach with the intention of improving the quality of care The
main methods of assessing quality assurance are as follows:
1. Training the nursing staff:- Training includes the explanation of the purpose of each critical
indicator meaning of each criterion ,proper approach of data collection.
2. Performing the audit:- An audit may be focused on the particular medical diagnosis and related to
the patient care while he is in the hospital. Audit are of two type
a) Concurrent audit-In this patient care is observed as it is given
b) Retrospective audit-In this patient care is evaluated only aeter the discharge of patient.
3. Analysis of medical record data:- After screening of sampled medical records ,the surveyor should
refer records showing variations from established criterion to the desired task,so that they can
determine whether the variation is justified or corrective action is taken.
4. Peer view:- Peer view is also one method for increasing nursing accountability for effective decision
making and interventions.In this view mainly evaluate the performance against accepted standards
The nursing process consist of six steps and uses a problem solving approach that has come to be
accepted as nursings scientific methodology. It is goal directed , with the objective being delivery
of quality client care.
Standards of care pertain to professional nursing activities that are demonstrated by the nurse
through the nursing process. These involve assessment, diagnosis, outcome identification,
planning, implementation, and evaluation. The nursing process is the foundation of clinical
decision making and encompasses all significant action taken by nurses in providing psychiatric
mental health care to all clients.
The psychiatric/ mental health nurses collects patient health data
The assessment interview which require linguistically and culturally effective communication
skills, interviewing, behavioural observation, record review and comprehensive assessment of the
patient and relevant system enable the mental health nurse to make sound clinical judgement and
plan appropriate interventions.
The mental health nurse analyzes the assessment data in determining diagnosis
Data gathered during the assessment are analysed. Diagnoses and potential problem statement are
formulated and prioritized.
The mental health nurse identifies expected outcomes individualized to the patient
Expected outcomes are derived from the diagnosis. They must be measurable and estimate a time
for attainment. They must be realistic for the clients capabilities, and are more effective when
formulated by the interdisciplinary members, the client, and significant other together.
The mental health nurses develops a plan of care that is negotiated among the patient, nurse,
family, and health care team and prescribes evidence based interventions to attain expected
A plan of care is used to guide therapeutic intervention systematically, document progress, and
achieve the expected patient outcome. The care plan is individualized to the clients mental health
problems, condition, or need and is developed in collaboration with the client, significant others,
and interdisciplinary team member. For each diagnosis identified, the most appropriate
interventions are selected.
The mental health nurse implements the interventions identified in the plan of care
In implementing the plan of care, mental health nurses use a wide range of interventions designed
to prevent mental and physical illness, and promote, maintain, and restore mental and physical
health. Intervention should be according to their level of practice.
Standard va.Counselling: the mental health nurse uses counselling intervention to assist client in
improving and regaining their previous coping abilities, fostering mental health and preventing
mental illness and disability.
Standard vb. Milieu therapy:
The mental health nurse provides, structures, and maintain a therapeutic environment in
collaboration with the client and other health care clinicians.
Standard vc. Promotion of self care activities:
The mental health nurse structures intervention around the clients activities of daily living to
foster self care and mental and physical well being.
Standard vd. Psychobiological interventions:
The mental health nurse uses knowledge of psychobiological interventions and applies clinical
skills to restore the clients health and prevent further disabilities.
Standard ve. Health teaching:
The mental health nurse, through health teaching, assist client in achieving satisfying , productive,
and healthy patterns of living.
Standard vf. Case management:
The mental health nurse case management to coordinate comprehensive health services and ensure
continuity of care.
Standard vg. Health promotion and health maintenance:
The mental health nurse employs strategies and interventions to promote and maintain health and
prevent mental illness.
Standard vh. Psychotherapy:
the certified specialists in mental health nursing uses individual, group, and family psychotherapy,
and other therapeutic treatment to assist clients in preventing mental illness and disability, treating
mental health disorders, and improving mental health status and functional abilities.
Standard vi. Prescriptive authority and treatment:
The certified specialist in mental health nursing uses prescriptive authority, procedures, and
treatments in accordance with state and federal laws and regulations, to treat symptoms of
psychiatric illness and improve functional health status.
Standard vj. Consultation:
The certified specialist mental health nursing provides consultation to enhance the abilities of
other clinicians to provide services for client and effect change in the system.
The mental health nurse evaluates the clients progress in attaining expected outcomes.
During evaluation step, the nurse measures the success of the intervention in meeting the outcome
criteria. The clients response to treatment is documented, validating use of nursing process in the
delivery of care. The diagnosis, outcomes, and plan of care are reviewed and revised as need is
determined by the evaluation.
A patient record shall be maintained, in accordance with accepted professional principles, for
each patient admitted for care in the facility.
Such records shall be kept confidential and only authorized personnel shall have access to the
record. Staff members and other persons having access to patient records shall be required to abide
by the written policies confidentiality of patient records and disclosure of information in the
record, as well as, all applicable federal, state and local laws, rules and regulations.
The facility shall have written policies and procedures that protect the confidentiality of patient
records and govern the disclosure of information in the records. The policies and procedures shall
specify the conditions under which information on applicants or patients may be disclosed and the
procedures for releasing such information.
A patient or his or her authorized representative may consent to the release of information
provided that written consent is given on a form containing the following information:
1. Name of patient;
2. Name of program;
3. The name of the person, agency or organization to which the information is to be
4. The specific information to be disclosed;
5. The purpose for the disclosure;
6. The date the consent was signed and the signature of the individual witnessing the
7. The signature of the patient, parent, guardian or authorized representative; and
8. A notice that the consent is valid only for a specified period of time. 31
The written consent of a patient, or his or her authorized representative, to the disclosure of
information shall be considered valid only if the following conditions have been met:
1. The patient or the representative shall be informed, in a manner calculated to assure his or her
understanding, of the specific type of information that has been requested and, if known, the
benefits and disadvantages of releasing the information.
2. The patient or the representative shall give consent voluntarily.
3. The patient or the representative shall be informed that the provision of services is not
contingent upon his or her decision concerning the release of information; and
4. The patient's consent shall be acquired in accordance with all applicable federal, state and local
laws, rules and regulations.
Every consent for release of information, the actual date the information was released, the specific
information released, and the signature of the staff member who released the information shall be
made a part of the patient record.
In a life-threatening situation or when an individual's condition or situation precludes the
possibility of obtaining written consent, the facility may release pertinent medical information to
the medical personnel responsible for the individual's care without the individual's consent and
without the authorization of the Chief Executive Officer or a designee, if obtaining such
authorization would cause an excessive delay in delivering treatment to the individual.
1. When information has been released under emergency conditions, the staff member responsible
for the release of information shall enter all pertinent details of the transaction into the individual's
record including at least the following items:
a. The date the information was released;
b. The person to whom the information was released;
c. The reason the information was released;
d. The reason written consent could not be obtained; and
e. The specific information released.
2. The patient or applicant shall be informed that the information was released as soon
as possible after the release of information.
Patient records shall not be removed from the facility except upon subpoena and court order.
Written policies and procedures shall govern the compilation, storage, dissemination and
accessibility of patient records. The policies and procedures shall be designed to assure that the
facility fulfills its responsibility to safeguard and protect the patient record against loss,
unauthorized alteration, or disclosure of information; to assure that each patient record contains all
required information; to uniformity in the format and forms in use in patient records; to require
entries in patient records to be dated and signed.
The facility shall provide facilities for the storage, processing and handling of patient records,
including suitably locked and secured rooms and files. When a facility stores patient data on
magnetic tape, computer files, or other types of automated information systems, adequate security
measures shall prevent inadvertent or unauthorized access to such data. A written policy shall
govern the disposal of patient records. Methods of disposal shall be designed to assure the
confidentiality of information in the records.
The patient records department shall maintain, control and supervise the patient records, and shall
be responsible for maintaining the quality.
A qualified medical record individual who is employed on at least a part-time basis, consistent
with the needs of the facility and the professional staff, shall be responsible for the patient records
department. This individual shall be a registered record administrator or an accredited record
When it can be demonstrated that the size, location or needs of the facility do not justify
employment of a qualified individual, the facility must secure the consultative assistance of a
registered record administrator at least twice a year to assure that the patient record department is
adequate to meet the needs of the facility.
1 All clinical information pertaining to a patient's stay shall be centralized in the patient's record.
2. The original or all reports originating in the facility shall be filed in the medical record.
3. Appropriate patient records shall be kept on the unit where the patient is being
treated and shall be directly accessible to the clinician caring for the patient.
The medical record shall contain sufficient information to justify the diagnosis and warrant the
treatment and end results. The patient record shall describe the patient's health status at the time of
admission, the services provided and the patient's progress in the facility, and the patient's health
status at the time of discharge. The patient record shall provide information for the review and
evaluation of the treatment provided to the patient. When appropriate, data in the patient record
shall be used in training, research, evaluation and quality assurance programs. When indicated, the
patient record shall contain documentation that the rights of the patient and of the patient's family
are protected. The patient record shall contain documentation of the patient's and, as appropriate,
family members' involvement in the patient's treatment program. When appropriate, a separate
record may need to be maintained on each family member involved in the patient's treatment
program. The patient record shall contain identifying data that is recorded on standardized forms.
This identifying data shall include the following:
1. Full name;
2. Home address;
3. Home telephone number;
4. Date of birth;
5. Sex
6. Race or ethnic origin;
7. Next of kin;
8. Education;
9. Marital status;
10. Type and place of employment;
11. Date of initial contact or admission to the facility;
12. Legal status, including relevant legal documents;
13. Other identifying data as indicated;
14. Date the information was gathered; and
15. Signature of the staff member gathering the information.
The patient record shall contain information on any unusual occurrences such as the following:
1. Treatment complications;
2. Accidents or injuries to the patient;
3. Morbidity;
4. Death of a patient; and
5. Procedures that place the patient at risk or that cause unusual pain.
As necessary, the patient record shall contain documentation of the consent of the patient,
appropriate family members or guardians for admission, treatment, evaluation, aftercare or
The patient record shall contain both physical and psychiatric diagnoses that have been made
using a recognized diagnostic system.
The patient record shall contain reports of laboratory, roentgenographic, or other diagnostic
procedures and reports of medical/surgical services when performed.
The patient record shall contain correspondence concerning the patient's treatment, and signed and
dated notations of telephone calls concerning the patient's treatment.
A discharge summary shall be entered in the patient's record within a reasonable period of time
(not to exceed 14 days) following discharge as determined by the professional staff bylaws, rules
and regulations.
The patient record shall contain a plan for aftercare.
All entries in the patient record shall be signed and dated. Symbols and abbreviations shall be used
only if they have been approved by the professional staff, and only when there is an explanatory
legend. Symbols and abbreviations shall not be used in the recording of diagnoses.
When a patient dies, a summation statement shall be entered in the record in the form of a
discharge summary. The summation statement shall include the circumstances leading to death
and shall be signed by a physician. An autopsy shall be performed whenever possible. When an
autopsy is performed, a provisional anatomic diagnosis shall be recorded in the patient's record
within 72 hours. The complete protocol shall be made part of the record within three (3) months.
Current records shall be completed promptly upon admission. Records of patients discharged shall
be completed within 14 days following discharge. The staff regulations of the facility shall provide
for the suspension or termination of staff privileges of physicians who are persistently delinquent
in completing records.
A system of identification and filing to ensure the prompt location of a patient's medical record
shall be maintained.
The patient index cards shall bear at least the full name of the patient, the address, the birth date
and the medical record number.
Records shall be indexed according to disease and physician, and shall be kept up to date. For
indexing, any recognized system may be used.
Indexing shall be current within six (6) months following discharge of the patient.