CHRISTIAN COLLEGE OF NURSING

NEYYOOR

SEMINAR
ON
QUALITY ASSURANCE
- CONTINUOUS

QUALITY IMPROVEMENT,
STANDARDS, MODELS, NURSING
AUDIT.

PRESENTED BY: GUIDED BY:

J. Asir Dhayani Dr. Mrs. Santhi Appavu MSc (N), M.Phil., Ph.D.

MSc (N) II Year, Principal

Medial Surgical Nursing (Dept.) Medial Surgical Nursing (Dept.)

Christian College of Nursing, Neyyoor Christian College of Nursing, Neyyyoor

. PRESENTED ON:

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 CONTROLLING
QUALITY ASSURANCE– CONTINUOUS QUALITY
IMPROVEMENT, STANDARDS, MODELS, NURSING
AUDIT

INTRODUCTION:
Planning and controlling are virtually inseparable functions, Siamese twins of
management. Controlling is the function of management that involves setting
standards, measuring performance against those standards, reporting the results and
taking action. Quality control is a specific type of controlling refers to activities that
evaluate monitor or regulate services rendered to customer. Quality assurance is the
very essence of quality control. It means assure quality in a product so that the
customer can buy it with confidence and satisfaction. Quality assurance is the
effective execution of all activities concerned in attaining the set goal.

TERMINOLOGY:
1. Clan:
A clan is a group of people united by actual or perceived kinship and
descent.

2. Tactical:
A tactic is a conceptual action implemented as one or more specific tasks.

3. Reconciliation:
An accounting process used to compare two sets of records to ensure the
figures are in agreement and are accurate. Reconciliation is the key process used to
determine whether the money leaving an account matches the amount spent,
ensuring that the two values are balanced at the end of the recording period.

4. Benchmarking:
Benchmarking is the process of comparing one's business processes and
performance metrics to industry bests or best practices from other industry.

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5. Steering Committee:
An advisory committee usually made up of high level stakeholders and/or
experts who provide guidance on key issues such as company policy and objectives,
budgetary control, marketing strategy, resource allocation, and decisions involving
large expenditures.

6. Quality Metrics
A “Quality Metric”, therefore, is a measure of quality as defined by the
customer.

7.Hazzle
Trouble; bother.

8. Destination
The place to which one is going or directed.

9. Protocol
A standard set of regulations and requirements that allow two electronic
items to connect to and exchange information with one another.

10. Brain storming:

If a group of people brainstorm, they have a meeting in which they all put
forward as many ideas and suggestions as they can think of.

11. Murphy’s law:

It is a lighthearted adage making the serious point that managers should
continually control. Check to see that organizational activities and processes are
going as planned.

12. Reprimand
A formal expression of disapproval. If you're reprimanded, someone in
authority speaks to you in an angry way because you've done something wrong.

CONTENT:
CONTROLLING
INTRODUCTION:
“Do not let circumstances control you.
You change your circumstances”.
-Jackie Chan.

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 Control is an evaluation to indicate needed corrective responses, the act of
guiding a process in which variability is attributable to a constant system of chance
causes control of an organization place, or system is the power to make all the
important decisions about the way that it is run. Control measures actual
performance. Controlling is one of the managerial functions like planning,
organizing, staffing and directing. It is an important function because it helps to
check the errors and to take the corrective action so that deviation from standards
are minimized and stated goals of the organization are achieved in desired manner.
Control in management means setting standards, measuring actual performance and
taking corrective action.

MEANING:
The process of monitoring activities to ensure that they are being
accomplished as planned and of correcting any significant deviations. It sees to it
that the right things happen, in the right ways and at the right time.

DEFINITION:
1. “Controlling means to guide someone in the direction it is meant to go”
- Louis Allen.
2. “Controlling is a systematic process of checking actual performance against
the standards or plans with a view to ensure adequate progress and also
recording such experience is gained as a contribution to possible future
needs”.
- EFL. Brech.
3. Controlling is the measurement and correction of performance in order to
make sure that enterprise objectives and the plans devised to attain them are
accomplished.
- Harold Koontz.

PLANNING CONTROLLING LINK:

Without planning, controlling is a meaningless exercise and without
controlling, planning is useless. Planning presupposes controlling and controlling
succeeds planning.

Planning
4

 Goal
 Organizing
Controlling

 Structure
 Standards  Human
 Measurements Resource
Management

Leading

 Motivation
 Leadership
 Communication
 Individual and
Group Behavior

PURPOSES
Control is one of the four basic management functions. The purposes of
control which helps the organization are.

1. FACILITATES CO- 3. MAKES SURE THAT

2. MAKES
ORDINATION ORGANIZATONAL
PLAN
ACTIVITIES ARE
EFFECTIVE
CONSISTENT

4. MAKES
5. AIDS
5 IN
ORGANIZATIONS
DECISION
EFFECTIVE AND
MAKING
EFFICIENT
 6. PROVIDE
FEEDBACK ON
PROJECT STATUS

7. CREATES BETTER
PURPOSES
QUALITY (LIMIT THE OF 9. TO CREATE
ACCUMULATION OF
ERROR) CONTROL FASTER CYCLES

A.TOTAL QUALITY A.SPEED IS

MANAGEMENT. ESSENTIAL

B.SPOTTING
PROCESS FLAWS.
8. TO COPE WITH
C.CORRECTING CHANGE (COPE WITH
ORGANIZATIONAL 11. TO FACILITATE
COMPLEXITY) DELEGATION AND
TEAMWORK.
A.CHANGE IS
INEVITABLE. A.PARTICIPATIVE
10. TO ADD VALUE.(TO MANAGEMENT.
ADOPT TO B.TO COMPETES WITH
ENVIRONMENTAL CHANGE) COMPETITORS. B.ENCOURAGE
EMPLOYEES TO
A.SPEED TO ADD VALUE, C.MATERIALS AND
WORK TOGETHER
COMPETITIVE EDGE. TECHNOLOGIES.
AS TEAMS.

B.ADDING VALUE C.THIS HELPS

CIRCUMVENTS EXPENSIVE MANAGER IN
AND RIGOROUS ACTIVITIES CARRYING OUT
TO COMPETE WITH DUTIES.
COMPETITORS.

12. TO
MINIMIZE
COST

CONCEPT (OR) PHASES (OR) PROCESS OF CONTROLLING:

Input

1. Man
2. Money
3. Machine
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4. Material
 Process (controlling process)

Work No correlative action

continues necessary Performance
equivalent
1. Measure Compare measurement to
performance to standards.
standards
where we are Determine the need for
(measurement) correct action Performance
significantly
New work Take corrective action different from
situation change plans, standards
begins organization or
influencing methods.
How can we get on
track again (correction)

Output where we planned to be

evaluation

Step – 1
Establish
performance
objectives and
standards

Step – 2
The
Step – 4 Measure
control actual
Take accessory
action proces performanc
e

Step – 3
Compare actual
performance
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with objectives
and standards
1. Setting standards: (Establish objectives and standards)
Anticipating the things that could go wrong and taking preventive measures
that they don’t. The control process begins with planning and the establishment of
performance objectives. Performance objectives are defined and the standards for
measuring them are set.
Standard is the level of activity establishes to serve as a model for
evaluating organizational performance. In essence, standards are the yardsticks that
determine whether organizational performance is adequate or inadequate.
There are two types of standards.
1. Output or Measurable or intangible standards:
Those standards which can be measured and expressed quantitatively are
called as measurable standards. They can be in form of cost, output, expenditure,
time, profit etc.
2. Input Non-Measurable or Intangible standards:
These are standards which cannot be measured quantitatively. Measures
work efforts that go into a performance task. Standards are desirable sets of
condition and performance necessary to ensure the quality of nursing care services
which are acceptable to those instrumental to or responsible for setting and
maintaining them.
For example performance of a manager, deviation of workers, their attitudes
towards a concern. These are called as intangible standards
3. Performance standards
A. Standards on structure:
Standards on structure are those that focus on the structure or management
system used by the agency to deliver care.
B. Process standards:
Refers to the decision and actions of the nurse relative to the nursing process
which are necessary to provide good nursing care.
C. Outcome standards:
Outcome standards are design to measure the results of care provided in
terms of changes of health status of clients served, changes in the level of their
knowledge, skills and attitudes and satisfaction of those served including the

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members of the nursing and health team. General electric gives us some insights
into different kinds of standards managers can establish. GE’s following standards,

 Profitability standards
 Market position standards
 Productivity standards
 Product leadership standards
 Personal development standards
 Employee attitude standards
 Social responsibility standards
 Standards reflecting the relative balance between short and long
range goals.
i. Profitability standards:
How much company would like to make as profit over a
given period of time.
ii. Market position standards:
Standards indicate the share of total sales in the market.
iii. Productivity standards:
How much various segments should produce.
iv. Employee attitude standards:
Indicates what type of attitude the company managers should
have to strive.

v. Social responsibility standards:

Making contributions to the society.
vi. Short range goal:
Standards that set a balance between the short range and long
range goals. These are the standards an organization sets at the beginning of a
control process.
2. Measuring actual performance:
Measurement of performance is an important procedure of the control
process; the deviations can be detected in advance by taking appropriate actions.
Measurements must be accurate enough to spot deviations or variances
between what really occurs and what is most desired. Without measurement,
effective control is not possible. Goal is accurate measurement of actual
performance results and/or performance efforts. Measurement must identify
significant differences between actual results and original plan.

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 Measurement of tangible performance is easy as it can be expressed in units,
cost, money terms, etc.
Intangible performance can be measured only by
i. Attitude of the workers.
ii. Their morale to work.
iii. The development in the attitudes regarding the physical
environment, and
iv. Their communication with the superiors.

Examples.
 Personal observation
 Statistical report
 The reports and written reports.
 Measurement by walking around (MBW)-A phrase used to describe
when a manager is out in the work area interacting with employee.
3.Comparing actual performance against a standard:
The comparison of actual performance with desired performance
establishes the need for action. Ways of making such comparisons include
Historical / Relative / Engineering / Benchmarking.
Deviation can be defined as the gap between actual performance and
the planned targets. The manager has to find out two things here – the extent of
deviation and cause of deviation.
Extent of deviation means that the manager has to find out whether
the deviation is positive or negative or whether the actual performance is in
conformity with the planned performance.
Comparison to objective measure: budgets, standards, goals. Range
of variance is between actual performance and the standard.
4. Taking managerial action to correct deviation or inadequate
standards (or) Taking Corrective Action.
After the actual performance has been measured and compared with the
established statement, the next step is to take corrective action if necessary.
Corrective action is managerial activity aimed at bringing organizational mistakes
that hinder organizations. Before taking correction actions, managers should make
sure that the standards are properly established and that their measurements of
performance are valid and reliable.
1. Immediate corrective action – correction a problem at once to get
performance back to track.

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 2. Basic corrective action – Determining how and why performance has
derived and then correcting the source of deviations.
3. Revising – the standard – Adjusting the performance standard to reflect
current and predicted future performance capabilities.
Taking any action necessary to correct or improve things. Management by
exception focuses managerial attention on substantial differences between actual
and desired performance. Management by exception can save the managers time,
energy and other resources. There are two types of exceptions: problems – below
standard, opportunities above standard.

NATURE OF CONTROL:
The regulation of organizational activities so that some targeted element of
performance remains within acceptable limits.
1. Provide organizations with indications of how well they are performing in
relation to their goals.
2. Provides a mechanism for adjusting performance to keep organizations
moving in the right direction.

PREREQUISITIES OF CONTROL SYSTEM:

Two major prerequisites must exist before any manager can devise or
maintain a system of control. These prerequisites are.

1. Control requires plans

2. Control requires
organizational structure
1. Control requires plans:
It is obvious that before a control technique can be used or a system devised,
control must be based on plans, and that the clearer, more complete, and more
integrated plans are, the most effective controls can be. All meaningful control
techniques are planning techniques. It is worthless to design control plans without
taking in account how well the plans are made.
Relationship between planning and controlling

(1)

Socio Economic Purpose

(2)

Mission
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(3)

Overall strategic objectives of the organization

 (4)

Decision objectives

(5)

Department or Unit

(6)

Individual objectives
2. Control Requires organization structure:
(a) Performance (b) Personal Development objective
One of the most frustrating situations managers can find themselves in is
knowing that something is going wrong in their company agency or department and
not knowing exactly where the responsibility for the trouble lies.
Since the purpose of control is to measure activities and take action to
assure that plans are being accomplished, we must also know where responsibility
of an enterprise for deviating from plans and taking action to make corrections, lies.
Control of activities operates through people. But we cannot know where the
responsibility for deviations and needs action are, unless organizational
responsibility is clear and definite. Therefore, a major prerequisite of control is the
existence of an organization structure. The clearer, more complete, and more
integrated this structure is, the more effective control action can be.

AREAS OF CONTROL:

1. Physical Resources
2. Human Resources
3. Informational Resources
4. Financial Resources
5. Structural Resources
6. Cultural
The six areas of organizational control are Resources
1. Physical Area:
The physical area includes buildings, equipment and tangible products.
Examples: There are equipment controls to monitor the use of computers, cars and
other machinery. There are inventory management controls to track of how many
products are in stock, how many will be needed, and what their delivery dates are
from suppliers. There are quality controls to make sure that products are being built

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according to certain acceptable standards. (E.g.) Inventory Management, Quality
control, and equipment control.
2. Human Resources Area:
The controls used to monitor employees include personality tests and drug
testing for hiring, performance tests during training and performance evaluations to
measure work productivity, and employee surveys to assess job satisfaction and
leadership. (E.g.) Selection and placement, training and development, performance
appraisal, and compensation.
3. Informational Area:
Production schedules, sales forecasts, environmental impact statements,
analyses of competition, public relations briefings. All these are controls on an
organization’s various information resources. (E.g.) Sales and Marketing forecasts,
environmental analysis, public relations, production scheduling and economic
forecasting.
4. Financial Area:
Are bills being paid on time? How much money is owed by customers?
How much money is owed to suppliers? Is there enough cash on hand to meet
payroll obligations? What are the debt-repayment schedules? What is the
advertising budget? Clearly the organization’s financial controls are important
because they can affect the preceding three areas. (E.g.) Managing capital funds and
cash flow, collection and payment of debts.
5. Structural Area:
How is the organization arranged from a hierarchical or structural
standpoint. Two examples are Bureaucratic control and decentralized control.
1. Bureaucratic control is an approach to organizational control that is
characterized by use of rules, regulations, and formal authority to guide
performance.
This form of control attempts to elicit employee compliance, using strict
rules, a rigid hierarchy, well-defined job descriptions, and administrative
mechanisms such as budgets, performance appraisals, and compensation
schemes (external rewards to get results). The foremost example of use of
bureaucratic control is perhaps the traditional military organization.
Bureaucratic control works well in organizations in which the tasks are explicit
and certain. While rigid, it can be an effective means of ensuring that
performance standards are being met.However,it may not be effective if people
are looking for ways to stay out of trouble by simply following the rules, or if
thy try to beat the system by manipulating performance reports, or if they try to
actively resist bureaucratic constraints.

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2. Decentralized control is an approach to organizational control that is
characterized by informal and organic structural arrangements.
The opposite of bureaucratic control. This form of control aims to get
increased employee commitment, using the corporate culture, group norms, and
workers taking responsibility for their performance. Decentralized control is
found in companies with a relatively flat organization.

6. Cultural Area:
The cultural area is an informal method of control. It influences the work
process and levels of performance through the set of norms that develop as a result
of the values and beliefs that constitute an organization’s culture if an
organization’s culture values innovation and collaboration, then employees are
likely to be evaluated on the basis of how much they engage in collaborative
activities and enhance or crate new products.

LEVELS OF CONTROL:

Long term control

Strategic corporate level
control
Intermediate control,
Tactical Control
Middle level.

Short term control,

Operations Control Lower level control.

There are three levels of control, which correspond to the three managerial
levels strategic planning by top managers, tactical planning by middle managers,
and operational planning by first line (supervisory) managers.
1. Strategic control by top managers:
Strategic control is monitoring performance to ensure that strategic plans are
being implemented and taking corrective action as needed. Strategic control is
mainly performed by top managers, those at the CEO and VP levels, who have an
organization-wide perspective. Monitoring is accomplished by reports issued every
3,6,12 or more months, although more frequent reports may be requested if the
organization is operating in an uncertain environment.

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2. Tactical control by middle managers:
Tactical control is monitoring performance to ensure that tactical plans-
those at the divisional or departmental level – are being implemented and taking
corrective action as needed. Tactical control is done mainly by middle managers
those with such titles as “division head”, “Plant Manager” and “branch sales
manager”. Reporting is done on a weekly or monthly basis.
3. Operational control by first level managers:
Operational control is monitoring performance to ensure that operational
plans-day-to-day goals-are being implemented and taking corrective action as
needed. Operational control is done mainly by first-level managers, those with titles
such as “department had”, “team leader”, or “supervisor”. Reporting is done on a
daily basis. Considerable interaction occurs among the three levels, with lower level
managers providing information upward and upper-level managers checking on
some of the more critical aspects on plan implementation.

ELEMENTS OF CONTROL:
2. Information feedback
1. Planning

ELEMENTS OF CONTROL

3. Delegation of authority 4. Remedial action.

Thus, planning is the basis, action is the essence, delegation is the key and
information is the guide to control.
1. Planning as the basis: Reciprocal relationship:
Plan-Goals and objectives, directs the behavior and activities in an
organization, affects controlling. Control-measures these behavior and activities,
affects planning.
2. Action as essence:
Control emphasizes what actions can be taken. It is important for
organizational effectiveness.

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3. Delegation as the key:
Control action can be taken only by the managers who are responsible for
performance and have authority to get things done by analyzing controllable and
uncontrollable factors. (Controllable factors person concerned will take necessary
corrective action, uncontrollable factors-Person concerned cannot be held
responsible).
4. Information as the guide:
Control action-guided by adequate information. Management information
and management control are closely interrelated. Information about performance
and standards are contribution of a manager.

CHARACTERISTICS OR FEATURES OF CONTROLLING:

1) Controlling is an end function:
Controlling is an end function- a function which comes once the
performances are made in conformities.
2) Controlling is a pervasive function:
Controlling is a persuasive function which means that it is performed
by managers at all levels and in all types of concerns.
3) Controlling is a dynamic process:
Controlling is a dynamic process, since controlling requires taking
reviewal methods; changes have to be made whenever possible.
4) Controlling is action oriented:
A process of monitoring performance and taking action to ensure
desired result
5) Controlling is exercised at all levels:
The level of management determines a chain of command, the
amount of authority & status enjoyed by any managerial position. The levels
of management can be classified in three broad categories:
i. Top level / Administrative level
ii. Middle level / Executory
iii. Low level / Supervisory / Operative / First-line
managers

Managers at all these levels perform different functions. The role of managers at all
the three levels is

2. PERVASIVE
1. END FUNCTION
FUNCTION

3. DYNAMIC PROCESS
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4.ACTION ORIENTED 5. EXERCISED AT ALL 6. CLOSELY LINKED
LEVELS WITH PLANNING

7. EMBEDDED IN CHARACTERISTICS
8.TOOL FOR
EACH LEVEL OF OR FEATURES OF
ACHIEVING
ORGANIZATIONAL CONTROLLING
ORGANIZATION
9.HIERARCHY
POSITIVE IN NATURE AL ACTIVITIES

10. OBJECTIVES
11. SUITABILITY 12. FORWARD
13. LOOKING
FEEDBACK
21. COMPETENT
19. ACTIVE 20. SUGGESTIVE AND TALENTED
PARTICIPATION STAFF
14.QUICK
ACTION 22.
15. DIRECTNESS 23.
SIMPLICITY PROMPTNESS

16. 24. (ACCURATE)

ECONOMY MOTIVATING
18. 27. CONTIUNOUS
REGULAR PROCESS 26. INTEGRATION
17. FLEXIBILITY REVISION 25. PROPER
WITH PLANNING
STANDARDS

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 6) Control is closely linked with planning:

Controlling function of management is closely linked with the planning

function because, it includes checking the performance of employees to see whether
the planned performance is being achieved by them or not..
7) Control is embedded in each level of organizational
hierarchy:

A tall structure will have many different levels of employees all reporting
upwards to team leaders and then up to operational management. It will have a wide
chain of command with a narrow span of control.

A flat organizational structure has fewer layers of management and wider

spans of control. This means operatives can access and communicate with managers
more easily and quickly. This relies on workers taking more responsibility for
decision-making.

8) Control is a tool for achieving organizational activities:

Budgetary control, Inventory control, quality control, profit and loss control,
Management audit, cost accounting and cost control, production control, financial
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control, break-even analysis and internal audit control are the important control
devices of controlling techniques

9) Control is positive in nature:

Nurse managers with positive leadership styles, who develop, stimulate, and
inspire followers to exceed their own self-interests for a higher purpose and are
based on a series of exchanges or interactions between leader and followers, had
more-satisfied staff.

10) Objectives:

A system of control can work more effectively when it is based on the main
objectives or goals of the organization. It should be related to the persons. It
becomes essential that the standards, which are set by the management, should not
be too high or too low. These should be told to the workers in time so that the
standards can be judged with the actual performance. A control system must be free
from bias and distortion. The control system should always focus on objectives. It
should aim to achieve the objectives of the organization.
This is because when controls are subjective, a manager’s personality may
influence judgments of performance in accuracy. Objective standards can be
quantitative such as costs or man hours per unit or date of job completion. They can
also be qualitative in the case of training programs that have specific characteristics
or are designed to accomplish a specific kind of upgrading the quality of personnel.
11) Suitability:

A business organization should adopt such a system of control which suits

its requirement. There is no hard and fast rule and readymade system of control
which give the correct and most favorable, results in all type of organizations and in
all circumstances.
Suitability of a system of control differs from organization to organization
and to make it favorable, it is necessary to know the nature of the business, needs of
the workers a circumstances prevailing inside the organization. The control system
should be suitable to the needs of the organization.

12) Forward looking:

Effective control is not possible without past being controlled. Controlling
always looks into the future so that a follow-up can be made whenever possible.

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 The system of control should be forward looking which enables the
managers to keep a control on operations in advance. Each and every deviation
from the standards should be noted in time to take corrective action before the task
is completed. This will avoid or minimize the deviation in future. The control
system should be forward-looking. It should also take steps to prevent these future
deviations. One can suggest future happenings and not the past. Managers suggest
corrective actions for the future period.

13) Feedback:

The success of a business depends on a system of control and for a

systematic control advance planning is needed. This advance planning should be
based on actual accurate post information collected through investigation. The
control system should be such that is based on past information and which would
also adjust if necessary to future actions.

14) Quick action:

Management gets the information from various line managers or supervisors
about the deviation in standards and these should be suggested to the planner to take
a correct and quick action to avoid future wastage. Actually speaking, the success
of control depends entirely on quick action and its implementation. A control
system should provide information as often as necessary.

15) Directness:
In order to make the system of control more effective, it is necessary that the
relation between the workers and management should be direct. It is quite obvious
that if the number of line supervisors is less in the organization then workers would
work effectively and objectives may be achieved in time because they will not take
much time in getting the correct information.

16) Economy:
The system of control must be economical. In simple words, cost of the
control system should not exceed its benefits. A system of control to be adopted by
the organization should be cheaper in terms of expenses.
The cost of implementation of the control system (mainly cost of data
collection and analysis) should not exceed its benefits.
The practical difficulty is that most managers, particularly in the field of
hospital care, find difficulties in estimating the cost of control and the expected
value or benefits to be achieved out of it. This means that control must worth their
cost. Although this requirement is simple, its practice is often complex. This is
because a manager may find it difficult to know what a particular system is worth,
or to know what it costs.

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 The control system should be economical. This means the cost of the control
system should not be more than its benefits.
17) Flexibility:

The system of control should be such that it accommodates all changes or

failures in plans. If plans are to be revised due to change in its objectives, the
system of control should also be adjusted to suit the changed circumstances.
The control system should be flexible. It should change according to the
changes in plans, situations, environments, etc. A rigid control system will always
fail. Hence flexibility is necessary for a control system.

18) Regular Revision:

The system of control should be based art objectives results, after proper
technical and analytical studies. They must be revised regularly and kept to meet
the objectives of the organization.
19) Active participation:

All members in the organization should participate in the effective

implementation of the control system. This is only possible when each and every
worker in the organization is asked to take active part in the discussions and
exchange views while selecting the system of control.
20) Suggestive:

The control system should also be suggestive. A system which detects

deviations only should not be held good, but should also tell the accurate and
correct alternative. The control system should be suggestive and it should give
complete answers for the following questions:-
 What is the problem?
 Where is the problem?
 How to solve the problem?
21) Competent and talented staff:

A system of control can work more effectively if it has talented and

competent people to work in the organization.
22) Promptness (Accurate):

The control system should be prompt. That is, it should find out the
deviations quickly. This will help the management to correct the deviations quickly.
In accurate results in bad decision making and inappropriate managerial actions.
1) Simplicity:

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 The control system should not be complicated. It should be easy to
understand and simple to use. Those who are going to use the control system should
understand it clearly and completely.
2) Motivating:

The control system should be motivating. That is, it should give more
importance to preventing the mistakes and less importance to punishing the
employees. So, it should encourage, not discourage the employees.
3) Proper standards:

The control system should have proper standards. The standards should be
very clear. They should be definite, verifiable, specific and measurable. They
should not be too high or too low.
4) Integration with planning:

The more control is linked to planning, the more effective the control
system.
5) Control is a continuous process:

Managerial control follows a definite pattern and timetable, month after

month and year after year on a continuous basis.

PRINCIPLES OF CONTROL IN MANAGEMENT:

The setting up of a good control system should be guided by certain important
principles.

1. Principle of reflection of plans

2. Principle of prevention

3. Principle of responsibility

4. Exception principle

5. Principle of critical points

1. Principle of reflection of plans:
6. Principle of pyramid.
The more clear and complete the plans of the organization and the more
control are designed to reflect these plans, the more effectively will control serve its
needs.
2. Principle of prevention:

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 The truth of the saying “Prevention is better than care is well established. In
control more attention should be directed to prevention of short falls than,
remedying them after they occur. Feed forward control is very helpful in this
respect.
3. Principle of responsibility:
Responsibility for control particular measurement of deviations taking
corrective action should be given to specific individuals at each stage of the
operation.

4. Exception principle:
The managers should concern themselves with exceptional cases (i.e.) those
where the deviations from standards are very significant. Deviations of a minor
mature may be left to subordinates for necessary action.
5. Principle of critical points:
All operations have got certain vulnerable or critical points. It is these which
cause most of the troubles give rise to major deviations. The managers should pay
more attention to the guarding of these points.
6. Principle of pyramid:
Feedback data should first be communicated to the bottom of the pyramid
(i.e.) those supervisors and even operating staff who is at the lowest levels. This
will give the employees opportunity to control their own situations, apart from
quickening remedial action.

TYPES OF CONTROL:
Types of control

According to time of Traditional Other

control
(Operations control)
Financial Information
Before During After
Feed Concurrent Feed Budgetary Other
forward black control tools of
Financial
control
According to source of
23
control
 External Internal Structural Strategic

Bureaucratic Clan

Integrating strategy and International

control strategic control

Feed
Concurrent Feedback
forward
control control
control

Anticipates Solves Solves

problems problems as problems after
they happen they occur

Focus is on
Focus is on
Focus is on

Inputs Ongoing processes Outputs

1. Feed forward control (or) Pre control (or) Preliminary or preventive

control:
Control that prevents anticipated problems:
The active anticipation and prevention of problems, rather than passive
reaction. Sometimes called the feed forward controls, they are accomplished before
a work activity begins. They make sure that proper directions (standards) are set
and that the right resources (human, material, and financial (money) resources
within the organization, are available to identify and prevent deviations. These
controls are evident in the selection and hiring of new employees.
For Example:

24
 Organizations attempt to improve the likelihood that employees will
perform up to standards by identifying the necessary job skills and by using tests
and other screening devices to hire people with those skills.

2. Concurrent (During) control (or) Screening control:

Monitoring and adjusting ongoing activities and Process:
Focus on what happens during the work process. Sometimes called steering
controls, they monitor ongoing operations and activities to make sure that things are
being done correctly. Monitor ongoing employee activity to ensure consistency
with quality standards. These controls rely on performance standards, rules and
regulations for guiding employee tasks and behaviors. Their purpose is to ensure
that work activities produce the desired results.
As an example many manufacturing operations include devices that measure
whether the items being produced meet quality standards. Employees monitor the
measurements; if they see that standards are not being met in some area, they make
a correction themselves or let a manager know that a problem is occurring.
It ensures the right things are being done as part of work-flow operations.
3. Feedback control (or) Post action control:
Checking a completed activity and learning from mistakes. They take place
after an action is completed. They focus on end results, as opposed to inputs and
activities. Managers have two broad options with respect to control. They can rely
on people to exercise self-control (internal) over their own behavior. Alternatively,
managers can take direct action (external) to control the behavior of others. It
involve reviewing information to determine whether performance meets established
standards.
For example, suppose that an organization establishes a goal of increasing
its profit by 12 percent next year. To ensure that this goal is reached, the
organization must monitor its profit on a monthly basis. After three months, if profit
has increased by 3 percent, management might assure that plans are going
according to schedule. It ensures that final results are up to desired standards. It
provides evidence of planning effectiveness. It provides motivational information to
employees.
4. Internal Control:
Allows motivated individuals to exercise self-control in fulfilling job
expectations. The potential for self-control is enhanced when capable people have
clear performance objectives and proper resource support.
5. External control:

25
 It occurs through personal supervision and the use of formal administrative
systems.
Performance appraisal systems, compensation and benefit systems,
employee discipline systems, and management by objectives.
6. Financial control:
Control of financial resources (i.e., revenues, shareholder investment) as
they flow into the organization, are held by the organization (i.e. working capital,
retained earnings), and flow out of the organization (i.e., payment of expenses)

(i) Budgetary control:

Budgets may be established at any organizational level. Budgets are
typically for one year or less. Budgets may be expressed in financial terms, units of
output, or other quantifiable factors. Budgets serve four purposes help managers
coordinate resources and projects, help define the established standards for control,
provide guidelines about the organization’s resources and expectations. It enable
the organization to evaluate the performance of managers and organizational units.
The types of budget are
1. Financial Budget:
1. Cash-flow or cash budget:
All sources of cash income and cash expenditures in monthly, weekly or
daily periods.
2. Capital expenditures budget:
Costs of major assets such as a new plant, machinery, or land.
3. Balance-sheet budget:
Forecast of the organization’s assets and liabilities in the event that all other
budgets are met.
2. Operating budget:
1. Sales or revenue budget:
Income the organization expects to receive from normal operations.
2. Expense budget:
Anticipated expenses for the organization during the coming time period.
3. Profit budget:
Anticipated differences between sales or revenues and expenses.
3. Non-monetary budget:

26
1. Labor budget:
Hears of direct labor available for use.
2. Space budget:
Square feet or meters of space available for various functions.
3. Production budget:
Number of units to be produced during the coming time period.
4. Organizational budget:
Prepared by budget committee and approved by budget committee,
controller and CEO.
5. Financial statements:
Financial statement is a profile of some aspect of an organization’s financial
circumstances. Financial statement depicts the financial position of the firm over a
period of time, generally one year. These statements are normally prepared along
with the last year’s statement so that the firm can compare its present performance
with the last year’s performance and take necessary action to improve its future
performance. As these statements are prepared at the end of the financial year, as a
measure of control, they provide tips to managers to improve their future
performance.
(i) Balance sheet:
A listing of assets (current and fixed), liabilities (short-and long term) and
stockholder’s equity at a specific point in time (typically year-ending) that
summarizes the financial condition of the organization. It is a statement of the
company’s financial position at a point of time, usually 31 st of March. A balance
sheet describes a company’s assets, liabilities and owner’s equity.
Assets=Liabilities + Equity
(ii) Income statement:
Summary of financial performance – revenues less expenses as net income
((i.e.) profit or loss) – over a period of time, usually one year. An income statement
depicts the company’s financial performance over a period of time (financial year :
from April to March). It is a statement of company’s revenues and expenses.
Revenues are the inflows arising out of the company’s sale of goods and services.
Expenses are the outflows incurred to earn the revenues.
6. Other tools of financial control:
(i) Ratio Analysis:
The calculation of one or more financial ratios to assess some aspect of the
organization’s financial health.

27
 There are five main categories of ratio analysis.
1. Liquidity
2. Leverage
3. Activity
4. Profitability
5. Equity.
(i) Liquidity Ratio’s:
The firm can know its cash position. It measure the firm’s ability to meet its
short term maturing obligations. It can therefore be used to measure the financial
risk of the company. The higher the liquidity ratio the lower the financial risk. They
are therefore inversely related to financial risk.
(ii) Leverage Ratios:
It measures the extent to which a firm is financed by non-owner supplied
funds. These ratios can be used to measure financial risk. They are directly related
to financial risk. Sometimes also known as gearing ratios.

(iii) Activity Ratios:

It measures the efficiency with which a firm uses its various resources to
generate sales revenue. They are also known as turnover ratios because they
indicate the rate at which assets are converted or turned into sales.
(iv) Profitability Ratios:
The excess of revenue over cost. It measure managements overall effectiveness as
shown by returns generated on sales and investments, therefore, profitability can be
measured in relation to
Sales – this indicates management’s ability to control production, operating
and financial decisions.
Investments – These measure the efficiency with which a firm uses its funds
to generate a return to the providers of funds.
(v) Equity (Evaluation Ratio’s):
It measures the firms overall performance and it may be important in
establishing the theoretical value of the firms securities. They are therefore very
important to investors in determining whether their securities are overvalued or
undervalued.

28
(ii) Financial Audits:
Audits – an independent appraisal of an organization’s accounting,
financial, and operational systems.
1. External Audit:
Financial appraisals conducted by experts who are not employees of the
organization to verify to external parties that the organization’s financial and
accounting procedures are legal and proper. External audit checks fraud lent
practices in preparing financial accounts .Outside parties like, investors, bankers
and financial institutions can enter into fair and honest dealing with the firm if its
accounts are audited. Verification of financial records by external agency or
individual conducted by an outside agency, such as a CPA (Certified Public
Accounting Firm).

2. Internal Audits:
Appraisals conducted by employees of the organization to determine the
accuracy, efficiency and appropriateness of financial and accounting procedures. It
refers to verification of various statistical data and reports so that correct and fair
presentation of financial statements is made. It evaluates the firm's internal
operations, determines where things have gone wrong and where corrective action
is needed Verification of financial records by an internal group of personnel. Wide
in scope, including evaluation of control system.
(iii) Budget analysis:
(a) Quantitative standards
(b) Deviations.
(iv) Trends in Financial control:
A. New Financial Control System

(a) Economic Value Added (EVA)

(b) Market Value Added (MVA)
(c) Activity Based Costing (ABC)
B. International Quality Standards
C. Corporate Governance.
1. New Financial Control Systems:
a. Economic Value Added (EVA)
A control system that measures performance in terms of after tax profits
minus the cost of capital invested in tangible assets. The aim of using economic

29
value added is to run the business more efficiently, satisfy customers, reward
shareholders, and make more cost-effective decisions.
b. Market Value Added (MVA)
Market value added measures the stock market’s estimate of the values of a
company’s past and expected capital investment projects. MVA and EVA goes
hand-in-hand with each other in general.
c. Activity Based Costing:
A measurement which allocates the costs across business processes. It
provides more accurate costs for various products, evaluate the cost of activities
that add value or not add value.
2. International Quality Standards:
ISO 9000 is a set of international standards for quality management systems
established by the international organization for standardization in 1987 and revised
in late 2000. The main objective is to evaluate and compare companies on a global
basis.
7. Market Control:
Market control emphasizes the use of external market mechanisms to
establish the standards used in the control system.
External measures: Price competition and relative market share.
8. Bureaucratic control:
A form of organizational control characterized by formal and mechanistic
structural arrangements. It emphasizes organizational authority and relies on rules,
regulations, procedures and policies.

9. Clan control:
An approach to organizational control characterized by informal and organic
structural arrangements. It regulates behavior by shared values, norms, traditions,
rituals, and beliefs of the firm’s culture.
10. Strategic control:
(i) Integrating strategy and control:
Control aimed at ensuring that the organization is maintaining an effective
alignment with its environment and moving toward achieving its strategic plan. It
focuses on structure, leadership, technology, human resources, and informational

30
and operational systems. Focuses on the extent to which implemented strategy
achieves the organization’s goals.
(ii) International strategic control:
Focuses on whether to manage the global organization from a centralized or
decentralized perspective. Centralization creates more control and co-ordination,
whereas decentralization fosters adaptability and innovation.
11. Information control:
Management information system is an arrangement of equipment and
procedures, often computerized that is designed to provide managers with
information.
Management control system (MCS) is a system which gathers and uses
information to evaluate the performance of different organizational resources like
human, physical, financial and also the organization as a whole considering the
organizational strategies.

TECHNIQUES OR TOOL:
1. Budgetary control / traditional:
i. Budgeting (Preplanned expenditure)
ii. Cost control (Control key resources)
iii. Production planning and control
iv. Organizational control
v. Inventory control
vi. Quality control
vii. Profit and loss control
viii. Statistical data analysis
a) Breakeven point analysis
b) Operational audit
c) Personal observation
ix. Inspection
2. Non-Budgetary control / modern:
i. Return on investment (ROI)
ii. PERT (Programme Evaluation and Review Technique)
iii. MIS – Management Information System
iv. Ratio Analysis
v. Management Audit
vi. Management by Objective and Appraisal by Results (MBO)
vii. Decision Tree Analysis

31
 viii. Computer Aided Design (CAD)
ix. Computer Aided Manufacturing (CAM)
x. Total Quality Management (TQM)
xi. Performance Appraisal
xii. Gantt chart (by Henry L. Gantt)

xiii. Responsibility Accounting

xiv. Critical Path Method(CPM)
xv. Balanced Scorecard:
xvi. Bench marking :
xvii. Linear Programming :
xviii. Statistical Data And Reports:

To even managers effectively control the organizational activities, a large

number of controlling techniques are available. They help to produce right quantity
and quality of goods at the right time. A manager should know these techniques,
situations in which they apply and variables that should be considered in applying
the techniques.
1. Budgeting (Preplanned Expenditure):
A budget is a statement which reflects future incomes, expenditures and
profit of the firm. It is a future projection of the firm’s financial position. A budget
is “The process of stating in quantitative terms, planned organizational activities for
a given period of time”. It facilitates comparison of actual performance with
planned performance and helps to correct deviations in actual performance. It is a
basic technique of control and is used at every level of organization.
2. Cost control:
The process or activity or controlling costs associated with an activity,
process, or company. Cost control typically includes (1) Investigation procedures to
detect variance of actual costs from budgeted costs (2) diagnostic procedures to
ascertain the causes of variance, and (3) corrective procedures to effect realignment
between actual and budgeted costs.
3. Production planning and control:
All manufacturing and service operations require planning and controlling,
although the formality and detail may vary. Some operations are more difficult to
plan than others. Those with high unpredictability can be difficult. Some are more
difficult to control than others. The day to day running of manufacturing and
service rests with production planning. The purpose of the production planning is to
ensure that manufacturing run effectively and efficiently and produces products as
required by customers.

32
 Capacity planning
Long term
1. Facility size
(Years)
2. Equipment procurement

Aggregate planning
Intermediate term
1. Facility utilization
(6 to 18 months)
3. Personnel needs

4. Subcontracting
Short term
Master Production Scheduling
(Weeks)
1. MRP Material Requirement
Production

2. Disaggregation of Master

Short term Scheduling Very short term

1. Work center loading (Hours-days)
2. Job sequencing

4. Organizational control:
The organizational control includes.
1. Management process
2. Compensation and benefits
3. Employee discipline
4. Information and financial
5. Purchasing
6. Project management

33
 7. Statistical quality control.
(i) Management Process
The Management Processes include.
(a) Strategy and objectives
(b) Policies and procedures
(c) Selection and training
(d) Performance appraisal
(e) Job design and work structure
(f) Performance modeling, norms and organization culture.

(ii) Compensation and benefits:

It attracts talented people and retains them. It motivates people to exert
maximum effort in their work. It recognizes the value of their performance
contributions.
(iii) Employee Discipline:
Discipline is defined as influencing behavior through reprimand.
Progressive discipline ties reprimand to the severity and frequency of the
employee’s infractions. Positive discipline tries to involve people more positively
and directly in making decisions to improve their behavior.
Red Hot Store Rule. It was first introduced by Douglas McGregor. It is
called so because it uses the familiar characteristic of a red-hot stove to highlight
four guiding principles for establishing discipline in organizations. “When we touch
a hot stove, the reaction is immediate, with warning, consistent, and impersonal:
a) Immediately characteristic:
If you touch a hot store, it burns. If you touch a hot store, it burns you
immediately, not some time later. Implication for leadership practice: Conversation
about performance should take place immediately after the event that triggers them,
not be left until later.
b) Forewarning characteristic:
As your hand approaches a hot stove, you can feel the heat; so you are fore
warned that if you touch it you will get burnt. Implication for leadership practice.
People must know in advance what performance behavioral standards are required
of them. A clear link needs to be made to recognize standards and prior warning
given that sanctions will be applied if certain conditions either are or are not met.
c) Consistency characteristic:
Whenever you touch a hot store, it always burns you; it doesn’t burn you at
sometimes and not others. Implication for leadership practice: For performance
conversations and any resulting actions to be effective these must take place in a
consistent fashion.
d) Impartiality characteristic:

34
 Whenever touches the stove will be burnt. It is the act of touching the stove
that leads to the painful effect, not some characteristic of the person; and it doesn’t
burn some people and not others. Implication for leadership practice. Effective and
fair performance conversations focus on the act, not the individual. These are also
carried out in an impartial way, not based upon personality or position.
(iv) Information and Financial:
(a) Activity based costing – The true cost of all products and services.
(b) Economic value added – Examine the value added by all activities.
(c) Understand the implication of key financial measures of (ratios)
organizational performance.
(v) Purchasing:
(a) Economic Order Quantity (EOQ)
Economic Order Quantity is the order quantity that minimizes total
inventory holding costs and ordering costs. An inventory related equation that
determines the optimum order quantity that a company should hold in its inventory
given a set cost of production, demand rate and other variables. This is done to
minimize variable inventory costs. The full equation is as follows.
2SD
EOQ = √ PI

Where
S = Setup costs
D = Demand rate
P = Production cost
I = Interest rate considered an opportunity cost,
so the risk-free rate can be used.

(b) Just in time scheduling:

Just in time is an inventory system where raw materials are delivered right
before they are needed on the assembly line, and finished goods are manufactured
just before they are shipped to customers. Just-in-time improves return on
investment by substantially reducing overhead cost, limiting quality inspections,
and eliminating obsolete inventory. JIT helps achieve quality because it is a
philosophy that seeks to constantly improve production processes and methods. In
this way, JIT has been called, a system of enforced problem solving.
(vi) Project Management:
Program Evaluation and Review Technique (PERT) identifies and controls
the many separate events in complex projects.
(vii) Statistical Quality Control: Statistical Quality Control (SQC) is the term used
to describe the set of statistical tools used by quality professionals. SQC is used to

35
analyze the quality problems and solve them. Statistical quality control refers to the
use of statistical methods in the monitoring and maintaining of the quality of
products and services. All the tools of SQC are helpful in evaluating the quality of
services. SQC uses different tools to analyze quality problem.
1) Descriptive Statistics
2) Statistical Process Control (SPC)
3) Acceptance Sampling

Descriptive Statistics involves describing quality characteristics and relationships.

SPC involves inspect random sample of output from process for characteristic.
Acceptance Sampling involves batch sampling by inspection. Based on the
establishment of upper and lower control limits, that can be graphically and
statistically monitored to ensure that products meet standards.
5. Inventory control:
The overseeing and controlling of the ordering, storage and use of
components that a company will use in the production of the items it will sell as
well as the overseeing and controlling of quantities of finished products for sale.
Inventory control is designed to support the requisition processing, inventory
management, purchasing and physical inventory reconciliation functions of
inventory management through a set of highly interactive capabilities.
6. Profit and Loss Control:
The profit and loss (P and L) statement is also known as the income. It
shows how well a company buys and sells inventory or services to make a profit.
Break Even Analysis
Break Even Analysis or Cost Volume Profit Analysis defines the relationship
between sales volume, costs and profits to find out sales at which sales revenue is
equal to cost .The point at which sales revenue is equal to total cost is the break-
even point. Sales volume beyond the break-even point will earn profits for the
organization and sales volume below the break-even point is a situation of loss. As,
a technique of controlling, managers compare their actual performance in terms of
output sold with the break-even point of sales and if they are not able to sell beyond
this point, they should improve their performance by increasing their sales or
reducing their costs.
Management Audit
Use of auditing techniques to evaluate the overall effectiveness of
management. Examines wide range of management practices and procedures.

Personal observation
Manager’s first hand observations of how well plans are carried out. It is the
natural part of manager’s job.

36
7. Quality control:
Quality control uses operational techniques and activities to sustain quality
of the product or service to satisfy customer needs. It aims to maintain quality of
goods at each stage of the manufacturing process rather than detecting errors at the
end of the production cycle where faculty products may have to be discarded or
rewarded.
Every worker's job becomes a quality control station. The worker is
responsible for inspecting his own work, identifying any defects and reworking
them in to non- defectives, and correcting any causes of defect.
Workers and manageress are organized in to quality circles- groups of
people who analyze quality problems, work to solve the problems, and implement
programmers to improve product quality.

8. Statistical Analysis:
Statistical data and reports help in applying statistical techniques of
averages, regression, correlation etc. to predict company’s performance.
9. Inspection
The act of determining conformance or non-conformance of the expected
performance is the function of inspection. By inspection, a manager seeks to
determine the acceptability non- acceptability of the parts, products or services. The
basis for inspection is usually a specification which is called inspection standard.
Inspection is made by comparing the quality of the product to the standard.
1. Crib Inspection
When someone comes and checks on something to make sure it is up to a
code or set of rules. For example, when an inspector inspects you're hospital, he
checks to make sure it is built to all the most recent standards formal or official
viewing or examination of something, has to meet certain parameters set by law or
orders.
2. Online inspection
On- line inspection provides affordable excellence and same day reporting
allowing you to go to market at optimum speed without having to develop, your
own inspection program. Instead, suppliers and buyers have the luxury of utilizing
Intertie's simplified, standardized, and Best- In- class inspection anywhere you do
business. Intertek now offers On-line inspection- a hassle free, standardized pre-
shipment inspection which offers quality focused inspection – reduced sample size.
Non-Budgetary control Techniques
Non-Budgetary control techniques can be classified into two types.
Qualitative Control Technique
Qualitative control techniques are methods based on human judgments
about performance that result in a verbal rather than a numerical evaluation.
For E.g. Customer service might be rated as “Outstanding”.
The competence and either of people collecting information for qualitative
controls influence the effectiveness of these controls.

37
Quantitative Control technique
Quantitative control techniques are methods based on numerical measures
of performance.
For E.g. such as lines of computer code produced per hour.
1) Return On Investment

Return on investment (ROI) is a financial ratio intended to measure the benefit

obtained from an investment. Time is usually of the essence in this measurement
because it takes time for an investment to realize a benefit.

2) PERT
Method of scheduling activities and events using time estimates. Measuring
how well the project is meeting the schedule. Program Evaluation and Review
Technique (PERT) PERT- A time event network analysis system in which the
various events in a project or program are identified with a planned time established
for each methodology preparation of the network. Network event analysis system in
which the various events in a project or program are indent analysis, scheduling,
time cost tradeoffs, resource allocation, project control.

3) Management Information System

The system of obtaining timely, relevant and accurate information based on

computer technology is known as information system. The system helps managers
in preparing reports for effectively carrying out planning and controlling functions.
According to Weihrich and koontz,”MIS is a formal system of gathering,
intergrating,comparing, analyzing and dispersing information interval and external
to the enterprise in a timely, effective and efficient manner”

4) Ratio Analysis
It refers to the systematic use of ratios to interpret the financial statements in
terms of the operating performance and financial position of a firm. It involves
comparison for a meaningful interpretation of the financial statements.

5) Management Audit:
Management Audit means periodic inspection of financial statements and
verifying that the statement and verifying that the statement are honestly and fairly
prepared according to accounting principles. Audit thus provides the basis for
control.

6) Management By Objectives
A key tenet of management by objectives is the establishment of a management
information system to measure actual performance and achievements against the
defined objectives. The major benefits of MBO are that it improves employee
motivation and commitment, and ensures better communication between
management and employees

38
 7) Decision Tree Analysis
A graphical tool for describing
(1) the actions available to the decision-maker,
(2) the events that can occur, and
(3) the relationship between the actions and events.

8) Computer Aided Design

Computer-aided design (CAD) is the use of computer systems to assist in
the creation, modification, analysis, or optimization of a design.

9) Computer Aided Manufacturing

The process of using specialized computers to control, monitor, and adjust
tools and machinery in manufacturing.

10) Total Quality Management

Total quality management (TQM) is a comprehensive and structured
approach to organizational management that seeks to improve the quality of
products and services .Through ongoing refinements in response to continuous
feedback. TQM is based on quality management from the customer's point of view.
TQM processes are divided in to four sequential categories: plan, do, check, and act
(the PDCA cycle). In the planning phase, people define the problem to be
addressed, collect relevant data, and ascertain the problem's root cause; in the doing
phase, people develop upon a measurement to gauge its effectiveness, in the
checking phase, people confirm the results through before- and- after data
comparison, in the acting phase, people document their results, inform others about
process changes, and make recommendations for the problem to be addressed.
Tools of total quality management is quality circle. Quality circle is a voluntary
group of people who meet together on a regular basis to identify, analyze and solve
quality, productivity, cost reduction, safety and other problems in their work area,
leading to improvement in their performance and enrichment of their work life.
11) Performance Appraisal
It is the formal method or system of measuring, evaluating and reviewing
employee performance. Points out areas of deficiency and areas for corrective
action; manager and group members jointly solve the problem.
12) Gantt chart (by Henry L. Gantt)
Chart depicting planned and actual progress of work on a project. Describes
progress on a project. Gantt chart system was developed by HENRY L. GANTT. A
bar chart that shows the time relationships between the events of a production
program. Milestone budgeting or milepost advanced technique of Gantt chart
milestone breaks a project down into controllable piece.
13) Responsibility Accounting:
Responsibility Accounting It divides the organization into small units where
manager of each unit is responsible for achieving the targets of his unit. These units
are called responsibility centers and head of each responsibility centre is

39
responsible for controlling the activities of his centre. Performance of responsibility
centre is judged by the extent to which targets of the centre are achieved.
14) Critical Path Method(CPM):
Critical Path Method (CPM) developed by M.R. WALKER of USA in 1956. It
is used for optimizing resource allocation and minimizing overall cost for a given
project.
15) Balanced Scorecard:
A performance measurement tool that looks at four areas-financial,
customer, internal processes and people.
16) Bench marking :
The search for best practices among the competitors or non-competitors that
lead to their superior performance.
17) Linear Programming :
According to WILLIAM M. FOX “Linear Programming is a planning technique
that permits some objective function to be minimized or maximized within the
framework of given situational restrictions.
18) Statistical Data And Reports:
It helps in applying statistical techniques of averages, regression, correlation
etc. to predict company's performance

SCOPE OF MANAGEMENT CONTROL SYSTEM:

Managerial control is an important process in which accounting
information is used as to accomplish the organization’s objective. Therefore scope
of control is very wide that covers a broad range of management activities.
According to Holden, Fish and Smith the main areas of control are
as follows:
1. Control over Policies:
The control of business hangs on formulation of sound policies and
proper implementation. There is a great need of control over policies.
2. Control over organization:
For the control over organization the management uses
organization’s manual and organizational chart. Designing and organizing various
departments for smooth running of business is very essential. If any problem or
conflict arises the management control attempts to remove the causes of such
frictions and rationalize the organizational structure as to ensure its efficient
working.
3. Control over personnel:
Anything that the business accomplishes is the result of the action of
those people who work in the organization. It is people, not figure, that get things
done. The personnel manager is responsible to draw a control plan for having
control over the personnel of the concern.

40
 4. Control over wages and salaries:
Control over wages and salaries are sometimes assigned to the
personnel department or a specially constituted wages and salary committee.
5. Control over cost:
The cost accountant who is responsible to control cost set, cost
standards, labor material and overhead. He makes comparison of actual rest data
with standard cost. Cost control is delicate task and is supplemented by budgetary
control system.
6. Control over technique:
It implies the use of best methods and techniques so as to eliminate
all waste in time, energy and material. The task is accomplished by periodic
analysis and checking of each department with a view to avoid and eliminate all
non-essential motions, functions and method.
7. Control over capital expenditure:

41
 Various projects entailing huge amounts require control. This is
exercised through a system of evaluation of projects in terms of capital. Capital
budget is prepared for whole concern. Every project is evaluated in terms of
advantage accruing to the firm. For this purpose capital budgeting, project analysis,
study of cost of capital etc. are carried op extensively.
8. Production control:
The function of production control is to plan, organize, direct and
control the necessary activities to provide products and services. Once the
production system is designed and activated the problems arise in the areas of
production, planning and control. Market needs and attitudes of consumer are
studied minutely for revision in product lines and their rationalizing. Routing,
scheduling, dispatching, follow up, inventory control, quality control are the various
techniques in production control.
9. Overall control:
A master plan is prepared for overall control and all the concerned
departments are made to involve in this procedure.
10. Control over external relations:
Public relations department should always be alert in improving
external relations. It may also prescribe norms and measure for other operating
departments to insist on cordial relations with all the parties.
11. Control over research and development:
Research activities, being technical in nature cannot be controlled
directly. But it should be seen that all facilities are provided to research staff to
improve their ability and keeping in touch with the up-to-date techniques and
devices. Training facilities should also be provided by having research budget in
business.

IMPORTANCE OF CONTROL:
1. Adjustment in operations:
Objectives form the basis of control. Adjustments can be done
through control.
2. Policy verification:
Policies generate the need for control. Managers set certain policies
which become the basis and reason for control. It verifies the quality of policies.

3. Managerial responsibility:
Managerial responsibility created through assignment of activities to
various individuals. It starts at the top level and goes down to the bottom level.
Manager is responsible for the ultimate performance of his subordinates.
4. Psychological pressure:
Psychological pressure on individuals to perform better. Rewards
and punishment based on the performances.
5. Coordination in action:
Co-ordination is achieved through proper performance. Manager
coordinates the activities of his subordinates to achieve the organizational goals.
6. Organizational efficiency and effectiveness:

42
 Proper control ensures organizational efficiency and effectiveness.
Control system-brings the organization closer to its objectives.
ADVANTAGES:
1. It minimizes wastage and increases productivity.
2. It ensures optimum utilization of resources.
3. It helps to fix responsibility.
4. It motivates employees.
5. It minimizes deviation, defect, and mistakes.
6. It facilitates delegation.
7. It helps meet deadlines.
8. It facilitates communication.
9. It improves safety.
10. It lowers costs.
11. It gives workers control over their environment.
12. Establish records of organizational performance.
DISADVANTAGES:
1. Controlling may lower the morale of the staff through bad supervision in the
way of duties are delegated.
2. Internal check system of institutions will frustrate employees.
3. It is usually an expensive system to install and maintain.
4. It may be rigidly designed and not suitable for the type of business and thus
difficult to sustain.
5. Control activities can encourage falsification of reports.
6. Control activities can create undesirable overemphasis on short term
production as opposed to long term production.
7. The control system causes human resistance due to
(i) Ambiguous standards
(ii) Check on freedom
(iii) Inaccurate measurement
(iv) Bias
(v) Untimely
(vi) Fear
(vii) Emotions

CONTEMPORARY ISSUES:
1. Cross cultural issues
(a) The use of technology to increase direct corporate control of local
operations.
(b) Legal constraints on corrective actions in foreign countries.
(c) Difficulty with the comparability of data collected from operations in
different countries.
2. Work place concerns
(a) Workplace privacy Versus Work Place Monitoring.
 Email, telephone, computers and Internet Usage.
 Productivity, harassment, security, confidentiality,
intellectual property protection.
(b) Employee theft

43
 The unauthorized taking of company property by employees for their
personal use.
(c) Workplace violence
Anger, rage and violence in the workplace is affecting employee
productivity.

3. Customer Interactions
(a) Service profit chain
Is the service sequence from employees to customers to profit.
(b) Service capability affects service value which impacts on customer
satisfaction that, in turn, leads to customer loyalty in the form of repeat
business (profit)
4. Corporate Governance
The system used to govern cooperation so that the interests of the corporate
owners are protected.
 Changes in the role of boards of directors.
 Increased scrutiny of financial reporting.
 More disclosure and transparency of corporate financial information.
 Certification of financial results by senior management.
APPLICATION OF CONTROL IN NURSING PRACTICE:
1. Establish participative decision making
i. Use an organized structure for nurse participation in decision
making.
ii. Ensure authority for clinical decision making resides with direct
care nurses.
iii. Include nurses on organizational committees.
iv. Minimize bureaucracy.
v. Support involvement by nurse on committees and work groups.
2. Enhance competence in decision-making
i. Teach nurses about the decision making process.
ii. Coach and support nurses through early decisions.
iii. Teach facilitation skills to leaders.
CONCLUSION:
Controlling is the measurement and correction of performance in order to
ensure that enterprise objectives and plans derived to attain them are accomplished
controlling is a function of every manager both at lower and upper since all hare
responsibility for the execution of plans.

QUALITY
“Most economical, Useful and always satisfactory to the customer or
audience”.
-Dr.Kaoru Ishikawa

INTRODUCTION:
44
 “Fit for use”-J.M.Juran
.Quality must be worked and anxiously achieved.

Q - Quantum, Quest/ search for excellence

U - Uphold, Understanding customer's need is to

understand what does a customer actually wants.

A - Assured, The action of a business to achieve

customer's appreciation

L - Level, Leadership (i.e.) a firm should be

determined to be a leader in terms of quality
product.

I - In, Involving all people (i.e.) every people should

product than whether he/ she is customer or
manufacturer.

T - Test, Team spirit to work for a common goal

Y - Yield, Yardstick (measuring rod) to measure

progress.

“Quality also means doing something right in the best possible way even
when no one is looking”. Quality saves money. Doing things right in the first time
saves the cost of correcting poor work.
Quality is first and foremost about meeting the needs and expectations of
customers. It is important to understand that quality is about more than a product
simply "working properly". Think about your needs and expectations as a customer
when you buy a product or service. This may include performance, appearance,
availability, delivery, reliability, maintainability, cost effectiveness and price. Think
of quality as representing all the features of a product or service that affect its
ability to meet customer needs. If the product or service meets all those needs –
then it passes the quality test. If it doesn't, then it is substandard.
The word QUALITY is emphasized more in all endeavors of day to day life
in today’s world. Quality is the ulmost expectation of any industry or institution. So
is the health care industry whose major goal is to provide quality care to its
consumers.
Quality refers to excellence of a product of a serve, including its
attractiveness, lack of defect, reliability and long-term durability. Quality is vitally
important in the field of Nursing. Quality means conformance to standards workers
must know exactly what performance standards they are expected to meet. Quality
comes from defect prevention, not defect correction. Leadership, training, and

45
discipline must prevent defects in the first phase. Quality as a performance standard
must mean defect-free work. The only acceptable quality standard is perfect work.
Quality denotes customer satisfaction, cost benefits. Florence Nightingale
introduced the concept of quality in nursing care in 1855. Nurses are the key to
quality in the health care delivery system. Holding unique role as care co-ordinated
at the interdisciplinary intersection of clients care delivery. Nurses manage quality
issue and do much of the quality surveillance and monitoring. Quality improvement
is linked to evaluation of care and accountability to society In evaluating health care
services one should consider the following.
1. The quality of inputs- which are resources that is necessary to carry out a
process (e.g. staffing, technology).
2. The quality of the service delivery process steps that come together to
transform inputs into outcomes (e.g. eligibility, billing, hours of operations,
satisfaction, both staff and clients).
3. The quality of outcomes- what outcome is you looking to achieve to assure
you here the right inputs and outcome, in order
Two aspects of quality: features: more features that meet customer needs
= higher qualityfreedom from trouble: fewer defects = higher quality
DEFINITION:
Quality
1. Quality is defined as the extent of resemblance between the purposes
of health care and the truly granted care.
- Donabedian 1986
2. Quality is the degree to which a product confirms to specification
and workmanship standards.
- John. D. McClellan
3. Quality: Proper performances of interventions that are known to be
safe, that are affordable to the society in question and that have the
ability to produce an impact on mortality, morbidity, disability and
malnutrition.
- WHO, 1988

4. Quality is the degree to which care services influencing probability

of optimal patient outcomes.
- American Medical Association
5. Quality of nursing practice is achievement when organization
processes and activities are designed and implemented to the needs
and expectations of the receiver on a competent consistent and
continuous basis,
- INC, 2000

6. The totality of features and characteristics of a product or service

that bears on its ability to satisfy stated or implied needs.
- American society for quality
7. Quality is the degree to which a service meets or exceeds established
professional standards and user expectations.
8. Quality as defined by Webster's dictionary is a "degree of
excellence".

46
MYTHS AND TRUTH OF QUALITY:
SL.NO MYTHS TRUTH

1. Quality means goodness, luxury, Quality is never luxury. It is

shininess or weight. essential to improve health
services and minimize waste
when resources are scarce.

2 Quality is intangible and therefore Quality of health care can be

cannot be measured. measured.

3 Quality is expensive “We cannot afford Quality of care can be improved

it”. with the same resources.

4 Quality problems are originated by the The majority of problems

worker. encountered are due to
inappropriate functioning of
health system and not the result
of errors of individual worker.

5 Quality originates in the quality Quality is everybody’s job.

department.

QUALITY GURUS:
o W. Edwards Deming
o Joseph Juran
o Philip Crosby
o Brain Joiner
QUALITY CHAIN:
According to Manwell, shaw, and Beurri
The quality chain focuses that the care should be, C-Comprehensive, cost
effective, contractual, A-Accessible, accredited, acceptable, R-Relevant, reliable,
resourced, E-Efficient, equitable, effective.

3As 3Rs 3Es

3cs
Accessible Relevant

Accredited 47 Reliable, Efficient,

Comprehensive
resourced Equitable,
Cost effective Acceptable Effective.
VIEWS OF QUALITY:
The different views of quality are
1. User Based
Better performance, more features.
2. Manufacturing – based
Conformance to standards, making it right the first time.
3. Product Based
Specific and measurable attributes of the product.
PURPOSE:
1. To meet the needs and expectation of the customers, both external and
internal.
2. To meet increased demand for effective and appropriate care.
3. Need for standardization and variance control.
4. To minimize the errors and farther eliminated to attain excellence in care.
5. To bring improvement in care and services.
6. To bring efficiency in the use of health care resources and effectiveness in
the delivery of care and services.
7. To reduce the failure and appraisal costs.
8. To fit into the pressure of competition and to enhance marketing.
9. For accreditation, certification and regulation.
10. To fulfill the ethical code to provide the best and most appropriate care
accessible to the patient.
11. To fulfill the desire for recognition and to strive for excellence.
12. To attract recognition in the field and fill encourage other individual
organizations or systems to emulate and follow (Bench marking).

DIMENSIONS OF QUALITY:
1. Performance
Basic operating characteristics of a product.
2. Features
Extra items added to basic features.

3. Reliability
Probability that a product will operate properly within an expected
time frame.
4. Conformance
The degree to which a product meets pre-established standards

48
 5. Durability
How long product lasts before replacement
6. Serviceability
Ease of getting repairs, speed of repairs, courtesy and competence of
repair person.
7. Aesthetics
How a product looks, feels, sounds, smells, or tastes
8. Safety
Assurance that customer will not suffer injury or harm from a
product.
9. Perceptions – Subjective perceptions
10. Time and Timeliness
How long a customer must wait for services and is it completes on
time. For E.g. Is an overnight package delivered overnight.
11. Competences
Is everything customer asked for provided?
12. Courtesy
How are customers treated by employees?
13. Consistency
Is the same level of service provided to each customers each time?
14. Accessibility and convenience
How easy is it to obtain service? Does a service representative answer you
calls quickly?
15. Accuracy
Is the services performed right every time?
16. Responsiveness
How well does the organization react to unusual situations.

COSTS OF QUALITY:
1. Prevention costs
Reducing the potential for defects.
2. Appraisal costs
Evaluating products, parts and services.
3. Internal Failure
Producing defective parts or service before delivery.
4. External costs
Defects discovered after delivery
QUALITY TOOLS:
a) Chart audits
It is the most common method of collecting quality data using charts
as quality assessment tool.

b) 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

49
 decide where to focus on process redesign aimed at improving patient
safety.
c) 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.
d) Flow charts
These are diagrams that represent the steps in a process.
e) Pareto diagrams
It is used to illustrate 80/ 20 rule, which states that 80% of all
process variation is produced by 20% of items.
f) Histograms
It uses a graph rather than a table of numbers to illustrate the
frequency of different categories of errors.
g) 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.
h) 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.
CONCEPT OR APPROACH TO QUALITY:
Juan developed a three part (Trilogy) approach to quality.

1) Quality planning
It involves determining who the customers are and
what their needs are, then developing products based on those needs and designing
processes to produce those products.
2) Quality control
It is the evaluation of performance to identify
discrepancies between actual performance and goals.

3) Quality Improvement
It establishes an infrastructure and the project terms to
carry out process improvement

Quality
Improvement
50
ELEMENTS:
There are three key element of quality: customer, process and employee.
Everything we do to remain a world-class quality company focuses on these three
essential elements.
1. The customer
2. The process
3. The employee
1. The customer-Delighting customers
Customers are the center: they define quality. They expect performance,
reliability, competitive prices, on time delivery, service, clear and correct
transaction processing and more. In every attribute that influences customer
perception; we know that just being good is not enough. Delighting our customers
is a necessity. Because if we don’t do it, someone else will.
2. The process-Outside-In thinking
Quality requires us to look at our business from the customer’s perspective
not ours. In other words, we must look at our processes from the outside in. By
understanding the transaction lifecycles from the customer’s needs and processes,
we can discover what they are seeing and feeling. With this knowledge, we can
identify areas where we can add significant value or improvement from their
perspective.
3. The Employee-Leadership commitment
People create results. Involving all employees is essential to quality
approach. It is committed to providing opportunities and incentives for employees
to focus their talents and energies on satisfying customers. All employees must be
trained in the strategy, statistical tools and techniques of six sigma qualities. Quality
is the responsibility of every employee. Every employee must be involved,
motivated and knowledgeable if we are to succeed.

QUALITY PROCESS (OR) ASPECTS OF QUALITY

51
 Quality is achieving excellence in any field of working. it is a spirit to be
inculcated at all levels to improve nursing services rendered to the clients. This
improvement is not one time process it involves various aspects like.

Quality Quality Quality

circle control Assurance

Total Quality Management Total Quality control

(TQM) Implementation

Total Quality Management

QUALITY CIRCLE-A TOOL FOR TOTAL

QUALITY MANAGEMENT
INTRODUCTION:
“Quality begins on the inside. . .
and then works its way out is a circular manner”.
Quality circle concept being adapted all over the world as a very effective
technique to improve the total of work life. Quality circle is one of the employee
participation methods. The Japanese description of the effectiveness of a quality
circle is expressed as “It is better for one hundred people to take one step than for
one person to take a hundred. Quality circles first emerged in Japan in the 1960’s
and Kaoru Ishikawa has been credited with creating Quality circles as a method of
improving quality.
Quality circles were originally associated with Japanese management and
manufacturing technique. The introduction of quality circle in Japan in the postwar
years was inspired by the lectures of W.Edwards Deming (1990-1993) a statistician
for the US government. It implies the development of skills, capabilities,

52
confidence and creativity of the people through cumulative process of education,
training, words experience and participation. It also implies the creation of
facilitative conditions and environment of work, which creates and sustains this
motivation and commitment towards work excellence.
Quality circles hare emerged as a mechanism to develop and utilize the
tremendous potential of people for improvement in product quality and
productivity. Quality circle uses statistical analyses of activities to maintain quality
products. Quality circles are effective when facilitators, leaders and members are
trained in group dynamics and quality circle techniques. The objects of quality
circle are participation, involvement, recognition and self-actualization among
clinical nurses caring for patients. Quality circles may use Pareto analysis,
histograms, graphing techniques, control charts, stratification, scatter diagrams,
brainstorming, cause-and-effect diagrams, run analysis, and conflict resolution.
Research indicates that productivity and morale improve when employees
participate in decision making and planning for change. Participation includes real
setting because participation leads higher levels of acceptance and performance of
these goals. Research also shows that highly non participatory jobs cause
psychological and physical harm.
MEANING:
Quality circle (QC) is one revolutionary management technique. It was
developed in Japan to upgrade quality, productivity and employee morale in an
organization. It is techniques useful for raising the productivity with peoples power
(i.e.) with the co-operation and participation of employees at various levels. Japan
achieved excellent results in the field of quality and productivity. Through this
technique Dr.Ishikawa Koru (1915-1989) who is popularly known as “Father of
Quality Circles”.
Quality circle is a system where the employees are identified, recognized
and their participation is drawn integrated with a system which satisfies their ‘ego’
needs so that they will be more motivated to work effectively than only their
participation.
DEFINITION:
1. A small group of between three and twelve people who do the same or
similar work, voluntarily meeting together regularly for about an hour per
week in paid time, usually under the leadership of their own superior, and
trained to identify, analyze, and solve some of the problems in their work,
presenting solutions to management, and where possible, implementing the
solutions themselves.
2. Quality circle refers to small group of employees, belonging to the same
work area who meet voluntary and regularly to identify, analyze and resolve
problems related to their work area.
- www. slideshare.net
3. A Quality circle is a voluntary group of employees who perform similar
duties and meet at periodic intervals, often with management, to discuss
work-related issues and to offer suggestions and ideas for improvements, as
in production methods or quality control.
- Prabhat Pandey (2012)
4. It is a participating management technique that enlists the help of employees
in solving problems related to their own jobs.

53
 5. Quality circles as “a small group of employees doing similar or related work
who meet regularly to identify, analyze, and solve product, quality and
production problems and to improve general operations. The circle is a
relatively autonomous unit (ideally about ten workers) usually led by a
supervisor or a senior worker and organized as a work unit.
6. Quality circles is a term used in human resources management that refers to
the techniques of motivating workers by allowing them input into decision
concerning the production process, thereby increasing productivity and
profits.
7. It is a way of capturing the creative and innovative power that lies within the
workforce.
ALTERNATIVE NAMES:
1. Small groups
2. Action circle
3. Excellence circles
4. Human Resource circles
5. Productivity circles
HISTORY:
Pioneered by Japanese. Japanese nomenclature Quality Control Circles
(QCC) generally now known as Quality circles (QC) of some call it as same group
Activity (SGA).
1962 - First QC circle was registered with QC circle Headquarters in
Japan.
1974 - Lockheed company, USA started Quality circle movement.
1977 - International Association of Quality circle (IAQC) was formed
in USA.
1980 - BHEL Hyderabad first in India starts Quality Circle.
1982 - Quality Circle forum of India (QCFI) was founded.
The concept of quality circle was launched in the public works department
of govt of Maharashtra from November 1997. Quality circles have been
implemented even in educational sectors in India and QCFI (Quality Circle Forum
on India) in promoting such activities.
CONCEPTS OR ATTRIBUTES:
The concept of QC is primarily based upon recognition of the value of the
worker as a human being, as someone who willingly activises on his job, his
wisdom, intelligence, experience, attitudes and feelings.
It is based upon the HRM (Human Resource Management) considered as
one of the key factors in the improvement of product quality and productivity. QC
concept has 3 major attribute.
(a) Quality circle is a form of participation management.
(b) Quality circle is a human resource development technique.
(c) Quality circle is a problem solving technique.

PHILOSOPHY:
The philosophy of quality circle is based on MASLOW theory.

54
 1. Quality circle is a people-building philosophy, providing self-
motivation and happiness in improving environment without any
compulsion or monetary benefits.
2. It represents a philosophy of managing people specially those at the
grass root level and as well as a clearly defined mechanism and
methodology for translating this philosophy into practice and a
required structure to make it a way of life.
3. It is bound to succeed where people are respected and are involved
in decisions, concerning their work life, and in environments where
peoples capabilities are looked upon as assets to solve work-area
problems.
4. The Quality circle philosophy calls for progressive attitude on the
part of the management and their willingness to make adjustments, if
necessary, in their style and culture.
OBJECTIVES:
The objectives of Quality circles are multi-faced
(a) Change in Attitude
From “I don’t care” to “I do care” continuous improvement in quality of
work life through humanisation of work. To secure employee involvement
motivation and development.
(b) Self Development
Bring out “Hidden potential of people. People get to learn additional skills.
(c) Development of Team Sprit
Individual vs. Team. “I could not do but we did it. Eliminate
interdepartmental conflicts.
 To improve management-employee relations.
 To improve communications at all levels.
 To develop team spirit among the employees.
(d) Improved Organizational culture
 Positive working environment
 Total involvement of people at all levels
 Higher motivational level
 Participate Management process
 To provide better working environment of employees.
CHARACTERISTICS OF QUALITY CIRCLE:
1. Small Homogenous group
Quality circles are small primary groups of employee of
homogenous group whose lower limit is three and upper limit twelve or 5-
10. Homogenous group, not an interdepartmental or interdisciplinary one.
Designations may differ, but work engagement should be common. (Stress
on group efforts). 1. The circle must choose its own leader from within its
own members

2. Voluntary
The membership of quality circle is most voluntary. If members are
forced to participate, it does not allow for a conducive team building
environment.

55
 3. Objectives
Each circle is led by area supervisor.
4. Organized
The members meet regularly every week or according to an agreed
schedule. QCS should meet for about an hour every week. Too long
intervals are not recommenced. Regularity is of great importance. The circle
members are specially trained in techniques of analysis and problem
solving.

5. Problem Identification and organized approach

The basic role of circles to identify and solve work related problems
for improving quality and productivity. The members of the Quality circle
set the rules and prioritizes / selects problems that will be approached and
discussed by the team. Organized problem-solving should be utilized, which
would include brain storming and cause-and-effect diagramming. This
organized approach also prevents the circles from holding unproductive
sessions as well.
6. Participative
Quality circle enables their member to exercise these hidden talents
for tackling challenging tasks.
7. Communication
All decisions are made by consensus, encouraging open
communication. Bottom up approach.

8. Creativity
Here problems are chosen, not given. Members are responsible for
identification of a problem and implementation of the solution.
9. Performance oriented, not problem focused

FACTORS INFLUENCING QUALITY CIRCLE:

There are fire fine golden rules for a successful quality circle programme. These
are
1. Organizational preparedness
2. Professional commitment
3. Selection of objectives
4. Voluntary Participation and training
5. Flexibility

PRINCIPLES OF QUALITY CIRCLE (QC):

The following are the basic principles of QC
1. Understanding to improve work life.
2. There is a general disposition towards active cooperation.
3. Mutual trust should be developed to make participation meaningful.
4. Even lower-level employees can make useful contribution to achieve overall
objectives of the organization.
5. Human development is made possible.

56
ORGANISATIONAL STRUCTURE:
A Quality circle has an appropriate organisational structure for its effective
and efficient performance. It varies from industry to industry, organization to
organisation. But it is useful to have a basic framework as a model.
The structure of a Quality circle consists of the following elements.
1. A steering committee
2. Coordinator
3. Facilitator
4. Circle header
5. Circle Members

Members

Leader

Facilitator

Steering
Committee

Coordinating
Agency

QC

1. A Steering Committee
This is at the top of the structure. It is headed by a senior executive and
includes representatives from the top management personal and human resources. It

57
establishes policy, plans and directs the program and conducts usually once in a
month.
2. Coordinator
He may be a personnel or Administrative officer who co-ordinates and
supervises the work of the facilitators and administers the programme.
3. Facilitator
He may be a senior supervisory officer. He coordinates the works of several
quality circles through the circle leaders.
4. Circle Leader
Leaders may be from lowest level workers or supervisors. A circle leader
organizes and conducts circle activities

5. Circle Members
They may be staff workers. Without circle members the programme cannot
exist. They are the lifeblood of quality circles. They should attend all meeting as far
as possible, offer suggestions and ideas, participate activity in group process, and
take training seriously with a receptive attitude.
TOOLS AND TECHNIQUES:
The members of the circles have mastered statistical quality control and
related methods and all utilize them to achieve significant results in quality
improvement, cost reduction, productivity and safety. The tools of quality control
are taught to all employees.
 Pareto charts
 Cause and effect diagrams
 Stratification
 Check sheets
 Histogram
 Scatter diagrams
 Shewhart’s control charts and graphs
 Run analysis
 Grouping Technique
 Conflict resolution
 Problem solving Techniques
 Brain storming
 Pareto Analysis
 Cost and Effect Analysis
 Data collection and Analysis
 Ishikara or Fishbone Diagram
 Tools used for Data Analysis
 Tables
 Bar charts
 Histograms
 Circle groups
 Line graphs
 Scatter diagrams
 Control charts
 New Tools
 Relations Diagram

58
  Affinity Diagram
 Systematic or Tree Diagram
 Matrix Diagram
 Matrix Data Analysis Diagram
 Arrow Diagram
 Progress Design Program (PDR) chart

TRAINING:
Each group should know beforehand the commitments and implications
involved as well as the benefit that can be obtained from quality circles. Such
training comprises of
1. Brief orientation programme for top management
2. Programme for Middle level executers
3. Training of facilitators
4. Training for circle leaders and members.
QUALITY CIRCLE PROCESS:
The operation of quality circle enrollers a set of sequential steps as under.
PROBLEM IDENTIFICATION

PROBLEM
PROBLEM SELECTION ANALYSIS

GENERATE ALTERNATIVE
SOLUTIONS

SELECT THE MOST APPROPRIATE

SOLUTION

PREPARE PLAN OF IMPLEMENTATION

ACTION OF SOLUTION

59
1. PROBLEM IDENTIFICATION
Identify a number of problems.
2. PROBLEM SELECTION
Decide the priority and select the problem to be taken up first.

ORGANIZATION TRAINING

8-10 members Group processes

same area Data Collection

Moderator Problem Analysis

PRESENTATION

Implementation

Monitoring

PROBLEM IDENTIFICATION

List Alternatives

Consensus

Brainstorming

SOLUTION

Problem PROBLEM ANALYSIS

Results Cost and Effect ,Data

Analysis

60
 3. PROBLEM ANALYSIS
Problem is clarified and analyzed by basic problem solving methods.
4. GENERATE ALTERNATIVE SOLUTION
Identify and evaluate causes and generate number of possible alternative
solutions.
5. SELECT THE MOST APPROPRIATE SOLUTION
Discuss and evaluate the alternative solutions by comparison in terms of
investment and return from the investment. This enables to select the most
appropriates solution.

6. PREPARE PLAN OF ACTION

Prepare plan of action for converting the solution into reality which includes
the considerations "who, what, when, where, why and how" of solving problems.
Present solution to management circle member's present solution to management
for approval.
7. IMPLEMENTATION OF SOLUTION
The management evaluates the recommended solution. Then it is tested and
if successful implemented on a full scale.

LAUNCHING QUALITY CIRCLES:

The major prerequisite for initiating quality circles in any organization is the
total understanding of, as well as complete conviction and faith in the participative
philosophy, on the part of the top and senior management. The launching of quality
circles involves the following steps.
1. Expose middle level executives to the concept.
2. Explain the concept to the employers and invite them to volunteer as
members of quality circles.
3. Nominate senior officers as facilitators
4. Form a steering committee
5. Arrange training of co- ordinates facilitators in basis of quality circle
approach, implementation, techniques and operation later facilitator may
provide training to circle leaders and circle members.
6. A meeting should be fixed preferably one hour a week for the quality circle to
meet.
7. Formally inaugurate the quality circle.
8. Arrange the necessary facilities for the quality circle meeting and its
operation.
ESSENTIALS OF QUALITY CIRCLE:
1. Realistic results
2. Total management commitment and support
3. Middle management participation
4. Active involvement of employees
5. Clear and ideal objectives
6. effectively implementation of Suggestions
7. Proper o- ordination
8. Adequate financial support
9. Competent Team

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 BENEFITS:
1. Increase productivity
2. Improve quality
3. Boost employee morale- reinforce worker morale and motivation
4. Internal leadership
5. Encourage a strong sense of teamwork in an organization
6. Higher quality
7. Greater upward flow of information
8. Broader improve worker attitude
9. Job enrichment
DISADVANTAGES / PROBLEMS/ LIMITATIONS:
1. Inadequate training
2. Unsure of purpose – lack of clear objectives.
3. Not truly voluntary
4. Lack of Management interest (commitment and support)
5. Quality circles are not really empowered to make decisions
6. Unrealistic expectations for fast results
7. Resistance by middle management
8. Failure to get solutions implemented
STUDENT QUALITY CIRCLES:
Student quality circles work on the original philosophy of Total quality
management. The idea of SQCS was presented by city Montessori school (CMS)
Luck now at a Conference in Hong Kong in October 1994. SQCS are considered to
be a Co- curricular activity. They have been established in India, Bangladesh,
Pakistan, Nepal, Sri Lanka, Turkey, Mauritius, Iran, UK and USA. In Nepal, Prof.
Dinesh. P. Chapagain has been promoting this innovative approach through
QUEST- Nepal since 1999. He has written a book entitled "A guide Book on
Student's quality circle. An approach to prepare total quality people, which is
considered a standard guide to promote SQCS in academia for student's personality
development.
ROLES AND RESPONSIBILITIES:

Top Steering Coordinator Facilitator Leader Members Non

Management Committee mem
bers

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Top Management
The success of the quality circle depends solely on the attitude of the top
management and plays an important role to ensure the success of implementation of
quality circles in the organization.
Steering Committee
Steering committee called Middle Management consists of chief executive
heads of different divisions.
Coordinator
The coordinator plays a positive role in quality circle activities for the
success of the efforts. The meetings are covered atleast once in one to two months
interval Coordinator also acts as a facilitator is an individual responsible for co-
coordinating and directing the quality circles out such functions as would make the
operations of quality circles smooth, effective and self- sustainable.
Facilitator
Facilitator also acts as a catalyst, innovator, promoter and teacher and is
nominated by the management
i. Communicating with all levels of management and obtaining their
support and assistance.
ii. Providing training to QCC leaders and assisting in training of QCC
members where required.
iii. Maintaining an open and supportive environment
iv. Ensuring QCC members direct their activities to work related
problems.
v. As a mediator in problem- solving
vi. As a resource person to the circle and
vii. Evaluating the costs and benefits of the QCC programme and
reporting to the management
Leader
Leader of the quality circles is chosen by the members among themselves
and they may decide to have a leader by rotation since the members are the basic
elements of the structure of quality circle
i. Training members on problem solving techniques with the assistance of the
facilitator where required
ii. Responsible for the smooth operation of QCC activities and fostering the
spirit of co- operation and harmony among members
iii. Assisting the circle members in record keeping and on the preparation of
management presentations
iv. Conducting meeting in an orderly effective manner
v. Showing interest and support to the circle.
vi. Encouraging other workers to become members
vii. Assisting members in problem- solving
viii. Enforcing team discipline
Members
Members of the quality circles are the small group of people from the same
work area or doing similar type of work whereas non- members are those who are
not members of the quality circle but may be involved in the circle
recommendation.

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 i. Attending meetings regularly
ii. Directing their efforts towards solving work- related problems,
identifying problems, contributing ideas, undertaking research and
investigation (where necessary, and assisting the QCC in problem –
solving
iii. Participating in management presentations.
INNOVATIONS IN QUALITY CIRCLE:
1. Cross functional teams, members drawn from different departments
2. Innovation quality circle (IQC) communication website facilitates exchange
of experiences and interact.
3. Impart new tools and techniques through workshops and courses
4. Members can come from suppliers as well – wider scope.
5. Leaders or mentor organization helping other organization.
CONCLUSION:
People are the greatest assets of an organization, because through people all
other resources are converted in to civilities. However Management of people
resources has always been a vexed problem ever since the beginning of organized
human activities. A number of managerial responses hare been developed to answer
this question.
Quality circles are not limited to manufacturing firms only. They are
applicable for variety of organizations where there is scope for group based solution
of work related problems. Quality circles are related for factories, firms, schools,
hospitals, universities, research institutes, banks, government offices etc., The
P.W.D. of Maharashtra is one such example of Government organizations marching
on the path of quality improvement. Hence it can be safety concluded that no
progressive organization can afford to ignore the concept of quality circles. When
quality circles were used in hospitals, the groups were most successful in solving
problems when circle leaders and members were specifically trained in problem-
solving techniques.
Quality circles are effective when facilitators, leaders and members are
trained in group dynamics and quality circle techniques.

QUALITY MANAGEMENT
INTRODUCTION
‘’ It costs a lot to produce a bad product.”
Norman Augustine

An operations manager's objective is to build a total quality management

system that identifies and satisfies customer needs. Quality management is focused
not only on product/ service quality, but also the means to achieve it. Quality
management therefore uses quality assurance and control of processes as well as
products to achieve more consistent quality.
The act of overseeing all activities and tasks needed to maintain a desired
level of excellence. This includes creating and implementing quality planning and
assurance, as well as quality planning and assurance, as well as quality control and
quality improvement. It is also referred to as total quality management (TQM).

64
Producing Products of the required quality does not happen by accident. There has
to be a production process which is properly managed. Ensuring satisfactory quality
is a vital part of the production process.

Quality Management is becoming integral to the delivery of health care.

Nursing is also benefited from this approach because strategic planning takes into
account what is needed to deliver the service. Various activities like program
design, involving personnel from different disciplines, goal setting and
administrative support are the integral to quality management. Education of staff,
recruitment and retention of qualified staff and similar issues become defined
targets in management of quality. In quality management, changes in any aspect of
service design must be considered from the whole.

DEFINITION OF QUALITY MANAGEMENT

It is defined as "the process by which people are mobilized to achieve
quality goals. Quality management becomes the umbrella under which all processes
and activities related to quality full.
The processes that include all the activities of performing organization that
determines quality policies, objectives, and responsibilities so that the project will
satisfy the needs for which it was undertaken
- Brainbish, 2009.

QUALITY MANAGEMENT TRIANGLE

Quality management triangle is visualized as the quality Management continuum.
This Quality Management continuum will be the focus of the Quality Management
Branch.

Quality Management Triangle

Defining Quality

QM

Improving Quality Measuring Quality

65
Three distinct pieces make up this continuum
a. Defining quality
b. Measuring quality
c. Improving quality

In defining "quality" the QMB will work with policy staff and, various
program staff and contractors to define the standards of care and program
requirements- what is it we are trying to meet.
Measuring quality – In the quality continuum measuring quality is
inextricably linked to defining quality since the indicators for quality measurement
are derived from the standards.
This means the quality management branch staff will work to assure that
review tools clearly reflect identified health care standards and program
requirements.
Improving quality- Improving quality involves applying appropriate
methods to close the gap between current and expected levels of quality as defined
by standards. The QI activities use quality management tools and principles to
understand and address systems deficiencies, enhance strengths and improve health
care processes. Quality improvement recognizes that both the resources (inputs) and
activities carried out (processes) must be addressed together to ensure improvement
in the quality care.

Quality Management is concerned with controlling activities with the aim of

ensuring that products and service are fit for their purpose and meet the
specifications. There are two main parts to quality management.
1. Quality assurance
2. Quality planning
3. Quality control

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QUALITY MANAGEMENT BRANCH
The Quality Management Brach (QMB) consists of nurses, nutritionists, a
case manager along (who monitors case management activities for pregnant women
and children), WIC Fiscal monitors, and regional staff who evaluate the delivery of
health care services provided with DSHS fund

Case Manager
Nurses

Quality Management
Staff

WIC Fiscal
Nutritionalists

Upon evaluation of health care activities, the Quality Improvement Team of

the QMB may identify the need for improvement of systems of care for individuals
and populations. These activities make up a continuum that ties the activities of
evaluation of services to the development of improved systems of care and services.

FOUR CORE PRINCIPLES OF QUALITY MANAGEMENT

(QM)
The four core principles of Quality Management are
1. Focus on the client
2. Focus on systems
3. Focus on measurement
4. Focus on teamwork
1. Focus on the client
Services should be designed to meet the needs and expectations of
clients and communities.
2. Focus on systems and Processes
Providers must understand the service delivery system and its key
service processes in order to improve them (e.g.) program requirements billing and
eligibility.

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 3. Focus on Measurement
Data are needed to analyze processes, identify problems, and
measure performance, (correctly measure what you want to evaluate)
4. Focus on team work
Quality is best achieved through a team approach to problem solving
and quality improvement (getting input from stakeholder’s community, client's
staff both clinical and non-clinical.
QUALITY MANAGEMENT PROGRAM
Quality Management Program is organization wide is designed to
 evaluate the quality and appropriateness of client care
 identify and resolve problems in care and performance
 make changes to improve care and clinical performance
Incorporating a Quality Management Program within an organization is an
ongoing process in which a set of activities structures and values becomes an
organization.
To develop a successful Quality Management system there must be
1. Buy – in from the agency and staff.
2. an active internal process
3. Standardized system; and
4. Implementation
Quality Management will be institutionalized when it is formally and
philosophically incorporated into the structure and functioning of an organization,
consistently implemented and supported by a culture of quality, as reflected in
organizational values and policies that and advocate quality care.
THE ROLE OF MANAGEMENT
“The support of top management is not sufficient. They must get involved;
they must act”
- W.C. Deming
Management has a key role, top management must be activity involved to
ensure oversight, coordination, delegation of roles and responsibilities, and
accountability. This includes leadership being involved in developing strategies,
setting priorities, being involved in follow-up and monitoring of progress.

THE COMPONENTS OF A QUALITY MANAGEMENT PLAN

The essential components of a Quality Management plan.
1. A Mission – that supports quality Management processes. An agency’s mission
and philosophy must support quality and quality management processes. The
agency’s mission statement and philosophy should demonstrate to staff and clients
the investment the agency has made in the quality process.
2. A committee – to monitor Quality Management activities. This component is
very important. The most effective of measurement systems will be of little value if
no one is responsible for evaluating and using the information to make
improvement.

The Quality Management program needs a home, it needs to be managed and

overseen – and that is the function of the Quality Management Committee. The role

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of the Quality Management is to monitor all aspects of service delivery including
administrative processed and facilities, and to use the QM process to improve
performance through the coordination of the QM activities.
The Quality Management committee at a minimum should consist of
The Executive Director or CEO
The Medical Director
Director of Nursing or clinical Manager
Members of management and representatives of all functional areas of activity to
ensure a comprehensive internal review process.

In a quality-oriented agency, quality becomes the business of everyone.

Employees begin to look at ways to do what they do better, more cost-effectively
but this activity needs to be focused and guided. The QM committee should
describe the roles and functions of all members involved in quality activities.
The committee should ensure that all persons involved know how to
effectively communicate suggestions and needs to the committee. All involved
should know that their activities will receive the serious consideration of the
committee.
The Quality Management committee must define its scope of duties and
how and by whom the duties will be fulfilled, the frequency of meetings, the
responsibilities of the frequency of meetings, the responsibilities of the members,
the purpose of the committee and the processes that will be used to identify
opportunities for improvement.
In the early stages of QM development, it may be useful to clearly outline
the specific duties, lines of reporting, and accountability for results, to ensure that
QM activities are duly implemented and that there is necessary time allocated for
staff participation. Staff must be allocated Time to monitor; analyze the data; and
look at outcomes.
Clearly defining the structure, responsibilities, purpose and scope of work of
the committee and its members provides a framework to guide the committee’s
activities and progress.
Quality Management committee should meet regularly to discuss quality
issues, and minutes of all such meetings should be kept. Ongoing reviews,
observations and other types of quality activities should be discussed and evaluated
at the meetings and recommendations for corrective actions should be made. The
QM committee should then define corrective actions to be implemented, and define
timelines for monitoring the results of the QI activities. The results of the QI
activities should be evaluated and reported to the committee.
3.A Road map – that will serve as a work plan, with tools, timeframes and
responsibility, to identify how often and what sources of data will be used for
QM activities. To ensure that the QM committee and the agency gets where it
wants to go, the route to quality should be plotted. The committee should have a
roadmap to know where it is going a work plan must be developed. The
committee should identify which areas of activity will be reviewed, how often
and what sources of data will be used. Identification of these elements guides
the committee’s activity in an organized and standardized manner. Because
quality management is not limited to a few areas of the agency, all functional
areas should be included in quality management activities.

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4. A Process
To incorporate Quality Management into the fabric/structure of an
organization, it is important that an environment exists that enables the initiation,
growth, and continuity of quality activities.
The continuity of QM activities must also incorporate supportive policies,
effective leadership, structure that support the performance of quality activities, and
adequate resource allocation that emphasizes the importance of quality and
encourages people to practice QM activities as part of their daily work. It is
important that quality is a part of everybody’s job. Make everybody feel that they
are a part of the process, because they are, and their revs and responsibilities are
equally important to the QM process.
The Mission

5. Measuring Data

A quality assessment frequently combines various data collection methods.

These methods typically involve either some form of direct observation or indirect
assessment of performance. Examples of such methods are.

a. Observation of service delivery

b. Audit of client records
c. Mystery client method
d. Client staff interviews
e. Data collection and Analysis
f. Client satisfaction surveys

6. Tools

The QM plan should include the tools necessary to do job. For the data
collected to be reliable it must be collected in a standardized manner, and
documented in a way to allow comparisons over time and among programs. The
tools should allow the reviewers and the QM committee to identify trends and an
acceptable threshold of quality so that improvement activities can be implemented.

7.Time Frame

All monitoring activities should occur within a specified period of time at a

specified frequency to provide the agency and the committee with a timetable for
QM activity and milestones by whack to measure progress.

Time periods, frequency of activities and size of sample must be defined

Example

Number of client records will be reviewed quarterly.

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 100% of staff will be observed for skill and technical expertise annually.

8. Responsibility

The individuals who are responsible for completing an activity should be

designated and be held accountable for the activity. In order for the process to be
ongoing, people want to know what they are responsible for.

The individual who will conduct activities should be identified.

Examples

The laboratory Director will observe 100 of laboratory staff every 6 months
to ensure adherence to proper testing technique.

The Director of Nurses will review a set percentage of all family planning
client records each quarter.

QUALITY MANAGEMENT PROCESS

The process by which findings and result of activities will be communicated
to and used by the QM committee to identify problems and success and to improve
services must be clearly identified and defined. A well-defined process promotes
successful quality implementation by providing direction and a system for
conducting QM activities.

The QM process must include a method to identify, track and monitor

outcome measures and indicators which include:

1. How outcomes will be tracked

2. Who will track them
3. Who, how and how often they will be tracked
4. Who, how and how often they will be reported
5. The changes and trends that occur

Finally the Quality Management Process must assist the agency in measuring
the outcome of service delivery. The end result is to ensure that outcome of service
delivery, meet the standard of care. A standard for implementing corrective actions
that ensures accountability for the implementation. A follow-up and review system
is essential to determining if the quality improvement activities are having the
desired effect.

71
 Re
assess Identify values

Enact

Choose indicators
solutions
solutions
Propose

Assess

Identify
problem
s
Evaluate

Quality Management requires more than a technical approach of tools and

methods sustained improvements often require a change of attitude and sense of
ownership for the quality of services provided by an organization. The quality
management process is not linear process, but rather, a circular process. Each step
in the process is influenced by the step which preceded it and by the step which
floccus it. The results of this continual circular process is a quality organization and
that is definitely worth the effort

PRINCIPLES OF QUALITY MANAGEMENT

The eight quality management principles on which the quality management
system standards of the ISO 9000 series are based. These principles can be used by

72
senior management as a framework to guide their organizations towards improved
performance. The principles derived from the collective experience and knowledge
of the international experts who participate in ISO Technical committee ISO/ TC
176, quality management and quality assurance, which is responsible for
developing and maintaining ISO 9000 standards.

Principle 1: Customer focus

Principle 2: Leadership

Principle 3: Involvement of people

Principle 4: Process approach

Principle 5: System approach to management

Principle 6: Continual Improvement

Principle 7: Factual approach to decision making

Principle 8: Mutually beneficial supplier relations.

Customer Focus

Organizations depend on their customers and therefore should understand

current and future customer needs, should meet customer requirements and strive to
exceed customer expectations. Without customers, the organizations would not
exist strive to understand current and future customer needs, and aim to exceed
customer expectations.

Leadership

Leaders establish unity of purpose and direction of the organization. They

should create and maintain the internal environment in which people can become
fully involved in achieving the organization's objectives. With vision and mission,
leaders establish unity of purpose and direction. Create an environment conducive
to employee involvement in achieving the goals of the organization.

Involvement of People

People at all levels are the essence of an organization and their full
involvement enables their abilities to be used for the organization's benefit. The
management and employees are the essence of the organization. For every involved
employee, abilities become resources. Being involved, feelings needed being
trusted and depended and are all motivating factors.

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Process Approach

A desired result is achieved more efficiently when activities and related

resources are managed as a process. Manage Activities and related resources as a
process. Recognize that there is an input, a discrete operation, and an output. When
trouble arises, focus on fixing the process, not the people.

System Approach to Management

Identifying, understanding and managing interrelated processes as a system

contributes to the organization's effectiveness and efficiency in achieving its
objectives. An organizations ability to achieve objectives is boosted when
interrelated processes are managed as a system.

Continual Improvement

Continual Improvement of the organization's overall performance should be

a permanent objective of the organization. Overall improvement of the organization
should be a permanent objective.

Factual Approach to decision making

Effective decisions are based on the analysis of data and information. Use
data and its analysis to make decisions, not opinions or simply the most recent data
point.

Mutually Beneficial supplier Relationships

An organization and its supplies are interdependent and a mutually

beneficial relationship enhances the ability of both to create value.

SCOPE OF QUALITY MANAGEMENT

Quality management is particularly important for large, complex systems.
The quality documentation is a record of progress and supports continuity of
development as the development team changes.

For smaller systems, quality management needs less documentation and

should focus on establishing a quality culture.

ETHICS AND QUALITY MANAGEMENT

1. Operations, Managements must deliver healthy, safe, quality products and
services
2. Poor quality risk injuries, lawsuits, recalls, and regulation.

74
 3. Organizations are judged by how they respond to problems.
4. All stakeholders much be considered

INTERNATIONAL QUALITY STANDARDS

ISO 9000 is an internationally recognized standard of quality, and includes
guidelines to accomplish the ISO 9000 quality standard. Organizations can be
optionally acidized to earn ISO 9000 certification.

ISO 9000 standard represents an international consensus on good

management practices with the aim of ensuring that the organization can time and
again deliver the product or services that meet the client's quality requirements.
These good practices have been distilled in to a set of system, regardless of what the
organization does, its size, or whether it is private or public sector.

Objective

To promote the development of standardization and related activities in the

world with a view to facilitating international exchange of goods and services, and
to developing cooperation in the spheres of intellectual, scientific, technological and
economic activity.

Principal concepts

i. Demonstrate ability to consistently provide product to meet customer and

applicable regulatory requirements
ii. Enhance customer satisfaction
iii. Improve the quality of its own operations.
iv. Provide confidence to internal management and interested parties that the
requirements of a quality management system are being effectively
implement

Benefits

1. ISO 9000 certification has become the de facto minimum requirement for
entering in to global markets.
2. It provides an opportunity to increase value to the activities of the
organization, by streamlining quality management system.
3. Improves the performance of processes/ activities continually thereby
reducing the cost of production
4. It gives importance to customer satisfaction.
5. It helps to improve customer relations by providing quality product or
service.
6. It also acts as an incentive to develop employee relations, employee
empowerment and organizational development.

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ISO which corruptly comprises the national standard bodies of 91 nations. The ISO
9001 standard is a quality management standard.

QUALITY PLANNING (EARLY STAGES)

Quality planning is defined as identifying which quality standards are
relevant to the project and determining how to satisfy them.

Quality planning is short as possible. There is a wide range of quality

attributes that should be considered during the quality planning process.

i. Correctness
ii. Testability
iii. Efficiency
iv. Usability
v. Flexibility
vi. Portability
vii. Maintainability
viii. Reusability

The quality planner should select those organization standards that are appropriate
to a particular process and development process this includes.

1. product introduction
2. product plans
3. process description
4. quality goals and plan
5. risk and risk management

Inputs

Enterprise environmental factors, organizational process assets, project

scope statement, and the project management plan.

Tools and techniques

Cost Benefit analysis, Bench marking, Design of experiments, cost of

quality (COQ), and additional quality planning tools.

Outputs

Quality management plan, quality metrics, quality checklists, process

improvement plan, quality baseline, and project management plan updates.

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 QUALITY CONTROL
The question “have we got it right?”
In Japan quality control is an approach representing a new way of thinking
about management. Dr. Kaoru Ishikawa defines quality control as "To practice
quality control is to develop, design and produce a service a quality product which
is most economical, most useful and always satisfactory to the consumer.

With the advancement of medical technology there is a great change in the

requirements expected by the patient from the nurse. In the broader sense quality
control in nursing means quality of work, quality of nursing service, quality of
information, quality of process, quality of information, quality of process, quality of
division/ department, quality of people including physicians, surgeons, paramedical
etc.

Quality control is the traditional way of managing quality. Quality control is

concerned with checking and reviewing work that has been done. For example, this
would include lots of inspection, testing and sampling. Quality control is mainly
about "detecting" defective output rather than preventing it. Quality control can also
be a very expensive process. Hence, in recent years, businesses have focused on
quality management and quality assurance.

Quality control is a specific type of controlling, refers to activities that

evaluate, monitor, or regulate services rendered to customer. Quality control is a
management information system that helps control fraud, abuse and errors.

Definition

i. Quality control involves monitoring specific project results to determine if

they comply with relearns quality standards and identifying ways to
eliminate causes of unsatisfactory results
-www. iroryocol. com

ii. Quality control is a management system for initiating and co- ordinating
quality development, quality maintenance and quality improvement in the
various departments of design and manufacturing, for achieving the two
objectives of economical production and customer satisfaction.
iii. Quality control is a process that is used to ensure a certain level of quality in
a product or service. It might include whatever actions a business deems

77
 necessary to provide for the control and verification of certain
characteristics of a product or service.
iv. A process through which a business seeks to ensure that product quality is
maintained or improved and manufacturing errors are reduced or eliminated.
Quality control requires the business to create an environment in which both
management and employees strive for perfection. This is done by training
personnel, creating benchmarks for product quality, and testing products to
check for statistically significant variations.
v. The observation techniques and activities used to fulfill requirements for
quality.
vi. Quality control (QC) is a procedure or set of procedures intended to ensure
that a manufactured product or performed service adheres to a defined a set
of quality criteria or meets the requirements of the client or customer.
vii. The overall system of technical activities that measures the attributes and
performance of a process, item, or service against defined standards to
verify that they meet the stated requirements established by the customer;
operational techniques and activities that are used to fulfill requirements for
quality.

OBJECTIVES OF QUALITY CONTROL

1. It is to provide products which are dependable, satisfactory and economical.
2. To ensure economical production of products of uniform quality acceptable
to the customer.
3. Aims at preventing the defects rather than detecting the deflects (To detect
errors and correct then before patients results are reported.
4. Reduce errors and enhance quality and productivity.
5. Inspire more effective teamwork.
6. Promote job involvement and participation.
7. Increase employee motivation.
8. Create problem solving capability.
9. Build an attitude of ‘problem prevention’
10. Improve communication in the organisation.

PROCESS OF QUALITY CONTROL

Quality control as a process has certain specific steps as follows

1. Establishment of control standards or criteria.

2. Identify the information relevant to criteria.

3. Determine ways to collect the information

4. Collect and analyze the information

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5. Compare collected information with established criteria

6. Make a judgment about quality

7. Provide information and if necessary, take corrective action regarding

findings of appropriate sources.

8. Determines ways to collect the information for further improvement.

In order to implement an effective QC program, an enterprise must first

decide which specific standards the product or service must be determined (for
example, the percentage of units to be tested for each lot). Next, the real world data
must be collected (for example, the percentage of units that fail) and the results
reported to management personnel. After this, corrective action must be decided
upon must be repaired or rejected and poor service repeated at no charge until the
customer is at no charge until the customer is satisfied). If too many unit failures or
instance of poor service occur, a plan must be devised to improve the production or
service process and then that plan must be put in to action. Finally the QC process
must be ongoing to ensure the remedial efforts, if required, have product
satisfactory results and to immediately detect recurrences or new Instances of
trouble.

How the assess patient's quality requirements

The first step in quality control is to assess patient requirement. Often the
requirements are expressed in terms of standards. To reflect true quality care it
needs to be measured and analyzed against some set standards. Nursing care
standards have to be set specifying the outcome of care. At the national laree these
standards need to reviewed and revised from time to time. Trained nurses
association has contributed to a great extent by bringing about publication of
nursing procedures manual on its platinum Jubilee celebration. Similarly
standardization of nursing education for various categories of personnel has to be
designed at national level. Indian nursing council has revised its B.Sc (Nursing)
syllabus in 2006.

QUALITY CONTROL CYCYLE (OR) PDCA CYCLE (OR)

SCHEWART CYCLE (QUALITY CIRCLES TOOL) (OR)
PDCA WHEEL. (OR) CONTROL CIRCLE / CYCLE (OR)
DEMING CYCLE
Dr. FW Taylor the father of scientific management described the
control with plan - Do- see. Japan replaced the term as plan Do check Act (PDCA).
PDCA was made popular by Dr. W. Edwards Deming, who is considered by many
to be the father of modern quality control, he always referred to it as the "shewhart
79
cycle" later in Deming's career, he modified PDCA to "plan, Do, study, Act"
(PDSA) because he felt that "check" emphasized inspection over analysis. It is a
four – step problem solving process. In six- sigma, PDSA cycle is called "Define,
Measure, analyze, improve, and control (DMAIC). In hospital settings, PDCA cycle
integrated with 10 step process model has been used as a framework for TQM

The steps in each successive PDCA cycle are

PLAN

Establish the objectives and processes necessary to deliver results in

accordance with the expected output (the target or goals). By establishing output
expectations, the completeness and accuracy of the specification is also a part of the
targeted improvement. When possible start on a small scale to test possible effects.

DO

Implement the plan, execute the process and make the product. Collect data
for charting and analysis in the following "CHECK: and "ACT" steps

CHECK

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 Study the actual results (measured and collected in "DO" above) and
compare against the expected results (targets or goals from the "PLAN") to
ascertain any differences. Look for deviation in implementation from the plan and
also look for the appropriateness and completeness of the plan to enable the
execution (i.e.) "DO" charting data can make this much easier to see trends over
several PDCA cycles and in order to convert the collected data in to information.
Information is what you need for the next step. "ACT".

ACT

Request corrective actions on significant differences between actual and

planned results. Analyze the differences to determine their root causes. Determine
where to apply changes that will include improvement of the process or product.

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Determine goals and Target

Those can be determined by making hospital policies, patient care policies,

in written and well informed to all personnel. Protocols for patients, relatives etc.
Should be displayed at corridors standing orders for treating patients .In casualty be
displayed so that nurses do not delay the care and treatment unnecessarily. Once
policy is determined goals can be expressed in quantitative terms.

Determine methods of reaching the goals

Quality control will end up as a more mental exercise in case of standing

orders, policies, regulations, are not made known to all workers in all places.
Quality control cannot simply present a goal and shout, "Work hard, work hard".
There should be open, frank and brainstorming sessions and clear- cut delegation of
authority to subordinates should be established.

Education and training

Nurses in the administrative post and senior nursing staff have the
responsibility of education and nurturing their subordinate staff who are going to be
affected by the set standards and regulations. Once the subordinate is educated it
becomes easy for the senior nurses to delegate authority and give them the freedom
to do the job. Man is by nature good and whom he is educated properly authority
can be delegated to him.

Implement work

If everything is done according to procedures implementation should be no

problem. In case a problem arises they have to be tackled by experience and skill,
which will make up for inadequacies in standards and regulations.

Check the effects of implementation

Management will not remain as management if there is no system of checking at

all. The purpose of checking is to discover exceptions and to ensure that things are
progressing as per goals and standards.

Action

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Take the appropriate action as needed to improve the nursing standards.

ELEMENTS OF QUALITY CONTROL

Quality control is an important aspect of successful
project management. These are many elements of quality control that must be
considered throughout any production environment. These elements include

a) Controls
b) Competence
c) Personnel.

All three of these elements must be functioning properly in order for total quality
control to be successful.

Control within a production environment often

includes management of the job, processes, performance and records. Job
management must be performed by someone who is capable of managing. The
person must be someone who the employees listen to. There must be processes in
place that are clear and concise for people to follow. Performance includes integrity
and employees working toward the same goal of the business. Performance must be
controlled. Record keeping must be maintained orderly and professionally. Record
keeping may be in hard copy or through a software package.

Quality control also includes competence. Anyone

working on a project must be entirely competent. This means they need to have
knowledge, skills, experience and qualifications. If employees do not have the
knowledge, it will be difficult to expect them to perform the required tasks.
Competence often includes providing training and resources for employees to have
the ability to perform their job. This also includes a manager hiring the right people
for positions and knowing how to utilize people resources in the right positions to
maximize productivity. A manager that does not place employees in the right
positions or on the right projects is the one failing, not the employees.

Personnel are another element of quality control that must be considered.

These are soft elements and include confidence, integrity, motivation, spirit, and the
culture of an organization. The people factor includes the personalities and how
well people work together. Is everyone on board with the new quality control
project? If the staff is not motivated to work toward a quality environment, the
company wills not succeed with the quality endeavor. Employees need to have the
confidence that they are capable of performing the job. They need to be honest and
uphold to confidential information. When employees are motivated, they believe
entirely in the goal the business wants to achieve. This is the only way to ensure
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they will help the business be successful and the employees with their personal
careers.

Quality control requires three elements in project management. These

elements include controls, competence, and personnel. Haring the ability to
integrate these elements together successfully is the best ways to work toward total
quality- Employees have total control over quality.

PERFORM QUALITY CONTROL

Quality control involves monitoring specific project
results to determine whether they comply with relevant quality standards and
identifying ways to eliminate causes of unsatisfying results.

Inputs

Quality management plan, quality metrics, quality

checklists, organizational process assets, work performance information, approved
change requests and deliverables.

Tools and techniques

Cause and effect diagram, control charts, flowcharting,

histogram, pareto chart, Run chart, scatter diagram, statistical sampling, inspection
and defect repair review.

Outputs

Quality control measurements, validated defect repair,

quality baseline updates, recommended corrective actions, recommended
preventive actions, requested changes, recommended reflect repair, organizational
process assets updates, validated deliverables, and project management plan
updates.

QUALITY CONTROL TECHNIQUES

1. JIT

2. Quality at source

3. Inspection

4. SQC

5. QC

6. TQM

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1. JIT (JUST IN TIME)

JIT helps achieve quality because it is a philosophy that

seeks to constantly improve production processes and methods. JIT contributes to
high product quality in the following ways
Production is highly standardized workers perform
standard tasks every day. They are familiar with their tasks. Familiarity ensures
high quality.
In process inventories are drastically reduced by cutting
lot sizes. Any interruption therefore causes production to stop until the problem has
been solved. In this way, JIT has been called, a system of enforced problem solving.
Now, this stoppage in production forces everybody to solve the quality problem so
that the defect will not defeat. Hence high product quality is ensured.
Suppliers of materials, under JIT system, supply
materials of perfect quality. Many companies do not even inspect supplier's
deliveries of materials; rather the emphasis is on working with suppliers to produce
perfect parts and materials.
JIT system envisages the use of automated equipment
and robots in production processes. Use of such sophisticated machines will ensure
high product quality.
JIT system also envisages the use of intensive
preventive maintenance programmers in order to prevent any machine breakdown.
This results in machines producing parts of perfect quality.
Workers are responsible for producing parts of perfect
quality or with zero defects before they are passed on to the next production
operation.

2. Quality at the source

The worker is pat in the driver's seat in controlling
product quality. The principles underlying quality at the source are Every worker's
job becomes a quality control station. The worker is responsible for inspecting his
own work, identifying any defects and reworking them in to non- defectives, and
correcting any causes of defect.

3.Inspection

The act of determining conformance or non-

conformance of the expected performance is the function of inspection. By
inspection, a manager seeks to determine the acceptability non- acceptability of the
parts, products or services. The basis for inspection is usually a specification which
is called inspection standard. Inspection is made by comparing the quality of the
product to the standard.

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1. Crib Inspection

When someone comes and checks on something to

make sure it is up to a code or set of rules. For example, when an inspector inspects
you're hospital, he checks to make sure it is built to all the most recent standards
formal or official viewing or examination of something, has to meet certain
parameters set by law or orders.

2. Online inspection

On- line inspection provides affordable excellence and

same day reporting allowing you to go to market at optimum speed without having
to develop, your own inspection program. Instead, suppliers and buyers have the
luxury of utilizing Intertie's simplified, standardized, and Best- In- class inspection
anywhere you do business. Intertek now offers On-line inspection- a hassle free,
standardized pre- shipment inspection which offers quality focused inspection –
reduced sample size.

4. Quality Circle

Quality circle is a voluntary group of people who meet together on a regular

basis to identify,analyse and solve quality,productivity,cost reduction, safety
and other problems in their work area, leading to improvement in their
performance and enrichment of their work life.

5. SQC

Statistical quality control techniques are used to monitor the quality of parts
produced at each work station/ and easy to understand charts and graphs are used to
communicate progress to workers and managers.

6. TQM

Total quality management (TQM) is a comprehensive

and structured approach to organizational management that seeks to improve the
quality of products and service.

FACTORS WHICH HINDER QUALITY CONTROL

INPATIENT CARE
The various factors, which result in to hindrance
usually, stem from people with negative thoughts. To mention a few the steps in
each successive PDCA cycle are.

a. Most nurses at the administrative positions avoid responsibilities.

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 b. Few nurses feel everything is all right and are satisfied with the status
gun.
c. Few people are egoistic and think about self before their organization.
d. Some people do not seek help and rely on their own shallow
experiences.
e. Some nurses live in watertight compartments and do not bother to think
about other compartments.
f. Some people have no ears for other's opinions.
g. Despair jealously and envy is other hindering factors.

To dispel these wrong attitudes nursing personnel at all

levels should have courage of their conviction, spirit of co- operation etc.

QUALITY ASSURANCE
INTRODUCTION:
"QUALITY ASSURANCE IS A JOURNEY AND NOT A
DESTINATION"
““Say what you do
Do what you say
Record that you have done it.
Audit for effective implementation
Feedback and Improve.”
Must give way to “are we doing it right?” quality assurance

Quality assurance is the very essence of quality control. It means to assure

quality in a product so that a customer can but it with confidence and use it for
along time with confidence and satisfaction. Health care quality is in the eye of the
beholder. In this, the primary goal is to secure the health care. It refers to the actual
delivery of care from the point of patients first signaling a desired to be considered
for potential treatment. Quality assurance in nursing is a pledge by the professional
nurse that they will work toward the goal of an optimal achievable degree of
excellence in the services rendered to every patient. In health care quality assurance
is being demanded and expected and providers are demanded and expected and
providers are judged by the quality of services and hence there is a need to sensitize
and train nursing personnel to provide quality care.
The act of giving confidence, the state of being certain or the act of making
certain. If you give someone an assurance that something is true or will happen, you
say that it is definitely true or will definitely happen, in order to make them feel less
worried. The planned and systematic activities implemented in a quality system so
that quality requirements for a product or service will be fulfilled. The Quality
Assurances or Quality control process does three things (Kinney, Freedom, and
cook, 1994).
(i) It sets standards for care.
(ii) It evaluates care provided on the basis of the standards.
(iii) It takes action to bring about change when care does not meet standards.

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QUALITY CONTROL VERSUS QUALITY ASSURANCE:

Sl.No Quality Assurance Quality Control

1. An overall management plan to
guarantee the integrity of data
(the system). QA is a set of
activities for ensuring quality in
the processes by which
products are
developed.qualityassurance is
process–oriented
2. Focus on QA aims to
prevent defects with a focus on
the process used to make the
product. It is a proactive quality
process.
3. Goal The goal of QA is to
improve development and test
processes so that defects do not
arise when the product is being
developed.
4. Responsibility
Everyone on the team
involved in developing the
product is responsible for
quality assurance. Verification
is an example of QA
5. Statistical Techniques
Statistical Tools &
Techniques c applied to
processes (process inputs &
operational parameters), they
are called Statistical Process
Control (SPC); & it becomes
the part of QA
A series of analytical measurements
used to assess the quality of the
analytical data (the tools). QC is a set
of activities for ensuring quality in
products. The activities focus on
identifying defects in the actual
products produced. Quality control is
concerned with the product
QC aims to identify (and correct)
defects in the finished product. Quality
control, therefore, is a reactive process
The goal of QC is to identify defects
after a product is developed and before
it's released.
Quality control is usually the
responsibility of a specific team that
tests the product for defects.
Validation/Software Testing is an
example of QC
Statistical tools & techniques are
applied to finished products (process
outputs), they are called as Statistical
Quality Control (SQC) & comes under
QC.

DEFINITION:
1.“Quality assurance is a judgment concerning the process of care,
based on the extent to which that cares contributes to valued
outcomes”
-Donabedian, 1982
2.“Quality assurance as the monitoring of the activities of client
care to determine the degree of excellence attained to the
implementation of the activities.”
-Bull, 1985.

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 3.Quality assurance as a systematic effort to maintain satisfactory
performance of improves medical care and its results.
-Sanzora, 1980.
4.Quality assurance, as making sure that the services provided by
the hospital are the best possible in a given existing resources and
current medical knowledge.
-WHO, 1992.
5.Quality assurance was initially defined as the process for
objectively and systematically monitoring and evaluating the
quality and appropriateness of patient care, and for resolving
identified problems.
-Joint commission.
6.Quality assurance encompasses necessary changes or
improvements to ensure survival. It involves identifying standards
for excellence, evaluating care against these standards and then
taking action to correct deficiencies to achieve the standard.
- Zimmer, 1974.

GOALS:
1. Increase the proportion of persons with health insurance.
2. Increase the proportion of persons who have a specific secure of
ongoing care.
3. Reduce the proportion of families that experience difficulties.
4. Increase the proportion of schools of medicine, schools of
nursing and other health professional trainers.
5. To ensure the delivery, of quality care.
6. To evaluate the efforts of the health care provider to provide
bets possible
OBJECTIVES OF QUALITY ASSURANCE:
According to Jonas (2002), the two main objectives are
i. To ensure the delivery of quality client care.
ii. To demonstrate the efforts of the health care providers to provide
the best possible results.
Other specific objectives of the Nursing Process are
a) Formulate plan of care
b) Attend to the patient’s physical and non-physical needs.
c) Evaluate achievement of nursing care.
d) Support delivery of nursing care with administrative and Managerial skills.

PURPOSES/NEED:
1. Rising expectations of consumer of services.
2. 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.
3. The increasing complexity of health care organizations.
4. Improvement of job satisfaction.
5. Highly informed consumer.

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 6. To present rising medical errors.
7. Rise in health insurance industry.
8. Accreditation bodies.
9. Reducing globel boundaries.

COMPONENTS OF QUALITY ASSURANCE:

Four essential components of quality assurance are
(a) Setting program objective
(b) Promoting quality
(c) Activity monitoring includes
i. Quality control: occurrence screening, nursing audit.
ii. Quality supervision: Supervisory rounds, incidence tracking.
(d) Performance assessment. It includes
i. Quality review
ii. Quality evaluation
iii. Quality approval.

QUALITY ASSURANCE PROGRAMS:

There are two different approaches to ensure
(a) Quality by Inspection
(b) Quality as opportunity.
(a) Quality by inspection:
Quality by inspection is often referred to as quality control. Quality by
inspection was used primarily in the manufacturing industry to ensure the quality of
manufactured products. Inspectors were hired to inspect the final product prior to
leaving the manufacturing plant (E.g.) The unit dose cart was filled by the
pharmacy technician, checked by the pharmacist prior to leaving the pharmacy, and
checked again by the pharmacist and nurse on arrival to the specific nursing unit.
(b) Quality as opportunity:
It should be seen as an opportunity to strengthen programs that are currently
of good quality or can achieve good quality as part of an overall process of
continuous improvement.

APPROACHES FOR A QUALITY ASSURANCE

PROGRAMME
Two major categories of approaches exist in quality assurance. They are
1. General
2. Specific.
General approach:
It involves large governing of official body’s evaluation of a persons or
agency’s ability to meet established criteria or standards at a given time.
1. Credentialing
2. Licensure
3. Accreditation
4. Certification.

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1. Credentiating:
It is generally defined as the formal recognition of professional technical
competence and attainment of minimum standards by a person or agency.
Credentiating process has four functional components.
(a) To produce a quality product.
(b) To confer a unique identity.
(c) To protect provider and public.
(d) To control the profession.
2. Licensure:
Individual licensure is a contract between the profession and the state, in
which the profession is granted control over entry into and exists from the
profession and over quality of professional practice. The licensing process requires
that regulations be written to define the scopes and limits of the professional’s
practice. Licensure of nurses has been mandated by laws and regulations since
1903.
3. Accreditation:
National league for Nursing (NLN) a voluntary organization has established
standards for inspecting nursing education’s program. In the part the accreditation
process primarily evaluated on agency’s physical structure, organizational structure
and personal qualification.
ISO
JCI
NABH
Accrediation Canada
NAAC.
4. Certification:
Certification is usually a voluntary process within the profession. A person’s
educational achievements, experience and performance on examination are used to
determine the person’s qualifications for functioning in an indentified specialty
area.
Specific Approaches:
Quality assurances are methods used to evaluate identified instances of
providers, and client interaction.
1. Peer review
2. Patient care profile analysis
3. Quality circles
4. Patient satisfaction (client feedback)
5. Standard as a device for quality assurance
6. Audit as a tool for quality assurance.
7. Control committees.
8. Review of Accident reports.
1. Peer review:
It is a process by which nurses evaluate one another’s job performance
against accepted standards.
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 into two types.
1. The recipients of health services by means of auditing the quality of
services rendered.

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 2. The health professional evaluating the quality of individual
performance.
2. Patient care profile analysis:
The analysis of longitudinal or cross-sectional complications of data about
patients with a particular diagnosis or problem.
3. Quality circles:
A quality circle is a small group of 5 to 15 employees who perform similar
work and meet for one hour each week to solve problems related to their work.
4. Standard as a device for quality assurance:
Standard is a predetermined baseline condition or level of excellence that
comprises a model to be followed and practiced. The ANA standard for practice
includes.
Standard 1:
The collection of data about health status of the patient is systematic and
continuous. The data are accessible, communicative, and recorded.
Standard 2:
Nursing diagnosis are derived from health status data.
Standard 3:
The plan of nursing care includes goals derived from the nursing diagnosis.
Standard 4:
The plan of nursing care includes priorities and the prescribed nursing
approaches or measures to achieve the goals derived from the nursing diagnosis.
Standard 5:
Nursing actions provide for patient participation in health promotion,
maintenance and restoration.
Standard 6:
Nursing actions assist the patient to maximize his health capabilities.
Standard 7:
The patient’s progress or lack of progress towards goal achievement is
determined by the patient and the nurse.
Standard 8:
The patient’s progress or lack of progress towards goal achievement directs
reassessment, re-ordering of priorities, new goal setting and a revision of the plan of
nursing care.
To evaluate quality nursing care regularly, many staff nurses develop
criteria, to review nursing care retrospectively and concurrently, and to discover
methods of achieving higher levels of quality nursing care.
5. Audit as a tool for quality assurance:
Nursing audit may be defined as a detailed review and evaluation of selected
clinical records in order to evaluate the quality of nursing care and performance by
comparing it with accepted standards. To be effective a nursing audit must be based
to established criteria and feedback mechanism that provide information to
providers on the quality of care delivered.
6. Control committees:
Committees may be set up in hospitals to evaluate a particular problem and
to take corrective measures. Examples are infection control committee, safety
committee etc.
7. Review of Accident reports:

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 Many kinds of accident can occur in a hospital situation. A good accident
report is a great help in preventing further accidents in future.
APPROACHES/ELEMENTS/COMPONENTS TO QUALITY
ASSURANCE:
According to Donabedian, there are three approaches from which nursing care be
evaluated to assure quality nursing practice.
1. Structure
2. Process and
3. Outcome
Since each of these interaction elements contributes to the quality of nursing care
delivered, an improvement in any of the three tends to produce the favorable change
in the other two.
Structural element:
The physical, financial and organizational resources provided for health care.

It includes the physical setting, instrumentality and conditions through

which nursing care is administered, such as philosophy, objectives, policies,
procedures, records, organizational structures, financial resources, equipment and
expectations and attitudes of patients and employees.
Process element:
The activities of a health system or health care personnel in the provision of care.
It includes steps of the nursing process itself, assessment, diagnosing,
planning, implementation and evaluation and all subsystems within the nursing
process, such as taking a health history, performing physical examination, making a
nursing diagnosis, determining nursing care goals, writing a nursing care plan,
measuring patient care outcome and recording and reporting patient’s response to
treatment. It is the criteria for measuring nursing care to determine if nursing
standards of practice are being met, so they are task oriented.
Outcome element:
A change in the patient’s current or future health that results from nursing
interventions.
It includes changes in patient health system that result from nursing
interventions. Ex. Modification in signs and symptoms, knowledge, attitude
satisfaction, skill level and compliance with treatment regimen, and established
patient outcome criteria.
.
PRINCIPLES OF QUALITY ASSURANCE:
The International standard for Quality management (ISO 9001:2008) adopts a
number of management principles that can be used by top management to guide
their organizations towards improved performance. The principles include.
1. Leadership
2. Commitment
3. Customer focus
4. Process oriented and outcome driven
5. Participative management
6. Individual responsibility
7. Employee empowerment

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 8. Protective improvement
9. A continuous process, not a programme
10. Data driven decision making
11. Team work
12. Inter disciplinarily
13. Education and retraining
14. A system of employee rewards and recognition
15. Preventive management – Look for improvement opportunities
16. Variance control setting standards
17. Branch making or positive competition
It is a bottom up approach as opposed to top down.

1. CUSTOMER FOCUS:
Since the organizations depend on their customers, they should understand
current and future customer needs, should meet customer requirements and should
try to exceed the expectations of customers. An organization attains customer focus
when all people in the organization know both the internal and external customers
and also what customer requirements must be met to ensure that both the internal
and external customers are satisfied.
2. LEADERSHIP:
Leaders of an organization establish unity of purpose and direction of it.
They should go for creation and maintenance of such an internal environment, in
which people can become fully involved in achieving the organization’s quality
objective.
3. INVOLVEMENT OF PEOPLE (COMMITMENT)
People at all levels of an organization are the essence of it. Their complete
involvement enables their abilities to be used for the benefit of the organization.
4. PROCESS APPROACH:
The desired result can be achieved when activities and related resources are
managed in an organization as process this may also affect it.
5. SYSTEM APPROACH TO MANAGEMENT:
An organization’s effectiveness and efficiency in achieving its quality
objectives are contributed by identifying, understanding and managing all
interrelated processes as a system. Quality control involves checking transformed
and transforming resources in all stages of production process.
6. CONTINUAL IMPROVEMENT:
One of the permanent quality objectives of an organization should be the
continual improvement of its overall performance.
7. FACTUAL APPROACH TO DECISION MAKING (DATA DRIVEN
DECISION MAKING)
Effective decisions are always based on the data analysis and information.
8. MUTUALLY BENEFICIAL SUPPLIER RELATIONSHIPS
(TEAMWORK)
Since an organization and its suppliers are interdependent, therefore a
mutually beneficial relationship between them increases the ability of both to add
value.
9. PARTICIPATIVE MANAGEMENT:

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 Participative management / leadership style, with wide participation in the
quality cycle, is generally accepted principle in performance improvement
initiatives.
10. EMPLOYEE EMPOWERMENT:
Employee involvement is very important in any T.QM initiative, as it is a
system wherein employees are encouraged to use their expertise and knowledge to
suggest methods for improvements in their work areas. Job enrichment involves
increasing the depth of the job to include responsibilities that have traditionally
been carried out at higher levels of the organization.
12. PROTECTIVE IMPROVEMENT:
The health and safety of all members of staff at their workplaces is ensured.
Environmental compatibility, safety and the highest quality of production and
products is guaranteed. Water and other precious resources are utilized in a
responsible and sustainable way and ethical principles receive full attention. A
management system unites aspects of environmental protection, quality
management and occupational safety all under one roof.
13. INTERDISCIPLINARY:
Interdisciplinary team work is increasingly prevalent, supported by policies
and practices that bring care closer to the patient and challenge traditional
boundaries. Ten characteristics underpinning effective interdisciplinary team work
were identified positive leadership and management attributes, communication
strategies and structures, personal rewards, training and development; appropriate
resources and procedures; appropriate skill mix; supportive team climate, individual
characteristics that support interdisciplinary team work, clarity of vision, quality
and outcomes of care, and respecting and understanding roles.
14. EDUCATION AND RETRAINING:
Staff training should include relationship of their work with other parts of
the process, trouble shooting, knowledge of the overall quality system and its
objectives, their particular responsibility within the quality system. Training can be
provided through on-the-job training, formal classroom session, technologist
certification programs, participation in intercomparison programmes, international
fellowship programmes.
15. A SYSTEM OF EMPLOYEE REWARDS AND RECOGNITION:
In a competitive business climate, more business owners are looking at
improvements in quality while reducing costs. Meanwhile, a strong economy has
resulted in a tight job market. So while small business need to get more from their
employees, their employees is looking for more out of them. Employee reward and
recognition programs are one method of motivating employees to change work
habits and key behaviors to benefit a small business. The types of reward programs
are variable pay (incentives), Business, Profit sharing.
16. PREVENTIVE MANAGEMENT-LOOK FOR IMPROVEMENT
OPPORTUNITIES:
Develops quality assurance plans by conducting hazard analyses; identifying
critical control points and preventive measures; establishing critical limits,
monitoring procedures, corrective actions, and verification procedures, monitoring
inventories.
17. VARIANCE CONTROL SETTING STANDARDS:
Quality assurance is critical than quality control as quality assurance has
responsibility to control the defect in future quality assurance has a role of defining

95
the quality policy and how to follow the policies in better way do that there went be
any issues/defects to customer.
18. BRANCH MAKING OR POSITIVE COMPETITION:
Higher competition is positively correlated with increased management
quality.
INDICATORS OF QUALITY ASSURANCE:
1. Waiting time for different services in the hospital.
2. Medical errors in judgment, diagnosis, laboratory reporting, medical
treatment or surgical procedures, etc.
3. Hospital infections including hospital acquired infections cross infections.
4. Quality of services in key areas like blood bank, laboratories, X-ray
department, central sterilization services, pharmacy and nursing
,
ORGANIZATIONS PROVIDING QUALITY INDEX:
The organizations providing quality indexes are:
AHRQ – Agency for Health care Research and Quality.
IHI – Institute for Health care Improvement.
JCAHO – Joint Commission on Accreditation of Health care Organizations.
NAHQ – National Association for Health care Quality.
IOM – Institute of Medicine.
NCQA – National Committee for Quality Assurance.
AREAS OF QUALILTY ASSURANCE:
The assurances in various key areas are.
1. OUTPATIENT DEPARTMENT:
The points to be remembered are
i. Courteous behavior must be extended by all, trained or untrained
personnel.
ii. Reduction of waiting time in the OPD and for lab investigations by
creating more service outlets.
iii. Provide basic amenities like toilets, telephone, and drinking water etc.
iv. Provision of polyclinic concept to give all specialty services under one
roof.
v. Providing ambulatory services or running day care centers.
2. EMERGENCY MEDICAL SERVICES:
Services must be provided by well trained and dedicated staff, and they
should have access to the most sophisticated lifesaving 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.
3. INPATIENT 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.
4. SPECIALTY SERVICES:
A high tech hospital with all types of specialty and super-specialty services
will increase the image of the hospital.
5. TRAINING:

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 A continuous training programme should be present consisting of ‘on the
job training’, skill training workshops, seminars, conferences, and case
presentations.
QUALITY ASSURANCE PROCESS:
It is the systematic process of evaluating the quality of care given in a
particular unit (or) institution. It is the process of evaluating the outcomes of care
and ensuring that each patient receive a predetermined high standard of care. It
involves the following steps.
a. Setting standards.
b. Comparing these standards to actual practice.
c. Analyzing and interpreting those comparisons.
d. Selecting and implementing action to change practice.
e. Evaluating the effectiveness of these actions.

SETTING STANDARDS

ESTABLISHING CRITERIA OF ACHIEVEMENT

DETERMINING OF CRITERIA HAVE BEEN MET

IMPLEMENTING ACTION PLAN FOR IMPROVEMENT

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 REEVALUATING STANDARDS

SETTING STANDARDS:
A standard is a desired quantity, quality or level of performance with
reference to a criterion against which performance is to be measured. The nursing
profession through the ANA itself has designated generic standards of nursing
practice. In addition, each patient care unit must designated standards specific to the
patient population served. These standards are the foundation upon which all other
measures of QA are based.

For Example:
Every patient will instruments are developed and selected to collect
evidence that indicates standards are being met.
There are three basic forms of nursing audits: structure, process and
outcome. Standards define nursing care customers as well as nursing activities of
structural resources needed. They are used for planning nursing care as well as for
evaluating it.
ASSIGN RESPONSIBILITY:
Assign responsibility to individual or committee.
DELINEATE SCOPE OF CARE:
Develop an inventory including the type of patients served, the conditions
and diagnoses treated, the treatment or activities performed, the type of
practitioners providing care, the site where care is provided. This will provide a
bases for subsequent steps in the evaluation process.
IDENTIFY IMPORTANT ASPECTS OF CARE:
Unit personnel should ask themselves “which of the things we do are most
important?” the answer should lead to identifying important aspects of care
(criteria). Priority should be given to those aspects of care which occur frequently,
affect large number of patients involves
risk or serious consequences or will deprive patient from substantial benefit if the
care is not provided correctly or problematic behavior.
DETERMINING CRITERIA:
Criteria must be determined that will indicate if the standards are being met
and to what degree they are met. Criteria must be general and specific to the
individual unit. A criteria is the value-free name of a variable that is known to be
reliable indicator of quality.
For example: A criterion to demonstrate that the standard regarding care
plan for every patient is being met would be:

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 “A nursing care plan is developed and written by a registered nurse within
12 hrs of admission.” This criterion provides a measurable indicator to evaluate
performance.
DATA COLLECTION:
Sufficient observations and random samples are necessary for producing
reliable and valid information. A useful rule is that 10 percent of the institutional
patient population per month should be sampled. Data collection methods include
i. Patient observations and interviews
ii. Nurses observations and interviews
iii. Review of charts.
EVALUATING PERFORMANCE:
The methods include
i. Reviewing documented records
ii. Observing activities as they take place
iii. Examining patients
iv. Interviewing patients, families and staff.
Records are most commonly used source for evaluation but they are not as reliable
as direct observations. It is quite possible to write in the patient’s chart activities
that were not done or to not record these things that were done. Also, the chart
indicates the care provided but it does not demonstrate the quality of that care.
For the stated criteria example: This step will be: Records would be
examined to determine if care plans were written on each patient within 12 hours of
admission and, if so, that standards had been met.
Another example: To measure quality of the care plan. Every care plan will
include patient education appropriate to the patient’s medical diagnosis, nursing
diagnosis, interventions planned and discharge planning.
PROBLEM IDENTIFICATION:
Analysis and reporting of the data gathered from the evaluation process will
lead to problem identification and isolation and the evidence is gathered through
round, observation and records. The nurse manager’s responsibility is to look for
patterns or trends of deviation from normal, further data collection and analysis
could be done for the identified problems.
PROBLEM SOLUTION:
One problem has been defined and isolated, plans are made to solve them on
a priority bases. Those that are critical, which involves safety and welfare of the
patient take first priority. Other factors use in determining priority will include
severity, frequency, benefit, cost and liability.
The first step is that the nursing unit must determine how much deviation
from the standard is acceptable before changes are made.
In the example of developing a written nursing care plan for every patient as
a standard, the unit should decide if 45 out of 50 patients admitted have a care plan
recorded within 12 hours of admission and the other 5 have recorded care plans
within the next 6 hours, is this deviation acceptable? if not, then how should this be
corrected.
Is the unit short-staffed?
Have there been an unusually large numbers of admissions recently?
Are a number of new graduates being oriented on the unit?

99
 After collecting all pertinent information about the possible causes, the
nurse manager after consultation with staff and / or supervisor should make plans
for correcting deficiencies in performance.
What needs change
- Structural element
- Process element
- Outcome element

MONITORING AND FEEDBACK:

Follow-up on how effective changes have been in improving performance is
very necessary step in the quality assurance process. If in the example prescribed,
the nurse manager found that the next 50 patients had care plans recorded within 12
hours, and then the performance had improved relative to that standard. If it had not
improved, then another approach would need to be taken or possibly, the criterion
should be evaluated for appropriateness for that unit

THE QUALITY ASSURANCE CYCLE:

The quality assurance process is a simple, logical and critical process for
planning and implementing quality assurance activities.

In practice, Quality assurance is 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 step 1-3,
or it may start with small-scale quality improvement activities (step 5-10).
Alternatively, the process may begin with monitoring (step 4). The ten steps in the
Quality Assurance Process are discussed.
1. Planning for Quality Assurance:
This first step prepares an organization to carry out quality assurance
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, products 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 deficiencies.

100
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 management opportunities by
monitoring and evaluating activities. Other means include solieiting suggestions
from health workers, performing system process analyses, reviewing patient
feedback or complaints, and generating ideas through brain storming 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 manifest
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 employee 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 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 interviews, health center register data, staff or patient
interviews, service delivery observations.

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 timeframe and decide
who will be responsible for implementation. It must also decide whether
implementation should begin with a pilot test in a area or should be launched on a
larger scale. The team should select indicators to evaluate whether the solution was
implemented correctly and whether at resolved the problem it was designed to
address. In-depth monitoring should begin when the quality improvement plan is

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implemented. It should continue until either the solution is proven effective and
sustainable, or the solution is effective, the team should continue limited
monitoring.

Step 1: Plan

Step 10 : Implement solution Step 2 : Set standards

Step 9 : Choose and Design solution Step 3 : Communicate standards

plan

Step 8 : Analyse and study Step 4 : Monitor

Step 7 : Identify who will work Step 5 : Identify and prioritize problem
opportunities for improvement

Step 6 : Define Problem

Quality Assurance Cycle

Nursing staff Suspected Hospital

development problem areas quality
assurance

Nursing committees
Standards of
care (a)
Measurement
criteria (b)
Recommendations
for change (e) Quality
care
wheel
Assessment (c)
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 Documented
problems (d)

QUALITY ASSURANCE MECHANISM: Accreditation

certification

Regulatory
Agencies Licensing

Voluntary certification /
Licensing
Accreditation
Standards
Profession
and criteria Peer review

Performance
Institutions Evaluation

Audits

QUALITY ASSURANCE COMMITTEE:

1. Medical Administrator
2. Senior clinicians
3. Pathologist
4. Radiologist
5. Nurse Administrator
6. Medical record officer.

RESPONSIBILITY OF QUALITY ASSURANCE

COMMITTEE:
1. Coordination
2. Information
3. Planning
4. Prodding
5. Consultation
6. Response
7. Search for expertise
8. Follow up
MODELS OF QUALITY ASSURANCE:
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 Nurse is expected to practice in adherence to existing health care delivery
system at national / state ad institutional level within the framework of QUALITY
ASSURANCE MODEL IN NURSING.
Nurses who are trained as per Indian Nursing Council regulations and
registered with state nursing registration councils are safe to provide care. INC has
developed a quality assurance programs for nurses in India. The program is
expected to develop mechanisms for ensuring quality of nursing practice.
Quality assurance model in nursing is the set of elements that are related to
each other and comprise of planning for quality development of objective setting
and actively communicating standards developing indicators, setting thresholds,
collecting data to monitor compliance with set standards for nursing practice and
apply solutions to improve care.
PHILOSOPHY OF QUALITY ASSURANCE MODEL IN
NURSING:
Indian Nursing council believes that nurse will
1. Do good for person / receiver of care, do no harm, maintain respect for life
and human dignity, believe in human justice and fairness to individuals in
terms of access to resources and care and protect the vulnerable.
2. Have moral obligation to provide services as per the prescribed of the
regulatory body / health care system / organization / institution even if it is
in conflict with her personal beliefs and values.
3. Be responsible and accountable for providing quality care in line with set
standards.
4. Be committed to understanding of dynamic nature of his/her role in
interdisciplinary health team.
5. Be obliged to create public awareness and consider social expectations
before making decisions for providing nursing care.
6. Be obliged to include receiver in making choices in planning and
implementation of care.
7. Work in conjugation with legislation, accreditation and political system.
8. Have obligation to promote education of self and others.
9. Be committed to advancement of profession.
PURPOSE OF QUALITY ASSURANCE MODEL:
1. To ensure quality nursing care provided by nurses in order to meet the
expectations of the receiver, management and regulatory body.
2. It also intends to increase the commitment of the provider and the
management.
GOALS OF QUALITY ASSURANCE MODEL:
1. Develop confidence of the receiver that quality care is being rendered as per
assurance.
2. Develop commitment of the management towards quality care.
3. Increase commitment of providers to adhere to set standards for nursing
practice and strive for excellence.
4. Strengthen documentation of nursing care.
5. Promote optimum utilization of resources in providing cost effective nursing
care.
1. A SYSTEM MODEL OF QUALITY ASSURANCE:

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 A systematic model for implementation of unit based quality assurance. The
basic components of the system are.
1. Input
2. Throughput
3. Output
4. Feedback
Input: can be compared to the present state of the system.
Throughput: The throughput to the developmental process
Output: To the finished product
Feedback: it is the essential component of the system because it maintains and
nourishes growth.

INPUT PROCESS OUTPUT

Previous Structural
Quality changes Unit
Assurance
Programme

FEEDBACK

2. AMERICAN NURSE’S ASSOCIATION (ANA) MODEL:

This model is given by long and black in 1975. This is the first proposed and
accepted model of quality assurance, which was meant for nursing profession but
was used by various other professional in the health care. This is a cyclical model.
It helps in self-determination of patient, and family, nursing health orientation,
patient’s rights to quality care and nursing contributions.

Identify
Evaluate
structure,
outcome of
standard
standards and
and criteria
criteria
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 Apply the process,
standards and criteria

The basic components of ANA model are.

Structure,pr
ocess,outco
me

1. IDENTIFY VALUE:
In the ANA value identification looks as such issue as patient/client,
philosophy, needs and rights from an economic, social, psychology and spiritual
perspective and values philosophy of the health care organization and the provider
of nursing services.

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2. IDENTIFY STRUCTURE, PROCESS AND OUTCOME STANDARDS
AND CRITERIA:
Identification of standards and criteria for quality assurance begins with
writing of philosophy and objectives of organization. The philosophy and
objectives of an agency services to define the structural standards of the agency.
Standards of structure are defined by licensing or accrediting agency. Another
standard of structure includes the organizational chart, which shows supervisory
methods, communication patterns, staff patterns and sometimes staff assignment. A
group internal or external to the agency does evaluation of the standards of
structure.
The evaluation of process standards is a more specific appraisal of the
quality of care being given by agency care provider. An agency can choose to use
the standards of care set forth by the provider professional organization such as the
ANA nursing standards or the agency can use the nursing process and apply it to
the activities of the nurses and the activities correspond to the procedures of care
defined by the agency. The primary approaches for process evaluation include the
peer review committee and the client satisfaction survey. The techniques included
are direct observation, questionnaire, interview, written audit and videotape of
client and provide encounter.
The evaluation of outcome standards reveals the end results of nursing care.
To be able to identify the net changes in the client’s health status as a result of
nursing care will give nursing profession data to show the contributors of nursing to
the health care delivery system. Research studies using the trace method or the
sentinel method to identify client outcomes and client satisfaction surveys are
approaches that may be used to evaluate outcome standards. Technique used is
client classification systems that are admission data on the client’s level of
dependence or problems and discharge data that may show changes in the level of
dependence.
3. SELECT MEASUREMENT NEEDED TO DETERMINE DEGREE OF
ATTAINMENT OF CRITERIA AND STANDARDS:
Measurements are those tools used to gather information or data, determined
by the selections of standards and criteria. The approaches and techniques used to
evaluate structural standards and criteria are nursing audit, utilization’s reviews, and
review of agency documents, self-studies and review of physicals facilities. The
approaches and techniques for the evaluation of process standards and criteria are
peer review, client satisfactions surveys, direct observations, questionnaires,
interviews, written audits and videotapes. The evaluation approaches for outcome
standards and criteria include research studies, client satisfaction surveys, client
classification, admission, readmission, discharge data and morbidity data.

4. MAKE INTERPRETATIONS:
The degree to which the predetermined criteria are met is the basis for
interpolation about the strengths and weaknesses of the program. The rate of
compliance is compared against the expected level of criteria accomplishment.
5. IDENTIFY COURSE OF ACTION:
If the compliance level is above the normal or the expected level there is
great value in conveying positive feedback and reinforcement. If the compliance
level is below the expected level, it is essential to improve the situations. It is

107
necessary to identify the cause of deficiency. Then, it is important to identify
various solutions to the problems.
6. CHOOSE ACTION:
Usually various alternative course of action are available to remedy a
deficiency. Thus it is vital to weight the pros and cons of each alternative while
considering the environmental context and the availability of resources. In the
recent that more than one cause of the deficiency has been identified, action may be
needed to deal with each contributing factor.
7. TAKE ACTION:
It is important to firmly establish accountability for the action to be taken. It
is essential to answer the questions of who will do? what? By when. This step then
concludes with the actual implementation of the proposed courses of action.
8. REVALUATION:
The final steps of QA process involves an evaluation of the results of the
action. The reassessment is accomplishment in the same way as the original
assessment and begins the QA cycle again. Careful interpretation is essential to
determine whether the course of action has improves the deficiency or the
deficiency was remedied, positive reinforcement is offered to those who
participated and the decision is made about when to again evaluate that aspect of
care. If the deficiency is not remedied, the problem solving process is repeated.
Thus according to this model all the 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 observation and events of the previous
stage influence the decision to be made, and action to be undertaken in the next.
The cycle is known as “Open” system. This openness is necessary to allow for the
idea of continuous quality improvements. Today’s highest possible standards may
not satisfy the consumers and professionals of tomorrow.
3. DONABEDIAN MODEL (1985)
Donabedian quality framework is recognized as a method of measuring
quality as structure, process and outcome in the mid of 1960s. Structure leads to
process, and process leads to outcome. This linear model has been widely accepted
as the fundamental structure to develop many other models in Quality Assurance.
Outcomes reflect the results of the application of structures, and processes in
a specific health care setting. Structure may directly influence outcome.
According to model, ‘structures’ include the adequacy of health care
facilities, the qualifications of practitioners and the financial aspects of care. The
‘processes’ were the aspects of care. And ‘outcomes’ are the precise and concrete
measurements of effectiveness of care.

Structure Process Outcome

Facility, resources, Standards, Client’s health

personnel mix, attitude, nursing care, goals met,
and skills client care plan, efficiency and
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mix. effectiveness, effectiveness of
client satisfaction. services.
4. QUALITY HEALTH OUTCOME MODEL:
Mitchell and colleagues (1998) proposed this model. The quality health
outcomes model includes the client in the model and proposes a two dimensional
relationship among component interventions always act through the system and the
client, creating a dynamic model. According to this model there are dynamic
relationships with indicators that not only act upon, but also reciprocally affect the
various components. A master curriculum of other models is that they do not lend
themselves to the population focus of community health nursing. However, this
model includes community as a client.

System

Individual, group, organization

Intervention Outcome

Client
(Individual, Family and Community)

5. FOCUS-PDCA Model (Quality Management Model)

It was devised in 1930, which has the following concepts Find, Organize,
clarify, understand. find a process to improve, organize a team that knows the
process, clarify current knowledge of process, understand causes of variation.
It is an improvement model advocated by Dr. Deming which is still
practiced widely that contains a distinct improvement phase.

109
 Use of PDSA model assumes that a problem has been identified and
analyzed for it’s 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.

Plan

Schewar
A t cycle
ct D
o

Che
ck

PDCA Cycle

6. SIX SIGMA:
It refers to six standard deviations from the mean and is generally used in
quality improvement to define the number of acceptable defect 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:
Process that are performing in a predictable way at a desirable level are in
control.
7. QUALITY MANAGEMENT MODEL:
This model of quality management was given by OBRA (Omnibu Budget
Reconciliation Act, 1987). This model is based on Theory Q, because it contains
two fundamental ideas about cause and effect in long term care (a) the higher the
quality of care received by the patient, the higher his or her level of functioning (b)

110
the higher the level of quality of life experienced by the patient, the higher his or
her level of experiences.
There are three dimensions in this model: assessment, care planning and
functional outcomes that can be observed by care givers and managers. Outcome
information is then feedback and compared with standards. The circle represents
this when the (+) sign indicates that outcomes might exceed standards and the
minus (-) sign that outcomes might fall short of standards.
If outcomes fail to ‘measure up’ to standards, quality assurance activities are
initiated. These results in changes in one or more of the steps to better fit care plans
and services to patient’s needs. However, patient’s outcomes show that standards
are met or exceeded, quality assurance can reallocate organization resources to new
patient goals or to services delivered to other clients.
Assessment Care planning Service delivery

Quality assurance -+

Standards
Casual flow
Control flow
Comparison Quality Management Model

8. QUALITY CARING MODEL:

Quality caring model reflects the trends towards evidence-based practice
while simultaneously representing unique contribution of nursing to quality health
care.
The model integrates biomedical and psychosocial-spiritual factors
associated with quality health care. This model is grounded in the works of
Donabedian and Watson and influenced by contribution from King, Mitchell and
Irvine. The overriding structure-process-outcomes components are blended with
major constructs in Human Caring Model and provide the central components of
the model. It has three components: structure, process and outcome.

Structure:
It is blended with construct, casual past and includes the participants as
concept. It includes the factors that are present prior to the delivery of health care.
These factors are related to (i) patient / family (ii) various health care providers and
(iii) health care system. Each factor has its sub-concepts. The concepts and sub-
concepts included in the structure component influence the process of care and may
directly or indirectly influence outcomes of care.
Process:

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 It involves interventions or practices that health care provider offers and is
the focus of this model. Caring relationship dominates the process and establishes
the groundwork for the two relationships, (ie) independent relationship and
collaborative relationship. Independent relationships include those patient/family
nurse interactions and collaborative relationships include those activities and
responsibilities that nurse’s share with other members of the health care team.
Outcomes:
This component corresponds to the future construct of the Human Caring
Model and refers to the end result of health care. These outcomes are related to
positive results of the interventions on the part of health care provider, patient and
health care system. Intermediate outcomes include the goals or the care plans and
clinical pathways but can also include feelings about the health care process. There
are reciprocal interactions between intermediate outcomes and terminal outcomes.

9. PERFORMANCE MANAGEMENT SYSTEM PARADIGM

An organization-wide performance management system derives three
critical programs awareness, measurement and improvement.

Performance
measurement
programme

Performance
Performance
improvement
awareness
programme
programme

Performance
management
system

AWARENESS
In this program, all the customers and stakeholders are educated to the
standards involved in the organization’s three domains of service, practice and
governance.
Measurement
A program that delineated exactly how measurement of key functions and
critical processes will occur in the three domains and how the data will be used to
reduce errors and calculate the cost of nonconformance.
Improvement
A program that will delineate expected outcomes in each domain and
benchmark success against indicators.

112
 In this way, the organization will be able to develop standards in all three
domain, can create and utilizes valid and reliable data from all departments and also
able to create a systematic method for continual organization-wide performance
improvement.
10. MARKER’S UMBRELLA MODEL
The marker model is a system for providing continuity, consistency and
competency in clinical patient care. The goal is to provide the above by developing
a structure to standardize professional nursing clinical practice, while maximizing
patient outcomes, preventing untoward occurrences, and controlling healthcare
costs. The model describes connecting characteristic for a comprehensive quality
assurance model are
i) standard development
ii) continuous advanced training
iii) Confirmation of technical authority
iv) Evaluation of the execution of cares measures
v) Examination
vi) Parallel examination
vii) Risk Management
viii) Control of the demand resources
ix) Active problem identification
Active (1987) using a hierarchical concept provides a framework for dividing
nursing standards into three categories: Structure, process, and outcome. The main
focus of this model is maintaining current competency, creating new competence or
responding to a quality assurance corrective action. She also suggested all programs
be tracked and monitored in conjunction with the program’s purpose.
11. MAXWELL SIX DIMENSION MODEL (1984)
The model is applicable in current situation is Maxwell six dimension
model. Maxwell (1984) has been a major influence on the development of
framework for quality assurance in health care. He identified six dimension of
quality in the health services. They are
1. Relevance in the needs.
2. Equity
3. Accessibility (Access to service)
4. Effectiveness
5. Acceptability (Social Acceptance)
6. Efficiency and Economy

12. WILSON’S MODEL (1987)

Wilson (1987) in the late 1980’s tried to operationalize Donabedian model
into a tangible and practical form. He redefined it as inputs, methods or procedures
and outcome. He described ‘inputs’ as people (personal), equipment and
environment (i.e.) the resources needs to attain a defined level of care ‘Methods’ or
procedures became the everyday practice that is required, (i.e.) the professional or
technical skill or expertise. Outcomes are the targets of care or services as measured
by productivity, quality and client satisfaction.
‘4’ Essential components of Quality Assurance according to Wilson.
i) Setting objectives
ii) Quality Promotion
iii) Activity Monitoring

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 iv) Performance assessment
13. OMAHA SYSTEM:
Omaha system has measurement approaches that make it a useful model for
determining the quality of nursing care provided to individuals, families and
communities. Evaluation focuses on process indicators, client outcome measures
and satisfaction with care with the use of this comprehensive. In this model
outcomes are rated in terms of knowledge and status. This approach allows for
qualifying a range of security as well as progress toward or away from optimal
health on going maintain of there departs as they relate to individual, family
community problems allows for evaluation of nursing interventions a necessary
component of both quality assurance and outcome arrangement.
For instance, individual evolved in a 6 week health promotion program on
weight management can be assured initially for this knowledge of healthy eating
and exercise their current behaviors relative to both and their current status (e.g.
body mass index). The outcome of the program can be assessed by measuring the
same indicators and then comparing the initially obtained individual and aggregated
data with data collected after the programme is concluded. Whereas individual
positive changes, such as decreased BMI, are a positive indicator, the impact on the
entire group is of even more importance in forms of community level health status.
14. QUALITY ASSURANCE AND JCAHO (Joint commission on Accreditation of Healthcare
Organizations)
In the year 1980, JCAHO recognized the deficiencies of retrospective the
chart review audit, JCAHO developed a new approach to quality assurance. During
the early 1980’s JCAHO developed and revised the quality assurance standards.
The focus shifted from a passive retrospective review system to a systematic
active search for deficiencies in client care. Additionally, JCAHO stressed that any
type of audit was permitted outcome, process or structural, so long as it achieved
the goal of identifying the problems to be rectified.
In the year 1984, further reinforcement of the JCAHO standards resulted in
the development of a systematic, planned and ongoing monitoring program.
THE ESSENTIAL COMPONENTS OF THIS NEW PROGRAMME ARE
1. Identification of important or potential problems or related concerns in the
patients.
2. Objective assessment of the cause and scope of problems or concerns,
including the determination of priorities for both investigating and solving
them.
3. Implementation-by appropriate individuals or through designed mechanisms
of decisions or actions that are designed to eliminate in so far as possible
identified problems.
4. Motivating activities designed to ensure that the desired result has been
achieved and sustained.
5. Documentation that reasonably substantiates the effectiveness of the overall
problem to enhance patient care and to assure sound clinical performance.
JCAHO and observation of Problem Areas
1. Complaints from clients and families
2. Reports of conflicts among professional staff members.
3. Unplanned returns to the operating room.
4. Unplanned transfers to other hospitals.
5. Unplanned admission to the critical care units.

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 6. Mishandling the emergency situations eg: cardiopulmonary arrest
7. Problematic situations in house emergency.’
8. Clients learning against medical advice.
9. Cancelled surgeries, repeated X-rays and laboratory tests.
10. Injuries, accidents or incidents.
JCAHO’S 10 steps of Quality Assurance
1. Clear assignment of responsibility.
2. A delineation of the scope of care for each practitioner.
3. An identification of the important aspects of care.
4. Specific indicators of care.
5. Establishment of thresholds for evaluation based on customer expectation.
6. Collected and organize data to monitor important aspects of care.
7. Evaluation of care.
8. Actions taken to solve problems and improve the care.
9. Assessment of those actions and documenting the improvement.
10. Communication of relevant information to the organization to broaden the
quality assurance program.
The Rush Model adds an eleventh step to address the lack of continuity of 10-step
model. The 11th step is: Continuous monitoring / improving the process.
JCAHO QUALITY ASSURANCE MODEL
Delineate scope  Hospital Infection control
 Incidence
Identify Important aspects of HAI  Awareness
 Administrative and clinical setup
 Training requisites
Identify Indicators  Implementation
 Structure, process and outcome
criteria
Establish standards for evaluation  Such as <2% incidence of HAI
for all procedures surgical
operations / Patient admissions
Cooect data
Compare with standards  Identify areas of improvement

 Take corrective measures

Attained Not Attained

Enhance standards

JCAHO QUALITY ASSURANCE

GUIDELINES/STEPS:
Founded in 1951, JCAHO has become the largest accrediting organization
in health care today. In 1980’s quality assurance was introduced into the JCAHO
accreditation standards with emphasis on a problem solving approach.
1. Assign responsibility:
According to the joint commission, “The nurse administrator is ultimately
responsible for the implementation of a quality assurance program. Completing step
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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 (ie)
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.
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.

15. ISO QUALITY ASSURANCE MODEL

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 11.Continual improvement of the quality management system

10Informati Customer
8Management
Customer on s
Responsibility
s
Act
Plan
7.measuremen
9.Resource t analysis and 6.satisfact
Managemen improvement ion
t check
Do 5.Output
2.Input 4.Produ
1.Require 3.Product ct customers
ment Realiation

15. Omaha system

Omaha system patient classification scheme-offers nurse a holistic,
standardized method for client assessment and nursing diagnosis and problem
identification. Intervention scheme-provides a framework for documenting plans
and intervention in the client record. Supervisory shared visit tool-a supervisor’s
evaluation instrument. Problem rating scales for outcomes-used to document client
progress in the record and during case conferences.

Omaha system has a measurement approach that makes it a useful model for
determining the quality of nursing care provided to individuals, families and
communities. Evaluation focuses on process indicators, client outcome measures
and satisfaction with care with the use of this comprehensive. In this model
outcomes are rated in terms of knowledge and status. This approach allows for
qualifying a range of security as well as progress toward or away from optimal
health on going maintain of there departs as they relate to individual, family
community problems allows for evaluation of nursing interventions a necessary
component of both quality assurance and outcome arrangement.
For instance, individual evolved in a 6 week health promotion program on
weight management can be assured initially for this knowledge of healthy eating
and exercise their current behaviors relative to both and their current status (eg
body mass index). The outcome of the program can be assessed by measuring the
same indicators and then comparing the initially obtained individual and aggregated
data with data collected after the programme is concluded. where as individual
positive changes, such as decreased BMI, are a positive indicator, the impact on the
entire group is of even more importance in forms of community level health status.

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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.

i. Approaches for measuring the quality of nursing practice

ii. Practice documentation and data management orientation
iii. Case conferences
iv. Shared evaluation visits and observations
v. Practice based in-service education
vi. Record ,audit ,peer review and utilization review
vii. Accreditation and external audit
viii. Client satisfaction services

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 a ‗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

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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.

BARRIERS OF QUALITY IMPROVEMENTS EFFORT

1. The nurse manager might become preoccupied with quality assessment.
2. It is impossible to identify all factors that influence nursing care quality.
3. Difficulty in defining outcome criteria that result solely from nursing
intervention.
4. Nurse’s documentation of care measures is at times vague, incomplete and
lacking in objectivity.
5. There is still no single, all purpose, all site quality assessment tool that is
universally appropriate for all health agencies.
6. Primary barriers in implementing effecting quality improvement is cost. The
cost of providing high quality care is very high whereas payments by clients
are decreased and increased cost of doing business. Quality improvements
also include cost effective care. Factors that influence the cost are high cost
of supplies, labor costs of staff, cutting down the cost of supplies and
manpower cost can also cause errors rather than quality.
7. Other barriers are tradition and failure to realize the changes that are needed.
8. Authoritative leadership style, do not value innocators.
9. Many practicing nurses resist to change because it seems threatening.
10. Lack of evidence based practice.

DEVELOPMENT OF QUALITY ASSURANCE PROGRAM

This program is a carefully planned, phased process, or it may be
implemented in one step as part of a fundamental organizational change.
Foster commitment to Quality
This process must continue throughout the life of a project and at all levels
of the organization. Commitment can be done through awareness raising seminars,
special planning meetings, or one-to-one discussion with an organizations later.
Conduct a preliminary review of quality related activities
It is important to conduct an initial review of the organization and to
develop a general description of the existing system.
Develop the purpose and vision for the Quality Assurance effort
Purpose is to build consensus between mangers and to set boundaries for the
quality assurance effort. The vision will help the staff to understand how their day-
to-day work relates to quality improvement.
Determine level and scope of Initial Quality Assurance Activities
It depend on the resources available the implementation time frame and the
receptivity of management and program staff to the idea of quality assurance. The
effort can be implemented at national, regional and district level or within a single
health agency.
Assign Responsibility for Quality Assurance
An Existing committee or management body will take on responsibility for
quality assurance, integrating it into the general management structure.
Allocate Resources for Quality Assurance

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 Local resources must be allocated to quality assurance programme to
become a permanent part of a health care organization. it may depend on outside
technical and financial assistance.
Develop a written Quality Assurance
This plan is a written document that describes the programme objectives and
scope, defines lines of responsibility and authority, and puts forth implementation
strategies. The plan helps the staffs to relate quality, goals and objective to their
routine activities.
Critical Management System
Quality assurance efforts will focus three critical management systems.
Supervision, training and management information systems.
Disseminate Quality Assurance Experience
Dissemination strategy should be devised to share experience inside and
outside the organization conferences which conduct at local, regional, national and
international level will reinforce success encourage dialogue and creativity.
Manage change
A careful, phased approach to change is required and an open and tousling
environment must be cultivated.
ROLE AND RESPONSIBILITIES OF A NURSE
ADMINISTRATOR IN DEVELOPING QUALITY ASSURANCE
SYSTEM
With present day focus on preductivity, it is necessary that although
appropriate and full utilization of personnel is important, it is equally nursing care is
provided in our hospitals. Through development of quality assurance program, the
nursing profession assumes the responsibility of self-evaluation and self-regulation.
Such professional accountability can only lead to improvement inpatient care and
validation of nursing contributions within the institution. Nursing is not an isolated
work for the patient and / or family. It is the plays activities rendered in cooperation
and coordination with other health team members so organization climate vital role
in developing a quality assurance program in her hospital. She participates in the
following steps as suggested for ensuring quality of nursing care.
1. Deciding upon the philosophy.
2. Make certain that you as well as your nurses know what you wish to
evaluate and why.
3. Formulate objectives
4. Set standards
5. Enlist expert guidance
6. Plan carefully and select the evaluation tools suitable to the unit.
7. Work cooperatively
8. Publish the report of the results of evaluation of care.

FACTORS AFFECTING QUALITY ASSURANCE IN

NURSING CARE:
1. LACK OF RESOURCES:

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 Insufficient resources, infrastructures, equipment, funds to meet the
minimum needs of patients, are major factors which affect the quality care.
2. LACK OF QUALIFIED NURSING PERSONNEL:
Lack of qualified skilled nurses, lack of motivation, in disciplined
organization climate affect the quality care.
3. UNREASONABLE PATIENTS AND RELATIVES:
Illness, anxiety, absence of immediate response to treatment, sometimes
lead to uncooperative attitudes from patient and significant others which ultimately
affect quality care.
4. IMPROPER MAINTENANCE:
Buildings and equipment’s require proper maintenance for efficient use. If
not maintained properly the equipment’s cannot be used in giving nursing care. To
minimize equipment down time it is necessary to ensure adequate after sale service
and service manuals. The building especially leakage of roofs, cleaning of
bathroom, toilets and wards have to be maintained properly otherwise patient may
develop hospital acquired infections.
5. ABSENCE OF WELL INFORMED POPULATION:
To improve quality of nursing care, it is necessary that the people become
knowledgeable and asset 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
(a) Inspect hospitals and ensures that basic requirements are met.
(b) Enquire into major incidence of negligence.
(c) Take actions against health professionals involved in malpractice.
7. LEGAL READERS:
Laws or torts in the hospital settings are very less applicable to the nursing
profession for their quality of care, and do not exist practically. Thus the
professional behavior may affect the quality of care.
8. LACK OF INCIDENT REVIEW PROCEDURES:
During a patients hospitalizations reveal incidents may occur which have a
bearing on the treatment and the patients final recovery. These critical incidents
may be
(a) Delayed attendance by nurses, surgeon, and physician.
(b) Barriers assisting out of faculty procedures. (Incorrect Medication)
(c) Burns arising out of faculty procedures
(d) Death in a corridor with no physican/Nurse accompanying the patient.
9. LACK OF GOOD HOSPITAL INFORMATION SYSTEM:
A good management information system is essential for the appraisal of
quality of care.
(a) Workload, statistic, admission, bed occupancy, procedure, length of stay.
(b) Activity audit, scheduling of procedures, lost list/procedures in critical
areas.
These information should be accurately informed.
10. ABSENCE OF PATIENT SATISFACTION SURVEYS:
Ascertainment of patient satisfaction at fixed points on an ongoing basis.
Such surveys carried out through questionnaires, interviews by social worker,

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hospital management trainers, consultant groups and help to document patient
satisfaction with respect to variables that are
(a) Delay in attendance by nurses and doctors
(b) Incidents of incorrect treatment.
11. LACK OF NURSING CARE RECORDS:
Nursing care records are perhaps the most useful source of information on
quality of care rendered. The records
(a) Detail of the patient condition.
(b) Document all significant interaction between patient and the nursing
personnel.
(c) For information regarding response to treatment nurses should use problem
oriented record system or use nursing process while recording the care given.
(d) Have the dates in an easily accessible form.
12. MISCELLANCEOUS FACTORS:
i. Lack of good supervision
ii. Substandard education and training
iii. Lack of policy and administrative manuals.
iv. Improper job description of the nurse.
v. Lack of adequate nurse administrator
vi. Shortage of trained nurses in hospital.
vii. Lack of supplies and equipment in hospital.

ISSUES AND QUALITY ASSURANCE IN NURSING

1. Mushrooming of nursing colleges without essential infrastructure.
2. Numerous categories of the nurses (e.g.) ANM, Diploma nurses, Diploma
Nurse, Graduate Nurse etc.

NEW TRENDS
1. Quality council
2. Quality health care
3. Concurrent monitoring
4. High risk assessment
5. Standard of quality care
6. Interdisciplinary quality assurance
7. Automation of data sources
8. Performance of the staff
9. Managed care
10. Evidence based practice.
Quality council:
The interesting development in quality assurance programme is the use of
quality council. The council is a governing body that oversees the quality of care
patients receive. The council would be responsible for developing standards and
assessing and monitoring the quality of care that patient receive.
Quality health care:
Professional nursing plays an important part in future health care delivery.
Regulating the approaches review that quality, quantity, and cost of hospital care
provided through Medicare. Instead, in patient hospital based services for Medicare
clients are paid a fixed amount based on diagnosis or condition. The aim of

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capitation is to build a payment plan to select the diagnosis or surgical procedures
that includes the best standards of care, including essential cost-effective diagnostic
and treatment procedures at lowest cost. A managed care organization bears
financial risk in addition to provide the client care. Successful health promotion
programs, such as those found in nursing centers, schools and community clinics
are designed to help the clients to acquire healthier lifestyles and achieve a decent
standard of living. Continuing care describes a collection of health personnel and
social services provided over a prolonged period to persons who are disables, who
were never functionally independent or who suffer a terminal disease.
Concurrent monitoring:
Intermittent assessment of quality does a lot to improve nursing practices.
Earlier the primary focus was on presence or absence of documentation. But the
presence of documentation might be a prony to the fact. Concurrent monitoring
provides a more scope to the best quality care.
High volume case assessment:
High volume cases are easy for nursing service to identify. One way to
assess high volume cases is to look at hospital utilization data. If medical patients
are admitted for cardiac problems, it is logical to monitor the care of cardiac
patients.
High risk assessment:
Aspects of care in which there is high risk to the patient are monitored.
Eg.
Patient falls
Medication errors
Standard of quality care:
Standard of quality care are used as guidelines for the development of
monitors. The use of standard in the evaluation of care will have positive effect on
the assurance of quality.
Interdisciplinary quality assurance:
The increased complexity of care often required the services of multiple
health care professionals but no one discipline is totally responsible for patient
outcomes multidisciplinary quality assurance activities are required for the ultimate
quality of patient care.
Automation of data sources:
Incident reports, direct observation and patient interview has been explored
now as data source for quality assurance studies. Earlier patient record was the
primary data source, but it was time consuming and also may not accurately reflect
the quality of care that patient receives.
Performance of the staff:
One of the basic ways of ensuring the quality of patient care is competent,
capable and caring. Ensuring competence require the development of structure and
process standard in four areas
Entry requirements
Performance expectations
Continuing education
Performance appraisal.
Managed care:
The managed care organization’s quality program administration including
its quality assurance plan, work plan, quality studies and activities, organization and

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staffing, credentialing program, medical records management, delegated activities
and quality of care complaints.
Evidence based practice:
Evidence based practice (EBP is the conscientious and judicious use of
current best evidence in conjunction with clinical expertise and patient values to
guide health care decisions.

ROLE OF NURSE
1. Professional nurses have an obligation to ensure that the care they provide is
evidence based.
2. Ensure service provide is based on “consumer centered”.
3. Provide quality care to the individual and to the public in reality with the
desired outcome.
4. Care provided should be consistent with current professional knowledge.
5. Functions as leader and Managers in various health care settings which
provide quality care.
6. Responsible to promote standards, measurements and involve in continuous
quality improvement.
7. Effective care to the clients should be the primary focus of all nurses
8. Initiator- creates an awareness or sensitizes the nurses about the importance
of quality assurance.
9. Facilitator
She facilitates to develop, implement, monitor and evaluate standards for
nursing practice at all times.
10. Co-ordinator
She coordinates the different units of quality assurance programmes
and co-ordinates the activities with the hospital quality assurance
programme.
11. Educator
She gives orientation to nursing personnel regarding the need for standards
and auditing of nursing service.
12. Leader
She communicates the quality message to all the staff members.
13. Evaluator
She evaluates the implementation of standards for nursing practice.
14. Supervisor
She supervises the activities of different committees she supervises the
nurses at first and second level leadership positions.

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APPLICATION IN EDUCATION AND SERVICE
EDUCATION
1. Helps to support teachers and build expertise and capacity in the education
system.
2. Helps to raise standards and expectations, and levels of consistency across
teachers and schools.
3. Staff uses a wide range of activities like monitoring, self-evaluation and
planning for improvement.
4. Provides assurance to parents and others that all learners receive appropriate
recognition.
5. Responsible for the internal verification of their assessment (accurate and
consistent).
SERVICE
1. Patients will be more confident in services.
2. Satisfy customer needs.
3. Information can be collected through patient surveys, regulators, audits, user
groups, performance indicators and bench marking.
4. Ensure everyone’s opinion and take all viewpoints and needs into
consideration.

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5. Quality standards are set at many levels, including within organizations and
departments.
6. Apply improved quality assurance measures.
7. Ensure high quality of work is everyone’s responsibility.
8. It is vital to monitor performance.
9. Need to make towards improving or maintaining quality within the
organization.
IMPLICATIONS TO NURSING SERVICE
10. The nursing superintendent is responsible to introduce and maintain
standard of care in nursing service. She uses various control mechanisms to
have a check on the standard of care. She works with her assistants and
departmental heads-all co-operating in keeping up the standard in every
patient care area.
11. The nursing superintendent should see that all the nursing staff
selected are registered with the state nursing council and are licensed to
practice. She must introduce mechanisms whereby all the documents
submitted by those candidates who are recruited are checked carefully for
genuineness of the documents.
12. The nursing service policies which reflect the philosophy of the
department and the organization as a whole, written in accordance with the
policies of the organization, should be made available to all the nursing
personnel especially to nurses who joined the institution newly. The
procedure manual should be available in all patient care areas. All nursing
staff follow the same methods in performing certain procedures to help
maintain standard.
13. The hospital of which the nursing service is a part may seek
accreditation in which case nursing service department also will be
accredited. The nursing superintendent should provide all facilities and
services the accreditating agency requires. She should take corrective action
to rectify lacunae as given in the accreditation report. The nursing
superintendent can introduce evaluation devices to assess the performance
of the staff and to evaluate the quality of care given.
14. To evaluate the nursing care through a review of patient’s records,
the nursing superintendent establishes nursing audit. She selects an audit
team and ensures training is given to the team. The team schedule nursing
audit in each patient care area, point out deficiencies and see that corrective
actions are instituted.
15. Nurses must keep updating their knowledge and skill to provide
quality nursing care. Continuing education programmes in service education
programmes are a means to keep current with the new knowledge and skill.
The nursing superintendent establishes a continuing education programme
department which schedules CE programmes the year round, in consultation
with the department of nursing service.
16. Scheduling the CE programme may be done jointly by nursing
service department and school/college of nursing. Both these departments
co-ordinate to plan the CE programme for the whole year-usually one topic
per month. They decide on the topic based on the need and current
development. The faculty members and senior nursing service staff will be

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 assigned the topics. All times an expert from outside may be invited to
handle a specialized topic.
17. Nursing rounds provide an excellent opportunity for bedside
learning.
18. Relevant and adequate documentation in nursing reflect good
nursing care. As a person in charge of nursing service department, the
nursing superintendent helps to maintain standard of care through proper
keeping of reports and records. A part from documentation of care in the
patient’s records, there are various other records maintained like medication
record including dangerous drug record, inventories of supplies, equipment,
linen, etc. client record, admission, discharge record, repairs and
maintenance record etc. Maintaining all the necessary recording and proper
reporting is essential for quality nursing care. In each unit the ward-in-
charge or a senior staff nurse checks the records to see that they are
maintained.
19. The nursing superintendent should emphasize use of quality
assurance means which focus on processes rather than which focus on
processes rather than output, which ensure that outputs achieve the required
quality. She must develop standards for nursing service with the criteria
outlined in terms of the structure of the services provided. She must ensure
facilities, equipment and personnel are adequate to provide quality nursing
care to patients. Periodical performance appraisal of the staff will help them
to know their level of performance and to take steps to strengthen work
areas. Appraisal by one’s professional colleagues of equal professional
status helps one to see oneself through the eyes of colleagues. Suggestions
for improvement given by professional colleagues usually are well taken.
Quality Patient care scale, when used helps to identify any shortfalls in the
care given and to take corrective action so as to maintain standard of care.
20. The nursing superintendent should encourage nursing rounds and
introduce a system of nursing rounds in all patient care areas. Regular
nursing rounds taken place during shift changes when nurses going off duty
handover the responsibility of care to nurses who are taking over.
21. Periodically, the ward-in-charges makes rounds with the nurses and
reviews care. It also provides opportunity for her to talk to patients and
listen to their complaints.
22. Similarly the departmental head may make rounds with the ward-in-
charges and review care being given. The clinical instruction or ward-in-
charge may make rounds with the students to discuss at the beside the care
of the patients assigned to the students.

23. Attendance at CE programmes is made mandatory. The CE

department works with the departments of nursing service to ensure nurses
are free to attend the CE programs to ensure that all nurses attend the
program, a particular parogramme may have to be schedules twice or thrice.
24. Promotion of nursing staff may be based on the attendance at CE
programmes apart from Performance Appraisal results.

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CONCLUSION
Hospital administrators and professionals must strive towards bring about,
the needed changes, adoption of quality assurance programmes, laying down
minimum standards for hospital professional. The nurse should work and come
forward to improve the quality of the nursing education and service.
Quality Assurance is the responsibility of professionals. They execute all the
actions concerned with attaining quality. Health care industry has a greater
obligation to promote and maintain quality. A quality system enables a health care
organization to ensure quality assurance. Mounting health care cost are another
factor which may be questioned. Proper Quality Assurance programme in health
care industry will answer this and promote cost effective health care to the
community.
The quality assurance effort must include nurses, physicians, administrators,
technicians, laboratory staff in short, the representatives of every major department.
Quality assurance committees have been established to bring everyone together and
10 ordinate the detection of finding resolution of problems encountered. They have
become a part of the effort to control the cost, to function the hospital efficiently
and provide the quality of expected.

STANDARD
INTRODUCTION:
“Agreed way of doing something’’.

S – Successful termination of helping relationship for client.

T – To have clear idea or conception of the distinct goal, nursing the patient and
health needs of society.
A – Assertive planning.
N – Nature of client nurse interaction
D – Directing others
A – Analytical thinking
R – Respect status and policies
D – Data collection in accordance with goal quality care. The standards provide the
yardstick for measuring.

A standard is a level of quality or achievement, especially a level that is

thought to be acceptable.
As a result of technological advancements, demand for highly specialized
staff, changing facility requirements and consumer’s awareness and demands, the
health care over the world is becoming progressively complex and expensive. Thus
demands careful evaluation of how we are doing. This demands development
understanding and use of hospital performance .Standards are becoming an
important part of health care and have taken a new prominence in the trend to
address quality of care issues, as it is being demanded and expected and providers
are judged by it. Each day the cost of health care is rising and resources are scare. It
is realized that nursing among all health care professions has the greatest potential

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for maintaining cost effectiveness. It is the standards through which the
organization translates quality into professional terms and allows the organization
to measure its level of quality. A professional characteristics framework forms the
foundation for the standards.
Nurses have been leaders in the field of standards development. Since
nursing is the largest health profession providing care to individuals, families,
groups, communities and populations in a multiplicity of settings standards have an
important role in guiding nursing practice. Standards enable nurses to promote safe,
competent and ethical practice. Today nurses are developing standards at a variety
of levels and in a range of settings.
Indian nursing council has made efforts on developing and testing of
standards for maintaining uniformity in nursing education and in nursing practice.
There is still a need to establish, monitor and enforce standards of professional
practice and conduct in India.
The standards maintained and the nursing audit conducted hence, become
the important tools for the quality management.

DEFINITION:
Standard:
1. Standard might simply be, defined as ‘a set of rules for ensuring quality’.
2. The term standard is sometimes used to describe protocols, standard
operating procedure, specifications, criteria for practice, and clinical
practice guidelines.
3. 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.
4. Standard is a predetermined baseline condition as level of excellence that
comprises a model to be followed and practiced. It is used as a measurement
tool.
5. Standards are needed to provide direction, reach agreement on expectations,
monitor and evaluate results, guide organizations, people and patients to
obtain optimal results.
- Kird and Hoesing (1991)
Nursing care standard:
1. Nursing care standard can be defined as a descriptive statement of desired
quality against which nursing care given to a patient is evaluated.
2. Nursing care standard is guideline. A guideline is a recommended path to
safe conduct, and aid to professional performance.
3. A nursing standard can be a target or a gauge. When used as a target, a
standard is a planning tool. When used as a gauge against which to evaluate
performance a standard is a control device.
4. Nursing practice standards can be defined as statements that describe the
desirable and achievable level of performance expected of nurses in their
practice, against, which actual performance can be measured.
CONCEPTS OF STANDARD:
S Are degrees of excellence.
T

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A
N Serves as basis of comparison.
D
A Are minimum parameters with which a community may
be reasonably content.
R
D
S Is recognized as a model for imitation.

COMPONENTS OF STANDARDS:
1. Standard is written.
2. Standards define the set of rules, actions or outcomes.
3. Standards are written for customers, staff members, and system.
4. The authority must approve standards.
CHARACTERISTICS OF STANDARD:
1. Standards statement must be broad enough to apply to a wide variety of
settings.
2. Standards must be realistic, acceptable, attainable, specific, measurable,
appropriate, reliable, and timely implemented.
3. Standards of nursing must be developed by members of the nursing
profession; preferable nurses practicing at the direct care level with
consultation of experts in the domain.
4. Standards should be phrased in positive terms and indicate acceptable
performance good, excellence etc.
5. Standards of nursing care must express what is desirable optimal level.
6. Standards must be understandable and stated in unambiguous terms.
7. Standards must be based on current knowledge and scientific practice.
8. Standards must be reviewed and revised periodically.
9. Standards may be directed towards an ideal, i.e., optional standards or may
only specify the minimal care that must be attained, i.e. minimum standard.
10. Standards that work are objective, achievable and flexible.

PURPOSES OF STANDARDS:
Setting standard is the first step in structuring evaluation system. The
following are some of the purposes of standard.
1. Standards give direction and provide guidelines for performance of nursing
staff.
2. Standards provide a baseline for evaluating quality of nursing care.
3. Standards help improve quality of nursing care, increase effectiveness of
care and improve efficiency.
4. Standards may help to improve documentation of nursing care provided.
5. Standards may help to determine the degree to which standards of nursing
care maintained and the necessary corrective action in time.
6. Standards help supervisors to guide nursing staff to improve performance.

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 7. Standards may help to improve basic for decision making and devise
alternative system for delivering nursing care.
8. Standards may help justify demands for resources association.
9. Standards may help clarify nurse’s area of accountability.
10. Standards may help nursing to define clearly different levels of care.
11. To compare and improve the existing nursing practice.
12. To provide a common base for practitioners to coordinate and unify their
efforts in the improvement or practice.
13. To identify the element of independent function of nursing practices.
14. To provide a basis for planning and evaluating educational program for
practitioners.
15. To inform society of our concern for the improvement of nursing practice.
16. To assist the public in understanding what to expect of nursing practice.
17. To assist the employers to what to expect of the practitioners.
18. To identify areas for developing core curriculum for practicing nurses.
19. To provide legal protection for nurses.
OBJECTIVES OF STANDARDS:
Major objectives of publishing, circulating and enforcing nursing standards
are to
(i) improve the quality of nursing care
(ii) decrease the cost of nursing and
(iii) determine the nursing negligence.

APPROACHES:
There are three approaches.
1. Centralized:
Decisions are taken at the most senior or central level.

2. Decentralized:
Decisions are taken at some level lower than the most senior; typically by
individual work units within the organization or even by individual staff.

3. Core periphery (or) combined:

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 Decisions are taken at both senior and lower levels, either separately or in an
integrated manner.

LEVELS OF STANDARD:
1. MINIMUM STANDARDS:
Minimum standards are generally thought to represent a level of
acceptability below which they eyes on those judging, lies the unacceptable. While
minimum standards are a must to meet, there are other standards which we
continually strive to achieve.
For example: In a hospital the minimum standard for nosocomial infection
may be 7-10 percent.
2. DESIRABLE OR OTIMAL STANDARDS:
Desirable or optimal standards, which represent a degree of excellence.
For example
Anything above 10 percent is unacceptable whereas the desired is 3 percent.
SOURCES OF NURSING CARE STANDARDS:
It is generally accepted that standards should be based on agreed up
achievable level of performance considered proper and adequate for specific
purposes. The standards can be established, developed, reviewed or enforced by
variety of sources as follows.
a. Professional organization, (e.g.) Associations, TNAI
b. Licensing bodies (e.g.) Statutory bodies, INC
c. Institutions / Health care agencies (e.g.) University Hospitals, Health
centers.
d. Department of institutions (e.g.) Department of nursing.
e. Patient care units. (e.g.) Specific patient’s unit.
f. Government units at National, state and local government units.
g. Individual (e.g.) Personal standards.

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PYRAMID OR NURSING STANDARDS:

Clien
t
Unit

Agency

Specialty

Regulatory body

Standards range from broad, profession-specific standards to detailed care

standards established by a specific agency. It illustrates the relationship among the
various types of nursing standards for practice. The base of the figure depicts the
standards for practice of the regulatory body, which describes expectations
regarding nursing practice across the profession. Client-care standards depicted at
the apex of the figure are client-focused and describe specific nursing actions and
interventions required to achieve desired client outcomes in a particular setting.
This range of standards represents complementary and congruent expectations, in
relation to the standards, for the nurse in practice (Smith, 1991).

TOOLS FOR QUALITY ASSURANCE:

Setting standards for the organization, Kouth and Weilrich (1988)
have identified following eight types of standards the most organization must
establish.
1. Physical standards:
Which include patient activity ratings to establish nursing care hours
per patient per day.
2. Cost standards:
Which include review of monetary investment or newly programmed
ones.
3. Capital standards:
Which include review of monetary investment or newly programmed
ones.
4. Revenue standards:
This includes revenue per patient per day for nursing care.

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 5. Programmed standards:
Which guide the development and implementation of programmers
to meet client needs.
6. Tangible standards:
Which include staff development or personal orientation cost.

7. Goal standards:
Which outline goals in short, and long term planning
8. Strategy plan standard:
This outlines parts in developing and implementing the organization
strategy plan.

CLASSIFICATION OF STANDARDS:
There are different types of standards used to direct and control nursing
actions.
1. According to quality:
(i) Normative standards:
Normative standards describe practices considered ‘good’ or ‘ideal’ by
some authoritative group. Normative standards describe a higher quality of
performance than empirical standards. Generally professional organizations
(ANA/TNAI) promulgate normative standards.
(ii) Empirical standards:
Empirical standards describe practices actually observed in a large number
of patient care settings. Low enforcement and regulatory bodies (INC/MCI)
promulgate empirical standards.
2. According to infrastructure:
(i) End standards:
The end standards are patient-oriented they describe the change as desired in
a patient’s physical status or behavior. Ends or (patient outcome) standards require
information about the patients.
(ii) Mean standards:
The mean standards are nursing oriented, they describe the activities and
behavior designed to achieve the ends standards. A means standard calls for
information about the nurse’s performance.
(iii) Structure standard: (Agency or Group Oriented)
A structural standard involves the ‘set-up’ of the institution. The philosophy,
goals and objectives, structure of the organization, facilities and equipment, and
qualifications of employees are some of the components of the structure of the
organization, e.g. recommended relationship between the nursing department and
other departments in a health agency are structural standards, because they refer to
the organizational structure in which nursing is implemented. It includes people
money, equipment, staff and the evaluation of structure is designed to find out the
effectiveness, degree to which goals are achieved and efficiency in terms of the
amount of effort needed to achieve the goal. The structure is related to the
framework, that is care providing system and resources that support for actual
provision of care. Evaluation of care concerns nursing staff, setting and the care
environment. The use of standards based on structure implies that if the structure is
adequate, reliable and desirable, standard will be met or quality care will be given.

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(iv) Process standard (nurse-oriented)
Process standard describe the behaviors of the nurse at the desired level of
performance. The criteria that specify desired method for specific nursing
intervention are process standards. A process standard involves the activities
concerned with delivering patient care. These standards measure nursing actions or
lack of actions involving patient care. The standards are stated in action-verbs that
is in observable and measurable terms e.g.: the nurse assess, “the patient
demonstrates. The focus is on what was planned, what was done and what was
communicated or recorded. Therefore, the process standards assist in measuring the
degree of skill, with which technique or procedure was carried out, the degree of
client participation or the nature of interaction between nurse and client. In process
standard there is an element of professional judgment determining the quality or the
degree of skill. It includes nursing care techniques, procedures, regimens and
processes.
(v) Outcome standards (Patient-oriented)
Descriptive standards of desired patient care results are outcome standards
because patient’s results are outcomes of nursing interventions. Here outcomes as a
frame of reference for setting of standards refers to description of the results of
nursing activity in terms of the change that occurs in the patient. An outcome
standard measures change in the patient health status. This change may be due to
during care, medical care or as a result of variety of services offered to the patient.
Outcome standards reflect the effectiveness and results rather than the process of
giving care.
3. Context of standards:
It specifies the context of standards. Each type or domain of standards has
its own specialized context of standards.
(i) Standards of service
(ii) Standards of practice
(iii) Standards of governance.
1. Nursing service standards:
There are eight standards that focuses on the provision, management and
monitoring of hospital-based nursing care.
Nursing (NR) service standards from the accreditation manual for hospitals.
(i) There is an organized nursing department/service.
(ii) The nursing department/service is directed by a qualified nurse
administrator and is approximately integrated with the medical staff and
with other hospital staffs that provide and contribute to patient care.
(iii) The nursing department/service is organized to meet nursing care needs
of patients and to maintain established standards of nursing practice.
(iv) The nursing department/service assignments in the provision of nursing
care are commensurate with the qualifications of nursing personnel and
are designed to meet the nursing care needs of patients.
(v) Individualized, goal-directed nursing care is provided to the patients
through the use of nursing process.
(vi) The nursing department/service personnel are prepared through
appropriate education and training programs for their responsibilities in
the provision of nursing care.
(vii) Written policies and procedures that reflect optimal standards of nursing
care practice guide the provision of nursing care.

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 (viii) As part of hospital’s quality assurance program, the quality and
appropriateness of the patient care provided by the nursing
department/service are monitored and evaluated, and identified problems
are resolved.
A standard of care focuses on the recipient of care-the patient. Joint commission has
defined ‘standard of care as those activities or outcomes of nursing activities that
focus on patient’s status or expectations.
2. Standards of nursing practice:
Whereas standards of nursing practice focus on the structure and process
elements used by the nurse and nursing service to provide patient care (Patterson).
It relates to or describes what the nurse does or how the nurse provides nursing care
to assist the patient to move toward that expected outcome. These are authoritative
statements that describes a common or acceptable level of professional nursing
performance. The standards of practice, therefore, define professional practice. The
nursing department of each health care standards of practice that is to legally
describe how nursing care to be provided to each patient or group of patients.
3. Standards of governance:
Each hospital should have a hospital wide quality assurance program
defined in a written plan. As a part of that plan, the nursing department/service is
required to monitor or evaluate both the quality as well as the appropriateness of
nursing care provided to patients. And for that one need to have standards of care
and practice.
With the revision of the joint commission on Accreditation of Health care
organizations (JCAHO) nursing standards in 1991a new emphasis has been placed
on the nursing standards of patient care and the standards of nursing practice
(Claflin, 1990). These standards provide the basis for nursing care and the
foundation for nursing’s contributions to an inter disciplinary quality improvement
program.
The joint commission on Accreditation of Health care Organizations
(JCAHO) 2004 set forth standards of care which include performance evaluation,
establishment of policies and procedures for nurses, oversight authority in
providing patient care, and improvement of patient outcomes.
JCAHO’S standards of performance include.
(i) An individual’s competence is assessed, demonstrated, and maintained.
(ii) Individuals who assess competency are qualified to do so.
(iii) Nurse executives establish standards of patient care and practice for
nurses.
(iv) Nurse executives and other RN staff write (nursing standard of patient
care, practice and standards) to measure, assess and improve patient
outcomes.
(v) Nurse executive has final authority over those providing nursing care.
TECHNIQUES USED IN PREPARATION OF STANDARDS
IN NURSING:
Professional standard techniques, comprehensive review systems, and
process appraisal techniques are used in nursing in order to prepare standards in
nursing profession.
Professional standards techniques:

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 The professional standards category contains the various guidelines and
standard documents which health care professionals have published as a basis for
quality assurance. These are based on structure, process and outcome quality
assurance model given by American Nurses Association.
Comprehensive review systems:
Many professional bodies have specified standards and guidelines for
practice, which are taken and applied in all settings where the relevant professional
works. These standards are at high level of generality and several professional
bodies suggest that their central standards should be used as framework for more
local exercises in specific standards setting. The local and specific should thus grow
out of the central and more general.
Nursing profession has adopted the opposite strategy. It provides guidelines
for a process for local standard setting on the assumption that later on general
standards can be developed from the local and specific ones.
For example, Royal college of Nursing’s Dynamic Standard Setting System
(DySSy) established in 1965 (UK) is typically carried out at the ward level. The
design of DySSSy system is based on comprehensive review systems. This system
is designed to facilitate local standard setting as well as quality appraisal and
improvement.
Process appraisal technique:
The process appraisal techniques focus primarily on appraisal of the quality
of processes of care. The process of care comprises all the procedures and activities
through which the health professionals and support workers deploy their time,
skills, knowledge and resources in pursuit of improved patient health and well-
being. It has technical, interpersonal and moral components and includes access,
diagnosis, treatment, discharge after care, and health education and promotion.
Process standards have been more extensively developed in nursing than in
any other professional area and almost all instruments for measuring process quality
are designed for use in nursing.
STAGES OF THE DEVELOPMENT OF INTERNATIONAL
STANDARDS:
An international standard is the result of an agreement between the member
bodies of ISO. It may be used as such, or may be implemented through
incorporation in national standards of different countries.
International standards are developed by ISO technical committees (TC) and
subcommittees (SC) by a six-step process.
Stage 1: Proposal Stage
Stage 2: Preparatory Stage
Stage 3: Committee Stage
Stage 4: Enquiry Stage
Stage 5: Approval Stage
Stage 6: Publication Stage
Stage 1: Proposal Stage:
The first step in the development of an international standard is to confirm
that a particular international standard is needed. A new work item proposal (NP) is
submitted for rote by the members of the relevant technical committee or
subcommittee to determine the inclusion of the work item in the programme of
work. The proposal is accepted if a majority of the P-members of the technical

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committee/subcommittee votes in favor and if at least five P-members declare their
commitment to participate actively in the project. At this stage a project leader
responsible for the work item is normally appointed.
Stage 2: Preparatory Stage:
Usually, a working group of experts, the chairman (convener) of which is
the project leader, is set up by the technical committee / subcommittee for the
preparation of a working draft successive working drafts may be considered until
the working group is satisfied that it has developed the best technical solution to the
problem being addressed. At this stage, the draft is forwarded to the working
group’s parent committee for the consensus-building phase.
Stage 3: Committee Stage:
As soon as a first committee draft is available, it is registered by the ISO
central secretariat. It is distributed for comment and, if required, voting, by the
members of the technical committee / subcommittee. Successive committee drafts
may be considered until consensus is reached on the technical content. Once
consensus has been attained, the text is finalized for submission as draft
international standards (DIS).
Stage 4: Enquiry Stage:
The draft international standard (DIS) is circulated to all ISO member
bodies by the ISO central secretariat for voting and comment within a period of five
months. It is approved for submission as a final draft international standard (FDIS)
if a two-thirds majority of the P-members of the technical committee and
subcommittee are in favor and not more than one-quarter of the total number of
vote’s castes are negative. If the approval criteria are not met, the text is returned to
the originating technical committee / subcommittee for further study and revised
document will again be circulated for voting and comment as a draft international
standard.
Stage 5: Approval Stage:
The final draft international standard (FDIS) is circulated to all ISO member
bodies by the ISO central secretariat for a final Yes/No Vote within a period of two
months. If technical comments are received during this period, they are no longer
considered at this stage, but registered for consideration during a future revision of
the international standard. The text is approved as an international standard if a two-
thirds majority of the P members of the technical committee / subcommittee is in
favor and not more than one-quarter of the total number of votes cast are negative.
If these approval criteria are not met, the standard is referred back, to the
originating technical committee / subcommittee for reconsideration in light of the
technical reasons submitted in support of the negative votes received.
Stage 6: Publication Stage:
One a final draft international standard has been approved, only minor
editorial changes, if and where necessary, are introduced into the final text. The
final text is sent to the ISO central secretariat which publishes the international
standard.
LEVELS OF STANDARD SETTING:
There are four levels of standard setting.
1. National and state level
2. Community level
3. Institution level

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 4. Department level
STEPS FOR THE DEVELOPMENT OF NURSING
STANDARDS:
General steps:
The following are the steps that are to be considered for the development of
nursing standards.
1. Identify a team or panel of nursing experts.
2. Decide on the area of nursing practice for which the standards are to be
formed.
3. Review philosophy, purposes and objectives.
4. Review nursing theories or existing nursing care practices, nursing process.
5. Identify the patient for nursing service, patient’s role, approaches and
strategies of nursing care services.
6. Discuss with the nursing service administrators to get their approval so that
they are made feasible.
7. Devise a mechanism for determining the achievement of standards.
8. Try out the standards for feasibility.
9. The standards are then put into practice.
10. Quality care is audited.
11. The standards are reviewed and revised
A seven – step methodology:
Using a seven-step methodology can develop setting standards.
1. Identify a function or system that requires standards:
Identify high volume, high risk and problem prone function as per the
priority and also use common criteria for selection among the possibilities as on the
basis of importance, feasibility, impact and cost.
2. Identify a team or panel of experts to address standard:
The team should include the right persons in order to address issue
necessary to complete the task (Barassard, 1989). Usually 5-8 members will be the
most effective team. It should include the qualified by virtue of their experiences,
training and role in the organization. It should include the technical experts and
someone from authority within the organization.
3. Identify the inputs, processes and outcomes of function or system:
The team must identify the elements for each of the components (ie) input,
processes and outcome of the function or system. First list the desired outcome for
an activity, then lists the processes necessary for those outcomes to occur and inputs
that the processes require. They also prepare a number of tools that are useful for
identifying inputs, processes and outcomes.
4. Define the quality characteristics:
The team then decides on the quality characteristics of each key element,
and then it will lead to define a standard for that.
5. Develop (or) Adopt standards:
Team set the standards in the following way.
Choose a format: mostly the format is selected in the form of
Statement Algorithms:
Mostly applied for process standards as a list of steps, or a few sentence in
paragraph form; and or as a map that outlines a stepwise approach to solve a
clinical problem.

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Flow chart: Sometimes called a decision tree (e.g.) comatose patient management.
Algorithm: If patient does not respond to stimuli, then you do_______, if responds,
then you do_________
Case management plans, nursing care plans.
Critical paths:
Process standards can be in the form of critical paths, which is “an optimal
sequencing and timing of interventions by physicians, nurses and other staff for a
particular diagnosis or procedure” – over a period of time. These are designed to
minimize delays in health services and resources use and to minimize the quality of
care.
Clinical care protocols:
These are practice guidelines which are explicit, criteria-based plans for
specific health care problems (Benson and Van Osdol, 1990)
6. Gather background information:
Information is to be gathered through various methods.
Review literature: review nursing theories, philosophies, existing nursing
practices and nursing processes.
Confer with experts
Benchmarking
Review past experiences

7. Draft the standards:

The following methods can be selected to draft standards or to begin with
‘seed’ standards
- Delphi method
- Flow charts
8. Develop the indicators for the standards:
Indicator is that well-defined objective and measurable variable used to
monitor the quality and/or appropriateness of an important aspect of care. An
indicator can be a structure, a process or an outcome about which data are collected
during monitoring activities. In order to develop the indicators the nurse should
keep in mind the following points.
- Use measurable terms to convert standards into indicators.
- Use indicators to monitor the compliance to the standard and to
measure the variance from the desired level of achievement that
standard.
9. Assess appropriateness of standards and indicators:
Appropriateness is a ratio or degree of congruence between what the patient
needed and the care the nurse has provided. Appropriateness relates to the extent to
which nursing care is efficacious (i.e.) based on scientific principles) is clearly
indicated for the patient is neither excessive nor deficient in number (for the
patient’s needs, and is provided in the appropriate, setting best suited to the
patient’s needs. During the assessment for the
STANDARDS IN THE CARE SETTINGS:
Standards are used in three evaluation processes.
1. Self-Assessment:

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 It is the evaluation of one’s own performance. Standards may be set by
oneself or in collaboration with an outside agent and evaluate how well the
standards are met.
2. Inspection:
It usually implies some sort of official examination. Those who inspect most
often have a conferred power to do so.
3. Accreditation:
It is a process where in standards would depend on whether they are used in
an ongoing process. Set standards should be observable, attainable and measurable.
They are to be compared to actual practices. Identify the strength and weaknesses,
take actions to correct deficiencies, review the effectiveness of those actions
through an audit protocol derived from the standard.
STANDARDS FOR NURSING SERVICES:
Various associations have drafted standards for nursing services. These are
appropriateness of standards and indicators, the following points should be kept in
mind.
 Standards should be appropriate to the organization.
 The team determines if the standards are valid, reliable, clear and
applicable before they are disseminated.
o Use test and retest method to test reliability.
o Assess for clarity and for applicability and reality.
o Conduct studies to check validity, reliability on the sample
representative to target population.
o Indicators should also have the same characteristics plus these
should be measurable.
 Use possible methods as staff meetings, anonymous questionnaires, and
fact-to-face interviews.
 Analyze the feedback and make necessary changes.
 The team should review and should develop a plan to revise and
implement the standard.
1. American Nurses Association Standards:
According to ANA, the following are the standards considered for the
nursing services.
(i) The nursing department has the responsibility and authority for the
practice of nursing in the health care facility.
(ii) The nursing department is allocated to finance necessary to carry out
the departmental program.
(iii) The nursing department promotes safe and therapeutically effective
nursing care through implementation of established standards of
nursing care.
(iv) It has clearly delineated responsibilities in the health facility’s disaster
plan.
(v) It has written personnel policies, which can be expected to attract,
qualified nursing programmes and opportunities for staff development.
(vi) It develops a written agreement with the educational institution for the
use of the clinical facilities by nursing students, which ensures the
safety and welfare of the patients.

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 (vii) It initiates and promotes studies of and where feasible research on
administrative, supervisory and nursing cares practices.
(viii) It ensures and provides the physical facilities, supplies and equipment’s
needed to carry out the objectives and standards of nursing department.
(ix) It continuously evaluates its administrative, supervisory and nursing
care practices.
1. ANA standards of care/practice:
The keystone of the ANA nursing standards, articulates who, what, where,
why, when and how of practice. There are 16 ANA standards of practice, six
standards of practice and nine standards of professional performance.
ANA standards of care/practice:
Standard I Assessment:
The registered nurse collects comprehensive data pertinent to patient’s
health or situation. Correctional nursing practice is characterized by a high degree
of autonomy and requires a broad-base of subjective and objective data.
Standard II Diagnosis:
The registered nurse analyzes the assessment data to determine diagnoses or
issues. The nurse analyzes the assessment data in determining diagnoses.
Standard III outcomes identification:
The registered nurse identifies expected outcomes for a plan individualized
to the patient or the situation. The nurse identifies outcomes individualized to the
client.
Standard IV planning:
The registered nurse develops a plan of care that prescribes strategies and
alternatives to attain expected outcomes. The nurse develops a care plan that
prescribes interventions to attain expected outcomes.

Standard V Implementation:
Standard 5a:
The nurse implements the interventions identified in the care plan. The
registered nurse co-ordinates care delivery. The registered nurse employs strategies
to promote health and a safe environment.
Standard 5b:
Health teaching and health promotion. The registered nurse employs
strategies to promote health and a safe environment.
Standard VI Evaluation:
The nurse evaluates the client’s progress toward attainment of outcomes.
The registered nurse evaluates the patient’s progress toward attainment of
outcomes.
ANA standards of professional performance:
Standard VII Quality of care:
The registered nurse systematically enhances the quality and effectiveness
of nursing practice.
Standard VIII Performance Appraisal:
The nurse evaluates his/her own nursing practice in relation to professional
practice standards and relevant statutes and regulations.
Standard IX Education:
The nurse registered attains knowledge and competency that reflects current
nursing practice.

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Standard X: Professional Practice Evaluation:
The registered nurse evaluates one’s own nursing practice in relation to
professional practice, standards and guidelines, relevant statutes, rules, regulations.

Standard XI: Collegiality:

The registered nurse interacts with and contributes to the professional
development of peers, colleagues and others.
Standard XII: Collaboration:
The registered nurse collaborates with the patient, family and others in the
conduct of nursing practice. The nurse collaborates with the care seekers,
significant others, other criminal justice system personnel and health care providers
in providing patient care.
Standard XIII: Ethics:
The registered nurse integrates ethical provisions in all areas of practice.
The nurse decisions and actions on behalf of health care seekers are determined in
an ethical manner.
Standard XIV: Research:
The registered nurse integrates research findings into practice.
Standard XV: Resource Utilization:
The registered nurse considers factors related to safety, effectiveness, cost
and impact on practice in the professional practice setting and the profession.
Standard XVI: Leadership:
The registered nurse provides leadership in the professional practice setting
and the profession.
Canadian Nurses Association (CNA) standards:
Professional responsibility:
The registered nurse is personally responsible and accountable for ensuring
that their nursing practice and conduct meet the standards of the profession and
legislative requirements.
Knowledge-Based practice:
The registered nurse continually strives to acquire knowledge and skills to
provide competent, evidence-based nursing practice.
Ethical practice:
The registered nurse complies with the Canadian Nurses Association (CNA)
code of Ethics of Registered Nurses (2002).
Provision of service to the public:
The registered nurse provides nursing service in collaboration with the
client, significant others and other health professional.
In Indian Scenario ‘Practice standards’:
The set of activities expected from professional group of nurses are
classified into six practice areas that are consistent with areas for code of ethics and
professional conduct. Each area has its specific standards, rationale for each
standard and the performance criteria (i.e.) the selected behaviors to achieve the
standard or the indicators. The practice areas are
Professional Responsibility and Accountability:
The following are the standards or the desired levels by which the nurses are
required to maintain professional responsibility and accountability.
Standard 1: Nursing care is based on quality assurance model:

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 Since the quality assurance model is essential to ensure quality of nursing
care in order to meet the expectations of customers, management and regulatory
bodies, the nurses are required to demonstrate an understanding of the concept of
quality assurance model.
Standard 2: Nursing care is professionally managed and ethically justified:
In order to maintain the role and retain the identity as a nurse in the
changing health world, the nurse has to manage the nursing care professionally and
justified it ethically. They are required to demonstrate knowledge of current ethical
issues in health care, adhere to the code of ethics and professional conduct and
participate effectively in ethical decision making. Ethical principles:
1. Ethical Principles of Respect and Autonomy:
 Respect for a person involves
Level of understand of another person or empathy and reducing exploitation.
 Autonomy
Person’s independence, self-determining action allow the patient to make decision.
2. Principle of Beneficence:
Activity seeking benefits, promotion of good. The duty to do balance
between benefits and harm, paternalism is an undesirable outcome of beneficence,
in which the health care provider decides what is best for the client and attempt to
encourage the clients to act against his or her own choices.
3. Principle of justice and families:
Basic principle is that each person has equal to the liberty available to
everyone.
4. Principle of veracity:
The obligation to tell the truth.
5. Principle of fidelity:
The duty to do what one has promised.
International and national code of ethics and professional standards for
nursing practice statements incorporate the concept of accountability. The emphasis
or place of accountability. The emphasis or place of accountability is placed with
the individual nurse. According to element of the International Council of Nurses
(ICN) code of ethics (2006), the nurse carries personal responsibility and
accountability for nursing practice, and for maintaining competence by continual
learning The American Nurses Association (2001) code of ethics emphasizes the
individual nurse is to accept responsibility and accountability for individual nursing
practice.
Standard 3: Nursing care is provided within the legal framework:
Nurses are required to work within the legal framework as it safeguards
rights of the clients and nurses. For that reason the nurses should be aware of legal
boundaries for their practice. They should perform activities that fall within those
boundaries. They should recognize breach of law related to practice and report to
appropriate authority.
Standard 4: Nursing care is documented accurately and completely:
Nurses are accountable for the care they render, so they should maintain
accurate and complete record and these will help her from legal complications.
Hence she should fulfill following criteria in order to achieve this particular
standard.
Demonstrates an understanding of the value and implications of maintaining
records.

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 Maintains legible, complete and accurate records. Keeps records
systematically and safely maintain confidentiality of records.
Standard 5: Nurse accepts responsibility and accountability for their own
actions:
Under this context, the performance criteria for the nurses would be
Nurses assume and delegates responsibility within the scope of nursing
practice and competence.
She consults other members of nursing team when requisites nursing care is
beyond own competence.
Consults other health care professionals as and when required.
Nursing practice:
Practice standards are essential for safe practice; they also provide legal
protection to nurse. The following are the standards related to nursing practice.
Standard 1: Nursing care reflects that practice standards are being adhered to
Nurses are required to demonstrate understanding of standards for nursing
practice, demonstrate adherence to satisfactory level of practice standards, maintain
records of care that are congruent with practice standards.
Standard 2: Delivery of nursing care reflects nursing process approach:
Nursing process is essential for the delivery of systematic and
comprehensive nursing care, to justify actions taken and to formulate
documentation. Hence the nurses are required to
Conduct systematic, comprehensive and accurate nursing assessment of
their clients/and groups.
Formulate a plan of actions based on priority needs.
Collaborates with individuals and groups in formulating the plan of care.
Implement the care as per the plan.
Evaluate the outcomes of action taken and revise plan of care.
Standard 3: Nursing care is provided in a safe environment:
Since the care provided in the safe environment contributes to promotion of
health and illness and complications, the nurses should ensure safe and therapeutic
environment in care settings.
Adhere to standard safety measures and universal precautions to prevent
infections.
Follow guidelines for biomedical waste management.
Sensitize co-workers, individuals and groups about the importance of safe
environment.
Communication and interpersonal relationships:
The following two standards are formulated related to communication and
interpersonal relationship.
Standard 1 : Nurse fosters effective interpersonal relationship with the clients
and families:
Effective communication and interpersonal relationship is important for
building trust and confidence with the clients by the nurse.
The nurse must
Establish and maintain rapport with clients and their families.
Demonstrate effective communication skills.
Demonstrate ability to listen attentively and patiently.
Respond empathetically and constructively to concern expressed by them.
Foster environment that is conducive for communication.

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 Maintain interpersonal relationship within professional boundaries.
Standard 2 : Nurse initiates strategies to promote the learning of clients and
groups:
Nurses needs to
(i) identify learning needs of client and groups
(ii) optimize learning opportunities for them
(iii) conduct planned and incidental teaching
(iv) evaluate outcome of teaching learning process
Valuing human beings:
Under valuing human being, the following standards have been developed.
Standard 1: Nursing care enhances the dignity, individuality and self-esteem of
individual and groups:
Nurses are expected to convey respects to individuals in all dealings,
promote and support self-awareness, self-esteem and self-determination among
individuals.
Standard 2: Nursing care reflects active pursuit for rights of all individuals
and in particular the vulnerable groups:
This standard of valuing is achieved when the nurses are able to describe the
constitutional and legal rights of individuals.
Inform and educate individual about their rights.
Seek consent of individuals after adequate and factual information.
Respect the rights individuals and families to refuse care after ensuring that
they understand the consequences of refusal as per policy.
Mobilize support of health team members, families and communities for
protection of the rights of vulnerable groups.
Standard 3: Nursing care reflects gender sensitivity towards the needs of
women related to their health:
This particular standard is based on that the existing cultural beliefs and
practices make it imperative to provide gender sensitive care to enhance the dignity,
individuality and self-determination of women, it also helps to increase the
utilization of health services. And this can be achieved when the nurses are able to
Describe cultural social, economic and political context in which women
live.
Promote and support self-awareness, self-esteem and self-determination
among women.
Enhance the dignity of them as reflected in dealing with them.
Promote health-seeking behavior in women.
Management:
In order to render organized and cost-effective services, effective
management is required. To have the effective management, the following
standards are formulated.
Standard 1: Management of nursing services reflects effective management
techniques:
Performance criteria are that nurse is expected to
Demonstrate understanding of different management techniques.
Performance criteria are that nurse is expected to
 Demonstrate understanding of different management techniques.
 Applies appropriate management techniques based on situational analysis.
 Initiate activities for enhancement of own managerial skills.

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Standard 2: Management of nursing services reflects use of Quality Assurance
model:
Performance criteria are that nurse is expected to
1. Appreciate the significance of quality assurance programme for quality
nursing care.
2. Demonstrate an understanding of quality assurance programme and own
role in implementation.
3. Involve team members in development and implementation of quality
assurance programme.
Standard 3: Management of nursing services organizes and utilizes resources
efficiently:
As efficient uses of resource are essential to provide cost-effective care, the
nurses are expected to perform following activities to fulfill this standard.
 Assess the essential requirement of resources for delivery of quality nursing
care.
 Demonstrate an understanding of the system for procuring, utilizing and
monitoring of resources.
 Delegate responsibilities to appropriate team members for inventory control.
 Ensure preventive maintenance of equipment.
Standard 4: Management of nursing services contributes to development and
implementation of institutional policies in conformity with statutory
regulations:
For this the nurse should
 Demonstrate understanding of institutional policy statutory regulations.
 Contributes to framing and reviewing the institutional policy as per
statutory regulations.
 Communicate the policies, rules and regulations to concerned persons and
ensure compliance.
Standard 5: Management of nursing services develops and implements staff
development and welfare programmes:
In order to achieve the institutional and personal goals, staff development
programmes are essential. The following are the behaviors the nurse is expected to
 Prepare a plan for the staff development
 Facilitate implementation of staff development related services.
 Participate in continuing educational programmes.
 Motivate the nurses for participation.
Standard 6: Management of nursing services ensures disaster preparedness:
The nurse are expected to
 Participate in institutional plan for disaster preparedness.
 Organize training and drill for the members of the disaster management.
Professional Development:
The standards developed related to professional development are
Standard 1: Nursing care reflects the commitment to ongoing education and
professional growth of self and others:
The standard can be achieved if the nurses are expected to
Participate in continuing education programme.
Review current literature.
Participate in professional meetings to professional practice.
Identify learning needs.

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Standard: 2 Nursing care includes activities, which focus on advancement of
profession:
The nurse is expected to
 Identify the needs for change in scope of nursing practice.
 Participate in research activities.
 Conducts nursing research.
 Interpret and utilize research findings in nursing practice.
 Contribute in advancement in nursing.
Standards and evaluation:
The nursing standards can be used in one of the three evaluation processes:
self-assessment, inspection and accreditation.

Self-Assessment:
Self-assessment can be done at different levels.
Self-assessment being one’s own performance, can be useful to analyze
one’s own strengths and weaknesses in the performance.
Individual nursing department may establish its own standards and measure
its own performance periodically.
Department programme may have the specific standards.
Standards can also be set to measure against other similar institution or
professional groups, for sharing experiences to achieve optimum level of nursing
care.
Inspection:
The inspection can be made more effective and purposeful by the use of
standards. A government agency / professional body / financial institution can
conduct inspection, a sort of / official examination. Ideally setting standards should
be a joint process and assessment of performance against the standards may be
voluntarily undertaken by health care facilities.
Accreditation:
Accreditation is a process where in standards are set and compliance with
them is measured. The setting of standards is always done through a consultative
process in which consumers among those who will use the standards are sought.
Standards are then after judging, is subjected to periodical and ongoing review to
ensure their continual appropriateness. Currently, accreditation generally rests with
autonomous organizations, as applied to government or individual professional
bodies or association.
JCAH (JOINT COMMISSION OF AMERICAN HOSPITAL) NURSING
SERVICES STANDARDS:
Standard I
The nursing department/service shall be directed by a qualified nurse
administer and shall be appropriately integrated with the medical staff and with
other hospital staffs that provide and contribute to patient care. The administrator of
the nursing department/service shall be a qualified. Registered nurse with
appropriate education, experience, and licensure and demonstrated ability in
nursing practice and administration.
Standard II
The nursing department/service shall be organized to meet the nursing care
needs of patients and to maintain established standards of nursing practice. The
nursing department/service shall have a written organizational plan that delineates

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lines of authority, accountability and communication. The manner in which the
nursing department/service is organized shall be consistent with the variety of
patient services offered and the scope of nursing care activities.
Reviewing and approving policies and procedures.
Establishing standards of nursing care accounting for professional and
administrative nursing staff activities. Implementing the approved policies of the
nursing department/service. Appointing committees as needed. Encouraging
nursing staff personnel to participate in staff education programs.
Standard III
Nursing department/service assignments in the provision of nursing care
shall be commensurate with the qualifications of nursing personnel and shall be
designed to meet the nursing care needs of patient.
A sufficient number of qualified registered nurses shall be on duty at all
times to give patients the nursing care that requires the judgment and specialized
skills of a registered nurse.
Standard IV
Individualized, goal-directed nursing care shall be provided to patients
through the use of the nursing process. The nursing process (assessment, planning,
intervention, evaluation) shall be documented for each hospitalized patient from
admission through discharge.
Standard V
Nursing department/service personnel shall be prepared through appropriate
education and training programs for their responsibilities in the provision of nursing
care.
Education/training programs for nursing department/service personnel shall
be ongoing and designed to augment their knowledge of pertinent new
developments in patient care and to maintain current competence. The scope and
complexity of program shall be based on the documented educational needs of
nursing staff personnel and the resources available to meet those needs.
Standard VI
Written policies and procedures that reflect optimal standards of nursing
shall guide the provision of nursing care. Written standards of nursing practice and
reflected policies and procedures shall define and describe the scope and conduct of
patient care provided by the nursing staff. The standards, policies and procedures
shall be reviewed at least annually, revised as necessary, dated to indicate the time
of the last review, signed by the responsible reviewing authority and implicated.
Standard VII
As part of the hospitals quality assurance program, the quality and
appropriateness of the patient care provided by the nursing department/service are
monitored and evaluated and identified problems are resolved.
The nursing department/service has a planned and systematic process for
monitoring and evaluation of the quality and appropriateness of patient care and for
resolving identified problems.
Every institution/health care agency need to develop their own standards for
providing quality patient care as per the international standards set for the nursing
practice.

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LEGAL SIGNIFICANCE OF STANDARDS:
Standards of care are guidelines by which nurses should practice. If nurses
do not perform duties within accepted standards of care, they may place themselves
in jeopardy of legal action. Malpractice suit against nurses are based on the charge
that the patient was injured as a consequence of the nurses failure to meet the
appropriate standards of care.
To recover losses from a charge of malpractice, a patient must prove that
 a patient-nurse relationship existed such that the nurse owed to the
patient a duty of due care
 the nurse deviated from the appropriate standard of care
 the patient suffered damages
 the patient’s damages resulted from the nurses deviations
BARRIERS AND CONSTRAINTS IN DEVELOPMENT OF
STANDARDS FOR NURSING SERVICE:
The barriers and constraints in development of standards for nursing service
are related to

Barriers Related to

Policies Nursing Equipment Physical Finance Monitoring

Man power and supply facilities system

Related to Policies:
 Absence of laid down standards.
 Lack of appropriate written policies for nursing practice
 Lack of specific job descriptions of various categories of nursing personnel
in different health care settings
 Absence of policy regarding renewal of registration of practice nurses
 Lack of political and professional support for improving standards for
nursing care
 Inadequate autonomy and accountability of nursing practice.
Related to Nursing manpower:
There are inadequate nurse patient ratios in totality and in different shifts.
There is lack of awareness regarding the concepts of standards, sensitivity to
the need of standards and knowledge as regards for developing, implementing and
monitoring of standards for nursing practice.
Lack of strategies for regular updating of knowledge and skills in various
clinical areas of nursing practice.
Inadequate and inappropriate supervision and monitoring of nursing services
provided by nursing personnel at all levels.
Lack of adequately prepared nurse administrators for planning and
organizing the nursing services.
Lack of promotional avenues for the nurses at all levels due to limited cadre
in nursing.

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 Absence of recognition, appreciation and motivation for the nursing
personnel in planning, organizing and providing nursing care. Absenteeism and
increased turnover rate among the nurses.
Lack of proper utilization of nurses.
Related to Equipment and other materials:
 Inadequate numbers of equipment’s and supplies to provide the nursing
care.
 Low quality and substandard equipment.
 Lack of training in handling various equipment’s, machines and monitors in
advanced clinical procedures.
 Lack of stationary items.
Related to Physical facilities:
 Inappropriate and inadequate physical setup of the hospital.
 Poor sanitation.
 Shortage of water and electricity supplies.
 Inappropriate drainage and waste disposal facilities.
Related to Finance:
Uncertainty for commitment of adequate financial support for development
and implementation of standards for nursing care.
Related to Monitoring system:
No auditing system to maintain or evaluate the care given, inspection or
accreditation.
ROLE OF NURSE ADMINISTRATORS IN DEVELOPING
STANDARDS FOR NURSING PRACTICE:
As per the expert committee of ‘Development of guidelines for standards for
nursing practice during year 1999, the role of nurse administrator was identified as
1. Initiator
She creates awareness/sensitizes the nurses at first and second level
leadership positions on nursing standards.
2. Facilitator:
She facilitates to develop, implement, monitor and evaluate standards for
nursing practice at all times.
3. She makes provision for necessary infrastructure for developing, implementing,
maintenance, monitoring of standards for nursing practice.
4. She forms a core group for developing, implementing, monitoring and
maintaining standards for nursing practice.
5. She assures on the job orientation and in service education to enhance
implementation and monitoring of standards for nursing practice.
6. She ensures auditing and reviewing of standards for nursing practice.
7. Educator:
As an educator she gives orientation to nursing personnel regarding the need
for standards of nursing practice, stimulates and motivates the nurses to implement
and maintain standards of nursing practice and also trains core group to develop,
implement, monitor, maintain and evaluate the standards for nursing practice.
8. Evaluator:
As an evaluator she monitors the implementation of standards for nursing
practice and also evaluates the auditing and reviewing process for updating
standards of nursing practice.

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NURSING CARE STANDARDS IN WARD MANAGEMENT:
FUNCTIONS OF NURSES:
The major functions of nurses are classified as
 Those dealing with organization and control of the patients environment
and to secure for him maximum mental and physical comfort.
 Those concerned with him immediate personal care
 Those performed under the direction and in cooperation with the
physician.
 Administrative duties of ward management.
RESPONSIBILLITIES OF HEAD NURSE:
1. Carrying out the instructions of medical officers regarding treatment of
patients.
2. General cleanliness and upkeep of ward and its surrounding areas to provide
neat and cheerful environments for patients.
3. Supervision of care and maintenance of buildings, furniture’s, fitings and
arranging their reports through CND or medical officer.
4. Keeping the ward equipment in optimum state of readiness by prompt
repairs and replacement through condemnation boards.
5. Assignment or duties for patient care to staff working.
6. Identifying the collection of various items of medical and other stores.
7. Ensuring that all specimens are sent to the laboratory in time and results
collected in due.
8. Maintaining strict control over accounting and distribution of controlled and
dangerous drugs.
9. Ensuring sufficient lines is available in the ward.
10. Training of nursing and other personnel working in the ward.
11. Maintenance of all the registers and documents required in the ward.
SAMPLE FOR STANDARDS AND NORMS IN NURSING
SERVICES:
The following is the sample for having standards and norms in the
department. This can be modified as per the need of the department.
CRITERIA STANDARDS

STRUCTURE

1. Professional qualification Registered Nurse with General Nursing BSc

Nursing MSc Nursing.

2. Qualities and competence Well-adjusted personality flexible in dealing

Maintaining ethical standards
Possess knowledge and skill.

3. Physical facilities Nursing station

Rooms/wards provide easy mobility of machine

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 space between the beds Adequate lighting.
Telephone facilities.
Provision of O2 and suction adequate water
supply 1:3

4. Nurse-patient ratio Therapeutic climate client’s physical safety.

5. Physical environmental Reception room

requirement Treatment room
Conference Room
Store Room

6. Drugs Availability of
Emergency drugs
Required drugs.

PROCESS

1. Assessment Collect pertinent data perceptual disorders

cognitive disorders physical disorders
Identification Data
Recognition of symptoms Affective disorders

Recording Each observation physical examination any

untoward behavior

2. Planning Establishes therapeutic relationship with client.

Determination of Assess client to set goals which are realistic
appropriate intervention Assess client’s progress.

3. Implementation Modified care plan and makes alternative

course of action.

OUTCOME

1. Short term care The client’s participation in the therapy client’s

keeps up regular appointments
Develop trusts in nurse
Recognizes the needs, abilities, strengths,
limitations, self-dependent.

2. Long term care Resumes normal job

Goes back to community
Engages in therapeutic activities.

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CONCLUSION:
Standards are professionally developed expressions of the range of
acceptable variations from a norm criterion” – Avedis Donabedias.
The success of standard would depend on whether they are used in an on
ongoing process. Set standards should be observable, attainable and measurable.
They are to be compared to actual practices. Identify the strengths and weaknesses,
take actions to correct deficiencies, review the effectiveness of those actions
through an audit protocol derived from the standard.

NURSING AUDIT: A QUALITY CONTROL

INSTRUMENT
INTRODUCTION:
When an accountant audits an organization’s accounts, he or she examines
the accounts officially in order to make sure that they have been done correctly.
Nursing services are necessary for virtually 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 critical to
effective, quality patient care. Nursing can no longer ignore the world trend of
professional accountability to an enlightened public. We as nurses, when we talk
about “quality nursing”, need to know our deficiencies and admit them to our peers.
Remedial steps needs to be taken only by such self-regulation we can retain our
identity with the health professional as true partners.
It is the important phenomenon of nursing care. Audits are measurement
tools. An audit is a systematic and official examination of a record, process or
account to evaluate performance. Auditing in health care organizations provides
managers with a mean of applying the control process to determine the quality of
services rendered.
Quality nursing care has become essential on day to day function. Nursing
audit is a way of ensuring quality nursing care is an evaluation of nursing services.
Nursing audit was first published in 1955.

MEDICAL AUDIT:
Medical audit is a systematic and critical analysis carried out by doctors
looking at the things that doctors do. It is also defined as the evaluation of medical
care in retrospect through analysis of clinical records.
CLINICAL AUDIT:
Clinical audit is systematic and critical analysis carried out by all health
professionals, including doctors when working with others health professionals
looking at the things that they do together.
NURSING AUDIT:
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 Nursing audit is an evaluation of patient care through analysis of the nursing
records maintained by nurses in the patient’s care. It is also defined as the basic
from of quality data collection in patient care.
BRIEF HISTORY:
Nursing audit is an evaluation of nursing service. Before 1955, very little
was known about the concept. It was introduced by the industrial concern and the
year 1918 was the beginning. George Grower, pronounced the term physician for
the first term medical audit. Ten years later Thomas R. Pondan M.D. established a
method of medical audit based on procedures used by financial account. He
evaluated the medical care by reviewing the medical records. First report of nursing
audit of the hospital was published in 1955, for the next 15 years, nursing plan,
nurses role, and patient condition and nursing care. Audit is reports from study or
records on the last decade. The program is reviewed from record nursing. One of
first ever clinical audits was undertaken by Florence Nightingale during the
Crimean war of 1853-1855.
DEFINITION OF AUDIT:
A systematic and critical examination to examine or verify.
DEFINITION OF MEDICAL AUDIT:
The systematic, critical analysis of the quality of medical care, including the
procedures for diagnosis and treatment, the use of resources, and the resulting
outcome and quality of life for the patient.
DEFINITION OF NURSING AUDIT:
1. (a) It is the assessment of the quality of nursing care (b) uses a record as an
aid in evaluating the quality of patient care.
2. Nursing audit is defined as the evaluation of nursing care in retrospect
through analysis of nursing records. It is a systematic 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.
3. Nursing Audit refers to assessment of the quality of clinical nursing.
- Elison.
4. (a) Nursing audit is an exercise to find out whether good nursing
practices are followed (b) The audit is a means by which nurses themselves
can define standards from their point of view and describe the actual
practice of nursing.
- Goster Walfer.
CONCEPT OF NURSING AUDIT:
Concept of nursing audit is based on debit and credit system.
Debit all negative activities. The Debit items are
1. Death note of the patient justifiable or otherwise could have been prevented.
2. Complications due to neglect of nursing care affecting the integrity of any
system.
3. Complications leading to mortality.
4. Hospital infection and nosocomial infection.
5. Error in treatment.
6. Patient left against medical-advice (LAMA)
7. Lack of application of nursing process.

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 8. Absence of total patient care.
9. Total nursing care provided in a hospital only by learners.

Credit positive activities. Credit items are

1. Number of recovered patients.
2. Shorter stay in hospital.
3. Expansion of health knowledge in patient’s population.
4. Research or problem oriented care approach.
5. Regular follow up in the community.
6. Improved image in public / clients.
7. Accurate nursing documentation.
Debit systems are negative in nature and emphasis is towards illness. In contrast the
credit system is positive in nature emphasizing on health.
PURPOSES OF NURSING AUDIT:
1. Evaluation: Evaluating the nursing care given.
2. Achieve deserved and feasible quality of nursing care
3. Verification: Stimulant to better records.
4. Focuses on care provided and not on care provider.
5. Contributes to research.
6. 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.
7. It encourages followers to be actively involved in the quality control process
and better records.
8. It clearly communicates standards of care to subordinates.
9. Facilitates more efficient use of health resources.
10. Helps in designing response orientation and in-service education
programme.
11. Necessitating adequate documentation of nursing care provided to the client
through the entire nursing process.
12. Directing attention to the design and utility of the charting record.
13. Encouraging the use of the problem oriented nursing system.
14. Supporting and becoming an integral part of nursing by objective program
15. Facilitating the co-operative planning and delivery of client care by
physicians and nursing service employees.
OBJECTIVES OF NURSING AUDIT:
Quality assurance of delivered care in relation to the change in health status of
the patient and cost effectiveness is the overall objective of the nursing audit
1. To study the quality of the patient care against defined criteria.
2. To justify the cost occurred on human and material resources.
3. To evaluate excellence of nursing practice.
4. To revise and plan standards of nursing care.
5. To avoid external audit being imposed on the profession from outside, it
means to avoid anticipatory problems if external audit is done.
6. To measure progress.
7. To promote the maintenance of medical research.
8. To increase medico-legal protection.
.

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CHARACTERISTICS:
1. It improves the quality of nursing care.
2. It compares actual practice with agreed standards of practice.
3. It is formal and systemic.
4. It involves peer review.
5. It requires the identification of variations between practice and standards
followed by the analysis of causes of such variations.

ESSENTIAL CHARACTERISTICS OF NURSING AUDIT

There should be
1. Written standards of care against which evaluate nursing care
2. Evidence that actual practice was measured against such standards, sharing
a percent conformance rate.
3. Examination and analysis of findings.
4. Evidence of corrective action being taken
5. Evidence of effectiveness of corrective action
6. Appropriate reporting of the audit programme
6. It provides feedback for those whose records are audited.
7. It includes follow-up or repeating an audit sometimes later to find out if the
practice is fulfilling the agreed standards.
PREREQUISITE FOR NURSING AUDIT
Audit committee
Before carrying out an audit, an audit committee should be formed,
comprising of a minimum of 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 nor more than to patients each month. That the
audit in about in minutes. If there are less than 0 discharges per month, then all the
records may be audited. If there are large number of records o be audited, then an
auditor may select 10 percent of discharges.
Reorientation of Auditors
A detailed discussion of the seven components of criteria. A group
discussion to see how the group rates the care received using the notes of a patient
who has been discharged.
These should be anonymous and should reflect a total period of care not
exceeding two weeks in length. Each individual auditor should then undertake the
same exercise as above. This is followed by a meeting of the whole committee who
compares and discusses its findings, and finally reaches a consensus of opinion on
each of the components.
Planning Medical care
Collects pertinent data in a systematic manner, includes description of
patients pre- hospital routines, has information about the severity of illness, has
information regarding lab tests, has information regarding vital signs, has
information from physical assessment etc., state nursing diagnosis, writes nursing
orders. Suggest immediate and long term care, implements the nursing care plan,
plans health teaching for patients and students, evaluates the plan of care at own
level.

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TYPES OF AUDIT
1. Internal Audit
Internal auditing is a control technique performed by an external auditor
who is an employee of the organization. He makes an independent appraisal the
policies, plans and points the deficits in the policies or plans and gives suggestion
for eliminating deficits.
Internal audits are carried out continuously by the hospital staff and which
consist records and evaluating the quality of medical care in individual. E.g.
Practitioner reviewing his own work, review the work of practitioners by consultant
or nurse manager.
2. External Audit
It is an independent appraisal of the organizations, financial account and
statements. The external auditor is a qualified person who has to certify the annual
profit and less account and prepare a balance sheet after careful examination of the
relevant books of accounts and documents.
An outside agency periodically evaluates the completeness and accuracy of
the internal audit. Review of work of practitioners by an outside body separated by
distance, experiences and values. It can be professional regulatory body/ committee
of government which has the authority to withdraw finds of recognition.
FORMS OF AUDIT
There are three basic forms of audit most frequently used in quality control
includes
1. structure audit
2. process audit and
3. outcome audit
Structure Audit
Structure audit monitors the structure or setting in which patient care is
provided such as the finances, nursing service, medical records and environment.
This audit assumes that a relationship exists between quality care and appropriate
structure. These above audits can occur retrospectively, concurrently and
prospectively. Checklist that focuses on these categories measure standard or
indicators structure standard includes content such as safe a defective environment,
staff knowledge and expertise in addition to policies and procedures of nursing
practice. Content related to specific nursing care to meet established standards are
included in nursing process audits.
Process Audit
Process audits are used to measure the process of care or how the care was
carried out process audit is task oriented and focus on whether or not practice
standards are being fulfilled. These audits assumed that a relationship exists
between the quality of the nurse and quality of care provided.
Process audits implement indicators for measuring nursing care to determine
whether nursing standards are met. They are generally task oriented. Process audits
first used by Maria Phaneuf in 1964 were based on the seven functions of nursing
established by lesnick and Anderson. These are.
1. Application and execution of physicians, legal orders

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 2. Observation of symptoms and reactions.
3. Supervision of the those participating in care
4. Reporting and recording
5. Application and execution of nursing procedures and techniques
6. Promotion of physical and emotional health by direction and teaching.
In this audit, the nurse is evaluated by district observation in a nurse- client
interaction. A 15% sample of nurse in a unit is considered adequate.
3. Outcome Audits
Naytor, Munro and Brooten (1991) define outcomes as the "end result of
care; the changes in patient's health status that can be attributed to the delivery of
health care services. Outcome audits determine what results if any occurred as
result of specific nursing intervention for clients. These audits assume the outcome
accurately and demonstrate the quality of care that was provided. Outcomes
traditionally used to measure quality of hospital care include mortality, its
morbidity, and length of hospital stay. Outcome audit based on Orem's description
of nine categories of self-care environment.
1. Air
2. Water and fluid intake
3. Food
4. Elimination
5. Rest, activity and sleep
6. Social interaction and productive work
7. Protection from hazards
8. Normalcy
9. Health deviation
Del Bueno (1993) describes, however that outcome evaluations are always
frustrating, because it is difficult to control the variables. Nurses compare the
outcome audit metaphorically.

METHODS OF NURSING AUDIT

1. Retrospective view
Retrospective audit is a method for evaluating the quality of nursing care by
examining the nursing care as it is reflected in the patient care records for
discharged patients. In this type of audit specific behaviors are described then they
are converted into questions and the examiner looks for answering the record. For
example the examiner looks through the patient's records and asks
a. was the problem solving process used in planning nursing care
b. whether patient data collected in a systematic manner
c. was a description of patients pre- hospital routines included
d. laboratory test results used in planning care
e. Did the nurse perform physical assessment.
f. How was information used?
g. Were nursing diagnosis stated?
h. Did nurse write nursing orders? And so on.
2. Concurrent Audit
It is performed during ongoing nursing care. The evaluations conducted on
behalf of patients who are still undergoing care. It includes assessing the
patient at the bed side in relation to pre- determined criteria. Interviewing

159
 the staff responsible for this care. Reviewing the patient's record and care
plan. It includes assessing the patient at the bed- side in relation to
predetermined criteria like errors, omissions, deficiencies, as well as
efficiencies and also excess in the care of patients under them. It involves
direct and indirect observation, interviewing the staff responsible for care,
and reviewing the patient's records and care plan. It can be also done to
identify the job satisfaction of staff nurses in accordance with their work
performance.
3. Peer Review
In nurse peer review nurses functioning in the same capacity that is peer's
appraise the quality of care or practice performance by others equally
qualified nurses. The peer review is based on pre- established standards or
criteria. There are two types of peer review
a. Individual peer review; focuses on the performance of an individual nurse.
b. Nursing audit, focuses on evaluating nursing care through the review of
records.
OTHER TYPES
1. Financial Audit
It is a historically oriented, independent evaluation performed for the
purpose of attesting the fairness, accuracy and reliability of financial data.
2. Operational Audit
It is a future – oriented, systematic, and independent evaluation of
organizational activities, financial data may be used, but the primary sources of
evidence are the operational policies and achievements related to organizational
objectives.
3. Department Review
It is a current period analysis of administrative functions, to evaluate the
adequacy of contracts, safe guarding of assets, efficient use of resources,
compliance with related laws, regulations and university policy and integrity of
financial information.

4. Integrated Audit
It is a combination of an operational audit, department review, and audit
application controls review. This type of review allows for a very comprehensive
examination of a functional operation within the University.
5. Investigative Audit
It is an audit that takes place as a result of report of unusual or suspicious
activity on the part of an individual or a department. It is usually focused on
specific aspects of the work of a department or individual.
6. Follow- Up Audit
These are audits conducted approximately six months after an internal or
external audit report has been issued. They are designed to evaluate corrective
action that has been taken on the audit issues reported in the original report. When
these follow up audits are done on external auditors reports, the results of the follow
up may be reported to those external auditors.
TYPES OF AUDITORS
1. Internal Auditors

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 Nursing experts as specialists in the hospital appointed by the hospital
management.
2. External Auditors
Experts from the external statutory agencies like TNAI, INC, tec.
SIX STAGES OF NURSING AUDIT (OR) AUDIT PROCESS
Stage - I preparing for audit stage (selecting a topic
Stage- II Selecting criteria using methods for quality care
Stage- III Measuring performance Environment stage (Review of
Records)
Stage- IV Making Improvements identifying barriers to changes
(peer reviews of all cases that do not meet criteria for
quality care sustaining improvement monitoring and
evaluation, Reinforcing improvement.
Stage- V Follow up of the topic (Reaudit).
Stage 1
Before the auditing is done one needs to identify the aspect of care which is
to be audited. Involve all the people concern
i. Fix time and plan resources
ii. Access the evidence/ data
iii. methodology to be followed pilot study
iv. Report for action, Reaudit
v. All activities should be documented

Selection of a topic for audit

Explicit criteria
Follow up selected for
of quality care.

Recommen Records
dations for reviewed
correcting
deficiencie
Peer review of all cases
not meeting criteria

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Stage II
The criteria for assessing the quality care has to be decided. Any type of audit needs
to have particular criteria on the basis of which auditing will be done. Each criteria
should be clearly phrased in numerical, descriptive or behavioral terms.
1. Define patient population
2. Identify a time framework for measuring outcomes of care
3. Identify commonly recurring nursing problems presented by the defined
patient population.
4. State patient outcome criteria.
5. State acceptable degree of goal achievement
6. specify the source of information
7. Design and type of tool.
Points to be remembered
 Quality assurance must be a priority
 Those responsible must implement a programme not only a tool
 A 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 programme
 Data must be reliable.
 Adequate orientation of data collection is essential.
 Quality data should be annualized and used by nursing
Stage- III
If the retrospective kind of auditing is to be done the auditor needs to decide
in what particular time he/ she wants to review the charts.
The data collected are to be precise; essential data, completed data, adequate
data computer stored data, case notes / Medical records, surveys, questionnaires,
interview focus groups
User group to be included (Eg) Immunization status of pregnant. Women
Do not by and collect too many items, keep it simple and short
Prospective recording of specific data. How will this be done to get required
information compare performance against the criteria keep focused on the objective
of the audit.
Stage. IV
If the criterion set for auditing is not met then peer review is done to find the
reasons
 Fear
 Lack of understanding
 Low morale
 Poor communication
 Individual culture
 Doubt of outcome
 Consensus not gained

Stage- V

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  Specific recommendation are given to correct deficiencies like staff
development programme in-service education etc.
 Identification of local barriers to change
 Change culture
 Support of team work
 Use of specific methods like delegation accountability
 Monitor and evaluate the change
 Maintain and reinforce change.
Reinforcing or motivating factors by the management; integration of audit,
strong leadership.
Stage- VI
After giving recommendations, one needs to do a follow up o assess.
 Review evidence
 Measure effectiveness
 Decide how often to reaudit
 Ongoing process monitoring
 Adverse incidents
 Significant audit
AUDIT CYCLE
In setting up on audit, it is necessary to lay out a plan that addresses the
sequence of events, this is known as the audit cycle. Audit cycle gives series of
actualities which when followed eliminate any confusion.
Select a practice

Set
Standard

Accept the standard of practice

Observe standard: Assess

Implement charge:
the selected practice
exhibit the result and
suggest the

Compare practice with

standard

Audit Cycle
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Setting standards
Minimum standards are set for structure, process and outcome audit.
Observes Practice
In observing practice, directing a concurrent auditing is done where direct
care is given by the care given whereas records are observed after the patient is
discharged.
Compare with standards
All observations whether ongoing or given in the past, are compared with
the set.
Implement change
After observing the deficiencies, motivation and education is given to the
care givers. So a change can be implemented and again reauditing can be
done to evaluate the quality of care.
AUDIT COMMITTEE
An audit committee (minimum 5 members) is responsible for setting the
criteria to assess the nursing care of selected types of patients. It has representatives
from each clinical nursing division in the institution. All committee members
should be experienced and employed in direct nursing specialist will be more
suitable as a committee member than a superior. A subcommittee can be formed
who practice at bed side so that the work is made cleaner.
In conducting nursing audit, the following points are important. Formulation
of nursing audit committee should meet once a month to audit records of patients
discharged during that time. Chairperson would assign the number of charts each
member will audit Member should be very honest and impartial in their judgment.
A confidential note should be sent to the individual if something outstanding has
been recorded, and review of audit is done by the members of the committee,
compiled and submitted to the authorities.
MEMBERSHIP TO THE AUDITING COMMITTEE
Membership of the audit committee should include representative of all
levels of professional nursing including
 Client care coordinators
 Supervisors
 Chairperson ( senior nurse)
 Head nurses ( 3 to 4 members)
 Clinical specialists
 Nurse clinician
 Licensed practice nurse
 Nursing assistants
 Other client care personnel
 Medical records administrator
FUNCTIONS OF THE AUDIT COMMITTEE
During I Phase
 Developing of purpose and objective
 Establishing standards and criteria

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  Establishing guidelines for conducting audit
 Deciding upon auditing forces
 Initiating the auditing forces
 Keeping up brief, pertinent minutes of all audit committee meetings.
During II Phase
It begins with actual implementation and maintenance of audit procedure.
NURSING AUDIT TEAM
Composition of audit team will be by and large is same except changes in
the type of consultants of different specialties depending on what is to be evaluated.
 Representative of nursing administration
 Representative of nursing services
 Representative of nursing education
 Representative of nursing specialist
 Representative of clinical nurses
RESPONSIBILITIES OF AUDIT COMMITTEE
 Planning audit sessions and scheduling
 Arrange for medical records to pull charts for retrospective audits and
retrieve data
 Evaluating audit results in committee
 Conducting process audits
 Preparing summaries of all audits
 Teaching professional nursing personal the auditing process
 Assisting nursing staffs in using audit result
 Making recommendations
 Keeping brief pertinent minutes of audit committee meetings.
 Reporting audit results, a committee's work, summary of audit activity
 An organized presentation of general findings
 Follow through action that has taken place
 Impact of follow up action on problem conditions.
AUDIT METHODOLOGY
There are different methods to carry out medical or nursing audit
 Statistical method
 Death or mortality review method
 On the spot medical or nursing audit
FACTORS INFLUENCING AUDIT PROCESS (OR) FAILURE
OF AUDIT
According to Nelson (1976) the failure audit has been due to
 Absence of proper records, protocol.
 Improper infrastructure or improper structure
 Inadequate supplies and equipments
 Lack of continuing nursing education and staff development programmes
Other factors
 Lack of resources
 Personal problems
 Unreasonable clients and attendants
 Absence of accreditation

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  Legal redress
 Lack of incident review procedure
 Lack of good hospital
 Advance of survey condition routine
 Lack of nursing case records
ADVANTAGES
1. Can be used as a method of measurement in all areas of nursing
2. Seven functions are easily understood
3. Scoring system is fairly simple
4. Results easily understood
5. Assesses the work of all those involved in recording care
6. May be useful program in areas a quality assurance program in areas where
accurate records of care are kept
7. Patient is assured of good service
8. Better planning of quality improvement can be done
9. It develops openness to change
10. It provided assurance, by meeting evidence based practice
11. It increases understanding of client's expectations.
12. It minimizes error or harm to patient
13. It reduces complaints or claims.
DISADVANTAGES
1. It may be considered as a punishment o professional group
2. Median – legal importance- they feel that they will be used in court
of law as any document can be called for in a court law
3. Many components overlap may make analysis difficult
4. It is time consuming
5. It requires a team of trained auditors
6. Appraises the outcomes of the nursing process, so it is not useful in
areas where the nursing process has not been implemented
7. Deals with a large amount of information
8. Only evaluates record keeping, it only serves to improve
documentation, not nursing care.

APPLICATION OF NURSING AUDIT

For nursing care services
It helps in modifying nursing care plans and nursing care process;
implementing a programme for improving documentation of nursing care through
improved charting policies, focusing attention, weaknesses identified; nursing
round and term conferences, and designing responsible orientation and in-service
education programme.
For Nursing Administrator
Providing evaluation of particular programme, such as orientation of
personnel or establishment of a particular teaching programme; support for
financing a particular programmers'; serving as basis for planning new
programmes; identification of areas of strength and weakness in various settings;
determining the influence of varied staffing patterns.

166
For supervisions and Head Nurses
Identifying areas of needed patient care improvement, providing basis for
in- service education programme, and identifying needs of staff members who gives
direct care to patient.
For staff nurses
It provides a self-examination of care; identifies a particular type of care in
which practice may be improved merely by increased attention and identified types
of care on which improvement will depend.
RESEARCH STUDIES
Auditing in health care organizations provides managers with a means of
applying control process to determine the quality of service rendered. Thomas
(2005) explained that information gained from an audit identifies educational needs,
risk management and possible complaints. An audit on hypertension at a clinic
found that many patients with raised blood pressure also had a high body mass
index. Based on these information obesity clinics was set up to help educate and
support the patients.
Kaur et al (2005) used a retrospective approach to access maintenance of 10
intake and output documents observation Performa was used for assessment.
Gournay and Bowers (2000) showed that significant use of audit in suicide
and self harm patients. Morgan (1994) pointed out that suicide in psychiatric
hospital demarks a careful evaluation of present day practice.
CONCLUSION
Nursing audit measures the quality of nursing care actually given to patients
retrospectively when the cycle care has ended. Audit findings always suggest for
improvement of care and there are ways in which nurses can take the initiative, both
unilaterally and in collaboration with others, in developing pattern of care and of
health services delivery systems.
A profession dedicated for the quality of its service to practice constitute the
heart of its responsibility to the public and audit helps to ensure that the quality of
nursing care desired and feasible is achieved.
Nursing audit on regular basis is used as a tool to improve nursing services
and quality care assurance in nursing. In India nursing administration of a hospital
or institution is for behind than medical audit team to constitute nursing audit team.
At least it can be started as internal nursing audit by the nursing leaders. They can
develop the protocol for their own hospitals and discuss with the medical
administrative authority while framing the policy of nursing services. This will help
us to implement concept of nursing audit in our own organization.
The community is becoming increasing by aware and interested in its health
rights in the present era. These who use public resources should be accountable to
the public for the way in which they use and dispose their resources. Consumer
organizations, health councils and other thoughtful lay bodies are increasing the
pressure for accountability of health care which leads to evaluate our work.

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QUALITY IMPROVEMENT – CONTINUOUS
QUALITY MANAGEMENT
INTRODUCTION
"Insanity is doing the same thing the same way and expecting different
results". Quality improvement is not necessarily a replacement for existing quality
assurance activities, but rather an approach that broadens the perspectives on
quality. Quality improvement: the continuous study and improvement of a process,
system or organisation.Quality improvement is a formal approach to the analysis of
performance and systematic efforts to improve it. Quality improvement is proactive
works on processes before problems occur but quality assurance is reactive; works
on problems after they occur. In Industry, quality efforts focus on topics like
product failures or work related injuries. In administration, one can think of
increasing efficiency or reducing re work. In medical practice, the focus is on
reducing medical errors and needless morbidity and mortality. Quality improvement
is a term often used to describe "a cycle of quality".
DEFINITION
1. Quality improvement can be defined as "an organized process that assesses
and evaluates health services to improve practice or quality of care.
2. Quality improvement (QI) is not simply an end goal. Quality Improvement
is a continuous process that employs rapid cycles of improvement.
QUALITY ASSURANCE VERSUS QUALITY IMPROVEMENT
Quality improvement is not necessarily a replacement for existing quality
assurance activities, but rather an approach that broadens the perspectives on
quality

S.No Quality assurance (QA) Quality Improvement (QI)

1  Inspection oriented
(detection)
2  Reaction
3  Correction of special
causes
4  Responsibility of few
people
5  Narrow focus
 Leadership may not be
6 vested
7  Problem solving by
authority
 Planning oriented (prevention)
 Proactive
 Correction of common causes
 Responsibility of all people
involved with the work
 Cross- functional
 Leadership actively leading
 Problem solving by employees at
all levels

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CONCEPTS
The process or processes of reducing variance is quality improvement. It is the
process of attaining a new level of performance or quality that is superior to any
previous level of quality.
1. Measurement is not an action. You need to change the processes to change
the outcome.
2. Quality improvement is a science with validated tools and methods
3. There are 6 principles of quality improvement
4. IOM aims and ACGME core competencies are drivers of improvement
5. The improvement model is the framework adopted for improvement
projects.

STEPS OF QUALITY IMPROVEMENT

According to the quality cycle developed by USAID QA project, the following
steps have to be in place before the intervention processes for improvement can
begin
 Planning for quality
 Setting a standard
 Communicating of standard
 Monitoring (against thresholds)
 Identification and prioritization of improvement opportunities(IQ)
 Defining the key IQs
 Organizing a team.
 Analyzing and studying the IQ’s for root causes.
 Developing solution and actions for improvement.
 Implementing and evaluating improvement efforts, then restarting the cycle
again.
CORE PRINCIPLES OF QUALITY IMPROVEMENT PROJECT
• Continuous improvement
• Customer focus
• Incident prevention
• Universal responsibility

MODELS OF QUALITY IMPROVEMENT

The models of quality improvement were
1. FADE
There are 4 broad steps to the FADE QI Model.
Focus - Define and verify the process to be improved.
Analyze - Collect and analyze data to establish baselines, identify
root causes and point towards possible solutions.

169
Develop - Based on the data, develop action plans for improvement,
including implementation, communication and measuring
/ monitoring.
Execute and Evaluate
Implement the action plans, on a pilot basis, and install on ongoing
measuring/ monitoring (process control) system to ensure success.
2. PDSA
The 4 steps in this model include
Plan : Plan a change or test of how something works.
Do : Carry out the plan.
Study : Look at the results. what did you discover?
Act : Decide what actions should be taken to improve.
SIX SIGMA (DMAIC- DEFINE, MEASURE, ANALYZE, IMPROVE, CONTROL)
An improvement system for existing processes falling below specification
and looking for incremental improvement.
CQI- CONTINUOUS QUALITY IMPROVEMENT
It focuses on the process rather than the individual, recognizes both internal
and external customers and promotes the need for objective data to analyze and
improve process. CQI is an approach to quality management that builds upon
traditional quality assurance methods by emphasizing the organization and systems.
TOTAL QUALITY MANAGEMENT
A Set of management practices throughout the organization, general to
ensure the organization consistently meets or exceeds customer requirements.
ROOT CAUSE ANALYSIS (RCA)
RCA is defined as a retrospective approach to error analysis that requires
rigorous application of established qualitative techniques. The report also identifies
2 major steps involved in root cause analysis.
Data Collection
Establishment of what happened through structured interviews, document
review, and/ or field observation. These data sets are used to generate a sequence or
timeline of events preceding and following the event.
Data Analysis
An interactive process to examine the sequence of events generated above
with the goals of determining the common underlying factors.
• Establishment of how the event happened by identification of active failures
in the sequence
• Establishment of why the event happened through identification of latent
failures in the sequence that can be generalized.

QUALITY IMPROVEMENT CYCLE

PDCA Cycle.
HEALTH CARE QUALITY IMPROVEMENT COMPONENTS
The best care possible can only happen if these two components are
addressed.
1. Clinical improvement
Doing the right thing. What we do to our patients.

170
2. Process improvement
Doing the right thing in the right way how we deliver care and al the
processes that support the delivery.

PRINCIPLES OF QUALITY IMPROVEMENT

There are 6 principles of quality improvement.
1. Customer focus
2. System thinking
3. Understanding variation in data
4. Collaboration / teamwork
5. Deciding on improvements and implementing changes
6. Leading improvements
1. Customer Focus
Meeting the needs of the external customers (patients, families, referral
sources, etc) and meeting the needs of internal customers (staff, physicians,
leaders).

2. System thinking
Understanding the process in which we work, appreciating how all the
processes are interdependent- must all come together to accomplish the aim of the
system. Decreasing needless variation and assure reliability. Error proofing
requires an understanding of the processes as doing studying why an adverse event
occurred.
3. Understanding variation in Data
Knowing how to interpret data plotted over time. Some variation in data require
immediate action (special cause) while some variation is inherent in the processes
(common cause). Knowing the difference is important in using resources wisely.
Understanding variation is also very important to determine if suggested changes
made o the system will result in improvements.
4. Collaboration / Treatment
Quality improvement cannot occur unless everyone who touches the process
is involved. This requires multidisciplinary teamwork collaboration can sometimes
be difficult to a amplest and requires knowledge of how group dynamics another
component of collaboration is an understanding of what motivates people to change
(or resist change) and how to manage that change.
5. Deciding on Improvement and Implementing changes
Deciding on proposed changes needs to be based on data.
6. Leading Improvement
This requires that leaders be open to input, know the tools of improvement
and be facilitators of change. Since not all changes will result in improvements,
when efforts fail to accomplish the desired aim, the leader must be able to redirect
the efforts of the team and continue motivating team members

SOLUTIONS OF THE QUALITY IMPROVEMENT:

Some of the solutions of quality improvement are:
a. Individual problem solving
b. Rapid team problem solving
c. Systematic team problem solving

171
 d. 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.

HISTORY OF CONTINUOUS QUALITY IMPROVEMENT

Continuous quality improvement is a concept which includes quality assurance the
provision of services that meet an appropriate standard. Problem resolution
including all departments involved on the issue at hand. Quality improvements a
continuous process involving all levels of the organizations working together across
departmental lines to produce better services for health care clients.
Continuous quality improvement (first called statistical process control) is a
science that was developed in the 1920s by Dr. Watter schewhart, a statistician Bell
labs. His students included Dr. W. Edwards Deming Dr. Joseph Juran and many
other prominent figures in the field of quality improvement.

172
 The first control chart by Dr. She what in 1924 laid the foundation for
quality improvement as a science with validated tools and methods. Health care like
other industries fundamentally has processes that lead to outcomes. If outcomes are
not optimal, then we need to improve (or completely redesign) the processes to
obtain better outcomes.
DEFINITION OF CQI
An approach to quality management that builds upon traditional quality
assurance methods by emphasizing the organization and systems focuses on
'process' rather than the individual, recognizes both internal and external
'customers', promotes the need for objective data to analyse and improve processes.
- Graham (1995)

Continuous quality improvement is a process to ensure programs are

systematically and intentionally improving services and increasing positive
outcomes for the clients they serve.

PRINCIPLES OF CONTINOUS QUALITY IMPROVEMENT

Nurse Managers who have implemented quality improvement efforts
have identified underlying principles for this control measure.
1) Because both physicians and nurses contribute to patient care
outcomes neither physicians or nurses should unilaterally carry responsibility for
quality improvement. Rather all health care professionals should collaborate in
projects to measure and improve care.
2) In planning a comprehensive quality-improvement program for a
health agency, the activities of various health care professionals must be
coordinated to ensure that efforts of diverse care givers enhance those of others.
3) Managers should undertake cost-benefit studies to ensure that
resource expenditure for quality assurance activities is appropriate in amount.
4) To ensure that resources invented in improvement efforts yield
significant results, nurses should monitor only critical performance factors, that is
those activities that yield the greatest health and financial benefit.
5) The key to improving patient care quality is accurate evaluation of
care and key to successful evaluation of care is adequate documentation of care.
6) The ability to achieve nursing objectives depends on the optimal
functioning of every step in the nursing process and effective monitoring.
7) Evaluation of care alone will not improve nursing practice.
Continuous feedback of nursing outcomes is needed to perpetuate good practice and
replace unsatisfactory interventions with more effective methods.
8) After nursing care quality is assed and needed improvements are
identified, peer pressure can provide the impetus needed to effect the prescribed
practice changes.
9) If assessment reveals the need for a different pattern of care delivery
recognition of care at unit level may require changes in formal organization
structure.
10)For quality improvement efforts to be effective, the collection and
analysis of quality assessment data must be performed by a nurse who has
decision making authority.

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APPROACHES OF CONTINUOUS QUALITY MANAGEMENT
The Donabedian Model provides three dimensions for the quality of care.
These dimensions are
1. Structure which represents the attributes of settings where care is delivered
2. The process or' whether or not good medical practices are followed, and
3. The outcome, which is the impact of the care on health status.

Continuous quality Improvement

Structure Proce
Out put Out
people ss
com

BASIC TENETS OF QUALITY IMPROVEMENT

According to JCAHO, the following are the seven basic tenets of quality
improvement.
1. Organization is commitment from the leadership to set quality
priorities,re-orient the organization to a customer focus, and
function as role models.
2. Leaders must define quality in their organization and incorporate it
into mission statements and planning documents.
3. Needs and expectations of customers, both internal and external to
organization must be explored with corresponding organization
changes to meet those needs.
4. The focus of improved quality must be directed towards work
processes instead of individuals.
5. Quality improvement must emphasize prevention with quality by
design rather than quality by inspection.
6. Quality improvement is based on the use of problem-solving
methods and statistical tools, with all the processes and decisions
being data driven.

THREE APPROACHES TO ENACTING QUALITY

IMPROVEMENT
Deming's fourteen points for Management
1. create constancy of purpose for improvement of product and service
2. adopt the new philosophy
3. lease dependence on inspection to achieve quality
4. End the practice of awarding business on the basis of price tag alone.
Instead, minimize total cost by working with a single supplier.

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 5. Improve constantly and forever every process for planning, production and
service.
6. Institute training on the job
7. Adopt and institute leadership
8. Drive out fear
9. Break down barriers between staff areas.
10. Eliminate slogans, exhortations, and targets for the workforce.
11. Eliminate numerical goudas for the workforce and numerical goals for
management
12. Remove barriers that rob people of pride of workmanship. Eliminate the
annual rating or merit system.
13. Institute a vigorous program of education and self- improvement for
everyone
14. Put everyone in the company to work to accomplish the transformation.
Furan's six steps to Quality Improvement
1. Identify a project Nominate projects evaluate a projects select a project
ASK: It it quality improvement
2. Establish a project prepare a mission statement. Select a team verify the
mission.
3. Diagnose the cause. Analyze symptoms confirm or modify the mission.
Formulate theories, test theories and identify root cause.
4. Remedy the cause
Evaluate alternatives
Design remedy
Design controls
Design for culture
Prove effectiveness
Implement
5. Hold the gains
Design effective quality controls.
Fool proof the remedy
Audit the controls
6. Replicate results and
Nominate projects
Replicate the project results
Nominate new projects
Crosby's fourteen steps to Quality Improvement
1. Make it clear that management is committed to quality
2. Form quality improvement teams with representatives from each
department.
3. Determine where current and potential quality problems lie.
4. Evaluate the cost of quality and explain its use as a management tool.
5. Raise the quality awareness and personal concern of all employees
6. Take actions to correct problems identified through previous steps.
7. Establish a committee for the zero defects program
8. Train supervisors to actively carry out their part of the quality improvement
program
9. Hold a "zero defects day" to let all employees realize that there has been a
change.

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 10. Encourage individuals to establish improvement goals for themselves and
their graphs
11. Encourage employees to communicate on to management the obstacles they
face in attaining their improvement goals.
12. recognize and appreciate those who participate
13. Establish quality councils to communicate on a regular basis
14. Do it over again to emphasize that the quality improvement program never
ends.

IOM SIX AIMS OF FOR IMPROVEMENT

Safe : avoiding injuries to patients from the care that is intended
to help them.
Effective : Providing services based on scientific knowledge to all
who could benefit, and refraining from providing
services to those not likely to benefit.
Patient centered:
Providing care that is respectful of and responsible to individual patient
preferences, needs and values and ensuring that patient values guide all clinical
decisions.
Timely
Reducing waits and sometimes harmful delays for both those who receive
and those who give care
Efficient
Avoiding waste, including waste of equipment, supplies, ideas, and energy.
Equitable
Providing care that does not vary in quality because of personnel
characteristics such as gender, ethnicity, geographic location, and socioeconomic
status.
QUALITY IMPROVEMENT CIRCLES:
Input output

Care Surve
givers y Compliance
activitie forms
rate
Director observation
complication
of care peer review
Patient rate
Direct retrospective chart
’s eruptions to
obser audit
charts standards
vation performance
of evaluation
Patient
mortality
and Feedback
morbidity Nursing
care
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standards
Lengt
h of
stay
statist

Since in 1970s the emphasis has shifted from presenting mistakes that lower health
care quality to ensuring the achievement of pre-established standards of care, to
continuous improvement in care quality. With this shift, many health agencies
instituted quality circles as means of motivating employees to improve patient care.
Quality circles were introduced in Japan during the 1960s to improve quality and
productivity in various industries. A quality circle is a group of 5-15 employees
who perform similar work and meet for one hour each week to solve work related
problems. The group activities begin by identifying problems associated with their
common task. Then the group concentrates on one problem at a time, exploring
problem causes, identifying possible solutions and proposing a preferred solution to
management through a formal presentation. While identifying and analyzing work
problems, the quality circle uses decision techniques s brain storming. When
management approves the group’s proposal, the circle implements its plan for
problem solution and evaluates solution effectiveness. If the problem is resolved the
quality circle group moves on to the next problem that they have identified and the
cycle begins new. When quality circles were used in hospitals, the groups were
most successful in solving problems when circle leaders and members were
pecifically trained in problem solving techniques.
Experts claim that the most common shortcoming of the older quality
assurance programs was the failure to provide adequate and timely feedback of
information about quality assessment data to care givers. This problem is associated
somewhat when caregivers, rather than managers, monitor critical indicators,
establish structure, process and outcome criteria and measure the achievement of
selected criteria.

METHODS OF CONTINOUS QUALITY MANAGEMENT

The primary purpose of nursing quality improvement program should be the
enhancement of patient outcomes. The thrust of nursing quality improvement
should be two fold.
1) To measure
2) To improve the quality of nursing interventions
The methods used are
i. Professional standards setting
ii. Peer review
iii. Continuous monitoring of critical clinical indicators.
iv. Quality circles
v. Patient care retrospective chart audit
vi. Patient care concurrent process audit

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PROFESSIONAL STANDARDS SETTING
The American nurses association has been instrumental in developing
professional standards for almost 80 years. A standard is a predetermined level of
excellence that serves as a guide for practice. Standards have distinguishing
characteristics that are predetermined, established by an authority and
communicated to and accepted by people affected them. standards for practice
define the scope and dimensions of professional nursing.

CONTINOUS MONITORING OR CRITICAL CLINICAL INDICATIONS

A clinical indicator is a quantitative measure that serves as a guide to monitor
and evaluate the quality of an important aspect of patient care. Data relating to
clinical indications are not direct.
Measures of care quality but flags that identify elements of patient care that
may require further evaluation. Indicators, like criteria, are of three types structure,
process and outcome. Care givers in each nursing unit should determine the
indications to be continuously monitored in that clinical setting. There are two
general types of indicators 1) sentinel event and rate based. A sentinel event
indicator such as medication error is a serious indicator. A rate based indicator
reflects the incidence or frequency of care process or patient care outcome that
varies from normal.
PATIENT CARE RETROSPECTIVE CHART AUDIT
In retrospective audit patient care is observed or evaluated only after the
patients discharge from the health facility. In retrospective audit, the patients
medical records is the sole source of information about care given during the
patient’s stay in the facility. The accuracy of an retrospective audit depends on the
accuracy and completeness of documentation by all of the patients care givers.
PATIENT CARE CONCERRENT PROCESS AUDIT
In concurrent process audit the patient care is observed as it is given to the
patient. This is more satisfactory than retrospective audit.

PEER REVIEW
Peer review is the process by which employees of the same profession, rank
and setting evaluate one another’s job performance against accepted standards. The
peer group should develop a performance appraisal tool for calculating the value of
each aspect of the nurse’s performance to be evaluated by peers. Peer review
activities are
a) Observe nurse giving care to one or two patients in careload.
b) Review nurse’s records of history and physical examination findings
c) Observe the nurse’s instructions of patients, families and other staff
members.
d) Observe the nurse’s participation in multi-disciplinary patient care
conferences.
e) Review the nurses documentation of care on medical records , cpr reports
f) Review the nurses change of shift reports, care management reports.
g) Review care plans, care studies, scholarly papers written by nurse.
QUALITY CIRCLES
Quality circles are introduced in Japan during 1960’s to improve quality and
productivity in various industries. A quality is a group of 5 to 15 employees who

178
perform similar work and meet for one hour each week to some work related
problems. The group activities begin by identifying problems associated with their
common task. Then the group concentrates on one problem at a time, exploring
problems, causes, identifying possible solutions, and proposing a preferred solution
to management through a formal presentation. When management approves the
group’s proposal the circle implements its plan for problem solution effectiveness.
If the problem is resolved then group moves to the next problem.

.
STEPS IN CONTINUOUS IMPROVEMENT
1. Form a team that has knowledge of the system needing improvement.
2. Define a clear cum
3. Understand the needs of the people who are served by the system.
4. Identify and define measures of success.
5. Brain storm potential change strategies for producing improvement
6. Plan, collect, and use data for facilitating effective decision making
7. Apply the scientific method to test and refine changes.

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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 .

COMMONLY USED CQI TOOLS AND METHODS

1. Brain storming
2. Scatter diagram
3. Story board
4. Conducting effective meetings
5. Pareto Charts
6. Fishbone Diagram
7. Histograms
8. Run Charts
9. check sheets
10. Flowchart
11. Control Charts

1. Brain storming – creating bigger and better ideas

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 To generate a high volume of ideas on any topic by creating a process that is
free of criticism and judgment
a) Nominal group Technique (NGR) – Ranking for consensus
To allow a team to quickly come to consensus on the importance of issues,
problems or solutions.
b) Motivating – Rating for consensus
To allow a team to quickly come to consensus on the importance of issues,
problems or solutions.
2. Scatter Diagram- Measuring relationship between variables
To study and identify the possible relationship between the changes
observed in two different set of variables.
3. Storyboard
A Communication vehicle to display improvement efforts to alert others of
changes being tested or carried out.
4. Conducting Effective Meetings
7 steps meeting process
5.Pareto Charts: - Focus on key problems
To focus efforts in the problems that effort the greatest potential for
improvement by showing their relative frequency or size in a descending bar graph
Pareto principles 20% of the sources cause 80% of any problem.
The Pareto chart is a histogram displaying the most significant factors
contributing to a problem. It is similar to histogram with frequency values on
vertical axis and categories on the horizontal axis. With the Pareto, however, the
frequent causes of the problem were plotted on the graph in descending
order.Therefore,it separates visually the significant causes from the significant ones.
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 analysis is used when
dealing with chronic problems and helps one identifies 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.

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5. Fishbone Diagram:

Find and cure causes, not symptoms. To identify, explore, and graphically
display in increasing detail, all of the possible causes related to a problem or
condition to discover its cause.
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. The major categories of causes are put on major branches
connecting to the backbone, and various sub-causes are attached to the branches.
The diagram identifies the variety of factors affecting a specific problem. It
is useful whenever one suspects several causes that may contribute to a problem.
Diagonal lines are drawn off the main line depicting major categories of
causes associated with the effect. Generally these categories are people, policies,
equipment, and procedures etc.
Brainstorming is used to identify all the contributing factors to a problem,
which are written on the appropriate diagonal line of the diagram.

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6.Histogram:
process centering, spread and shape
To summarize data from a process that has been collected over a period of
time, and graphically present its frequency.

A histogram is a graph of frequency distribution of a set of data. It is useful

in data analysis phase of quality improvement. It provides a visual summary of the
data. It is constructed by graphing frequency values on the vertical axis in a logical
order. Data is then graphed appropriately.
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

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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. To process results and readily determine if a current process was able to produce
positive results assist with decision-making

7.Run chart:

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Run (Trend) chart- Tracking trends
To study observed data (a performance measure of a process) for trends and
patterns over a specified period of time
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.
8.Check sheets:

Item A B C D E F G

------- √ √ √ √ √ √ √ √√ √ √
------- √ √ √√ √ √ √√
------- √

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.
9.Flowcharts:

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picturing the process.To identify the actual flow or sequence of events in a process
that any product or service follows.

A flowchart is a pictorial representation of the steps in a process. It is a

cornerstone of an analysis by clarifying process and identifying inefficiencies. A list
of all the tables involved in the process is developed. Symbols are used to highlight
process steps. Flowcharts are usually drawn using standard symbols;however,some
special symbols can also developed when required.

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: -

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
10.Control chart-recognizing sources of variation
To monitor, control, and improve process performance over time by
studying variation and its source.
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 process, 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 tomaintain stability in a process by depicting when
a process may be affected by special causes. The consistency of a process is usually

186
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.

Performance Metric

Time

BASIC TECHNIQUES
1. Critical thinking
Flow chart/ Diagram
2. Bench marking
Compare to best practice
3. Using technology
Barcodes for medications.

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 4. Creative thinking
Become a patient for a day
5. Use change concepts
Change work environment, manage time, focus on variation, and focus on
error proofing (checklist)

BARRIERS OF CONTINUOUS QUALITY IMPROVEMENT

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

TOTAL QUALITY CONTROL (TQC)

Total quality control Simply means we do what we are supposed to do. In
health care quality tended to be limited to establish standards for structure and
processes in clinical care we now realize that limited quality restricts our ability to
succeed we need to expand our approach to total quality or "Big Q" Total quality
means
1. Clinical care
2. Service to all customers
3. Support services
4. Process including all functions.

TOTAL QUALITY MANAGEMENT

Competition is getting harder and becoming global. Companies now have to
bemore responsive, offer a better product and keep improving. Total quality
management (TQM) increases customer satisfaction by boosting quality. It does
this by motivating the workforce and improving the way the company operates. In
an increasingly competitive market, firms with a continuous improvement culture
and external focus are more likely to survive and prosper.TQM is considered an
important catalyst in this context.
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 Before deciding to apply the principles of total quality management (TQM)
the top manager should learn the theory of TQM. All members of the team should
read "out of the crisis" in which Deming describes his theory of TQM and the
deadly disease of management and recommends a management philosophy. The
following are some of the goals for the new breed of nurse leaders.
1. Change the management style and operating climate
2. Do the job right the first time to meet and exceed customer expectations
3. Stop producing waste. Innovate and exited the customer with high quality
services.
4. Look at the waste standards and spoilage problems of nursing
5. Use process data to change methods, techniques and technology to create
improvements.
6. Replace boss imposed solutions with group interaction.
Total quality management is the new wave of nursing management. It is a
proven theory waiting for broad application.
Health care professionals must be accountable for the quality of their practice
and self-regulating professional organizations have the responsibility to ensure that
the public receive the best possible care to which it is entitled.

In 1985, Nancy Warren, a behavioral scientist in the US Navy, first suggested

“Total Quality Management’ History of TQM Total quality management was
developed in the 1940s by Dr. W. Edward Deming who at the time was an advisor
in sampling at the Bureau of census and later became a professor of statistics at the
New York University graduate school of business administration. He had little
success convincing American business to adopt TQM but his management methods
did gain success in Japan.In the 1970 and 1980s many American companies
including Ford, IBM and Xerox, began adopting Dr. Deming’s principle of
TQM.This gradually lead to their regaining some of the markets previously lost to
the Japanese. Although TQM gained it’s prominence in the private sector, in recent
years it has been adopted by some public organization.
DEFINITION
It is an organized and integrated system of continuous quality
improvement (CQI) aimed at meeting customer’s expectations.
It is the process of individual &organizational development the purpose of
which is to increase the level of satisfaction of all the stakeholders.

PIKE, R J BARNES

TQM is an approach to improving the effectiveness and flexibilities of business

as a whole. It is essentially a way of organizing and involving the whole
organization, every department, every activity and every single person at every
level. TQM ensures that the management adopts a strategic overview of the quality
and focuses on prevention rather than inspection.
OBJECTIVES
Meeting the customers’ requirements is the primary objective and the
key to organizational survival and growth.

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 The second objective of TQM is continuous improvement of quality. The
management should stimulate the employees in becoming increasingly competent
and creative.
Third, TQM aims at developing the relationship of openness and trust among
the employees at all levels in the organization.
According to Slee and Slee, 1991; Gillem 1988, the objectives of TQM are as
follow
To establish specific quality goals.
To incorporate the improvement of quality as a responsibility shared by all
employees.
To educate and train the employees.
To formally recognize efforts to improve quality.
To identify specific projects that promise to improve quality.
To provide necessary resources, both real and financial.
To regard employees as not only a provider but also a user of the services or
results produced by antecedent events in the process of rendering on episode3 or
regimen of care.
To focus continually on methods of improving the quality of care.
According to McLanghlin and Kaluzncy,1994:The primary objective of TQM is
not only to focus on the needs of the clients, a concept that includes employees and
patients, but also to lower costs by improving quality and reducing waste.

KEY PRINCIPLES OF TQM

The principles of TQM are focused on work processes, customer orientation,
and statistical data analyses are as follows
Management accountability
Teamwork
Continuous improvements.
PRINCIPLES OF TOTAL QUALITY MANAGEMENT
TQM can be defined as the management of initiatives and procedures that are
aimed at achieving the delivery of quality products and services. A number of key
principles can be identified in defining TQM, involving

190
 Executive Management
Top management should act as the main driver for TQM and create an
environment that ensures its success.
Training
Employees should receive regular training on the methods and concepts of
quality.
Customer focus
Improvements in quality should improve customer satisfaction. The customer
ultimately determines the level of quality. No matter what an organization does to
foster quality improvement—training employees, integrating quality into the design
process, upgrading computers or software, or buying new measuring tools—the
customer determines whether the efforts were worthwhile.
Decision-making
Quality decisions should be made based on measurements.
Methodology and Tools
Use of appropriate methodology and tools ensures that non-performances are
identified, measured and responded to consistently.
Continuous Improvement
Companies should continuously work towards improving manufacturing and
quality procedures.
Company Culture
The culture of the company should aim at developing employees ability to
work together to improve quality.
Employee Involvement
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 Employees should be encouraged to be proactive in identifying and
addressing quality related problems. All employees participate in working toward
common goals. Total employee commitment can only be obtained after fear has
been driven from the workplace, when empowerment has occurred, and
management has provided the proper environment. High-performance work
systems integrate continuous improvement efforts with normal business operations.
Self-managed work teams are one form of empowerment.

Process Centered
A fundamental part of TQM is a focus on process thinking. A process is a
series of steps that take inputs from suppliers (internal or external) and transforms
them into outputs that are delivered to customers (again, either internal or external).
The steps required to carry out the process are defined, and performance measures
are continuously monitored in order to detect unexpected variation.
Integrated System
Although an organization may consist of many different functional specialties
often organized into vertically structured departments, it is the horizontal processes
interconnecting these functions that are the focus of TQM. Micro-processes add up
to larger processes, and all processes aggregate into the business processes required
for defining and implementing strategy. Everyone must understand the vision,
mission, and guiding principles as well as the quality policies, objectives, and
critical processes of the organization. Business performance must be monitored and
communicated continuously. …….to be continued
An integrated business system may be modeled after the Baldrige National
Quality Program criteria and/or incorporate the ISO 9000 standards. Every
organization has a unique work culture, and it is virtually impossible to achieve
excellence in its products and services unless a good quality culture has been
fostered. Thus, an integrated system connects business improvement elements in an
attempt to continually improve and exceed the expectations of customers,
employees, and other stakeholders.
Strategic and SystemicApproach
A critical part of the management of quality is the strategic and systematic
approach to achieving an organization’s vision, mission, and goals. This process,
called strategic planning or strategic management, includes the formulation of a
strategic plan that integrates quality as a core component.
Continual Improvement
A major thrust of TQM is continual process improvement. Continual improvement
drives an organization to be both analytical and creative in finding ways to become
more competitive and more effective at meeting stakeholder expectations.
Fact-Based Decision Making
In order to know how well an organization is performing, data on performance
measures are necessary. TQM requires that an organization continually collect and
analyze data in order to improve decision making accuracy, achieve consensus, and
allow prediction based on past history.
Communications
During times of organizational change, as well as part of day-to-day operation,
effective communications plays a large part in maintaining morale and in
motivating employees at all levels. Communications involve strategies, method, and
timeliness.

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 ELEMENTS OF TQM
Elements of TQM these elements can be divided into four groups according
to their function. The groups are:
Foundation – It includes: Ethics, Integrity and Trust.
Building Bricks – It includes: Training, Teamwork and Leadership.
Binding Mortar – It includes: Communication.
Roof – It includes: Recognition.

TQMFoundation: TQM is built on a foundation of ethics, integrity and trust.

It fosters openness, fairness and sincerity and allows involvement by everyone. This
is the key to unlocking the ultimate potential of TQM. These three elements move
together, however, each element offers something different to the TQM concept.
Ethics – Ethics is the discipline concerned with good and bad in any situation. It
is a two-faceted subject represented by organizational and individual ethics.
Organizational ethics establish a business code of ethics that outlines guidelines that

193
all employees are to adhere to in the performance of their work. Individual ethics
include personal rights or wrongs.
Integrity –Integrity implies honesty, morals, values, fairness, and adherence to
the facts and sincerity. The characteristic is what customers (internal or external)
expect and deserve to receive. People see the opposite of integrity as duplicity.
TQM will not work in an atmosphere of duplicity.
Trust – Trust is a by-product of integrity and ethical conduct. Without trust, the
framework of TQM cannot be built. Trust fosters full participation of all members.
It allows empowerment that encourages pride ownership and it encourages
commitment. It allows decision making at appropriate levels in the organization,
fosters individual risk-taking for continuous improvement and helps to ensure that
measurements focus on improvement of process and are not used to contend people.
Trust is essential to ensure customer satisfaction. So, trust builds the cooperative
environment essential for TQM.
TQM Bricks: Basing on the strong foundation of trust, ethics and integrity,
bricks are placed to reach the roof of recognition. It includes:
TQMTraining – Training is very important for employees to be highly productive.
Supervisors are solely responsible for implementing TQM within their departments,
and teaching their employees the philosophies of TQM.Training that employees
require are interpersonal skills, the ability to function within teams, problem
solving, decision making, job management performance analysis and improvement,
business economics and technical skills. During the creation and formation of
TQM, employees are trained so that they can become effective employees for the
company.
TQMTeamwork – To become successful in business, teamwork is also a key
element of TQM. With the use of teams, the business will receive quicker and better
solutions to problems. Teams also provide more permanent improvements in
processes and operations. In teams, people feel more comfortable bringing up
problems that may occur, and can get help from other workers to find a solution and
put into place. There are mainly three types of teams that TQM organizations adopt:
Quality Improvement Teams or Excellence Teams (QITS) – These are
temporary teams with the purpose of dealing with specific problems that often re-
occur. These teams are set up for period of three to twelve months.
Problem Solving Teams (PSTs) – These are temporary teams to solve certain
problems and also to identify and overcome causes of problems. They generally last
from one week to three months.
Natural Work Teams (NWTs) – These teams consist of small groups of skilled
workers who share tasks and responsibilities. These teams use concepts such as
employee involvement teams, self-managing teams and quality circles. These teams
generally work for one to two hours a week.
TQMLeadership – It is possibly the most important element in TQM. It appears
everywhere in organization. Leadership in TQM requires the manager to provide an
inspiring vision, make strategic directions that are understood by all and to instill
values that guide subordinates. For TQM to be successful in the business, the
supervisor must be committed in leading his employees. A supervisor must
understand TQM, believe in it and then demonstrate their belief and commitment
through their daily practices of TQM.
The supervisor makes sure that strategies, philosophies, values and goals are
transmitted down throughout the organization to provide focus, clarity and

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direction. A key point is that TQM has to be introduced and led by top
management. Commitment and personal involvement is required from top
management in creating and deploying clear quality values and goals consistent
with the objectives of the company and in creating and deploying well defined
systems, methods and performance measures for achieving those goals.
TQMBinding Mortar: Communication – It binds everything together. Starting
from foundation to roof of the TQM house, everything is bound by strong mortar of
communication. It acts as a vital link between all elements of TQM.
Communication means a common understanding of ideas between the sender and
the receiver.
The success of TQM demands communication with and among all the
organization members, suppliers and customers. Supervisors must keep open
airways where employees can send and receive information about the TQM
process. Communication coupled with the sharing of correct information is vital.
For communication to be credible the message must be clear and receiver must
interpret in the way the sender intended.
There are different ways of communication such as: A. Downward
communication – This is the dominant form of communication in an organization.
Presentations and discussions basically do it. By this the supervisors are able to
make the employees clear about TQM.
Upward communication – By this the lower level of employees are able to
provide suggestions to upper management of the affects of TQM. As employees
provide insight and constructive criticism, supervisors must listen effectively to
correct the situation that comes about through the use of TQM. This forms a level
of trust between supervisors and employees. This is also similar to empowering
communication, where supervisors keep open ears and listen to others.
Sideways communication – This type of communication is important because it
breaks down barriers between departments. It also allows dealing with customers
and suppliers in a more professional manner.
TQM Roof: Recognition –Recognition is the last and final element in the entire
system. It should be provided for both suggestions and achievements for teams as
well as individuals. Employees strive to receive recognition for themselves and
their teams. Detecting and recognizing contributors is the most important job of a
supervisor. As people are recognized, there can be huge changes in self-esteem,
productivity, quality and the amount of effort exhorted to the task at hand.
Recognition comes in its best form when it is immediately following an action
that an employee has performed. Recognition comes in different ways, places and
time such as,Ways - It can be by way of personal letter from top management. Also
by award banquets, plaques, trophies etc.Places - Good performers can be
recognized in front of departments, on performance boards and also in front of top
management.Time - Recognition can given at any time like in staff meeting, annual
award banquets, etc.

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 SIGNIFICANCE OF TQM
The importance of TQM lies in the fact that it encourages innovation, makes the
organization adaptable to change, motivates people for better quality, and integrates
the business arising out of a common purpose and all these provide the organization
with a valuable and distinctive competitive edge.

FIVE STRATEGIES TO DEVELOP THE TQM PROCESS

Strategy 1: The TQM element approach

The TQM element approach takes key business processes and/or organizational
units and uses the tools of TQM to foster improvements. This method was widely
used in the early 1980s as companies tried to implement parts of TQM as they
learned them.

Examples of this approach include quality circles, statistical process control,

Taguchi methods, and quality function deployment.

Strategy 2: The guru approach

The guru approach uses the teachings and writings of one or more of the leading
quality thinkers as a guide against which to determine where the organization has
deficiencies. Then, the organization makes appropriate changes to remedy those
deficiencies.

For example, managers might study Deming’s 14 points or attend the Crosby
College. They would then work on implementing the approach learned.

Strategy 3: The organization model approach

In this approach, individuals or teams visit organizations that have taken a

leadership role in TQM and determine their processes and reasons for success. They
then integrate these ideas with their own ideas to develop an organizational model
adapted for their specific organization.

This method was used widely in the late 1980s and is exemplified by the initial
recipients of the Malcolm Baldrige National Quality Award.

Strategy 4: The Japanese total quality approach

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 Organizations using the Japanese total quality approach examine the detailed
implementation techniques and strategies employed by Deming Prize–winning
companies and use this experience to develop a long-range master plan for in-house
use.

This approach was used by Florida Power and Light—among others—to

implement TQM and to compete for and win the Deming Prize.

Strategy 5: The award criteria approach

When using this model, an organization uses the criteria of a quality award, for
example, the Deming Prize, the European Quality Award, or the Malcolm Baldrige
National Quality Award, to identify areas for improvement. Under this approach,
TQM implementation focuses on meeting specific award criteria.

Although some argue that this is not an appropriate use of award criteria, some
organizations do use this approach and it can result in improvement.
TOOLS AND TECHNIQUES
Total quality management is an overall approach to management it needs
systems tools and techniques that can convert this approach into realities. These
tools are as follows

 Creating client focus

 Long-range plan
 Continuous improvement
 Daily process management
 Employees involvement
FACTORS CONTRIBUTING TO SUCCESS OF TOTAL
QUALITY MANAGEMENT
TQM is the most successful when it focuses as described by Orlikoff
1. Fixing an existing problem
2. Preventing problems.
3. Changing systems to address the root causes of problems and
4. Managing innovation
However, the hospitals are also implementing the total quality improvement
(TQM) Model, which has been successful in order industries. Hospitals in
developing countries that had integrated TQM philosophy have dramatically
changed their managerial approach. Moreover, the adoption of TQM requires a
cultural transformation of the entire organization with changing beliefs, attitudes
and behaviors. The successful integration of TQM is based on several principles.
TQM is a multidisciplinary approach geared to provide customer with the
highest level of care.Buccini lists the goals of TQM as achieving quality outcomes,
reducing costs, producing internal loyal customers, and creating a climate of
teamwork.
The TQM method also uses interdisciplinary teams to examine organizational
processes. There is an emphasis on team approach. The interdisciplinary teams
identify problems and follow a process similar to that used in nursing process.

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Thompson describes this as the processes of identifying the problem, agreeing on
testing methods, and implementing a plan. The team is also responsible for
continuous assessment of the processes and for implementing changes as needed.

TQM functions on the premise that the quality of products and processes is the
responsibility of everyone who is involved with the creation or consumption of the
products or services offered by an organization. In other words, TQM capitalizes on
the involvement of management, workforce, suppliers, and even customers.

CONCLUSION
Today's health care organization witness highly, level of competition,
48,000 to 98,000 lives are last each year due to medical errors, that increase the
needs to improve the quality of care (Kohn, Corrigan and Donaldson, 2000),
nursing needs to be diligent in advocating for quality patient care and must continue
to educate the greater community on how to achieve quality and thus a safer
environment for our patients.

JOURNAL ABSTRACT
1.Wang. L.et.al (2013) conducted a study on the roles of quality control
circles in sustained improvement of medical quality. They used quality control
circles (QCC) followed by the PDCA Deming cycle and analyzed the
application of QCC to the sustained improvement of a medical institution in
Zhejiang province. Analyses of the tangible and intangible achievements of
QCC revealed that the achievement indices for reductions in internal errors,
reduction in costs, improvements in the degree of patient satisfaction,
improvement in work quality, and improvements in economic performance
were 109.84% 16.47%, 135.04% 50.33%, 126.26% 53.69%, 100.58%
22.83 and 104.07% 5.45% respectively. The improvements in these areas
were 61.12% 13.2% , 60.47% 28.91%, 34.41% 22.96%, 49.22%
25.39% and 73.70% 5.24% respectively. The intangible achievements were
reflected as follows 5% of QCC members showed an activity growth value of 1-
2 points, 83% 1-2 points, 12% more than 2 points. As a result, QCC activity
showed prominent results in fostering long- lasting improvement in the quality
of medical institutions in terms of both tangible and intangible factures. In short,
QCC can be used as an effective tool to improve medical quality.
2. Terry (2000) conducted a study on development of an audit instrument for
nursing care plans in the patient record to develop, validate and test the
reliability of an audit instrument that measures the extent to which patient
records describe important aspects of nursing care. Twenty records from each of
three hospital wards were collected and audited. The auditors were registered
nurses with knowledge of nursing documentation in accordance with the VIPS
model- a model designed to structure nursing documentation (VIPS is an
acronym formed from the Swedish words for wellbeing, integrity, prevention
and security. An audit instrument was developed by determining specific
criteria to be met. The audit questions were aimed at revealing the content of the
patient for nursing assessment, nursing diagnosis, planned interventions and
outcome. Each of the 60 records was reviewed by the three auditors.

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 3.Mu. Hugh. M.D. 2011 (et. al) conducted a study on nurses widespread job
dissatisfaction burnout and frustration with health benefits signal problems for
patient care.
Job dissatisfaction among nurses contributes to costly labor disputes,
turnover, risk to patients. Examining survey much higher job dissatisfaction and
burnout among nurses who were directly caring for patients in hospitals and
nursing homes than among nurses working in other jobs or setting such as the
pharmaceutical industry. Strikingly, nurses are particularly dissatisfied with
their health benefits, which highlight the need for a benefits review to make
nurses benefits more comparable to those of other white- collar employees.
Patient satisfaction levels are lower in hospitals with more nurses who are
dissatisfied or burned out – a finding that signals problems with quality of care.
Improving nurse's working conditions may improve both nurses and patient's
satisfaction as well as the quality of care.
Independently and the reliability of the instrument was tested by calculating
the inter- rater reliability co- efficient. Control validity was tested by using an
expert panel and calculating the control validity ratio. The criterion related
validity was estimated by the correlation between the score of the Cat- Ch- Ing
instrument and the score of an earlier developed and used audit instrument. The
results were tested by using Pearson's correlation coefficient. The new audit
instrument named Cat- Ch- Ing consists of 17 questions designed to judge the
nursing documentation. Both quality and quality variables are judged on a rating
scale from zero to three, with a maximum score of 80. The inter rater reliability
co efficient were 0.95, 0.98 and 0.92 respectively and the criterion related
validity showed a significant correlation of r= 0.68 (p<0.0001) between the two
proved to be a valid and reliable audit instrument for nursing records. When the
VIPs model is used as the basis of the documentation.
A.V. AIDS
1. Chart
2. OPH
3. Flannel board
4. Pamphlet
5. Leaflet
6. Projected Aid- LCD.
BIBLIOGRAPHY
TEXT BOOK
1. Basheer, P.S. Khan. Y.S. (2012). A Concise Text book of Advanced
Nursing Practice. (1st ed). Emmesis Pg. No. 50- 62.
2. Neelam Kumari. (2011). A textbook of Management of nursing services and
education. (2nd ed). Jalandhar Vikas and company. Pg. No. 211.
3. Jogindra Vato. (2013). Principles and practice of nursing Management and
Administration: (1st ed). Jaypee . New Delhi. Pg. No. 92- 106.
4. Samson, R. (2009). Leadership and Management in Nursing Practice and
Education. (1st ed). Jaypee . New Delhi. Pg. No. 124- 130.
5. Kaur, S. (2013). Textbook of Nursing Management and services. (1st ed).
New Delhi. Jaypee. Pg. No. 104- 152.
JOURNAL

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1. Wang, L. et.al. (2013). The Role of quality control circles in sustained
improvement of Medical quality 5 (1). Springer opens Journal. Pg. No.1
2. Terry. (2000). Development of an audit instrument for nursing care plans in
the patient record. 6 (3). Pg. No. 3
3. Mc. Hugh. M.D. (2011). Nurses widespread job dissatisfaction, burnout and
frustration with health benefits signal problems for patient care 30 (2) Pg. No.
202- 210.
ELECTRONIC VERSION
1. Quality Assurance, www.scribd.com
2. Quality control.www.slideshare.com
3. Nursing Audit. www. slideshare.com

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