ntroduction

Standard is an acknowledged measure of comparison for quantitative or qualitative value, criterion,

or norm. A standard is a practice that enjoys general recognition and conformity among
professionals or an authoritative statement by which the quality of practice, service or education can
be judged. It is also defined as a performance model that results from integrating criteria with
norms and is used to judge quality of nursing objectives, orders and methods

A standard is a means of determining what something should be. In the case of nursing practice
standards are the established criteria for the practice of nursing. Standards are statements that are
widely recognised as describing nursing practice and are seem as having permanent value.

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

Characteristics of Standard

Standards statement must be broad enough to apply to a wide variety of settings.

Standards must be realistic, acceptable, attainable.

Standards of nursing care must be developed by members of the nursing profession; preferable

nurses practising at the direct care level with consultation of experts in the domain.

Standards should be phrased in positive terms and indicate acceptable performance good,
excellence etc.

Standardsof nursing care must express what is desirable optional level.

Standards must be understandable and stated in unambiguous terms.

Standards must be based on current knowledge and scientific practice.

Standards must be reviewed and revised periodically.

Standards may be directed towards an ideal ,ie,optional standards or may only specify the minimal
care that must be attained,ie, minimum standard.

And one must remember that standards that work are objective, acceptable, achievable and flexible.

Purposes of Standards

Setting standard is the first step in structuring evaluation system. The following are some of the
purposes of standards.

Standards give direction and provide guidelines for performance of nursing staff.

Standards provide a baseline for evaluating quality of nursing care

Standards help improve quality of nursing care, increase effectiveness of care and improve
efficiency.

Standards may help to improve documentation of nursing care provided.

Standards may help to determine the degree to which standards of nursing care maintained and
take necessary corrective action in time.
Standards help supervisors to guide nursing staff to improve performance.

Standards may help to improve basis for decision-making and devise alternative system for
delivering nursing care.

Standards may help justify demands for resources association.

Standards my help clarify nurses area of accountability.

Standards may help nursing to define clearly different levels of care.

Major objectives of publishing, circulating and enforcing nursing care standards are to:

1. improve the quality of nursing care,

2. decrease the cost of nursing, and

3. determine the nursing negligence.

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:

Professional organisation, e.g. Associations, TNAI,

Licensing bodies, e.g. Statutory bodies, INC,

Institutions/health care agencies, e.g. University Hospitals, Health Centres.

Department of institutions, e.g. Department of Nursing.

Patient care units, e.g. specific patients' unit.

Government units at National, State and Local Government units.

Individual e.g. personal standards

Classification of Standards

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

1. Normative and Empirical Standards

Standards can be normative or empirical. Normative standards describe practices considered 'good'
or 'ideal' by some authoritative group. Empirical standards describe practices actually observed in a
large number of patient care settings. Here the normative standards describe a higher quality of
performance than empirical standards. Generally professional organisations (ANA/TNAI) promulgate
normative standards where as low enforcement and regulatory bodies (INC/MCI) promulgate
empirical standards.

2. Ends and Means Standards

Nursing care standards can be divided into ends and means standards. The ends standards are
patient-oriented; they describe the change as desired in a patient's physical status or behaviour. The
means standards are nursing oriented, they describe the activities and behaviour designed to
achieve the ends standards. Ends (or patient outcome) standards require information about the
patients. A means standard calls for information about the nurses performance.
3. Structure,Process and Outcome Standards

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

a. Structure Standard

A structural standard involves the 'set-up' of the institution. The philosophy, goals and objectives,
structure of the organisation, facilities and equipment, and qualifications of employees are some of
the components of the structure of the organisation, e.g. recommended relationship between the
nursing department and other departments in a health agency are structural standards, because
they refer to the organisational 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.

b. Process Standard

Process standards describe the behaviours of the nurse at the desired level of performance The
criteria that specify desired method for specific nursing intervention are process standards. A
process standard involves the activities concerned with delivering patient care.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.eg :the nurse assesses", "the patient
demonstrates". The focus is on what was planned, what was done and what was communicated or
recorded. Therefore, the process standards assist in measuring the degree of skill, with which
technique or procedure was carried out, the degree of client participation or the nature of
interaction between nurse and client.In process standard there is an element of professional
judgement determining the quality or the degree of skill. It includes nursing care techniques,
procedures, regimens and processes.
c.Outcome Standards

Descriptive statements of desired patient care results are outcome standards because patient's
results are outcomes of nursing interventions. Here outcome as a frame of reference for setting of
standards refers to description of the results of nursing activity in terms of the change that occurs in
the patient. An outcome standard measures change in the patient health status. This change may be
due to nursing care, medical care or as a result of variety of services offered to the patient. Outcome
standards reflect the effectiveness and results rather than the process of giving care.

LEGAL SIGNIFICANCE OF STANDARDS

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

To recover losses from a charge of malpractice, a patient must prove that:

a patient-nurse relationship existed such that the nurse owed to the patient a duty of due care,

the nurse deviated from the appropriate standard of care,

the patient suffered damages,

the patient's damages resulted from the nurses deviations from the standard of care.

CONCLUSION

Quality assurance is to provide a higher quality of care. It is necessary that nurses develop standards
of patient care and appropriate evaluation tools, so that professional aspects of nursing involving
intellectual and interpersonal activities. Quality will be ensured and attention will be given to the
individual needs and responses to patients.The formulation of standards is the first step towards
evaluating the nursing care delivery. The. standards serve as a base by which the quality of care can
be judged. This judgement may be according to a rating or other data that reflect the conformity of
existing practice with the established standards. The standards must be written, regularly reviewed
and well-known by the nursing staff.

REFERENCES

Basavanthappa BT. Nursing Administration. 1st edn. New Delhi: Jaypee Brothers; 2000

Johnson M and Closkey J.C. The Delivery Of Quality Health Care Series On Nursing Administration.
London: Mosby 1992

Koch M.W And Fairly T.M. Integrated Quality Management: The Key To Improving Nursing Care
Quality. st Edition.St.Louis,Missouri:MosbyPublications;1993.

Ward MJ, Price SA .Issues in nursing administration. St.Louis: Mosby;1991.

Marquis B.L. ,Hutson C.J . Leadership roles and management functions in nursing– Theory and
application. 5th ed. Philadelphia: Lippincott Williams and Wilkins; 2006.

Douglass L M. The effective nurse- leader and manager. 5th ed. Mosby: St. Louis; 1996.

Morrison M. Professional skills for leadership. Mosby: US; 1993.

Ellis J R, Hartley C L. Managing and Co-ordinating nursing care. 3rd ed. Lippincott: Philadelphia;1995.

Anthony, Mary K., Theresa; Hertz, Judith .Factors Influencing Outcomes After Delegation to
Unlicensed Assistive Personnel. JONA. 30(10):474-481, October 2000.

Cheryl L. Plasters, Seagull F J, Xiao Y. Coordination challenges in operating-room management: an in-

depth field study. Amia annu symp proc; 2003.
NTRODUCTION: The field of quality assurance is an old as modern nursing. “FLORENCE
NIGHTINGALE” introduced the concept of quality nursing care in 1855 while attending the soldiers in
the hospital during the Crimean war. Quality assurance necessitates that institutions and health
professionals render care in a most efficient, effective and economical manner. This entails a cost
benefit analysis to define strategies for optimum utilization of resources, focus on cost effective
methods and introduce systematic ongoing quality control programmes to continuously monitor and
improve the quality of care rendered.

3. DEFINITION A quality assurance programme is an ongoing systemic process designed to evaluate

and promote excellence in the health care provided to the clients. - KOZIER- It is a sequential
process that involves setting standards of care, measuring patient care, according to those
standards, gathering data from chart review, observing patient care, interviewing patient care givers
and then making recommendations for improvement. - F.A.DAVIS-

4. CONCEPTS Quality assurance originated in manufacturing industry. The idea was to ensure that
the product consistently achieved customer satisfaction. quality assurance is dynamic process
through which nurses assume accountability for quality of care they provide. It is a guarantee to
the society that services provided by nurses are being regulated by members of profession.

5. APPROACHES General approach: it involves large governing of persons or agency ability to meet
established criteria or standards at a given time. Specific approach: Quality assurances are
methods to evaluate identifies instances of providers and client interaction.

6. GENERAL APPROACH CREDENTIALING: Credentialing refers to ways in which professional

competence is ensured and maintained. Three processes are used for credentialing in nursing. They
are accreditation, licensure and certification. LICENSURE: Licensure is a specialized form of
credentialing based on laws passed by a state legislature. A license is a legal document that permits
a person to offer to the public skills and knowledge in a particular jurisdiction, where such practice
would otherwise be unlawful without a license.

7. ACCREDITATION: State legislative bodies have authority to enact laws controlling occupational
and professional groups. Nursing is one of the groups operating under state laws that promote the
general welfare by determining minimum standards of education through accreditation of school of
nursing. CERTIFICATION Where as licensure measures entry-level competence, certification
validates specialty knowledge, experience and clinical judgment. Nursing certification is offered by
professional organizations.

8. SPECIFIC APPROACH PEER REVIEW: Peer review is an organized effort whereby practicing
professionals review the quality and appropriateness of services ordered or performed by their
professional peers. Peer Review in Nursing is the process by which practicing Registered Nurses
systematically assess, monitor and make judgments about the quality of nursing care provided by
peers, as measured against professional standards of practice. ANA,1988

9. SPECIAL APPROACH STANDARD: Standard is a pre-determined baseline condition or level of

excellence that comprises a model to be followed and practiced CLASSIFICATION: - Normative and
empirical standard - Ends and means standard - Structure, process and outcome standard
10. SOURCES: •Professional organization, e.g. Associations, TNAI, •Licensing bodies, e.g. Statutory
bodies, INC, •Institutions/health care agencies, e.g. University Hospitals, Health Centers.
•Department of institutions, e.g. Department of Nursing. •Patient care units, e.g. specific patients'
unit. •Government units at National, State and Local Government units. •Individual e.g. personal
standards

11. NURSING AUDIT DEFINITION: Nursing audit is defined as “an evaluation of patient care and
analysis of the written records maintained by nurses in patients treatment profile”. TYPES OF
NURSING AUDIT: Concurrent nursing audit Retrospective nursing audit

12. PURPOSE To provide the evidence of the quality of nursing services being rendered. To
evaluate nursing administrative, supervise nursing care practice. To measure progress. Identify
problems. To promote the maintenance of medical records. To increase medico-legal protection..

13. NURSING AUDIT PROCESS

14. MODEL OF QUALITY ASSURANCE ANA MODEL OF QUALITY ASSURANCE: 1) Identify values 2)
Identify structure, process and outcome standards and criteria 3) Select measurement 4) Make
interpretation 5) Identify course of action 6) Choose action 7) Take action 8) Reevaluate

15. FACTORS AFFECTING QUALITY ASSURANCE Lack of resources Personal problems

Unreasonable patients and attendants Improper maintenance Absence of accreditation laws

16. • Legal redress •Lack of incident review procedures •Lack of good hospital information system
•Absence of conducting patient satisfaction surveys

17. FRAMEWORK FOR QUALITY ASSURANCE Lang (1976): •Identify and agree values •Review
literature, Known QAP •Analyze available programmes •Determine most appropriate QAP •Establish
structure, plans, outcome criteria and standards •Ratify standards and criteria

18. Evaluate current levels of nursing practice against ratified structures •Identify and analyze
factors contributing to results •Select appropriate actions to maintain or improve care •Implement
selected actions •Evaluate QAO

19. QUALITY ASSURANCE PROCESS 1.Establishment of standards or criteria 2.Identify the

information relevant to criteria 3.Determine ways to collect information 4.Collect and analyze the
information 5.Compare collected information with established criteria

20. …. 6.Make a judgment about quality 7.Provide information and if necessary, take corrective
action regarding findings of appropriate sources 8.Determine ways to collect the information

21. IMPACT OF QUALITY ASSURANCE IN NURSING Nurses are accountable for their actions
Nurses can deliver a high standard of care Guaranteeing standards of care to the public Nurses
are actively involved in audit and consumer relations Improves the overall quality of nursing care

22. Improves all type of documentation and communication Helps in professional growth Helps
to maintain international standard Helps to compare the standard with another institution
Avoids malpractice and bias
23. CONCLUSION: Quality assurance programme will helps to improve the quality of nursing care
and professional development. Individuals with the profession must assume responsibility for their
professional actions and be answerable to the recipients for their care.

24. BIBLIOGRAPHY Kozier, fundamental of nursing, Dorling Kindersley pvt.ltd, second edition, 2006,
p.no: 202, 360-361. F.A. Davis, legal ethical and political issues in nursing, Davis Company, second
edition, 1994, p.no: 231-244. Carol Taylor, fundamental of nursing, Lippincott publications, sixth
edition, 2005, p.no: 328-331. Dugas, introduction to patient care, saunder publications, fourth
publications, 2001, p.no: 97. Potter and Perry, fundamental of nursing, Mosby publications, fourth
edition, 1997, p.no: 44, 172-176.

25. JOURNAL: Nurses of India, July 2006, vol-7, p.no: 9-10. Nurses of India, July 15, 2008, vol – 9,
p.no: 5-6. Nursing journal of India, august 1999, vol-8, p.no: 173. NET: http://
currentnursing.com/nursing management/total qualitymanagementhealthcare.html
www.indiannursingcouncil.com/qualityassuranceinnursing-standards.

Introduction of quality and quality assurance. Objectives of quality assurance. Approaches for
quality assurance. General approach. Specific approach. Models used in evaluating quality
assurance . Systematic model . ANA quality assurance model. Purposes of quality assurance
model.

3. Research evidence. Conclusion

4. Quality is defined as the extent of resemblance between the purpose of health care and truly
granted care. Actually, quality is interactive process between customer and provider.

5. Quality assurance is a judgement concerning the process of care, based on the extent to which
that cares contributes to valued outcomes(Donabedian 1982)

6. Quality assurance is the defining of nursing practice through well written nursing standards and
the use of those standards as a basis for evaluation on the improvement of client care.(Maker 1989)

7. To ensure the delivery of quality client care. To provide technical assistance in correcting
systemic deficiencies. To refine existing methods for ensuring optional quality health care. To
provide the best possible results.

8. Approaches General approach Specific approach

9. General approach Credentialing Accreditation Certification Licensure

10. It involves large governing of official body evaluation of a person’s or agency’s ability to meet
established criteria or standards at a given time.

11. It is the process through which a healthcare professional or agency is determined qualified to
have certain medical privileges and have predetermined criteria.
12. It is the mandatory process by which a governmental agency grants time-limited permission to
an individual to engage in a given occupation after verifying that he or she has met predetermined
and standardized criteria. Examples: Licensed Estate nurse , Licensed Practice Nurse

13. CERTIFICATION

14. It is a Voluntary process by which a nongovernmental body grants a time- limited recognition
to an individual after verifying that he or she has met predetermined and standardized criteria.
Examples:Certified Meeting Planner, certified dialysis nurse trainer

15. It is a voluntary process by which a nongovernmental body grants a time- limited recognition to
an organization after verifying that it has met predetermined and standardized criteria. Eg.
Accredited healthcare facility

16. SPECIFIC APPROACH Peer review Utilization review Evaluation studies Client satisfaction Incident
review

17. These are designed to monitor client specific aspects of care appropriate for certain levels of
care. The audit has been the major tool used by peer review committee to ascertain quality of care.

18. Utilization review activities are directed towards assuring that care is actually needed and that
the cost appropriate for the level of care provided.

19. Prospective: Assessment of the necessity of care before giving services. Concurrent :Review
of care while the care is being given. Retrospective : Analysis after the care has being given.

20. Three major models have been used to evaluate quality they are: Donabedian’s structure
process outcome model The tracer model The sentinel model

21. Measure both process and outcome of care. Provides nurses with data to show the
differences in outcomes as a result of nursing care standards.

22. It is an outcome measure for examining specific instances of client care . Eg. cases of
disability, deaths,morbidity mortality etc.

23. It can be assessed using person or telephone interviews and mailed questionnaire.

24. The critical incidents may be delayed attendance, incorrect medications, lack of cleanliness,
lack of asespsis leading to infection, carelessness in carrying out nursing procedures.

25. MODELS OF QUALITY ASSURANCE

26. MODELS OF QUALITY ASSURANCE MODELS A SYSTEMATIC MODEL AMERICAN NURSES

ASSOCIATION (ANA) QUALITY ASSURANCE MODEL

27. It is the system approach in which the task is broken down into manageable components based
on defined objectives.

28. 1.INPUT 2.THROUGHPUT 3.OUTPUT 4.FEEDBACK

29. AMERICAN NURSES ASSOCIATION (ANA) QUALITY ASSURANCE MODEL

30. 1)Identify values 2)Identify structure, process and outcome 3)Select measurement 4)Make
interpretation 5)Identify course of action 6)Choose action 7)Take action 8)Reevaluate

31. To ensure quality nursing care provided by nurses in order to meet the expectations of the
receiver,management and regulatory body.

32. Title : “Donabedian's structure-process- outcome quality of care model: Validation in an

integrated trauma system.” Journal :The journal of trauma and acute care surgery,2015. Authors
:Moore l, lavoie A, Borgeois G, Lapointe J.

33. According to Donabedian's health care quality model, improvements in the structure of care
should lead to improvements in clinical processes that should in turn improve patient outcome.
The objective of this study was to assess the performance of an integrated trauma system in terms
of structure, process, and outcome and evaluate the correlation between quality domains.

34. The study evalauated quality of care for patients treated in a Canadian provincial trauma
system in 2005-2010 in 57 centers, n = 63,971) using quality indicators (QIs) developed and validated
previously. Outcome performance was measured using risk- adjusted rates of mortality,
complications, and readmission as well as hospital length of stay (LOS). Correlation was assessed
with Pearson's correlation coefficients.

35. Statistically significant correlations were observed between structure and process , process and
outcome. This study suggest that Donabedian's structure-process-outcome model is a valid model
for evaluating trauma care. Trauma centers that perform well in terms of structure also tend to
perform well in terms of clinical processes, which in turn has a favorable influence on patient
outcomes.

36. Quality assurance is the monitoring of the activities of client care to determine the degree of
excellence attained to the implementation of the activities.There are general and specific approach
to assure quality.ANA quality assurance model and systematic models are the models of quality
assurance.

37. Quality assurance is monitoring the activities of client care to determine the degree of
excellence attained to the implementation of the activities and it is very essential to optional quality
health care.

38. A) Peer review B)Accreditation C)Utilization review D)Evaluation studies B)Accreditation

39. 1)Donabedian’s structure process outcome model 2)The tracer model 3)The sentinel model.

40. Basher Shebeer.p, khan S.yaseen. A concise textbook of advanced nursing practice. 1st ed.
Banglore: Emmess medical publishers; p.50- 55 Soni Samta. Textbook of advance nursing
practice.1st ed. Newdelhi: jaypee brothers medical publishers; p.14-22.
 Definitions QUALITY • “Quality is defined as the degree to which health services for the
individuals and populations increase the likelihood of the desired health outcomes and are
consistent with current professional knowledge”. -Joint Commission on Accreditation of Healthcare
Organizations (2002) • “Quality of a service is defined as the totality of features and characteristics
of a service that bear on its ability to satisfy the stated and implied needs of the patients.” -
International Organization for Standardization (ISO 8402) 2

3. Definitions QUALITY ASSURANCE • “Quality Assurance is an on-going, systematic comprehensive

evaluation of health care services and the impact of those services on health care services. - Kozier. •
Quality assurance is defined as all activities undertaken to predate and prevent poor quality. -
Neetvert(1992) 3

4. KEY TERMS RELATED TO QUALITY ASSURANCE • Quality improvement • Total Quality

Management/ Continuous Quality Improvement • Quality Control • Quality circles 4

5. OBJECTIVES OF QUALITY ASSURANCE According to Jonas (2000), the two main objectives are; • To
ensure the delivery of quality client care • To demonstrate the efforts of the health care providers to
provide the best possible results 5

6. Other specific objectives are; • Formulate plan of care • Attend the patients physical and non-
physical needs • Evaluate achievement of nursing care • Support delivery of nursing care with
administrative and managerial services 6

7. PRINCIPLES OF QUALITY ASSURANCE • Customer focus • Leadership • Involvement of people •

Process approach • System approach to management • Continual improvement • Factual approach
to decision making • Mutually beneficial supplier relationship 7

8. COMPONENTS OF QUALITY ASSURANCE • STRUCTURE EVALUATION • PROCESS EVALUATION •

OUTCOME EVALUATION 8

9. QUALITY ASSURANCE PROCESS 1. Establishment of standards or criteria 2. Identify the information

relevant to criteria 3. Determine ways to collect information 4. Collect and analyze the information
5. Compare collected information with established criteria 9

10. Cont.. 6. Make a judgment about quality 7. Provide information and if necessary, take corrective
action regarding findings of appropriate sources 8. Determine ways to collect the information 10

11. MODELS OF QUALITY ASSURANCE 11

12. 1. System Model 1. Input 2. Throughput 3. Output 4. Feedback 12

13. Donabedian Model 13

14. ANA Quality Assurance Model 14

15. Plan, Do, Study, Act cycle 15

16. LEVELS OF EVALUATION OF QUALITY OF CARE • National Level • Trust or organization level •
Local Level 16
17. APPROACHES OF QUALITY IMPROVEMENT General Approaches • Credentialing • Licensure •
Accreditation • Certification • Charter • Academic Degrees 17

18. Cont… Specific Approaches • Peer Review Committees (Staff Review Committees) • Standard as
a device for quality assurance 18

19. FACTORS AFFECTING QUALITY ASSURANCE IN NURSING PRACTICE • Lack of resources •

Personnel problem • Improper maintenance • Unreasonable patients and attendants • Absence of
well-informed population • Absence of accreditation laws • Lack of incident review procedure 19

20. cont • Lack of good hospital information system • Absence of patient Satisfaction Surveys • Lack
of nursing care research • Miscellaneous Factors 20

21. BARRIERS OF QUALITY IMPROVEMENT EFFORTS • The Nurse Manager might become pre
occupied with quality assessment • It is impossible to identify all factors that influence nursing care
quality. • Difficulty in defining outcome criteria that result solely from nursing intervention • Nurse’s
documentation of care measures is at times vague, incomplete and lacking in objectivity • There is
still no single, all purpose, all site quality assessment tool that is universally appropriate for all health
agencies. • High cost 21

22. ROLE OF NURSES IN QUALITY ASSURANCE • Nurses are the active participant of interdisciplinary
quality improvement team • Develop mechanism for continually monitoring the effectiveness of
nursing care both a collaborative and an individual professional activity. • Contribute innovations
and improvement of patient care • Participating in improvement projects and patient safety
initiatives 22

23. Cont…. • Participate continuing educational programs and in- service educational programs for
continuing professional development • Periodic and continuing appraisal and evaluation of health
care situation of the patient • Participate research works related to quality assurance • Identify any
area of needed improvement in delivery of care. 23

AIM: At the end of the seminar, the group is able to identify and describe the quality assurance in
nursing.

3. SPECIFIC OBJECTIVES: The group is able to define Quality, and certain other terms in relation to
it. The group is able to understand the concept of quality in health care. The group is able to
enumerate the purposes of quality assurance. The group is able to identify various approaches of
quality assurance programme. The group is able to state the principles of quality assurance in
nursing. The group is able to outline the frameworks of quality assurance in nursing. The group is
able to explain in brief about JCAHO, and list down its components. The group is able to illustrate
the various models of Quality assurance.

4. CONTD.. The group is able to express on the ANA model of quality assurance. The group is able
to identify the various AHRQ quality indicators, and interpret a few. The group is able to recognize
the factors affecting quality assurance in nursing. The group is able to discuss about the quality
assurance in nursing standards. The group is able to summarize on the topic of quality assurance in
nursing.

5. INTRODUCTION: Assessing the quality of university education has been presented as one of the
main issues on the agenda of education reforms worldwide. Ensuring quality is a combination of
planned and systematic actions that are necessary to provide the adequate reliability that a product
or service meets the requirements given for quality, which should be supported in meeting the
expectations of customers. Quality assurance is based on planning, production, presentation,
distribution, statistical techniques of control and staff training.

6. DEFINITION: Quality Assurance: It is a systematic, ongoing and continuous review, analysis and
evaluation of the level of compliance with the standards set at local, national and international level.

7. CONCEPT OF QUALITY ASSURANCE: Quality is defined as the extent of resemblance between the
purpose of healthcare and the truly granted care (Donabedian 1986). Quality assurance originated
in manufacturing industry “to ensure that the product consistently achieved customer satisfaction”.
Quality assurance is a dynamic process through which nurses assume accountability for quality of
care they provide. It is a guarantee to the society that services provided by nurses are being
regulated by members of profession. “Quality assurance is a judgment concerning the process of
care, based on the extent to which that cares contributes to valued outcomes”. (Donabedian 1982).
“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)

8. BENEFITS AND PURPOSES OF QUALITY ASSURANCE: Quality assurance (QA) enables .. •bring
internal benefits to the university/faculty/department/school/program and the staff; •bring
external benefits to the students and the reputation of the institution; •continuously improve
themselves, the students and the work of the university. Continuous improvement is both the
medium and outcome of quality assurance; •serve accountability and accreditation requirements;
•enhance the reputation of the faculty/department/school/university, and meet external demands
for demonstrating quality, quality assurance and quality enhancement.

9. APPROACHES FOR A QUALITY ASSURANCE PROGRAMME: Two major categories of approaches

exist in quality assurance they are 1. General 2. Specific

10. 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 formal
recognition of professional or technical competence and attainment of minimum standards by a
person or agency Credentialing process has four functional components: a) To produce a quality
product b) To confer a unique identity c) To protect provider and public d) To control the
profession.

11. CONTD.. 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. 3) Accreditation ISO JCI NABH NAAC Accreditation Canada
4) Certification Voluntary process.

12. SPECIFIC APPROACHES : 1) Peer review •Peer review is divided in to two types. a. The
recipients of health services by means of auditing the quality of services rendered. b. The health
professional evaluating the quality of individual performance. 2) Standard as a device for quality
assurance Standard is a pre-determined baseline condition or level of excellence that comprises a
model to be followed and practiced. 3) 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.

13. PRINCIPLES OF QUALITY ASSURANCE: •Managers need to be committed to quality

management. •All employees must be involved in quality improvement. •The goal of quality
management is to provide a system in which workers can function effectively. •The focus quality
management is on improving the system. •Every agency has internal and external customers.
•Customers define quality. •Decision must be based on facts.

14. FRAMEWORKS FOR QUALITY ASSURANCE: 1. Maxwell (1984) Maxwell recognized that, in a
society where resources are limited, self- assessment by health care professionals is not satisfactory
in demonstrating the efficiency or effectiveness of a service. The dimensions of quality he proposed
are: •Access to service •Relevance to need •Effectiveness •Equity •Social acceptance
•Efficiency and economy

15. CONTD.. 2. Wilson (1987) Wilson considers there to be four essential components to a QA
programme. These are: •Setting objectives •Quality promotion •Activity monitoring
•Performance assessment

16. CONTD.. 3. Lang (1976) This framework has subsequently been adopted and developed by
the ANA. The stages includes; •Identify and agree values •Review literature, Known QAP
•Analyse available programmes •Determine most appropriate QAP •Establish structure, plans,
outcome criteria and standards •Ratify standards and criteria •Evaluate current levels of nursing
practice against ratified structures •Identify and analyse factors contributing to results •Select
appropriate actions to maintain or improve care •Implement selected actions •Evaluate QAO

17. JCAHO: JCAHO is the nation’s predominant standards-setting and accrediting body in health
care. Since 1951, The Joint Commission has maintained state-of-the-art standards that focus on
improving the quality and safety of care provided by health care organizations. The Joint
Commission’s comprehensive accreditation process evaluates an organization’s compliance with
these standards and other accreditation requirements. To earn and maintain The Joint
Commission’s Gold Seal of Approval, an organization must undergo an on-site survey by a JCAHO
survey team at least every three years. (Laboratories must be surveyed every two years.)

18. WHO IS ELIGIBLE? The Joint Commission provides evaluation and accreditation services for the
following types of organizations: •General, psychiatric, children’s and rehabilitation hospitals
•Critical access hospitals •Medical equipment services, hospice services and other home care
organizations •Nursing homes and other long term care facilities •Behavioural health care
organizations, addiction services •Rehabilitation centres, group practices, office-based surgeries
and other ambulatory care providers •Independent or freestanding laboratories

19. STANDARDS AND PERFORMANCE MEASURES: JCAHO standards address the organization’s level
of performance in key functional areas, such as patient rights, patient treatment, and infection
control. The standards focus not simply on an organization’s ability to provide safe, high quality
care, but on its actual performance as well. The Joint Commission develops its standards in
consultation with health care experts, providers, measurement experts, purchasers, and consumers.

20. MODELS OF QUALITY ASSURANCE: 1. System Model •Tasks are broken down into
manageable components based on defined objectives. The basic components of the system are
1. Input 2. Throughput 3. Output 4. Feedback The input can be compared to the present state
of systems, the throughput to the developmental process and output to the finished product. The
feedback is the essential component of the system because it maintains and nourishes the growth.

21. 2) ANA Quality Assurance Model The basic components of the ANA model are: 1. Identify
values 2. Identify structure, process and outcome standards and criteria 3. Select measurement
4. Make interpretation 5. Identify course of action 6. Choose action 7. Take action 8. Re-
evaluate

22. 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 providers of nursing services. 2) Identify
structure, process and outcome standards and criteria: •Identification of standards and criteria for
quality assurance begins with writing of philosophy and objective of organization. •The philosophy
and objectives of an agency serves to define the structural standards of the agency. •Standards of
structure are defined by licensing or accrediting agency. •Evaluation of the standards of structure
is done by a group internal or external to the agency. •The evaluation of process standards is a
more specific appraisal of the quality of care being given by agency care providers.

23. 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, 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 interpretation about the strengths and weaknesses of
the program. •The rate of compliance is compared against the expected level of criteria
accomplishment.

24. 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 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 weigh the pros and cons of each alternative while considering the environmental
context and the availability of resources.

25. 7) Take Action •It is important to firmly establish accountability for the action to be taken.
•This step then concludes with the actual implementation of the proposed courses of action. 8)
Re-evaluate •The final step of QA process involves an evaluation of the results of the action.
•The reassessment is accomplished 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, positive reinforcement is offered to those who participated and the
decision is made about when to again evaluate that aspect of care.

26. WHAT ARE THE AHRQ QUALITY INDICATORS? The Quality Indicators (QIs) developed and
maintained by the Agency for Healthcare Research and Quality (AHRQ) are one response to the need
for multidimensional, accessible quality measures that can be used to gage performance in health
care. These measures are currently organized into four modules: the Prevention Quality Indicators
(PQIs), the Inpatient Quality Indicators (IQIs), the Patient Safety Indicators (PSIs), and the Paediatric
Quality Indicators (PDIs).

27. The AHRQ QI Modules: The AHRQ PQIs are one set of quality measures that can be used to
identify potential problems; follow trends over time; and ascertain disparities across regions,
communities, and providers. The PQIs help answer questions such as •Does the admission rate
for diabetes complications in my community suggest a problem in the provision of appropriate
outpatient care to this population? •How does the admission rate for congestive heart failure vary
over time and from one region of the country to another?

28. THE INPATIENT QUALITY INDICATORS (IQIS): The AHRQ IQIs provide information about the
quality of medical care delivered in a hospital. The provider-level volume IQIs are: •Oesophageal
resection volume •Pancreatic resection volume •Abdominal aortic aneurysm (AAA) repair
volume •Coronary artery bypass graft (CABG) volume •Percutaneous transluminal coronary
angioplasty (PTCA) volume

29. THE PATIENT SAFETY INDICATORS (PSIS): The PSIs are a set of quality measures that use
hospital inpatient discharge data to provide a perspective on patient safety. •Postoperative
pulmonary embolism or deep vein thrombosis •Postoperative respiratory failure •Postoperative
sepsis •Postoperative physiologic and metabolic derangements •Postoperative abdominopelvic
wound dehiscence

30. THE PAEDIATRIC QUALITY INDICATORS (PDIS): The AHRQ PDIs are a set of quality measures
that use hospital administrative data and involve many of the same challenges associated with
measure development for the adult population. •Accidental puncture and laceration •Decubitus
ulcer •Foreign body left in during procedure •Iatrogenic pneumothorax in neonates •Iatrogenic
pneumothorax in non-neonates •Paediatric heart surgery mortality

31. FACTORS AFFECTING QUALITY ASSURANCE IN NURSING CARE: 1) Lack of Resources 2)

Personnel problems 3) Improper maintenance 4) Unreasonable Patients and Attendants 5)
Absence of well-informed population 6) Absence of accreditation laws 7) Lack of incident review
procedures 8) Lack of good and hospital information system 9) Absence of patient satisfaction
surveys 10) Lack of nursing care records 11) Miscellaneous factors

32. QUALITY ASSURANCE IN NURSING: STANDARDS: INTRODUCTION: A standard is a means of

determining what something should be. In the case of nursing practice standards are the established
criteria for the practice of nursing. Standards are statements that are widely recognised as
describing nursing practice and are seem as having permanent value. A nursing care standard is a
descriptive statement of desired quality against which to evaluate nursing care. It is guideline. A
guideline is a recommended path to safe conduct, an aid to professional performance.

33. CHARACTERISTICS OF STANDARD: •Standards statement must be broad enough to apply to a

wide variety of settings. •Standards must be realistic, acceptable, and attainable. • Standards of
nursing care must be developed by members of the nursing profession; preferable • Nurses
practising at the direct care level with consultation of experts in the domain. • Standards should be
phrased in positive terms and indicate acceptable performance good, excellence etc.

34. CONTD.. • Standards of nursing care must express what desirable optional level is. •
Standards must be understandable and stated in unambiguous terms. • Standards must be based
on current knowledge and scientific practice. • Standards must be reviewed and revised
periodically. •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. • And one must
remember that standards that work are objective, acceptable, achievable and flexible.

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

36. CONTD.. • Standards help supervisors to guide nursing staff to improve performance. •
Standards may help to improve basis for decision-making and devise alternative system for
delivering nursing care. • Standards may help justify demands for resources association.
•Standards my help clarify nurses area of accountability. • Standards may help nursing to define
clearly different levels of care.

37. MAJOR OBJECTIVES OF PUBLISHING, CIRCULATING AND ENFORCING NURSING CARE STANDARDS
ARE TO: 1. Improve the quality of nursing care, 2. Decrease the cost of nursing, and 3.
Determine the nursing negligence.

38. SOURCES OF NURSING CARE STANDARDS: • Professional organisation, e.g. Associations, TNAI,
• Licensing bodies, e.g. statutory bodies, INC, • Institutions/health care agencies, e.g. University
Hospitals, Health Centres. • Department of institutions, e.g. Department of Nursing. • Patient
care units, e.g. specific patients' unit. • Government units at National, State and Local Government
units. • Individual e.g. personal standards

39. RESEARCH: A number of the AHRQ QIs have been used in health care research projects. On the
whole, researchers use the indicators because of the quality and level of detail of the AHRQ
documentation of the QIs as well as the fact that these measures capture important aspects of
clinical care. The AHRQ QIs, their documentation, and the related software reside in the public
domain and are downloadable from the AHRQ Web site, free of charge. The QIs can be used with
readily available administrative data, which researchers have ready access to in the form of HCUP.
Further, researchers appreciate the fact that they can dissect indicator results and relate them back
to individual records, which helps to gain a better understanding of the logic used in the measures,
which, in turn, assists in distinguishing data quality issues from actual quality problems .Topics of
studies using the AHRQ QIs include an analysis examining the association between the Joint
Commission accreditation scores and the AHRQ IQIs and PSIs, the effect of resident physician work
hour limits on surgical patient safety, and the determination of whether persons with Alzheimer’s
disease were at greater risk for in-hospital mortality than non-Alzheimer’s patients.

40. ANY DOUBTS???

41. CONCLUSION: To ensure quality nursing care within the contemporary health care system,
mechanisms for monitoring and evaluating care are under scrutiny. As the level of knowledge
increases for a profession, the demand for accountability for its services likewise increases.
Individuals within the profession must assume responsibility for their professional actions and be
answerable to the recipients for their care. As profession become more interdependent, it appears
that the power base will become more balanced, allowing individual practitioners to demonstrate
their competence and expertise. Quality assurance programme will helps to improve the quality of
nursing care and professional development.

42. BIBLIOGRAPHY: INTERNET SOURCES: http://www.ncbi.nlm.nih.gov/books/NBK2664/

http://www.qualityindicators.ahrq.gov/ http://hospaa.org/the-joint-commission-on-accreditation-
of-health-care- organizations-jcaho-2/ http://hospaa.org/the-joint-commission-on-accreditation-
of-health-care- organizations-jcaho-2/
http://currentnursing.com/nursing_management/quality_standards_nursing.html
http://globalpoint.hubpages.com/hub/deepthipiyush

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INTRODUCTION THE EXPENSE OF QUALITY IS AN INTERACTIVE PROCESS BETWEEN CUSTOMER &

PROVIDER. QUALITY ASSURANCE USUALLY FOCUSES ON MATERIAL, GOOD WORK & SERVICE
PROVIDED EFFECTIVELY. ANY LACK IN SERVICE PROVIDED CAUSES DECREASE IN QUALITY.

4. QUALITY It is degree to which health services for individuals & population increase the likelihood
of desired health outcomes & are consistent with current professional knowledge. -Joint
Commission on Accreditition of health care organization ,2002 (JCAHO)

5. ASSURANCE It is statement or indication that inspires confidence.

6. QUALITY ASSURANCE • Quality assurance is an on-going, systematic, comprehensive evaluation of

health care services & impact of those services on health care services. -Kozier • Quality assurance is
defined as all activities undertaken to predate & prevent poor quality. -Neetvert

7. NURSING The unique function of nurse is to assist in individual sick or well in performance of
those activities contributing to health or its recovery or to a peaceful death that he would perform
unaided if he had necessary strength will or knowledge & to do this in such a way as to help him to
gain independence as rapidly as possible.” - Virginia Henderson
8. OBJECTIVES • To ensure the delivery of quality client care. • To demonstrate efforts of health care
providers to provide good results. • To formulate plan of care. • To evaluate achievement of nursing
care.

9. • To support delivery of nursing care with administrative & managerial services. • To explain
quality assurance models as pre- requisite for quality nursing care. • To state code of ethics &
professional conduct for nurses in India.

10. • To appreciate importance of practicing standard safety measures. • Plan & conduct patient
teaching sessions. • To identify appropriate management techniques to be used for managing
resources in given situation.

11. PURPOSES • It is required to introduce code of ethics & professional conduct for nurses in India.
• To prepare staff nurse for implementation quality assurance model in nursing. • To provide best
care to patients by maintaining standards.

12. PRINCIPLES 1. Customer focus- It focuses on patient’s care with standard & recent medical
knowledge. 2. Leadership – It helps to inculcate qualities of leadership in staff. 3. Involvement of
People- It should involve maximum nursing staff so that standards can be maintained.

13. 4) Process approach- There should be a systematic & planned approach to provide quality care.
5) Factual approach to decision making- There should be fact or appropriate reason in taking certain
decision for quality assurance of patient.

14. APPROACHES TO QUALITY ASSURANCE 1. Methods for measuring performance: As nursing care
is delivered within a framework of independent relationships with physicians and a multiplicity of
other health care personnel .The most commonly used methods of nursing care are task analysis and
quality control.

15. 2) Measuring actual performance: It is an ongoing repetitive process with the actual frequency
dependant on the type of activity being measured. It is better to clarify the purpose of the
measurement and to measure performance on a continuous basis.

16. 3) Comparing results of performance with standards and objectives and identifying strengths and
areas for correction: The standards and objectives and methods of measurement have been set ,if
performance matches standards and objectives , managers may assume that things are under
control if performance is a contrary to standards and objectives, action is necessary.

17. 4) Acting to reinforce strengths or success and taking corrective action as necessary: Positive
aspects needed to be identified in order that they may e translated into encouragement and
motivation for the nursing members involved in achieving them.

18. DEVELOPMENT OF A QUALITY ASSURANCE PROGRAM • Foster Commitment of Quality • Conduct

a Preliminary Review of Quality- Related Activities • Develop the Purpose and Vision for the Quality
Assurance Effort • Determine level and scope of initial Quality Assurance Activities • Assign
responsibility for Quality Assurance

19. • Allocate resources for quality assurance • Develop a written quality Assurance plan • Critical
Management System • Disseminate Quality Assurance Experience • Manage Change
20. APPROACHES FOR QUALITY ASSURANCE PROGRAM Approaches of quality assurance are divided
into 2 types: 1. General Approach 2. Specific Approach

21. GENERAL APPROACHES It involves large governing of official body’s evaluation of person’s or
agency’s ability to meet standard at a given time. 1. CREDENTIALING - It is process of determining &
maintaining nursing standards.

22. Functional Components Of Credentialing Process According to Hinsvark, credentialing process

has 4 functional components:- 1. To produce a quality product. 2. To confer a unique identity. 3. To
protect provider & public. 4. To control the profession

23. 2. LICENSURE Individual licensure is a contract between profession & state in which profession is
granted control over entry into & exists from profession & over quality of professional practice.

24. 3. ACCREDITATION Accreditation is the act of granting credit or recognition especially to an

educational institution that maintains suitable standards.

25. 4. CERTIFICATION Certification is usually a voluntary process within the professions. A person’s
educational achievement, experience & performance on examination are used to determine
person’s qualification for functioning in an identified specialty area.

26. SPECIFIC APPROACHES Quality assurances are methods used to evaluate identified instances of
provider and client interaction 1. Peer review committee- These are designed to monitor client
specific aspects of care appropriate for certain levels of care. The audit is used by peer review
committee to ascertain quality of care.

27. 2. NURSING AUDIT – Nursing audit is evaluation of patient care through analysis of written
records maintained by nurses in patient’s treatment profile. - Avtar Brar

28. GOALS OF NURSING AUDIT • To improve quality of health care. • To promote improved
communication among nurses & other health team members. • To improve quality of nursing care. •
To detect & analyze problems & errors.

29. NURSING AUDIT PROCESS

30. ADVANTAGES OF NURSING AUDIT • Provides quality of nursing • A patient is assured of good
services. • It will give valuable and pertinent information for the staff. • It will lead to between co-
operation and communication among the nurse & health team.

31. • It will help each professional nurse for her self evaluation. • It helps the administration as
better planning. • It will reduce the incidence of medical legal complication. • It will broaden and
strengthen nursing service.

32. 3.Utilization Review Utilization review activities are directed towards assuring that care actually
needed and that the cost appropriate for the levels of care provided

33. TYPES OF UTILIZATION REVIEW • Prospective: It is an assessment of the necessary of care before
giving services. • Concurrent: A review of the necessity of care while the care is being given. •
Retrospective: It is analysis of the necessity of the services received by the client after the care has
being given

34. 4.Evaluation Studies Donabedian’s Structure-Process-Outcome model Donabedian introduced 3

major method of evaluating quality care:-

35. 1. Structural evaluation This method evaluates setting & instruments used to provide care such
as facilities, equipments & characteristics of administrative organization & qualification of health
provider. The data can be obtained from existing documents.

36. 2. Process Evaluation This method evaluates activities as they relate to standards & expectations
of health providers in management of client care. Data is collected through direct observations,
review of records, audit etc.

37. 3.Outcome Evaluation The net changes that occur as a result of health care or net results of
health care. The data of this method can be collected from vital statistics records such as death
certificate or telephone client interview, mailed questionnaire & client records.

38. MODELS OF QUALITY ASSURANCE System Model System model is used for implementation of
unit based quality assurance program. It involves making changes in organizational structure &
individual roles. In system model, task is broken down into manageable components based on
defined objectives.

39. Basic Components of System Models • Input- The input can be compared to the present state of
systems. • Throughput- It is developmental process. • Output- It is finished product or result. •
Feedback- It is essential component of system because it maintains & nourishes growth.

40. ANA Quality Assurance Model Identify values Identify standards & criteria Secure measurement
Make measurement Identify course of action Choose action Take action Reevaluation

41. PDCA CYCLE PDCA CYCLE PLAN DO CHECK ACT

42. FACTORS AFFECTING QUALITY ASSURANCE IN NURSING CARE

43. QUALITY IMPROVEMENT • Quality improvement is defined as an approach to the continuous

study & improvement of process of providing health care services to meet the needs of clients &
others. -Joint commission on accreditation of health care organization (JCAHO)

44. PRINCIPLES • It requires continuous quality improvement. • Knowledge of customer expectation

needs. • Processes of customer supplier relationship. • Belief in people. • Statistical analysis. • Costs
of poor quality.

45. CONDITIONS IN WORK ENVIRONMENT • Employer’s involvement. • Improvement. • An

environment that support taking risk. • Team work. • Data collection & analysis skills. • Group
interaction skills. • Structure & management to enable improvement. • Tools to facilitate
improvement.

46. COMPONENTS OF QUALITY IMPROVEMENT PROGRAMS • Establish responsibility &

accountability. • Define scope of service for clinical area. • Define key aspects of service for clinical
area • Develop quality indicators to monitor outcomes & appropriateness of care delivered. •
Establish threshold for evaluation of indicators. • Collect & analyze data from monitoring activity.

47. • Evaluate results of monitoring activities to determine the need for change in practice. •
Resolve problems through development of action plans. • Reevaluate to determine if plan was
successful. • Communicate quality improvement results to organization.

48. TOTAL QUALITY MANAGEMENT • It focuses the production and service, i.e.: the environment
must be customer responsive. • It identifies and do the right things, the right way, the first time and
the prevent problems. • In this, customer needs and experiences with the end product are
constantly evaluated .

49. STANDARDS Standard is an established rule as basis of comparison in measuring or finding

capacity, quality context & value of objects in same category.

50. Classification of nursing care standards 1) Structure standards • It involves setup of institution. •
The philosophy, goals & objectives, structure of organization, facilities, equipment, qualification of
employees are some of components of structure of organization.

51. 2) Process standard • It describes behavior of nurse at desired level of performance. • It involves
activities concerned with delivering patient care.

52. 3)Outcome standard • An outcome standard measures changes in patient health status. • This
change may be due to nursing care, medical care or as a result of variety of services offered to
patient.

53. ROLE OF A NURSE • Role of nurse is to participate in quality improvement team. • Properly
supervises & check whether patient is receiving proper care or not.

54. • Contribute innovation & improvement of patient care. • Participating in improvement projects
&patient safety initiatives.

55. • Participating in CNE programs & in-service education programs. • Periodic & continuing
appraisal & evaluation of health care situation of patient. • Participate in research works related to
quality assurance. • Nurse identifies area where need improvement in delivery of care

56. RELATED RESEARCH 1) Development of an instructional quality assurance model in nursing

science • Result- The result of instructional quality in nursing science program is in high level (level 4
& 5 according to rating scale). Generally all standards are in good level.

57. 2)Evaluation of quality assurance model for Public Health Nursing. • Project was conducted for
one year period. The project was based on ANA Model for Quality Assurance & assessed standard
for an overall Quality Assurance Program.

58. • Purpose of the study- To analyze baseline outcome criteria for a Quality Assurance Program
and to implement and interface evaluation methodologies on Public Health Nursing (PHN) services
within the IHS to:
59. 1) Identify the amount and kind of quality services provided and the strengths and barriers. 2)
Provide recommendations for improvement in the quality of service. 3) Provide an action plan for
implementing changes to improve the quality of PHN care to recipients.

60. • STUDY FINDINGS- Outcome criteria standards are being met in a high percentage of instances -
in the 60 to 70 percentiles. • This was considered outstanding. • Patient Satisfaction Surveys
indicated extremely high satisfaction with public health nursing services - in the 95 to 99 percentiles.
• Peer Review and Utilization Review standards also showed a very high positive percentile ranking.

61. THEORY APPLICATION • FLORENCE NIGHTINGALE ENVIRONMENT THEORY Florence Nightingale

was the first person to describe about standards of nursing (1859) in “Notes of nursing, what it is &
what it is not”. In this, she wrote about change to achieve high standards.

62. . NNDCLIENTCLIENT HOUSING AIRLIGHT FOOD NOISE CLEANLINESS BEDDING VARIETY HEALTH
OF HOUSE HOPES/EMOTIONS

63. MODEL APPLICATION STRUCTURE PROCESSOUTCOME

64. • SYSTEM- Diarrhoea control program • STRUCTURE • Trained community workers. • ORS
packets. • Accessible health centres. • PROCESS • Education to mothers. • Rehydration therapy. •
Diagnostic studies.

65. • OUTCOME • Number of children treated. • No. of complications arose. • No. of deaths due to
diarrhoea.

66. A STRUCTURE PROCESS OUTCOMES (CAUSAL PAST) FUTURE PARTICIPANTS CARING

RELATIONSHIP (TERMINAL OUTCOMES) 1. PROVIDER • PHENOMENALFIELD • DESCRIPTORS • LIFE
EXPERIENCE 2. PATIENT /FAMILY • PHENOMENALFIELD • DESCRIPTORS • LIFE EXPERIENCE 3.
SYSTEM • RESOURCES • WORKLOAD • ENVIRONMENT OF ORGANIZATION 1. PROVIDER •
SATISFACTION • PERSONALGROWTH 2. PATIENT • QUALITY OF LIFE • SAFETY • SATISFACTION OF
TREATMENT • KNOWLEDGE 3. UTILIZATION • RESOURCE • CONSUMPTION • COST IMMEDIATE
OUTCOMES FEEL “CARED FOR” RELATIONSHIP CENTERED INDEPENDENT RELATIONSHIP PT. /FAMILY-
NURSE + COLLABORATIVE RELATIONSHIP WITH HEALTH CARE TEAM NURSE PROFESSIONAL
ENCOUNTERS

67. Presenter’s view

68. Point to be discussed Current Scenario of Quality Assurance in Government & Private Hospitals
In Madhya Pradesh.

Quality Quality is measured in terms of costumer perspective Performance improvement consists

of those activities and behaviors that each individual does to meet customers expectation Doing
things right the first time and continually striving to do better 12

12. A degree or grade of excellence. Proper performance 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. Quality……. -Roemer, M.I. and C.Montoya Aguilar,
WHO, 1988. 13

13. Effect of Poor Quality of Care Patient Physical discomfort Mental stress Increased length of
stay Complication development Loss of working days Increased expenses 14

14. Family Inconvenient Loss of trust Higher expenses Family disputes Effect of Poor Quality of
Care….. 15

15. Society Increased prevalence of disease Increased risk of certain infection Diminished
productivity, Unhealthy people is medically more demanding and economically less productive Effect
of Poor Quality of Care… 16

16. Hospital or institution Increased length of stay, overcrowding, further degradation of quality
care Higher rate of complication Increased risk of accidents and mishaps Adverse publicity
Decreased outcome Effect of Poor Quality of Care… 17

17. Care provider/staff Reduced motivation Risk of infection to staff High turn over rate Burn
out / frustration Effect of Poor Quality of Care… 18

18. Why Quality Assurance? Insure the right of the people to assess to quality health services
Improve the health status of the people Meet costumers needs and expectation Increased
demand for efficient utilization of limited resources Increased demand for effective and
appropriate care 19

19. Minimize waste of limited resources and reduce cost Standardize care and control variation
Ensure safety and minimize risk Fulfill the ethical duty of health professional Why Quality
Assurance?......... 20

20. History of Quality Assurance 1800 B.C. - King Hammurabi of Babylon Laws for monitoring and
controlling good and bad acts 21

21. 22

22. 1859 B.C. - Florence Nightingale During Crimean war she noticed direct correlation between
good nursing care to wounded soldiers and their low mortality rate - Developed standards for
nursing practice Concept of different wards Concept of Intensive Care Unit Father of Hospital
Administration Many more……………………... History of Quality ………. 23

23. 1895 - Dr. Abraham Flexor - Recommend a set of strict guidelines for standard of medical
education and adopted by US Government. 1910 - Ernest Codman - Suggested routine follow up
to determine the outcome of medical intervention History of Quality ………. 24

24. 1916 - The American College of Surgeons Developed the minimum standard for hospitals
1926 - In USA First medical standard manual was printed 1952 - Joint Commission Accreditation
of Hospital History of Quality ………. 25
25. 1966 - Dr. Avedis Donabedia System model for evaluating health care quality 1980 :WHO
Intiation in Europe to introduce QA program 1986: Edward Deming The concept of TQM was
developed Introduced in health care from industry. History of Quality ………. 26

26. Purposes of Quality Increased demand for effective and appropriate care Need for
standardization and variance control Benchmarking Necessity for cost saving measures
Accreditation, certification and regulations Performance appraisal of the provider 27

27. Need for improvement in care and services Ethical considerations Requirement to define and
meet patient needs and expectations. Pressure of competition and to enhance marketing Desire
for recognition and the strive for excellence. Purposes of Quality……… 28

28. Myths Truth It leads to wasted time and increase workload Quality means more expensive
service Quality means goodness, luxury ,shininess or weight It build a system which leads to less
time and effort It can be improved with the same resources Quality is never luxury,it is essential
to improve health service and minimize waste MYTHS AND TRUTH OF QUALITY 29

29. Myths Quality is intangible and not measurable Quality problems are originated by the
workers. Quality originates in the quality department. It can be measured The majority of the
problems encountered are due to inappropriate functioning of health systems, and not necessarily
the result of errors of individual workers Quality is everybody’s job Truth MYTHS AND TRUTH
OF……….. 30

30. Terminology Quality The degree of excellence Assurance A promise that you will definitely
do the best (provided formal guarantee) Quality Assurance Defines performance measurements
and compare actual processes and outcomes to clinical and satisfaction indicators 31

31. Quality Assurance in Nursing Quality assurance is a program for formal guarantee for provision
of quality nursing care against set standards Quality Control Involves performance management
and maintenance and includes systemic methods of ensuring conformance to a desired standard or
norm Terminology…… 32

32. Quality Care - right person (health worker ) doing: The right thing (evidence based practice)
In the right way (skills and competence) At the right time (providing treatment/ services when the
patient needs them) In the right place (location of treatment /services) With the right result
(clinical effectiveness / maximizing health gain). Terminology…… 33

33. Quality Circle A participative management approach in which employees and manages share
the responsibility for decision making and problem solving in client care Terminology…… 34

34. Quality Improvement (QI) is concerned with performance improvement and is ongoing,
involved with fixing problems now, costly mistakes in the future, and fostering breakthroughs.
Standard Predetermined level of excellence that serves as a guide for perfect practice
Terminology…… 35

35. Total Quality Management (TQM) Also referred to as continuous quality improvement
Philosophy developed by Dr. W. Edward Deming First implemented in Japan Focus on satisfying
customers' expectations, identifying problems, building commitment, and promoting open decision-
making among workers. Terminology…… 36

36. Purpose of QA To ensure high quality patient care, To ensure medical surveillance To ensure
population health management through continuous monitoring and evaluation of the patient care
37

37. Principles of Quality Assurance Focus on client needs Focus on data as basis for decision
Focus on systems and processes Focus on team approach to problem solving and quality
improvement 38

38. Dimension of Quality Assurance Efficacy Degree to which the intervention has been shown to
accomplish the indented outcome Appropriateness Degree to which the intervention is relevant
to client needs 39

39. Availability Degree to which appropriate interventions are available to meet client needs
Timeliness Degree to which the intervention is provided at the most beneficial time to the client
Dimension of Quality Assurance… 40

40. Effectiveness Degree to which the intervention is provided in the correct manner to achieve
the intended client outcome Continuity Degree to which the interventions are coordinated
between organizations ,among care providers and across time Dimension of Quality Assurance… 41

41. Safety Risk of an intervention and risk in the environment are reduced for both client and
health care provider Efficiency Care has the desired effect with the minimum of effort , waste and
expenses Dimension of Quality Assurance… 42

42. Respect and caring Clients are involved in health care decisions and are trusted with sensitivity
and respect for their individual needs, expectations and differences by health care providers.
Dimension of Quality Assurance… 43

43. Factors Influencing Quality Improvement Customer demand Financial viability Professional
accountability Regulatory requirements Progress in quality improvement technique Change in
health care delivery 44

44. Quality control A specific type of controlling, refers to activities that evaluate , monitor or
regulate service rendered to consumers The criterion or standard is determined Information is
collected to determine if the standard has been met Education or corrective action is taken if the
criterion has not been met 45

45. Quality Control as a Process Establish control criteria Identify information relevant to criteria
Determine ways to collect information Collect and analyze the information Compare collected
information with the established criteria 46

46. Make a judgment about quality Provide information and if necessary take corrective action
regarding findings to appropriate sources Quality Control as a Process….. 47
47. Components of Quality Management Program Statement of purpose, philosophy and objective
Standards for measuring quality care Policies and procedure Analysis and reporting Use of
results to prioritize Monitoring Evaluation 48

48. Principle of TQM Create a constancy of purpose for improvement of the products and service
Adopt a philosophy of continual improvements Focus on improving processes End the practice of
awarding business on price alone, instead minimize total cost by working with simple supplier 49

49. Improve constantly every process of planning , producing and service Institute job training and
retraining Develop leadership in the organization Encourage employees to participate actively in
process Principle of TQM…….. 50

50. Foster interdependent co-operation Focus on quality not on quantity Promote team work
Eliminate slogans and targets for the workplace. Educate to maximize personal development
Principle of TQM…….. 51

51. Comparison of QA and QI process QAP QIP Goal Improve quality Improve quality Focus Discovery
and correction of errors Prevention of error Major task Inspection of nursing activities and chart
Review of nursing activities , innovation and self development Quality team QA personnel
Multidisciplinary Outcome Set by QA team Set by QI team52

52. Technique for Obtaining Quality of Care Observe the behavior of the client and family
Interview Conduct focus group discussion Analyze solicited comments or letters from client
Survey Front line people (organization) 53

53. Employee feed back Customer care services Conduct telephone survey Toll free telephone
numbers Costumer visit Mail survey to discharged patient if feasible Technique for Obtaining
Quality of Care……….. 54

54. Steps in Quality Improvement Process Select a nursing activity for improvement Assemble a
multidisciplinary team to review and revise the nursing activity Describe all components of the
activity using a flow chart Collect data Discuss various plans to meet the standard Collect data to
evaluate the implementation 55

55. Component of Integrated Quality Management Quality assessment and improvement

Infection control Utilization management Risk and safety management 56

56. Standards It is a pre-determined baseline condition or level of excellence that comprises a

model to be followed and practiced. Distinguishing characteristic of standard: Predetermined
Established by an authority Communicated to and accepted by the individuals affected by standard
57

57. Type of standard Core standard Clinical standard 58

58. Areas of standard Clinical Communication Environment 59

59. Areas of standards Structure Physical Personnel organization Process What is done Why
is done Outcome Effect on the health of the patient 60
60. Steps in standard Identify the system Identify the expert Identify the input, process and
output Develop standard Chose format Appropriate intervention 61

61. The ANA standards for Practice 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. 62

62. Standard 3: The plan of nursing care includes goals derived from the nursing diagnoses.
Standard 4: The plan of nursing care includes priorities and the prescribed nursing approaches or
measures to achieve the goals derived from the nursing diagnoses. The ANA standards for Practice…
63

63. 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.
The ANA standards for Practice… 64

64. 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 re- assessment, re-ordering of priorities, new goal setting, and a revision of the
plan of nursing care. The ANA standards for Practice… 65

65. QA Model in Nursing QAM in nursing is a set of elements that are related to each other and
comprise of planning for quality , development of objectives, setting and actively communicating
standards , developing indicators , setting thresholds, collecting data to monitor compliance with set
standards for nursing practice and applying solution to improve care 66

66. Purpose of QAM Develop confidence of receivers that quality care is being rendered as per
assurance Ensure quality nursing care To meet the expectation of receiver, management and
regulatory body Intends to increase the commitment of provider and management 67

67. Cycle of Quality Assurance Define acceptable standards of service Compare services of
standard Implement developments and changes as needed Monitor the effects of changes and
developlment 68

68. Models of Quality Assurance System Model for Quality assurance ANA Quality Assurance
Model JCAHO Quality Assurance Model ISO Quality Assurance Model PDCA Six Sigma
DMAIC DMADDV 69

69. System Model Tasks are broken down into manageable components based on defined
objectives. The basic components of the system are: 1. Input (Structure) 2. Throughput (Process) 3.
Output (Outcome) 4. Feedback Models of Quality Assurance 70

70. System Model System Environment Environment Transformation Employee’s work activities
Management activities Technology and operations methods OutputsInputs Raw materials Human
resources Capital Technology Information Products and services Financial results Information Human
results Feedback 71

71. Structural Elements… Geographical location of facility Beds Personnel Nurse to patient ratio
Equipments and supplies Space Rules and procedures Technology Finance 72
72. Process Elements… Treatment process Technical aspect of care Appropriateness Use of
efficacious therapy Use of diagnostic test Use of procedure Treatment delay(including waiting
time) IPR Conflict/grievance /readdress procedure Documentation73

73. Outcome Elements…. Death rate Adverse event Readmission Length of hospital stay Cost
of service Patient’s satisfaction 74

74. ANA Quality Assurance Model This is also based on the system model 75

75. Identify value Identify structure, process, outcome standard and criteriaObtain measureme nt to
determine attainment of standard and criteria Interpretati on based on measureme nt Identify
possible courses of action Choose course of action Take action Evaluate Action taken

76. JCAHCO QA Model Enhance standard Compare standard Attained Not attained Collect data
Establish standard for evaluation Identify indicator Identify important aspect of concerned subject
Delineate scope 77

77. ISO QA Model Planning Implementation Evaluation Review 78

78. Plan Do Check Act (PDCA) Cycle 79

79. Six sigma Given by Bill Smith while working at Motorola Six Sigma describes quantitatively how
a process is performing. To achieve Six Sigma, a process must not produce more than 3.4 defects
per million opportunities 80

80. DMAIC Define Measure process performance Analyze the process Improve process Control
the improved process 81

81. DMADDV Define Measure of quality Analyze Design Detail Verify the definition 82

82. Tools to Measure Quality Audit Client records are reviewed for compliance to predetermined
criteria that measure process and outcome of care Peer review Care is evaluated based on the
judgments of a colleague with equal education and experience 83

83. Benchmarking Measuring service and practice against the competition Clinical pathway
Measuring the performance of care according to critical outcomes and key incident that must occur
within the given time frame Tools to Measure Quality… 84

84. Audit It is a systematic and official examination of record, process or account to evaluate
performance. Structure audit Process audit Outcome audit 85

85. It is the process of collecting information from nursing reports and other documented evidence
about patient care and assessing the quality of care by the use of quality assurance program. Nursing
Audit 86

86. Purposes of Nursing Audit Evaluating nursing care given Achieve desired and feasible quality of
nursing care Stimulant to better records Focuses on care provided and not on care provider
Contribute to research 87
87. Nursing Audit Process Select topic Develop criteria Ratify the criteria Review charts
Identify variations Analyze the problem Develop solution Implement solution Evaluate and re-
audit 88

88. Structure Audit Physical facilities Equipment Caregiver Organization Policies, standard
management protocol , procedure and clinical records Checklist measures standard Structure
should include knowledge and experience 89

89. Process Audit Task oriented Implement indicators for measuring nursing care to determine
whether nursing standards are met Retrospective, being applied to measure the quality of nursing
care received by the client The phaneuf audit seven subsection 90

90. Phaneuf Audit… Application and execution of physician’s legal instruction and advices
Observation of symptoms and reactions Supervision of client Supervision of those participating
in care Recording and reporting Application and execution of nursing procedures and techniques
Promotion of physical and emotional health 91

91. Outcome Audit Evaluate by establishing client outcome criteria National centre for health
services developed an outcome criteria based on Orem’s description-air, water, food, elimination,
rest, social interaction, protection from hazards, normalcy and health deviation 92

92. Outcome Audit….. Morbidity, disability and mortality during and after health care service
Nursing assessment and intervention Grouping items for efficiency When outcome are not
satisfactorily met, deficiencies are identified , corrected and followed up 93

93. Evaluated in terms of………. Requirement is met Client has the necessary knowledge to meet
the requirement Client has the necessary skill and performance Client has necessary motivation
94

94. Methods of Auditing A concurrent nursing audit A retrospective nursing audit A prospective
nursing auditing 95

95. Types of Auditing Internal auditing External auditing 96

96. Set standards Observe practice Compare with standards Implement Change Audit cycle 97

97. Approaches For A Quality Assurance Program Two major categories of approaches exist in
quality assurance Program: General Specific 98

98. 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 5. Charter 6. Academic degree 99

99. 1. Credentialing Formal recognition of professional or technical competence and attainment of

minimum standards by a person or agency Credentialing process has four functional components
To produce a quality product To confer a unique identity To protect provider and public To
control the profession. 100
100. 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. 101

101. Licensure of nurses has been mandated throughout the world by laws and regulations. In
Nepal : Nepal nursing council (NNC) is the governing body to regulate nursing licensure NNC is a
member of International Council of Nursing (ICN) 2. Licensure………….. 102

102. 3. Accreditation Accreditation is the process by which authorized body evaluates the quality of
a higher education institution as a whole or of a specific educational program in order to formally
recognize it as having met certain predetermined minimal criteria or standards. 103

103. International Accreditation organization Joint Commission International (USA) United

Kingdom Accreditation Forum (UKAF) Quality Health New Zealand (QHNZ) National Accreditation
Board for Hospitals & Healthcare Providers (NABH) Accreditation Canada International (ACI) 104

104. 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 identified specialty area. 105

105. ISO (International Organization for Standardization ) Focus on good management practices
Ensures that the organization deliver the product or services that meet the customer's quality
requirements and Enhance customer satisfaction, and achieve continual improvement of its
performance in pursuit of these objectives. 106

106. Standards in the ISO 9000 family include: ISO 9001:2015 - Sets out the requirements of a
quality management system ISO 9001:2008: Quality management system ISO 9000:2015 - Covers
the basic concepts and language ISO 9004:2009 - Focuses on how to make a quality management
system more efficient and effective ISO 19011:2011 - Sets out guidance on internal and external
audits of quality management systems.107

107. Charter A charter is the grant of authority or rights, stating that the granter formally
recognizes the rights of the recipient to exercise the rights specified 108

108. B. Specific Approaches Peer review Standard as a device for quality assurance Audit as a
tool for quality assurance 109

109. Factors Affecting Quality Assurance In Nursing Care Lack of resources Personnel problems
Improper maintenance Unreasonable Patients and Attendants Absence of well informed
population Absence of accreditation laws 110

110. Lack of incident review procedures Lack of good and hospital information system Absence
of patient satisfaction surveys Lack of nursing care records Lack of good supervision Factors
Affecting Quality Assurance In Nursing Care……………… 111

111. Absence of knowledge about philosophy of nursing care Lack of policy and administrative
manuals. Substandard education and training Lack of evaluation technique Factors Affecting
Quality Assurance In Nursing Care……………… 112
112. Lack of written job description and job specifications Lack of in-service and continuing
education and staff development program Nurse prescription – No provision yet. Factors Affecting
Quality Assurance In Nursing Care……………… 113

113. Legal and Ethical Implication Law , regulation and ethics play a major role Define professional
practice Laws define legal practice, regulation define guideline for delivery of care and ethics define
personal performance Code of ethics and professional conduct for the nurses must be there in any
country 114

114. The code of ethics helps to protect the rights of individuals, families, & community and also
the rights of the nurse. Code can’t be broken – should follow at any circumstances. Failure to
provide quality health care can result in law suit Legal and Ethical Implication… 115

115. Nursing practice standard Professional responsibility and accountability Nursing practice
Communication and interpersonal relationship Valuing human beings Management
Professional advancement 116

116. Professional Responsibility and Accountability Based on quality assurance model

Professionally managed and ethically justified Provided within the legal frame work Documented
accurately and completely Responsibility and accountability for own actions 117

117. Nursing practice Reflects adherence to practice standards Reflects nursing process approach
Provided in a safe environment 118

118. Communication and interpersonal relationships (IPR) Fosters effective interpersonal

relationship with individuals and families Initiates strategies to promote the learning of individuals
and groups Nurses at all levels must have Large open/ public area or Quadrant 1 in JOHARI Model -
Self awareness about the professional role. 119

119. Valuing Human Beings Enhances the dignity, individuality and self esteem of individuals and
groups Reflects active pursuit for rights of all individuals and in particular the vulnerable groups
Reflects gender sensitivity towards the needs of women related to their health 120

120. Management Reflects use of effective techniques Reflects use of quality assurance model.
Organizes and utilizes resources efficiently Ensures disaster preparedness 121

121. Management… Contributes to development and implementation of institutional policies in

conformity with statutory regulations Develops and implements staff development and welfare
programs. 122

122. Professional advancement Reflects the commitment to ongoing education and professional
growth of self and others. Includes activities which focus on the advancement of profession 123

123. Nursing Theories and Quality Theory development in 1950’s Hildegard E. Paplau:
Interpersonal relationship in nursing, 1952 Virgenia A Henderson :Independence theory:1955
Theory in the 1960’s: Faye Glenn Abdellah: Patient centred approach theory, 1960 Ida Jean
Orlando : Nursing Process Theory-1961 Dorothy E Johnson : Behavioral system model for nursing
,1968 124
124. Theory in the 1970’s Sister Callista Roy: Adaptation model ,1970 Dorothea E Orem: Theory
of self care deficit , 1971 Betty Neuman : Neuman system model ,1974 M Jean Watson: Theory of
human caring ,1979 Theory in the 1980’s Madeleine M Leininger : Culture care diversity and
universality , 1985 & so on…………….. Nursing Theories and Quality….. 125

125. Role of Nurse in Quality Assurance Maintenance of a current knowledge base and
competencies Interpersonal skills Caring and compassion Mutual decision making with client and
nurse Individualized treatment Strive for excellence in everything that is done (Nurses, Nurse
manager or clinician, team member ) 126

126. Nurses role in legal complication Review nursing practice periodically Know their job
description Follow nursing standards Follow …. Rights Use professional judgment before
implementing Do not attempt anything beyond level of competence 127

127. Federal regulation (International ) Social security act (1965,1972) Consolidated omnibus
budget reconciliation act(COBRA) 1985,1986 Health care quality care improvement (1986) Clinical
laboratory improvement amendment (CLIA) Patient self determination act(1990) Safe medical
device act (1990) Occupational safety and health administration (1991,1993) 128

128. Regulations in India –NABH standard 1992:Quality council of India Establishment of national
accreditation board of hospital and health care provider(NABH) Access, assessment and continuity
of care (AAC) Patient right and education(PRE) Care of patient (COP) 129

129. Management of medication (MOM) Hospital infection control (HIC) Continuous quality
improvement (CQI) Responsibility of management (ROM) Facility management and safety (FMS)
Human resource management (HRM) Information management system (IMS) NABH
standard………… 130

130. Constitution of Nepal: Mentioned about Quality Care Ministry of Health Ministry of
Education Nepal Nursing Council (NNC) Nursing Association of Nepal (NAN) Nepal Medical
Council (NMC) Nepal Health Professional Council (NHPC) Nepal Pharmacy Council QA in Nepal
131

131. QA in Nepal….. 1991 – Family planning services focused in quality In 1993 health institution
and manpower development division was created 1993/94 -National workshop on QA in health
service. 132

132. 1994-plan of action to strengthen QA activities 1994/95 – reviewed and developed standard
guideline for SHP ,HP and PHC level 1999- developed nursing procedure manual 90’s- workshop
for awareness of QA in health service in 5 developmental region QA in Nepal….. 133

133. In 9th (1997-2002) health plan policy “improving public health and related indicator and
providing quality health, service are the long term objective 2009- Policy on quality health
service,2064 2014-Minimum service standard ,2071 QA in Nepal….. 134

134. QA in CMCTH QA committee Infection prevention committee Incidence report Nursing

manual -2014 136

135. 137
136. Journal of Taibah University Medical Sciences (2015) 10(4), Implementation of total quality
management in hospitals Emad A.S 70% of variance in implementing TQM can be achieved by
following the principles of TQM(continuous improvement, teamwork, training, top management
commitment and customer focus.) Continuous improvement was the most significant factor in
explaining variance in implementing TQM principles 138

137. International journal for quality in health careVol 18 ,Issue 6 Pp. 414 - 421 (2006) Towards
patient-centered health services in India—a scale to measure patient perceptions of quality Rao K
D.,PetersD H Better staff and physician interpersonal skills, facility infrastructure, and availability of
drugs have the largest effect in improving patient satisfaction at public health facilities. 139

138. British Medical Journal 2012;344:e1717 Patient safety, satisfaction, and quality of hospital care:
cross sectional surveys of nurses and patients Aiken L H et al Nurse burnout (10% (Netherlands) to
78% (Greece) Job dissatisfaction (11% -Netherlands) to 56% (Greece), and Intention to leave (14%
(US) to 49% (Finland, Greece) 140

139. Common wealth fund ,2004 Hospital quality: ingredients for success— overview and lessons
learned Jack A. (2004) Essential elements of a successful strategy, according to the study, include
Developing the right culture, Attracting and retaining the right people, Devising and updating the
right in-house processes, and Giving staff the right tools to do the job. 141

140. Satisfaction with Health Care Services of Out Patient Department at Chitwan Medical College
Teaching Hospital, Nepal Rajbanshi L et al. (2014) Total sample :776 Satisfaction level was
75.9% Level of satisfaction Access to care: 98.5% quality of care : 91.5% physical facility:
56.3% cost of healthcare: 61.3% courtesy of healthcare provider:50.8% 142 Satisfaction with
Health Care Services of Out Patient Department at Chitwan Medical College Teaching Hospital, Nepal

141. Reasons for turn over among the nurses working at BPKIHS Mehta R S et al. Sample:150
Reasons for leaving institution Higher education Negative attitude of nursing leader Inadequate
salary Proper promotion opportunity -Nursing and Midwifery Research Journal, April 2005, Vol-1,
No. 2, 143

142. Stress Among Nurses Working In Critical Care Areas At A Tertiary Care Teaching Hospital Nepal
Level of stress Moderate stress: 56% had Mild stress :34%, Severe stress: 6%, No stress :4%
144

143. The Internet Journal of Healthcare Administration™ ISSN: 1531-2933 Effects Of Nurse
Prescribing Of Medication: A Systematic Review Citation: L. M. Van Ruth, P. Mistiaen & A. L. Francke
: Effects Of Nurse Prescribing Of Medication: A Systematic Review . The Internet Journal of
Healthcare Administration. 2008 Volume 5 Number 2 145

144. Clinical outcomes of patients being prescribed by Nurses or Physicians - Most of the studies
found no differences between prescribing nurses and GPs and some found that the patients who
were given prescriptions by nurses had better clinical parameters. Satisfaction with care- Most of
the studies found that patients being treated by nurses were just as satisfied or more satisfied than
patients being treated by physicians 146
145. Patient enablement- Studies report that patient enablement, i.e. the extent to which patients
understand their illness and are able to cope, is similar for nurse practitioners and GPs Quality of
care – Most of studies in primary care report that quality of care provided by nurses is similar to or
better (in some cases) than that provided by GPs. 147

146. Consultation time- Most of studies reporting on consultation times found that nurses
generally spent more time with patients. Information and documentation- Nurses were found to
give more advice than GPs about home remedies, self-medication and general self-management.
Patients managed by nurse practitioners reported receiving more information about their illnesses
and well documented. 148

147. Effects on costs and other characteristics of health care system- Netherlands showed that the
costs incurred for personnel were lower for the group of patients being treated and prescribed for
by the specialist nurse. 149

148. Quality History Myths and truth about quality Terminology Principle of QA Dimensions
of quality assurance QA model Factors affecting quality assurance QA approach Legal and
ethical implication Role of nursing Winding Up 150

149. Take home message TQM is a new wave of nursing management Customer is anyone who
uses the products, services or process within an organization Quality management programs make
certain that the patient care delivered meets established standards Doing things right the first time
and every time. 151

150. 152

151. 153

152. 154

153. 155

154. Reference Singh, I. (2012). Leading and Managing in Health (5th ed.). J.B. Singh Publication:
Kathmandu. Kelly, P. (2008). Leadership and Management in Nursing (1st ed.). Cengage Learning
India Pvt. Ltd.: India. Meheta, R.S., & Pokheral, T. (2012). Leadership and Management (3rd ed.).
Makalu Publication: Kathmandu. Wolper,L. (2004). Health Care Administration (3rd ed.). Jones and
Bartlett Publication: Masschesetts. 156

155. Sakharkar,B.M. (2008). Principles of Hospital Administration and Planning (5th ed.). Jaypee
Publication: New Delhi, India. Sah, A.P. (2011). Essential of Health Management (1st ed.) Vidyarthi
Pustak Bhandar: Kathmandu. Peter, R.K. (2007). Essential Managed Health Care (5th ed.). Jones
Barllett Publishers sudbury: Massachusetts. Reference…. 157

156. Dill, D.D. (2000) Designing Academic Audit: lessons learned in Europe and Asia, Quality in
HigherEducation, Vol. 6, No. 3 Askling, B. (1997) Quality Monitoring as an Institutional Enterprise,
Quality in Higher Education, Vol. 3,No. 1 Harvey, L. (2002) The End of Quality?, Quality in Higher
Education, Vol. 8, No. 1 Reference…. 158
157. Rasmussen, P. (1997) A Danish Approach to Quality in Higher Education, The Case of Aalborg
University, in Brennan, J. de Vries, P. and Williams, R. (eds.) Standards and Quality in Higher
Education, Higher Education Policy Series, Vol. 37, Jessica Kingsley Reference…. 159

158. Kelvin B. H., Singhal V.R. (1997)Does Implementing an Effective TQM Program Actually Improve
Operating Performance? Empirical Evidence from Firms That Have Won Quality Awards.pubsonline.
Volume 43, Issue 9( September 1, 1997) http://pubsonline.informs.org/doi/abs/10.1287/mnsc.
43.9.1258 Reference…. 160

159. Schouten L M T(2008) Evidence for the impact of quality improvement collaboratives:
systematic review.The BMJ http://www.bmj.com/content/336/7659/1491.short Rao K D.,PetersD H
(2006),Towards patient-centered health services in India—a scale to measure patient perceptions of
quality. International journal for quality in health care .Volume 18, Issue 6. Pp. 414 - 421
Reference…. 161

160. Aiken L H et al (2012). Patient safety, satisfaction, and quality of hospital care: cross sectional
surveys of nurses and patients in 12 countries in Europe and the United States. BMJ 2012;344:e1717
http://www.bmj.com/content/344/bmj.e1717 R AN, M KK, P RM, Akanksha J, S BB. Patients’ Waiting
Time and Their Satisfaction of Health Care Services Provided at Outpatient Department of
Government Medical College, Nanded (Maharashtra, India). . IJHSR. 2014; 4(4): 21-27
http://www.scopemed.org/?jft=107&ft=107-1398677084 Reference…. 162

161. Derek Milne, Bob Drummond, (1990) "Quality Assurance: Implementation in Nursing Practice",
International Journal of Health Care Quality Assurance, Vol. 3 Iss: 5
http://www.slideshare.net/HareeshSasidharan/qua lity-assurance-26354281 Reference…. 163

Quality:<br />Quality is defined as the extent of resemblance between the purpose of healthcare
and the truly granted care (Donabedian1986).<br />

4. Quality assurance<br />"Quality assurance is the monitoring of the activities of client care to
determine the degree of excellence attained to the implementation of the activities". (Bull, 1985)<br
/>

5. Quality assurance is the defining of nursing practice through well written nursing standards and
the use of those standards as a basis for evaluation on improvement of client care (Maker 1998).<br
/>

6. APPROACHES FOR A QUALITY ASSURANCE PROGRAMME:<br />Two major categories of

approaches exist in quality assurance they are<br />General<br />Specific<br />

7. General Approach:<br />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.<br />1) Credentialing:<br
/> 2) Licensure:<br /> 3) Accreditation:<br /> 4) Certification:<br />

8. 1) Credentialing:<br />It is generally defined as the formal recognition of professional or technical

competence and attainment of minimum standards by a person or agency According to Hinvasky
(1981)<br />
9. credentialing process has four functional components<br /> a) To produce a quality product<br />
b) To confer a unique identity<br /> c) To protect provider and public<br /> d) To control the
profession.<br />

10. 2) Licensure:<br />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.<br />

11. 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 law since 1903<br />

12. 3) Accreditation:<br />National league for nursing (NLN) a voluntary organization has established
standards for inspecting nursing education's programs. In the part the accreditation process
primarily evaluated on agency's physical structure, organizational structure and personal
qualification<br />

13. 4) Certification:<br />Certification is usually a voluntary process with in the profession. A

person's educational achievements, experience and performance on examination are used to
determine the person's qualifications for functioning in an identified specialty area.<br />

14. Specific approaches:<br />Quality assurances are methods used to evaluate identified instances
of providers and client interaction.<br /> 1) Peer review:<br /> 2) Standard as a device for quality
assurance:<br /> 3)Audit as a tool for quality assurance:<br />

15. 1) Peer review:<br />To maintain high standards, peer review has been initiated to carefully
review the quality of practice demonstrated by members of a professional group. Peer review is
divided in to two types. One centers on the recipients of health services by means of auditing the
quality of services rendered. The other centers on the health professional by evaluating the quality
of individual performance.<br />

16. 2) Standard as a device for quality assurance:<br />Standard is a pre-determined baseline

condition or level of excellence that comprises a model to be followed and practiced. The ANA
standard for practice include;<br />Standard 1: The collection of data about health status of the
patient is systematic and continuous. The data are accessible, communicative, and recorded.<br />

17. Standard 2: Nursing diagnosis are derived from health status data.<br />Standard 3: The plan of
nursing care includes goals derived from the nursing diagnoses.<br />Standard 4: The plan of nursing
care includes priorities and the prescribed nursing approaches or measures to achieve the goals
derived from the nursing diagnoses.<br />

18. Standard 5: Nursing actions provide for patient participation in health promotion, maintenance,
and restoration.<br />Standard 6: Nursing actions assist the patient to maximize his health
capabilities.<br />

19. Standard 7: The patient's progress or lack of progress towards goal achievement is determined
by the patient and the nurse.<br />Standard 8: The patient's progress or lack of progress towards
goal achievement directs re-assessment, re-ordering of priorities, new goal setting, and a revision of
the plan of nursing care.<br />
20. To evaluate quality nursing care regularly, many staff nurses do indeed welcome opportunity to
develop criteria, to review nursing care retrospectively and concurrently, and to discover methods of
achieving higher levels of quality nursing care.<br />

21. 3) Audit as a tool for quality assurance:<br />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<br />

22. To be effective a nursing audit must be based on established criteria and feedback mechanism
that provide information to providers on the quality of care delivered.<br />

23. QUALITY ASSURANCE MODEL IN NURSING<br />Quality assurance model in nursing is the set of
elements that are related to each other and comprise of planning for quality development of
objectives 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 <br />

24. PHILOSOPHY OF QUALITY ASSURANCE MODEL IN NURSING <br />Indian nursing council believes
that nurse will <br />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 <br />

25. 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 <br
/>Be responsible and accountable for providing quality care in line with set standards <br />

26. Be committed to understanding of dynamic nature of his / her role in interdisciplinary health
team<br />Be obliged to create public awareness and consider social expectations before making
decisions for providing nursing care <br />Be obliged to include receiver in making choices in
planning and implementation of care <br />

27. Work in conjugation with legislation, accreditation and political system <br />Have obligation to
promote education of self and others<br />Be committed to advancement of profession <br />

28. PURPOSE OF QUALITY ASSURANCE MODEL<br />To ensure quality nursing care provided by
nurses in order to meet the expectations of the receiver, management and regulatory body <br />It
also intends to increase the commitment of the provider and the management <br />

29. GOALS OF QUALITY ASSURANCE MODEL<br />Develop confidence of the receiver that quality
care is being rendered as per assurance <br />Develop commitment of the management towards
quality care<br />Increase commitment of providers to adhere to set standards for nursing practice
and strive for excellence <br />

30. MODELS OF QUALITY ASSURANCE<br />System Model for Quality assurance.<br />ANA Quality
Assurance Model<br />JCAHO Quality Assurance Model<br />ISO Quality Assurance Model<br />
31. A System Model for Quality assurance.<br />The basic components of the system are<br
/>Input<br />Throughput<br />Output<br />Feedback<br />

32. i) Input:- Can be compared to the present state of the system.<br /> <br />ii) Through put:- The
through put to the developmental process.<br /> <br />iii) Out put:- To the finished product.<br />
<br />iv) Feed Back:- It is the essential component of the system because it maintains and nourish
growth.<br />

33.

34.

35. AMERICAN NURSES ASSOCIATION MODEL FOR QUALITY ASSURENCE<br />Identify values<br
/>Identify structure, process and outcome standards and criteria<br />Select measurement<br
/>Make interpretation<br /> <br />

36. Identify course of action<br />Choose action<br />Take action<br />Reevaluate<br />

37. 1) Identify Value:<br />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 providers of nursing services.<br />

38. 2) Identify structure, process and outcome standards and criteria:<br />Identification of
standards and criteria for quality assurance begins with writing of philosophy and objective of
organization. The philosophy and objectives of an agency serves to define the structural standards of
the agency. <br />

39. 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 assignments. Evaluation of the standards of structure is
done by a group internal or external to the agency.<br />

40. 3) Select measurement needed to determine degree of attainment of criteria and standards:<br
/>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, review of agency documents, self studies and review
of physicals facilities. <br />

41. 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.<br />

42. 4) Make interpretations<br />The degree to which the predetermined criteria are met is the
basis for interpretation about the strengths and weaknesses of the program. The rate of compliance
is compared against the expected level of criteria accomplishment.<br />

43. 5) Identify Course of Action<br />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 necessary to identify the
cause of deficiency. Then, it is important to identify various solutions to the problems.<br />

44. 6) Choose action<br />Usually various alternative course of action are available to remedy a
deficiency. Thus it is vital to weigh 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.<br
/>

45. 7) Take Action:<br />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.<br />

46. 8) Reevaluate:<br />The final step of QA process involves an evaluation of the results of the
action. The reassessment is accomplished in the same way as the original assessment and begins the
QA cycle again. <br />

47. Careful interpretation is essential to determine whether the course of action has improves the
deficiency, positive reinforcement is offered to those who participated and the decision is made
about when to again evaluate that aspect of care.<br />

48. JCAHO<br />

49.

50.

51. JCAHO QUALITY ASSURENCE MODEL<br />

52. ISO QUALITY ASSURENCE MODEL<br />

53.

54.

55. QUALITY ASSURANCE PROCESS:<br />Establishment of standards or criteria<br />Identify the

information relevant to criteria<br />Determine ways to collect information<br />Collect and
analyze the information<br />Compare collected information with established criteria<br />Make a
judgment about quality<br />Provide information and if necessary, take corrective action regarding
findings of appropriate sources<br />Determine ways to collect the information<br />

56.

57. FACTORS AFFECTING QUALITY ASSURANCE IN NURSING CARE<br />1) Lack of Resources:<br />2)
Personnel problems:<br />3) Improper maintenance:<br />4) Unreasonable Patients and
Attendants<br />5) Absence of well informed population.<br />6) Absence of accreditation laws<br
/> <br />

58. 7) Lack of incident review procedures<br />8) Lack of good and hospital information system<br
/>9 Absence of patient satisfaction surveys<br />10) Lack of nursing care records<br />
59. 1) Lack of Resources:<br />Insufficient resources, infrastructures, equipment, consumables,
money for recurring expenses and staff make it possible for output of a certain quality to be turned
out under the prevailing circumstances.<br />

60. 2) Personnel problems:<br />Lack of trained, skilled and motivated employees, staff indiscipline
affects the quality of care.<br />

61. 3) Improper maintenance:<br />Buildings and equipments require proper maintenance for
efficient use. If not maintained properly the equipments cannot be used in giving nursing care. To
minimize equipment down time it is necessary to ensure adequate after sale service and service
manuals.<br />

62. 4) Unreasonable Patients and Attendants<br />Illness, anxiety, absence of immediate response
to treatment, unreasonable and un co-operative attitude that in turn affects the quality of care in
nursing.<br />

63. 5) Absence of well informed population.<br />To improve quality of nursing care, it is necessary
that the people become knowledgeable and assert their rights to quality care. This can be achieved
through continuous educational program.<br />

64. 6) Absence of accreditation laws<br />There is no organization empowered by legislation to lay

down standards in nursing and medical care so as to regulate the quality of care. It requires a
legislation that provides for setting of a stationary accreditation / vigilance authority to<br />

65. a) Inspect hospitals and ensures that basic requirements are met.<br />b) Enquire into major
incidence of negligence<br />c) Take actions against health professionals involved in malpractice<br
/>

66. 7) Lack of incident review procedures<br />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<br />a) Delayed attendance by nurses, surgeon, physician<br />

67. b) Incorrect medication<br />c) Burns arising out of faulty procedures<br />

68. 8) Lack of good and hospital information system<br />A good management information system is
essential for the appraisal of quality of care.<br />a) Workload, admissions, procedures and length of
stay<br />b) Activity audit and scheduling of procedures.<br />

69. 9 Absence of patient satisfaction surveys<br />Ascertainment of patient satisfaction at fixed

points on an ongoing basis. Such surveys carried out through questionnaires, interviews to by social
worker, consultant groups, and help to document patient satisfaction with respect to variables that
are<br />

70. a) Delay in attendance by nurses and doctors.<br />b) Incidents of incorrect treatment<br />

71. 10) Lack of nursing care records<br />Nursing care records are perhaps the most useful source of
information on quality of care rendered. The records.<br />a) Detail the patient condition<br />b)
Document all significant interaction between patient and the nursing personnel.<br />
72. c) Contain information regarding response to treatment<br />d) Have the dates in an easily
accessible form.<br />

73.

74. Thank you for your patient listening<br />

ntroduction of dialysis Types Dialysis process Physiological principles Types of peritoneal

dialysis Indications Complications Nursing care : before, during and after 2

3. Dialysis is the procedure used to correct fluid and electrolyte imbalances and to remove waste
products in renal failure. 3

4. DO: waste removal and fluid removal. Do Not Do not correct the endocrine functions of the
kidney. Hence , dialysis is not a cure for kidney failure. 4

5. 5 Types: 1. Hemodialysis. 2. Peritoneal dialysis. Dialysis

6. 6

7. How long does hemodialysis take? Hemodialysis usually is done three times a week. Each
treatment lasts from 2 to 4 hours. During treatment, patient can read, write, sleep, talk, or watch TV.
7

8. HOW DIALYSIS 8

9. 9

10. 10

11. Dialyzer are hollow-fiber artificial kidneys that contain thousands of tiny tubules that act as
semipermeable membranes. The blood flows through the tubules, while a solution (the dialysate)
circulates around the tubules. The exchange of wastes from the blood to the dialysate occurs
through the semipermeable membrane of the tubules 11

12. The blood flows in one direction and the dialysate flows in the opposite. 12

13. Robert W. Hamilton 13

14. 14

15. Diffusion- movement of solutes from an area of greater concentration to an area of lower
concentration. ◦ In renal failure urea, creatinine, uric acid, and electrolytes( Potassium, phosphate),
move from the blood to the dialysate with the net effect of lowering their concentration in the
blood. ◦ But WBC’s, RBC’s and other contents within the blood are too large to diffuse across the
membrane. 15

16. The movement of fluid from an area of lesser to an area of greater concentration of solutes.
Glucose is added to the dialyzing solution and creates an osmotic gradient across the membrane to
remove excess fluid from the blood. 16
17. Ultra filtration is defined as water moving under high pressure to an area of lower pressure.
This process is much more efficient at water removal than osmosis. Ultra filtration is accomplished
by applying negative pressure or a suctioning force to the dialysis membrane. 17

18. Access to the patient’s vascular system must be established to allow blood to be removed,
cleansed, and returned to the patient’s vascular system . Several types of access are available. ◦
Fistula ◦ Graft 18

19. FISTULA A more permanent access. created surgically (usually in the forearm) by joining an
artery to a vein, either side to side or end to side. The arterial segment of the fistula is used for
arterial flow and the venous segment for reinfusion of the dialyzed blood. 19 FISTULA

20. The fistula takes 4 to 6 weeks to mature before it is ready for use. This gives time for healing
and for the venous segment of the fistula to dilate . The patient is encouraged to perform exercises
to increase the size of these vessels (i.e, squeezing a rubber ball for forearm fistulas). 20

21. An arterio venous graft can be created by subcutaneously inserting a biologic, semi biologic, or
synthetic graft material between an artery and vein . Indications: When the patient’s vessels are
not suitable for a fistula. Grafts are usually placed in the forearm, upper arm, or upper thigh. 21

22. 22

23. 23

24. Peritoneal membrane , serves as the semi permeable membrane for dialysis. It involves
repeated cycle of instilling dialyzing solution into the peritoneal cavity through a catheter into it. 24

25. 25

26. CAPD - which stands for Continuous Ambulatory Peritoneal Dialysis - happens throughout the
day, at home or at work, while the person goes about his or her daily life. Between 1.5 and 3 litres
of fluid is run each time for four times a day, exchanging for the fluid from the previous exchange.
Patient doesn’t need a machine for CAPD; all he/she needs is gravity to fill and empty the abdomen.
26

27. APD - Automated Peritoneal Dialysis - in which the dialysate solution is changed by a machine,
at night, while you are asleep. The machine will exchange 8-12 litres over 8-10 hours . 27

28. 28

29. HEMODIALYSIS Hypotension Muscles cramps Clot formation Septicemia Hepatitis

Disequilibrium syndrome PERITONEAL DIALYSIS Exit site infection, peritonotis, abdominal pain
Hernia Lowback pain Protein loss Atelactasis and pneumonia 29

30. 30

31. Informed Consent Explanation Ask the patient to void. Check Wt., vitals ( BP ) at the
beginning and at least every 30 minutes. Check for cannula and fistula for patency and palpate for
the thrill and auscultation of bruits. Withhold antihypertensive on the day of HD. Assurance 31
32. Regular observation of complications. Check and record vitals X15 minutes. Serve foods as
patient’s interest ( not for hypotensive prone patients) Each treatment lasts from 2 to 4 hours.
During treatment, Pt. is allowed to read, write, sleep, talk, or watch TV. Back care and divertional
therapy Inform to Dr. if complications. 32

33. Check and record vital signs, Wt. after HD and total UF. Record the condition of the patient.
Medications as ordered( if) Explain about the care necessary after HD. Inform the family and
patient of date for next dialysis. Send the patient home or ward. 33

34. Make sure that nurses or Dr check the access before and after each treatment. Use the
access site only for dialysis. Keep access clean at all the time. Do not let anyone put a BP cuff on
access arm. Do not wear jewellory or tight clothes over access site. Do not sleep with your access
arm under head or body. Do not lift heavy objects or put pressure on access arm. 34

35. Care of vascular access. Detection of complications. Diet : Tell the patient to eat animal
proteins such as meat and chicken. to Avoid too much potassium diet. to limit fluid intake to
avoid excess salt. to limit foods contain the mineral phosphorus such as milk, cheese, nuts, etc. 35

36. 36

ALITY ASSURANCE

4th informal Conference of Ministers of Education

from the Western Balkans

Strasbourg, 27-28 November 2006

Prof. Luc E. WEBER,

Rector Emeritus, University of Geneva

Chair CDESR, Council of Europe

Setting the European scene

Statements of the ministers of education in the

framework of the Bologna process

Bologna Declaration (1999) Promotion of

European co-operation in quality assurance with a

view to developing comparable criteria and

methodologies..

Prague communiqué (2001) .Ministers called

upon the universities and other higher education

institutions (HEI), national agencies and ENQUA,

in cooperation with corresponding bodies from

countries which are not members of ENQUA, to

collaborate in establishing a common framework of

reference and to disseminate best practice.

Berlin communiqué (2003) At the European

level, Ministers call upon ENQUA through its

members, in co-operation with the EUA, EURASHE

and ESIB, to develop an agreed set of standards,

procedures and guidelines on quality assurance,

to explore ways of ensuring an adequate peer

review system for quality assurance and/or

accreditation agencies or bodies, ...

Bergen communiqué (2005) .we urge HEI to

continue their efforts to enhance the quality of

their activities through the systematic

introduction of internal mechanisms and their

direct correlation to external quality assurance

.. We adopt the standards and guidelines for

quality assurance in the EHEA as proposed by

ENQA. .

.. We welcome the principle of a European

register of quality assurance agencies .

.We underline the importance of cooperation

between nationally recognised agencies with a

view to enhancing the mutual recognition of

accreditation or quality assurance decisions.

Two related statements

Communication from the EU commission (2006)

Universities will not become innovative and

responsive to change unless they are given real

autonomy ..

In return for being freed from over-regulation

and micro-management, universities should accept

full institutional accountability to society at

large for their results.

Recommendation 1762 of the Parliamentary Assembly

of the Council of Europe (30/06/2006)

Art 4. The Assembly reaffirm the right to

academic freedom and University autonomy

Art 11 Accountability, transparency and quality

assurance are pre-conditions..

Outline

Why quality assurance (QA)?

How to organize QA?

To conclude

WHY QUALITY ASSURANCE?

The public responsibility

The responsibility of HEI

THE PUBLIC RESPONSIBILITY FOR QA

Public responsibility for HER

Collective return

Equal opportunity

Public responsibility for QA

HER is costly

Absence of a system of sanctions and rewards

Participation to the EHEA (Bologna process)

Public responsibility for QA embraces

Public institutions direct control

Private institutions indirect control

(regulation)

The responsibility of HEI

QA is an imperative for HEI

The environment is changing increasingly rapidly

Globalization, scientific and technological

progress, Bologna process

Consequences increasing competition and

necessity to cooperate

European HEI are underfinanced

The governance and leadership of HEI are not up

to the autonomy they request and to the poor

financial situation?

Limits of a decentralized decision system

centered on professors

Decision process not favorable to decisions (to

change)

Conclusions

Public authorities feel the need to intervene

(danger or a vicious circle)

Institutions it is in their own interest to

promote a quality culture (quality improvement)

HOW TO ORGANIZE QA

HEI are very specific institutions

QA is in a state of adolescence

Strategic choices re. QA

10

HEI are very specific institutions

Missions

Keep the knowledge accumulated by society

Transfer knowledge
Create new knowledge

Use knowledge to solve societal problems

Nature of services

Teaching teach how to learn

Research complex and unpredictable processes

11

QA is in a State of adolescence

Origin A couple of national agencies 20 years

ago

Multiple actors, strategies and designations

National or branch specific organizations

ENQUA, European Network of Quality Assurance

ECA, European Consortium for accreditation

EUA, European University Association

Impact

Low efficiency (accreditation and evaluation)

Weak benefit-cost ratio

Promote strategic behaviors

Still to come evaluation/accreditation becomes a

business

Cause

Too little research re-invention of the wheel

Political opportunism overactivity, mistrust

12

A couple of definitions
Accreditation

Authorization which applies to

institutions and/or teaching programs

private or public, as well as LLL programs

Aims

to protect the name University

to guarantee that an institution or a program

satisfies a minimum quality standard

to protect the investment made by the

students-consumers

Responsibility of the State (regulatory role of

the State)

Could also serve to assess

If a program has reached some specified quality

level (business, engineering)

The internal quality assurance procedures of an

institution

The final aim of accreditation is NOT the

assessment of the relative quality level

(therefore, it promotes quality only indirectly)

13

Quality assessment or evaluation

More ambitious and delicate goal is to assess

the relative quality of

an institution,

a teaching program,
a faculty or department

and/or a discipline in a country

research

Necessary for

The knowledge society (improving the quality of

teaching and research)

The Bologna process (building trust

accreditation will not be sufficient to secure

acceptance in good research universities)

14

Quality culture (quality improvement)

Extended ongoing effort on the part of an

institution (and encouraged by the State) to

develop the capacity for change through the

development of

Internal quality

Strategic leadership

This effort must be

supported by external evaluations

and monitored (evaluated) externally from time to

time

15

Strategic choices re. QA

Formative or summative?

Formative encouragement and support

Summative sanction (yes no)

This choice greatly influences behavior

(attitude)

Fitness for purpose or evaluation according to

pre-defined criteria?

Pre-defined criteria positive for very broad

general criteria difficult to generalize in a

very complex and diversified environment

Fitness for purpose Evaluation based on what the

institution wants to do

16

Qualitative or quantitative criteria?

Quantitative seems to be ideal, but indicators

are not sufficiently homogenous or relevant (ex.

of rankings!)

Qualitative softer, however, very flexible

result depends on transparency of institution and

professionalism and independence of evaluators

Institution centered or agency centered?

Subsidiarity principle responsibility of HEI!

(Berlin 2003)

But, responsibility of the State to make it

compulsory and to control

17

Other open questions?

Link between evaluation and financial support?

promote transparency of institution (for its own

sake)?

or reward performance?

Independence of agency!

Basically, 4 possibilities

State agency,

Universities agency

Joint Sate and universities agency

Private (for profit?) agency run by a profession

or a foundation

None is fully independent from influence

(political, universities or financial)

18

Independence of evaluators!

Highly desirable!

But difficult

Higher education is a small world

Increasing obligation to compensate evaluators

for their work will make them more prudent (less

disinterested)

Publication of results?

At first sight, very desirable (transparency)

But danger that evaluation reports are self

censored
19

TO CONCLUDE

20

ENQUA Standard and Guidelines for Quality

Assurance in the EHEA. Basic principles

Focus on HE institutions

Universities are responsible to develop an

internal quality culture. It implies

Self-evaluation

Visit of peers

However, independent agencies (national or

trans-national) should

Set the framework (general rules)

Control the process in each institution

21

HEI should be proactive that is develop a serious

quality culture

Evaluation of teaching is good, but also an alibi

not to do more

Quality improvement in academic and

administrative affairs should be an essential

element of the strategy of change

Public authorities, on the contrary, are too

pro-active (intervene too deeply) vicious

circle!

Accreditation of programs goes too far this

should be the responsibility of well governed

institutions

Accreditation of whole public institutions is an

alibi (heavy and costly, superficial and it

rarely changes anything)

22

THANK YOU

I hope it is useful

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NURSING STANDARDS

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NURSING STANDARDS :NURSING STANDARDS KIRAN RANDHAWA ARMY COLLEGE OF NUIRSING

INTRODUCTION:INTRODUCTION Standards are professionally developed expressions of the range of

acceptable variations from a norm or criterion"- Avedis Donabedian . Standards may be defined as
"Benchmark of achievement which is based on a desired level of excellence.

WHAT ARE NURSING STANDARDS?:WHAT ARE NURSING STANDARDS? All standards of practice
provide a guide to the knowledge, skills, judgment & attitudes that are needed to practice safely.
They reflect a desired and achievable level of performance against which actual performance can be
compared. Their main purpose is to promote, guide and direct professional nursing practice.
(Registered Nurses Association of BC (2003) & the College of Nurses of Ontario (2002)

IMPORTANCE:IMPORTANCE Outlines what the profession expects of its members. Promotes guides
and directs professional nursing practice – important for self-assessment and evaluation of practice
by employers, clients and other stakeholders. Provides nurses with a framework for developing
competencies Aids in developing a better understanding & respect for the various & complimentary
roles that nurses have. ( Registered Nurses Association of BC (2003) & the College of Nurses of
Ontario

PROFESSION:PROFESSION Characteristics of a Profession according to Houle (1980) Concept of

mission open to change. Mastery of theoretical knowledge. Capacity to solve problems. Use of
theoretical knowledge. Continued seeking of self-enhancement by its members. Formal training.
Credentialing system to certify competence

Cont……………d :Cont……………d Legal reinforcement of professional standards. Creation of subculture.

Ethical practice. Penalties against incompetent or unethical practice. Public acceptance. Role
distinctions that differentiate professional work from that of other vocations and permit
autonomous practice. Service to society.

Professionalization of nursing :Professionalization of nursing Professionalization is the process by

which an occupation achieves professional status. The status of nursing as a profession is important
because it reflects the value society places on the work of nurses and the centrality of this work to
the good of society

Cont……….d:Cont……….d Professional nursing practice involves “specialized skills essential to the

performance of a unique, professional role” the two main concepts that are in the forefront of
professional nursing and its services ideal are accountability and autonomy .

Slide 9:Accountability is the state of being responsible and answerable for one’s own behavior. The
sphere of a nurse’s accountability is to self, the client, the employing agency, and the profession.
Autonomy in nursing is the freedom and the authority to act independently. It implies control over
one’s practice, and it applies to both decisions and actions

Professional standard & nursing process :Professional standard & nursing process Professional
standards ensure that the highest level of quality nursing care is promoted. Excellent nursing
practice is a reflection of sound ethical standards. Client care requires more than just the application
of scientific knowledge. A nurse must be able to think critically, solve problems, and find the best
solution for client’s needs to assist clients in maintaining, regaining, or improving their health.
Critical thinking requires the use of scientifically based and practice-based criteria for making clinical
judgments. These criteria may be scientifically based on research findings or practice based on
standards developed by clinical experts and quality improvement initiatives.
NURSING AS A PROFESSION:NURSING AS A PROFESSION Nursing is not simply a collection of specific
skills, and the nurse is not simply a person trained to perform specific tasks. Nursing is a profession.
No one factor absolutely differentiates a job or a profession, but difference is important in terms of
how nurse practice. When one can say a person acts “professionally”, for example, we imply that the
person is conscientious in actions, knowledgeable in the subject, and responsible to self and others.

Standard of professional performance:Standard of professional performance The ANA Standards of

professional Performance describes a competent level of behavior in the professional role, including
activities related to quality of care, performance appraisal , education, collegiality, ethics,
collaboration, research, and resource utilization, this document serves as objective guidelines for
nurses to be accountable foe their actions, their patients, and their peers . the standards provide a
method to assure clients that they are receiving high-quality care, that the nurses know exactly what
is necessary to provide nursing care, and that measure are I n place to determine whether the care
meets the standards.

ANA Standards of professional performance:ANA Standards of professional performance Standards

Definition Measurement criteria I: quality of practice The registered nurse systematically enhances
the quality and effectiveness of nursing practice 1. Demonstrates quality by documenting the
application of the nursing process in a responsible, accountable and ethical manner. 2.Uses quality
improvement activities to initiate changes in nursing practice and health care delivery system 3.Uses
creativity and innovation to improve nursing care delivery 4. Incorporates new knowledge to initiate
changes in nursing practice if desired outcomes are not achieved. 5. Participates in quality
improvement activities.

cont…..d :cont…..d II: education The nurse attains knowledge and competency that reflects current
nursing practice 1. Participates in ongoing educational activities related to clinical knowledge and
professional issues. 2.Demonstrates commitment to life long learning 3.Seeks experiences to
maintain clinical skills 4.Seeks knowledge and skills appropriate to the practice setting 5. Maintains
professional records that provide evidence of competency and lifelong learning.

Cont………d:Cont………d III: Professional practice evaluation The nurse evaluates one’s own nursing
practice in relation to professional practice standards and guide line, relevant statutes, rules and
regulations. 1.Engage in self evaluation on a regular basis 2.Seeks constructive feedback regarding
ones own practice 3.Takes action to achieve goals identified during the evaluation process
4.Participates in systematic peer review as appropriate 5.Practice reflects knowledge of current
practice standards, laws and regulations 6.Provides age appropriate care in culturally and ethnically
sensitive manner
Cont……..d:Cont……..d IV: collegiality The nurse interacts with and contribute to the professional
development of peers and other health care providers as colleagues 1.Shares knowledge and skills
with peers and colleagues 2.Provides peers with feedback regarding their practice 3.Interacts with
peers and colleagues 4.To enhance ones own professional nursing practice 5.Maintains
compassionate and caring relationships with peers and colleagues 6.Contributes to an environment
that is conductive to clinical education nursing students as appropriate 7.Contributes to a supportive
and healthy work environment

Slide 17:V: Collaboration The nurse collaborates with patient, family, and others in the conduct of
nursing practice 1.Communicates with the patient, significant others, and health care providers
regarding patient care and nursing’s role in the provision of care 2.Collaborates with patient, family
and others health care providers in the formulation of overall goals and the plan of care and in the
decisions related to care and delivery of services 3.Partners with others to effect change and
generate positive outcomes 4.Document referrals, including provisions for continuity of care, as
needed

Cont..d:Cont..d VII: Research The nurse integrates research findings in practice 1.Utilize best
available evidence including research findings to guide practice decisions 2.Participates in research
activities as appropriate to the nurse’s education and position such as the following: 3.Identifying
clinical problems suitable for nursing research a. Participating in data collection b. Participating in a
unit, organization, or community research committee c. Sharing research activities with others
conducting research d. Critiquing research for application to practice e. Uses research findings in
the development of policies, procedures, and practice guidelines for patient care f. Incorporates
research as a basis for learning

Slide 19:VII: Research utilization The nurse considers factors related to safety effectiveness, cost, and
impact on practice in the planning and delivery of nursing services. 1.Evaluates factors related to
safety, effectiveness, availability and cost when practice options would result in the same expected
patient outcome 2.Assists the patient and family in identifying and securing appropriate and
available services to address health related needs 3.Assigns or delegates tasks as defined by the
state nurse practice acts and according to the knowledge and skills of the designated care giver
4.Assigns or delegate tasks based on the needs and condition of the patient, the potential for harm,
the stability of the patients condition, the complexity of the task, and the predictability of the
outcome 5.Assists the patient and family in becoming informed consumers about the cost ,risks, and
benefits of treatment and care

Slide 20:IX: leadership The nurse provides leadership in the professional practice setting and the
profession 1. Engages on team work. 2. Works to create and maintain healthy work environments. 3.
Teach others to succeed through mentoring. 4. Exhibits creativity and flexibility during change. 5.
Directs coordination of care across settings and care givers. 6. Serves in key roles in the work settings
by participating on committees, councils, and administrative. 7. Promotes advancement of the
profession. 8. Display the ability to define a clear vision, the associated goals, and a plan to
implement and measure progress. 9. Demonstrates energy, excitement and a passion for quality
work. 10. Willingly accepts mistakes by self and others, thereby creating a culture in which risk-
taking is not only safe, but expected

Standard of care :Standard of care The standards of care in the ANA nursing: Scopes and Standards
of practice (2004) describe a competent level of nursing care. The levels of care are demonstrated
through the nursing process. The nursing process is the foundation of clinical decision making and
includes all significant actions taken by nurses in providing care to clients. Within these are the
nursing responsibilities for diversity , safety, education, health promotion, treatment , self care, and
planning for the continuity of care.

Code of ethics :Code of ethics Nursing has a code of ethics that defines the principles by which nurse
provide care to their clients. In addition, nurses incorporate their own values and ethics into
practice. The code of ethics for nurses with interpretive statements provides a guide for carrying out
nursing responsibilities that provide quality nursing care and provides for the ethical obligations of
the profession

Standard nursing care: An Asset :Standard nursing care: An Asset In order to ensure quality care the
nursing care needs some standards. Standards are degree of excellence. The aim of standard nursing
care is to support and contribute to excellent practices. The role of nurse is constantly changing to
meet the growing needs of health services

Objective :Objective Plan Holistic Approach Appropriate Diagnosis Realistic Goal Selecting
Appropriate Media Quality Care rather than quantity Economize Time, Material, Energy

TYPES OF STANDARD CARE:TYPES OF STANDARD CARE Structure -- Things we use Process -- Things
we do Outcome -- The result

Characteristics of standard care :Characteristics of standard care Dynamic Reflects Changes Not
Static
Brief description of methods and procedure :Brief description of methods and procedure 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.

CONT…………D:CONT…………D Standard : Nursing practice requires that a conceptual model for

nursing be the basis for the independent part of that practice. Elements : Nurses are required to
have clear idea or conception of the distinct goal nursing, the patient, the health needs of the
society, the source of client difficulty, the focus, and modes of nursing intervention and the expected
consequences of nursing activities.

CONT……….D:CONT……….D Standard : Nursing practice requires the effective use of the nursing
process. Elements : Nurses are required to collect data in accordance with their conception of the
goal of nursing, client, the source of client difficulty, the four and modes of intervention conceptual
models for nursing

CONT…..D:CONT…..D Standard : Nursing practice requires that the helping relationship be the nature
of client nurse interaction. Elements : Nurses are required to increase the likelihood that the client
will perceive the health service experience as understandable, manageable and meaningful at the
outset. Nurses are required to ensure a successful termination of the helping relationship.

CONT…..D:CONT…..D Standard : Nursing practice requires nurses to fulfill professional

responsibilities. Elements : Nurses are required to respect status and policies relevant to the
profession and the practice setting. Nurses are required to comply with the code of ethics of their
profession. Nurses are required to function as members of a health team.

Professional Responsibilities :Professional Responsibilities Health team member Ethics Policies

Conceptual Health needs of society Nursing intervention Effective use of nursing process Data
collection Diagnosis Goal Intervention Evaluation

Cont……..d:Cont……..d Unity Setting standards Planning individual patient care Monitoring and
evaluating patient and environment

The discipline of Nursing is an art and science committed to professional excellence by providing
highest quality care possible . Quality of care is determined by identifying the observable
characteristics that depict desired and valued degree of excellence and the expected, observable
variations.

Slide 3: The quality of nursing care can be managed both by evaluating the degree of excellence of
results of delivered care and by taking action for the improvements that in future will result in high
degree of care. The standards maintained and the nursing audit conducted hence, become the
important tools for the quality management.

WHAT ARE STANDARDS? : WHAT ARE STANDARDS? Standard is a quantitative or qualitative measure
against which someone or something is judged, compared or used to service as an example.
Standards are professionally agreed levels of performance, which are achievable, and measurable.

Slide 5: The Oxford dictionary provides several key concepts for the definition of standards. First, it
notes that standards represent a degree of excellence. Second, it suggests that standards serve as a
basis of comparison. Third, it notes that standards are minimum with which a community may be
reasonably content. Finally, a standard is recognized as a model for imitation.

IMPORTANCE OF STANDARD : IMPORTANCE OF STANDARD A standard is a practice that enjoys

general recognition and conformity among professionals or an authoritative statement by which the
quality of practice, service or education can be judged. One of the determinants of profession is that
the members of the profession adopt standards of practice of their calling, establish criterion by
which conformance to the standards will be measured and have the primary responsibility for seeing
that the standards are enforced. A nursing care standard is a descriptive statement of desired quality
against which is evaluate nursing care. It is a guideline, a path to safe conduct and an aid to
professional performance.

Slide 7: PURPOSE OF STANDARDS To evaluate the quality of nursing practice in any setting. To
compare and improve the existing nursing practice. To provide a common base for practitioners to
coordinate and unify their efforts in the improvement or practice. To identify the element of
independent function of nursing practices. To provide a basis for planning and evaluating
educational program for practitioners. To inform society of our concern for the improvement of
nursing practice. To assist the public in understanding what to expect of nursing practice. To assist
employers to understand what to expect of Practitioners. To identify areas for developing core
curriculum for practicing nurses. To provide legal protection for nurses.

Slide 8: CHARACTERISTICS OF STANDARDS Objective, acceptable, achievable and flexible. Must be

framed by the members of the nursing profession. Should be phrased in positive terms like good,
excellent, etc. Must be understandable and unambiguous. Must be based on current knowledge and
scientific practice. Must be reviewed and revised periodically.

Slide 9: SOURCE OF NURSING CARE STANDARDS Standards can be developed, established, reviewed
or enforced by: Professional organization like TNAI. Licensing body e.g. INC, statutory bodies.
Institutions/Health care agencies. Department of institutions e.g. Nursing Department. Patient care
unit e.g. Medical ICU. Government units at national, state and local government units. Individual e.g.
personal standards.

Slide 10: LEVELS OF STANDARD: MINIMUM VS OPTIMUM Minimum standards are generally
thought to represent a level of acceptability below which they eyes on those judging, lies the
unacceptable. The desirable or optimal standards, represent a degree of excellence. For example, in
a hospital the minimum standard for nosocomial infection may be 7-10 per cent. Anything above 10
per cent is unacceptable whereas the desired is 3 per cent.

TYPES OF STANDARDS : TYPES OF STANDARDS Normative standards: These standards are descriptive
of practices, which are considered ideal by authority. These standards describe highest quality of
practices. For example, standards set by professional bodies, standards for the recruitment of nurses
working in any setting. Empirical Standards: These standards are description of practices which are
actual practice in large number of settings and which are agreed upon and achievable. For example,
standards set by law enforcement bodies and regulatory bodies. End standards: These are patient
oriented; they describe the change as desired in a patient’s physical status or behavior. Means
Standards: These are nursing oriented; they describe the activities and behavior to achieve ends
standards.

Slide 12: FRAMES OF REFERENCE FOR STANDARDS Structure Standards: These are institution
oriented and related to care providing system and resources that support for actual provision of
care. They include the following: Physical facilities, building, etc. Policies, goals and objectives.
Staffing members: training, qualification, job responsibilities. Equipment and supplies.
Administrative setup and channel of communication. Recording system. Budgeting. Structure
standards already exist, though not proved ideal scientifically.

Slide 13: Process Standards: These are nursing oriented and referred to the behavior and actions
which a nurse should carryout. Here focus is on nursing standards technique and procedures e.g.
planning, implementation, nurses interaction, client’s participation, communication and recording.
Process standards help in assessing the degree of skills with which the techniques are performed,
the degree of client involvement, and interaction between nurse and client. Thus, it implies
professional judgment in determining quality of nursing care/skills. Nurse prepares appropriate
written nursing care plan for the patient, which includes identification of: Personal needs, disease
related needs and therapy needs. Nursing actions: Assessment , Diagnosis , Outcome identification
etc. Resources. Implementation of actions. Evaluation of the results or effectiveness of nursing
actions taken. Professional Performance: Performance appraisal , Education , Ethics, Research .

Slide 14: Outcome Standards: These are patient centered or client centered. These are the
description statement of result of care for the patient and can be both qualitative and quantitative.
Outcome standards are related to patient’s health status, such as: Self-care or disability. Morbidity
or mortality status. Non-occurrence of complication and restoration of body functions, etc. The
results of outcome standards may be positive or negative. If one discovers that outcomes are not
according to the expectation, then one needs to scrutinize the structure and process standards e.g.
patients developing infections postoperatively, explore the causes and take remedial actions
accordingly.

Slide 15: STEPS OF STANDARD FORMULATION Organize into small groups of nurses who work in the
same field and meet periodically. Decide on the area of nursing practice for which you want to work
out standards. Review philosophy, purposes and objectives of institution. Review existing nursing
care practices, nursing process and identify your client for nursing service, client’s role and strategies
for nursing care services. Write the statements considering all the frame of reference giving
rationale and criteria i.e. assessment indicators see that standards are relevant. Discuss them with
nursing service administrators to get their approval. Devise a method for determining achievement
of standards. It may be through the use of criteria checklist for – making observation of care given;
examining records; self evaluation checklist; patients’ opinion, etc. Determine validity by giving to
the experts. Try out the standards to determine the feasibility. The standards are put into practice
and quality care is audited. Updating of standards periodically with continuous renewal.

Slide 16: LEVELS OF STANDARD SETTING There are four levels of standard setting: National and state
level, Community level , Institution level, Department level. HOW ARE STANDARDS USED? Mainly in
health care settings, standards are used in: Self-assessment: 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. Inspection: It usually implies some sort of official
examination. Those inspecting most often have a conferred power to do so. 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.

Slide 17: CONCLUSION The success of standard 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 strengths and weaknesses, take actions to correct
deficiencies, review the effectiveness of those actions through an audit protocol derived from the
standard.

NURSING AUDIT : NURSING AUDIT 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.

Slide 19: Audit: A systematic and critical examination to examine or verify. According to Elison
“Nursing audit refers to assessment of the quality of clinical nursing”. According to Goster Walfer:
Nursing audit is an exercise to find out whether good nursing practices are followed. The audit is a
means by which nurses themselves can define standards from their point of view and describe the
actual practice of nursing. Nursing audit is defined as the evaluation of nursing care in retrospect
through analysis of nursing records. It is a systemic format and written appraisal by nurses of the
quality of content and the process of nursing service from the nursing records of the discharged
patient.

Slide 20: BRIEF HISTORY OF AUDIT 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 time medical
audit. Ten years later Thomas R. Pondon 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.

PURPOSES OF NURSING AUDIT : PURPOSES OF NURSING AUDIT Evaluation: Evaluating the nursing
care given. Achieve deserved and feasible quality of nursing care. Verification: Stimulant to better
records. Focuses on care provided and not on care provider. Contributes to research. Review of
professional work or in other words the quality of nursing care i.e. we try to see how far the nurses
have confirmed to the norms and standards of nursing practice while taking care of patients. It
encourages followers to be actively involved in the quality control process and better records. It
clearly communicates standards of care to subordinates. Facilitates more efficient use of health
resources. Helps in designing response orientation and in-service education programme.
Slide 22: METHODS OF NURSING AUDIT There are two methods: Retrospective View: This refers to
an in-depth assessment of quality after the patient has been discharged, and uses the patient’s chart
as the source of data. Concurrent Review: This refers to the evaluations conducted on behalf of
patients who are still undergoing care. It includes assessment the patient at bedside in relation to
pre-determined criteria, interviewing the staff responsible for his care and reviewing the patient
record and care plan. ESSENTIAL CHARACTERISTICS OF NURSING AUDIT: There should be: Written
standards of care against which to evaluate nursing care. Evidence that actual practice was
measured against such standards, sharing a percent conformance rate. Examination & analysis of
findings. Evidence of corrective action being taken. Evidence of effectiveness of corrective action.
Appropriate reporting of the audit programme.

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

Slide 24: C. Design the type of tool: Quality assurance must be a priority. Those responsible must
implement a program not only a tool. A co-coordinator should develop and evaluate quality
assurance activities. Roles and responsibilities must be delivered. Nurses must be informed about
the process and the results of the program. Data must be reliable. Adequate orientation of data
collection is essential. Quality data should be analyzed and used by nursing personnel at all levels. D.
Plan and implement the tool: What is to be evaluated? Who is going to collect the information? How
many sample in the target group? Time period? E. Recording/Analysis, Concluding: Record the
information, Analyze the information, Make a summary, Compare with set standard, Conclusion. F.
Using results : The results aid to modify nursing care plans & the nursing care process, including
discharge planning, for selected patient outcome, implementing a program for improving
documentation of nursing care through improved charting policies, methodologies & forms, focusing
of nursing rounds & team conferences. Focusing supervisory attention upon areas of weakness
identified, such as one particular nursing unit or specific employees. Designing responsive
orientation & in-service education programs. Gaining administrative support for making changes in
resources, including personnel.

Slide 25: ADVANTAGES OF NURSING AUDIT Can be used as a method of measurement in all areas of
nursing. Seven functions are easily understood. Scoring system is fairly simple. Results easily
understood. Assesses the work of all those involved in recording care. May be a useful tool as part of
a quality assurance programmed in areas where accurate records of care are kept. Enables the
professional group to highlight the deficiencies and how good they are in giving care. Better planning
can be done. Helps in re-allocation of resources. Administrators are also sure that patients are
getting quality care

Slide 26: DISADVANTAGES Appraises the outcomes of the nursing process, so it is not so useful in
areas where the nursing process has not been implemented. Many of the components overlap
making analysis difficult. It time consuming. Requires a team of trained auditors. Only evaluates
record keeping. It only serves to improve documentation, not nursing care.\ Medical legal
importance. The professionals feel that they will be used in court of law as any document can be
called for in court of law. Deals with a large amount of information.

Slide 27: PREREQUISITES OF NURSING AUDIT Audit Committee: Before carrying out an audit, an
audit committee should be formed which consists of fair and impartial members including senior
nurses as members to do nursing audit. This committee should comprise of minimum five members
who are interested in quality assurance, are clinically competent and able to work together in a
group. It is recommended that each member should review not more than 10 patients each month
and that the auditor should have the ability to carry out an audit in about 15 minutes. It there are
less than 50 discharges per month, all the records may be audited. If there are large numbers of
records to be audited, an auditor may select 10 per cent of discharges. The impetus must come from
the nursing staff themselves, realizing the benefits to the patients and themselves. A good system of
nursing record keeping.

Slide 28: AUDIT AS A TOOL FOR QUALITY CARE The audits most frequently used in quality control
include outcome process and structure audits. Outcome Audit: Outcomes are the end results of
care; the changes in the patient’s health status and 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 the clients. Examples of outcomes traditionally used to measure quality of hospital
care include mortality, its morbidity, and length to hospital stay. Process Audit: Process audits are
used to measure the process of care or how the care was carried out. Process audit it task oriented
and focuses on whether or not practice standards are being fulfilled. These audits assume that a
relationship exists between the quality of the nurse and quality of care provided. Structure Audit:
Monitors the structure or setting in which patient care occurs, 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

Slide 29: ROLES AND FUNCTIONS OF NURSE MANAGER FOR EFFECTIVE QUALITY CARE: ROLES
Encourages followers to be actively involved in the quality control process. Clearly communicates
standards of care to subordinates. Encourages the setting of high standards to maximize quality
instead of setting minimum safety standards. Implement quality control proactively instead
reactively. Uses control as a method of detraining why goals were not met. Is positively active in
communicating quality control finding. Acts as a role model for followers in accepting responsibility
and accountability for nursing actions.

Slide 30: FUNCTIONS In conjunctions with other personnel in the organization establishes clear cut,
measurable standards of care and determines the most appropriate method for measuring if those
standards have been met. Selects and uses process, outcome and structure audits appropriately as
quality control tools. Assesses appropriate sources of information in data gathering for quality
control tools. Determines discrepancies between care provided and unit standards and seeks further
information regarding why standards were not met. Uses quality control findings as a measure of
employee performance and rewards, coaches, counsels, or disciplines employees accordingly. Keeps
abreast of current government and licensing regulations that affect quality control.

Slide 31: CONCLUSION In the new era, with the changing concepts in the health care delivery, the
nurse manager role ;is becoming critical to effective qualities patient care. Nursing audit is on one of
the important tools to provide quality-nursing care services to the clients and maintain professional
accountability.

NURSING AUDIT:NURSING AUDIT The world trend of professional accountability to an enlightened

public can no longer be ignored by nursing. Nurses easily use the words “QULITY NURSING” but have
Nurses know their deficiences ? Are nurses ready to admit their deficiences to their peers? Are they
taking steps to remedy them? only by such self regulation nurses can retain their identity with the
health professional as nature mothers

MEANING OF TERM Qulity A judgement of what constitutes good or bad. Audit A systematic and
critical examination to examine or verify. Nrsing audit: (a)It is the assessment of the qulity of nursing
care (b)Uses a record as an aid in evaluating the qulity of patient care :MEANING OF TERM Qulity A
judgement of what constitutes good or bad. Audit A systematic and critical examination to examine
or verify. Nrsing audit: (a)It is the assessment of the qulity of nursing care (b)Uses a record as an aid
in evaluating the qulity of patient care

Brief History Of Nursing Audit:Brief History Of Nursing Audit 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 of medical audit. George Groword pronounced the
term physician for the first time medical audit.Ten years later,Thomas.R . Pondon MD,estaon
procedures used by financial account.He evaluated the medical care by reviewing the medical
records. First report of nursing audit of the hospital published in 1955.For the next 15 years,nursing
audit is reported from study or record on the last decarole . The program is reviewed from record
nursing plan, nurses notes, patient condition, nursingcare
Nursing Care Audit Audit related to the planning, delivery and evaluation of care. It is an important
component of nursing care. 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. :Nursing Care Audit Audit related to the planning,
delivery and evaluation of care. It is an important component of nursing care. 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)According to elison“Nursing audit refers to assessment of the

quality of clinical nursing.” (2)According to Goster walfer (a)Nursing Audit is an exerecise 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.:DEFINITION OF NURSING AUDIT ( 1)According to elison“Nursing audit refers to assessment
of the quality of clinical nursing.” (2)According to Goster walfer (a)Nursing Audit is an exerecise 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.

Purpose of Nursing Audit (1)Evaluating Nursing care given. (2)Achieves deserved and fecsible quality
of nursing care. (3)Stimulant to better records. (4)Focuses on care provided and not on care
provider. (5)Contributes to research. :Purpose of Nursing Audit (1)Evaluating Nursing care given.
(2)Achieves deserved and fecsible quality of nursing care. (3)Stimulant to better records. (4)Focuses
on care provided and not on care provider. (5)Contributes to research.

METHOD OF NURSING AUDIT There are two mathods. (1)Retrospecive view This refers to an
indepath assessment the quality after the patient has been discharged have the patients chart to the
source of data. (2)The concorrent review This refers to the evaluations conducted on behalf of
patients who are still undergoing care.It includes assessing the patient at the beside in relation to
predetermind crieteria interviewing the staff responsible for his care and reviewing the patients
record and care plan.:METHOD OF NURSING AUDIT There are two mathods . (1) Retrospecive view
This refers to an indepath assessment the quality after the patient has been discharged have the
patients chart to the source of data. (2)The concorrent review This refers to the evaluations
conducted on behalf of patients who are still undergoing care.It includes assessing the patient at the
beside in relation to predetermind crieteria interviewing the staff responsible for his care and
reviewing the patients record and care plan.

MEHOD OF DEVELOP CRITERIA (1)Define patient population (2)Identfy a time frame work for
measuring outcomes of care. (3)Identify commonly recuuring nursing problems presented by the
defined patient population.:MEHOD OF DEVELOP CRITERIA ( 1)Define patient population (2) Identfy
a time frame work for measuring outcomes of care. (3)Identify commonly recuuring nursing
problems presented by the defined patient population.

What is AUDIT ?:What is AUDIT ? Audit is a review of the clinical records used to determine the
presence or absence of pre determined criteria - Schmele (1980)

What is Nursing Audit?:What is Nursing Audit? An assessment of the quality of clinical nursing ---
Elison A method of evaluating quality of care through appraisal of the nursing process as it is
reflected in the patient care records for discharged patients

In other words…..:In other words….. An exercise to find out good nursing practices that are followed
. i.e., it is a means by which nurses themselves can define standards from their point of view and
describe the actual practise of nursing.

In Community………..:In Community……….. Audit comprises of …….. a systematic review …… of a

specified number of service records in a given period of time & the development and
implementation of corrective measures when deficiencies in quality care are identified

Types of Audit:Types of Audit Financial Audit Cost Audit Stationary Audit Medical audit Nursing/
Patient care audit

Concurrent Audit:Concurrent Audit Open chart audit Done when client is receiving care in the health
center, home etc

Retrospective Audit :Retrospective Audit Closed chart audit After the client care is completed.

Purposes ::Purposes : To evaluate the care provided To achieve desired quality care To achieve
feasible quality care For better recording As a legal document Provides accountability of care It
contributes to research.

Types of Auditors:Types of Auditors Internal Audit External Audit Internal Audit External Audit

Internal Auditors:Internal Auditors Nursing staff Done continuously Consists of abstracting and
classifying clinical records and evaluating the quality of care for clients.
External Auditors:External Auditors Medical administrators from ministry/ professional bodies/
other agencies. Periodically Done

Audit Committee:Audit Committee Minimum 5 members Each member reviews not more than 10
records in about 15 minutes If less than 50 cases in a month, then all records be audited. More than
50 cases, then 10% of the cases may be selected

Slide 14:SET STANDARD OBSERVE PRACTICE CAMPARE WITH STANDARDS IMPLEMENT CHANGE
AUDIT CYCLE

Focus of Nursing Audit:Focus of Nursing Audit Diagnosis e.g.. DM Diagnostic test. e.g. Blood smear
collection Problem e.g. referrals, home visit. Process e.g. TPR, Dressing, Any procedures

Approaches to Audit:Approaches to Audit Structure Audit Process audit Outcome Audit

Structure Audit:Structure Audit Focusses on the nurses notes, based on the assumption that good
nurses notes, reflected quality care. Today it involves the setting in which health care is provided–
the organizational structure, physical set up, resources and equipment and qualification of the care
giver.

Process Audit:Process Audit Earlier(prior to 1964) evaluated whether a nurse performed her
assigned duties Today, it involves : The Quality patient Care Scale The Phaneuf Nursing Audit

Outcome Audit:Outcome Audit A retrospective audit. Compares with the standards that were set or
outcome criteria

Audit Processing:Audit Processing Audit done -------- submit a report to the chairman---------
conducts meeting--------- reviews the findings--------- prepares a report-------- and recommendations -
-------- submits for signature.

Phaneuf Nursing Audit Tool:Phaneuf Nursing Audit Tool Application and execution of medical
officers legal orders Observation of symptoms and reactions Supervision of the client Supervision of
those participating in care Reporting and Recording Application and execution of nursing procedures
and technique

Application & execution of MO Orders:Application & execution of MO Orders Medical diagnosis and
orders complete Prompt execution of the orders

Observation of Symptoms & Reactions :Observation of Symptoms & Reactions Vital signs checking
and recording Symptoms identified and promptly reported Any complications due to treatment

Supervision of the client and those participating in care:Supervision of the client and those
participating in care Safety of the client Security of the client Continuing assessment of client’s
condition and capacity. Interaction with family & significant others Care taught to client, family
Consideration of client’s physical, emotional capacity to learn.

Reporting and Recording:Reporting and Recording Essential facts reported to client. Facts on which
further care depended were recorded. Client & family alerted as to what to observe and report to
physician. Continuity of care.

Application & Execution of Nursing Procedures and Techniques:Application & Execution of Nursing
Procedures and Techniques Administration of medications as per standing orders / MO orders
Personal Care Nutrition and special diets Physical activity Rehabilitation & prevention of
complications Procedures / techniques taught to the client.

AUDIT METHODOLOGY:AUDIT METHODOLOGY Statistical method Mortality review committee

method Random table method Scoring method On the spot method.

Concept of Nursing Audit:Concept of Nursing Audit DEBIT ITEMS Death of client Complications due
to neglect Infection at health center. Wrong treatment Incorrect information/ education. Inadequate
care. CREDIT ITEMS Number of clients recovered Shorter duration of illness Good records Expansion
of client knowledge Client acceptance of care.

Failure of Audit ::Failure of Audit : Rejects standard use of the evaluation tool Lack of knowledge
Fear of criticism Resistance on part of management Absence of client care records/ documents.
Absence of standards.
Slide 30:Thank you !!!

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NURSING AUDIT The world trend of professional accountability to an enlightened public can no
longer be ignored by nursing. We nurses easily use the worlds “quality nursing” but have we defined
what we mean by quality? Do you know our deficiencies? Are we ready to admit our deficiency to
our peers? Are we taking steps to remedy them? Only by such self regulation we can relate our
identity with the health professional as nature partners.

Brief history of nursing audit:Brief history of nursing audit Nursing 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 being of medical audit. George Groword pronounced the term physician
for the first time medical audit ten years later Thomus R Pandon MD established a method of
medical audit based on procedures used by financial account. He evaluated the medical care by
reviewed the medical records. First report of nursing audit of the hospital published in 1955. For the
next 25 years nursing audit is reported from study or records on the last decade. The programmer is
reviewed from record nursing plan, nursing care.

Meaning of terms:Meaning of terms Quality A judgment of what constitute good or bad Audit A
systematic and critical examination to examine or verify Nursing audit 1) It is the assessment of the
quality of nursing care 2) Uses a record as an aid in evaluating the quality of patient care
PowerPoint Presentation:Nursing standards Defines a standard as the desirable and achievable level
of performance against which actual practice is compared. The standards must meet the needs of
the patient

Definition::Definition: According to elision ‘nursing audit refers to assessment of the quality of

clinical nursing’ 2) According to Goster welfare 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 3) A nursing audit is a
method of evaluating care that evolve reviewing patient records to assess the outcomes were
achieved

PowerPoint Presentation:Nursing care audit Audit related to the planning, delivery and evolution of
care. It is an important component of nursing care Medical audit; the systematic critical analysis of
the quality of medical care including the procedures for diagnosis and treatment the use of resource
and the result sing outcome and quality of life for the patient

Types of audit:Types of audit Internal auditing Internal auditing is a control technique performed by
an external auditor who is an employee of the organization. Makes an independent appraisal the
policies, plans and points the deficits in the policies or plans and give suggestion for eliminating
deficits External auditing 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 loss
account and prepare a balance street after careful examination of the relevant books of accounts
and documents

Evaluation of nursing audit:Evaluation of nursing audit There are 3 types of evaluation of nursing
audit: 1) Retrospective evaluation 2) Concurrent evaluation 3) Peer review

PowerPoint Presentation:Retrospective evaluation : It means relating to past events. It is the

evaluation of a clients record after discharge from agency. It may use post discharge questionnaires
patient interview( by telephone , face to face ) or chart review, Nursing audit to collect data. The
type of retrospective audit most familiar to nurses working in hospitals is the retrospective chart
review. This activities body initially required hospitals to conduct certain number of per year.

PowerPoint Presentation:Concurrent audit : It is the evaluation of a client’s health care while the
client is still receiving care from the agency. These evaluation use interviewing direct observation of
nursing care and review of clinical records to determine whether the specific evaluative criteria have
been met.
PowerPoint Presentation:Peer review : In nurse peer review nurses functioning in the same capacity
that is peer’s appraise the quality of care or practice performed by others equally qualified nurses.
The peer review is based on pre-established standards or criteria. There are two types of peer
reviews. Individual and nursing audit 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

Purposes of nursing audit:Purposes of nursing audit Evaluating nursing care given Achieves deserved
and feasible quality of nursing care Stimulant to better records Focuses on care provided and on
care provider Contributes to research

Methods of nursing audit:Methods of nursing audit 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

PowerPoint Presentation:7) design and type of tool a) quality assurance must be priority b) those
responsible must implement a programmer not only a tool c) a coordinator should develop and
evaluate quality assurance activity d) roles and responsibilities must be delivered e) nurses must be
informed about the process and the result of the programmed f) data must be reliable g) adequate
orientation of a data collection is essential h) quality data should be analyzed and used by nursing
personnel at all levels

Audit cycle:Audit cycle Set standards Implementation change observe practice Compare with
standard

Advantage of nursing audit:Advantage of nursing audit Can be used as a method of measured in all
areas of nursing Seven function are easily understood Scoring system is fairly simple Results easily
understood Assess the work of all those involved in recording care May be useful tool as part of a
quality assurance program in areas where accurate records of care are kept

Disadvantage of nursing audit:Disadvantage of nursing audit Appraises the outcomes of the nursing
process , so it is not so useful in areas where the nursing process has not been implemented Many of
the components overlap making analysis difficult Is time consuming Requires a team of trained
auditors Deals with a large amount of information Only evaluates record keeping. It only serves to
improve documentation not nursing care
PowerPoint Presentation:Audit committee Before carrying out an audit committee should be
informed comprising of a minimum of five member who are interested in quality assurance are
clinically competent and able to work together in a group. It is recommended that each member
should review not more than 10 patients each month and that the auditor should have the ability to
carry out an audit in about 15 minute. If there are less than 150 discharge per month. Then all the
records may be audited if they all the records to be audited then an auditor may select 10% of
discharge

Conclusion:Conclusion A professional concerns for the quality of its service constitute the heart of its
responsibility to the public. An audit helps to ensure that quality of nursing care desired and feasible
is achieved. This concept is often referred to as quality assurance.

PowerPoint Presentation:Thank you By , Jayadeepa J