1. QUALITY ASSURANCE
Prepared by : Mrs. Namita Batra Guin
Associate Professor, Community Health Nursing
Since the Alma Ata Declaration, in which the international community committed itself to
providing primary health care (PHC) for all, major efforts have been made in nearly all
developing countries to expand PHC services. This has been achieved through increased
resources allocated by both national and international sources, expanded health worker training,
and major health system reorganization. Dramatic increases in outreach and health coverage
have been reported by most countries, many of which have posted modest declines in infant and
child mortality and some reductions in selected morbidity. However, the reported improvements
have not always been commensurate with the resources expended. Furthermore, not enough has
been done to assess service quality or to ensure that resources are having an optimal impact.
Quality assurance (QA) methods can help health program managers to define clinical guidelines
and standard operating procedures, to assess performance compared with selected performance
standards, and to take tangible steps toward improving program performance and effectiveness.
What is quality? Quality is a relative term that defines something with high merit or excellence,
where excellence is compared with some standards or norms. In other words, quality is always
the result of high intentions, sincere efforts, intelligent direction, and skillful execution. It is the
wise choice of many alternatives. It means proper performance of interventions that are known to
be safe, affordable to the society.
What is quality control? It means to ensure that all products and services conform to
predetermined levels of quality and certain standards or norms that satisfy clients.
What is quality care? It means the services provided match the needs of the population, are
technically correct, and achieve beneficial results. It has four components: professional
performance, efficient use of resources, minimal risk to the client of illness or injury associated
with care, and patient satisfaction.
Quality assurance refers to the system for monitoring outcomes of professional interventions and
departmental activities compared with established standards to evaluate and document
appropriateness and effectiveness of the practices.
2. Quality assurance is the process of verifying or determining whether products or services
meet or exceed customer expectations. Quality assurance is a process-driven approach with
specific steps to help define and attain goals. Quality assurance encompasses necessary changes
or improvements to ensure survival. It involves identifying standards for excellence, evaluating
care against those standards and then taking action to correct deficiencies and achieve the
How does Quality Assurance relate to Total Quality Management:-
Quality assurance identifies problems to solve them or examine what was done wrong.
(Maddox, 1998). Continuous Quality Improvement builds upon traditional quality assurance
by using the analysis methods of the scientific process to look at the work systems and processes
of an organization. Similarly, Total Quality Management is a structured, systematic process for
planning within the organization. Traditional approaches to quality, like those used in quality
assurance, focus on assessing or measuring the performance, ensuring that performance
conforms to standards, taking action to bring about change when care does not meet standards.
This definition is too narrow to meet the needs of many clients, both internal and external to the
agency. Many agencies now also include total quality management strategies in their program of
quality evaluation and improvement. It is a process driven and customer- oriented philosophy of
management that embodies leadership, teamwork, employee empowerment, individual
responsibility, and continuous improvement of system process that lead to improved outcomes.
Customer satisfaction is important in TQM. For example, assume that women have to wait along
time in a woman, infants and children’s program in order to be certified as eligible to receive
support. Using CQI, all the steps in the appointment process are considered to see where the
system’s efficiency and effectiveness have stalled and why the women are waiting for a long
Difference between Quality Assurance and Continuous Quality Improvement:-
Quality assurance Continuous Quality Improvement
Detects errors and deficiencies.
Fixes blame and responsibilities.
Post event investigation.
Quality assurance department
Determines requirements and
Identifies process improvement
All members in organization
3. FACTORS INFLUENCING QUALITY ASSURANCE:-
Various factors which may adversely influence the quality assurance program are:-
Lack of resources- infrastructure, equipments etc.
Personnel problem- lack of trained, skilled and motivated employees.
Unreasonable expectations of the patients and their attendants.
Absence of well informed populace.
Absence of accreditation laws.
Lack of incident review procedures.
Lack of god hospital information system.
Lack of proper maintenance of nursing care records.
Codes of conduct- boundaries are set for acceptable practice and professional behavior.
And if we, as a practitioner operate outside your code of conduct, our license to practice
may be withdrawn.
Growth of economy or accountability- commitment to a consistent and accountable
service is a major aim of a quality assurance system.
Inter-professionalism- A quality service to clients often demands an inter- professional
approach. This means that communication between the professions must be effective and
Moral issues- There is a moral obligation on everyone working in health care to provide a
responsible and caring service to every client.
Demographic change- Changing demography compels the adoption of quality assurance
in health care. For e.g. existing population changes will lead to a society with an
increasing number of dependent people whose health care must be paid for by the
economically active people.
Resource distribution- Quality assurance provides objective evidence for the
accountability. It establishes that the service delivered is appropriate and meets client’s
needs at an acceptable cost.
Socio/ political factors:
Public awareness- pressure from the society creates the need for more efficient health
service. The public generally are better informed about the health care and their rights to
health care. They are more inclined to use formal complaint procedures, when a
seemingly unacceptable level of service is received.
4. Social expectations- There is a growing number of consumer bodies which campaign for
the rights of individuals or groups. Some of these have drawn up quality standards for use
in client care settings.
Legislation- The law clearly has voice in maintaining standards in health care.
Accreditation- accreditation of hospitals is very important. Private nursing homes need a
licence to operate and are inspected by officers of the local health authority.
International pressure- As a member of WHO countries are committed to the
development of quality assurance systems in health care.
The Four Tenets of Quality Assurance
1. Quality Assurance is oriented toward meeting the needs and expectations of the patient
and the community.
2. Quality assurance focuses on systems and processes.
3. Quality assurance uses data to analyze service delivery processes.
4. Quality assurance encourages a team approach to problem solving and quality
Quality assurance is oriented toward meeting the needs and expectations of the patient and the
community. Quality assurance requires a commitment to finding out what patients and the
community need, want, and expect from the health services. The health team must work with
communities to meet service demand and to promote acceptance of needed preventive services.
Subsequent program planning and quality improvement efforts should be evaluated according to
these needs and expectations. Quality assurance also requires that health workers. professional
needs and expectations be met.
Quality assurance focuses on systems and processes. By focusing on the analysis of service
delivery processes, activities, and tasks as well as outcomes, quality assurance approaches allow
health care providers and managers to develop an in-depth understanding of a problem and to
address its root causes. Rather than merely treating the symptoms of a quality- related problem,
quality assurance seeks to find a cure. In the advanced stages of a QA program, the health center
team can go even further by analyzing processes to prevent problems before they occur.
Quality assurance uses data to analyze service delivery processes. Simple quantitative
approaches to problem analysis and monitoring are another important aspect of quality
improvement. Data-oriented methods allow the QA team to test its theories about root causes;
5. effective problem solving should be based on facts, not assumptions.
Quality assurance encourages a team approach to problem solving and quality improvement.
Participatory approaches offer two advantages. First, the technical product is likely to be of
higher quality because each team member brings unique perspective and insight to the quality
improvement effort. Collaboration facilitates a thorough problem analysis and makes
development of a feasible solution more likely. Second, staff members are more likely to accept
and support changes that they helped to develop. Thus, participation in quality improvement
builds consensus and reduces resistance to change.
QUALITY ASSURANCE CYCLE:-
6. 1. Planning for Quality Assurance
This first step prepares an organization to carry out QA activities. Planning begins with a review
of the organization.s scope of care to determine which services should be addressed. For most
organizations, it is impossible to improve quality in all areas at once. Instead, QA activities are
initiated in a few critical areas. High-priority, high-volume, or problem-prone services are often
selected for special attention at the start of a QA program.
2. Setting Standards and Specifications
To provide consistently high-quality services, an organization must translate its programmatic
goals and objectives into operational procedures. In its widest sense, a .standard. is a statement of
the quality that is expected. Under the broad rubric of standards there are practice guidelines or
clinical protocols, administrative procedures or standard operating procedures, product
specifications, and performance standards.
Practice guidelines, sometimes called clinical protocols or practice parameters, define how
clinical processes such as antenatal care are carried out.
Administrative procedures, sometimes called standard operating procedures, define routine
Specifications usually pertain to product characteristics or material inputs such as drugs or
technical equipment related to health service delivery.
Performance standards are specific criteria used to measure the outcome of service delivery and
the activities that support it. They are also used to measure compliance with guidelines. These
standards differ from guidelines or standard operating procedures; they are designed to evaluate
practice rather than to assist practitioners and patients.
Health workers at all levels should participate in developing guidelines and setting
standards. Because health workers often understand local conditions better than high-level
managers, the resulting guidelines are likely to be more appropriate and effective. Also, staff
participation will generate commitment to quality because health workers are more likely to
implement and support an effort that they have helped to develop.
3. Communicating Guidelines and Standards
Once practice guidelines, standard operating procedures, and performance standards have been
defined, it is essential that staff members communicate and promote their use. This will ensure
that each health worker, supervisor, manager, and support person understands what is expected
of him or her. This is particularly important if ongoing training and supervision have been weak
or if guidelines and procedures have recently changed.
Activities that communicate guidelines and standards include developing job descriptions,
translating performance guidelines into job aids, developing and conducting training programs,
holding formal conferences or informal presentations about new procedures, providing on-the-
job training through supervisory activities, and informing providers of changes in protocols
through administrative announcements.
7. 4. Monitoring Quality
Monitoring is the routine collection and review of data that helps to assess whether program
norms are being followed or whether outcomes are improved. By monitoring key indicators,
managers and supervisors can determine whether the services delivered follow the prescribed
practices and achieve the desired results. Detailed assessment of processes through special
comprehensive studies or routine assessments can provide useful information about specific
service delivery problems.
5. Identifying Problems and Selecting Opportunities for Improvement
Program managers can identify quality improvement opportunities by monitoring and evaluating
activities. With effective monitoring systems, health programs can conduct special community or
patient surveys or comprehensive assessments. The studies highlight specific service delivering
problems requiring attention. Once a health facility team has identified several problems, it
should set quality improvement priorities by choosing one or two problem areas on which to
focus. Selection criteria will vary from program to program. Two important principles should
guide this process. The criteria should reflect team, not individual, priorities. They should also be
explicit so that the decision-making process is as objective and as thorough as possible. Criteria
might include the technical feasibility of addressing the problem, the potential impact of
improving quality on the population’s health, or the adequacy of the necessary available
6. Defining the Problem
Having selected a problem, the team must define it operationally--as a gap between actual
performance and performance as prescribed by guidelines and standards. The problem statement
should identify the problem and how it manifests itself. It should clearly state where the problem
begins and ends, and how to recognize when the problem is solved. Developing a problem
statement is a crucial step in the QA process, and its apparent simplicity is deceptive.
7. Choosing a Team
Once a health facility staff has employed a participatory approach to selecting and defining a
problem, it should assign a small team to address the specific problem. The team will analyze the
problem, develop a quality improvement plan, and implement and evaluate the quality
improvement effort. The team should comprise those who are involved with, contribute inputs or
resources to, and/or benefit from the activity or activities in which the problem occurs. This
ensures the involvement of those most knowledgeable about the process.
8. Analyzing and Studying the Problem to Identify the Root Cause
Achieving a meaningful and sustainable quality improvement effort depends on understanding
the problem and its root causes. Given the complexity of health service delivery, clearly
identifying root causes requires systematic, in-depth analysis. Analytical tools such as system
modeling, flow charting, and cause-and-effect diagrams can be used to analyze a process or
8. 9. Developing Solutions and Actions for Quality Improvement
The problem-solving team should now be ready to develop and evaluate potential solutions.
Unless the procedure in question is the sole responsibility of an individual, developing solutions
should be a team effort.
10. Implementing and Evaluating Quality Improvement Efforts
Implementing quality improvement requires careful planning. The team must determine the
necessary resources and time frame and decide who will be responsible for implementation. In-
depth monitoring should begin when the quality improvement plan is implemented. It should
continue until either the solution is proven effective and sustainable, or the solution is proven
ineffective and is abandoned or modified.
Once the solution has proved to be effective, program managers should codify and
disseminate the new process so that others can learn from the experience. The QA team should
also make plans to identify a new problem, either through a team process or through data
generated by an existing monitoring system. The team may then repeat the quality improvement
MODELS IN QUALITY ASSURANCE:-
1. DONABEDIAN’S MODEL:
The model was given in 1966. The model is closely bound to systems theory of inputs,
throughputs and outputs used in industrial production, it has had a major impact on the
development of quality assurance program and assessment methods because of the simple
framework it provides for defining the criteria against which quality can be evaluated.
Donabedian breaks down the delivery of health care into three interlinking elements:-
Structure :- it relates to the physical, financial and organisational resources and other
characteristics of the system that provides care. These include- building, equipment, ancilliary
services, staff, agreed policies and procedures, rules and regulations and the organisational
system. It also includes differentiation, coordination, power, specification of work procedures,
visibility of consequences etc.
Process :- it us the interaction between patients/ clients and practitioners- the actions performed
by staff in the promotion of health care, including:- assessment techniques and procedures,
methods of monitoring care, methods of delivering care etc.
Outcomes :- they are the result or effects of the health care interventions, including- patient’s
behaviour or responses, patient’s level of knowledge, health status of the patient, satisfaction of
patients with the services provided.
9. In quality assurance model that draw on Donabedian’s ideas, a standard is defined in
terms of structure, process and outcome criteria. Each of these elements is important because the
resources available and the way in which they are used can have a direct influence on the
outcome of care.
2. LANG’S MODEL:-
This model is based on a problem- solving approach and is one of the earliest models specifically
developed for nursing. Lang’s identified 8 stages which are represented in the circle below.
10. According to the model, in the first step, values are identified. Major sources of these values are
societal, professional and scientific. As society and its values change, the characteristics of
quality must also change. The second step, identifying the standards and criteria, draws on
Donabedian’s framework of structure, process and outcome. In the next step, many methods are
used to measure the current level of nursing practice. Interpretations are made based on the
results of measurements. Then possible plans of action are suggested to improve upon the weak
points like:- continuing education, research, self-initiated change etc. Out of the plans suggested
best plan is taken up for implementation. After the implementation, reevaluation is also done.
3. THE DYNAMIC STANDARD SETTING SYSTEM:-
This framework represents a multidisciplinary approach to the quality of care and centres on
asking questions such as how individual patients feel, what information they are given etc. In the
early stages of developing this framework, the following principles were identified (Kitson 1989)
that represented the beliefs of the group about what constituted a quality nursing service.
The importance of the service being patient focussed at all times.
The need for the participation and involvement of the staff in standard setting and
in evaluating the services.
The importance of clinical staff owing and controlling the standards they set.
The need for a multidisciplinary approach to standard setting and assuring a
The setting of achievable, rather than optimal or minimal, standards for practice.
The model of quality assurance used in DySSSy is in some respects similar to the Lang’s, but it
incorporates a larger number of steps, divided into three phases. These three phases are-
describing, monitoring and taking action.
In describing phase, a group of practitioners are helped by a trained facilitator to select their
topics for quality improvement, device a standard statement that reflects the overall intention of
the exercise, and identify the elements or criteria necessary for implementation.
Once the criteria have been recognised, organised and refined the standard statement is reviewed
and edited if necessary. In order to measure practice against the standard, an audit form is then
devised by the group from the structure, process and outcome criteria.
The final phase of the cycle involves action planning. Data are summarised and brought back to
the group to interpret the findings and decide on what action is needed. Actions are prioritised
and individuals are given responsibilities for seeing that the action plans are carried out in an
agreed period of time and date for re- audit negotiated.
This model is increasingly being used as basis for standard setting, audit and
taking actions by practitioners at local level.
11. Building a Quality Assurance Program:-
A QA program is a comprehensive set of quality assessment and improvement activities that is
incorporated into an organization.s routine management functions. As health care organizations
learn more about the QA process, they are likely to discover that some of their current activities
are related to quality improvement. In fact, most organizations already do some type of QA.
These existing activities provide a foundation upon which to build a comprehensive QA
program. There are two distinct approaches to building a QA program. The first is the
comprehensive QA strategy; the second is the problem-oriented strategy. The two approaches are
contrasted here to provide an overview of the wide range of strategic options available to
program managers. In practice, most organizations combine these approaches as they introduce
In the comprehensive approach, QA policies, procedures, and processes are
implemented simultaneously, starting at the top and moving down the organizational structure.
Comprehensive service quality assessments are useful in countries where information systems are
inadequate. Systems analysis allows managers to use interviews and observation to assess
primary health care services and their associated support activities. The comprehensive approach
works best when there is a commitment throughout the system to addressing quality of care and
when organizations have the necessary resources to implement a QA program on a large scale.
The problem-oriented approach to QA emphasizes practical, small-scale, quality-
related activities that produce incremental quality improvements. Rather than carrying out a
comprehensive assessment, individuals or teams focus on a single problem that is important to
Key Activities in the Development of a Quality Assurance Program
Foster commitment to quality
Conduct a preliminary review of QA-related activities
Develop the purpose and vision for the QA effort
Determine level and scope of initial QA activities
Assign responsibility for QA
Allocate resources for QA
Develop a written QA plan
Strengthen QA skills and critical management systems
Disseminate QA activities
Foster Commitment to Quality:-
Building a permanent QA program requires the early support of top- and mid-level managers.
Over time, this commitment to QA should be shared by all staff and reflected in the
organization’s mission, purpose, and procedures.
12. Conduct a Preliminary Review of Quality-Related Activities:-
Before introducing new QA activities, it is important to conduct an initial review of the
organization and to develop a general description of the existing system. This review will allow
the new QA effort to build on existing strengths. One important function of the initial assessment
is to determine the best place in the organization to launch a QA initiative. Different approaches
can be used to conduct a preliminary assessment. Depending on the resources available, the
assessment can be a comprehensive study. It may include collecting new data or a rapid
assessment based on available data and the expert opinion of key informants.
Develop the Purpose and Vision for the Quality Assurance Effort:-
Building commitment to QA within an organization requires that top managers and their staff
share an overall vision of quality improvement. The purpose of a vision statement is to build
consensus between managers and to set boundaries for the QA effort. The vision statement will
help staff at all levels to understand how their day-to-day work relates to quality improvement. It
can be developed through a variety of consensus-building techniques that can be employed by
the senior management team.
Determine Level and Scope of Initial Quality Assurance Activities:-
The level and scope of initial QA activities depend on the resources available, the
implementation time frame, and the receptivity of management and program staff to the idea of
QA. An organization must also consider external political factors. A QA effort can be
implemented at the national, regional, and district level or within a single health facility. Where
services are organized as vertical programs, one program may be the focus of initial QA
Assign Responsibility for Quality Assurance:-
To ensure continuity, accountability for QA activities must be clear, and QA must be a
prominent organizational emphasis. In some organizations a single person may be responsible
for QA, while in others it may be the domain of quality committees. Occasionally, an existing
committee or management body will take on responsibility for QA, integrating it into the general
Allocate Resources for Quality Assurance:-
Local resources must be allocated to quality assurance in order for a QA program to become a
permanent part of a health care organization. Often, the initial QA effort may depend on outside
technical and financial assistance. Over time, the organization should support its own QA
program with minimal dependency on external resources.
Develop a Written Quality Assurance Plan:-
A QA plan is a written document that describes the program objectives and scope, defines lines
of responsibility and authority, and puts forth implementation strategies. The plan should help
staff members to relate quality goals and objectives to their routine activities. It should also be a
living document that is regularly referred to and revised.
13. Strengthen Quality Assurance Skills and Critical Management Systems:-
QA activities are an important part of management and may occasionally be reformulated into a
total quality management system. In general, however, QA efforts will focus more narrowly on
three critical management systems: supervision, training, and management information systems.
Special effort should be made to strengthen these systems as a QA program develops.
Disseminate QA Experiences:-
Early in the life of a QA program, a dissemination strategy should be devised to share
experiences inside and outside the organization. Some dissemination programs use newsletters
that contain educational articles and project progress reports. Newsletters also serve as an
effective way to recognize the initiative of local individuals and groups. Conferences at the local
regional, national, and international level can also be effective because they reinforce success,
encourage dialogue and creativity, and generate political momentum for the program.
Developing a Quality Assurance Resource Center is another effective dissemination strategy.
Resistance is almost inevitable when trying to implement a QA program. Initially, some
managers and staff fear criticism, loss of power, and change itself. Staff members who are new
to leadership and decision-making roles may be fearful or nervous about their new
responsibilities. Even healthy changes involve discomfort, uncertainty, and conflict. To minimize
resistance, a careful, phased approach to change is required and an open and trusting
environment must be cultivated. Although change management strategies must be adapted to
meet each organization.s needs, several recommendations are generally applicable.
QUALTY MANAGEMENT IN COMMUNITY HEALTH NURSING:-
Faced with limited resources available and escalating costs of care, health care agencies must be
able to identify services and programs that best serve the needs of the community. The methods
of quality assurance enhance the quality of care delivered by the home care organisations. When
the various nursing interventions within a group are proven to be highly satisfactory and cost-
efficient, these interventions should be consistently chosen over those that fails such tests. There
are many areas in community health in which the current system of services does not meet the
needs of large segments of the population.
New and innovative public health programs arise from the realisation by the
public health practitioner that time- honoured methods have become ineffective in addressing the
problems of those at risk. Such realisations come from scrutinizing the public health services. the
process of continually improving and assuring quality provides a framework for collecting and
evaluating the data on an ongoing basis.
ROLE OF NURSE IN QUALITY MANGEMENT IN THE COMMUNITY:-
Although nurse who deliver care directly to client are not managers as such improving or
assuring quality is largely a “management” activity. CHN may not be responsible for a staff or
14. agency budget and functioning, they are responsible for managing a caseload of client with needs
of varying degrees of urgency. Using the resources available, they must provide priority services
that will promote the highest level possible of personal and group functioning and health.
Role of nursing administration is to develop a formalised quality management
program that includes a three- pronged focus:-
Review organisational structure, personnel, and environment
Focus on standard of nursing care, methods of delivering nursing care(process)
Focus on the outcomes of that care. (Donabedian, 1985)
Agencies, whether small or large, are complex organisations with interrelated components. The
nursing staff has input into or some control over the quality of care delivered to clients who use
the services of the agency. The following are the roles of nurse in each of the areas of structure,
process and outcome.
The nurse should know the organisational structure and financial stability of the agency. The
nurse should focus on the availability of sufficient resources to maintain present services and
introduce additional services as needed by the community people.
The agency should maintain the standards set by the professional staffs. Nursing administration
should encourage the staff to contribute to evaluation of the standards and revise them as needed.
They should also encourage them to attend in –service and additional educational programs for
quality care. Administration and staff have compatible working relationship. Each staff member
contributes to the process as a member of a peer review committee or quality improvement or
Standards of care are met or surpassed. Client outcomes are consistent with agency goals and
quality care. They are measured against the set standards. To measure the outcome, nursing
services used in community health set up can be- well child care, self care education with
chronically ill adults, or various screening programs.
Quality management for community health nursing is vital. It seeks to assure that sufficient
health care services are provided in a timely manner and that services being provided are very
likely to produce positive effects on the health and perception of health of those being served.
Overtime, the quality management tools have changed, becoming more inclusive and using
participative management system. Standards of practices and client care have been refined and
new methodologies have been validated. The models or framework on which quality
management system are based include a classic way of looking at programs through
organisational structure, process and outcome, and the inter-relatedness of each component. The
15. current use of quality circles is having an impact on the health care arena. These circles provide
new way to involve staff in participative management opportunities.
All the service an agency provides should be reviewed periodically to determine whether the
current standards are being met. Increasing focus has been placed on quality care indicators, such
as client outcomes and client satisfaction, because of increasing competition among health care
providers. Nurses needs to define and quantify client outcomes and client satisfaction in order to
assess the quality of care being delivered. Whether the quality management techniques are
formally or informally practices, any time nurses monitors, assess, and judge the quality and
appropriateness of care as measured against professional standards, the interest of the clients are
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