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Quality Assurance Standards unit 6H. Williams & J. BrahamDepartment of Nursing NCUQuality Assurance (QA) is a management method that is defined as all those planned and systematic actions needed to provide adequate confidence that a product, service or result will satisfy given requirements for quality and be fit for use.

A Quality Assurance programme is defined as the sum total of the activities aimed at achieving that required standard (ISO, 1994).

ISO 1994 Quality Management and Quality Assurance - a Vocabulary. InternationalOrganization for Standardization, Geneva.Total Quality AssuranceQuality refers to excellence of a product or a service, including its attractiveness, lack of defects, reliability, and long-term durability.

Quality assurance provides the mechanisms to effectively monitor patient care provided by health care professionals using cost-effective resources.

Nursing programmes of quality assurance are concerned with the quantitative assessment of nursing care as measured by proven standards of nursing practice.(Ellis, 1995)

Quality assurance system motivates nurses to strive for excellence in delivering quality care and to be more open and flexible in experimenting with innovative ways to change outmoded systems.

Florence Nightingale introduced the concept of quality in nursing care in 1855 while attending the soldiers in the hospital during the Crimean war.

CONCEPT OF QUALITY IN HEALTH CAREQuality is defined as the extent of resemblance between the purpose of healthcare and the care duly given (Donabedian 1997).

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 (Ellis, 1995).

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 1997).

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).

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).

2) LicensureIndividual licensure is a contract between the profession and the state, in which the profession is granted control over entry into and exists from the profession and over quality of professional practice.

The licensing process requires that regulations be written to define the scopes and limits of the professionals practice.

Licensure of nurses has been mandated throughout the world by laws and regulations.

Approaches for a quality assurance programmesTwo major categories of approaches that exist in quality assurance:

General

Specific

A. General ApproachIt involves large governing of official bodys evaluation of a persons or agencys ability to meet established criteria or standards at a given time.

1) Credentialingformal 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 productb) To confer a unique identityc) To protect provider and publicd) To control the profession

3) AccreditationAAA (Adventist Accreditation Association)UCJ (University & Colleges of Jamaica)NCJ (Nursing Council of Jamaica)

4) CertificationCertification is usually a voluntary process with in the profession.A persons educational achievements, experience and performance on examination are used to determine the persons qualifications for functioning in an identified specialty area.

B. Specific approaches 1) Peer reviewPeer review is divided in to two types. The recipients of health services by means of auditing the quality of services rendered.The health professional evaluating the quality of individual performance.

2) Audit as a tool for quality assuranceNursing 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.3) Standard as a device for quality assuranceStandard is pre-determined baseline condition or level of excellence that comprises a model to be followed and practiced.

Standards 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.(Marquis & Huston, 2013)

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 recognized as describing nursing practice and are seem as having permanent value.

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.(Marquis & Huston, 2013)

Characteristics of StandardsStandards 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 practicing 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 and so on

Standards of 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.(Marquis & Huston, 2013)

Standards must be reviewed and revised periodically.

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

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

(Marquis & Huston, 2013)

Purposes of StandardsSetting 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.(Marquis & Huston, 2013)

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.

Classification of StandardsThere are different types of standards used to direct and control nursing actions. Normative and Empirical StandardsStandards 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. (Marquis & Huston, 2013)

Here the normative (written) standards describe a higher quality of performance than empirical standards (generally accepted).

Generally professional organizations (Nursing Council) promulgate normative standards whereas low enforcement and regulatory bodies (KPH) promulgate empirical standards.

(Marquis & Huston, 2013)

Ends and Means StandardsNursing 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.

(Marquis & Huston, 2013)

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.

(Marquis & Huston, 2013)

Structure StandardA structural standard involves the 'set-up' of the institution.

The philosophy, goals and objectives, structure of the organization, facilities and equipment, and qualifications of employees are some of the components of the structure of the organization.

For example, recommended relationship between the nursing department and other departments in a health agency are structural standards, because they refer to the organizational structure in which nursing is implemented.

It includes people money, equipment, staff and the evaluation of structure is designed to find out the effectiveness ,degree to which goals are achieved and efficiency in terms of the amount of effort needed to achieve the goal.

The structure is related to the framework, that is care providing system and resources that support for actual provision of care.

(Marquis & Huston, 2013)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.

Process StandardProcess 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.

(Marquis & Huston, 2013)

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 for example: 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(Marquis & Huston, 2013)

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.

(Marquis & Huston, 2013)

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 STANDARDSStandards 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.

CONCLUSIONQuality 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.

MODELS OF QUALITY ASSURANCE

Systems ModelTasks are broken down into manageable components based on defined objectives.

The basic components of the system are InputThroughputOutputFeedback

(Ellis, 1995)

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.

Quality Assurance ProcessEstablishment of standards or criteria for evaluating process - benchmarking is the process of measuring products, practices, and services against best-performing organizations.

Identify the information relevant to the criteria

Determine ways to collect information

Collect and analyze the information(Ellis, 1993; Marquis & Huston, 2013)Compare collected information with established criteria

Make a judgment about the quality of the service or product

Provide information and if necessary, take corrective action regarding findings of appropriate sources

Determine ways to collect the information(Ellis, 1993; Marquis & Huston, 2013)

FACTORS AFFECTING QUALITY ASSURANCE IN NURSING CARE

Material ResourcesInsufficient resources, infrastructures, equipment, consumables, money for recurring expenses and staff make it possible for output of a certain quality to be turned out under the prevailing circumstances.

2) Personnel ResourcesLack of trained, skilled and motivated employees and staff indiscipline affects the quality of care.

(Marquis & Huston, 2013)3) Improper maintenanceBuildings and equipment require proper maintenance for efficient use.

If not maintained properly the equipment cannot be used in giving nursing care.

To minimize equipment down time it is necessary to ensure adequate after sale service and service manuals

(Ellis, 1995)4) Unreasonable Patients and AttendantsIllness, anxiety, absence of immediate response to treatment, unreasonable and un-cooperative attitude that in turn affects the quality of care in nursing.

5) Absence of well informed populationTo improve quality of nursing care, it is necessary that the people become knowledgeable and assert their rights to quality care.

This can be achieved through continuous educational program.

6) Lack of good hospital information system

A good management information system is essential for the appraisal of quality of care.

a) Workload, admissions, procedures and length of stay

b) Activity audit and scheduling of procedures.(Ellis, 1993)7) Absence of patient satisfaction surveysAscertainment of patient satisfaction at fixed points on an ongoing basis.

Such surveys carried out through questionnaires, interviews by social worker, consultant groups, and help to document patient satisfaction with respect to variables that are

Delayed in attendance by nurses and doctorsb) Incidents of incorrect treatment

8) Lack of nursing care recordsNursing care records are perhaps the most useful source of information on quality of care rendered. The records:

a) Detail the patients conditionb) Document all significant interaction between patient and the nursing personnel.c) Contain information regarding response to treatment d) Have the dates in an easily accessible form.

9) Miscellaneous factors

Lack of good supervisionAbsence of knowledge about philosophy of nursing careLack of policy and administrative manuals.Substandard education and trainingLack of evaluation techniqueLack of written job description and job specifications

Lack of in-service and continuing educational programmes

Donabedian A. The quality of care: How can it be assessed? Journal of the American Medical Association. 1988; 260 (12): 1743-1748. Ellis, Roger. (1995). Quality Assurance for University Teaching. Society for Research into Higher Education. London: The quality of care: How can it be assessed?Avedis DonabedianArchives of Pathology & Laboratory Medicine; Nov 1997; 121, 11; ProQuest Nursing Journalspg. 1145