M.Sc. NURSING 2nd YEAR
KGMU INSTITUTE OF NURSING
At the end of discussion student will able to:
• Introduce quality assurance
• Define quality assurance
• Explain models of quality assurance
• Enlist steps of quality improvement
• Illustrate quality evaluation
• Introduce standards
• Discuss concept of standard
• Explain components of standards
• Enlist characteristics of standards
• Determine steps of development of standard
• To explain techniques used in preparation of
standards in nursing
• Introduce nursing audit
• Define nursing audit
• Illustrate advantages & disadvantages of
• Determine basis of nursing audit
• Explain types of nursing audit
• Discuss nursing audit process
• The quality is not synonymous with luxury or
goodness. A product or a service that confirms
to its specifications demonstrates quality,
whatever the product.
• According to Ellie Green:- Quality is a matter
of perception and, like beauty, lies in the eyes
of the beholder.
• According to AV Fiegenbaum:- Quality is
defined as the capability of a product to fulfill
its intended purpose, produced with least
DEFINITIONS OF QUALITY IN HEALTH
• “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
• “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)
• According to Coyne C, Killien M:- Quality
assurance is the process for evaluating patient
care in a particular setting by developing
standards of care and implementing
mechanisms for ensuring that the standard
• WHO (1992) defined quality assurance, as
making sure that the services provided by the
hospital are the best possible in a given
existing resources and current medical
MODELS OF QUALITY ASSURANCE
AND QUALITY MANAGEMENT
MODELS OF QUALITY ASSURANCE
AND QUALITY MANAGEMENT
There are various models of quality assurance and
• AMERICAN NURSES’ ASSOCIATION (ANA) MODEL
• DONABEDIAN MODEL
• WILSON’S MODEL
• FOCUS- PDCA Model (Quality Management Model)
AMERICAN NURSES’ ASSOCIATION
• This model is given by Long & Black in 1975.
This is the first proposed and accepted model
of quality assurance, which was meant for the
nursing profession but was used by various
other professionals in the health care. This is a
cyclic model. It helps in self determination of
patient, and family, nursing health orientation,
patient’s right to quality care and nursing
Basic components of ANA Model:-
• 1. Identify value:- in the ANA, value identification looks as
such issue as patient , philosophy and spiritual perspective
and values philosophy of the health care organization and the
provider 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 objectives 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. Another standard of structure
includes the organizational chart, which shows
supervisory methods, communication patterns, staff
patterns and sometimes staff assignments.
• A group internal or external to the agency does
evaluation of the standards of structure. Evaluation
process includes peer review, direct observation,
interview, questionnaire etc.
• 3. Select measurement needed to determine degree of
attainment of criteria and standards:- measurements are
those tools used to gather information, determined by the
selection of standard and criteria. The approaches and
techniques used to evaluate structural standards and criteria
are, nursing audit, utilization reviews, and review of agency
documents, self-studies and reviews of physical facilities.
• 4. Make interpretations:- the degree to which the
predetermined criteria are met is the basis for interpolation
about the strengths and weakness of the program. The rate of
compliance is compared against the expected level of criteria
• 5. Identify course of action:- identify the compliance
level. If it is above the expected level , there is great
value in conveying positive feedback and
reinforcement. If it is below the expected level , then it
is essential to improve the situation.
• 6. Choose action:- usually various alternative of
actions are available to remedy a deficiency. Thus it is
vital to weigh pros and cons of alternative.
• 7. Take action:- it is important to firmly establish
accountability for the action to be taken.
• 8. Revaluation:- the final step of QA process involves
an evaluation of the results of the action.
• Donabedian quality framework is recognized
as a method of measuring quality as structure,
process and outcome in the mid of 1960s.
structure leads to process, and process leads
to outcome. Outcome reflects the results of
the application os structure, and process in a
specific health care setting.
• According to model, ‘structure’ include the
adequacy of health are facilities, the
qualification of practitioners and the financial
aspect of care.
• The ‘process’ were the aspects of care.
• And ‘outcome’ are the precise and concrete
measurements of effectiveness of care.
• Wilson (1987) in the late 1980’s tried to
operationalize Donabedian model into a
tangible and practical form. He refined it as
inputs, methods or procedures and outcomes.
FOCUS- PDCA Model (Quality
This model has following concepts:-
• Find a process to improve
• Organize a team that knows the process
• Clarify current knowledge of process
• Understand causes of variation
• PDCA (plan-do-check-act) is a four step problem solving
process. It is used in quality control. It is also known as the
Shewhart Cycle, Deming Cycle.
• Plan: Establish the objectives and process necessary to
deliver results in accordance with the specifications.
• Do: Implement the processes.
• Check: Monitor and evaluate the processes & results
against objectives and specifications & report the outcome.
• Act: Apply actions to the outcome for necessary
• This means reviewing all steps (plan-do-check-act) and
modifying the process to improve it before its next
• The process or processes of reducing variance
is quality improvement. It is the process of
attaining a new level of performance or
quality that is superior to any previous level of
STEPS OF QUALITY IMPROVEMENT
According to the quality cycle developed by USAID QA project:-
• Planning for quality
• Setting a standard
• Communicating of standard
• Identification and prioritization of improvement opportunities
• Defining the key IQs
• Organizing a team
• Analyzing and studying the IQs for root causes
• Developing solution and actions for improvement
• Implementing and evaluating improvement efforts, then
restarting the cycle again.
APPROACH TO QUALITY:-
• Juran developed a three-part (trilogy) approach to
quality: Quality planning, quality control and quality
• Quality Planning:- it involves determining who the
customers are and what their needs are, then
developing products based on those needs and
designing processes to produce those products.
• Quality control:- it is the evaluation of performance to
identify discrepancies between actual performance
• Quality improvement:- it establishes an infrastructure
and the project teams to carry out process
QUALITY EVALUATION SYSTEM IN
• The following are the examples of different
approaches to quality evaluation that are used
in different countries:
• SPECIFIC APPROACHS
• REGULATORY APPROACHES
• 1. Audit system:
• 2. Quality awards
• 3. Peer Assessment
• 4. Utilization review: Utilization review activities are
directed towards assuring that care is actually needed
& the cost appropriate for the level of care provided.
There are three types of utilization review:
• 5. Clients’ satisfaction
• Standards can be defined as a benchmark of
achievement, which is based on a desired
level of excellence. As such, standards become
model to be initiated & may serve, in turn, as
basis of comparisons. (oxford dictionary)
CONCEPTS OF STANDARDS
• These are degree of excellence.
• Serves as basis of comparison
• Are minimum parameters with which a
community may be reasonably content
• Is recognized as a model for imitation.
COMPONENTS OF STANDARDS
• 1. Standards are written.
• 2. Standards define the set of rules, actions
• 3. Standards are written for customers, staff
members and system.
• 4. Standards are approved by authority.
CHARACTERISTICS OF STANDARDS
• Standards must be:
• • Specific
• • Measureable
• • Appropriate
• • Reliable
• • Timely bounded
STEPS FOR DEVELOPMENT OF
• • Identify a team or panel of nursing experts.
• • Decide an area of nursing practice for which
the standards are to be formed.
• • Review philosophy, purposes and objectives.
• • Review nursing theories or existing nursing
care practices, nursing process.
• • Identify the patient for nursing services,
patients’ role, approaches & strategies of nursing
• Discuss with the nursing service administrators to
get their approval so that they are made feasible.
• • Devise a mechanism for determining the
achievement of standards.
• • Determine the validity and reliability of the
• • Try out the standards for feasibility.
• • The standards are then put into practice.
• • Quality care is then audited.
• • The standards are reviewed & revised.
TECHNIQUES USED IN PREPARATION
OF STANDARDS IN NURSING
• 1. Professional standards techniques
• This category contains the various guidelines
& standard documents which health care
professionals have published as a basis for
quality assurance. These are based upon
structure, process & outcome quality
assurance model given by ANA.
• 2. Comprehensive Review System
• These standards are at high level of generality
& several professional bodies suggest that
their central standard should be used as a
framework for more local exercises in specific
standard setting. They local & specific thus
grow out of the central and more general.
• 3. Process Appraisal Technique
• It focuses primarily on appraisal of the quality of process of care.
The process of care comprises all the procedures & activities
through which the health professional & support worker deploy
their time, skills, knowledge & resources in pursuits of improved
patient health & well-being. It has technical, interpersonal & moral
components & includes access, diagnosis, treatment, discharge,
after care, & health education & promotion.
• Nursing audit one of the control tools,
responsible for controlling the activities of the
nurses that focuses on providing the best
possible nursing care. The actual nursing
rendered is compared with the standards. This
is mainly refers to the clinical nursing audit.
The nursing management audit is an
evaluation of nursing management as a
• According to Elison:-
• Nursing audit refers to assessment of the
quality clinical nursing.
• According to Cott:-
• It is the process of evaluating appropriateness
& effectiveness of nursing care measures.
• According to RANF:-
• Nursing audit is a formal detailed systematic
review of records or observation of nursing
actions in order to evaluate the quality of
nursing care by comparing the documented
evidence with accepted standards & criteria.
• Department of Health, London:-
• The clinical audit has been defined ‘the
systematic & critical analysis of the procedure
used for diagnosis, care & treatment, the
associated use of resources and the effect care
has on the outcome & quality of life for the
OBJECTIVES OF NURSING AUDIT
Following are the main objectives:-
• • To improve the quality of nursing care.
• • To measure the degree of quality of patient care
against a defined criteria.
• • To decrease the cost of nursing care.
• • To provide a basis for determining nursing
• • To provide education to all the nursing personnel
by the process of self education.
• • To enhance professional knowledge from past
experiences by learning from past mistakes in records.
BASES OF NURSING AUDIT
• 1. Debit items:- these includes the items like death of the
patient, complication of disease, hospital infection, errors
in treatment, patient left against medical advice etc. these
criteria or variables are against the quality care.
• 2. Credit items:-these are the items that gives credit to
the care rendered. Number of recovered patients,
expansion of health knowledge in patient population,
shorter stay of patients etc is the example of this type of
• 3. Nursing auditors:- Nursing auditors required are of two
types: internal and external. These should be trained
• 4. Quality:- it is a degree of excellence that need to
be defined and predetermined on the basis; the
nursing audit is to be done.
• 5. Nursing standard:- these should be valid and
explicit statement about the quality of fact of nursing
care. These are classified as : structure, process &
• 6. Activities:- these are goal oriented transactions
required to carry out for auditing.
• 7. Resources:- these are in relation to human and
material required for auditing and desired health care.
TYPES OF NURSING AUDIT
• 1. According to methodology
• 2. According to type of auditors
2. According to type of auditors:
• a) Internal audit: review of work is done by
peers or nursing personnel continuously.
• b) External audit: the audit is carried out by
the outside agency. Usually periodically test,
completeness and accuracy of internal audit is
done. Review is done by non nursing
1. Describing phase:
• a) Identify topic or issue or problem: this
stage involves the selection of a topic to be
audited. The topic should be important or
significant and interest those conducting the
audit. The topic can be selected from various
• Standard given by Indian Nursing Council
• Problem encountered in practice
• Recommendation of patient
• b) Identify core group & form an audit team
• Audit committee comprising of minimum of
five members either from unidisciplinary or
multidisciplinary, who are interested in quality
assurance, are clinically competent & able to
work together in a group.
Preferably the audit committee should have:-
• clinical consultants,
• representatives of hospital administrator,
• statistical record officer,
• representative of nursing personnel of all
• special invitee members.
• c) Set audit criteria and standard:
• an audit criteria is a measurable outcome of
care aspect of practice or capacity in a
statement form that can be used to assess the
• d) Develop an audit protocol:
• An audit protocol should include:
• • Audit objectives
• • The target group
• • Selection of audit sample
• • Method of data collection
• • Tools to be prepared
2. Preparing & implementing phase:
• a) Define criteria & prepare audit tools: prepare
a rough draft of audit tools after refining criteria.
Check the validity & reliability of tools.
• b) Make a plan for gathering information:
• This should include:
• • Who is going to gather information.
• • Select the auditors
• • When to gather the information.
• • How large the target group at one time.
• c) Get ethical approval from ethical committee
• 3. Implementing phase: during this phase
data gathering has to be done.
4. Analysis & Concluding phase:
• a) Analyze data & compare results with criteria
& standard: after collection, analyze the data.
Apply appropriate statistics, usually data is
calculated in percentage in order to determine
the level of standard. Compare data with set
• b) Make an audit summary: specify how far the
standards have been met & the reasons for
failures to meet the standards in some cases.
Make a brief report & give recommendations
after discussion with audit team.
• c) Plan & implementing change: a detailed
action plan should be made specifying in detail
who, when, what & how the changes are to be
implemented. All the members of the committee
are required to be informed & members ate to be
assigned to monitor the changes implemented.
• d) Reaudit : it is undertaken to ensure that the
changes have been made in response to first
audit & that the practice has improved or how
effective the first audit.
• 1. Fabiane Gorni BorsatoI; Mariana Ângela Rossaneis
et al. conducted a study on Assessment of quality of
nursing documentation in a University Hospital
Londrina (PR), Brazil. It was a descriptive, quantitative
research study with data collection supported by the
available reports of quality assurance in nursing at the
institution, from 2002 to 2009. Attributed to the item,
"Documentation of Nursing", were these criteria:
complete, incomplete, not filled in, and incorrect, for
which was adopted as satisfactory: over 80%, below
15%, below 5%, and 0%, respectively. The division of
inpatient satisfaction reached in 2007, with 82.2% of
the documentation completed. The intensive care units
did not achieve satisfaction in any of the criteria. The
Maternal-Child Health Division had 90.7% of records
complete in 2009.
• 2. Mansoureh Z. Tafreshi, Mehrnoosh
Pazargadi et al. conducted a qualitative study
on Nurses' perspectives on quality of nursing
care in Shaheed Beheshti Medical Sciences
University, Tehran, Iran. In this paper data
were collected in two phases (ten individual
interviews and five focus group discussions). A
total of 44 clinical nurses and ten nursing
experts participated through a purposeful
sampling frame. Data analysis was conducted
by latent content analysis to achieve a
definition of nursing care quality.
• The findings in this paper show that, according to
similarities and differences between nursing experts'
and clinical nurses' perspectives on quality, the final
definition is “delivery of safety care based on nursing
standards which eventuates in patient satisfaction”.
Findings reveal that in nurses' perspectives on quality
definition two important aspects have been mostly
considered: “standard of care” and “patient
satisfaction”. Moreover, both participant groups have
emphasized the benefits of collaborative work in
health care (teamwork). Further in this study,
organizational and socio‐cultural roles in delivering
quality nursing care have been mentioned such as
staffing, budget, leadership, and social perspectives
about nursing as a highly educated profession.
• 3. Sarieh Poortaghi, Mahvash Salsali et al. conducted a
descriptive study on findings from a nursing care audit
based on the nursing process. In this study nursing audit
checklist was designed and validated for assessing nurses’
compliance with nursing process. A total of 300 nurses from
various clinical settings of Tehran university of medical
sciences were selected. Data were analyzed using
descriptive and inferential statistics, including frequencies,
Pearson correlation coefficient and independent samples t-
tests. The compliance rate of nursing process indicators was
79.71 ± 0.87. Mean compliance scores did not significantly
differ by education level and gender. However, overall
compliance scores were correlated with nurses’ age (r =
0.26, P = 0.001) and work experience (r = 0.273, P = 0.001).
Nursing process indicators can be used to audit nursing
care. Such audits can be used as quality assurance tools.
• 1. Joginder vati. Principles and Practice of Nursing Management and
Administration. Jaypee publication. Page no. 93- 125, 145-150
• 2. Yoder wise. Leading and Managing in Nursing. Elsevier publications.
Page no. 144- 160
• 3. Fabiane Gorni BorsatoI; Mariana Ângela Rossaneis et al. conducted a
study on Assessment of quality of nursing documentation in a University
Hospital Londrina (PR), Brazil. Acta paul. enferm. vol.24 no.4 São Paulo
• 4. Mansoureh Z. Tafreshi, Mehrnoosh Pazargadi et al. conducted a
qualitative study on Nurses' perspectives on quality of nursing care in
Shaheed Beheshti Medical Sciences University, Tehran, Iran. international
journal of health care quality assurance volume 20, issue 4. Pp 320-328.
• 5. Sarieh Poortaghi, Mahvash Salsali et al. conducted a descriptive
study on findings from a nursing care audit based on the nursing process.
Nurs Midwifery Stud. 2015 Sep 23; 4(3): e30181. doi: