QUALITY ASSURANCE

Introduction:-
Defining and attempting to measure quality of care is not new. Infact, the quality of
health care is an idea generally attributed to ernest Codman, a physician who first proposed the
end result idea in [Link] of care can be evaluated from the perceptive if individuals,
populations or communities. The main aim of quality assurance us to achieved desired outcomes.
Definition of quality:-
Quality means usually think in terms of an excellent product or service that fulfills or
exceeds our expectations.
Quality is defined “as the degree to which a set of inherent characteristics fulfills
requirement”.
Definition of quality care:-
Quality care is the term used to describe care and services that allow recipients to attain
and maintain their highest level of physical and psychological health.
Definition of quality Assurance:-
Quality assurance is achievable through on going evaluation of patient care which would
assure the hospital that all that was done for the patient.
sakharkar B.M (1999)
Quality Assurance is a program adopted by an institution that is designed to promote the
best possible care.
Deloughery(1995)
Quality assurance is program used by providers and managed care plans to evaluate the
care provided to plan members and identify and correct care delivery problems.
Cesta G.T (2002)
Purpose of quality assurance:-
 Help patients and potential patients by improving quality of care.
 Assess competence of medical staff, serve as an impetus to keep up to date and prevent
future mistakes.
 Bring to notice of hospital administration the deficiencies and in correcting the
causative factors.
 Help to exercise a regulatory function.
 Restricting undesirable procedures.
Principles of quality assurance:-
1. Quality assurance is a never ending process of creative destruction, with rapid advances
in science and technology and reduced half life of medical knowledge continuous
updating is essential.
2. The emphasis is on establishing professional excellence patient satisfaction at a
reasonable cost.
3. Quality is not proportionate to the use of sophisticated technology or to be expense
incurred.

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 4. Motto of fees for service should not be pregnant with the comedy of needless services for
a fee and tragedy of no services if no fee
5. Technical imperative should not insist on prolonging life at any lost with no
consideration to quality of life.
Constraints in rendering quality care:-
1. Inadequate resources
2. Poor maintenance
3. Medical supply – inadequate ,interrupted
4. Delays
5. Poor work culture
6. Attitudes of patients and public.
1. Inadequate Resources:-
a) Space – Shortage, wastage, unplanned growth empire building by
certain individuals
b) Infrastructure – inadequate, improper, irrelevant
c) Funds – inadequate, improper, lop sided priorities wastage.
d) Equipment – not available, not functioning overused, misused, abused
e) Staff – inadequate, poorly motivated, poorly trained, dishonest.
2. Maintenance:-
a) Building – poorly maintained, leakages, peeled off paint, hanging wires.
b) Premises – unclean, no sin ages, poor housekeeping
c) Equipments – non function, idle, poor functioning
d) Installations – poor safety precautions
e) Hazardous practices–improper waste disposal and improper sterilization.
3. Medical supplies:-
a) Faulty procedures for procurement, storage and distribution.
b) Shortages
c) Supply – inadequate, interrupted
d) Substandard items
e) Adulterated items
f) Pilferage
g) Unfair practices and kick back
4. Delay:-
a) Procedural bottle necks
b) Indifference
c) Negligence
d) Management by crisis
e) Poor accountability
f) Poor recognition of performance
5. Work Culture
a) Poor discipline
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 b) Too much job security
c) Too much job insecurity
d) Frequent transfers.
e) Poor leadership
f) Disruptive conflicts
g) Poor intersectional cooperation and coordination
h) Corruption
i) Interference from outside agencies e.g. politicians
6) Attitudes of patients and public:-
a) Prejudiced about hospital and staff.
b) Ignorance about disease
c) Ignorance about management of the disease
d) Ignorance about likely outcome
e) Too much or unreasonable expectations
f) Uncooperative behavior
g) Crisis of confidence – poor doctor patient relationship
h) Resigned acceptance giving no feedback.
Effects of poor quality of care:-
If medical care given is substandard or it is of poor quality, its effects may be
immediately noticed e.g. Fall from cot, wound infection, sudden death etc, poor quality care
can effect:-
1. patients
2. family
3. society
4. hospitals
5. staff
1. Effects on patients:-
a. Physical discomfort: e.g.
 Disturbed sleep due to noise of staff talking loudly, cleaning utensils etc.
 Wound infection
 poor quality of food causing abdominal pain
 I V fluid going out vein causing swelling or thrombophlebitis
[Link] stress
[Link] in complication rate
[Link] mortality rate
[Link] of working days
[Link] expenses
2) Effects on family
a. Inconveniences
b. Higher expenses

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 c. Frequent changes
d. Loss of trust
e. Faulty finding even for genuine actions
f. Black mailing, particularly for iatrogenic complications, refusing to pay the bills.
g. Increased possibility of litigations.
3) Effects on society:-
a. Increased prevalence of certain disease
b. Increased risk of certain infections
c. Medicalization of social problems e.g. Alcohol dependence, substances abuse etc.
d. Diminished productivity, unhealthy person is medically more demanding and
economically less productive.
e. Avoiding use of scientific hospital management and taking treatment from quacks.
4) Effects on hospital:-
a. Increased length of stay leading – overcrowding in public hospitals, cross infection,
reduction in turnover leading to longer waiting list for routine admissions, higher
expenses, and shortage of linen.
b. Higher rate of complications leading to additional investigations, additional
medications, need for revision surgery.
c. Accidents and mishaps
d. Litigations
e. Hospital image getting tarnished
f. Adverse publicity by media which undermines other good services.
5) Effects on staff:-
a. Reduced motivation
b. Indiscipline
c. Risk of infection to staff
d. Hostility towards management
e. Difficulty to attract good staff
f. Fast turn over
g. Frustration.
Method of quality assurance:-
A quality assurance programme can be either concurrent or retrospective.
1) Concurrent quality assurance: –
A hospital administrator uses this method routinely so far as no clinical aspects of
hospital care concerned, in the form of daily and periodical administrative rounds. Concurrent
evaluation provides opportunity for simultaneous corrective action. Nevertheless, this can also
profitably form part of the ward round of clinicians and consultants, because it is done while the
patient is still in the ward, oversees things as they happen from day - to- day.
2) The Retrospective quality assurance:-
Retrospective evaluation acts as a continuous and ongoing self, improvement process. In
many instances where people are keen to carryout such an evaluation, the whole process has
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been gone through with no preparation and in the most haphazard manner. Needless to add, any
quality assurance programme requires a step by step approach to derive the desired result.
Prerequisites of retrospective audit. There are three fundamental prerequisites that need to be
fulfilled before the programme is instituted:-
 good medical records
 establishment of criteria for diagnosis, investigations and treatment and
 cooperation and involvement of medical staff.
Types of quality assurance: - There are two
1. External quality assurance
2. internal quality assurance
1. External quality assurance:-
Quality assurance can be evaluated by independent assessors (or) people from outside the
institution/hospital.
2. Internal quality assurance:-
Quality assurance can be evaluated by local assessors (or) senior person from the same
institution/hospital.
Quality Assurance Committee (QAC):-
The committee should consist of the following.
 Medical administrator
 Two senior clinicians
 Pathologist
 Radiologist
 Nurse administrator
 Medical records officer – secretary
 Additional personnel such as super specialist and consultants can be
co –opted on the committee as and when required.
Functions of QAC:-
1) Coordination:-
 Collecting information
 Consider activities that should be related, e.g. Quality appraisal and continuing
education
 Communication across patient care disciplines
 Co –ordinate actions of hospital authority groups.
2) Information:-
 Provide a centralized source of reports to the board.
 Suggest head for intervention to hospital authority groups.
3. Planning:-
Establish priorities
4. Prodding:-
Insist on effective, productive quality appraisal efforts from all hospital components

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5. Consultation:-
Provide specific assistance, usually through the coordinator.
6. Response:-
 Internally, acknowledge issues of importance to individuals and departments when
suggesting high priority areas for immediate attention.
 Externally, provide the organization home for responding to quality requirement of
external agencies of any e.g. medical companies.
7. Search for expertise:-
Operate openly, not behind closed doors, seek out the specific clinical and or
management expertise necessary to reach sound conclusions.
8. Follow up:-
 Insist on reports if the impact if implemented changes.
 Committee members must recognize that their major functions are
 To coordinate not to control
 To inform, not to scold
 To plan and suggests priorities not to do detailed studies in committee and
 To recommend report, not to intervene directly.
Quality assurance model:-
Quality assurance model in nursing is developed by Lang and adapted by the American
nurses Association. The evaluation model is open and circular, indicating a cyclical process that
can be entered at any point.

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Source:-
Quality Assurance model: MC closkey (1985)
1. Identification of values –
Emphasizes the need to clarify the social, institutional, professional and individual
values, along with the advances in scientific knowledge which influence nursing practice.
Examination of these beliefs offers insight into what clients, nurses and others think is
important in nursing care. Consensus among all interested parties regarding what constitutes
good nursing care is needed in order to determine the standards and criteria used to judge
quality.
2. identify standards and criteria:-
The standards and criteria derived from the values describe the level of nursing care
considered acceptable. These standards may range from minimal to achievable, excellent or
comprehensive. Standards represent the agreed upon level of excellence, whereas criteria are
specific, measurable statements which reflect the intent of the standard and can be compared
to actual nursing practice.

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 There are three types of standards and criteria in general use – structure process and out
come.
a) Structure standards – describe organizational, financial and physical attributes if an
agency or service and provider characteristics. E.g. Patient classification system used
to determine staffing needs and all registered nurses must have a minimum of a
baccalaureate degree in nursing.
b) Process standards – focus on the nature of activities and interventions according events
in delivery of nursing [Link] includes nurse performance, the nurse patient
relationship, continuity and timeliness of care and interactions with other health care
professional. For eg: the nurse will systematically collect data about the patient’s
health status, and the nurse will treat all patients with respect.
c) Outcome standards:-
 This will pertain to the end result of nursing care and measurable changes in the patient
health status.
 Outcomes include increased health knowledge improved health status and patient
satisfaction for e.g.: The patient correctly states the names of all medications, and the
patient verbalizes that pain is controlled.
All three types of standards and criteria can be used alone or in
combination to evaluate the quality of nursing practice. However, experts agree that no one
type is sufficient to describe the quality of care.
3) Secure measurement:-
The next component involves the measurement of current nursing practice against the
established standards and criteria. There are many methods which could be used to perform the
comparison including concurrent and retrospective audit, direct observation of nurse or patient
performance, questionnaire, patient or nurse interview and knowledge testing. The method
selected is dependent upon the purpose of the evaluation study and the available instruments and
resources. Strengths and weakness of nursing practice should be revealed through this
comparison.
4) Make interpretations:-
Analysis and interpretation of the data follow as the next component of the model. The
purpose here is the identification of discrepancies between the established criteria and current
practice. If no variations are discovered, then the remainder of the model is by passed and one
begins again with value clarification .It is unlikely, however, that no discrepancies will be found.
Judgments are made about strengths, deficiencies and other problems in quality.
5) Course of Action:-
Suitable courses of action are then considered .Alternatives intended to resolve
discrepancies and reward strengths are identified and examined. Decisions may range from
simple actions to complex plans entailing many changes.
6) Choose Action:-

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 The last two components of the model consist of the selection and implementation of the
best actions. Judgments are made about strengths, deficiencies and other problems in quality; it
may be positive or negative.
7) Take Action:-
Some actions may need to be performed immediately while others take longer to initiate.
The decisions as to which action to choose are influenced by the organization context and
available resources. At this point the cycle is repeated and the actions are reassessed to determine
if the expected improvements in practice actually occurred or have been maintained.
The comprehensive quality Assurance system (QAS):-
Professional reviews, concurrent evaluation medical audit, external evaluation, peer review
each these methods has strengthens that make them most appropriate in some situations and
limitations that make them in appropriate in others.
- Submits audit standards to the central QA committee for priority setting and
measurements
- Purpose for setting standards is not to create performance standards or directions for
proper practice

Factors affecting quality assurance in nursing care:-

Quality assurance necessitates that institutions and health professionals render care in a
most efficient, effective and economical manner, there are some factors which are affecting
quality assurance in nursing care. They are as follows.
1. lack of Resources
2. personal problems
3. unreasonable patients and attendants
4. improper maintenance
5. absence of well informed populance
6. absence of accreditation laws
7. legal redress
8. lack of incident review procedures
9. lack of good hospital information system
10. absence of conducting patient satisfaction surveys
11. lack of nursing care records
12. Miscellaneous factors like lack of good supervision, Absence of knowledge about
philosophy of nursing care, substandard education and training, lack of policy and
administrative manuals.
CONCULSION:-
Quality assurance is the responsibility of the hospital management and (workers) health
personnel to assure a higher quality of care. The administrators generally have to face the
consequences in terms of poor reputation of the hospital, legal expenses and higher hospital cost.