INTRODUCTION:Quality assurance,refers to activities that evaluate, monitor, or regulate services rendered to consumers.

In nursing ,the goal of quality assurance would be to ensure a quality product while meeting intended purposes.quality assurance can be bronken down into three basic steps. 1.The criteria or standards must be determined. 2. Information is collected to determine if standards have been met. 3. Corrective action is taken if the criteria were not met. Quality assurance in nursing is a process of establishing a target degree of excellence for nursing intervention and then taking steps to ensure that each client receives the agreed upon level of care. Quality assurance programs began in hospital in the 1960s with voluntary implementation of nursing audit. Initially nursing quality assurance program were designed to set standards for nursing care delivery and establish the criteria by which to evaluate these standards. The term has emerged in the health care field as a synonym for evaluation. DEFINITION:-

A. QUALITY ASSURANCE:-Quality assurance defines the performance measurement and compares actual process and outcomes to clinical and satisfaction indicators. B. QUALITY CONTOL:-It involves performance management and maintain and includes systemic methods ofensuring conformance to a desired standard or norm. C. QUALITY IMPROVEMENT:-It is concerned with development and is ongoing,involvd with fixing problems now,costly mistakes in the future and fostering breaktrough. CHARACTERSTICS OR FEATURES OF QUALITY ASSURANCE: I. Direction oriented. II. Reactive III. Narrow focus IV. Getting by V. Tradition and safety VI. Busyness VII. Leadership not vested VIII. Employee as expendible IX. Responisibility of few X. Problem solving by authority XI. We-they thinking XII. Cypniasm

THE DEVELOPMENT OF STANDARD FOR QUALITY ASSURANCE:-A standard is a baseline level of excellence. It is not an evalution in itself but provides the yardstick for measuring the quality of service provided.Duke university hospitals nursing service list four qualities necsessory for development of standards I. II. III. IV. The standard must be explicit in terms of what is measured,at what level of performance and at what times. It must distinguish various differences in quality of care. The organization must posses the technology necessary for the measurement of the criteria. The measurement of standard must be cost-effective. ANA STANDRAD OF NURSING PRATICE(1973):I. II. III. IV. V. VI. The collection of data about the health status of client is systematic and continous the data are accessible,communicative and recorded. Nursing diagnosis are derived from health status data. The nursing care includes goals derived from the nursing diagnosis. Nursing actions provide for client participation in health promotion,maintenance and restoration. Nursing actions assist clients to maximize their health capabilities. The plan of nursing care includes priorties the prescribed nursing approaches or measures to achieve the goals derived from the nursing diagnosis. The clients progress or lack of progress toward goal achievement is determined by client and nurse. Standards of practice allow the organization to more objectively measure unit and individual performance and KOONTZ&WEIHRICH identified eight types of standards:a. PHYSICAL STANDARDS:-IT INCLUDES PATIENTacuity ratings to establish nursing care hours per patient day. b. COST STANDARDS:-The cost per patient day for nursing care would be an example.

VII.

3.CAPITAL STANDARDS:-By which monetory investments or new program would be reviewed. c. REVENUE STANDARDS:-The revenue per patient day for nursing care would be an example. d. PROGRAMM STANDARDS:-Guide the development and implementationof new program to meet client needs. e. INTANGIBLE STANDARDS:-COULD INCLUDE STAFF DEVELOPMENT OR orientation cost for personnel. f. GOAL STANDARDS:-Outline qualitative goals in short and long term planning. g. STRATEGIC PLAN STANDARDS:-Outline checkpoints in the development and implementation of the organisations strategic plan. The ANA and national league for nursing both publish manual in 1959 to help establish standards for health care.during 1960s the ANA STARTED FOR NURSING practice to deveop standard for nursing practices which become the basis for quality assusance program. JACHO 10 STEP MONITORING AND EVALUATION PROCESS:a. ASSIGN RESPONSIBILITY AND ACCOUNTABLITY:-A director of quality improvement can be found within each organization that is responsible and accountable for an activity during program.in nursing care area,clinics a nurse manager is often responsible and accountable for proper implementation of program to assure quality of care and work co-ordinately and co-operatively with other and individual staff is responsible for monitoring quality,decision making and ensuring high quality care. b. DELNATE,SCOPE OF CARE OR SERVICES:- Each nursing unit area involved in the care of selected group of clients provides a well-defined set of services. An analysis of a units scope of

services reveals the types of client who recive care and type of process involved in delivering care and how much or either they are beneficial for client and its understanding allow staff to focus on quality issue related typical group. c. IDENTIFY IMPORTANT ASPECT OF CARE:-In this committee asses activities or services considered most important to providing high-quality services to clients.e.g,-key aspects of service in the medicine unit migt include client,education, diagnostic monitoring and admission of I.V therapy. d. IDENTIFY INDICATOR:-QUALITY INDICATOR IS A QUantative mearsures of an important aspect of care that determine whether quality of service conform to requirement.e.g,incidence of wound infection,self administration of insulin these are of three types:1.STURCTURE INDICATORS:-Evaluate structure or system for delivering care. 2.PROCESS INDICATORS:-EVALUATE the manner in which care is delivered. 3.OUTCOMES INDICATOR:-Evaluate the end results of care delivered. e. ESTABLISHING THRESHOLDS OR EVALUATION:-After selection of quality indicator and form a threshold is a standard for determining whether a problem with quality exist and measure ment that fall below the threshold indicates problem.e.g,-staff may set a standard that states 90% of clients who receive instruction will correctly self-administration of insulin and after test only 80% of client are able to administer insulin.when QI is an ongoing process, staff continuously work to improve outcome or performance by raising threshold. f.COLLECTION AND ANALYSIS OF DATA:-staff must collect meaningful information on a sufficient no. of clients to allow for accurate analysis of the appropriateness of care.e.g,-diabetic instruction and insulin

administration,staff might monitor criteria including use of recommended teaching material staff compliancewith teaching standards and each client score on a return demonstration test.collection of relavant data allows accurate analyaia of potential problem with quality and their possible cause. g.EVALUATION OF CARE:-Monitoring of quality indicator evaluation if specifically defined process reach to desired outcome. If results exceed or meet threshold or performance is within the control we are able to say performance is well. h.TAKE ACTION TO IMPROVE CARE:-After evaluation staff develop action to improve the shortcoming of the process.it is important to establish action that will result in success. I.ASSESS THE ACTINS AND DOCUMENT IMPROVEMENT :-After re-implementation of an action plan to improve quality of care and re-evaluate the success of plan. The change may be positive or negative.e.g,-if client test score improve the team has suceesfully improved outcome. J.COMMUNICATE INFORMATION:-The results of QI activities must be communicated to staff inn all appropriate organizational department. If there is no communication of findings practice will not change The incorporation of a QI program within a health care settings benefits the clients,staff and institution. NURSING STANDARDS OF PROFESSIONAL PERFORMANCE:a. QUALITY OF PRATICE:-The registered nurse systemically enhances the quality and effectiveness of nursing practice. b. EDUCATION:-The registered nurse attains knowledge and competency that reflects current nursing practice. c. PROFESSIONAL PRACTICE EVALUATION:-The registered nurse evaluate own nursing practice in relation to professional practice standards and guidelines,relavant statutes,rules and regulations.

d. COLLEGIALITY:-Nurse interacts with and contributes to the professional development of peers and colleagues. e. COLLABORATION:-The registered nurse collaborates with the patient,family and others in the conduct of nursing practice. f. ETHICS:-The registered nurse integrates ethical provisions in all areas of practice. g. RESEARCH:-The registered nurse integrates research findings in practice. h. RESOURCE UTILIZATION:-The registered nurse consider factors related to safety,effectiveness,cost and impact on practice in planning and delivering nursing services. i. LEADERSHIP:-The registered nurse provides leadership in the professional practice settings and the profession. McLARMICK MODEL OF QUALITY ASSURANCE:-McLARMICK illustrates a model for computerization of quality assurance which incorporates the inputs of nursing to affectoutput such as input includes essential elements in a hospital patients nursing record,including demographics information,patient history,physical information,nursing problem,his recovery program,medication administered and drug interactions.
INPUT Staff Performance care plan. Diagnostic criteria Personal profile Facilities Inventory Patient record Acuity RISK Manage ment Nursing Deptt. Education Research Hospital quality, assurance committee OUTPUT REPORT Computer Processor Computer graphics

Educationreview Utilization
Cost, Bugdet $ Census Staff Planning $ allocation Information feedback, Policy changes, Maintenance system changes, Educational Opportunities, Structural Changes.

QUALITY ASSURANCE MODEL IN NURSING:-Quality assurance model in nursing is the set of elements that are related each to other and qualitycomprise of planning for quality,development of objectives,setting thresholds,collecting data to monitor compliance with set standards for nursing practice and applying solutions to improve care. PHILOSPHY OF QUALITY ASSURANCE MODEL IN NURSING:Indian nursing council believe that nurse will:I. Do good for person/receiver of care,do no harm,maintain respect for life and human diginity, believe in justice and fairness to individual in terms of acess to resources and care and project the vulnerable. Have moral obligation to provide services as per the prescribed norms of the regulatory body/health care system/organization/institution even if it is conflict with her personal belief and values. Be responsible and accountable for providing quality care in line with set standards. Be commited to understanding of the dynamic nature of her/his role in interdisciplinary health team. Be obliged to create public awareness and consider social expectations before making decisions for providing nursing care. Be obliged to include receiver in making choices in planning and implantation of care. Work in conjugation with legislation, accreditation and political system. Have obligation to promote education of self and others. Be commited to advancement of the profession. PURPOSE OF QUALITY ASSURANCE MODEL:To ensure quality nursing care provided by nurses in order to meet the expectations of receiver,management and regulatory body. It also need to increase the commitment of provider and the management. GOALS OF QUALITY ASSURANCE MODEL:QAM intends to:-

II.

III. IV. V. VI. VII. VIII. IX.

A. Develop confidence of the reciver that quality care is being rendered as per assurance. B. Develop commitment of the management towards quality care. C. Increase commitment of providers to adhere to set standards for nursing practice and strive for excellence. D. Strengthen documentation of nursing care. E. Promote optimum utilization of resources in providing cost-effective nursing care. TRAINING PROGRAMME FOR QUALITY ASSURANCE IN NURSING IN NURSING:INTRODUCTION:-Quality is rapidly becoming a concern to both the consumers and the providers of the services. In health care quality is being demanded and expected and the provider we judged by the quality of services.nurses play a vital role in delivery of health care services and hence there is need to sensitize and train nursing personnel to provide quality care. The purpose,objective and the suggested training programme for nursing personnel enable them to provide quality care is given below:PURPSOE:a. To introduce code of ethics and professional conduct for nurses in Indian to the nursing personnel b. To prepare nursing personnel for implementation of quality assurance model in nursing. OBJECTIVES:-At the end of training programme, the participants will be able to:I. II. State the code of ethics and professional conduct for nurses in india. Recongnize the significance of following code of ethics and professional conduct in nursing practice.

III. IV. V. VI. VII. VIII. IX. X. XI. XII.

Explain QAM as a pre-requisite for quality nursing care. Describe standards for nurses and their rationale. Identify the legal boundaries for nursing practices. Prepare a nursing care plan following the nursing process approach. Appreciate the important of practicing standard safety measures Identify appropriate communication techniques to be used in given interpersonal situations. Plan and conduct patient teaching session. Identify appropriate management techniques to be used for managing resources in given situations. Appreciate the importance of continuing education and research for development of self others and of the use Describe the institutional disaster preparedness plan and nurse role. QUALITY ASSURANCE IN NURSING:Quality assurance is a program for formal guarantee for provision of quality nursing care against set standards. QUALITY ASSURANCE MEMOS:-Incident report are called quality assurance memos an incident is any unsual happening such as fall, medication error,malfunction in equipment or injury to client or victim. Each agency has a standardized form on which the witnessing.nurse can record client or visitor incidents.nurses oftenly avoid sounding judgemental when documenting incidents.some facilties use incident report related to nursing procedure as away to evaluate the quality of care and these may be collect quality assurance memos. QUALITY ASSURANCE ACTIVITIES IN A HOSPITAL:a. CLIENT CARE AUDITS:-client care audits are of two types-

b.

c.

d.

e.

1.CONCURRENT AUDIT:-It is one in which the client care is observed and evaluated as it provided. 2.RETROSPECTIVE AUDIT:- It is one in which client care is evaluated after the client discharge from hospital. The accuracy of retrospective or concurrent audit depends upon its accuracy and completeness of records by all care giver. PEER REVIEW:-It is the evaluation and judgement of a nurses performance by other nurses with equal status and ability who can expected to assess accurately the appropriateness of an assiociates responses to a particular nursing care needs. CLIENTS SATIAFACTION STUDIES:-Client are interviewed in which the clients state how the experienced the hospital stay. CONTROL CCOMMITTEES:-Committees may be set up in hospital to evaluate a particular problem and to take corrective measures e.g,-infection control committee. REVIEW OF ACCIDENT REPORTS:-There are so many types of accidents can occur in hospital situation. A good accident report guides us for taking the steps for their prevention. The report should contain detail of patients and also the accident.

COMMITTEE SELECTION AND FUNCTIONS:Quality assurance committee to established criteria and a process for quality assurance and to evaluate care make recommendations and do follow-up work. A chairperson with enthusiasm and attention to detail helps ensure a successful programme. member also needs to be interested in quality assurance and knowledge about channels of communication ,hospital resources, patient population and nursing needs. representation

oproces of staff nurses, head nurses, clinical specialists and units helps produce a wide variety of ideas preset meeting time allow for staffing to accommodate attendance and committee membership supplies personal to do the work. TOOLS USED IN MEASUREMENT OF QUALITY ASSURANCE:- For the measurement of quality care is done by audit .an audit is a systematic and official examination of a record,process or account to evaluate performance. There are so many audit are used to ensure quality. I. PROCESS AUDIT:-These audit are used to how the care was carried out. Process audit are task oriented and focus on whether or not standards of nursing practice are being met. Process standards may be documented in patient care plans, procedure manuals or nursing protocol statements II. STRUCTURE AUDIT:-This audit monitor the structure or setting in which the patient care occurs. e.g, -nursing services structure ,medical records and accrediating bodies ensure a safe and effective environment. III. OUTCOME AUDIT:-By this audit the end results of care , the changes in the patientss health status that can be attributed to the delivering of health care services. Outcome audits determine what results occurred as aresult of specific intervention by nurses for the clients. QUALITY ASSURANCE /IMPROVEMENT PROGRAMME:It is an ongoing process designed to evaluate and promote excellence in health care provided to clients. Evaluation can also focus on the quality of nursing care provided to groups of clients with similar problems nursing diagnosis. Quality improvement programmes are mechanical called quality assurance monitor, total quality management , total quality improvent. These programs ensure that quality client care is provided and standard are upheld.

Quality improvent is the combined result of consumers demands for high-caliber health services and soaring health care csots.also governmental agencies, accreditation groups and regulatory bodies have preesured the nursing profession to respond to quality improvent issues. Description of objectives of these assiociations are:AMERICAN NURSES ASSIOCIATION:ANA established the standards of nursing practice in 1973 and updated in 1998 with 2nd edition of standards of clinical nursing practice which included standards of care and standards of professional performance standards of care are composed of seven nursing and behavior and roles of professional nurses are described in eight standards of professional performance. Both standards are used as criteria for evaluating nursing care and performance. JOINT COMMISSION ON ACCREDIATION OF HEALTH CARE ORGANIGATIONS:The JCHAO(1996) is an external review board that establishes standards for institutions to ensure that the institution fuctions with specialized guidelines. The hospital standards for nursing care are applicable to all the clients in every settings. Evaluation of the quality of nursing care provided to the department of nursing. ORGANISATION STRUCTURE OF QUALITY ASSURANCE PROGRAMME: Organisational structure of a quality assurance programme is defined by organizational policy encompassing every department and medical staff. It is large organization a full or part-time persons is assigned to oversee the program.quality assurance committee often function at the level of both organization and nursing department. CONTINUOUS QUALITY IMPROVENT IN NURSING:-

INTRODUCTION:-Quality improvent and evaluation in nursing professional practice at any hospital facilitates and support the excellence in patient care through evidence based practice in a safe,caring and collaborative environment. every employee is responsible for quality, by participating in continuous quality improvement activities nurse and other staff improve quality of care. The nursing quality improvement co-ordinators provide quality improvement expertise to clinical teams,co-ordinate,monitor and evaluate the continuous quality improvement program for nursing. Clinical nurses collaborates on the identification of quality indicators and participates in continuous improvement activities and work groups. PURPOSE:1.To enhance patient care through systematic assessment and improvement of quality and appropriateness of care rendered. 2. To improve the standards or techniques thorugh which nursing is provides. 3. To deliver patient care which is optimal,customer focused and achieves improved patient health outcome. 4.To improve the patient care through evaluation of clinical and operational performance measures. GOALS AND OBJECTIVES:1.To improve the delivery,quality and efficiency and outcome of patient care and services. 2.To ensure that all the activities are done in accordance with standards of professional health care practices or regulatory bodies. AUTHORITY:-The chief nursing officer.officer has the authority and direct responsibility for continous assessment and improvement of the quality of services provided. The director will incorporate these qualities measures into daily department operations and management decision and will report significance. Outcome or unresolved issue to their administrative officer.

SCPOE:-The nursing services quality improvement program encompasses relavant dimensions of performance including those that are high volume ,high risk orproblem prone.nursing care is provided on a 24-hour bases to patient from infancy to old age encompassing health care needs. Nursing care is provided in an organized and systematic process under registered professional nurse. Nursing process begins with assessment and recongnition of patient priorty ,development and implementation of a plan of care and finally evaluate plan. discharge planning ,patient teaching, implementation of current nursing standards and collaboration with the interdisciplinary team are key improtants. TOTAL QUALITY MANAGEMENT It is based on the premise that the individual is the focal element on which production and services depends. Quality is built into the service or product , rather than assuming that inspection of and removal of errors lead to quality. Identify and doing the right things, right way, first-time and problem-prevention planning not only inspection and reactive problems solving lead to quality outcomes. TQM is a never ending process. Everything and everyone in the organization are subject to continuous improvement efforts. TQM philosophy says there is always room for improvement. Customer needs and experience with the end-product are constantly evaluated. PRINCIPLES OF TOTAL QUALITY MANAGEMENT:ACCORDING TO DEMINGS:a. Create a constancy of purpose for the improvement of products and services. b. Adopt a philosophy of continual improvement. c. Focus on improving process, not on inspection of [roduct. d. End the practice of awarding business on price alone, instead, minimize total cost by working with a single a supplier. e. Improve constantly every process for planning,production and services f. Institute job training and retraining.

g. ,Develop the leadership in the organization. h. Drive out fear by encouraging. Employees, to participate actively in the process. i. Foster interdepartment co-operation,and breakdown barriers between departments. j. Eliminate slogans, exhortations and targets for the work force. k. Focus on quality and not just quanity eliminate quota system if they are in place. l. Promote team work rather than individual accomplishments eliminate the annual ratting or merit system. m. Educate/train employees to maximize personal development. n. Charge all employees with carrying out the total quality management package. DEFINITION OE NURSING STANDARDS:Defines a standard as the desireable and achievable level of performance against which a practice is compred.the standards must meet the needs of the patient. CLASSIFICATION OF STANDARDS:There are different types of standards used to direct and control nursing actions. Standard can be normative or empirical. standards can be classified and formulated according to frames of references relating to nursing structure, process and outcome ,because standard is a descpritive statement of desired level of performance against which to evaluate the quality of service structure, process oroutcomes. STRUCTURE STANDARD:-A standard involves the set up 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,e.g. recommended relationship between the nursing the nursing department and other departments in a health agency are structural standards .

PROCESS STANDARDS: 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 standards involves the activities concerned with delivering patient care. In process standard there is an element of professional judgement , i.e. determining ,the quality or the degree of skill. It includes nursing care techniques, procedures , regimens, processes. OUTCOME STANDARDS:Descriptive statements of desired patient care results are outcome standards , because patients results are outcomes of nursing interventions. An outcome standard measures change in the patient health status. Out comes standards reflect the effectiveness and results rather than the process of giving care. In quality assurance outcomes are stated in positive terms as the nursing goal is to improve the health status of client. NURSING AUDIT:1.According to elison nursing audit refers to assessment of the