Quality Assurance in Nursing Essay Sample

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The field of quality assurance is an old as modern nursing. Florence Nightingale introduced the concept of quality in nursing care in 1855 while attending the soldiers in the hospital during the Crimean war. It is a matter of pride for nurses that the nursing profession has attained a distinct position in the search for quality in health care. Quality is rapidly becoming concern to both consumers and the providers of the services. In health care quality is being demanded and expected and providers are judged by the quality of services and hence there is a need to sensitize and train nursing personnel to provide quality care Meaning

The dictionaries define quality as “a degree of excellence a peculiar and essential character”. Quality is defined as the extent of resemblance between the purpose of healthcare and the truly granted care -(Donabedian 1986). Definition of Quality Assurance

* Quality assurance is a dynamic process through which nurses assume accountability for quality of care they provide. * Bull 1985 defined quality assurance as the monitoring of the activities of client care to determine the degree of excellence attained to the implementation of the activities. Quality control

* It is a specific type of controlling, refers to activities that evaluate, monitor, or regulate services rendered to consumer. Definition of standardsA standard is a predetermined level of excellence that serve as a guide for practice. Standards have distinguish characteristic, they are predetermined, established by an authority, and communicated to and accepted by the people affected by the standards. ANA Standards of nursing practice

* The collection of data about the health status of clients is systematic and continuous. The data are accessible, communicated and recorded. * Nursing diagnosis are derived from health status data.

* The plan of nursing care includes goal derived from nursing diagnosis * The plan of nursing care includes priorities and prescribed nursing approaches or measure to achieve the goal derived from nursing diagnosis. * Nursing action provide for client participation in health promotion, maintaince, and restoration. * Nursing action help client to maximize their health capabilities. * The client progress or lack of progress towards goal achievement is determined by the client and the nurse * The client progress or lack of progress towards goal achievement direct towards reassessment, reordering prioties, new goals setting and revision of plan. Organizational standards

It is an outline level of acceptable practice within the institution. For example, each organization develops policy and procedure manual that outline its specific standards. Quality management:
It refers to a philosophy that define a corporate culture emphasizing customer satisfaction, innovation, and employee involvement Benefits of Quality Management
* The current financial environment with prospective payment has constrained budgets, which has caused a decrease in staff. * Greater efficiency and proactive planning while maintaining quality may overcome some of the problem with prospective payment * Abundance of legal malpractice suits emphasis the need for quality of care. * It involves everyone on the improvement team and encourages everyone to make contribution. Evolution of Quality management

* Create constancy of purpose for improvement of product and service * Adopt the new philosophy.
* Cease dependence on inspection to achieve quality.
* End the practice of awarding business on the basis of price tag * Improve constantly and forever the system of production and service * Institute training on the job
* Institute leadership
* Drive out fear
* Breakdown barrier between departments.
* Eliminate slogans, extortions, and target for the workplaces. * Remove barrier that rob people of pride and workmanship * Institute a vigorous program of education and self improvement for everyone * Put everyone in the company to accomplish the transformation. Quality improvement:

It refers to an ongoing process of innovation, prevention of error and staff development that is used by corporation and institution that the quality management philosophy.
Principle of Quality improvement
* Quality management operates most effectively within a flat, democratic organizational structure. * Manager and worker must be committed to quality improvement * The goal of improvement is to improve the system and processes, not to assign blame * Customer define quality

* Quality improvement focuses on outcome
* Decision must be based on data.

Quality improvement process
* Establish measurable outcome and quality indicators.
* Select and implement a plan to meet the outcome.
* Collect data to evaluate to implementation of the plan and the achievement of outcome. * Establish measurable outcome and quality indicators.
* Select and implement a plan to meet the outcome.
* Collect data to evaluate to implementation of the plan and the achievement of outcome. * Establish measurable outcome and quality indicators.
* Select and implement a plan to meet the outcome.
* Collect data to evaluate to implementation of the plan and the achievement of outcome.
Approaches of Quality assurance
Two major categories of approaches exist in quality assurance they are 1. General
2. Specific
1) General Approach:
It involves large governing of official body’s evaluation of a persons or agency’s ability to meet established criteria or standards at a given time. 1) Credentialing:
A person generally defines it as the formal recognition of professional or technical competence and attainment of minimum standards by a person or agency. According to Hinsvark (1981) credentialing process has four functional components a) To produce a quality product

b) To confer a unique identity
c) To protect provider and public
d) To control the profession.
2) Licensure:
Individual 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 professional’s practice. Law has mandated licensure of nurses since 1903. 3) Accreditation:

National league for nursing (NLN) a voluntary organization has established standards for inspecting nursing education’s programs. In the part the accreditation process primarily evaluated on agency’s physical structure, organizational structure and personal qualification. In 1990 more emphasis was placed on evaluation of the outcomes of care and on the educational qualifications of the person providing care. 4) Certification:

Certification is usually a voluntary process with in the professions. A persons educational achievements, experience and performance on examination are used to determine the persons qualifications for functioning in an identified specialty area. 2) SPECIFIC APPROACHES:

Quality assurances are methods used to evaluate identified instances of provider and client interaction.
1.) Peer review committee:
These are designed to monitor client specific aspects of care appropriate for certain levels of care. The audit has been the major tool used by peer review committee to ascertain quality of care. 2) The audit Process – Audit is a systematic and official examination of a record, process or account to evaluate performance.

3) Utilization Review (UR)
Utilization review activities are directed towards assuring that care is actually needed and that the cost appropriate for the level of care provided. Three type of Utilization Review (UR) is there:

1) Prospective: Its aim is to assess the necessity of care before giving service. 2) Concurrent: a review of the necessity of care while the care is being given. 3) Retrospective: is analysis of the necessity of the services received by the client after the care has being given. Advantages of Utilization Review:

1. It is designed to assist clients to avoid unnecessary care. 2. It may serve to encourage the consideration of care options by providers, such as home health care rather than hospitalization 3. It can provide guidelines for staff development program . 4) Evaluation Studies:

There are some models have been used to evaluate quality they are:- 1. Donabedian’s structure- process-outcome model
Donabedian introduced 3 major method of evaluating quality care. A) Structural evaluation:
This method evaluates the setting and instruments used to provide care such as facilities, equipments and characteristics of the administrative organization and qualification of the health providers. The data for structural evaluations can be obtained from the existing documents of an agency or from an inspector of a faculty. B) Process evaluation:

This method evaluates activities as they relate to standards and expectations of health provider in the management of client care, data for
this can be collected through direct observations of provider encounters and review of records, audit, check list approach and the criteria mapping approach are used to establish the client encounter protocol. C) Outcome Evaluation:

The net changes that occur as a result of health care or the net results of health care. The data of this method can be collected from vital statistical records such as death certificates or telephone client interviews, mailed questionnaire and client records. * The Tracer method: is a measure of both process and outcome of care. To use the tracer method, one must identify a volume of client with a particular characteristic resuming specific health care management. Physicians and nurse practitioners, to identify persons with certain illness such as HTN, ulcers, UTI and to establish criteria for good medical and nursing management of the illnesses have used the tracer method.

This method provides nurses with data to show the differences in outcome as a result of nursing care standards. * The Sentinel method: It is an outcome measure for examining specific instances of client care the characteristics of this method are, a) Cases of unnecessary disease, disability deaths are counted. b) The circumstances surrounding the unnecessary event or the sentinel is examined in detail. c) In review of morbidity and mortality are used as an index. d) Health status indicator such as changes in social, economic, political and environmental factors are reviewed which may have an effect on health outcomes. AUDIT

Audit: A systematic and critical examination to examine or verify. Nursing audit refers to assessment of the quality of clinical nursing. Qualities of Auditor
* Knowledge of accountancy and the commercial law:
The auditor should know the principles of accounting of transactions and the different ways in which the accounts are maintained. * Honesty and integrity: The auditors certificates are taken as true and the profession is recognized for its moral and honesty. * Skills & tact’s:- An auditor often has to act with care & skills to elicit information from his clients & the accounting staff of the business & to satisfy about the trustful of transaction. He may have to ask questioning such a way that the staff may not be opposed to answer them. Hence tact required. * Patience & perseverance: – an auditor must almost patience in caring out his duties. He must hear his client fully. * Ability to work hard: – Auditors should be hard worker. * Knowledge of report writing: – the observation& finding of the auditor are to be written in the form of a report & send to client for information, the report is to be written in a concise, understandable language, free from ambiguity. * Common sense: – The auditor must possess common sense .he must have practical wisdom & act with presence of mind. He should act in a rational manner should exercise constant vigilance.

* Evaluating nursing care
* Identify way to improve patient care.
* Focuses on care provided and not on care provider.
* Contribute to research.
The nursing audits are mainly of two types
1. Concurrent audit
2. Retrospective audit
1. Concurrent Audit:
The concurrent audit has also been called as the open chart audit because it is done while the patient is receiving care. It is a process audit that evaluates the quality of ongoing care being perceived by clients by looking at the nursing process. 2. Retrospective Audit:

Refers to an in-depth assessment of the quality, after the client has been discharged, having the client chart as a source of data. Focuses on 2 factors:

* It can be used as a method of measurement
* Functions are easily understood
* Scoring system is fairly simple
* Results are easily understood
* Assess the work of all those involved in recording case. * May be useful tool as part of a quality assurance program in area where accurate records of case are kept.

* It is not so useful in areas where the nursing process has not been implemented. * Many components overlap making analysis difficult
* It is time consuming
* Requires a team of trained auditors.
* Deals with a large amount of information

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