Nursing
Management

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Total Quality Management (TQM) in
Nursing Care

INTRODUCTION

• Quality 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.

• 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 CARE

• Quality is defined as the extent of resemblance between the
  purpose of healthcare and the truly granted care (Donabedian
  1986).

• 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.

• 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 1982).

•  “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).

APPROACHES
FOR A QUALITY ASSURANCE PROGRAMME

Two major categories of approaches exist in quality
assurance they are

1. General
2. Specific

A. 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

• formal 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 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.

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

3) Accreditation

• ISO
• JCI
• NABH
• Accrediation Canada
• NAAC

4) Certification

• Certification is usually a voluntary process with in the
  profession.
• A person’s educational achievements, experience and performance
  on examination are used to determine the person’s qualifications for
  functioning in an identified specialty area.

B. Specific approaches

1)  Peer review

• Peer review is divided in to two types.
  1. The recipients of health services by means of auditing the
     quality of services rendered.
  2. The health professional evaluating the quality of individual
     performance.

2) Standard as a device for quality assurance

Standard is a pre-determined baseline condition or
level of excellence that comprises a model to be followed and
practiced. The ANA standard for practice include:

• Standard 1: The collection of
  data about health status of the patient is systematic and
  continuous. The data are accessible, communicative, and recorded.

• Standard 2: Nursing diagnosis
  are derived from health status data.

• Standard 3: The plan of nursing
  care includes goals derived from the nursing diagnoses.

• Standard 4: The plan of nursing
  care includes priorities and the prescribed nursing approaches or
  measures to achieve the goals derived from the nursing diagnoses.

• Standard 5: Nursing actions
  provide for patient participation in health promotion,
  maintenance, and restoration.

• Standard 6: Nursing actions
  assist the patient to maximize his health capabilities.

• Standard 7: The patient’s
  progress or lack of progress towards goal achievement is
  determined by the patient and the nurse.

• Standard 8: The patient’s
  progress or lack of progress towards goal achievement directs
  re-assessment, re-ordering of priorities, new goal setting, and a
  revision of the plan of nursing care.

3) Audit as a tool for quality assurance

• Nursing 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.

MODELS OF
QUALITY ASSURANCE

1. System Model

• Tasks are broken down into manageable components based on defined
  objectives.

The basic components of the system are

1. Input

2. Throughput

3. Output

4. Feedback

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.

2) ANA Quality Assurance
Model

The basic components of the ANA model are:

1. Identify values

2. Identify structure, process and outcome standards and criteria

3. Select measurement

4. Make interpretation

5. Identify course of action

6. Choose action

7. Take action

8. Reevaluate

1) Identify Value

In the ANA value identification looks as such issue
as patient/client, philosophy, needs and rights from an economic,
social, psychology and spiritual perspective and values, philosophy of
the health care organization and the providres 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 objective 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.
• Evaluation of the standards of structure is done by a group
  internal or external to the agency.
• The evaluation of process standards is a more specific appraisal
  of the quality of care being given by agency care providers.

3) Select measurement needed to determine
degree of attainment of criteria and standards

• Measurements are those tools used to gather information or data,
  determined by the selections of standards and criteria.
• The approaches and techniques used to evaluate structural
  standards and criteria are, nursing audit, utilization’s reviews,
  review of agency documents, self studies and review of physicals
  facilities.
• The approaches and techniques for the evaluation of process
  standards and criteria are peer review, client satisfactions
  surveys, direct observations, questionnaires, interviews, written
  audits and videotapes.
• The evaluation approaches for outcome standards and criteria
  include research studies, client satisfaction surveys, client
  classification, admission, readmission, discharge data and morbidity
  data.

4) Make interpretations

• The degree to which the predetermined criteria are met is the
  basis for interpretation about the strengths and weaknesses of the
  program.
• The rate of compliance is compared against the expected level of
  criteria accomplishment.

5) Identify Course of Action

• If the compliance level is above the normal or the expected level,
  there is great value in conveying positive feedback and
  reinforcement
• . If the compliance level is below the expected level, it is
  essential to improve the situations.
• It is necessary to identify the cause of deficiency. Then, it is
  important to identify various solutions to the problems.

6) Choose action

• Usually various alternative course of action are available to
  remedy a deficiency.
• Thus it is vital to weigh the pros and cons of each alternative
  while considering the environmental context and the availability of
  resources.

7) Take Action

• It is important to firmly establish accountability for the action
  to be taken.
• This step then concludes with the actual implementation of the
  proposed courses of action.

8) Reevaluate

• The final step of QA process involves an evaluation of the results
  of the action.
• The reassessment is accomplished in the same way as the original
  assessment and begins the QA cycle again.
• Careful interpretation is essential to determine whether the
  course of action has improves the deficiency, positive reinforcement
  is offered to those who participated and the decision is made about
  when to again evaluate that aspect of care.

QUALITY
ASSURANCE PROCESS

1. Establishment of standards or criteria

2. Identify the information relevant to criteria

3. Determine ways to collect information

4. Collect and analyze the information

5. Compare collected information with established
   criteria

6. Make a judgment about quality

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

8. Determine ways to collect the information

FACTORS
AFFECTING QUALITY ASSURANCE IN NURSING CARE

1) Lack of Resources

• Insufficient 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 problems

• Lack of trained, skilled and motivated employees, staff
  indiscipline affects the quality of care.

3) Improper maintenance

• Buildings and equipments require proper maintenance for efficient
  use. If not maintained properly the equipments cannot be used in
  giving nursing care.
• To minimize equipment down time it is necessary to ensure
  adequate after sale service and service manuals.

4) Unreasonable Patients and Attendants

• Illness, anxiety, absence of immediate response to treatment,
  unreasonable and unco-operative attitude that in turn affects the
  quality of care in nursing.

5) Absence of well informed population

• To 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) Absence of accreditation laws

There is no organization empowered by legislation to
lay down standards in nursing and medical care so as to regulate the
quality of care. It requires a legislation that provides for setting
of a stationary accreditation / vigilance authority to:

a) Inspect hospitals and ensures that basic
requirements are met.

b) Enquire into major incidence of negligence

c) Take actions against health professionals
involved in malpractice

7) Lack of incident review procedures

During a patients hospitalizations reveal incidents
may occur which have a bearing on the treatment and the patients final
recovery. These critical incidents may be:

a) Delayed attendance by nurses, surgeon, physician

b) Incorrect medication

c) Burns arising out of faulty procedures

d) Death in a corridor with no nurse / physician
accompanying the patient etc.

8) Lack of good and 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.

9) Absence of patient satisfaction surveys

Ascertainment of patient satisfaction at fixed points
on an ongoing basis. Such surveys carried out through questionnaires,
interviews to by social worker, consultant groups, and help to
document patient satisfaction with respect to variables that are

a) Delay in attendance by nurses and doctors.

b) Incidents of incorrect treatment

10) Lack of nursing care records

Nursing care records are perhaps the most useful
source of information on quality of care rendered. The records.

a) Detail the patient condition

b) 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.

11) Miscellaneous factors

a. Lack of good supervision

b. Absence of knowledge about philosophy of nursing
care

c. Lack of policy and administrative manuals.

d. Substandard education and training

e. Lack of evaluation technique

f.  Lack of written job description and job
specifications

g. Lack of in-service and continuing
educational program

FRAMEWORKS
FOR QUALITY ASSURANCE:

1.      Maxwell
(1984)

Maxwell recognized that, in a society where resources
are limited, self assessment by health care professionals is not
satisfactory in demonstrating the efficiency or effectiveness of a
service. The dimensions of quality he proposed are:

• Access to service
• Relevance to need
• Effectiveness
• Equity
• Social acceptance
• Efficiency and economy

2. Wilson (1987)

Wilson considers there to  be four essential
components to a QA programme. These are:

• Setting objectives
• Quality promotion
• Activity monitoring
• Performance assessment

3. Lang (1976)

This framework has subsequently been adopted and
developed by the ANA. The stages includes;

• Identify and agree values
• Review literature, Known QAP
• Analyze available programmes
• Determine most appropriate QAP
• Establish structure, plans, outcome criteria and standards
• Ratify standards and criteria
• Evaluate current levels of nursing practice against ratified
  structures
• Identify and analyze factors contributing to results
• Select appropriate actions to maintain or improve care
• Implement selected actions
• Evaluate QAO

STAGES OF THE
DEVELOPMENT OF INTERNATIONAL STANDARDS

An International Standard is the result of an
agreement between the member bodies of ISO. It may be used as such, or
may be implemented through incorporation in national standards of
different countries.

International Standards are developed by ISO
technical committees (TC) and subcommittees (SC) by a six-step
process:

• Stage 1: Proposal stage
• Stage 2: Preparatory stage
• Stage 3: Committee stage
• Stage 4: Enquiry stage
• Stage 5: Approval stage
• Stage 6: Publication stage

The following is a summary of each of the six stages:

Stage 1: Proposal stage

The first step in the development of an International
Standard is to confirm that a particular International Standard is
needed. A new work item proposal (NP) is submitted for vote by the
members of the relevant TC or SC to determine the inclusion of the
work item in the programme of work.

The proposal is accepted if a majority of the
P-members of the TC/SC votes in favour and if at least five P-members
declare their commitment to participate actively in the project. At
this stage a project leader responsible for the work item is normally
appointed.

Stage 2: Preparatory stage

Usually, a working group of experts, the chairman
(convener) of which is the project leader, is set up by the TC/SC for
the preparation of a working draft. Successive working drafts may be
considered until the working group is satisfied that it has developed
the best technical solution to the problem being addressed. At this
stage, the draft is forwarded to the working group’s parent committee
for the consensus-building phase.

Stage 3: Committee stage

As soon as a first committee draft is available, it
is registered by the ISO Central Secretariat. It is distributed for
comment and, if required, voting, by the P-members of the TC/SC.
Successive committee drafts may be considered until consensus is
reached on the technical content. Once consensus has been attained,
the text is finalized for submission as a draft International Standard
(DIS).

Stage 4: Enquiry stage

The draft International Standard (DIS) is circulated
to all ISO member bodies by the ISO Central Secretariat for voting and
comment within a period of five months. It is approved for submission
as a final draft International Standard (FDIS) if a two-thirds
majority of the P-members of the TC/SC are in favour and not more than
one-quarter of the total number of votes cast are negative. If the
approval criteria are not met, the text is returned to the originating
TC/SC for further study and a revised document will again be
circulated for voting and comment as a draft International Standard.

Stage 5: Approval stage

The final draft International Standard (FDIS) is
circulated to all ISO member bodies by the ISO Central Secretariat for
a final Yes/No vote within a period of two months. If technical
comments are received during this period, they are no longer
considered at this stage, but registered for consideration during a
future revision of the International Standard. The text is approved as
an International Standard if a two-thirds majority of the P-members of
the TC/SC is in favour and not more than one-quarter of the total
number of votes cast are negative. If these approval criteria are not
met, the standard is referred back to the originating TC/SC for
reconsideration in light of the technical reasons submitted in support
of the negative votes received.

Stage 6: Publication stage

Once a final draft International Standard has been
approved, only minor editorial changes, if and where necessary, are
introduced into the final text. The final text is sent to the ISO
Central Secretariat which publishes the International Standard.

IMPACT OF ISO IN A LOCAL
HOSPITAL:

Positive impacts:

1. Nurses are accountable for their actions and,
   professionally, we have responsibility to evaluate the
   effectiveness of our care

2. Nurses can deliver a high standard of care, and
   being empowered to identify and resolve problems can add to
   personal satisfaction with work

3. Documents state clearly how the health service
   should perform and what the patient can expect

4. Guaranteeing standards of care to the public must
   be a duty of all those who work within the health service

5. Nurses are actively involve in audit, service
   reviews, standard-setting and customer relations

6. Improves the overall quality of nursing care

7. Improves all types of documentation and
   communication

8. Helps in professional growth

Negative impacts:

1. Lack of adequate resources

2. Lack of trained, skilled and motivated
   employees, staff indiscipline affects the quality of care.

3. ISO activities may overburden the nursing
   personnel

4. Nurses will not get adequate time to spent with
   the patient, most of the time may be spending for recording and
   reporting

5. The hospital will be restricted only to ISO
   standards

6. Hospital has to provide special training for all
   the staffs those who are involved in ISO inspection

7. All types of services will be under the control
   of ISO

IMPACT OF ISO IN A LOCAL 
NURSING EDUCATIONAL INSTITUTIONS:

Positive impacts:

1. Improves the quality of nursing education

2. improves the quality of nursing practice

3. Helps to maintain international standard

4. Helps to compare the standard with another
   institution

5. Helps in personnel development of teachers

6. Helps to maintain all the records in time

7. Avoids malpractice and bias

8. Encourages extra-curricular activities also

9. Act as a control for all the activities

10. Improves professional growth

Negative impacts:

1. Gives more importance to documentation

2. Over-burden for the teachers

3. Teachers need to take special training in
   maintaining the standards

4. Not observing the actual practice

5. Organizational philosophy and policies has to be
   modified according to the ISO standards

CRITICAL ANALYSIS:

• Strengths: ISO
  helps to improve and maintain the quality of educational
  institutions and hospitals
• Weakness:
  Standards are set by the institution itself, it may be biased
• Opportunities:
  Helps in professional growth
• Threats:
  Organizational philosophy and policies may not be considered

CONCLUSION

To ensure quality nursing care within the
contemporary health care system, mechanisms for monitoring and
evaluating care are under scrutiny. As the level of knowledge
increases for a profession, the demand for accountability for its
services likewise increases. Individuals within the profession must
assume responsibility for their professional actions and be answerable
to the         recipients for
their care. As profession become more interdependent, it appears that
the power base will become more balanced, allowing individual
practitioners to demonstrate their competence and expertise. Quality
assurance programme will helps to improve the quality of nursing care
and professional development.

REFERENCES

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   trends. JB Lippincott company; Philadelphia: 1992
2. Karen P, Corrigan P. Quality improvement in nursing and health
   care. Chapman& Hall; Newyork: 1995
3. Patrica& Cerrell. Nursing leadership and management; A
   practical guide. Thomson Delmar; Canada: 2005
4. Roger E. Professional competence and quality assurance in the
   caring professions. Chapman& Hall; USA: 1993
5. Basavanthappa BT. Nursing administration. Jaypee brothers; New
   Delhi: 2000
6. Srinivasan AV. Managing a modern hospital. Sage publishers; New
   Delhi: 2000
7. Barbara C. Contemporary nursing issues trends and management,
   Mosby publication; St Louis: 2001
8. Ganong J.M and Ganong W.L, “Nursing Management”. Aspin
   Publication: 1980.
9. Stanhope. Community Health Nursing Process and Practice for
   promoting health. Mosby publication; St Louis: 1988.

This page was last updated on: 09/12/2020