Total Quality Management (TQM) in Nursing Care

  • 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.
  • 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).
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.
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.
  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
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
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
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.
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
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
  • 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
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.
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