Quality assurance, obstetric auditing, records, reports, norms, policies, protocols, practice and standards for OBG unit
In the changing healthcare environment, quality of care is receiving greater attention than ever before. As consumer become more knowledgeable as a result of increased information available to them, much of the mystique surrounding healthcare is being dissipated. The focus of efforts to measure quality has also expanded from inside the boundaries of hospital to community and long term care setting.
Meaning of Quality:
- The dictionary defines quality as "a degree of excellence; a peculiar and essential character."
- Although individual writers suggest slightly different view about quality, several communalities emerge when reviewing their approaches.
- Quality can be measured
- Quality measures a standard or a degree of excellence
- Excellence needs to be determined by validating standard of care or measuring professional conduct when caring for patients.
The British Standards Institute defines Quality as "the totality of features or characteristics of a product or services that bears on its ability to satisfy a given needs." It can be paraphrased into "quality is that which gives complete customer satisfaction.
Elements of quality
Shaw (1998) approaches these dimensions similarly but describes them as elements of quality. He sets out the following elements:
Appropriateness: the service or procedure is what the population or individual actually needs.
Equity: a fair share is available for all the population
Accessibility: services are not compromised by undue limits of time and distance.
Effectiveness: services are achieving the intended benefits for the individual and for the population.
Acceptability: services are provided such as to satisfy the work expectations of patients, providers and the community.
Efficiency: resources are not wasted on one services or patient to the determent of another.
Definition of quality assurance
Quality assurance is a process in which achievable and desirable levels of quality are described, the extent to which there level are achieved is measured, and action to enable them to be reached is taken."
Quality assurance is "an assessment of the effectiveness of health care provision, the efforts made to improve care as a result of assessment, combined with an assurance that quality care will be maintained."
Goals of quality assurance
Maciorowski provides three major goals of an effective nursing quality assurance program. These areas-
Evidenced of nursing accountability for services rendered and compliances with standards of practice.
A defined mechanism to identify, measures and resolves, clinical issues related to practice.
A defined mechanism of evaluating quality
indicators, collecting data, developing corrective action and assessing
Components of quality assurance plan
A quality assurance plan provides the foundation and framework of all quality control activities. A quality assurance plan should include the following components.
Clearly stated goals
Measurable objectives of how the goals will be met
Designated accountability for written objectives
Delineated methods of QA activities
Outlined responsibilities conducting QA activities
Outlined mechanisms of reporting of reporting data
Outlined mechanisms of corrective action
Clear statement of confidentiality
The World Health Organization in their booklet 'The principles of Quality Assurance' (1983) set out four particular components that must be addressed in any quality assurance activities. They are:
Ø Performance ( technical quality)
Ø Resources use ( efficiency )
Ø Risk management ( the identification and avoidance of injury or illness associated with service provided)
Ø Patient satisfaction with the services provided.
Measurement of Quality Care
In 1988, at a meeting of the American Association of College of Nursing, Diers described a model for quality care measurement. In this model services render in the healthcare delivery system result in products such as, X-Ray, Lab-test results, hours of patient care delivered, meals served etc. This products or intermediate outputs delivered over a given episode of patient care result in a final output or out come. When comparing the cost of producing products to final outcomes, a measure of quality care can be determined based on cost. Diers maintain the database arguments in nursing are necessary to relate efficiency to effectiveness and that a comparison on these will be the basis for determining quality in the future.
This model views nursing services of a specific type (staff mix and model, i.e. case management, primary care, modular care) as an input that results in a product. It provides a means for analyzing the efficiency or productivity of nursing unit, for patients hospital stay. But the question whether efficient utilization of services delivered according to standards result in quality patient outcomes, remains unanswered. By focusing on outcomes as compared to inputs, the questions become:
Comparing the quality of outcomes, was the cost efficiency of services within an acceptable range?
These issues and concerns are potentially addressed by a new integrated model, which considers the new aspects of measurements like computers and cost accounting.
A Systematic Measure of Quality Nursing Care
Professional nurses can provide more efficient and cost effective services to the consumer with aid of advanced technologies viz. computers and cost accounting.
A systematic integrative model of quality care measurement, will determine quality of outcomes based on antecedents (structure elements and process). In such model, structural inputs into the nursing care system would include those elements in the settings in which nursing care are given.
According to Donabedian, the culture within the organization is the most crucial factors associated with quality care.
The process elements measured in such systematic approach would address the interaction between the nurse, the patient/client, and the patient's / client's environment.
Components of quality assurance
In the United Kingdom, British Standards 5750, and sets out how a quality system might be set up with in an company. There are 19 components that describe how the quality system is to be applied to the design and manufacture of a product or services.
Review of quality system operation
Control of design activities
Documentation and change control.
Control of inspection, measuring and test equipment.
Control of purchased material.
Control of manufacture.
Purchaser supplied material.
Completed item inspection and test
Control of non conforming material
Indication of inspection status
Protection and preservation of product quality
The component of a nursing quality assurance program were originally developed by Lang and adopted by the American Nurses' Association as a model for quality assurance in nursing. The evaluation model is open and circular, indicating a cyclical process that can be entered at any point.
The American Nurses Association model for quality assurance and implementation of standards
Identification of values emphasizes the need to clarify the social, institutional, professional and individual values, along with the advances in scientific knowledge which influences nursing practice.
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 reflects the intent of the standards and can be compared to actual nursing practice.
The next component involves the measurement of current nursing practice against the established standards criteria.
Standards refer to the level of nursing care that is to be provided.
Criteria are the characteristics or behaviors used to measure the level of care.
Outcome standards and criteria reveal the end result of nursing care.
Quality circles: - A quality control program, or simply quality circle (QC), is a group of people from the same organizational area who meet regularly to solve problems they experience at work. Members are trained in solving problems, in applying statistical quality control, and in working groups. Usually a facilitator works with each group, which normally consists of six to twelve members. The QC's may meet 4hours a month. Although QC members may receive recognition, they usually do not receive monetary rewards.
Quality circles evolve from suggestion programs. In both approaches, workers participate in solving work related problems.
Factors influencing quality management
Ø Good organization structure/ function
Ø Good quality staff
Ø Continuing professional development
Ø Continuing structure/ functional performance evaluation
Ø Learning from failures and moving from low quality to high quality organization.
Guidelines for quality control
While approaches to quality improvement depend on the situation criteria guidelines can be helpful:-
While top- management commitment is of vital importance, everybody in an organization, from top to bottom, must be committed to quality.
Most quality problems require the cooperation and coordination of many functional departments, production design testing, engineering, manufacturing, marketing, and so.
Ideas and suggestions foe quality improvement can come from many, often unexpected, sources.
Quality control should be done at crucial steps in the operations process.
A quality improvement plan is not enough. Provision must make for its implementation.
Implementation of quality assurance in nursing
Quality improvement is the commitment and approach used to continuously improve every process in every part of an organization, with in intent of meeting and exceeding customer expectations and outcomes.
Monitor compliance on structure standards and process standards
I. Establish standards
All standards of practice provide a guide to the knowledge, skills, judgment & attitudes that are needed to practice safely.
A nursing care standard is "a descriptive statement of desired quality against which to evaluate nursing care given to a patient". Gillies(1989)
They reflect a desired and achievable level of performance against which actual performance can be compared. Their main purpose is to promote, guide and direct professional nursing practice. (Registered Nurses Association of BC (2003) & the College of Nurses of Ontario (2002)
Purpose of standards.
To provide a baseline for evaluating quality of nursing care, ranging from excellent care to unsafe care.
To help to improve quality of nursing care, increase effectiveness of care and improve efficiency.(Quality assurance)
To improve documentation of nursing care provided i. e maintain record of care.
Help to determine the degree to which standards of nursing care maintained and take necessary action time.
To help supervisors to guide nursing staff to improve performance.
To help to improve the decision making and devise alternative system for delivering nursing care.
It may help justify demands for resources association or improvement.
To help to clarify nurses area of accountability.
To help nursing to define clearly different levels of care.
Help to decrease the costs of nursing care of eliminating nonessential nursing tasks.
Be used as a framework or basis for determining nursing negligence.
Motivate nurses to achieve excellence.
Uses and advantages of standard:
1. They establish norms and allow community members and individuals to know what level of service to expect/ demand. Because they are written down they can be made public.
2. They demonstrate quality provision and act as a bench mark to monitor quality performance.
3. They focus on the core and critical tasks that must be performed in the actual situation and can be tailored to meet specific and local situation.
4. They improve efficiency and lead to better utilization of resources.
5. They improve staff utilization and staff motivation.
6. They can be used to access the practical aspects of both basic and post basic education and training.
A frame work for implementing the standards considers three possible approaches:
1. Centralized/ National approach
2. Decentralized/ Local approach
3. Combined approach
1. Centralized/ National approach:
It relies on the centre taking a lead, making all the decisions and initiating all the activities. For this approach to be effective there should be an effective management system. This approach has not been successful because it relies on decisions made at levels away from where the activities will eventually take place. Sometimes local level difficulties arise which can not be foreseen at the national level at the time when the plan is being developed.
2. Decentralized/ Local approach:
This approach is when the centre takes the lead in making the policy decision to use midwifery standards as a major component of quality assurance. However the planning of activities and adaptations of the midwifery standards are left to the local districts.
Lack of expertise in the local level.
It does not ensure the use of national norms and consistency, as each site may make their own adaptations and decisions.
3. Combined approach:
The centre at the National level remains responsible for the overall implementation of the midwifery standards; but uses local demonstration sites to try them out, to learn lessons on how they can be implemented elsewhere, and what adaptations are required to make them specific to the country situation. The centre must therefore work closely and take action with the local demonstration sites at all stages, right from the initial decision making and planning stages to the evaluation stage.
- The approach is flexible. It allows for local differences, while at the same time ensuring consistency and uniformity in the midwifery standards.
- The approach is good for developing expertise within and across the country, as each district is involved with all parts of the implementation process
- The approach lends itself to long term sustainability.
The standards development cycle.
Step 1. Define and agree. In this step, the goal is to define and agree on several areas and issues that will define the standards.
o Clarify the consensus process, both for topic selection and approval
o Clarify the approval process for the standards.
Step 2. Select who should be involved. Identify, at the outset of the process, all stakeholders, I .e, those individuals or groups with a vested interest in the successful development of the standards.
Step 3. Gather information. In this step, the working group information about the topic under review and other resources that can help define the key elements that should be included in the standards. A flowchart may be developed to better understand the points in the current process requiring the development of standards.
Step 4. Draft standards. There are several components to drafting standards:
o Decide the structure and format of the standards, depending on their purpose. After the format is decided, the working group drafts the standards.
o Develop indicators to measure performance according to the standards.
o Prior to field testing, the graft standards should be evaluated internally.
Step 5. Test the standards. Once indicators are developed, the working group must decide whether a field test is needed.
Step 6. Communicate the standards. Although the standards -setting process might be completed with the approval of the standards, the impact of well- developed standards depends on health care providers using the standards. Standards communication and implementation strategies are critical to achieving healthcare provider performance according to the standards.
Legal significance of standards
o Standards of care are guidelines by which nurses should practice.
o Malpractice suit against nurses are based on the charge that the patient was injured as a consequences of the nurses failure to meet the appropriate standards of care.
II. Implementation of standards
Each employees of the institution should follow the standards developed by the organization.
III. Monitor compliance on structure standards and process standards
Compliance monitoring is done by survey and auditing
Standards for nursing practice:
The standards for nursing practice are interrelated and all equally important.
- Standard 1: Accountability- the registered nurse is accountable to the public for competent, safe and ethical nursing practice.
- Standard 2: continuing competence- the registered nurse attains and maintains competencies relevant to own scope of nursing practice.
- Standard 3: application of knowledge, skills and judgment- the registered nurse demonstrates competencies relevant to own scope of nursing practice.
- Standard 4: professional relationships an advocacy- the registered nurse establishes professional therapeutic relationships with clients and advocates for clients in their relationships with the health system.
- Standard 5: professional leadership- the registered nurse demonstrates professional leadership in the delivery of quality nursing and health care services to the public
- Standard 6: self regulation- the registered nurse assumes personal accountability to practice nursing competently and ethically.
The importance of standards for quality maternity and midwifery care
A standard serves to establish norms and states what level of performance is required to obtain a specific desired outcome. In doing so, it provides protection to the public by having criteria against which products and the performance of practitioners can be assessed.
Standard statements are usually expressed in behavioral and measurable terms. They will say precisely what the workers will do and how they will carry out the task. Eg: correctly, accurately, gently. It is also important that standards are realistic, desirable and achievable.
Standards of practice can help identify the actual competencies required by a midwifery trained personnel in routine normal practice. Such standards can be used as the basis for assessing current practice, organizing refresher and updating programmes, as well as developing future curricula.
Format of midwifery standard
Each standard includes seven major components i.e. The code, title, aim, standard statement, outcome, prerequisites, process, and audit.
Each standard has a title and code for easy reference.
The aim indicates the intended objectives of the standard. The standard statement describes precisely what the midwifery trained personnel will do and to what level of competence.
The expected outcomes are stated in measurable terms although some of the outcomes are long term outcomes such as increased utilization of midwifery trained personnel
The pre requisites include those elements that are required to allow the health worker to perform the standard. Eg: training, resources, knowledge, equipment, drugs and system.
Process: the critical task to be followed for meeting the standard have been specified as process
The audit is an integral part of the standard. It includes a checklist and action plan. The check list can be used to test or audit the standard. The action plan is the critical part of the audit. It is intended to identify the areas which need strengthening or correcting and to assist the supervisors, managers in their routine supervisory visits. With out action following the audit, standards will be difficult to maintain and impossible to improve.
The essential elements that must be in place to enable the midwifery trained personnel to carry out the standard effectively. A review or revision of the supportive regulations and policies may be necessary to allow the midwifery trained personnel to perform the standard correctly. Other elements/ structures, which must be in place to ensure success, include:
1. supportive guidelines, policies or legislation
2. training needs
3. essential equipment; and
4. systems and other essential structures that must be in place.
The critical task that must be undertaken to achieve the desired outcomes.
Code of the standard
Title of the standard
a. check list:
a list of items to assess whether essential pre requisites, knowledge, skills and/or equipment are in place as well as critical tasks are performed correctly.
b. Action plan:
A series of questions to identify the deficiencies in the pre requisites and process components of standard as well as action needed to rectify the deficiencies or to strengthen the standard including target dates for completion of each action and responsible person to implement the action.
Example for antenatal care standard:
To estimate gestational age, monitor fetal growth and accurately identify lie, presentation and position of the fetus.
Pregnant women attend ANC
1. Midwifery- trained personnel have been trained in the correct procedure for conducting abdominal palpation
2. Essential equipment such as tailor's measure tape and fetal stethoscope is available and in good working condition.
3. A culturally appropriate place is available which allows privacy to conduct the abdominal palpation.
4. Pregnancy records are in use
5. A fully operational referral system is in place for the pregnant women identified as at risk or who develops complication to receive appropriate care and treatment.
Midwifery trained personnel must:
1. Carry out abdominal palpation at every antenatal visit
2. Ask the pregnant women prior to the palpation how she feels, if the baby is moving and when her last menstrual cycle occur or the date she felt the baby first moved.
3. Ensure the place for conducting palpation provides the pregnant women with privacy
4. Prior to an abdominal palpation ask the pregnant women to empty her bladder
5. Lay the pregnant women on her back with upper part of her body supported with cushions. Never lie a pregnant women flat on her back as the heavy uterus may compress the main blood vessels returning to the heart and cause fainting (supine hypotension)
6. Inspect the abdomen for scar, previous stretch mark, signs of over distension/ other signs of multiple pregnancy such as fetal parts felt to fetal heads palpated, excessive or reduced amount of amniotic fluid. Record findings and refer for institutional deliveries. If the women had a previous caesarean section or there are signs of excessive or reduced amniotic fluid or multiple pregnancy.
7. Estimate gestational age and assess the fetal growth. After 24 weeks of pregnancy the most effective way to estimate gestational age is to use a tailor's tape measure.
8. Using the measuring tape, measure from the upper border of the symphysis pubis to the top of the fundus. Record the measurement in centimeters. If measurement is different from calculated weeks by more than 3 c.m. or there is no growth or poor growth from the last examination, refer for further investigation.
9. Gently palpate the abdomen to assess the lie of the fetus
10. Using two hands palpate the abdomen and pelvic area to identify the presenting part
11. After 37 weeks especially in primi gravida assess the fetal head is engaged. If not, ask the pregnant women to sit/ stand up and see if the head can be made to fit in to the pelvis. If the head will not going to the pelvis refer to the first referral unit/ hospital.
12. Identify where the fetal back is and listen to the fetal heart sound
13. Discuss all findings with the pregnant women, her husband/ accompanying family members
14. Record all findings accurately. Reveal all findings and if any deviations are found refer to the first referral unit/ hospital for most specialized investigation as appropriate.
Audit in obstetrics:
Audit is defined as the systematic and critical analysis of the quality of medical care.
Nursing Audit: is a means by which nurses themselves can define standards from their point of view and describe the actual practice of nursing.
Objective of carrying out an audit is to improve the quality of clinical care. It is done by changing and strengthening many aspects of hospital, practice and administration.
Audit could be medical where scrutiny is done over the medical aspect of the work performed by the doctors. It could be clinical, where scrutiny is done over the work done by all health professionals including the doctors.
Structuring an audit:
Important aspect to organize an obstetric audit is motivation of all doctors, midwives, and other health professionals. Proper documentation of facts and figures must be there. Audit should be kept confidential and is considered as an educational tool.
When to audit:
The audit should be done 3 to 6 months or 12 months after commencement, then:
1. At regular intervals such as annually, or
2. Immediately when a major incident or problem occurs, or
3. As soon as feasible when there is a complaint by the midwifery- trained personnel that they are unable to fulfill the standard, or a complaint is raised by the community about the quality services,
4. When a new intervention related to the standard is implemented, such as the use of some new technology or treatment/ drug. In this case there should be an interval of a minimum of three months before the audit is conducted so that the full benefits/ effects of the new treatment, equipment or drug can be seen.
How to conduct audit:
Audit should be pre arranged with the midwifery trained personnel. The auditor should go to the field/ unit where the midwifery trained personnel is working to observe the standard in practice in the local situation. This should be done over 2-3 days so that the auditor can observe the midwifery trained personnel in different situations.
Importance of carrying out an audit:
1. A well structured and efficient audit is based on scientific evidences with facts and figures.
2. It can replace the out of date clinical practice with the better one
3. It can remove the disbelieving and agonistic attitudes between hospital management and professionals and also amongst the professionals.
4. It improves awareness between doctors and patients
5. It is an efficient educational tool
Use of audit results:
After conducting the audit and depending on the results, the decision will be made either to:
1. Continue with the standard since it is working effectively.
2. Take further specific action to strengthen the standard or correct deficiencies
3. Revise the standard.
From the result of the audit check list, it will be possible to develop an action plan to further improve or strengthen the standard. It is important in action plan to set target dates for completion of each task.
If the result shoes that the standard is operating correctly, then a date should be set for re- audit of the standard annually, or as national policy states. It may be necessary to re audit earlier if, there is any major change or any problem/ incident, or there is a complaint from either the midwifery trained personnel that they can not achieve the standard, or from the community about the quality of care and performance.
Unless the audit is simple one, it requires lot of time, staff commitment and technology.
Clinical audit is about improving practice and providing a better service for consumers. Practitioners are expected to measure and demonstrate the effectiveness of the care they provide and one way of assessing practice by clinical audit.
Clinical audit is a continuous process that involves identifying an area to be examined, the collection of appropriate data and the introduction of changes in practice as a result of analysis of the data. It is crucial that the effect of changes is monitored by repeating the audit and introducing further changes, if indicated. Health care professionals are mainly concerned with the outcome of clinical intervention, but there are other aspects of clinical practice that may influence outcome. Audit may influence aspects of service structure and process as well as the outcome of clinical care.
Process of clinical audit:
When embarking on a process of clinical audit for the first time, it is better to concentration a small area of study, and one that is amenable to change. An example might be to improve breast feeding rates. One must decide what it is necessary to know in order to achieve this. It is extremely important to define objectives at the start of any process of audit and how the results of the process might be used to influence practice.
When an area of study has been chosen, it is vital for there to be clinical consensus on what constitutes good care, that is, what should be happening, a desired level of achievement, a standard. It is likely to be easier to agree any changes as a result of the audit if clinical consensus on good care has been obtained.
Example for audit check list:
Evaluation of procedure on Bed bath
Date of evaluation:
Name of the patient:
Date of admission:
Name of student Nurse
Fundamental steps in Admission procedure:
1. Preparing the patient's unit
2. Explanation to the patient
3. Action of bed bath
4. Comfortable position to the patient
5. Termination of the articles
6. Recording and reporting
Observation checklist on Admission procedure
Area of observation
Preparation of patient's unit:
Wash basin with warm water
Wash cloth (sponge cloth)
Explanation to the patient:
Explain the procedure to the patient/mother before starting
Action of bed bath:
-wipe the eye from inner canthus to outer canthus
-change side of sponge cloth before wiping the other eye
Comfortable position to the patient:
Provide a comfortable position to the child
5. Termination of the articles
- Discard the water of basin,
- Wash the sponge cloth and basin
- Spread the sponge cloth to dry it
Recording and reporting:
Record the significant observation on the patient's chart
Criteria for evaluation: poor=0-23
Remark: - the student nurse obtains a total score of 28, which is categorized as average. Necessary corrections given to the student nurse and advised to practice regularly.
Rule 42 (UKCC 1993) requires the midwife to keep detailed records which must be made as contemporaneously as is reasonable, in other words as near the event as possible. Records must be in a form acceptable to the employer and approved by the local supervising authority. A midwife in independent practice will discuss the format of her records with her supervisor of midwives.
The midwife's record is distinct from that of the doctor although she may contribute to the medical record, especially during pregnancy. She must keep records of the midwifery history, and of all antenatal examinations which she makes. During labour, records of observations, examinations and care are essential and it is particularly important to enter details promptly, because events move on so rapidly. A register of controlled drugs is kept for the purpose of monitoring the issue and use of drugs of addiction. The midwife's register of births is usually kept communally by hospital midwives but individually by a community midwife.
Maternity units use a wide variety of records and notes, including those which are designed to be entered into a computer and others which are appropriate to the midwifery process or to varying styles of individualized care.
All records that are made by a midwife must be preserved for a period of not less than 25 years. The reason for this is that the record may be needed for the midwife's protection in case of litigation or allegations of professional misconduct.
Protocols, guidelines and procedures:
A protocol is a written system for managing care that should include a plan for audit of that care. Most protocols are binding on employees as they usually relate to the management of consumers with urgent, possibly life threatening conditions. A protocol may exist for the care of the woman with ante partum hemorrhage but not for the care of women in labour without complication.
Guidelines or procedures are usually less specific than protocols and may be described as suggestions for criteria or levels of performance which are provided to implement agreed standards.
Fraser M.D, Cooper. A. M, Fletcher. G. Myles Text book for midwives. 14th ed. Edinburgh: Churchill livingstone;2003
Moree K, "what nurses learn from nursing audit", Nursing out look, January 1988, 26 (1) 48.
S.Sridhar. Quality assurance in nursing Indian Journal of Nursing and Midwifery Vol. 2 Sept 1988.
Basavanthappa B.T, Nursing Administration, 1st Edition 2000, Jaypee Brothers Page: 161, 435 - 438.
Ganong J.M and Ganong W.L, "Nursing Management" 2nd Edition 1980, Aspin Publication Page 96 - 97: 194 - 207.
National institute for health and clinical excellence: Audit criteria- intrapartum care; issued in 2007
Standards of midwifery practice for safe motherhood. Vol:1- standards document, WHO, New Delhi, 1999.
This page was last updated on: 09/12/2020