Nursing Management


Total Quality Management (TQM) in Nursing Care




Two major categories of approaches exist in quality assurance they are

  1. General
  2. Specific

A. General Approach

1) Credentialing

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

3) Accreditation

4) Certification

B. Specific approaches

1)  Peer review

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:

3) Audit as a tool for quality assurance


1. System Model

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:

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

4) Make interpretations

5) Identify Course of Action

6) Choose action

7) Take Action

8) Reevaluate


  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

2) Personnel problems

3) Improper maintenance

4) Unreasonable Patients and Attendants

5) Absence of well informed population

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.


  1. Margaret MM. Professionalization of nursing; current issues and 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