The fifth stage of nursing process — TDMUV (2022)

The fifth stage of nursing process:Evaluation. Documentation


Evaluation is the fifth step in the nursing process and involves determiningwhether the client goals have been met, have been partially met, or have notbeen met. Even though it is the final phase of the nursing process, evaluationis an ongoing part of daily nursing activities that determines theeffectiveness of those activities in helping clients achieve expected outcomes.

Evaluationis not only a part of the nursing process, but it is also an integral processin determining the quality of health care delivered. In addition to discussingevaluation as part of the nursing process, this chapter also describes the roleof evaluation in delivering quality care.

Thischapter discusses the purposes, components, and methods of evaluation. Therelationship between evaluation and quality of care is described.


Evaluationis the measurement of the degree to which objectives are achieved. Therefore,evaluating the care provided to clients is an essential part of professionalnursing. “Evaluation is a planned, systematic process . . .[that] compares the client’s health status with the desired expected outcomes”(Kenney, 1995, p. 195).

TheAmerican Nurses Association (1998), in its Standards of Clinical NursingPractice, designates evaluation as a fundamental component of the nursingprocess (see the accompanying display).

Thepurposes of evaluation include:

To determine the client’s progress or lackof progress toward achievement of expected outcomes

To determine the effectiveness of nursingcare in helping clients achieve the expected outcomes

To determine the overall quality of careprovided

To promote nursing accountability(discussed later in this chapter)

Evaluationis done primarily to determine whether a client is progressing—that is,experiencing an improvement in health status. Evaluation is not an end to thenursing process, but rather an ongoing mechanism that assures qualityinterventions. Effective evaluation is done periodically, not just prior totermination of care. Evaluation is closely related to each of the other stagesof the nursing process. The plan of care may be modified during any phase ofthe nursing process when the need to do so is determined through evaluation.Client goals and expected outcomes provide the criteria for evaluation of care.

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Evaluationis a fluid process that is dependent on all the other components of the nursingprocess. As shown in Figure 10-1, evaluation affects, and is affected by,assessment, diagnosis, outcome identification andplanning, and implementation of nursing care. Table 10-1 shows how evaluationis woven into every phase of the nursing process.

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Ongoingevaluation is essential if the nursing process is to be implementedappropriately. As Alfaro-LeFevre (1998) states: Whenwe evaluate early, checking whether our information is accurate, complete, andup-to-date, we’re able to make corrections early. We avoid making decisionsbased on outdated, inaccurate, or incomplete information. Early evaluationenhances our ability to act safely and effectively. It improves our efficiencyby helping us stay focused on priorities and avoid wasting time continuinguseless actions. (p. 22)

There arespecific criteria to be used in the process of evaluation. The evaluationcriteria must be planned, goal-directed, objective, verifiable, and specific(that is, strengths, weaknesses, achievements, and deficits must beconsidered).


Effectiveevaluation results primarily from the nurse’s accurate use of communication andobservation skills.

Bothverbal and nonverbal communication between the nurse and the client can yield importantinformation about the accuracy of the goals and expected planned outcomes andthe nursing interventions that have been executed for resolution of theclient’s problems. The nurse needs to be sensitive to clients’ willingness orhesitation to discuss their responses to nursing actions and must use thetechniques of therapeutic communication to collect all necessary data.

Thenurse must be sensitive to changes in the client’s physiological condition,emotional status, and behavior.

Becausethese changes are often subtle, they require astute observational skills on thepart of the nurse.

Observationoccurs through use of the senses. In other words, what the nurse sees, hears,smells, and feels when touching the client all provide clues to the client’scurrent health status.

Sources ofData

Evaluationis a mutual process occurring among the nurse, client, family, and other healthcare providers.

Bothsubjective and objective data are used in evaluating the client’s status. Asking clients to describe how they feel results in subjectivedata. Objective data consist of observable facts, such as laboratoryvalues and the client’s behavior. When a nurse communicates an assessment of aclient’s response to an actual or potential health problem, clients and familiesare empowered to discuss their concerns and questions. When feedback is given,the nurse must avoid being defensive, because that attitude may cause clientsor families to avoid being open and honest. As a result, they may only say whatthey think the nurse wants to hear or they may completely refuse to participatein the evaluation process.

Thenurse’s verbal and nonverbal communication establishes the atmosphere in whichclients and families freely share their comments, both positive and negative.

Goals andExpected Outcomes

Theeffectiveness of nursing interventions is evaluated by examination of goals andexpected outcomes. Goals provide direction for the plan of care and serve asmeasurements for the client’s progress or lack of progress toward resolution ofa problem.

Realisticgoals are necessary for effective evaluation. These goals must take intoconsideration the client’s strengths, limitations, resources, and the timeframe for achievement of the objectives. Examples of client strengths areeducational background, family support, and financial resources (for instance,money to purchase medications and foods that support the prescribedinterventions). Examples of client limitations are delayed developmental level,poverty, and unwillingness to change (lack of motivation).


Thenurse who successfully evaluates nursing care uses a systematic approach thatensures thorough, comprehensive collection of data. Evaluation is an orderlyprocess consisting of seven steps, which are explained here.


Specificcriteria are used to determine whether the demonstrated behavior indicates goalachievement.

Standardsare established before nursing action is implemented. Evaluation of criteriaexamines the presence of any changes, direction of change (positive ornegative), and whether the changes were expected or unexpected.


Assessmentskills are used to gather data pertinent to goals and expected outcomes. Thenurse must be proficient in assessment skills for effective, comprehensiveevaluation to occur. Evaluation data are collected to answer the followingquestion: Were the treatment goals and expected outcomes achieved?

DeterminingGoal Achievement

Dataare analyzed to determine whether client behaviors indicate goal achievement.This process is validated through analysis of the client’s response to thespecific nursing interventions that are developed in the plan of care. Forexample, these data can take the form of either physiological responses (suchas the client’s being able to cough productively in order to promote effectivebreathing patterns) or psychosocial responses (such as the client’s being ableto verbalize concerns about an impending surgical procedure in order toalleviate anxiety).

RelatingNursing Actions to Client Status

Nursinginterventions are examined to determine their relevance to the client’s needsand nursing diagnoses. Efficient nursing actions are those that addresspertinent client needs and are proven to be primary factors in helping clientsappropriately resolve actual or potential problems.

Judging theValue of Nursing Interventions

Critical-thinkingskills are employed to determine the degree to which nursing actions have contributedto the client’s improved status. These skills enable the nurse to apply ananalytical focus to the client’s responses to the nursing interventions andthus to evaluate the benefits of those actions and identify additionalopportunities for change.

Reassessingthe Client’s Status

Theclient’s health status is reevaluated through use of assessment and observation skills.Evaluation focuses on the client’s health status and compares it with baselinedata collected during the initial assessment. Omissions or incomplete datawithin the database are identified so that an accurate picture of the client’shealth status is obtained.

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Modifying thePlan of Care

Ifthe evaluation data indicate a lack of progress toward goal achievement, theplan of care is modified. These revisions are developed through the followingprocess: reassessment of the client; formulation of more appropriate nursingdiagnoses; development of new or revised goals and expected outcomes; andimplementation of different nursing actions or repetition of specific actionsto maximize their effectiveness (for instance, client teaching). See theNursing Checklist for guidelines for evaluating effective application of thenursing process to client care.

Evaluationis performed by every nurse, regardless of the practice setting. For example,the home health nurse evaluates the care provided regularly throughout theclient’s relationship with the agency. Evaluation of the home care client iscarried out in order to determine whether the care was delivered in aneffective and efficient manner, to modify the plan of care as needed, and todecide when the client is ready for discontinuation of home care services. Theaccompanying display provides an example of evaluation performed by the home healthcare nurse.

CriticalThinking and Evaluation

Evaluationis a critical thinking activity. It is a deliberate mechanism used to analyzeand make judgments.

Nursesneed to remain objective when evaluating client care in order to modify carebased on reason rather than emotion. One critical thinking strategy,juxtaposing, is described as “putting the present state condition next to theoutcome state in a side-by-side contrast” (Pesut& Herman, 1999, p. 93). Nurses use juxtaposing throughout evaluative activitiesby comparing client responses to expected behaviors. They make conclusionsabout whether expected outcomes have been met.

Inorder to make such conclusions, assessment data is needed to determine clientprogress toward achievement of objectives. Evaluation involves analysis and ismuch more complex than merely answering questions.

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Evaluationis performed at the individual and institutional levels. For example, individualevaluation focuses on the client’s achievement of goals and also on theindividual nurse’s delivery of care. Quality and evaluation are closelyrelated. This section examines the role of evaluation in assuring the deliveryof quality health care. Because it is the mechanism used by nurses indetermining the need for improvement, evaluation assists in the provision ofquality care. The aspects that need to be evaluated to determine the quality ofhealth care are:

Appropriateness (the care provided adheredto standards and resulted in achievement of goals)

Clinical outcomes

Client satisfaction


Access to care

Availability of resources

Qualitymanagement involves constant, ongoing evaluation (monitoring of activities).

Elements inEvaluating the Quality of Care

Organizationalevaluation examines the agency’s overall ability to deliver quality care.Evaluation can be classified according to what is being evaluated: thestructure, the process, or the outcome. Table 10-2 provides an overview of thetypes of evaluation. Figure 10-2 illustrates the variables to be assessed ineach type of evaluation.

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Structureevaluation is a determination of the health careagency’s ability to provide the services offered to its client population. Thistype of evaluation focuses on assessing the systems by which nursing care isdelivered (Barnum & Kerfoot, 1995). Structureevaluation examines the physical facilities, resources, equipment, staffingpatterns, organizational patterns, and the agency’s qualifications for staff.The majority of problems with providing effective health care stems fromproblems in the structural area. The purpose of structure evaluation is toidentify any system errors, which can then be corrected.

Structureevaluation involves determining whether client care meets legal andprofessional standards. A frequently used method to evaluate whether the agencyprovides care within legal parameters is a review of policy and proceduremanuals to check for compliance with regulations.


Processevaluation is the measurement of nursing actionsby examination of each phase of the nursing process. This type of evaluation isdone to determine whether nursing care was adequate, appropriate, effective,and efficient. Nursing interventions are judged to be effective when use of theaction results in the desired outcome. A nursing intervention is determined tobe efficient through analysis of the intervention’s cost–benefit ratio (Gillies, 1994). Process evaluation determines the nurse’sability to establish an environment that promotes the client’s health. SeeTable 10-2 for sample questions used during process evaluation.

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Outcomeevaluation is the process of comparing theclient’s current status with the expected outcomes. This type of evaluationexamines all direct care activities that affect the client’s health status.According to Kenney (1995), “Outcome evaluation, though difficult, is the mostmeaningful way to judge the effectiveness of nursing interventions” (p. 200).

Outcomeevaluation focuses on changes in the client’s health status. A basic questionto ask when evaluating the outcome is: Has the expected change occurred? Suchchanges may include “modifications of symptoms; signs; knowledge; attitudes;satisfaction; skill; and compliance with treatment regimen” (Gillies, 1994, p. 517). Another variable assessed duringoutcome evaluation is the client’s self-care ability. Has the clientdemonstrated an improved ability to care for self? Does the client verbalizeknowledge related to self-care needs? See Table 10-2 for suggested approachesto performing outcome evaluation.

Nursing Audit

Anursing audit is the process of collecting and analyzing data toevaluate the effectiveness of nursing interventions.

Anursing audit can focus on implementation of the nursing process, clientoutcomes, or both in order to evaluate the quality of care provided. Nursingaudits examine data related to:

Safety measures

Treatment interventions and clientresponses to the interventions

Preestablished outcomes used as basis for interventions

Discharge planning

Client teaching

Adequacy of staffing patterns

Auditsare based on components such as institutional policies; federal, state, andlocal regulations; accreditation standards; and professional standards (seeFigure 10-3). Audits assist in identifying strengths and weaknesses that, inturn, provide direction for areas needing revision. Corrective action plans aredeveloped in accordance with the audit results.

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Anothermethod of evaluating quality of care is peer evaluation (also referredto as peer review), the process by which professionals provide to theirpeers critical performance appraisal and feedback that are geared towardcorrective action. According to the ANA (1988): Peer review in nursing is theprocess by which practicing Registered Nurses systematically assess, monitor,and make judgments about the quality of nursing care provided by peers, asmeasured against professional standards of practice. (p. 3)

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In1984, Lucille Joel postulated that peer review is the basis of nursing’s autonomy and self-governance (Joel, 1984). Thisperspective is still very relevant in today’s health care climate. Byevaluating itself, nursing is demonstrating an essential criterion by whichprofessions are recognized. Peer evaluation promotes both professional and individualaccountability.

Thequality of nursing care is strongly evident to coworkers and nurses who areexpected to assess the work of their peers. “Peer review isan essential mechanism for evaluating the judgment and performance of clinicalproviders” (Wakefield, Helms, & Helms, 1995, p. 11).

Suchjudgment may result in one of the following outcomes:

Destructive: Complaints and attacks thatundermine morale and cohesiveness

Constructive: Positive feedback thatimproves the quality of care

Peerevaluation can be destructive if the parties involved begin to personalize theprocess, misunderstand the purpose, or deliver feedback in an unfeeling andnonobjective manner. Peer evaluation can be threatening when guidelines havenot been established for the process and when the assessment focuses onemotions and personalities instead of on behaviors. Conversely, peer evaluationis constructive when the focus remains on quality improvement and encouragesthe continued growth and learning of all the parties involved. The accompanyingdisplay provides principles that promote the use of objective, nonbiased peerevaluation.

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Accountabilitymeans assuming responsibility for one’s actions. Evaluation enhances nursingaccountability by providing a mechanism for assisting the nurse to define,explain, and measure the results of nursing actions.

Accountabilityis increased by ongoing evaluation; nurses are continually checking their ownprogress against predetermined standards.

Accountabilityis an integral part of professional nursing practice and is an important methodthrough which commitment to quality client care can be demonstrated.

“Nurses are accountable for designing effective care plans, implementingappropriate nursing actions, and judging the effectiveness of their nursinginterventions” (Kenney, 1995, p. 195).In other words, nurses are accountable, for their judgments, decisions, andactions, to:

Clients, families, and significant others



The general public (society)

The nursing profession


Nursesdemonstrate their commitment in a variety of ways, including:

Maintaining expertise in skills

Participating in continuing educationprograms

Achieving and maintaining certification

Participating in peer evaluation

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The fifth stage of nursing process — TDMUV (13)


Evaluatingthe quality of care provided is a responsibility shared among members of thehealth care team. In addition to those directly involved (the health careproviders, clients, and families), others interested in the outcomes ofevaluation include the community and third-party payers (both public andprivate reimbursement organizations).

Anongoing monitoring process is implemented to evaluate quality of care. Ideally,every discipline monitors its own quality efforts. No single discipline isresponsible for all-inclusive evaluation of client care. However, in mosthealth care agencies, nurses are actively involved in monitoring evaluationactivities. Many agencies have nurses on staff whofunction either as quality management coordinators, utilization reviewevaluators, or both.

Whenhealth care providers from all the relevant disciplines are involved inevaluation, the result is decreased fragmentation of care. The team approachmandates active involvement of all care providers in the evaluation of qualitycare. Multidisciplinary evaluation helps promote a continuum of care for theclient, from the preadmission phase to discharge planning and follow-up care.


Evaluation, the fifth step in the nursingprocess, involves determining whether the client goals have been met, have beenpartially met, or have not been met.

The purposes of evaluation are to determinethe client’s progress or lack of progress toward achievement of clientobjectives, to judge the value of nursing actions in helping clients to achieveobjectives, to determine the health care agency’s overall ability to delivercare in an effective and efficient manner, and to promote nursingaccountability.

Evaluation is based primarily on theskills of communication and observation.

Evaluation is a mutual, ongoing processoccurring among the nurse, client, family, and other health care providers.

The effectiveness of nursing interventionsis evaluated by examination of goals and expected outcomes that providedirection for the plan of care and serve as standards by which the client’sprogress is measured.

Evaluation is an orderly process consistingof seven steps: establishing standards; collecting data related to the goalsand expected outcomes; determining goal achievement; relating nursing actionsto client status; judging the value of nursing interventions in assistingclients to achieve goals and objectives; reassessing the client’s status; andmodifying the plan of care if necessary.

There is a relationship between qualitymanagement and evaluation. Evaluation is necessary in the provision of qualitycare because it is the mechanism used by nurses in determining how to improvecare.

Structure evaluation judges a health careagency’s ability to provide the services offered to its client population.

Process evaluation measures nursingactions by examining each phase of the nursing process to determine theeffectiveness of the actions in helping clients meet expected outcomes and goals.

Outcome evaluation compares the client’scurrent status with the expected outcomes and examines all direct careactivities that affect the client’s status.

A nursing audit can focus onimplementation of the nursing process, client outcomes, or both in order toevaluate the quality of care provided.

Peer evaluation (peer review) is theprocess by which professionals provide to their peers performance appraisalfeedback geared toward corrective action.

Evaluation enhances professional nursingaccountability by providing a mechanism for assisting the nurse to define,explain, and measure the results of nursing actions.

Evaluating the quality of care is a sharedresponsibility among members of the health care team.


As a result of a global economy, increased competition, andspiraling health care costs, health care organizations must work to continuallyimprove and strive for higher performance. For health care organizations tooperate successfully and instill the drive for excellence in each employee,structures must be in place to empower employees to take ownership in theirwork. A new style of leadership that can facilitate teamwork and processimprovement must prevail.

Qualityof care, cost, and access are dominant themes in health care delivery. Healthcare services must be delivered in a manner that increases the likelihood ofdesired health outcomes and they must be consistent with current knowledge(Joint Commission on Accreditation of Healthcare Organizations [JCAHO], 1999).Nurses, as well as all other health care providers, are accountable for qualitycare. The challenge for nursing has never been greater as political, economic,and regulatory requirements increase and the demand for quality careintensifies.

Thischapter discusses the historical development of quality management in healthcare and describes the principles that form the basis of quality improvement.It also presents the structure on which quality management programs can beestablished and explains the mechanisms and tools by which process improvementcan be introduced and maintained within health care organizations.


Aquality management system in health care is similar to quality management inother businesses. A brief overview of the development of the quality initiativeas it relates to health care is discussed in the following sections.


Table25-1 provides a historical perspective on the development of the qualitymovement. The American College of Surgeons,established in 1913, was the first organized effort to develop qualitystandards in health care. This body later established the HospitalStandardization Program, which evolved into today’s Joint Commission on theAccreditation of Healthcare Organizations (JCAHO).

Role of theJCAHO in the Quality Movement

Foundedin 1951, JCAHO has become the largest accrediting organization in health caretoday. JCAHO provides standards for hospitals, mental health care facilities,ambulatory care facilities, home health care agencies, and long-term carefacilities. Participation in the accreditation process is a voluntary processthat is not a condition of licensure but is often a condition for reimbursementby many payers, such as the Federal Health Care Finance Administration (HCFA).

Inthe 1980s, quality assurance was introduced into JCAHO accreditation standardswith emphasis on a problem-solving approach. Each department of an organizationwas monitored and evaluated for service delivery. The 1990s marked asignificant change in quality management in health care. There was a shift fromdepartmental review to interdisciplinary performance improvement. Thissubsequent transition from quality assurance to the current approach of continuousquality improvement was derived from quality management in industry. Thesection entitled Quality Improvement discusses the concepts of qualityassurance and continuous quality improvement in more detail.

JCAHOhas made the following modifications in their survey process (effective January2000):

Random unannounced surveys will beconducted.

Health care organizations will no longerreceive advance notification of impending random surveys.

The focus and scope of the review duringthe survey will vary from agency to agency.

On-site surveys will occur duringevenings, nights, and weekends rather than be limited to weekdays (Gropper, 1999).

Allof these changes have been made in an attempt to improve the quality of healthcare delivered in organizations participating in JCAHO’s accreditation process.


Healthcare has struggled for many years to define and measure quality. Quality isdefined as meeting or exceeding requirements of the customer/client. A customeris anyone who uses the products, services, or processes of an organization.Quality is measured in terms of customer perspective. Clients are concernedwith the following:

Accessibility and availability of service

Timely and safe delivery of service

Coordination and continuity of carebetween services

Effectiveness of services, that is, thedelivery and outcome of care

Inits 1998 report, JCAHO identified nine dimensions of quality performance. Thesedimensions are described in the accompanying display. Basically, a health careorganization must be concerned with doing the right thing (efficacy,appropriateness) and doing the right things well (availability,timeliness, effectiveness, continuity, safety, efficiency, and respect andcaring).

Performanceimprovement consists of those activities andbehaviors that each individual does to meet customers’ expectations. It isdoing the right thing well and continually striving to do better (JCAHO, 1998).

Inmeasuring quality, there are three domains to measure: structure, process, andoutcome. Each of these components is interrelated. The American NursesAssociation’s (ANA’s) Standards of ClinicalNursing Practice (1991) uses these three components of care to guidenursing practice within the framework of the nursing process.

FactorsInfluencing the Quality Movement in Health Care

Todaythere are many consumers of health care in addition to clients and theirfamilies. One major consumer of health care is third-party payers, such asinsurance companies, managed care organizations, and federal and stategovernments. The diversity of needs represented by these consumers requiresimprovement in health care delivery systems. The major factors that haveinfluenced the development of the quality movement in health care are consumerdemands, financial viability, professional accountability, regulatoryrequirements, progress in quality improvement techniques, and changes in healthcare delivery.


Heathcare consumers are sophisticated, knowledgeable, and selective. Clients nolonger place blind trust in their physicians and realize that variables inpractice and results occur. Today’s consumers negotiate services and comparehealth care costs among providers.


Healthcare has entered an era of increased competitiveness for services, staff, andcustomers. There is a demand to reduce spending and contain costs. Budgetaryconstraints continue to increase in both the private and public health sectors.Health care organizations must strive to reduce professional liability,increase reimbursement eligibility, and promote cost effectiveness throughincreased efficiency.


Emphasison clinician accountability and adherence to codes of ethical practice isincreasing. Health care professionals must be dedicated to reducing practicevariances to protect the public.


TheHealth Care Financing Administration (HCFA) standards, JCAHO standards, andnumerous laws require quality improvement programs. HCFA is a subsidiary of theDepartment of Health and Human Services and is the federal agency responsiblefor administering the Medicare and Medical programs. The regulationsestablished by these organizations for accreditation and reimbursement havefacilitated the quality initiative in health care. Such externally mandatedregulations have promoted the development of internal monitoring and evaluationsystems within health care organizations.

Progress inQuality Improvement Techniques

Duringthe past decade, health care providers have spent valuable resources on definingand measuring quality. As a result, evaluation methodologies have improvedconsiderably. Information systems are available through which national andregional norms for comparative data can be obtained. Measurability methods havebeen upgraded and include a variety of process improvement models. Processimprovement examines the flow of client care between departments to ensurethat the processes work as they were designed and that acceptable levels ofperformance are achieved.

Seminars,workshops, videotape training programs, and educational consultants are nowavailable to teach process improvement in health care. Overall qualityimprovement methodologies enhance performance and work processes.

Changes inHealth Care Delivery

Significantchanges in health care delivery have occurred and unprecedented change isanticipated in the future. Clients being admitted to hospitals today aresicker, yet are being discharged more quickly.

Alternativecare options such as home health care, inhomeintravenous therapy, and intermediate care facilities have proliferated,resulting in an even greater need to coordinate a continuum of services.

Factorsthat have influenced the quality movement in health care have also protectedthose populations most vulnerable to inadequate health care; for example, theuninsured, the elderly, and low-income families. Thequality movement has promoted access to care, standards of care, cost-effectiveservice, and a continuum of care. Thus, the quality movement in health care hasserved as an advocate for consumers.

Legal andEthical Implications

Nurses,as well as other health care providers, must understand the roles that law,regulations, and ethics play in the quality movement. These aspects defineprofessional practice. Laws define legal practice, regulations defineguidelines for delivery of care, and ethics define personal performance.


Legalconsiderations have an impact on quality management in several ways:

Laws and regulations create the externalstructure for quality management.

Failure to provide quality health care canresult in lawsuits.

Institutions can face liability for actiontaken against a practitioner if objective measures are not applied toperformance and due process is not provided.

Qualitymanagement programs must protect against substandard care and ultimately reducelitigation.

Organizationsmust have clearly defined processes for professional review. Theseresponsibilities are based on case law and federal regulations.

Case Law

Caselaw refers to the legal opinion rendered in court cases. Numerous legal caseshave resulted in rulings that affect quality management. Several landmark caseshave established the following issues within the quality management movement:

Hospitals are liable for the care providedto clients.

Hospitals are responsible for adepartment’s practice.

Limited immunity for peer review exists.

Federal Regulations

Anumber of federal agencies regulate health care standards; for example, HCFA,the Food and Drug Administration (FDA), and the Occupational Safety and HealthAdministration (OSHA). Specific regulations issued by these agencies thatdirectly affect quality of care are shown in the accompanying display.

Failureto adhere to the guidelines in these legislative acts can result in sanctionsfor violation of standards.

Federalfunding and payment for services can be denied for failure to provide qualitycare.


Lawsestablish standards of acceptable conduct; however, they often represent only aminimum acceptable standard. For example, registered nurse licensure indicatesthat the nurse possesses the basic knowledge, skills, and abilities tosafely practice general nursing.

Professionalsare expected to adhere to a code of ethical practice that espouses aresponsibility to self, profession, client, and society. Ultimately, nurseshave an ethical responsibility to deliver the highest possible quality ofhealth care. Nurses are obligated by licensure to be knowledgeable about thecare they are providing and to practice according to an established code ofethics and standards of practice, as exemplified by the ANA’sCode for Nurses (1985). See Chapter 24 for a complete discussion aboutethical responsibilities.

Lawsprovide guidelines, and ethics provide a sense of obligation. Individualpractitioners and institutions have a legal and ethical requirement to deliverquality care.

Quality andCost

Healthcare costs have skyrocketed in the past decade.

Theprimary source of health insurance in the United States is employer coverage.Payers are becoming increasingly concerned about health care costs, and theissue of health care expenditures is being debated furiously.

Deliveryof poor quality care has a negative financial impact on health careorganizations. Yet, management will often argue that the quality improvementinitiative is costly because of staff time involved in such activities.

However,one must consider the cost of poor quality, which results in the followingproblems:

Duplicated work between departments

Loss of time due to inefficient taskperformance

Loss of staff due to job dissatisfaction

Recruitment and training of new employees

Expenditure of energy and time ininvestigation of complaints and allegations

Litigation and malpractice settlements

Employees continually executing tasksincorrectly despite direction

Reporting and correcting errors

Expenses related to overutilizationof diagnostic tests to avoid malpractice

Originally,the perception of quality was that of doing more, that is, the performance ofmore tasks that resulted in intensive intervention. Today, it is believed thatefficiency can be improved without compromising quality.

Healthcare leaders must now look at individual and collective effectiveness oforganizational management.

Organizationsmust also begin to examine the cumulative cost associated with aless-than-optimal ability to plan, delegate, communicate, and listen. The prevailingphilosophy is to do more with less. Such an approach to health care managementhas resulted in downsizing, cross-training, and reduction of middle managementstaff.

Theprimary cost-containment measure in health care delivery has been the proliferationof managed care systems.

Ongoingdebate over the effect of cost containment on quality of care continues. TheSurvey of Physicians and Nurses, a survey of 1,053 physicians and 768 nurses,was conducted by the Kaiser Family Foundation and the Harvard School of PublicHealth in 1999. The nurses in this survey (Kaiser Family Foundation, 1999)stated that managed care has led to the following:

Decreased the amount of time they spendwith clients

Decreased clients’ ability to see medicalspecialists

Decreased the quality of care forindividuals who are ill

Increased the likelihood that clientswould receive preventive services


Qualitymanagement has its own array of terminology.

Despitethe similarities, there are differences in the concepts, as outlined below:

Quality assurance (QA) is the traditional approach to quality management in whichmonitoring and evaluation focus on individual performance, deviation fromstandards, and problem solving.

Continuous quality improvement (CQI) is the approach to quality management in which scientific,data-driven approaches are used to study work processes that lead to long-termsystem improvements.

Thisconcept has evolved into systems such as process improvement or performanceimprovement.

Total quality management (TQM) is the method of management and system operation used to achieveCQI. TQM promotes an organization culture that supports customer need, empowersemployees to work as teams, emphasizes self-development, and requires a newleadership style in which employees are viewed as resources.

TQMis a system of operation, whereas CQI is the desired outcome of a qualitymanagement program. It is difficult to achieve performance improvement withouta TQM culture. The goal of a quality management program is to focus on processimprovement, which will ultimately improve the quality of care.


BecauseCQI examines ways in which the entire organization can improve, the involvementof everyone, especially administration is required. CQI is based on thefollowing principles:

1.Quality is a central theme to theorganization. It is part of the organization’s mission and the core of dailyactivities.

2.Leadership is committed to an involved increating an organizational culture (commonly held beliefs, values,norms, and expectations that drive the work force) for process improvement.

3.All staff members are personallyresponsible for quality; therefore, decision making is done by the people doingthe work.

4.Education and training must be continualto improve skills and promote self-development.

5.Processes and system operation, inaddition to individual performance, are monitored.

6.Work processes that influence outcome arestudied and improved, rather than relying solely on problem solving.

7. A scientific approachbased on analysis of data is used.

8.Good information is available and must beused in decision making. Individuals and institutions can no longer use opinionand intuition; they must manage by facts.


Promotingcustomer satisfaction requires an organizational commitment from top to bottomwith every employee, especially direct care workers, being sensitive to the needs,wants and expectations of customers. This commitment requires putting thecustomer first.

Customersinclude those internal and external to the organization, such as clients,suppliers, third-party payers, families, visitors, employees, and the community.

Managersmust meet employee needs and service delivery demands. The direct care providermust meet client needs, coworker’s needs, and organizational needs.

Organizationsrely on customer relations programs to develop strategies to keep their customerssatisfied. A program of customer relations can be costly to operate. Itinvolves staff education, cost of survey materials, public relationsrepresentation, administrative time for evaluation and follow-up, and expensesfor corrective action.

Correctiveaction may involve equipment, staffing, education, structural renovations, ornew procedures. Focusing on the customer can be both time consuming andstressful because it may require change, which may evoke resistance in bothemployees and managers.

Thereality is that health care agencies do not have unlimited resources allocatedsolely to keeping customers happy. Therefore, the organization and eachemployee must understand the implications of customer dissatisfaction from afinancial perspective. The loss of one admission is relatively insignificant toa multimillion dollar budget; however, multiple losses can have a substantialeffect on a health care facility’s financial well-being.

Thereis additional potential revenue loss from related ancillary services followinghospitalization, such as home health care, laboratory procedures,pharmaceutical supplies, and office follow-up. A customer’s dissatisfactionwith one facet of service can be generalized to all related delivery systems.

Andersonand Zemke (1998) have identified the 10 leadingcauses of customer dissatisfaction. As you read the accompanying display, thinkof how these factors can adversely affect a client’s satisfaction with healthcare services.

Anothereffect of customer dissatisfaction is a tarnished community image. There is amultiplier effect in which one bad encounter can affect the attitude andopinion of many. An unhappy client may inform the immediate family, extendedfamily, neighbors, friends, and coworkers. Seemingly simple acts, such as thoselisted below, can result in client dissatisfaction despite a positive healthoutcome:

A cold food tray

Failure to respond to a call light

Waiting for tests

Late treatment

Unemptied bedpan

Delayed pain medication

Healthcare organizations must have a strong dispute resolution program to mediatecustomer complaints. In addition, strong efforts must be made to solicitcustomer feedback about services. Satisfaction is a subjective perception;therefore, health care providers must listen to the customer constantly todetermine satisfaction and dissatisfaction. Then, improvements can beinitiated.


Becausequality has become a central issue in health care delivery, nurses mustconsider the impact of organizational structure on the quality of careprovided.

Nursesare key in establishing a culture for excellence inmost health care organizations.

Severalfactors within an organization affect quality management: organizationalculture, work force diversity, empowerment, leadership, and teamwork. Toimprove the quality of care, the organization should be viewed as a system thatis comprised of governance, management, clinical, and support devices. Manyprocesses within the system involve more than one group. Therefore, a frameworkmust be established to promote collaboration.


Organizationshave both formal and informal cultures.

Incongruencebetween the formal operational style espoused by management in meetings and documentsand the style demonstrated and felt by staff members may be evident. This canresult in an ineffectual organization in which achieving continual improvementis difficult.

Thus,the culture of an organization can affect the quality of care. A positiveculture promotes trust, information sharing, collaboration, and risk taking,whereas a negative culture produces divisiveness, resistance, and a desire tomaintain the status quo. In a negative culture, inertia develops and there is alack of creativity and self-direction by employees. Table 25-2 comparescharacteristics of organizational culture within traditional andhigh-performance organizations.

Work ForceDiversity

Healthcare will be delivered by a more diverse work force throughout the 21st century.The organization, managers, and workers must be able to maximize diversity.

Tomorrow’swork force and population will consist of more women, older Americans, peopleof color, and collegeeducated individuals. Despiteincreases in these groups, the overall available work force will decrease dueto declining population growth. Employees can become more selective in jobplacement and seek new employment opportunities if dissatisfied. Employeesdesire self-actualization; therefore, job satisfaction will become imperative.

Theslower growth in the work force will result in fewer applicants and a shortageof technical and professional staff. Rapid advances in technology will increasecomplexity of jobs and lead to increased competition for skilled workers. Aflatter organizational structure, in which middle management is reduced, willrequire increased interaction and ability to work together.

Groupsmust enhance ways of communicating to be more productive.

Thischange in the work force will affect methods of delivery; therefore, theorganization must be able to maximize the potential of each employee. Toachieve a work environment that capitalizes on diversity, the organization mustimplement a program that addresses individual, group, and organizationalbiases. Education must be provided to eliminate stereotyping. Such educationalprograms are aimed at:

Identifying individual beliefs and values

Discussing assumptions and biases based ongender, race, age, and religion

Explaining cultural differences

Identifying legal responsibilities

Valuing differences of specific groups.

Managementpractices must build an organizational climate that values each individual’scontribution to group achievement, and the organization must develop policiesto promote and support cultural needs and differences.

Theseactions are essential in reducing the costs of employee turnover and litigationfrom discrimination and sexual harassment suits. The outcome of suchefforts can be an increase in retention, productivity, market share,creativity, flexibility, and optimism of staff while effectinga decrease in complaints, grievances, litigation, and cost. Specific advantagesof having a culturally diverse work force in nursing are shown in theaccompanying display. Health care providers must consider transculturalprinciples and human rights in managing the work force and delivering qualitycare.


Fororganizations to operate successfully and instill the drive for excellence ineach employee, the staff must be empowered to take ownership of their jobs. Empowermentis the process of enabling others to dofor themselves. Employees need responsibility andauthority to solve problems and take action in their work group. Empowermentrecognizes the uniqueness of employees and conveys a message of value. As aresult of empowerment within a work group, an environment is created in whichthe collective creativity is more diverse than the ideas and knowledge of asingle individual.

Tosurvive in today’s health care environment, all providers must work together toaccomplish the organization’s mission, vision, and goals to achieve aphilosophy of continual improvement. Restructuring health care deliveryrequires each individual to improve work processes. Work redesign, downsizing,consortiums, managed care, and cross-functional task sharing are but a few ofthe many efforts underway to reorganize health care in order to reduce waste,duplication of work, and cost. All health care providers must be involved inthe process of change to minimize fear, reduce resistance, promoteaccountability, add credibility, and produce lasting results. To accomplishchange, health care organizations need to maximize employees’ capabilities andmotivate them toward continual improvement.


Leadershipis the interpersonal process that involvesmotivating and guiding others to achieve goals. Leaders in a health careorganization include the governing body, chief executive officer, seniormanagers, leaders of the medical staff, department heads, nurse executives, andsenior nursing leaders.

Effectiveleadership works across departmental lines to address multidisciplinary workfunctions and processes.

Traditionally,territorial issues (the so-called turf battles) have produced divisiveness andcompetition among departments and disciplines. The tools for combating suchdivisiveness and building effective work groups are collaboration andfacilitation.

Organizationalleadership contributes to the creation of the culture based on CQI beliefs andpractice. Leadership must create a people-oriented culture. In today’sfast-paced, high-tech, cost-driven health care environment, the human factor isfrequently overlooked. Although staffing incurs the greatest expense and is aprimary target for cost reduction, it is the people in the health careorganization who are the greatest asset, and management must focus on ensuringa return on this important resource.

Empoweringemployees, valuing diversity, creating organizational change, and promotingprocess improvement requires a new style of leadership that shifts from highmanager/low employee participation. The manager becomes a coach instead of asupervisor. In this role, the manager facilitates collaboration and advocacy,serves as a consultant, and provides support.


Humanresource management has become an essential function of health care managers.Authoritarian, hierarchical, and traditional ways of management are no longereffective; therefore, health care organizations are turning to team-basedstrategies for organizing labor. Improving quality requires team effort.

Ateam is a group of individuals who work together to achieve a commongoal. The dynamics of team interaction are important. Teams must demonstrate commitment,cooperation, and communication. The way the team communicates and solvesproblems has a significant impact on outcome and delivery of service. Forquality care to occur, work groups must function as teams.

Forquality improvement, teams are used to study processes. There are two types ofprocess improvement teams: functional and cross-functional. A functionalteam is a departmental or unit-specific group whose scope is limited todepartmental or work area processes. A crossfunctionalteam is an interdepartmental, multidisciplinary group that is assigned tostudy an organization-wide process (Figure 25-1). An effective teamdemonstrates mutual respect and trust, displays open communication, builds onskills of members, and seeks consensus.

Theuse of teams to restructure and improve work processes has many advantages,such as:

Increased involvement and understanding

More opportunities to share ideas

Assistance in building relationships

Involvement of staff in problem solving

Theteam approach is effective for coordinating and integrating interdepartmentalwork processes.


Foryears, the focus of health care quality has been on performance improvement. Itwas eventually recognized that no individual’s performance really stands alone.Each person’s action in an organization is actually a performance step that isconnected to the action of others. This series of interconnected steps is knownas a process; processes interconnect to form a system.


Qualityimprovement focuses on processes or systems within organizations thatsignificantly contribute to outcome. This requires refocusing from solelydepartmental issues to crossdepartmental lines. Priorto a process improvement philosophy, quality improvement efforts were performedwithin departments. However, processes operate between departments and requiremultidisciplinary involvement.

Tocontinually improve, an organization must realize that it is a system ofinterdependent parts all with the same mission of meeting the needs andexpectations of customers. Understanding interdepartmental processes is crucialto quality improvement.

Inprocess improvement, the emphasis is on system variation, not performance ofindividuals. Process improvement does not just address problem solving; it alsopromotes ongoing improvement of stable processes and correct establishment ofnew systems. Process improvement is intended to reduce variability, improveefficiency, and reduce complexity in systems.

Processimprovement efforts must be directed at analyzing systems that have significantimpact on the organization of care delivery. Important aspects of care involveactivities or processes that are:

High volume: occurfrequently or affect large numbers of clients

High risk: placeclients at risk of serious consequences if not provided or provided incorrectly

Problem prone: tend to produce problems for clients or staff (JCAHO, 1998)

Organizationsmust effectively use resources by focusing on high-priority systems that affectclient outcome.


Typically,problem solutions are generated without timely analysis. A “ready, fire, aim”approach to process analysis is frequently used, in which action is takenwithout first thoroughly evaluating the problem. To counter this haphazardmethod, a scientific approach to performance improvement must be undertaken. Inthe scientific approach, data are used to measure process.

Suchan approach results in the following:

Minimal use of intuition and opinion

More accurate and effective problemidentification

Increased understanding of root causes ofvariation

Improved evaluation of alternativesolutions

Ability to statistically measureimprovement

Thescientific approach to improving quality performance consists of the followingsteps:

1.Identify an important process to evaluate.

2.Measure the current process.

3.Assess variations.

4.Formulate improvements.

5.Implement change in the process.


Avariety of tools are used to collect and analyze data so that decisions can bemade about organizational performance.

Theaccompanying display describes mechanisms frequently used to obtain and measuredata.

Inaddition to measuring processes, data can also be used in benchmarking (aprocess that evaluates products, services, and priorities against theperformance of others). Comparative data can be obtained from the literature,practice guidelines, and an increasing number of external reference databases.


Theprimary purpose of nursing is to provide quality care to clients. To do someans always seeking to improve the care delivered. Nurses function asclinicians, team members, and managers. Each role has specific responsibilitiesfor quality performance and requires certain skills to achieve the expectedlevel of performance (Table 25-3).

Thereare several characteristics of quality nursing care, including the following:

Maintenance of a current knowledge baseand competencies

Interpersonal skills (with clients andcoworkers)

Caring and compassion

Mutual decision making with client andnurse

Individualized treatment

Whetherfunctioning as a clinician, team member, or manager, nurses continually strive forexcellence in everything they do. By using a CQI approach, which examinesstructure and process instead of individual performance, nurses can moveforward in the provision of quality care. Quality improvement identifiessituations when nursing teams are more productive and functioning at a higherquality level.


The nine dimensions of quality performanceas identified by JCAHO are efficacy, appropriateness, availability, timeliness,effectiveness, continuity, safety, efficiency, and respect and caring.

The quality movement was initiated byconsumer demands, financial viability, professional accountability, regulatoryrequirements, progress made in quality improvement techniques, and changes inhealth care delivery.

Case law and federal regulations establishguidelines for quality management.

Health care professionals adhere toethical codes of practice that espouse a responsibility to self, profession,client, and society.

Continuous quality improvement focuses onstudying work processes that promote system improvements.

Total quality management is a method oforganizational operation that establishes a work environment to achievecontinuous improvement.

A customer is anyone who uses theproducts, services, or processes within an organization. Clients, families,visitors, employees, suppliers, and the community are all considered customerswithin the health care system.

Customer dissatisfaction can havesignificant financial implications for health care organizations.

Quality management requires positiveorganizational culture, work force diversity, empowerment, leadership, andteamwork.

A variety of tools, such as audits, peerreviews, and benchmarking are available through which data about variations inprocess improvement can be collected and analyzed.

The nurse is responsible for qualityimprovement as a clinician, team member, and manager.

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