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Quality Assurance and Quality Improvement

According to the Health Resources and Services Administration (HRSA), quality assurance (QA) measures compliance against certain necessary standards, typically focusing on individuals, whereas quality improvement (QI) is a continuous improvement process focused on processes and systems. QA tends to be defensive with a focus on providers. QI is proactive and preventive in nature, focusing on patient care.

The World Health Organization (WHO) notes that evaluation and monitoring are important aspects of all forms of health care provision,108 and the care of patients who have been victims of sexual violence is included. 

QA and QI can take place at many levels and, depending on what is being evaluated, should involve the SANEs, and may involve other members of the multidisciplinary team or community. The SANE medical director plays a role in the process based on their expertise with medical and forensic issues. It is important to be clear about what type of information will be evaluated and who will have access to the results. Information that could identify a specific patient should not be shared unless proper consent from the patient has been obtained. 

SANE programs should outline their definition of quality, as quality can differ from organization to organization, and they should involve stakeholders as well as staff. SANE program stakeholders include the patient, provider, employer, members of the multidisciplinary team, and even payers. Some hospitals and clinics may have programs in place to evaluate patient satisfaction.109 One example of this type of quality measure is the Press-Ganey customer satisfaction survey. For this survey, patients receive a questionnaire following their hospital, outpatient, or emergency care visit that evaluates their perception of that care. While these surveys are helpful for looking at patient satisfaction for routine hospital or clinic care, it is important for SANE programs to ensure contact by surveyors does not disclose to someone other than the sexual assault patient the fact that the patient sought care for a medical forensic examination. Sexual assault patients should be given the option to decline participation in the survey. If they agree to participate, they should be offered a method of contact, such as a personal cell phone, that guarantees their confidentiality. Many SANE programs opt out of automated surveys such as the Press-Ganey entirely, and give other types of evaluation tools to the patient at discharge and provide a pre-addressed and stamped envelope for the patient to return the evaluation and avoid any privacy violations.

Most health care systems moved away from the traditional QA approach to one of QI in an effort to avoid assigning blame and focus on ways to prevent the error or variation from standard from occurring in the first place. 

The National Committee on Quality Assurance recommends the following simplified formula:

  1. Measure
  2. Analyze
  3. Improve
  4. Repeat

If QI is performed internally, and meets both state and federal requirements, the results may be kept confidential and cannot be discovered in most legal situations. If a QA process includes team members who are not part of the health care team, results may not be protected from legal discovery. It is essential to have input from the hospital's legal counsel and risk management to make sure you know whether your process is protected. 

While internal evaluation of nursing practice provides one type of information, it may also be beneficial to have a process where other team members have input about the performance of a nurse. In many settings, the only person who directly observes how the nurse interacts with the patient may be the rape crisis or victim advocate. They may be able to provide valuable feedback about whether a nurse is patient-centered when providing care.