NURSING AUDIT

Lt Col Jyoti P Shewale

NURSING AUDIT

• Nursing audit is a way of ensuring quality nursingcare.Nursing audit is a detailed review and evaluationof selected clinical records by qualifiedprofessional personnel to identify, examine, orverify the performance of certain specified aspectsof nursing care by using established criteria.“Quality nursing care” has become essential onday to day functioning.With the implementation of CPA professionalaccountability to an enlightened public can nolonger be ignored by nursing staff

HISTORY OF NURSING AUDIT• Whilst Codmans clinical approach is in contrast withNightingales

‘epidemiological audits, both methods serve tohighlight the different methodologies that can be used in theprocess of providing quality patient care.Another famous figure who advocated clinical auditwas Ernest Codman (1869–1940) by monitoring surgicaloutcomes .Florences gift of statistic kept meticulous records of themortality rates among the hospital patients.She and her team of 38 nurses applied strict sanitaryroutines and standards of hygiene to the hospital andequipment,On arrival at the medical barracks hospital in Scutari in1854, Florence was pained by the unsanitary conditions andhigh mortality rates among injured or ill soldiers.One of first ever clinical audits was undertaken by FlorenceNightingale during the Crimean war of 1853-1855

• The program is reviewed from record nursing plan,nurses notes, patient condition, nursing care.For the next 15 years, nursing audit is reported fromstudy or record on the last decade.First report of Nursing audit of the hospitalpublished in 1955.Before 1955 very little was known about the conceptof nursing audit.

PURPOSES OF NURSING AUDIT1

• 1.Evaluating Nursing care given,2. Achieves deserved and feasiblequality of nursing care,3. Stimulant to better records,4. Focuses on care provided andnot on care provider,5. Contributes to research.

• TYPES OF NURSING AUDIT NURSING AUDITINTERNAL EXTERNAL

TYPES OF NURSING AUDIT1• Internal auditing:Internal auditing is a control technique

performedby an external auditor who is an employee of theorganization. He makes an independent appraisalthe policies, plans and points the deficits in thepolicies or plans and give suggestion for eliminatingdeficits2) external auditing:it is an independent appraisal of the organizationsfinancial account and statements. The externalauditor is a qualifed person who has to certify theannual pprofit and loss account and prepare abalance street after carefull examination of therelevant books of accounts and documents

INTERNAL AUDIT• RETROSPECTIVE EVALUATION

• : Retrospective audit is amethod for evaluating the quality of nursing care by examiningthe nursing care as it is reflected in the patient care records fordischarged patients.• In this type of audit specific behaviors are described then theyare converted into questions and the examiner looks for answersin the record.For example the examiner looks through the patients recordsand asks :a. Was the problem solving process used in planning nursing care?b. Whether patient data collected in a systematic manner?c. Was a description of patients pre-hospital routines included?d. Laboratory test results used in planning care?e. Did the nurse perform physical assessment?f. How was information used?g. Were nursing diagnosis stated?h. Did nurse write nursing orders? And so on.

• 9. Reviewing the patients record and care plan.III. PEER REVIEW : In nurse peer review nurses functioning inthe same capacity that is peer’s appraise the quality of care orpractice performed by others equally qualified nurses.•The peer review is based on pre-established standards orcriteria.There are two types of peer reviews:a) individual peer review; focuses on the performance of anindividual nurse.b) nursing audit; focuses on evaluating nursing care through thereview of records.Interviewing the staff responsible for this care .It includes assessing the patient at the bedside in relation topre-determined criteria,The evaluations conducted on behalf of patients who are stillundergoing care.II. CONCURRENT AUDIT : It is performed during ongoingnursing care.

• Outcomes traditionally used to measure quality of hospitalcare include mortality, its morbidity, and length of hospital stay.These audits assume the outcome accurately anddemonstrate the quality of care that was provided.Outcome audits determine what results if any occurred asresult of specific nursing intervention for clients.The changes in the patients health status and can beattributed to delivery of health care services.Outcomes are the end results of care;QUALITY AUDIT1. OUTCOME AUDIT:

• These above audits can occur retrospectively, concurrently andprospectively.This audit assumes that a relationship exists between qualitycare and appropriate structure.Such as the finances, nursing service, medical records andenvironment.Structure audit monitors the structure or setting in which patientcare is provided.These audits assumed that a relationship exists between thequality of the nurse and quality of care provided.3. STRUCTURE AUDIT:Process audit is task oriented and focus on whether or notpractice standards are being fulfilled.Process audits are used to measure the process of care or howthe care was carried out.2. PROCESS AUDIT:

AUDIT CYCLEAUDIT IS A CYCLIC PROCESS

• PRE-REQUISITE FOR NURSING AUDIT CLINICAL AUDITCLINICAL AUDIT PLANNING COMMITTEE MEDICAL CARE RE ORIENTATION OF AUDITORS

• 14. If there are large number of records to be audited,then an auditor may select 10 per cent of discharges. If there are less than 50 discharges per month, thenall the records may be audited,That the auditor should have the ability to carry outan audit in about 15 minutes.It is recommended that each member should reviewnot more than 10 patients each month. who are interested in quality assurance, areclinically competent and able to work together in agroup.Before carrying out an audit, an audit committeeshould be formed, comprising of a minimum of fivemembersAUDIT COMITTEE

• 15. RE ORIENTATION OF AUDITORSa. A detailed discussion of the seven components ofcriteria.b. A group discussion to see how the group rates thecare received using the notes of a patient who hasbeen discharged,c. These should be anonymous and should reflect atotal period of care not exceeding two weeks inlengthd. Each individual auditor should then undertake thesame exercise as above.e. This is followed by a meeting of the wholecommittee who compare and discuss its findings, andfinally reach a consensus of opinion on each of thecomponents.

• Has information from physical assessment etc.b. State nurses diagnosis,c. Writes nursing orders,d. Suggests immediate and long term care,e. Implements the nursing care plan,f. Plans health teaching for patients and students,g. Evaluates the plan of care at own level, has information regarding vital signs, has information regarding lab tests, has information about the severity of illness,. includes description of patients pre-hospitalroutines,PLANNING MEDICAL CAREa. Collects patient data in a systematic manner,

• SIX STAGES OF NURSING AUDIT STAGE –I PREPARING FOR AUDIT STAGE –II SELECTING CRITERIA USING METHODS STAGE –III CREATING MEASURING PERFORMANCE ENVIRONMENT STAGE –IV MAKING IMPROVEMENT STAGE –V SUSTAINING IMPROVEMENT STAGE-VI RE AUDIT

• SELECTING A TOPIC-starting point-careful thought and planning- There seems little point in trying to audita rare condition, with an insignificantoutcome

• Re-auditAll activities should be documented.Report for ActionPilot studyMethodology to be followedAccess the evidence/data Fix time and Plan resourcesInvolve ALL the people concern.PLANNING AUDIT

• DEVELOPING CRITERIA1. Define patient population.2. Identify a time framework for measuring outcomes of care,3.Identify commonly recurring nursing problems presented by the definedpatient population,4. State patient outcome criteria,5. State acceptable degree of goal achievement,6. Specify the source of information.7. Design and type of toolPoints to be remembered:a. Quality assurance must be a priority,b. Those responsible must implement a programme not only a tool,c. A coordinator should develop and evaluate quality assuranceactivities,d. Roles and responsibilities must be delivered,e. Nurses must be informed about the process and the results of theprogramme,f. Data must be reliable,g. Adequate orientation of data collection is essential,h. Quality data should be annualized and used by nursing

• MEASURING LEVEL OF PERFORMANCE•The data collected are to be precise•Essential data•Completed data•Adequate data•User group to be includedExample:Immunisation status of pregnant women•Do not try and collect too many items, keep it simple andshort.•Computer stored data, Case notes/Medical Records,Surveys , Questionnaires, Interviews Focus Groups,•Prospective recording of specific data- How will this be done to get required information-Compare performance against the criteria-Keep focused on the objective of the audit

• MAKING IMPROVEMENTSIDENTIFYING BARRIERS TO CHANGE:- Fear- Lack of understanding- Low morale- Poor communication- Individual Culture- Doubt of outcome-Consensus not gainedSYSTEMATIC APPROACH:•identification of local barriers to change•change culture•support of teamwork•use of a variety of specific methods like delegation andaccountability

• SUSTAINING IMPROVEMENTMONITORING AND EVALUATION:systematic approach to changing professional practiceshould include plans to:•monitor and evaluate the change•maintain and reinforce the changeREINFORCING IMPROVEMENT:•reinforcing or motivating factors by the management .•integration of audit•strong leadership6. RE-AUDIT:-Review evidence-Measure effectiveness-Decide how often to re-audit- Ongoing process monitoring-Adverse incidents-Significant events audit