STANDARDS AND NURSING AUDIT: A TOOL FOR QUALITY MANAGEMENT” EXPERT: ROHINI SHARMA

Slide 2: The discipline of Nursing is an art and science committed to professional excellence by
providing highest quality care possible . Quality of care is determined by identifying the observable
characteristics that depict desired and valued degree of excellence and the expected, observable
variations.

Slide 3: The quality of nursing care can be managed both by evaluating the degree of excellence of
results of delivered care and by taking action for the improvements that in future will result in high
degree of care. The standards maintained and the nursing audit conducted hence, become the
important tools for the quality management.

WHAT ARE STANDARDS? : WHAT ARE STANDARDS? Standard is a quantitative or qualitative measure
against which someone or something is judged, compared or used to service as an example.
Standards are professionally agreed levels of performance, which are achievable, and measurable.

Slide 5: The Oxford dictionary provides several key concepts for the definition of standards. First, it
notes that standards represent a degree of excellence. Second, it suggests that standards serve as a
basis of comparison. Third, it notes that standards are minimum with which a community may be
reasonably content. Finally, a standard is recognized as a model for imitation.

IMPORTANCE OF STANDARD : IMPORTANCE OF STANDARD A standard is a practice that enjoys

general recognition and conformity among professionals or an authoritative statement by which the
quality of practice, service or education can be judged. One of the determinants of profession is that
the members of the profession adopt standards of practice of their calling, establish criterion by
which conformance to the standards will be measured and have the primary responsibility for seeing
that the standards are enforced. A nursing care standard is a descriptive statement of desired quality
against which is evaluate nursing care. It is a guideline, a path to safe conduct and an aid to
professional performance.

Slide 7: PURPOSE OF STANDARDS To evaluate the quality of nursing practice in any setting. To
compare and improve the existing nursing practice. To provide a common base for practitioners to
coordinate and unify their efforts in the improvement or practice. To identify the element of
independent function of nursing practices. To provide a basis for planning and evaluating
educational program for practitioners. To inform society of our concern for the improvement of
nursing practice. To assist the public in understanding what to expect of nursing practice. To assist
employers to understand what to expect of Practitioners. To identify areas for developing core
curriculum for practicing nurses. To provide legal protection for nurses.

Slide 8: CHARACTERISTICS OF STANDARDS Objective, acceptable, achievable and flexible. Must be

framed by the members of the nursing profession. Should be phrased in positive terms like good,
excellent, etc. Must be understandable and unambiguous. Must be based on current knowledge and
scientific practice. Must be reviewed and revised periodically.

Slide 9: SOURCE OF NURSING CARE STANDARDS Standards can be developed, established, reviewed
or enforced by: Professional organization like TNAI. Licensing body e.g. INC, statutory bodies.
Institutions/Health care agencies. Department of institutions e.g. Nursing Department. Patient care
unit e.g. Medical ICU. Government units at national, state and local government units. Individual e.g.
personal standards.

Slide 10: LEVELS OF STANDARD: MINIMUM VS OPTIMUM Minimum standards are generally
thought to represent a level of acceptability below which they eyes on those judging, lies the
unacceptable. The desirable or optimal standards, represent a degree of excellence. For example, in
a hospital the minimum standard for nosocomial infection may be 7-10 per cent. Anything above 10
per cent is unacceptable whereas the desired is 3 per cent.

TYPES OF STANDARDS : TYPES OF STANDARDS Normative standards: These standards are descriptive
of practices, which are considered ideal by authority. These standards describe highest quality of
practices. For example, standards set by professional bodies, standards for the recruitment of nurses
working in any setting. Empirical Standards: These standards are description of practices which are
actual practice in large number of settings and which are agreed upon and achievable. For example,
standards set by law enforcement bodies and regulatory bodies. End standards: These are patient
oriented; they describe the change as desired in a patient’s physical status or behavior. Means
Standards: These are nursing oriented; they describe the activities and behavior to achieve ends
standards.

Slide 12: FRAMES OF REFERENCE FOR STANDARDS Structure Standards: These are institution
oriented and related to care providing system and resources that support for actual provision of
care. They include the following: Physical facilities, building, etc. Policies, goals and objectives.
Staffing members: training, qualification, job responsibilities. Equipment and supplies.
Administrative setup and channel of communication. Recording system. Budgeting. Structure
standards already exist, though not proved ideal scientifically.
Slide 13: Process Standards: These are nursing oriented and referred to the behavior and actions
which a nurse should carryout. Here focus is on nursing standards technique and procedures e.g.
planning, implementation, nurses interaction, client’s participation, communication and recording.
Process standards help in assessing the degree of skills with which the techniques are performed,
the degree of client involvement, and interaction between nurse and client. Thus, it implies
professional judgment in determining quality of nursing care/skills. Nurse prepares appropriate
written nursing care plan for the patient, which includes identification of: Personal needs, disease
related needs and therapy needs. Nursing actions: Assessment , Diagnosis , Outcome identification
etc. Resources. Implementation of actions. Evaluation of the results or effectiveness of nursing
actions taken. Professional Performance: Performance appraisal , Education , Ethics, Research .

Slide 14: Outcome Standards: These are patient centered or client centered. These are the
description statement of result of care for the patient and can be both qualitative and quantitative.
Outcome standards are related to patient’s health status, such as: Self-care or disability. Morbidity
or mortality status. Non-occurrence of complication and restoration of body functions, etc. The
results of outcome standards may be positive or negative. If one discovers that outcomes are not
according to the expectation, then one needs to scrutinize the structure and process standards e.g.
patients developing infections postoperatively, explore the causes and take remedial actions
accordingly.

Slide 15: STEPS OF STANDARD FORMULATION Organize into small groups of nurses who work in the
same field and meet periodically. Decide on the area of nursing practice for which you want to work
out standards. Review philosophy, purposes and objectives of institution. Review existing nursing
care practices, nursing process and identify your client for nursing service, client’s role and strategies
for nursing care services. Write the statements considering all the frame of reference giving
rationale and criteria i.e. assessment indicators see that standards are relevant. Discuss them with
nursing service administrators to get their approval. Devise a method for determining achievement
of standards. It may be through the use of criteria checklist for – making observation of care given;
examining records; self evaluation checklist; patients’ opinion, etc. Determine validity by giving to
the experts. Try out the standards to determine the feasibility. The standards are put into practice
and quality care is audited. Updating of standards periodically with continuous renewal.

Slide 16: LEVELS OF STANDARD SETTING There are four levels of standard setting: National and state
level, Community level , Institution level, Department level. HOW ARE STANDARDS USED? Mainly in
health care settings, standards are used in: Self-assessment: It is the evaluation of one’s own
performance. Standards may be set by oneself or in collaboration with an outside agent and
evaluate how well the standards are met. Inspection: It usually implies some sort of official
examination. Those inspecting most often have a conferred power to do so. Accreditation: It is a
process where in standards would depend on whether they are used in an ongoing process. Set
standards should be observable, attainable and measurable. They are to be compared to actual
practices. Identify the strength and weaknesses, take actions to correct deficiencies, review the
effectiveness of those actions through an audit protocol derived from the standard.

Slide 17: CONCLUSION The success of standard would depend on whether they are used in an
ongoing process. Set standards should be observable, attainable and measurable. They are to be
compared to actual practices. Identify the strengths and weaknesses, take actions to correct
deficiencies, review the effectiveness of those actions through an audit protocol derived from the
standard.

NURSING AUDIT : NURSING AUDIT Nursing services are necessary for virtually every client seeking
care of any type, including health promotion, diagnosis and treatment. With the changing trends in
the health care delivery, the role of the nurse manager is becoming critical to effective, quality
patient care. Nursing can no longer ignore the world trend of professional accountability to an
enlightened public. We as nurses, when we talk about “quality nursing”, need to know our
deficiencies and admit them to our peers. Remedial steps needs to be taken only by such self-
regulation we can retain our identity with the health professional as true partners.

Slide 19: Audit: A systematic and critical examination to examine or verify. According to Elison
“Nursing audit refers to assessment of the quality of clinical nursing”. According to Goster Walfer:
Nursing audit is an exercise to find out whether good nursing practices are followed. The audit is a
means by which nurses themselves can define standards from their point of view and describe the
actual practice of nursing. Nursing audit is defined as the evaluation of nursing care in retrospect
through analysis of nursing records. It is a systemic format and written appraisal by nurses of the
quality of content and the process of nursing service from the nursing records of the discharged
patient.

Slide 20: BRIEF HISTORY OF AUDIT Nursing audit is an evaluation of nursing service. Before 1955,
very little was known about the concept. It was introduced by the industrial concern and the year
1918 was the beginning. George Grower, pronounced the term physician for the first time medical
audit. Ten years later Thomas R. Pondon M.D. established a method of medical audit based on
procedures used by financial account. He evaluated the medical care by reviewing the medical
records. First report of nursing audit of the hospital was published in 1955. for the next 15 years,
nursing plan, nurses role, and patient condition and nursing care. Audit is reports from study or
records on the last decade. The program is reviewed from record nursing.

PURPOSES OF NURSING AUDIT : PURPOSES OF NURSING AUDIT Evaluation: Evaluating the nursing
care given. Achieve deserved and feasible quality of nursing care. Verification: Stimulant to better
records. Focuses on care provided and not on care provider. Contributes to research. Review of
professional work or in other words the quality of nursing care i.e. we try to see how far the nurses
have confirmed to the norms and standards of nursing practice while taking care of patients. It
encourages followers to be actively involved in the quality control process and better records. It
clearly communicates standards of care to subordinates. Facilitates more efficient use of health
resources. Helps in designing response orientation and in-service education programme.

Slide 22: METHODS OF NURSING AUDIT There are two methods: Retrospective View: This refers to
an in-depth assessment of quality after the patient has been discharged, and uses the patient’s chart
as the source of data. Concurrent Review: This refers to the evaluations conducted on behalf of
patients who are still undergoing care. It includes assessment the patient at bedside in relation to
pre-determined criteria, interviewing the staff responsible for his care and reviewing the patient
record and care plan. ESSENTIAL CHARACTERISTICS OF NURSING AUDIT: There should be: Written
standards of care against which to evaluate nursing care. Evidence that actual practice was
measured against such standards, sharing a percent conformance rate. Examination & analysis of
findings. Evidence of corrective action being taken. Evidence of effectiveness of corrective action.
Appropriate reporting of the audit programme.

PROCESS OF NURSING AUDIT: : PROCESS OF NURSING AUDIT: A. Set the key criteria (item): It should
be measurable against identified values, set standard & in terms of desired patient outcome.
Methods to develop criteria are: Define patient population. Identify a time framework for measuring
outcomes of care. Identify commonly recurring problems presented by the defined patient
population. State patient outcome criteria. State acceptable degree of goal achievement. Specify the
source of information. B. Prepare Audit Protocol keeping in mind Audit Objectives, Target groups,
Method of information gathering (by asking, observing, checking records), Criterion you are
measuring, identify the time framework for measuring outcome of care, identify commonly
recurring nursing problems, State acceptable of goal achievement.

Slide 24: C. Design the type of tool: Quality assurance must be a priority. Those responsible must
implement a program not only a tool. A co-coordinator should develop and evaluate quality
assurance activities. Roles and responsibilities must be delivered. Nurses must be informed about
the process and the results of the program. Data must be reliable. Adequate orientation of data
collection is essential. Quality data should be analyzed and used by nursing personnel at all levels. D.
Plan and implement the tool: What is to be evaluated? Who is going to collect the information? How
many sample in the target group? Time period? E. Recording/Analysis, Concluding: Record the
information, Analyze the information, Make a summary, Compare with set standard, Conclusion. F.
Using results : The results aid to modify nursing care plans & the nursing care process, including
discharge planning, for selected patient outcome, implementing a program for improving
documentation of nursing care through improved charting policies, methodologies & forms, focusing
of nursing rounds & team conferences. Focusing supervisory attention upon areas of weakness
identified, such as one particular nursing unit or specific employees. Designing responsive
orientation & in-service education programs. Gaining administrative support for making changes in
resources, including personnel.

Slide 25: ADVANTAGES OF NURSING AUDIT Can be used as a method of measurement in all areas of
nursing. Seven functions are easily understood. Scoring system is fairly simple. Results easily
understood. Assesses the work of all those involved in recording care. May be a useful tool as part of
a quality assurance programmed in areas where accurate records of care are kept. Enables the
professional group to highlight the deficiencies and how good they are in giving care. Better planning
can be done. Helps in re-allocation of resources. Administrators are also sure that patients are
getting quality care

Slide 26: DISADVANTAGES Appraises the outcomes of the nursing process, so it is not so useful in
areas where the nursing process has not been implemented. Many of the components overlap
making analysis difficult. It time consuming. Requires a team of trained auditors. Only evaluates
record keeping. It only serves to improve documentation, not nursing care.\ Medical legal
importance. The professionals feel that they will be used in court of law as any document can be
called for in court of law. Deals with a large amount of information.

Slide 27: PREREQUISITES OF NURSING AUDIT Audit Committee: Before carrying out an audit, an
audit committee should be formed which consists of fair and impartial members including senior
nurses as members to do nursing audit. This committee should comprise of minimum five members
who are interested in quality assurance, are clinically competent and able to work together in a
group. It is recommended that each member should review not more than 10 patients each month
and that the auditor should have the ability to carry out an audit in about 15 minutes. It there are
less than 50 discharges per month, all the records may be audited. If there are large numbers of
records to be audited, an auditor may select 10 per cent of discharges. The impetus must come from
the nursing staff themselves, realizing the benefits to the patients and themselves. A good system of
nursing record keeping.

Slide 28: AUDIT AS A TOOL FOR QUALITY CARE The audits most frequently used in quality control
include outcome process and structure audits. Outcome Audit: Outcomes are the end results of
care; the changes in the patient’s health status and can be attributed to the delivery of health care
services. Outcome audits determine what results if any occurred as result of specific nursing
intervention for the clients. Examples of outcomes traditionally used to measure quality of hospital
care include mortality, its morbidity, and length to hospital stay. Process Audit: Process audits are
used to measure the process of care or how the care was carried out. Process audit it task oriented
and focuses on whether or not practice standards are being fulfilled. These audits assume that a
relationship exists between the quality of the nurse and quality of care provided. Structure Audit:
Monitors the structure or setting in which patient care occurs, such as the finances, nursing service,
medical records and environment. This audit assumes that a relationship exists between quality care
and appropriate structure. These above audits can occur retrospectively, concurrently and
prospectively

Slide 29: ROLES AND FUNCTIONS OF NURSE MANAGER FOR EFFECTIVE QUALITY CARE: ROLES
Encourages followers to be actively involved in the quality control process. Clearly communicates
standards of care to subordinates. Encourages the setting of high standards to maximize quality
instead of setting minimum safety standards. Implement quality control proactively instead
reactively. Uses control as a method of detraining why goals were not met. Is positively active in
communicating quality control finding. Acts as a role model for followers in accepting responsibility
and accountability for nursing actions.

Slide 30: FUNCTIONS In conjunctions with other personnel in the organization establishes clear cut,
measurable standards of care and determines the most appropriate method for measuring if those
standards have been met. Selects and uses process, outcome and structure audits appropriately as
quality control tools. Assesses appropriate sources of information in data gathering for quality
control tools. Determines discrepancies between care provided and unit standards and seeks further
information regarding why standards were not met. Uses quality control findings as a measure of
employee performance and rewards, coaches, counsels, or disciplines employees accordingly. Keeps
abreast of current government and licensing regulations that affect quality control.

Slide 31: CONCLUSION In the new era, with the changing concepts in the health care delivery, the
nurse manager role ;is becoming critical to effective qualities patient care. Nursing audit is on one of
the important tools to provide quality-nursing care services to the clients and maintain professional
accountability.