COMMUNITY HEALTH AUDIT

DEFINITION OF AUDIT
Nursing audit is a review of the patient record designed to identify, examine, or verify the performance of certain
specified aspects of nursing care by using established criteria.
Nursing audit is the process of collecting information from nursing reports and other documented evidence about
patient care and assessing the quality of care by the use of quality assurance Programmes.
Sanction
 Authoritative permission or approval that makes a course of action valid or permission.
 Support or encouragement, as from public opinion or established custom.
 A consideration, influence, or principle that dictates an ethical choice.
Auditing for community health services in India
 It is also the evaluation of health services. The general steps are:
 Determine what is to be evaluated
 Establish standards and criteria
 Plan the methodology to be applied
 Gather information
 Analyze the results
 Take action
 Re-evaluate
Importance of auditing For community health service
 Errors are located
 Frauds are discovered
 Advice about weakness
 High moral values
 Efficiency improves
 Dispute is settled
 Planning becomes possible
 Improvement of the internal control For government
 Better performance
 Progress of economy
Auditors External auditors
 It is an independent public accounting firm engaged by the client subject to the audit, to express an opinion of
whether the companies financial statements are free of material misstatement, whether due to fraud or error.
 External auditors are regarded as independent auditors. They are also called as statutory auditors.
Internal auditors
Internal auditors are not considered independent of the company they perform audit procedures for, internal
auditors of publically traded companies are required to report directly to the board of directors or a sub- committee
of the board of directors, or not to management, so to reduce the risk that internal auditors will be pressured to
produce favorable assessments.
Purpose of community health services audits:
 monitor the progress of national health programs.
 modify the deficiency of certain programs. assess the performance of physicians, nurses, and other
paramedical.
 Record auditing: to see the records whether they are properly maintained and updated or not. Financial
auditing.
  Auditing of vaccines preventable diseases and other communicable diseases and non communicable
diseases.
 Audits of stocks and inventory.
Audit process it consist of 6 steps:
Step 1: Identify the problem or issue: This stage involves the selection of a topic or issue to be audited, and is
likely to involve measuring adherence to healthcare processes that have been shown to produce best outcomes for
patients.
Step 2: Define criteria & standards
Decisions regarding the overall purpose of the audit, either as what should happen as a result of the audit, what
question you want the audit to answer .
Criteria are explicit statements that define what is being measured and represent elements of care that can be
measured objectively. The standards define the aspect of care to be measured, based on the best available evidence.
Step 3: Data collection
To ensure that the data collected are precise, and that only essential information is collected, certain details of what
is to be audited must be established from the outset.
Data to be collected may be available in a computerized information system, or in other cases it may be
appropriate to collect data manually or electronically using data capture solutions.
Step 4: Compare performance with criteria and standards
 This is the analysis stage.
 the results of the data collection are compared with criteria and standards.
 The end stage of analysis is concluding how well the standards were met and, if applicable, identifying reasons
why the standards weren't met in all cases.
 These reasons might be agreed to be acceptable,
Step 5: Implementing change
Once the results of the audit have been published and discussed, an agreement must be reached about the
recommendations for change.
Using an action plan to record these recommendations is good practice; this should include who has agreed to do
what why and when.
Each point needs to be well defined, with an individual named as responsible for it, and an agreed timescale for its
completion.
Step 6: Re-audit: Sustaining Improvements
 After an agreed period, the audit should be repeated.
 The same strategies for identifying the sample, methods and data analysis should be used to ensure
comparability with the original audit.
 The re-audit should demonstrate that the changes have been implemented and that improvements have been
made. Further changes may then be required, leading to additional re-audits.
This stage is critical to the successful outcome of an audit process - as it verifies whether the changes implemented
have had an effect and to see if further improvements are required to achieve the standards of healthcare delivery
identified in stage 2.
Types of audit Internal auditing
Internal auditing is a control technique performed by an external auditors who is not a employee of the
organization. He makes an independent appraisal of the policies, plan and the points deficits in the policies or plans
and give suggestion for eliminating deficits.
External auditing
 It is an independent appraisal of the organizations, finances, accounts and statements. The external auditors is the
qualified persons who has to certify the annual profits and accounts and prepare a balance sheet after careful
examinations of the relevant books, accounts and documents.
Types of internal audit Retrospective audit:
It evaluates the quality of care through appraisal of nursing process after the client’s discharge from the health care
system.
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.
Retrospective audit:
Advantages
 Less time consuming and less expensive.
 For companies of actual practical findings
 For analysis of actual practical findings
 A total picture of care given.
 Encourages accurate recording.
Disadvantages
 Focus of evaluation is directed away from ongoing care
 Corrective action can only be used to improve the care of future clients
 Care giver may chart care activities without giving care to client
Types of internal audit Concurrent audit:
It is the method of evaluating the quality of ongoing care through appraisal of nursing process.
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.
Concurrent audit Advantages
 Identification of problems at the time of care given
 Provision of mechanism for identifying & meeting client’s needs during care
 Implementation of measures to fulfill professional responsibilities
 Provision of mechanism for communicating on behalf of the client
Disadvantages
 Time consuming
 More costly to implement than retrospective
 Does not present the total picture of care that client will ultimately receive
Peer review
Peer review nurses functioning in same capacity that is peer appraise the quality of care or practice performed by
others equally qualified nurses. The peer review is based on pre-established standards or criteria.
There are two types of nurses review
 Individual peer review - Focuses on the performance of an individual nurses.
 Nursing audit – focus on evaluating the nursing care through the records.
Quality audits
Quality audits are performed to verify conformance to standards through review of objectives evidence. quality
audits may verify the effectiveness of a quality management system. This is a part of certification such as ISO.
Quality audits are essentials to verify the existence of objective evidence showing conformation to required
process, to assess how successfully processes have been implemented, for judging the effectiveness of achieving
any defined target levels,
The audits most frequently used in quality control include outcome, process and structure audits
 Outcome audit
 It is the end result of care.
 The changes in the patients health status and can be attributed to delivery of health care services.
 It determines the results of specific nursing intervention.
Process audit : It is used to measure the process of care or how the care was carried out. This audit is task
oriented and focuses on whether or not practice standards are being fulfilled.
Structure audit :
This type of audit monitors the structure or setting in which the patient care occurs. The audit is done for assessing
the physical facilities, equipments and supplies describe whether they fulfill the set standards or not.
Energy audits :An energy audit is an inspection, survey and analysis of energy flows for energy conservation in a
building, process or system to reduce the amount of energy into the system without negatively affecting the
outputs.
Instruments of community health services audit
Numerous audit instruments can be found.
 Two valid and reliable tools are phaneuf nursing are the slater nursing competencies rating scale and the
quality patient care scale.
 Phaneuf nursing audit.
 This 50 item instrument measures seven functions of professional nursing as they relate to nursing
process.
 his instrument is the example of retrospective audit instrument
The slater nursing competencies scale : It is an 84 item scale intended to rate nurses performance in the clinical
setting after direct observation of an identified number of nurses and client encounters.
The quality of patient care scale is a 68item scale intended to measure the quality of care received by a client
either through direct nurse client encounters or interventions with others on behalf of the client.
Other nursing audits instruments are
 Rush- Presbyterian – st. luke’s medical centre medicus methodology for monitoring quality patient care.
 The professional practitioner’s performance rating scale.
 The CASH nursing care evaluation instrument.
 The critical incident performance appraisal system.
Regular health check audits
Regulatory audits : The aim of regulatory audit is to verify that a project is compliant with regulations and
standards.
Record audit: A commonly used method for collecting performance data in community health services is the
record audit. Both concurrent and retrospective record auditing is carried out.
The audit committee is a committee of the board of community health services. Its primarily function is to assist
the board in fulfilling its oversight responsibility by reviewing the independent audit report as to the system of
internal controls.
The committee experts advised of:
 The financial information provided to the governmental regulatory bodies.
 The status of examinations/ audits conducted by other government states or regulatory bodies.
Responsibilities of audit committee
 It provides an open avenue of communication between the board, management and the independent
auditors.
 It also provides insight with regard to the manner in which the financial reporting of the department of
community health services.
  The audit committee is appointed annually by the board of community health services.
 The audit committee consists of at least three members of whom at least one should have background in
financial reporting, accounting, and auditing.
 There is chairperson in audit committee. It is the responsibility of the chairperson to schedule the meeting
of the committee and to suggest agenda items for the committee’s consideration.
 The audit committee meets as often as it determines necessary, but not less frequently than 4 times per
calendar year. The audit committee meets the management and independent auditors in separate executive
sessions.
Responsibilities and duties of audit
 Review and reassess the adequacy of the charter annually and recommended any proposed changes to the board
for approval.
 Maintain other records of meetings and activities.
 Review management’s independent audit procurement process and confirm the selection of independent
auditors.
 Review reports from independent auditors regarding their independent audit . At the committee’s
discretion, discuss such reports with the auditors and if appropriate, recommend that the board take action to
satisfy itself or the independent auditor.

Review of department’s periodic report of major financial risk exposure includes:

 Fraud and other misconduct.  Change in accounting to policies and procedure.
 Review the annual audited financial statements with management including:
 Major accounting issues and changes to accounting principles and auditing standards.
 Adequacy of internal controls that could significantly affects the department’s financial statements
 Meet with the independent auditors as necessary to monitor the progress of the annual financial and single
audit. Evaluate the results of annual audits including, but not limited to:
 The audited financial statements
 The adequacy of the system of internal controls.
 The adequacy of the department’s accounting policies and procedures, including the level of compliance
with governmental regulations
 Discuss with the independent auditor the matters required by AICPA professional standards.
 Establish guidelines in accordance with applicable laws and government auditing standards.
 Review a current list of examinations and/ or audit of DCH in process or recently completed conducted by:
 Governmental or other authorities.  Internal audit staff.
 Periodically review and evaluate the adequacy of department’s monitoring of compliance with reporting
requirements of governmental agencies and other organization. 11. Initiate investigation of other matters
the committee deems appropriate and relevant to the committee’s purpose.
What need to be done in health sector in india
 The audit has benefitted in the implementation of the program and increasing transparent accountability.
 It become an important tool for effective program implement awareness generation, program monitoring and
evaluation, reducing the chances of corrupt and grievance redressal, and follow up on corrective actions.
 As of now, there are only a few examples of use of audits in health sectors in india,
 however, it is expected that with the time will increase. The use of this approach in maternal death audits and
infant mortality audit a long way in achieving millennium development goals.