JINKA GENERAL HOSPITAL

NURSING & MIDWIFERY AUDIT

PROTOCOL

SEPTEMBER 2015/2022
BY N &M DIRTECTOR &QIU
Contents
INTRODUCTION.........................................................................................................................................2
PURPOSES OF NURSING AUDIT.............................................................................................................3
Define/set criteria and standards....................................................................................................................3
Objectives of Nursing Audit..........................................................................................................................3
General objectives......................................................................................................................................3
Specific objective.......................................................................................................................................3
NURSING/MIDWIFERY PRACTICE AUDIT PROGRAM.......................................................................4
Methods of Nursing/Midwifery Audit:......................................................................................................4
1. Retrospective Review........................................................................................................................4
2. Concurrent Review...........................................................................................................................4
STEPS FOR CONDUCTING N&M AUDIT................................................................................................4
PRE REQUISITE FOR N&M AUDIT..........................................................................................................5
QUALITYOF N&M AUDIT.........................................................................................................................6
1) OUTCOME AUDIT..........................................................................................................................6
2) PROCESS AUDIT.............................................................................................................................6
3) STRUCTURE AUDIT:......................................................................................................................6
NURSING & MIDWIFERY AUDIT CYCLIC PROCESS..........................................................................7
MAIN RESPONSIBILITIES OF N&M AUDIT TEAM:-............................................................................8
FREQUENCY OF N&M AUDIT.................................................................................................................9
ETHICAL CONSIDERATIONS...................................................................................................................9
CONCLUSION..............................................................................................................................................9
REFERENCES..............................................................................................................................................9
Checklist to audit the quality of nursing care..............................................................................................10
Nursing/Midwifery Care Standard Checklist...............................................................................................13
JINKA GENERAL HOSPITAL N&M AUDIT MEMBERS.....................................................................14

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INTRODUCTION
Audits are a method of evaluating the care process. A clinical audit can identify activities that
should or should not be performed in clinical settings. It not only improves care quality but also
helps nurses to acquire and use the knowledge, skills, and attitudes necessary for creating a
meaningful, productive, and satisfying working environment. The first step in operationalizing
the clinical audit is to identify specified indicators of the domain. The nursing process can be
used as a framework for developing auditing indicators. Healthcare audit is not new. It is a
quality improvement activity that most healthcare employees have done for a long time as part of
everyday practice

One of first ever clinical audits was undertaken by Florence Nightingale during the Crimean
war of 1853-1855. Florence Nightingale is regarded as one of the earliest pioneers of clinical
audit. She was appalled at the conditions patients experienced at the barracks hospital in Scutari
in 1854 and kept meticulous records of the mortality rates among the wounded patients. She
applied strict standards of hygiene for the hospital and its equipment and was able to demonstrate
a fall in mortality rates from 40% to 2%. More recently, the 1989 White Paper, Working for
Patients, saw the first attempt to standardize clinical audit as part of professional health care.

Nursing audit is a detailed process of evaluating the quality of nursing care through the review
of clinical records made by healthcare professionals. It helps healthcare institutions ensure that
patients consistently receive quality patient care and allows nurse managers to determine
healthcare improvement opportunities. “Quality nursing care” has become essential on day to
day functioning. Nursing audit is a way of ensuring quality nursing care. Nursing audit is a
detailed review and evaluation of selected clinical records by qualified professional personnel to
identify, examine, or verify the performance of certain specified aspects of nursing care by using
established criteria.

The purpose of this document is to implement focused nursing audit by addressing the main
nursing practice. This document is extracted from the HSTQ protocol. It is short and easy to use
than the HSTQ. The document can be used on daily and/or weekly based on the need of the
hospital. The HSTQ Nursing and Midwifery service audit implementation also continue as
previous on quarterly basis.

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PURPOSES OF NURSING AUDIT
It aids nursing heads in determining if patient care is aligned with the healthcare institution’s
standards and in reviewing clinical records that can help indicate gaps and areas for improvement
in patient care. The purpose of healthcare audit is to monitor to what degree standards for any
given healthcare activity are met, identify reasons why they are not met, and identify and
implement changes to practice to meet those standards. These standards should be evidenced
based. Audit is an essential tool for Continuous Quality Improvement (CQI).
The main purposes of nursing &midwifery audit are:-
Enable nurses to evaluate, measure practice and standards
Evaluates nursing/midwifery care patients/clients receive
Promotes quality improvement of nursing/midwifery care
Offers a way to assess and improve patient care &to uphold professional standards
Identifying and measuring areas of risk within the service
Stimulant to better records
Create a culture of quality improvement and best practice in the clinical setting
Focuses on care provided and not on care provider
Improve the Quality, Safety, Equity, Person Centered Care, Effectiveness and
Efficiency of Healthcare.
Improves quality of record keeping
Contributes to research.

Define/set criteria and standards

Criteria are explicit statements that define what is being measured. It is a measurable outcome of
care. This is usually given as a percentage. Recommendations from clinical practice guidelines
can be used to develop criteria and standards.

Objectives of Nursing Audit

General objectives

 To assess quality of nursing &midwifery care in Jinka General Hospital Jinka,

SNNP,Ethiopia

Specific objective
 To determine the nursing &midwifery care given as standards
 To identify gap of nursing &midwifery care& its associated factors
 To monitor nursing care was properly practice & documented
 To follow evidence based nursing care

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NURSING/MIDWIFERY PRACTICE AUDIT PROGRAM
The nursing/midwifery practice audit program should be part of the overall hospital quality
improvement program. Nursing/midwifery practice audit is one of the tools to ensure the clinical
effectiveness of nursing/midwifery care patients/clients receive.
Methods of Nursing/Midwifery Audit:
1. Retrospective Review - this refers to an in-depth assessment of the quality of care after the
patient has been discharged. The patient’s chart is the source of data.
Retrospective audit is a method for evaluating the quality of nursing care by examining the
nursing care, as it is reflected in the patient care records for discharged patients. In this type of
audit, specific behaviors are described then they are converted into questions and the examiner
looks for answers in the record. For example, the examiner looks through the patient's records
and asks:
 Was the problem solving process used in planning nursing care?
 Was patient data collected in a systematic manner?
 Was a description of patient's pre-hospital routines included?
 Were laboratory test results used in planning care?
 Did the nurse perform a physical assessment? How was the information used?
 Did the nurse write nursing orders? And so on.
2. Concurrent Review - this refers to the evaluations conducted on behalf of patients who are
still undergoing care. It includes assessing the patient at the bedside in relation to a pre-
determined criterion; interviewing the staff responsible for this care and reviewing the patient’s
record and care plan.

STEPS FOR CONDUCTING N&M AUDIT

1) Create an audit team composed of senior nurses and other members who will be
impartial auditors.
2) Get the buy-in of healthcare staff. Help them understand the goal of the audit and the
benefit to the patients, staff, and the healthcare institution.
3) Determine the type of nursing audit method and proceed with the nursing audit using
technology that can help measure the nursing audit result and analyze the information
gathered.
4) Review and analyze the data gathered to determine if the patient care being provided
is at par with the healthcare institution’s standards.
5) Promote best practices and maintain quality patient care by conducting internal audits
and address gaps found

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PRE REQUISITE FOR N&M AUDIT
1) AUDIT COMITTEE
 Before carrying out an audit, an audit committee should be formed, comprising of
a minimum of five members
 Who are interested in quality assurance, are clinically competent and able to work
together in a group.
 That the auditor should have the ability to carry out an audit in about 15 minutes.
 If there are large number of records to be audited, then an auditor may select 10
per cent of discharges.
2) RE ORIENTATION OF AUDITORS
 A detailed discussion of the seven components of criteria.
 A group discussion to see how the group rates the care received using the notes of
a patient who has been discharged,
 These should be anonymous and should reflect a total period of care not
exceeding two weeks in length
 Each individual auditor should then undertake the same exercise as above.
 This is followed by a meeting of the whole committee who compare and discuss
its findings, and finally reach a consensus of opinion on each of the components.

3) PLANNING MEDICAL CARE

 Collects patient data in a systematic manner, Includes description of patients pre-
hospital routines, has information about the severity of illness, has information
regarding lab tests, has information regarding vital signs, Has information from
physical assessment etc.
 State nurse’s diagnosis,
 Writes nursing orders,
 Suggests immediate and long term care,
 Implements the nursing care plan,
 Plans health teaching for patients and students,
 Evaluates the plan of care at own level
 Focused Nursing Audit is the systematic critical analysis of the quality of clinical
care, including the procedures used for diagnosis and treatment, the use of resources
and the resulting outcome and quality of life for the patient.”

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QUALITYOF N&M AUDIT
1) OUTCOME AUDIT:
 Outcomes are the end results of care;
 The changes in the patients’ health status and can be attributed to delivery of
health care services.
 Outcome audits determine what results if any occurred as result of specific
nursing intervention for clients.
 These audits assume the outcome accurately and demonstrate the quality of care
that was provided.
 Outcomes traditionally used to measure quality of hospital care include mortality,
its morbidity, and length of hospital stay.
2) PROCESS AUDIT:
o Process audits are used to measure the process of care or how the care was carried
out.
o Process audit is task oriented and focus on whether or not practice standards are
being fulfilled.
o These audits assumed that a relationship exists between the quality of the nurse
and quality of care provided.
3) STRUCTURE AUDIT:
 Structure audit monitors the structure or setting in which patient care is provided.
 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.

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NURSING & MIDWIFERY AUDIT CYCLIC PROCESS

1st
Identify Problem

6th 2nd
Re- Audit Set Criteria

N&M AUDIT
CYCLE

5th
Make Change 3rd Start
&Sustaining Audit
Improvement

4th Identify
Barriers

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 MAIN RESPONSIBILITIES OF N&M AUDIT TEAM:-
1, IDENTIFY PROBLEM
Assess detail of nursing care what was not met as standard, address the implementation and
quality of a nursing process, patient monitoring, pain management, medication administration,
and client education, list problems, prioritize problems
1.1, Planning Audit
Involve ALL the people concern, Fix time and Plan resources ,Access the evidence/data
Methodology to be followed ,Pilot study ,Report for Action ,Re-audit All activities should be
documented.
2, Developing Criteria
2.1. Define patient population.
2.2. Identify a time framework for measuring outcomes of care,
2.3. Identify commonly recurring nursing problems presented by the defined patient population,
2.4. State patient outcome criteria,
2.5. State acceptable degree of goal achievement,
2.6. Specify the source of information.
2.7. Design and type of tool Points to be remembered:
o Quality assurance must be a priority,
o Those responsible must implement a program not only a tool,
o A coordinator should develop and evaluate quality assurance activities,
o Roles and responsibilities must be delivered,
o Nurses must be informed about the process and the results of the program,
o Data must be reliable,
o Adequate orientation of data collection is essential,
o Quality data should be annualized and used by nursing
3, Measuring Level of Performance Daily, Assess &Monitor N&M Care
4, Identify Gap, Barriers to Change, & Do Action Plan
5, Follow &sustain Quality Improvement, Monitoring and Evaluation:
 Systematic approach to changing professional practice
 Monitor and evaluate the change
 Maintain and reinforce the change REINFORCING IMPROVEMENT:
 Reinforcing or motivating factors by the management.
 Integration of audit
 Develop strong leadership
6. RE-AUDIT:
 Review evidence
 Measure effectiveness
 Decide how often to re-audit
 Ongoing process monitoring
 Adverse incidents -Significant events audit

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FREQUENCY OF N&M AUDIT/TOR/
Will be conducted daily basis, routine assessment weekly, clinical supervision of service area
every two weeks, monthly meeting with team members &matron or beyond according to the type
of issue to be audited. HSTQ nursing audit will be conducted on quarterly bases as usual.
Amendment of TOR Will be 2years or early as much as possible.

ETHICAL CONSIDERATIONS
The audit should follow the principles of ethical approach. Clinical audit should always be
conducted within an ethical framework. This means abiding by the principles of the Data
Protection Act; e.g. by ensuring patient and staff confidentiality and by ensuring that data is
collected and stored appropriately.

CONCLUSION
A profession dedicated for the quality of its service to patients constitutes the heart of its
responsibility to the public. An audit helps to ensure that the quality of nursing care desired and
feasible is achieved. This concept is often referred to as quality assurance.

Source of information
 Primary data (clients, care takers if client is unable to give the required information for
a medical or other reasons like disabilities)
 Secondary data (Charts review)

REFERENCES

1, Jinka General Hospital Focused Nursing Audit September, 2019 G.C

2, National Comprehensive Training on Standards of Nursing Practice August 2017
3, WWW.NURSING AUDIT DR. N. C. DAS https://www.slideshare.net/Jyothi19587/nursing-audit

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 Customized By Megersa Alene {B.Sc. N, QU}

Checklist to audit the quality of nursing care

ANNEX I: Nursing process

CARD # ……………………………….
Standard Verification criteria Met = 1
Unmet =0
Nursing assessment done There is written evidence of a compilation
Correct Nursing diagnosis made of data based on
Correct nursing care plan outlined Gordon’s functional model
Nursing plan implemented as appropriate Nursing assessment is completed within 2
Nursing evaluation done at least in each shift and re- hours patient’s arrival
planning done as appropriate The nursing process must be inter-related
each other
Vital sign taken Every 6hrs (as per physician order if
requested)
All medications are provided as per order and clearly Medication is timely given as ordered
documented (legible, date & time recorded, named Administering nurse name and signature
and signed) Name of medication administered recorded

ANNEX II: Access assigned nurse for a routine care and management of complications
Standard Verification criteria Met = 1
Unmet =0
Assigned nurse name was accessibly displayed Client Interview
throughout my stay and at all shifts
Nurses visit me at least every 2 hours and ask me for( Client Interview
pain, position change and potty etc) for comatose
patient every 1 hours Attendance interview (For comatose
patients)

At all times when I was left alone, I was told on Client Interview
where and how to call for help
I am satisfied with the overall nursing care Client Interview

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ANNEX III: Effective communication in response to their needs and preferences

Standard Verification criteria Met = 1

Unmet =0
My care provider introduced him/herself during the Client Interview
first contact
At all times of contact, I was addressed by my name Client Interview
My Nurses demonstrated me to ask questions and Client Interview
support in problem- solving
I was adequately informed and my choices are Client Interview
respected during all examinations, any actions and
decisions taken about my care

ANNEX IV: Information provision

Standard Verification criteria Met = 1

Unmet =0
I was explained with all the precautions I have to take Client Interview
after discharge (diet, alcohol, time to functional
return etc)

Me and my families were briefed about, and aware Client Interview

of, their patient and family rights
I was briefed on waste segregation and toilet accesses Client Interview

During discharge, all patients felt involved in the Client Interview

plans for their discharge and given appointment
instruction

ANNEX V Medication Administration

Standard Verification criteria Met = 1

Unmet =0

Safe medication administration principles followed Observation &staff interview

Authority, Competence, Education, Risk, Safety &
Collaboration.

knowledge, skill and judgment to assess the

appropriateness of a particular medication for

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 the client
knowledge of the actions, interactions, usual
dose, route, side effects and adverse effects of
the drug

Follow the medication “rights” and “checks” to

ensure client safety; and consider the client’s needs ‘
Staff interview
Medication was administered using 10 rights

Calculating the dosage and preparing the medication

correctly

understanding the indications for Observation &staff interview

administration Chart review
monitoring the client during and following
administration
managing side-effects or adverse effects of
the drug
evaluating the effect of the medication on the
client’s health status
Appropriate documentation of the process and client
outcomes

ANNEX VI Pain score &management

Standard Verification criteria Met = 1

Unmet =0

Pain was monitored as 5th vital sign Observation &staff interview

Availability &utilization of pain mgt
protocol

Pain was scored appropriately Chart review

Appropriate Pain management was given according

to pain score

Monitoring mechanism was developed for pain Staff interview

management including patient orientation on it

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 Nursing/Midwifery Care Standard Checklist
s.no Standards Yes No/unmet
/met

1 There is a system for coordinating and managing nursing staff

2 Job descriptions for nursing positions have been developed.
3 A nursing workforce plan has been developed.
4 The hospital‘s nurse staff requirements are defined in the nursing workforce
5 Nurse to patient ratios for each service area are defined in the nursing
6 There is a written policy for the nursing process.
7 Nurses complete nursing admission assessments for inpatients.
8 Nurses complete a nursing care plan for inpatients.
9 There are written guidelines for nursing verbal and written communication
10 There are written guidelines for medication administration.
11 There is an established nursing/midwifery care practice audit program.
12 Nurses implement regular nursing/midwifery hours (eight)‘ shift
13 Nurses conduct nursing care based on hourly rounds*
14 There is a central medication room or cabinet
15 There is a centralized nursing/midwifery station set-up in each ward

M and E Framework

Focused nursing audit Score (%) = Total meet standard *100%

Total standard score

Number of correct nursing care plan executed

Number of pressure ulcer
Percent of audit is conducted per months

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 JINKA GENERAL HOSPITAL N&M AUDIT MEMBERS
S.No Name Position Responsibility Phone No Sign
1 Megersa Alene Quality Officer Chair Person 0915930205
2 Amanuel Kasa OR Focal Secretory 0966682731
3 Tagany Mordokiyos ICU Focal Member 0930618180
4 Adisu Kusse SW Focal Member 0926568040
5 Mintesinot Mangistu Tfc Focal Member 0916904335
6 Antene Dani’el Mw Focal Member 0926568180
7 Ehitayehu Kibiret OB Focal member 0910448604
8 Banchiwosen Asefa Matron Member 0941037346
9 Buzayehu Kafiyalew Vice Matron Member 0910018485

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