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Dr.(Mrs.) S.Valliammal Lecturer CON NIMHANS



Nursing is a service profession. The service rendered by nurses are essential to life and welfare of the clients. Therefore the profession as a whole should be accountable for the quality care delivered by individual practitioners. Nursing concern for the quality of service constitutes the heart of its responsibility to the public.


Concern for measurement of quality care provided to patients is not new, but acknowledgement that quantitative measurement of quality is possible is relatively recent. There are instruments /tools which have been demonstrated effective for providing quantitative measurement.

History of Nursing 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 of medical audit. George Groword, pronounced the term physician for the first time medical audit. Ten years later Thomas R Pondon MD 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 published in 1955. For the next 15 years, nursing audit is reported from study or record till the last decade.

The program is reviewed from record nursing plan, nurses notes, patient condition, nursing care.

Meaning of the terms
1. Quality - a judgement of what constitutes good or bad. 2. Audit - a systematic and critical examination to examine or verify. 3. Nursing audit (a) It is the assessment of the quality of nursing care (b) Uses a record as an aid in evaluating the quality of patient


According to Elison "Nursing audit refers to assessment of the quality of clinical nursing".

II. According to Goster Walfer: a. Nursing Audit is an exercise to find out whether good nursing practices are followed. b. The audit is a means by which nurses themselves can define standards from their point of view and describe the actual practice of nursing.

What is clinical audit?

‘Clinical audit is a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change’

(NICE 2002)

Why do audit? - purposes
It can lead to ………….
 

Improved quality of care . A sense of personal and professional achievement. Stimulation of Continuing Professional Development (CPD) Improved Team-Working Improved communication within an organisation A greater understanding of the structure and process operating within the organisation Improved practice based skills such as the identification, management and use of information

   

Why do audit? -puposes
Evaluating Nursing care given,  Achieves deserved and feasible quality of nursing care,  Stimulant to better records,  Focuses on care provided and not on care provider,  Contributes to research.

What makes a good audit?
Good choice  Patient centred  Possible to measure  Resources allocated (time/funds)  Important  Frequently occurring problem  Standards agreed  Good team involvement  Will be possible to change and improve

Poor choice
× Clinician

centred × Not possible to measure × Resources not allocated × Unimportant × Only happens rarely × No standards agreed × Relies on one or two individuals × Impossible to change even if needed

Types of audit
Organisational audit  Peer review

Audit is a form of peer review and involves a cycle of activity as given below.
Measure selected topic

Review standards

The Audit Cycle

Review against standard

Implement action

Identify gaps

Decide action

DEFINE/ REVIEW Criteria and Standards (Based on the best possible up to date evidence – where it exists)

Implement change

Design Audit Tool

IDENTIFY Need for change Involve everyone COLLECT Data on Performance Record & Analyse

ASSESS Data Performance against criteria & Standards

Common approaches  Prospective review  Concurrent review  Retrospective review

Retrospective view

 

This refers to an in-depth assessment of the quality after the patient has been discharged, have the patients chart to 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. Without such use of the record, care cannot be personalized, cannot be safe, and will not be characterized by continuity which is an essential component of quality. In addition, the record is legal documentation of care, and records are available and easily accessible for audit.

Retrospective view…
The method was designed for use in hospitals,  public health nursing agencies, and nursing homes because the responsibilities  of professional nurses for the care of people are not altered by the settings in which care is given.  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 : 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 patient's pre-hospital routines included? d. Laboratory test results used in planning care? e. Did the nurse perform physical assessment? How was information used? f. Were nursing diagnosis stated? g. Did nurse write nursing orders? And so on.

Method to Develop Criteria
1. Define patient population. 2. Identify a time framework for measuring outcomes of care, 3. Identify commonly recurring nursing problems presented by the defined patient population, 4. State patient outcome criteria, 5. State acceptable degree of goal achievement, 6. Specify the source of information. 7. Design and type of tool

Points to be remembered:
a. Quality assurance must be a priority, b. Those responsible must implement a programme not only a tool, c. A co-ordinator should develop and evaluate quality assurance activities, d. Roles and responsibilities must be delivered, e. Nurses must be informed about the process and the results of the programme, f. Data must be reliable, g. Adequate orientation of data collection is essential, h. Quality data should be annualized and used by nursing personnel at all levels

Audit is a team effort

Audit Committee
Before carrying out an audit, an audit committee should be formed, comprising of a minimum of five members consisting of Chairman (e.g. senior nurses,) and 3-4 members (supervisors/Head nurses).

who are interested in quality assurance, are clinically competent and able to work together in a group

Procedure for nursing audit
Committee should meet once in a month to audit records of patients discharge during that time.  The chairman would assign the number of charts each member will audit. Steps outlined for evaluation /auditing are:  Visit the unit to complete the evaluation form  Compile the score for each patient.  Meet the committee to discuss the finding.

3.Members should be very honest and impartial in their judgement. A confidential note should be sent to the individual if something very outstanding has been recored. 4.Review of the audit is done by the members of the committee, compiled and submitted to the authorities with recommendations for future action.

Training for auditors should include the following
a. A detailed discussion of the seven components. b. A group discussion to see how the group rates t he 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.

Steps to problem Solving Process in Planning Care :
a. Collects patient data in a systematic manner 1. includes description of patients prehospital routines, 2. has information about the severity of illness, 3. has information regarding lab tests, 4. has information regarding vital signs, 5. Has information from physical assessment etc.

b. States nurses diagnosis, c. Writes nursing orders, d. Suggests immediate and long term goals, e. Implements the nursing care plan, f. Plans health teaching for patients, g. Evaluates the plan of care,

An audit is a systematic and official examination of a record, process or account to evaluate performance. Auditing in health care organization provide managers with a means of applying control process to determine the quality of service rendered. Nursing audit is the process of analyzing data about the nursing process of patient outcomes to evaluate the effectiveness of nursing interventions.

Audit as a Tool for Quality Control

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. Example of outcomes traditionally used to measure quality of hospital care include mortality, its morbidity, and length of hospital stay.

Process audit

Process audits are used to measure the process of care or how the care was carried out. Process audit is task oriented and focus on whether or not practice standards are being fulfilled. These audits assumed that a relationship exists between the quality of the nurse and quality of care provided.

Structure audit
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.

For the effective quality control, the nurse manager has to play following roles and functions.
1. Application and execution of physician's legal orders 2. Observation of symptoms and reactions 3. Supervision of the patient 4. Supervision of those participating in care 5. Reporting and recording 6. Application of nursing procedures and techniques 7. Promotion of health by direction and teaching.

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.

Disadvantages of the Nursing Audit

     

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, Is time consuming, Requires a team of trained auditors, Deals with a large amount of information, Only evaluates record keeping. It only serves to improve documentation, not nursing care.


They are:  Without this foundation stone, the structure of quality assessment cannot be built.  Having accepted responsibility for the quality of care, there still remains a decision about the level and scope of agency concern.  One may distinguish several steps in a progression of widening concern.

1. The care provided by a specified professional group (in this case, nursing) in a particular agency. 2. That portion of patient care provided by a particular agency, including the contribution of all professionals involved in the care of any given patient. 3. The total care of any given patient irrespective of the source of care. 4. The provision of health services for the community (however defined) as a whole.

It is necessary to explicitly specify the level and scope of concern because the aspects of care that require assessment may vary from level to level and so may the methods best suited for their assessment. For example, the degree of access to care is an essential concern at the community level; it is much less relevant when the question asked is whether a patient already under care receives quality nursing.

There are a set of issues that concern the selection among available approaches to evaluation. One may classify these approaches under three headings: structure,process, and outcome.

The evaluation of process consists in the appraisal of the care itself. The nursing audit is an example of this approach.  It is not satisfied with the mere presumption of quality in any specified setting. It subjects to professional judgment the elements and details of care.

It puts to actual test the assumptions that certain structural characteristics are related to certain levels of performance.  The evaluation of outcomes consists in the assessment of the end results of care-usually specified in terms of patient health, welfare, and satisfaction.  The extent to which agreed-upon desired outcomes are achieved is the ultimate test of the assumptions

The distinction between process and outcome is, to some extent, an abstraction. Between the initiation of care and its termination there are a number of completed tasks("procedural end points") and states of the patient ("intermediate outcomes") that can be used as indicators of the quality of care.

A well-rounded system of quality appraisal would probably include concurrent or coordinate assessments of structure, process, and end results, to the extent that each of these is observable and measurable under the constraints inherent in any given setting.

Some Technical Issues

There are a number of technical problems and issues in the nursing audit that can be only briefly mentioned. 1. The Record as a Source of Information- One objection to audits, whether medical or nursing, is that they assess the quality of the record rather than that of the care actually provided.

Skillful recording may give a false impression of quality, and omissions from the record may convey a false impression of poor care.

The record is, of course, an indispensable tool of patient management and it is perfectly legitimate to evaluate the quality of recording.

The doubts that are cast on the record as a true mirror of the care actually provided are probably exaggerated;  but they have never been fully erased.  There are a number of precautions that may be taken to minimize possible misrepresentation by the record.  The most important are to devise appropriate records, to enforce reasonable standards of recording, and to allow for discussion of the findings with the person who has provided care.

2. Definitions, Criteria and Standards- It is extraordinarily difficult to define what quality is. Very probably quality is not a homogeneous property but a large bundle of characteristics.
Certainly clients, physicians, and nurses may look for different characteristics as signifiers of quality and/or weight them differently. As a prelude to any evaluation it is necessary, therefore, to arrive at some agreement concerning what aspects of care are to be assessed and on what constitutes "goodness" in each aspect.

Criteria and standards are implicit in any judgment of quality. The extent to which these are made explicit may, however, vary. Some authorities in medical audits favor explicit formulation of criteria and considerable specificity in standards. Others favor a more unstructured approach in which expert judges are simply guided by how they themselves would have managed a given patient.

3.Scales and Measurements-Some examiners have a preference for over-all ratings with a minimum of divisions such as "good," "fair," or "poor."  Others have assigned numerical scores to elements of care and cumulated them  to arrive at an over-all numerical representation of the quality of care. The nursing audit is an example of the latter approach.

For example, treatment depends on antecedent diagnosis.  In extreme cases,performance in one element may be so bad that it cannot be compensated for by excellence in other elements, and the care must be rated "poor."  Second, it is difficult to defend the weights (whether equal or unequal) that are assigned to different components or elements of care.

4.Validity and Reliability-We have already suggested that the validity of the assessments of process can be tested by determining the outcomes of care

There is reason to believe that reasonably reliable judgments can be obtained through the audit of medical records.  It is also claimed that reliability is improved by the prior specification of criteria and standards.  Nevertheless, more attention needs to be given to establishing reliability in the assessment of patient care.

Some Operational Issues
There are a number of issues that pertain to the implementation of professional care audits in general. 1. Who Should Conduct Them and for What Purpose ?There is general agreement that each profession is solely competent to judge the quality of care provided by its members.  However, as the concern broadens to include the total care of individual patients it will become necessary to develop methods that require joint assessment by representatives of several

2.A second question is whether the audits should be internal, conducted by agency personnel, or external, conducted by persons from outside the agency that is under examination. There is some evidence to suggest that external auditors tend to be more critical than are internal auditors

However, experience has shown that both internal and external audits can be effective.
A "mixed" audit committee as proposed by Miss Phaneuf may combine the advantages of both. The purposes of the audit are recognized to be primarily educational and constructive rather than punitive or destructive.

Some authorities have suggested that this preferred orientation be institutionalized by confining the analysis to the identification of pervasive patterns of agency performance.

2. Implementation and Effectiveness  There has been remarkably little study of the
ability of professional audits to bring about lasting changes in professional behavior.

There have been anecdotal accounts of remarkable success and of object failure; but little is known about the circumstances that determine success or failure.

There is urgent need for studies of the professional audit primarily as a complex social process rather than merely a technical problem of measurement.

3. Cost, and Cost in Relation to EffectivenessData on the cost of audits are almost nonexistent.  Nor are there any data on cost in relation to effectiveness of audits or of alternative methods of appraisal.  Such studies are surely needed.

A profession concerns for the quality of its service 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.