Nursing Audit

NURSING AUDIT
DR. N. C. DAS

NURSING AUDIT
With the implementation of CPA professional
accountability to an enlightened public can no
longer be ignored by nursing staff.
“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.

HISTORY OF NURSING AUDIT
One of first ever clinical audits was undertaken by Florence
Nightingale during the Crimean war of 1853-1855.
On arrival at the medical barracks hospital in Scutari in
1854, Florence was pained by the unsanitary conditions and
high mortality rates among injured or ill soldiers.
She and her team of 38 nurses applied strict sanitary
routines and standards of hygiene to the hospital and
equipment,
Florence's gift of statistic kept meticulous records of the
mortality rates among the hospital patients.
Another famous figure who advocated clinical audit
was Ernest Codman (1869–1940) by monitoring surgical
outcomes .
Whilst Codman's 'clinical' approach is in contrast with
Nightingale's ‘epidemiological' audits, both methods serve to
highlight the different methodologies that can be used in the
process of providing quality patient care.

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

PURPOSES OF NURSING AUDIT

1.Evaluating Nursing care given,
2. Achieves deserved and feasible
quality of nursing care,
3. Stimulant to better records,
4. Focuses on care provided and
not on care provider,
5. Contributes to research.

TYPES OF NURSING AUDIT

NURSING AUDIT
INTERNAL EXTERNAL

TYPES OF NURSING AUDIT
1) Internal auditing:
Internal auditing is a control technique performed
by an external auditor who is an employee of the
organization. He makes an independent appraisal
the policies, plans and points the deficits in the
policies or plans and give suggestion for eliminating
deficits
2) external auditing:
it is an independent appraisal of the organizations
financial account and statements. The external
auditor is a qualifed person who has to certify the
annual pprofit and loss account and prepare a
balance street after carefull examination of the
relevant books of accounts and documents

INTERNAL AUDIT
• RETROSPECTIVE EVALUATION : 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 :
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?
f. How was information used?
g. Were nursing diagnosis stated?
h. Did nurse write nursing orders? And so on.

II. CONCURRENT AUDIT : It is performed during ongoing
nursing care.
The evaluations conducted on behalf of patients who are still
undergoing care.
It includes assessing the patient at the bedside in relation to
pre-determined criteria,
Interviewing the staff responsible for this care .
Reviewing the patients record and care plan.
III. PEER REVIEW : In nurse peer review nurses functioning in
the same capacity that is peer’s 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 peer reviews:
a) individual peer review; focuses on the performance of an
individual nurse.
b) nursing audit; focuses on evaluating nursing care through the
review of records.

QUALITY 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:
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.
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.

AUDIT CYCLE
AUDIT IS A CYCLIC PROCESS

PRE-REQUISITE FOR NURSING
AUDIT

CLINICAL
AUDIT

CLINICAL AUDIT PLANNING
COMMITTEE MEDICAL CARE

RE
ORIENTATION
OF AUDITORS

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.
It is recommended that each member should review
not more than 10 patients each month.
That the auditor should have the ability to carry out
an audit in about 15 minutes.
 If there are less than 50 discharges per month, then
all the records may be audited,
If there are large number of records to be audited,
then an auditor may select 10 per cent of discharges.

RE ORIENTATION OF AUDITORS
a. A detailed discussion of the seven components of
criteria.
b. A group discussion to see how the group rates the
care received using the notes of a patient who has
been discharged,
c. These should be anonymous and should reflect a
total period of care not exceeding two weeks in
length
d. Each individual auditor should then undertake the
same exercise as above.
e. 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.

PLANNING MEDICAL CARE
a. 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.
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,

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 audit
a rare condition, with an insignificant
outcome

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.

DEVELOPING 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 coordinator 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

MEASURING LEVEL OF PERFORMANCE
•The data collected are to be precise
•Essential data
•Completed data
•Adequate data
•User group to be included
Example:
Immunisation status of pregnant women
•Do not try and collect too many items, keep it simple and
short.
•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 IMPROVEMENTS
IDENTIFYING BARRIERS TO CHANGE:
- Fear
- Lack of understanding
- Low morale
- Poor communication
- Individual Culture
- Doubt of outcome
-Consensus not gained
SYSTEMATIC APPROACH:
•identification of local barriers to change
•change culture
•support of teamwork
•use of a variety of specific methods like delegation and
accountability

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

ADVANTAGE Vs DISADVANTAGE
ADVANTAGE DISADVANTAGE

• Can be used as a method of • appraises the outcomes of the
measurement in all areas of nursing process, so it is not so
nursing. useful in areas where the
• Seven functions are easily nursing process has not been
understood, implemented,
• Scoring system is fairly simple, • many of the components
• Results easily understood, overlap making analysis
difficult, is time consuming,
• Assesses the work of all those
• requires a team of trained
involved in recording care,
auditors,
• May be a useful tool as part of a
• deals with a large amount of
quality assurance programme
information,
in areas where accurate records
of care are kept. • only evaluates record keeping.
It leading to improve
documentation, not nursing
care

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.

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Hospital Administration Made Easy

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Hospital Administrator.
DR. N. C. DAS

Nursing Audit

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