Posted by Afandi on December 19, 2008
Prepared By: Binil.V, MSc.N, manipal College of Nursing, ManipalUniversity
The world trend of professional accountability to an enlightened public can no longer be ignored by nursing. We nurses easily use the words “Quality Nursing” but have we defined what we mean by “Quality?”. Do we know our deficiencies? Are we ready to admit our deficiencies to our peers? Are we taking steps to remedy them? Only by such self regulation we can retain our identity with the health professional as nature partners.
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 care.
4. Medical audit – the systematic, critical analysis of the quality of medical care, including the procedures for diagnosis and treatment, the use of resources, and the resulting outcome and quality of life for the patient.
1. According to Elison “Nursing audit refers to assessment of the quality of clinical nursing”.
2. 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.
Brief 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 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.
Methods of Nursing Audit :
There are two methods:
a. 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. 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.
b. The 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 pre-determined criteria, interviewing the staff responsible for this care and reviewing the patients record and care plan.
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
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 Cycle :
Implement change observe practice
Compare with standards
Audit Committee :
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 and 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.
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.
c. 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 pre-hospital 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,
Audit as a Tool for Quality Control :
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. The audits most frequently used in quality control include outcome, process and structure audits.
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. Example of 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 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.
Advantages of Nursing Audit :
1. Can be used as a method of measurement in all areas of nursing.
2. Seven functions are easily understood,
3. Scoring system is fairly simple,
4. Results easily understood,
5. Assesses the work of all those involved in recording care,
6. May be a useful tool as part of a quality assurance programme in areas where accurate records of care are kept.
Disadvantages of the Nursing Audit :
1. appraises the outcomes of the nursing process, so it is not so useful in areas where the nursing process has not been implemented,
2. many of the components overlap making analysis difficult,
3. is time consuming,
4. requires a team of trained auditors,
5. deals with a large amount of information,
6. Only evaluates record keeping. It only serves to improve documentation, not nursing care.
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.
1) Kamal S Jogelkar. Hospital word management; professional adjustments and trends in nursing. Mumbai; Vora medical- publications : 1990.
2) BT Basavanthappa. Nursing Administration. New Delhi; Jaypee Brothers : 2002.
3) SL Goel, R Kumar. Hospital administration and management. New Delhi; Deep and Deep publishers : 2000.
1) C Bjorvell. Development of an audit-instrument for nursing care plans in the patient record. J. Quality in health care. 2000; 9:6-13.
2) G Johnston. Reviewing audit: barriers and facilitating factors for effective clinical-audit. J. Quality in health care. 2000; 9:23-36.
3) G Jamtvedt. Audit and feedback: effects-on professional practice and health care outcomes. J. Quality in health care. 2000; 7:27-36.
4) FM Cheater and M Keane. Nurses participation in audit: A regional study. J. Quality in health care. 1998;