NURSING AUDIT

Lt Col Jyoti P Shewale

NURSING AUDIT
Nursing audit is a way of ensuring quality
nursingcare.Nursing audit is a detailed review
and evaluationof selected clinical records by
qualifiedprofessional personnel to identify,
examine, orverify the performance of certain
specified aspectsof nursing care by using
established criteria.Quality nursing care
has become essential onday to day
functioning.With the implementation of CPA
professionalaccountability to an enlightened
public can nolonger be ignored by nursing staf

HISTORY OF NURSING AUDIT

Whilst Codmans clinical approach is in contrast
withNightingales epidemiological audits, both methods serve
tohighlight the diferent methodologies that can be used in
theprocess of providing quality patient care.Another famous
figure who advocated clinical auditwas Ernest Codman (1869
1940) by monitoring surgicaloutcomes .Florences gift of
statistic kept meticulous records of themortality rates among
the hospital patients.She and her team of 38 nurses applied
strict sanitaryroutines and standards of hygiene to the
hospital andequipment,On arrival at the medical barracks
hospital in Scutari in1854, Florence was pained by the
unsanitary conditions andhigh mortality rates among injured
or ill soldiers.One of first ever clinical audits was undertaken
by FlorenceNightingale during the Crimean war of 1853-1855

 The program is reviewed from record

nursing plan,nurses notes, patient
condition, nursing care.For the next 15
years, nursing audit is reported fromstudy
or record on the last decade.First report
of Nursing audit of the hospitalpublished in
1955.Before 1955 very little was known
about the conceptof nursing audit.

PURPOSES OF NURSING AUDIT1

1.Evaluating Nursing care given,2.
Achieves deserved and feasiblequality of
nursing care,3. Stimulant to better
records,4. Focuses on care provided
andnot on care provider,5. Contributes to
research.

 TYPES OF NURSING AUDIT NURSING

AUDITINTERNAL EXTERNAL

TYPES OF NURSING AUDIT1

Internal auditing:Internal auditing is a control technique
performedby an external auditor who is an employee of
theorganization. He makes an independent appraisalthe
policies, plans and points the deficits in thepolicies or
plans and give suggestion for eliminatingdeficits2)
external auditing:it is an independent appraisal of the
organizationsfinancial account and statements. The
externalauditor is a qualifed person who has to certify
theannual pprofit and loss account and prepare
abalance street after carefull examination of therelevant
books of accounts and documents

INTERNAL AUDIT RETROSPECTIVE

EVALUATION
: Retrospective audit is amethod for evaluating the quality of
nursing care by examiningthe nursing care as it is reflected in
the patient care records fordischarged patients. In this type of
audit specific behaviors are described then theyare converted
into questions and the examiner looks for answersin the
record.For example the examiner looks through the patients
recordsand 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 patients prehospital 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.

 9.Reviewing the patients record and care plan.III. PEER

REVIEW : In nurse peer review nurses functioning inthe same
capacity that is peers appraise the quality of care orpractice
performed by others equally qualified nurses.The peer review is
based on pre-established standards orcriteria.There are two
types of peer reviews:a) individual peer review; focuses on the
performance of anindividual nurse.b) nursing audit; focuses on
evaluating nursing care through thereview of
records.Interviewing the staff responsible for this care .It
includes assessing the patient at the bedside in relation topredetermined criteria,The evaluations conducted on behalf of
patients who are stillundergoing care.II. CONCURRENT
AUDIT : It is performed during ongoingnursing care.

 Outcomes traditionally used to measure quality

of hospitalcare include mortality, its morbidity,
and length of hospital stay.These audits
assume the outcome accurately anddemonstrate
the quality of care that was provided.Outcome
audits determine what results if any occurred
asresult of specific nursing intervention for
clients.The changes in the patients health
status and can beattributed to delivery of health
care services.Outcomes are the end results of
care;QUALITY AUDIT1. OUTCOME AUDIT:

 These above audits can occur retrospectively, concurrently

andprospectively.This audit assumes that a relationship
exists between qualitycare and appropriate structure.Such
as the finances, nursing service, medical records
andenvironment.Structure audit monitors the structure or
setting in which patientcare is provided.These audits
assumed that a relationship exists between thequality of the
nurse and quality of care provided.3. STRUCTURE
AUDIT:Process audit is task oriented and focus on whether
or notpractice standards are being fulfilled.Process audits
are used to measure the process of care or howthe care was
carried out.2. PROCESS AUDIT:

AUDIT CYCLEAUDIT IS A CYCLIC PROCESS

 PRE-REQUISITE FOR NURSING AUDIT CLINICAL AUDITCLINICAL

AUDIT PLANNING COMMITTEE MEDICAL CARE RE ORIENTATION
OF AUDITORS
14.If there are large number of records to be audited,then an auditor
may select 10 per cent of discharges. If there are less than 50
discharges per month, thenall the records may be audited,That the
auditor should have the ability to carry outan audit in about 15
minutes.It is recommended that each member should reviewnot
more than 10 patients each month. who are interested in quality
assurance, areclinically competent and able to work together in
agroup.Before carrying out an audit, an audit committeeshould be
formed, comprising of a minimum of fivemembersAUDIT COMITTEE

 15.RE ORIENTATION OF AUDITORSa. A detailed

discussion of the seven components ofcriteria.b. A
group discussion to see how the group rates thecare
received using the notes of a patient who hasbeen
discharged,c. These should be anonymous and
should reflect atotal period of care not exceeding two
weeks inlengthd. Each individual auditor should then
undertake thesame exercise as above.e. This is
followed by a meeting of the wholecommittee who
compare and discuss its findings, andfinally reach a
consensus of opinion on each of thecomponents.

 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, has information regarding
vital signs, has information regarding lab tests,
has information about the severity of illness,.
includes description of patients prehospitalroutines,PLANNING MEDICAL CAREa.
Collects patient data in a systematic manner,

 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 pointcareful thought and planning- There

seems little point in trying to audita rare
condition, with an insignificantoutcome

 Re-auditAll activities should be

documented.Report for ActionPilot
studyMethodology to be
followedAccess the evidence/data
Fix time and Plan resourcesInvolve
ALL the people concern.PLANNING
AUDIT

 DEVELOPING CRITERIA1. Define patient population.2. Identify a

time framework for measuring outcomes of care,3.Identify
commonly recurring nursing problems presented by the
definedpatient population,4. State patient outcome criteria,5. State
acceptable degree of goal achievement,6. Specify the source of
information.7. Design and type of toolPoints 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 assuranceactivities,d. Roles and
responsibilities must be delivered,e. Nurses must be informed
about the process and the results of theprogramme,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 PERFORMANCEThe data

collected are to be preciseEssential dataCompleted
dataAdequate dataUser group to be
includedExample:Immunisation status of pregnant
womenDo not try and collect too many items, keep it
simple andshort.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 IMPROVEMENTSIDENTIFYING
BARRIERS TO CHANGE:- Fear- Lack of
understanding- Low morale- Poor
communication- Individual Culture- Doubt of
outcome-Consensus not gainedSYSTEMATIC
APPROACH:identification of local barriers to
changechange culturesupport of
teamworkuse of a variety of specific methods
like delegation andaccountability

 SUSTAINING IMPROVEMENTMONITORING AND

EVALUATION:systematic approach to changing
professional practiceshould include plans
to:monitor and evaluate the changemaintain
and reinforce the changeREINFORCING
IMPROVEMENT:reinforcing or motivating
factors by the management .integration of
auditstrong leadership6. RE-AUDIT:-Review
evidence-Measure efectiveness-Decide how
often to re-audit- Ongoing process monitoringAdverse incidents-Significant events audit