NURSING AUDIT

Nursing audit- definition, history, purposes, methods, characteristics, process

Nursing services are necessary for every client seeking care of any type, including health promotion, diagnosis and treatment. With the changing trends in the health care delivery, the role of the nurse manager is becoming largely devoted to the holistic care of client which can only achieved through the careful appraisal of the services in order to make further reforms.

Audit

A systematic and critical examination to examine or verify.

Systematic review and evaluation of records and other data to determine the quality of the services or products provided in a given situation.

Nursing Audit

Nursing audit is defined as the evaluation of nursing care in retrospect through analysis of nursing records. It is a systemic format and written appraisal by nurses of the quality of content and the process of nursing service from the nursing records of the discharged patient.

Definition

A review of the patient record designed to identify, examine, or verify the performance of certain specified aspects of nursing care by using established criteria. Often a nursing audit and a medical audit are performed collaboratively, resulting in a joint audit

(Mosby’s Medical Dictionary, 8th edition. © 2009, Elsevier)

“Nursing audit refers to assessment of the quality of clinical nursing”   Elison

“Nursing audit is an exercise to find out whether good nursing practices are followed”  Goster Walfer

The audit is a means by which nurses can define standards from their point of view and describe the actual practice of nursing.

Nursing audit is also defined as

.....part of the cycle of quality assurance. It  incorporates the systematic and critical analysis by nurses,midwives in conjunction with other staff , of the planning,delivery and evaluation of nursing ang midwifery care,in terms of their use of resources and the outcome for patients and clients, and introduces appropriate change in response to that analysis                 

BRIEF HISTORY OF NURSING AUDIT

Before 1915- very little was known about the concept.

1918- industrial concern introduced for the beginning of medical audit.

George Groword- introduced 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.

1955- First report of nursing audit of the hospital published

Next 15 years, nursing audit is reported from study or record.

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

PURPOSES OF NURSING AUDIT

• Evaluation: Evaluating the nursing care given. Achieve deserved and feasible quality of nursing care.
• Verification: Stimulant to better records. Focuses on care provided and not on care provider.
• Contributes to research. Review of professional work or in other words the quality of nursing care i.e. we try to see how far the nurses have confirmed to the norms and standards of nursing practice while taking care of patients.
• It encourages followers to be actively involved in the quality control process and better records.
• It clearly communicates standards of care to subordinates.
• Facilitates more efficient use of health resources.
• Helps in designing response orientation and in-service education programme.

METHODS OF NURSING AUDIT

There are two methods:

• Retrospective View: This refers to an in-depth assessment of quality after the patient has been discharged, and uses the patient’s chart as the source of data.
• Concurrent Review: This refers to the evaluations conducted on behalf of patients who are still undergoing care. It includes assessment the patient at bedside in relation to pre-determined criteria, interviewing the staff responsible for his care and reviewing the patient record and care plan.

ESSENTIAL CHARACTERISTICS OF NURSING AUDIT

There should be:

• Written standards of care against which to evaluate nursing care
• Evidence that actual practice was measured against such standards, sharing a percent conformance rate.
• Examination & analysis of findings.
• Evidence of corrective action being taken.
• Evidence of effectiveness of corrective action.
• Appropriate reporting of the audit programme.

PROCESS OF NURSING AUDIT   

                                         

1. Set the key criteria (item): It should be measurable against identified values, set standard & in terms of desired patient outcome.

Methods to develop criteria are:

• Define patient population.
• Identify a time framework for measuring outcomes of care.
• Identify commonly recurring problems presented by the defined patient population.
• State patient outcome criteria.
• State acceptable degree of goal achievement.
• Specify the source of information

2. Prepare Audit Protocol keeping in mind Audit Objectives, Target groups, Method of information gathering (by asking, observing, checking records), Criterion you are measuring, identify the time framework for measuring outcome of care, identify commonly recurring nursing problems, State acceptable of goal achievement.
3. Design the type of tool: Quality assurance must be a priority. Those responsible must implement a program not only a tool. A co-coordinator should develop and evaluate quality assurance activities. Roles and responsibilities must be delivered. Nurses must be informed about the process and the results of the program. Data must be reliable. Adequate orientation of data collection is essential. Quality data should be analyzed and used by nursing personnel at all levels.
4. Plan and implement the tool: What is to be evaluated? Who is going to collect the information? How many sample in the target group? Time period
5. Recording/Analysis, Concluding: Record the information, Analyze the information, Make a summary, Compare with set standard, Conclusion.
6. Using results : The results aid to modify nursing care plans & the nursing care process, including discharge planning, for selected patient outcome, implementing a program for improving documentation of nursing care through improved charting policies, methodologies & forms, focusing of nursing rounds & team conferences. Focusing supervisory attention upon areas of weakness identified, such as one particular nursing unit or specific employees. Designing responsive orientation & in-service education programs. Gaining administrative support for making changes in resources, including personnel.