STRUCTURE

Dr. Gehan M. A. Mostafa
Faculty Of Nursing
Helwan Univerisiy, Egypt


Identify structure

Standards & criteria

Take action & Evaluate
Philosophy

objectives

Resources

Policies
Procedures

Job description

Personal qualification
Identify strengths & limits




Standards and criteria to evaluate outcome

- Change in clients health states

- Client disposition

- Personnel / client safety

- Client / personnel satisfaction

- Documentation of care effectiveness

- Efficiency of services






Identify

Values
Identify process standards & criteria

- Professional standards application

- Nursing process application

- Nursing procedures

- Client satisfaction

- Personnel performance evaluates


OUTCOMES PROCESS

Identify alternative problem Salving choices

NURSING AUDIT:

Introduction:

Quality in product services, is the demand of the day as per a famous statement “You cannot insert quality into the product; quality must be built into the product as service”. The level of quality is determined at the point of service, which is experienced and perceived by the clients and reflected through the audit process.

History of Nursing Audit:

Before 1955 very little was known about the concept of “Nursing Audit”. George Groward a physician was the first one to pronounce the term medical audit in 1918. Ten years later Thomas. R. Pondon HD established a method of Medical Audit based on procedures used by financial account. The 18th report of Nursing Audit of the hospital published in 1995.

DEFINITION:

According to Ganong & Ganong;

“Nursing audit is a method for assuring documentation of the quality of nursing care in keeping with the standards of the agency, the nursing department, and the professional, governmental and accrediting groups.

According to Phaneuef (1976).

A method for evaluating quality of care through appraisal of nursing process as at is reflected in the patient care records for discharged patients.

According to Eclison :

Nursing audit refers to assessment of the quality of clinical nursing.

PURPOSES OF NURSING AUDIT:

1. Necessitating adequate documentation of nursing care provided to the client through the entire nursing process.

2. Directing attention to the design and utility of the charting record.

3. Encouraging the use of the problem oriented nursing system.

4. Supporting and becoming an integral part of nursing by objective program

5. Facilitating the co-operative planning and delivery of client care by physicians and nursing employees.

6. Increasing the priority for a results oriented performance evaluation program for nursing service employees.

7. Enriching and providing direction to in service education effects.

8. Providing a specific management technique in carrying out evaluation and control function.

9. Identifying ways to improve patient care.

10. Providing a meaningful ways for nursing staff members to participate and achieve career growth.

CONCEPT OF NURSING AUDIT:

Nursing Audit mainly comprises of

I. Debit II. Credit

I. Debit:

Debit is all negative activities in nature e.g.. Hospital infection.

II. Credit:

Credit mainly involves all positive activities in nature

Eg. Satisfactions of care

Debit Items of Nursing Audit:

1. Death of the client not justifiable as otherwise could have been prevented.

2. Complications due to the neglect of nursing care.

3. Complications of diseases leading to morbidity.

4. Hospital infection

5. Errors in treatment

6. Clients discharged against medical advice.

7. Absence of total client care.

8. Lock of application of nursing process.

Credit Items in Nursing Audit:

i) No : of recovered patients

ii) Shortens stay in the hospital

iii) Expansion of health knowledge in client population.

iv) Research as need for problem oriented care approach.

v) Regular follow up in the community.

vi) Measures to improve the public image

vii) Well maintained nursing audit

TYPES OF AUDITORS:

Auditing whether general as nursing can be conducted by two types of auditors.

1. Internal auditors

2. External auditors

1. Internal Auditors:

In nursing auditing, external auditors are the nursing experts as specialists in the hospital appointed by the hospital management eg : Nurse Manager, Director.

2. External Auditors:

The experts from the external statutory agencies to the auditing process ag : inspectors from TNAI, KNC etc.

ORGANISATION OF NURSING AUDIT:

Nursing Audit has become mandatory for 3 basic reasons.

1. The increasing cost of the care.

2. The need to improve the quality of care.

3. The need for the proof of the quality of care actually delivered, proof for the–

a) Nurse, b) Agency, c) Client

STEPS OF NURSING AUDIT PROCESS:

I. According to Logufo and Brook (1984)

1. Selection of a topic for study

2. Selection of explicit criteria for quality care

3. Review of records to determine whether criteria are met.

4. Peer review of all cases that do not meet criteria.

5. Specific recommendations to correct problem

6. Fallow-up to determine whether problems have been eliminated.

II. The Joint Commission in Accreditation of Hospitals (JCAH) the audit procedure should include following 6 steps.

1. Standards and Criteria Established

Standards are designed to provide measurement criteria and must be a objective, achievable, practical flexible and acceptable.

Methods to develop criteria are;

a) Define client population.

b) Identify a time framework for measuring outcomes of care

c) Identify commonly recurring nursing problems presented by the defined patient population.

d) State client / patient outcome criteria

e) State acceptable degree of goal achievement

f) Specify the source of information



AUDIT CYCLE:



Set standards

­

Implement --------- Audit Cycle ---- Observe practice Change

­

Compare with standard






2. Measurement of Actual Practice Against Criteria

This means to secure the charts from medical records (possibly by random selection, collect the necessary data, measure the result against set standards.

3. Evaluation of the results

4. Action taken to correct deficiencies

5. Follow up and reassessment

6. Report to nursing service administration and needed staff

TYPES OF NURSING AUDIT:

The nursing audits are mainly of two types

1. Concurrent audit 2. Retrospective audit

1. Concurrent Audit:

The concurrent audit has also been called as the open chart audit because it is done while the patient is receiving care. It is a process audit that evaluates the quality of ongoing care being perceived by clients by looking at the nursing process.

Purpose: To assess the post and present care given to a client.

Components:

1. Assessing the client

2. Interviewing the nursing staff

3. Reviewing the clients record and care plan.

Advantages of Concurrent Audit:

1. Indications of problems at the time of caring

2. Provision of a mechanism for identifying and meeting clients’ needs during care

3. Implementation of measures to fulfill professional responsibilities.

4. Provision of a mechanism for communicating on behalf of the client.

Disadvantages:

1. Concurrent audit is a time consuming procedure

2. It is costly to implement than the retrospective audit

3. Does present the total picture of care that the client ultimately well receive

4. Rosenthal effect: changing results at expectations of care gives

2. Retrospective Audit:

Refers to an in-depth assessment of the quality, after the client has been discharged, having the client chart as a source of data.

Focuses in 2 factors – Discharge status and complications the 3 components of discharge status are:

- Heath - Activity - Knowledge

Advantages:

i) Comparison of actual practice to standards of care

ii) Analysis of actual practice findings

iii) A total picture of care given

iv) More accurate data for planning corrective action

Disadvantages:

1. The focus of evaluation is directed away from ongoing care

2. The clients’ problems are identified after discharge

OTHER TYPES OF NURSING AUDITS:

(i) Structure audit:

The inspection of the management process as carried out and documented by the nurse manager.

(ii) Process audit:

In this type of audit inspection of the nursing process, as carried out and documented by staff nurses to evaluate competence with established standards of nursing care.

(iii) Outcome audit:

It mainly identifies client outcomes (satisfactory and unsatisfactory and the patterns of nursing care that appears to be responsible.

NURSING AUDIT COMMITTEE:

The 1st step in organizing a nursing quality assurance program is establishing a Nursing Audit Committee.

The nursing audit committee should be a standing committee of the department of nursing and should submit monthly and annual reports to the nursing administrator. Actual audits may be performed by personnel within specialty areas (eg. Medicine, surgery, obstetrics, pediatrics, psychiatry, cardiac case, emergency case etc) as by representation from these specialities serving on the standing committee larger agencies may decentralize the auditing to subcommittees.

MEMBERSHIP TO THE AUDITING COMMITTEE:

Membership of the Audit committee should include representative of all levels of professional nursing including

- Client care coordinators

- Supervisors

- Head nurses

- Clinical specialists

- Nurse clinicians

- Licensed practical nurses

- Nursing assistants

- Other client care personnel

- Medical records administrator

FUNCTIONS OF THE AUDIT COMMITTEE

During the 1st phase

Development of purposes and objectives

Establishing standards and criteria

Establishing guidelines for conducting audits

Deciding upon auditing forces (JCAH forms)

Initiating the auditing process

Keeping up brief, pertinent minutes of all audit committee meetings.

During 2nd phase:

It begins with the actual implementation and maintenance of the audit procedure.

ONGOING RESPONSIBILITIES OF NURSING AUDIT COMMITTEE:

1. Planning audit sessions and scheduling

2. Arrange for medical records to pull charts for retrospective audits and retrieve data.

3. Evaluating audit results in committee.

4. Conducting process audits

5. Preparing summaries of all audits

6. Teaching professional nursing personnel the auditing process

7. Assisting nursing staff in using audits results

8. Making recommendations

9. Keeping brief pertinent minutes of audit committee meetings.

REPORTING AUDIT RESULTS:

The provide, a record of

- A committee’s work

- Summary of audit activity

- An organized presentation of general findings

- Recommendation for actions that have been presented.

- Follow through action that has taken place

- Impact of follow up action on problem conditions.

EXAMPLE OF AN AUDIT SUMMARY:

To: Ward or unit: Date :

From: Audit Committee Signed Chairman

Re: Audit Topic

Quality Control Check of Nursing Process

- Number of open charts audited

- Number of clients observed / interviewed

- Number of personnel observed / interviewed

RETROSPECTIVE AUDIT OF PATIENTS OUTCOMES:

- Number of closed charts audited

- Finding and recommendations

1. Indication of quality case

2. Outstanding problems

3. Indications of improvement

4. Recommendation for improvement

5. Special comments

FACTORS AFFECTING AUDITING PROCESS IN NURSING:

- Lack of resources

- Personnel problems

- Unreasonable clients and attendants

- Improper maintenance

- Absence of well-informed population

- Absence of accreditation laws

- Legal redress

- Lack of incident review procedure

- Lack of good hospital information system

- Absence of survey condition routine

- Lack of nursing case records

- Miscellaneous factors

ADVANTAGES OF NURSING AUDIT:

- Method of measurement

- Functions are easily understood

- Scoring system is fairly simple

- Results are easily understood

- Assess the work of all those involved in recording case.

- May be useful tool as part of a quality assurance program in area where accurate records of case are kept.

DISADVANDAGES

- It is not so useful in areas where the nursing process has not been implemented.

- Many components overlap making analysis difficult

- It is time consuming

- Requires a team of trained auditors.

- Deals with a large amount of information.

- Only evaluates record keeping

BIBLIOGRAPHY :

Barbara Cherry, Contemporary nursing issues trends and management, Mosby publication. 2nd Edition Page 419.

Basavanthappa B.T, Nursing Administration, 1st Edition 2000, Jayper Brothers Page : 161, 435 – 438.

Ganong J.M and Ganong W.L, “Nursing Management” 2nd Edition 1980, Aspin Publication Page 96 – 97 : 194 – 207.

Laura Mae Dongla. The effective nurse leader and manager, 4th edition, Page 193 – 196.

Stanhope (1988). Community Health Nursing Process and Practice for promoting health mosby publication. Page 233 – 347, 447-448.

Schroeder Patricia S and Maibusel Regena M, “Nursing quality Assurance”, 1984, Aspen Publication, London Page 193 – 199.

Stevens J “Nursing Management” 1996, Mosby Publications New York.

Journals :

Andrades, Christine, 2000 “Importance of Clinical audit in the prevention and control of hospital acquired infection”. Asian Journal of Cardio Vascular Nursing 10 (2) : 9 – 13.

Brar A, 1989 “An evaluation of patient cax, The Nursing Journal of India. NewDelhi Vol. LXXX No. 10 : 268 – 269.

Khan G. August 1999 “Factors affecting quality assurance in nursing care”. Nursing Journal of India Vol. LXXXX No. 8 Page 173 – 174.

Moree K, “what nurses learn from nursing audit”, Nursing out look, January 1988, 26 (1) 48.

S.Sridhar. Quality assurance in nursing Indian Journal of Nursing and Midwifery Vol. 2 Sept 1988.

QUALITY ASSURANCE SETTING STANDARDS

Dr. Gehan M. A. Mostafa
Faculty Of Nursing
Helwan University

For more than 100 years, a authors have written about the evaluation of nursing practice as a process with minimal elements of

1. Setting standards

2. Comparing nursing practice to such standards

3. Instituting changes to increase the adherence to the standards

EVOLUTION OF STANDARDS:

The first to write about standards in English language was Florence Nightingale whose notes on nursing what it is and what it is not was first published in England in December 1859. In it she frequently called for change to achieve high standards.

Nightingale developed a multitude of standards of nursing care in the 19th century whether the care was provided by a family member as some one far such service. Notes on nursing have standards regarding.

· Noise and its control around sick.

· Consistency of food and when it should be served.

· Type of bed and mattress to be used, as well as prospects about the bed linens

· Position of the bed in relation to windows so that the patient can look out.

· Cleanliness of the room.

· Personal cleanliness.

Though Nightingale made no comparison between her standards and the existing conditions, within 6 months she reduced the mortality to 2%. In other words a quality assurance as quality control process was used. Much has been done since that time to isolate the concept of setting standards from the larger process of evaluation. Establishing schools of nursing after 1873, was quite an indirect approach in terms of setting standards for practice and meaning improved compliance. Almost two decades after schools of nursing has been established. Efforts were again made to set standards far them. This in turn improved the care of side in the hospitals, because schools of nursing were intimately associated within the hospitals. Eldredge addressed the quality of nursing care in 1932 predominantly in terms of the quality of care given by students in hospitals. She defined quality of nursing care in terms of the quality of care given by students in hospitals. She defined quality of nursing care in terms of outcomes of nursing practice although not in the measurable outcomes used today.

After the World War II the attention was again focused on establishing standards and upgrading nursing care. In the 1950’s as the nursing process emerged, as an identifiable entity with the specific elements evaluation of care was almost always included as a step in nursing process. Orlando identified function, process and principles of professional nursing. She stressed on the evaluation of nursing process. Carrier and Sitzman in 1971 included evaluation as the final point in the six step process of the nursing care plan. In 1973 the ANA legitimized the nursing process. Thus started the era for the evaluation of the nursing profession for better quality care of the patient and quality assurance of the profession itself.

STANDARDS

Definition: Standard is an established rule as basis of comparison in measuring or finding capacity, quality context and value of objects in the same category. Standard is a broad statement of quality. It is a definite level of excellence as adequately required, aimed at or possible.

Standard is a predetermined baseline condition as level of excellence that comprises a model to be followed and practiced. It is used as a measurement tool.

Professional Standards of Nursing Practice:

Professional standards of nursing practice as established by professional nursing organization exist to guide the nurse in providing case.

“A standard in a model of established practice which has general recognition and acceptance among registered professional nurses and is commonly accepted as correct standards of practice are agreed on levels of competence as determined by the ANA and specially nursing organizations” [ANA – 1996].

“Standards are defined as authoritative statements that describe a common level of care as performance by which the quality of practice can be determined or measured. Standard help define professional practice (Hubes – 1996).

Importance of standards in Nursing :

It is an authoritative statement by which the quality of nursing practice, service and education can be judged.

In nursing practice, standards are established criteria for the practice of nursing.

It is a guideline and a guideline far is a recommended path to safe conduct an aid to professional performance.

It provides a baseline for evaluating quality of nursing care, increase effectiveness of care and improve efficiency.

Standard, help supervisors to guide nursing staff to improve performances

Standards may help to clarify nurses’ area of accountability

Standards may help nursing to clearly define different levels of care

Standard is a device for quality assurance as Quality control.

PURPOSES OF STANDARDS:

The purposes of publishing, circulating and enforcing nursing care standards are to

Improve the quality of nursing

Decrease the cost of nursing

Determine the nursing negligence

CHARACTERISTICS OF STANDARDS

1. Statement must be broad enough to apply a wide variety of settings.

2. Must be realistic, acceptable and attainable.

3. Nursing care must be developed by members of the nursing profession.

4. Must be understandable and stated in unambiguous term.

5. Must be based on current knowledge and scientific practice.

6. Must be reviewed and revised periodically.

7. Must be directed to

wards an optimal standard.

SOURCES OF NURSING CARE STANDARD:

The standard can be established, developed, reviewed as enforced by variety of sources as follows

Professional organizations like TNAI

Licensing bodies IC, MCI, & DCI etc

Departments of the institution

Patient care unit

Government unit at national, state and local government unit

Individual personal standard

CLASSIFICATION OF STANDARDS:

Koont and Weitrich (1988) have identified the following eight type of standard the most organization must establish.

Physical standard: which include patient activity rating to establish nursing care hours per patient per day.

Cost standard – which includes the cost per patient per day.

Capital standard – which include the review of monitory investments as new program

Revenue standards: which include the revenue per patient day for nursing care

Program standard – which guide the development and implementation of program to meet client needs.

Intangible standards: which include staff development as personnel orientation cost.

Goal standard: which outlines qualitative goal in short and long term planning.

Strategies plan standard, which out lines check point in developing and implementing the organization strategic plan.

NURSING CARE STANDARDS can be divided into ends and means standards

1. End Standards :

The end standards are patient oriented; they describe the change as desired in a patients physical status or behavior.

2. Mean Standards:

The mean standards are nursing oriented, they describe the activities and behavior designed to achieve end standards.

End standards require information about the patients. A mean standard calls for information about the nurses’ performance.

NURSING CARE STANDARDS can be classified according to frame of references, relating to nursing structure, process and outcome.

1. STRUCTURE STANDARD:

A structural standard involves the setup of the institution. The philosophy, goals and objectives, structure of the organizations, facilitates and equipment and qualifications of employees are some of the components of the structure of the organization. Example, recommended relationship between the nursing department and other departments in a healthy agency are structural standards, because they refer to the organizational structure in which nursing is implemented. It includes people, money equipment, staffing policies etc. The use of standards based on structure implies that if the structure is adequate reliable and desirable, standard will be met as quality care will be given.

2. PROCESS STANDARD

Process standards describe the behaviors of the nurse at the desired level of performance. A process standard involves the activities concerned with delivering patient care. These standards measure nursing action or lade of actions involving patient care. The standards are stated in action verbs that are in observable and measurable terms. Eg : “the patient demonstrates. The focus is on what was planned, what was done and what was communicated as recorded. In process standard there is an element of professional judgment ie determining the quality as the degree of skill. It includes nursing care technique, procedures, regimens, and processes.

3. OUTCOME STANDARDS :

Descriptive statements of desired patient care results are outcome standard, because patients results are outcome of nursing intervention.

An outcome standard measures changes in the patient health status. This change may be due to nursing care, medical care or as a result of variety of services offered to the patient. Outcome standards reflect the effectiveness and results rather than the process of giving care.

Thus structural standards are agency or group oriented, process standards are nurse oriented and outcome.