NURSING AUDIT

Introduction

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.

Meaning :

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.

Definition :

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

Points to be remembered:

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 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
Conclusion

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.

Material management in jospitals

INTRODUCTION

Hospital supplies and equipments are dealt with under material management. Supplies are those items that
are used up or consumed; hence the term consumable is used for supplies. The supplies in hospital include
drugs, surgical goods (disposables, glass wares), chemicals, antiseptics, food materials, stationeries, the linen
supply etc. The term equipment is used for more permanent type of article and may be classified as fixed and
movables. Fixed equipment is not a structure of the building, but it is attached to the walls or floors (egg;
steriliser,) Movable equipment includes furniture, instruments etc.

PURCHASE OF SUPPLIES AND EQUIPMENT

The purchase of supplies and equipments in a hospital is carried out through;

1. General store
2. Dietary department and
3. Pharmacy department

When planning for the purchase of articles , budgeting is done not only for the actual price of articles but also
for the additional costs that are involved such as ;

 Transport charges ( local delivery reduce the transport charge)

 Incidental costs
 Cost of chemicals and other consumable to be used with the equipment (eg; ECG paper for an ECG
machine )
 Operating cost (hiring a technician )
 Cost of maintenance service; 10-20% of hospital equipment may remain idle if serving is not done
periodically.
 Cost of technology obsolesces: when a better quality appears in market there is tendency to discard the
old model.
 Replacement cost of equipment

Selection of article- while buying articles it has to meet the standards. Indian Standards Institution is the
national agency set up to bring standardisation of articles in India. Articles that meet the criteria specified by
the Indian Standard Institution will be marked by ISI markings. The articles bought should provide safety to the
patient and personnel. Faulty instruments and equipments cause not only inconvenience in the patient care,
but also it may cause the loss of life.

Purchasing article:

 The material used for any equipment should be durable, non-corroding, non toxic and safe for use.
 Should have standard shapes and dimensions to fit into various situations
 Reparability and spare part availability of the article
 Interchangability of the article
 All surgical instruments used in a hospital should be sterilisable and they should stand the tests for
leakage , hydraulic pressure tests for bursting etc
 Should have accuracy in measurements
  Should have ease of operation

The central supply service

Most hospitals have a central department where equipments and supplies are stored and from which they are
distributed to the units. The type of materials that is kept in the central supply room varies from hospital to
hospital. In some hospital the central soppy room deals with only the sterile supplies and ward trays. In other
hospitals all types of equipment such as oxygen, suction, ward trays, catheters, syringes etc are stored here.

Linen supply: Methods of handling linen supply include;

a) Departmentalised system: Here the supply of linen for each department of the hospital is
marked for that department. The head of the department is responsible for making a linen
standard for his own department.

b) Centralised linen supply: Under centralised system, linen is issued on exchange basis, that is
clean linen is exchanged for soiled linen.

FACTORS TO BE CONSIDERED

1. Type of service provided by the hospital: a maternity hospital requires more equipment related to
gynaecologic procedures than a cardiac hospital.
2. Age of patients: children need different type and amount of equipments than adults.
3. Sex- men and women sometime require different type of equipment.
4. Degree and type of illness- neurologic patients sometimes require more bedsides, rubber mattress and
linen than patients with other type of illness.
5. Cost of items- cost of items will limit the purchase of number of equipment.

GENERAL UTILITY SERVICES IN THE HOSPITAL

1. Electric supply and installations

A hospital must have a steady electrical supply at a stable voltage. Voltage fluctuations play
havoc with sophisticated electronic equipment, endoscope, sterilisers, X-ray equipments etc.
While planning hospital departments, provision should be made for voltage stabilisation in areas
with heavy concentration of electrical and electronic equipment. This is preferred over using
voltage stabilisers with individual equipment. There should be an emergency generator capable
of supplying power to all emergency areas of the hospital. This generator should be of right
capacity and kept in working order by periodic test runs.

2. Water supply

Since safe water supply is not always assured, hospitals must have their own purification
system. Also there should be plumbing system.

3. Disposal of waste –liquids and solids.

Disposal of waste both solid and liquid is a totally neglected area. A hospital incinarator good for
the waste management.

4. Refrigeration, air conditioning, ventilation and environment control.

Air conditioning is required for protection of sophisticated electronic equipment, X ray, machines
etc.
 5. Transport

Lifts are needed for vertical transport. There should be separate lifts for patients, visitors, staff
and supply. Patients lift should accommodate a standard hospital bed. Sides of the lift must be
protected to prevent damage by trolleys. Lift surfaces and flooring should be capable of easy
cleaning and disinfection. Ventilation, communication and emergency escape system should be
provided on all lifts. As for horizontal transport also trolleys and ramps with gentle gradient are
useful.

6. Supply of medical gases , compressed air, hot water, vacuum suction and gas plants

Piped supply of medical gases , compressed air, vacuum suction , hot water, steam,
necessitates thoughtful planning at all stages to consider problems of –

 Easy uninterrupted safe supply

 Fire and explosion hazards
 Easy of servicing and maintenance without disrupting hospital services.

7. Laundry- A hospital laundry has 2 separate areas, with provision for decontamination and sterilising of
soiled linen.
8. Fire hazard- there should be consideration of ventilation, exhaust systems and adequate earthing of all
electrical installation.
9. Communication- public telephone and internal telephones are required in each hospital.
10. Repairs workshop

There should be provision for repair and maintenance of necessary equipments used in the
hospital .

MATERIALS USED IN HOSPITALS

Hospital material medical side Hospital material management side

 Perfusion materials  Computer, fax, telephone, stationary

 Surgical disposables items
 Instruments  Public address items overhead
 Drugs, medicine, oxygen, linen projector
 Biomedical equipment  Audiovisual systems
 Disinfecting items
 Computers, telephone and fax
 Food and beverage materials
 Anaesthetic equipment
 Electro medical equipment
 Glass ware, dental machines
 Surgical dressing utensils
 Artificial limbs ,bandages, cots for patient,
furniture
 Engineering items and many others

ESSENTIAL EQUIPMENTS FOR A 50 BEDDED DISTRICT HOSPITAL (WHO)

1) Scope of services

 Essential clinical services- medicine, surgery, paediatrics., OBG, and acute psychiatry (when
necessary)
  Optional clinical services – oral surgery, orthopaedic surgery, otolaryngology, neurology and psychiatry.
 Essential clinical support- anaesthesia, radiology and clinical laboratory
 Optional clinical support services- pathology and rehabilitation including physiotherapy.

2) Essential medical equipment

 Diagnostic imaging equipment –it include x-ray and ultrasound equipment. X-ray equipment can be
stationary in one room or mobile
 laboratory equipment –
o microscope
o blood counter
o analytical balance
o calorimeter( spectrophotometer)
o Centrifuge – a small centrifuge that can accommodate six 15ml tubes should be available.
o Water bath – used for stabilising temperature at 25, 37, 42, or 56degree Celsius.
o Incubator/oven- a small hot air oven to carry out standard cultivations and sensitisations.
 Refrigerator – an ordinary household refrigerator with a freezer unit, for storing preparations, vaccines,
blood etc.
 istillation and purification apparatus - it should be made of metal that resists acid, and alkali and should
be free standing.

3) Electrical medical equipment.

 Portable electrocardiograph
 Defibrillator( external)
 Portable anaesthetic unit – 2 small aesthetic units should be obtained, complete with a range of masks.
 Respirator – it should be applicable for prolonged administration during post operative care.
 Dental chair unit- a complete unit should be available to carry out standard dental operations.
 Suction pump –one portable and one other suction pump are required.
 Operating theatre lamp- one main lamp with at least 8 shadows lamp and an auxiliary of 4 lamp units.
 Delivery table- it should be standard and manually operated.
 Diathermy unit – a standard coagulating unit which is operated by hand or foot switch, with variable
poor control.

4) Other equipment

 autoclave – for general stabilisation

 Small sterilisers- for specific services- eg. Stabiliser
 cold chain and other preventive medical equipment
 ambulance

5) Small , inexpensive equipment and instruments

 Equipment and instrument, such as BP apparatus, oxygen manifolds, stethoscope, diagnostic sets and
spotlights.

CONCLUSION

Health care services are the result of a number of materials used in the process. As hospital
administrators nurses should also know about the materials .Medical items such as perfusion materials,
surgical disposables, instruments, electrical, civil and engineering items for maintenance , house keeping
materials, linen, biomedical equipment . drugs, food items etc pay an effective role in improving the quality of
health care services.