Quality assurance

1. QUALITY ASSURANCE IN
NURSING

2. INTRODUCTION
Quality is rapidly becoming
concern to both consumers and the
providers of the services . In health
care quality is being demanded and
expected and providers are judged by
the quality of services and hence
there is a need to sensitize and train
nursing personnel to provide quality
care

3. CONCEPT OF QUALITY IN
HEALTH CARE
• INTERACTIVE PROCESS
BETWEEN CUSTOMER AND
PROVIDER
• EXAMPLE A DOCTOR WRITING
PRESCRIPTION

4. QUALITY
Definition:
• The extent of resemblance between the
purpose of health care and the truly
granted care
• The extent of accomplished relief care
with a justified use of means and services
• Weighing out between results and costs to
fulfil certain expectations in health care

5. CONCEPT OF QUALITY
ASSURANCE
• Dynamic process through which
nurses assume accountability for
quality of care they provide
• Guarantee to the society that
members of a profession are
regulating services provided by
nurses

6. • It is judgement concerning the
process of care based on the extent
to which that care contributes to
valued outcome
• Monitoring of activities of client
care to determine the degree of
excellence attained to the
implementation of activities

7. • Q.A is the defining of nursing
practice through well written
nursing standards and the use of
those standards as the basis of
evaluation on improvement of
client care
• so in order to provide quality care
there is a need to train nursing
personnel

8. PURPOSES
• To introduce code of ethics and
professional conduct for nurses in
India to the nursing personnel
• To prepare nursing personnel for
implementation of quality
assurance model in nursing

9. OBJECTIVES
• State the code of ethics and the
professional conduct for nurses in India
• Recognize the significance of following
code of ethics and professional conduct in
nursing practice
• Explain QAM as pre-requisite for quality
nursing care
• Describe the practice standards for nurses
and their rationale

10. • Identify the legal boundaries for nursing
practice
• Prepare nursing care plan following nursing
process approach
• Appreciate the importance of practicing
standard safety measures
• Identify appropriate communication
techniques to be used in given interpersonal
situation

11. • Plan and conduct patient teaching session
• Identify appropriate management techniques
to be used for managing resources in a
given situation
• Appreciate the importance of continuing
education and research for development of
‘self’ , ‘others’ and of the ‘profession’
• Describe the institutional disaster
preparedness plan and nurses role

12. APROACHES FOR QUALITY
ASSURANCE PROGRAM
Two major categories of approaches
exist :
1)GENERAL
2)SPECIFIC

13. GENERAL APPROACH
• It involves large governing of
official body ‘s evaluation of
person’s or agency’s ability to
meet established criteria or
standards at given time

14. 1) CREDENTIALING
Formal recognition of professional or
technical competence and attainment of
minimum standards.
It has four functional components
• to produce quality product
• to confer a unique identity
• to protect provider and public
• to control the profession

15. 2) LICENSURE
• Contract between the profession
and the state
• Profession granted control over
entry and exit from profession and
over quality of professional
practice
• Regulations are written to define
the scope and limits of the
professional practice

16. 3)ACCREDITATION
• National league for nursing has
established standards for inspecting
nursing education programs
• Evaluation is particularly for agency’s
physical structure, organizational
structure ,and personal qualification
• Emphasizes on evaluation outcome of
care and on educational qualification of
person providing care

18. 4) CERTIFICATION
• Voluntary process within a profession
• Person’s education achievements
,experience and performance on
examination are used to determine the
person's qualification for functioning in
an identified specialized area

19. SPECIFIC APPROACHES
Quality assurances are the methods
used to evaluate identified
instances of provider and client
interaction

20. 1) PEER REVIEW COMMITTEE
monitors client specific aspects of
care appropriate for certain levels
of care
• audit has been used as major tool
by peer review committee to
ascertain quality of care

22. 2) AUDIT PROCESS
• Follow up of problem topic study
selected
• Recommendations for correcting
deficiencies explicit criteria
selected for quality care, peer
review of all cases not meeting
criteria records reviewed

23. 3)UTILIZATION REVIEW
Directed towards ensuring that care is
actually needed and the cost appropriate
for the level of care provided
Three types
a) Prospective:assessment of necessity of
care before giving service

24. b) CONCURRENT REVIEW
Necessity of care while the care is being
given
c) RETROSPECTIVE REVIEW
Analysis of the necessity of services
received by the client after the care has
been given
• U.R primarily used in hospitals to
establish the need of admission and
length of stay

25. ADVANTAGES OF UTILIZATION
REVIEW
1) avoids unnecessary care in clients
2)serve to encourage the consideration of
care options by providers such as home
health care rather than hospitalization
3)provide guidelines for staff of program
development
4)provide measure of agency's
accountability to the consumer

26. DISADVATAGE OF
UTILIZATION REVIEW
Not all the clients fit for classic
picture presented by explicit
criterion that serves as the basis for
approval or denial of care

27. EVALUATION STUDIES
Three major methods are used
• Donabedian’s structure -process -
outcome method
• The tracer model
• The sentinel model

28. • DONABEDIAN ‘S MODEL

29. Donabedian Model of Quality
Structure Process Outcome

31. TRACER METHOD
• Measure of both process and outcome of
care
• Volume of client with a particular
characteristic resuming specific health
care management is identified e.g patient
with hypertension
• Provides nurses with data to show the
difference in outcome as result of nursing
care standards

33. SENTINEL METHOD
• Cases of unnecessary disease, disability ,
deaths are counted
• Circumstances surrounding the
unnecessary event examined in detail
• Morbidity and mortality are used as index
• Health status indicators as changes in
social ,economic ,political and
environmental reviewed which may effect
on health outcomes

34. CLIENT DISSATISFACTION
Can be assessed using
• person
• telephone interviews
• mailed questionnaire
these are used to measure structure
process and outcome of care given

35. INCIDENT REVIEW
During patient’s hospitalization various
incidents can occur which have a bearing
on treatment and patient’s final recovery
.They can be :
•Delayed attendance by the nurse or physician
•Incorrect medications
•Lack of cleanliness and asepsis leading to infection
•Carelessness in carrying out nsg procedures.

37. REPORT CONTAINS
Since these reports are of legal value so
should be written carefully and in detail.
Should contain:
• name ,age time and place
• description how it occurred
• precautions taken
• condition of patient before and after the
incident

38. RISK MANAGEMENT
• Developed for the purpose of
eliminating or controlling health
care situations that has the
potential to inure endangers or to
create risk for the clients the
activities are directed towards :

39. IDENTIFICATION
ANALYSIS
EVALUATION OF SITUATION TO PREVENT
INJURY AND SUBSEQUENT FINANCIAL LOSS

40. MALPRACTICE LITIGATION
• Specific approach to be imposed on
health care delivery system by legal
system
• malpractice litigation
results from client
dissatisfaction with the
provider and with the
content of care received

42. QUALITY IMPROVEMENT
Principles and conditions for total
quality management
• continuous quality improvement
• knowledge of customer expedition needs
• processes of customer supplier
relationship
• belief in people
• statistical analysis
• costs of poor quality

43. Conditions in the working
environment
• employer involvement
• improvement
• environment that supports risk taking
• team work
• data collection and analysis skills
• group interaction skills
• structure and management to enable
improvement
• tools to facilitate improvement

44. FRAMEWORK FOR QUALITY
Quality in nursing practices
JCAHO 1997 defines quality improvement
as an approach to the continuous study
and improvement of processes of
providing health care services to meet the
needs of clients and others

45. STEPS IN QUALITY IMPROVEMENT
Quality defined
1) Professional standards:authoritative
statements used by the profession in
describing the responsibilities for which
its practitioners are accountable
a) policies: non-negotiable aspects of
practice that allow for professional
judgement or interpretation in their
implementation e.g professional dress
policy

46. B) job description :qualifications and
responsibilities for individual within a
position or job category e.g clinical
director , staff nurse .
C)outcomes:conditions to be achieved as a
result of care delivery . It ells whether the
interventions were effective ,whether
client progresses , how well the standards
are being met and whether changes are
necessary

47. • Professional outcome
• Client outcome
• developing quality development
team (composed of all staffs from
all departments within a hospital

48. COMPONENTS OF QUALITY
IMPROVEMENT PROGRAM
JCAHO’s 10 steps for Q.I program
1) establish responsibility and accountability for
Q.I program
2) define the scope of service for the clinical
area
3) define the key aspects of service for clinical
area
4) develop quality indicators to monitor the
quality outcomes and appropriateness of the
care given
5) establish thresholds for evaluation of

49. 6) collect and analyze data from
monitoring activities
7) evaluate results of monitoring activities
to determine need for change in practice
8) resolve problems through development
of action plans
9) reevaluate to determine if the plan was
successful
10) communicate Q.I results to the
organization

50. MODELS OF QUALITY ASSURANCE
1) UNIT BASED QUALITY ASSURANCE
PROGRAM
The basic components of the system are:
• INPUT: present state state of system
• THROUGHPUT :developmental process
• OUTPUT :finished product
• FEEDBACK :maintains and nourishes
growth

51. 2)AMERICAN NURSES
ASSOCIATION MODEL
• Developed in 1997
• widespread applicability
• used as guide to implement QA
program
• first step in developing QA
program is continuing education

52. ANA QUALITY ASSURANCE
MODEL
Basic components of of ANA model are :
• IDENTIFY VALUES
• IDENTIFY STRUCTURE ,PROCESS AND
OUTCOME STANDARDS AND CRITERIA
• SELECT MEASUREMENT
• MAKE INTERPRETATION

53. • IDENTIFY COURSE OF
ACTION
• CHOOSE ACTION
• TAKE ACTION
• REEVALUATE

54. DEVELOPING QUALITY
INDICATORS
• Quality indicator is a quantitative
measure of an important aspect of service
that determines whether the service
conforms to established standards or
requirements
• it’s the focus for quality improvement

55. THREE TYPES OF QUALITY
INDIACTORS
1) STRUCTURE INDICATORS
evaluate structure or system for
delivering care
2)PROCESS INDICATORS
Evaluate the manner in which care is
delivered
3)OUTCOME INDICATORS
evaluate the end result of care delivered

58. When the unit based team sits together it
sets forth certain criteria as to how
nursing care can be improved .It may
includes
• weak process that is causing problems
• a stable process that is adequate but can
benefit for improvement
• a process related to negative outcome

59. ESTABLISHING THRESHOLD FOR
EVALUATION
After selecting quality indicator, staff
members must determine the ways to
quantitatively measure the indicator .
• A threshold is A standard for determining
whether a problem exists
• a measurement that falls below the
threshold indicates problems

60. • staff will then thoroughly review the
factors interfering with successful client
education and adherence
• staff continuously work to improve
outcome or performance by raising
threshold
• intend of QI is to seek ways to
continuously improve . This includes
defining the acceptable level of
performance and allowing for normal

61. DATA COLLECTION AND ANALYSIS
• main motive is in obtaining accurate
results that help in making appropriate
decisions regarding quality care issues
• even formal research studies are
conducted.statistical techniques are used
to determine if the problem identified is
significant
• if QI involves introduction of new
procedures statistics can show whether it
made significant difference in outcome

62. IMPORTANT IN DATA
COLLECTION IS TO COLLECT
DATA ON RIGHT CRITERION AND
THEN TO HAVE ADEQUATE DATA
FROM WHICH TO MAKE
DECISION

63. EVALUATION OF CARE
Monitoring of quality indicators evaluates
whether a specifically defined process
reaches the desired outcome
• if results > or = it implies no problem ,
process is performing well

64. • if results < threshold then process is not
working well so staff must try to find
problem]
• staff uses FOCUS , PDCA model
• allows the staff to find the aspect of
process to improve
• select an expert team understand any
source of variation and select solution

65. if results < threshold then process is not working well
so staff must try to find problem]
staff uses FOCUS , PDCA model this
allows the staff to find the aspect of process to improve and
select an expert team who knows the process
clarify knowledge about process understand any source
of variation and select solution
Team collaborates to discover the factors associated with
practice problems
team recommends approaches for improving the process
with the goal of achieving desired outcomes

66. Evaluation of Improvement:
After implementing an action plan, the
staff must reevaluate its success. In the
E.g. Staff members may repeat
monitoring of the teaching process and
the results of client testing to see if
improvement has been made. The
change may be positive or negative.

67. Communication of Results:
The results of QI activities must be communicated to staff
in all appropriate organizational departments. If findings
and results are not communicated, practice changes will
likely not occur.
 Regular discussions of QI activities through staff
meetings, newsletters and memos are examples of
communication strategies. Often a QI study reveals
information requiring organization wide change. In this
case the organization must be responsible for responding
to problem with the resources needed to make changes.

68.  Revision of policies and
procedures, modification
of standards of ways that
an organization may
respond,care and
implementation of system
changes are examples of
ways that an organization
may respond

69. Factors affecting Quality Assurance in
Nursing Care
1) Lack of Resources:
Insufficient resources,
infrastructures, equipment,
consumables, money for recurring
expenses and staff make it possible
for output of a certain quality to be
turned out under the prevailing
circumstances.

70. 2) Personnel problems:
Lack of trained, skilled and motivated
employees, staff indiscipline affects the
quality of care.
3) Improper maintenance: Buildings and
equipment’s require proper maintenance for
efficient use. If not maintained properly the
equipment’s cannot be used in giving nursing
care. To minimize equipment down time it is
necessary to ensure adequate after sale service
and service manuals.

71. 4) Unreasonable Patients and
Attendants: Illness, anxiety, absence
of immediate response to treatment,
unreasonable and uncooperative
attitude that in turn affects the quality
of care in nursing.

72. 5) Absence of well informed
population.
To improve quality of nursing care, it
is necessary that the people become
knowledgeable and assert their rights
to quality care. This can be achieved
through continuous educational
program.

73. 6) Absence of accreditation laws
There is no organization empowered by
legislation to lay down standards in nursing and
medical care so as to regulate the quality of
care. It requires a legislation that provides for
setting of a stationary accreditation / vigilance
authority to
a) Inspect hospitals and ensures that basic
requirements are met.
b) Enquire into major incidence of
negligence
c) Take actions against health professionals
involved in malpractice

74. 7) Lack of incident review procedures
During a patient’s hospitalizations reveal
that incidents may occur which have a
bearing on the treatment and the patients’
final recovery. These critical incidents may
be
a) Delayed attendance by nurses, surgeon,
physician
b) Incorrect medication
c) Burns arising out of faulty procedures
d) Death in a corridor with no nurse /
physician accompanying the patient etc.

75. 8) Lack of good and hospital information
system
A good management information system is
essential for the appraisal of quality of care.
a) Workload, admissions, procedures and
length of stay
b) Activity audit and scheduling of
procedures

76. 9) Absence of patient satisfaction surveys
Ascertainment of patient satisfaction at
fixed points on an ongoing basis. Such
surveys carried out through questionnaires,
interviews to by social worker, consultant
groups, help to document patient
satisfaction with respect to variables that
are
a) Delay in attendance by nurses and
doctors.
b) Incidents of incorrect treatment

77. 10) Lack of nursing care records
Nursing care records are perhaps the most
useful source of information on quality of
care rendered. The records.
a) Detail of the patient condition
b) Document all significant interaction
between patient and the nursing personnel.
c) Contain information regarding response
d) Have the dates in an easily accessible form.

79. 11) Miscellaneous factors
Lack of good supervision
Absence of knowledge about philosophy of
nursing care
Lack of policy and administrative manuals.
Substandard education and training
Lack of evaluation technique
Lack of written job description and job
specifications
Lack of in-service and continuing
educational program

81. QUALITY ASSURANCE MODEL
IN INDIA:
Nurses who are trained as per Indian
nursing council regulations and
registered with state nursing registration
councils are safe to provide care
INC has developed a quality assurance
program for nurses in India. The
program is expected to develop
mechanisms for ensuring quality of
nursing practice

82. QUALITY ASSURANCE MODEL IN
NURSING
Quality assurance model in nursing is the
set of elements that are related to each other
and comprise of planning for quality
development of objectives setting and
actively communicating standards developing
indicators, setting thresholds, collecting data
to monitor compliance with set standards for
nursing practice and apply solutions to
improve care

83. PHILOSOPHY OF QUALITY
ASSURANCE MODEL IN
NURSING
Indian nursing council believes that
nurse will
 Do good for person /receiver of care,
do no harm, maintain respect for life
and human dignity, believe in human
justice and fairness to individuals in
terms of access to resources and care
and protect the vulnerable

84.  Have moral obligation to provide
services as per the prescribed of the
regulatory body / health care system/
organization /institution even if it is in
conflict with her personal beliefs and
values
 Be responsible and accountable for
providing quality care in line with set
standards
 Be committed to understanding of
dynamic nature of her / her role in
interdisciplinary health team

85.  Be obliged to create public awareness
and consider social expectations before
making decisions for providing nursing
care
 Be obliged to include receiver in
making choices in planning and
implementation of care
 Work in conjugation with legislation,
accreditation and political system
 Have obligation to promote education
of self and others

86.  Be committed to advancement of
profession
Nurse is expected to practice in
adherence to existing health care
delivery system at national / state and
institutional level within the framework
of QUALITY ASSURANCE MODEL
in nursing

87. PURPOSE OF QUALITY
ASSURANCE MODEL
 To ensure quality nursing care
provided by nurses in order to meet the
expectations of the receiver,
management and regulatory body
 It also intends to increase the
commitment of the provider and the
management

88. GOALS OF QUALITY ASSURANCE
MODEL
 Develop confidence of the receiver that
quality care is being rendered as per
assurance
 Develop commitment of the management
towards quality care
 Increase commitment of providers to
adhere to set standards for nursing
practice and strive for excellence

89.  Strengthen documentation of nursing care
 Promote optimum utilization of resources
in providing cost effective nursing care
Quality assurance setting standards
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

90. 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 a family member as some
one far such service provided the care.
Notes on nursing have standards regarding.

91.  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.

92. 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.

93. Almost two decades after
schools of nursing has been
established. Efforts were
again made to set standards
for them. This in turn
improved the care of side in
the hospitals, because
schools of nursing were
intimately associated within

94. 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.

95. 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.

96. 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.

97. 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.

98. Professional Standards of Nursing
Practice:
Professional standards of nursing practice
as established by professional nursing
organization exist to guide the nurse in
providing care.

99. 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

100. 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.

101.  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.

102. 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

103. CHARACTERISTICS OF STANDARDS
1. Statement must be broad enough to apply a
wide variety of settings.
2. Must be realistic, acceptable and attainable.
3. Members of the nursing profession must
develop nursing care.
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 towards an optimal
standard.

104. 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.

105. 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.

106. 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.

107. 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 of actions
involving patient care. The standards are
stated in action verbs that are in
observable and measurable terms.

108. 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.

109. 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.

110. 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.

111. 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.

112. According to Phaneuef (1976).
A method for evaluating quality of care
through appraisal of nursing process as
it is reflected in the patient care records
for discharged patients.
According to Eclison:
Nursing audit refers to assessment of the
quality of clinical nursing.

113. 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

114. 5. Facilitating the co-operative planning
and delivery of client care by physicians
and nursing employees.
6. Increasing the priority for results
oriented performance evaluation
program for nursing service employees.
7. Enriching and providing direction to
in service education effects.

115. 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.

116. CONCEPT OF NURSING AUDIT:
Nursing Audit mainly comprises of
1) Debit
2) Credit
I. Debit:
Debit is all negative activities in nature
e.g.. Hospital infection.
II. Credit:
Credit mainly involves all positive
activities in nature
E.g. Satisfactions of care

117. 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. Lack of application of nursing
process.

118. 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

119. AUDIT CYCLE

122. 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.

123. 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

124. TYPES OF NURSING AUDIT:
The nursing audits are mainly of two
types
1)Concurrent audit
2) Retrospective audit

125. 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.

126. OTHER TYPES OF NURSING
AUDITS:
(i) Structure audit:
The inspection of the management
process as carried out and
documented by the nurse manager.

127. (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.

128. 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

129. 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.

130. DISADVANDAGES OF
NURSING AUDIT:
- 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

131. 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 -

132.  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.

133.  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.

134. 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.

135. 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.

136.  S.Sridhar. Quality assurance in nursing Indian Journal of
Nursing and Midwifery Vol. 2 Sept 1988.
 Indian nursing council (2006), teaching material for quality
assurance model: nursing edition 1st
, indain nursing council
publications page 8,9

138. Backbone of the QA Network
National Agency for
Quality Assurance
Institutional units for
quality assurance
University center for
quality assurance
Pero Lucin, May 2004.

140. Pero Lucin, May 2004.