RAJKUMARI AMRIT KAUR COLLEGE OF NURSING

COMMUNITY HEALTH NURSING

TOPIC: QUALITY ASSURANCE IN COMMUNITY HEALTH NURSING
ADVISOR: Mrs. SARITA SHOKANDHA (ASSISTANT PROFESSOR)
PRESENTED BY: Ms. ANMOL RATTAN (MSc. NSG 1st YEAR)

QUALITY ASSURANCE
As a result of advancement in healthcare technology, increased competition, privatization and
awareness among the clients, healthcare system has become well aware of the need to ensure
quality. Evolution of nursing as a scientific discipline has accountability toward the patient care,
keeping in mind the patient's rights, cost of health services demands quality assurance in nursing.
Defining and attempting to measure quality of care is not new. In fact, the quality of health care is
an idea generally attributed to Ernest Codman, a physician who first proposed the end result idea
in 1869. Quality of care can be evaluated from the perceptive if individuals, populations or
communities. The main aim of quality assurance us to achieved desired outcomes. As now a days
we are giving more importance to achieve health for all so quality standard is not only applied to
tertiary level of hospital but also in primary care setting like PHC and CHC, etc.
Concept of Quality
Quality is a matter of perception, and like beauty, lies in the eyes of the beholders. It refers to
excellence of a product or a service, including its attractiveness, lack of defects, reliability, and
long-term durability and the capability to fulfil its intended purpose, produced with least possible
cost. It is also defined 'as the degree to which a set of inherent characteristics fulfills requirement.
'Juran developed a three-part (Trilogy) approach to quality: Quality planning, quality control and
quality improvement'.
 Quality planning: It involves determining who the customers are and what their needs are,
then developing products based on those needs and designing processes to those products.
 Quality control: It is the evaluation of performance to identify discrepancies between actual
performance and goals.
 Quality improvement: It establishes an infrastructure and the project teams to carry out
process improvement.
Definition of Quality in Healthcare Settings
'The quality is described as levels of excellence produced and document in the process of patient
care, based on the best knowledge available and achievable at a particular facility!
-The National Association of Quality Assurance Professionals
Concept of Quality Assurance
Quality assurance (QA) is the process of assuring compliance to specification, requirements or
standards and implementing methods for conformance.
It includes planning and design for quality, setting and communicating indications for
performance monitoring and compliance of standards. It also includes monitoring of activities of
patient care to determine the degree of excellence attained in the implementation of activities.
QA may also viewed as a measure of competence demonstrated by efficiency in performance. It
also includes evaluation of process, outcome.
In nursing, quality assurance has focused on nursing care delivery structure, process and
outcomes. Problem identification, analysis and corrective action has gradually evolved to
systematic monitoring of nursing services. It can be a program for formal guarantee for provision
of quality nursing care against set standards. The standards of nursing care for patient outcomes
and for nurse performance are the basic components of quality management approach.
Definition of Quality Assurance
Quality assurance is a judgment concerning the process of care, based on the extents to which that
care contributes to valued outcomes.
-Donabedian, 1982

Quality assurance as the monitoring of the activities of client care to determine the degree of
excellence attained to the implementation of the activities.
-Bull, 1985
Quality assurance is achievable through ongoing evaluation of patient care which would assure
the hospital that all that was done for the patient.
-Sakharkar B.M, 1999
Objectives of Quality Assurance
Quality assurance whether in health or education have the main the objectives are:
• To provide technical assistance in designing and implementing effective strategies for
monitoring quality and correcting systemic deficiencies
• To refine existing methods for ensuring optimal quality health care through an applied research
program.
Purpose of Quality Assurance
1. Help patients and potential patients by improving quality of care.
2. Assess competence of medical staff, serve as an impetus to keep up to date and prevent future
mistakes.
3. Bring to notice of hospital administration the deficiencies and in correcting the causative
factors.
4. Help to exercise a regulatory function.
5. Restricting undesirable procedures.
Areas of Improvement in Quality Assurance
In an organization there are several areas for quality improvement. The areas are classified under
three broad headings, those are professional, economic and social.
Identification of such areas for improvement and selective attention to the development of new
techniques in areas of greatest need is essential.

QUALITY ASSURANCE

PROFESSIONAL ECONOMIC SOCIAL/POLITICAL

Codes of conduct Demographic changes. Public awareness
Autonomy Resource distribution Social expectation
Accountablity
Interprofessionalism
Moral issues
Principles of Quality Assurance
1. Quality assurance is a never-ending process of creative destruction, with rapid advances in
science and technology and reduced half life of medical knowledge continuous updating is
essential.
2. The emphasis is on establishing professional excellence patient satisfaction at a reasonable
cost.
3. Quality is not proportionate to the use of sophisticated technology or to be expense incurred.
4. Motto of fees for service should not be pregnant with the comedy of needless services for a fee
and tragedy of no services if no fee.
5. Technical imperative should not insist on prolonging life at any lost with no consideration to
quality of life.
6. Managers need to be committed to quality management and all employees must be involved in
quality improvement.
7. The goal of quality management is to provide a system in which workers can function
effectively.
8. The focus of quality management is on improving the system, not on assigning blame.
9. Every agency has internal and external customers and customers will define quality of the
products.
Methods of Quality Assurance
A quality assurance program can be either concurrent or retrospective.
 Concurrent Quality Assurance
A hospital administrator uses this method routinely so far as no clinical aspects of hospital care
concerned, in the form of daily and periodical administrative rounds. Concurrent evaluation
provides opportunity for simultaneous corrective action. Nevertheless, this can also profitably
form part of the ward round of clinicians and consultants, because it is done while the patient is
still in the ward, oversees things as they happen from day-to-day.
 The Retrospective Quality Assurance
Retrospective evaluation acts as a continuous and ongoing self, improvement process. In many
instances where people are keen to carryout such an evaluation, the whole process has been gone
through with no preparation and in the most haphazard manner. Needless to add, any quality
assurance program requires a step by step approach to derive the desired result.
Prerequisites: There are three fundamental prerequisites that need to be fulfilled before the
program is instituted:
1. Good medical records
2. Establishment of criteria for diagnosis, investigations and treatment and
3. Cooperation and involvement of medical staff.
Types of Quality Assurance
There are two types of quality assurance:
1. External quality assurance
2. Internal quality assurance
 External Quality Assurance
Quality assurance can be evaluated by independent assessors (or) people from outside the
institution/hospital.
 Internal Quality Assurance
Quality assurance can be evaluated by local assessors (or) senior person from the same
institution/hospital.
Process of Quality Assurance
At a basic level, quality assurance process incorporate the following stages/steps (Lang, 1984):
• Setting actual achievements
• Appraising actual achievements
• Planning for improvement
• Taking action when required.

These are referred to as the quality wheel.

SET
ACT
STANDARDS

PLAN APPRAISE
• Setting standards: Involves writing statements that describe achievable and desirable levels of
quality care.
• Appraising actual achievement: Appraising actual achievement involves comparing practice
with the defined standards through measurement criteria.
• Planning for improvement: It is necessary when after appraisal many gap between provision
and expectation is identified.
• Taking action when required: If quality of care is below the stated accepted levels, the action
is taken to raise quality until standards.
MODELS OF QUALITY ASSURANCE AND QUALITY MANAGEMENT

 American Nurses' Association (ANA) Model

 Donabedian Model
  Wilson's Model

 Quality Health Outcome Model

 Joint Commission 10-Step Process Model

Joint Commission 10-Step Process:

1. Assign responsibilities.
2. Delineate scope of care/service.
3. Prioritize aspects of care/service. Categorize as high volume, high risk, problem prone, or
high cost of poor quality.
4. Identify at least two projects to address.
5. Flowchart the process.
6. Establish indicators for identified projects.
7. Establish thresholds for evaluation based on customer expectations
8. Collect and analyze data.
9. Evaluate effectiveness of care and document the level of improvement and determine and
implement appropriate actions.
10.Evaluate effectiveness of action and document the level of improvement communicate
results.
QUALITY ASSURANCE CYCLE

In practice, QA is a cyclical, iterative process that must be applied flexibly to meet the needs
of a specific program.
The process may begin with a comprehensive effort to define standards and norms as
described in steps 1-3, or it may start with small-scale quality improvement activities (steps 5-
10). Alternatively, the process may begin with monitoring (step 4).
The ten steps in the QA process are discussed .

Quality Evaluation System in Health Care

The following are the examples of different approaches to quality evaluation that are used in
different countries:
APPROACH OF QUALITY ASSURANCE PROGRAM

 GENERAL APPROACH

 SPECIFIC APPROACH

In general approach involved large governing body which asses the person or agency to meet
the standard criteria, it includes

1. Credentialing- credentialing is a process of maintaining and determining nursing standard.

It have 3 principles:
  Licensure- Individual licensure is a contract between the profession and the state, in
which the state is granted control over entry into and exists from the profession and over
quality of professional practice. The licensing process requires that regulations be
written to define the scopes and limits of the professional's practice. Law has mandated
licensure of nurses since 1903.

 Accreditation- it is the act of granting credit or recognition especially to an educational

institution that maintain suitable standard. For example JCI, ISO, NABH, NAAC and
accreditation Canada

 Certification-Certification is usually a voluntary process within the profession. A

person's educational achievement, experience and performance on examination are used
to determine the person's qualifications for functioning in an identified specialty area.

2. In specific approach

Quality assurances are methods used to evaluate identified instances of provider and client
interaction.
 Peer review committee- These are designed to monitor client-specific aspects of care
appropriate for certain levels of care. The audit has been the major tool used by peer
review committee to ascertain quality of care.
 The audit process-(stan hope han caster 2000)

 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.

 Utilization review-Utilization review activities are directed towards assuring that care is
actually needed and that the cost appropriate for the level of care provided.

 Evaluation study
 Donabedian structure- process-outcome model
 Tracer method
 Sentinel method
 Constraints in Rendering Quality Care
 Inadequate resources
 Poor maintenance
 Medical supply-inadequate, interrupted
 Delays
 Poor work culture
 Attitudes of patients and public.

Inadequate Resources
• Space-shortage, wastage, unplanned growth empire building by Certain individuals.
• Infrastructure-inadequate, improper, irrelevant.
• Funds inadequate, improper, lop sided priorities wastage.
• Equipment-not available, not functioning overused, misused, abused.
• Staff-inadequate, poorly motivated, poorly trained, dishonest.

Maintenance
• Building-poorly maintained, leakages, peeled off paint, hanging wires.
• Premises-unclean, no sin ages, poor housekeeping
• Equipments-non function, idle, poor functioning
• Installations-poor safety precautions
• Hazardous practices-improper waste disposal and improper sterilization.

Medical Supplies
• Faulty procedures for procurement, storage and distribution.
• Shortages
• Supply-inadequate, interrupted
• Substandard items
• Adulterated items
• Pilferage
• Unfair practices and kick back.

Work Culture
• Poor discipline
• Too much job security
• Too much job insecurity
• Frequent transfers
• Poor leadership
• Disruptive conflicts
• Poor intersectional cooperation and coordination
• Corruption
• Interference from outside agencies, e.g., politicians

Attitudes of Patients and Public

• Prejudiced about hospital and staff.
• Ignorance about disease
• Ignorance about management of the disease
• Ignorance about likely outcome
• Too much or unreasonable expectations
• Uncooperative behavior
• Crisis of confidence-poor doctor patient relationship
• Resigned acceptance giving no feedback.
STANDARD
Standard can be defined as a benchmark of achievement, which is based on desired level of
excellence. As such standards become model to be initiated and may serve, in turn, as basis of
comparisons.

-The Oxford Dictionary, 1964

Standard is a established rules or basis of comparison in measuring or judging capacity

quantify contest and value of objects in the same category.

Nursing Standard

It is descriptive statement of desired quality against which to evaluate nursing care.

Purpose of Standard

• Give direction and provide guidelines for performance of nursing staff.

• Provide a base for evaluating quality of nursing care, ranging from excellent care of usage
care.
 • Help to improve quality of nursing care increases effectiveness of care and improves
efficiency.
• Help to improve documentation and record of care.
• Help to determine the degree to which standards of nursing care maintained and take
necessary corrective action in time.
• Help supervisor to guide nursing staff to improve performance.
• Help to improve basis for decision making and desire alternative system for delivering
nursing care.
• Justify demands or resource association.
• Helps to clarify nurses area of accountability.
• Help nurses to define clearly different level of care.

Characteristics of Standards
 Statement must be broad enough to apply to a wide variety of setting.
 Must be realistic, acceptable and attainable.
 Standards of nursing care must be developed by member of nursing profession.
 Should be phased in positive terms and indicated, acceptable performance that in good
excellent etc.
 It must express what is desirable.
 It must be understandable and stated in unambiguous terms.
 It is based on current knowledge on scientific practice.
 It must be reviewed and revised periodically.

Sources
The standard can be established, developed, reviewed or enforced by variety of sources as
follows:
• Professional organization, e.g., TNAI
• Licensing bodies, e.g., INC, MCI and DCI etc.
• Institution/healthcare agencies, e.g., university Hospital, Health centers.
• Department of institution, e.g., Department of nursing.
• Patient care unit, e.g., Specific patient unit
• Government unit at national, state local units
• Individual, e.g., personal standard.
 STANDARD FOR COMMUNITY HEALTH NURSING PRACTICE
Canadian Community Health Nursing
Standards of Practice

All community health nurses are expected to know and use the following standards of practice:

1. Promoting health.
a) Health promotion.
b) Prevention and health protection.
c) Health maintenance, restoration and palliation.
2. Building individual and community capacity.
3. Building relationships.
4. Facilitating access and equity.
5. Demonstrating professional responsibility and accountability

These standards apply to community health nurses working in practice, education, administration
or research. The standards set a benchmark for new community health nurses and become basic
practice expectations after two years of experience. The practice of expert community health
nurses will extend beyond these standards. Each standard applies to the practice of home health
nurses and public health nurses—nurses may emphasize different elements of specific standards
according to their practice focus.

Standard 1: Promoting health

Community health nurses view health as a dynamic process of physical, mental, spiritual and
social well-being. Health includes self-determination and a sense of connection to the community.
Community health nurses believe that individuals and communities realize hopes and satisfy
needs within their cultural, social, economic and physical environments. They consider health as
a resource for everyday life that is influenced by circumstances, beliefs and the determinants of
health.
Social, economic and environmental health determinants include: (Health Canada, 2000)
• income and social status
• social support networks
• education
• employment and working conditions
• social environments
• physical environments
• biology and genetic endowment
• personal health practices and coping skills
• healthy child development
• health services
• gender
 • culture
Community health nurses promote health using the following strategies:
(a) health promotion
(b) prevention and health protection
(c) health maintenance, restoration and palliation.
a) Health promotion

Community health nurses focus on health promotion and the health of populations. Health
promotion is a mediating strategy between people and their environments. It is a positive,
dynamic, empowering and unifying concept based in the socio-environmental approach to health.
It recognizes that basic resources and conditions for health are critical for achieving health. The
population’s health is closely linked with the health of its members and is often reflected first in
individual and family experiences from birth to death. Community health nurses also consider
socio-political issues that may be underlying individual and community problems. Healthy
communities and systems support increased options for well-being in society.

The community health nurse:

1. Collaborates with individual, community and other stakeholders to do a holistic assessment of
assets and needs of the individual or community.

2. Uses a variety of information sources to access data and research findings related to health
at the national, provincial, territorial, regional and local levels.
3. Identifies and seeks to address root causes of illness and disease.

4. Facillate planned change with the individual, community or population by applying the
Population Health Promotion Model.

5. Collaborates with the individual and community to help them take responsibility for
maintaining or improving their health by increasing their knowledge, influence and control
over the determinants of health.

6. Understands and uses social marketing, media and advocacy strategies to raise awareness of
health issues, place issues on the public agenda, shift social norms and change behaviours if
other enabling factors are present.

7. Helps the individual and community to identify their strengths and available resources and
take action to address their needs.

8. Recognizes the broad impact of specific issues on health promotion such as political climate
 and will, values and culture, individual and community readiness, and social and systemic
structures.

9. Evaluates and modifies population health promotion programs in partnership with the
individual, community and other stakeholders.
B)Prevention and health protection

The community health nurse applies a range of activities to minimize the occurrence of diseases or
injuries and their consequences for individuals and communities. Governments often make
health protection strategies mandated programs and laws for their overall jurisdictions.
The community health nurse:
1. Recognizes the differences between the levels of prevention (primary, secondary, tertiary).
2. Selects the appropriate level of preventive intervention.

3. Helps individuals and communities make informed choices about protective and preventive
health measures such as immunization, birth control, breastfeeding and palliative care.

4. Helps individuals, groups, families and communities to identify potential risks to health.

5. Uses harm reduction principles to identify, reduce or remove risk factors in a variety of
contexts including the home, neighbourhood, workplace, school and street.

c)Health maintenance, restoration and palliation

Community health nurses provide clinical nursing care, health education and counselling to
individuals, families, groups and populations whether they are seeking to maintain their health
or dealing with acute, chronic or terminal illness. Community health nurses practice in health
centres, homes, schools and other community-based settings. They link people to community
resources and coordinate or facilitate other care needs and supports. The activities of the
community health nurse may range from health screening and care planning at an individual
level to intersectoral collaboration and resource development at the community and population
level.
The community health nurse
1. Assesses the health status and functional competence of the individual, family or population
within the context of their environmental and social supports.

2. Develops a mutually agreed upon plan and priorities for care with the individual and family.
 3. Identifies a range of interventions including health promotion, disease prevention and direct
clinical care strategies (including palliation), along with short- and long-term goals and
outcomes.

4. Maximizes the ability of an individual, family or community to take responsibility for and
manage their health needs according to resources and personal skills available.

5. Supports informed choice and respects the individual, family or community’s specific
requests while acknowledging diversity, unique characteristics and abilities.

Standard 2: Building individual and community capacity

Building capacity is the process of actively involving individuals, groups, organizations and
communities in all phases of planned change to increase their skills, knowledge and willingness
to take action on their own in the future. The community health nurse works collaboratively
with the individual or community affected by health-compromising situations and with the
people and organizations that control resources. Starting where the individual or community is,
community health nurses identify relevant issues, assess resources and strengths, and determine
readiness for change and priorities for action. They take collaborative action by building on
identified strengths and involving key stakeholders such as individuals, organizations,
community leaders. They work with people to improve the determinants of health and “make it
easier to make the healthier choice.” Community health nurses use supportive and empowering
strategies to move individuals and communities toward maximum autonomy.

The community health nurse

1. Works collaboratively with the individual, community, other professionals, agencies and
sectors to identify needs, strengths and available resources.
2.Facilitates action in support of the five priorities of the Jakarta Declaration to
 promote social responsibility for health.
 increase investments for health development.
 expand partnerships for health promotion.
 increase individual and community capacity.
 secure an infrastructure for health promotion.
3.Uses community development principles.
• Engages the individual and community in a consultative process.
• Recognizes and builds on the readiness of the group or community to participate.
• Uses empowering strategies such as mutual goal setting, visioning and facilitation.
• Understands group dynamics and effectively uses fa- cilitation skills to support group
development.
• Helps the individual and community to participate in the resolution of their issues.
 • Helps the group and community to gather available resources to support taking action on
their health issues.

Standard 3: Building relationships

Community health nurses build relationships based on the principles of connecting and caring.
Connecting involves establishing and nurturing relationships and a supportive environment that
promotes the maximum participation and self-determination of the individual, family and
community. Caring involves developing empowering relationships that preserve, protect and
enhance human dignity. Community health nurses build caring relationships based on mutual
respect and understanding of the power inherent in their position and its potential impact on
relationships and practice.
One of the unique challenges of community health nursing is building a network of relationships and
partnerships with a wide variety of relevant groups, communities and organizations. These
relationships happen within a complex, changing and often ambiguous environment with sometimes
conflicting and unpredictable circumstances.

The community health nurse

1. Recognizes her or his personal beliefs, attitudes, assumptions, feelings and values about health
and their potential effect on interventions with individuals and communities.

2. Identifies the individual and community beliefs, attitudes, feelings and values about health
and their potential effect on the relationship and intervention.
3. Is aware of and uses culturally relevant communication when building relationships.
Communication may be verbal or non-verbal, written or graphic. It may involve face-to-face,
telephone, group facilitation, print or electronic methods.

4. Respects and trusts the ability of the individual or community to know the issue they are
addressing and solve their own problems.

5. Involves the individual, family and community as an active partner to identify relevant needs,
perspectives and expectations.

Standard 4: Facilitating access and equity

Community health nurses embrace the philosophy of primary health care. They collaboratively
identify and facilitate universal and equitable access to available services. They collaborate with
colleagues and with other members of the health care team to promote effective working
relationships that contribute to comprehensive client care and optimal client care outcomes.
They are keenly aware of the impact of the determinants of health on individuals, families,
groups, communities and populations. The practice of community health nursing considers the
financial resources, geography and culture of the individual and community.
The community health nurse
1. Assesses and understands individual and community capacities including norms, values,
beliefs, knowledge, resources and power structures.

2. Provides culturally sensitive care in diverse communities and settings.

3. Supports individuals and communities in their choice to access alternate health care options.

4. Advocates for appropriate resource allocation for individuals, groups and populations to
support access to conditions for health and health services.

5. Refers, coordinates or facilitates access to services in the health sector and other sectors.

Standard 5: Demonstrating professional responsibility and accountability

Community health nurses work with a high degree of autonomy when providing programs and
services. Their professional accountability includes striving for excellence, ensuring that their
knowledge is evidence- based and current, and maintaining competence and the overall quality
of their practice. Com- munity health nurses are responsible for initiating strategies that will
help address the determinants of health and generate a positive impact on people and systems.

The community health nurse

1. Takes preventive or corrective action individually or in partnership to protect individuals and
communities from unsafe or unethical circumstances .
2. Advocates for societal change in support of health for all.

3. Uses nursing informatics (including information and communication technology) to generate,

manage and process relevant data to support nursing practice.

4. Identifies and takes action on factors which affect autonomy of practice and quality of care.

5. Participates in the advancement of community health nursing by mentoring students and new
practitioners.
Indian Public Health Standards
Indian Public Health Standards are a set of standards envisaged to improve the
quality of health care delivery in the country under the National Rural Health
Mission.
Need for IPHS
The health care system in India has expanded considerably over the last few
decades. However, the quality of services is not uniform due to various reasons
like non-availability of manpower, problem of access, acceptability, lack of
community involvement, etc. Hence, standards are being introduced in order to
improve the quality of public health level.
Recommendation of these standards
A Task Group under the Director General of Health Services was constituted to
recommend the Standards. The IPHS is based on its recommendation.
Who will it be applicable to?
The NRHM aims at strengthening hospital care, for rural areas. At present these
standards are being applied only to the Community Health Centres (CHCs). As
a first steps requirements for a Minimum Functional Grade of a CHC are being
prescribed. Further upgradation will be proposed after these minimum
requirements have been met. Subsequently, standards for PHC and SC shall also
be developed.
Various recommendations under IPHS:
 Improvement in the availability of specialist services in the CHCs by
ensuring availability of all the sanctioned specialists. Additional sanction of
the post of Anaesthetist and Public Health Manager is also envisaged.
 Strengthening support staff, by recommending a Public Health Nurse and an
ANM in all these Centres, in addition to the existing staff.
 Norms for infrastructure, equipment, laboratory, blood storage facilities, and
drugs have been formulated.
Guidelines for management of routine and emergency cases under National
Health Programmes are being provided to all CHCs, to maintain uniformity and
optimum standardised treatment.
How will compliance to these standards be ensured?
• Monitoring and evaluation would be both internal as well as external.
• Training of medical as well as para medical staff.
• Charter of Patients 'Rights would be' prominently displayed in all these
centres.
• Rogi Kalyan Sanitis would be formed to improve accountability.
• The District Health Mission would monitor the progress for maintenance of
standards at facility level.

NURSING AUDIT

Introduction
 Quality:A judgment of what constitutes good or bad.
 Audit:A systematic and critical examination to examine or verify.
 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
Definition
According to Elison "Nursing audit refers to assessment of the quality of
clinical nursing"
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
Purpose
• Evaluating nursing care given
• Achieves deserved quality of nursing care
• Stimulates to better health.
• Contribute to research
• Focuses on care provides.
History of Nursing Audit
Nursing audit is an evaluation of Nursing service before 1995, very little was
known about the concept. It was introduced by the industrial concern and the
year was the beginning of medical audit.
Essential Characteristics of Nursing Audit
 Written standards of care against which to evaluate nursing care Evidence
that actual practice was measured against such standards.
 Examination and analysis of findings.
 Evidence of corrective action being taken.
 Evidence of effectiveness of corrective action.
 Appropriate recording of the audit program.
Concept of Nursing Audit
A nursing audit is a thorough investigation made to evaluate the overall nursing
care received by a patient. An audit is generally done by experienced nurses and
audit committee who do not actually work in the ward where the audit is being
carried out.
The concept of nursing audit is based on debit and credit system.
Debit System
• Death of the patient which have been prevented.
• Complication of disease due to neglect of nursing care.
• Left against medical advice.
• Hospital born infection.
• Error in treatment
• Absence of total patient care
• Lack of application of nursing process.
• Nursing care learners.
Credit System
• Number of recovered patient.
• Expansion of health knowledge in patient's population.
• Short stay in the hospital
• Regular follow-up in the community
• Research or problem oriented care approach
• Measures for improving public image
• Good nurses record.
Debit system is negative in nature. Its emphases on illness where as credit
system is positive in nature and it emphases on health.
Guideline for Nursing Audit
• Objective or aim: Involvement of the health care and fact- finding mission.
• Standards: Should be set by participating clinicians.
• Control: Should be by participating clinicians and by voluntary participation.
• Method: Should be no threatening interesting objective and repeatable.
• Records: Should have adequate clinical materials.
• Types of audit: There are two types:
Internal audit: It is carried out continuously by hospital staff and which consists
of process of separating and classifying clinical records and evaluating the
nursing care given.
External audit: An outside agency periodically tests the completeness and
accuracy of internal audit.
Methods of Nursing Audit:
There are two methods:
• Retrospectives view: This refers to an in depth assessment of the quality after
the patient has been discharged, and patient chart is the sources of data.
Retrospective audit is 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
records.
For example the examiner looks through the patient records and asks:
 Was the problem solving process used in planning nursing care?
Whether patient data collected in a systematic manner?
 Was a description of patient's pre-hospital routines included?
 Laboratory test results used in planning care.
 Did the nurse perform physical assessment?
 Were nursing diagnosis stated?
 Did nurse write nursing orders? and so on.
• Concurrent view: This refers to the evaluation conducted on behalf of the
patients who are still underlying care. It includes assessing the patient at the
bedside in relation to predetermined criteria, interviewing the staff responsible
for his care and reviewing the patient records and care plan.
Audit Committee
Before carrying out an audit, on audit committee should be found. 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 numbers of records to be audited, then an auditor may select
10% discharge.
Nursing Auditors
The choice of nursing auditors depends upon whether the type of nursing audit
to be under taken is internal and external accordingly.
• Internal auditors: The nursing experts from within the hospital are deputed
for internal audit and the auditing is done within agency or hospital.
• External auditors: The nursing and medical administration from the
ministry, other agency or professional association like TNAI undertake the
nursing audit in desired agency of a hospital.
Audit Cycle

SET STANDARDS

IMPLEMENT OBSERVE
CHANGE PRACTICE

COMPARE WITH
STANDARDS

Steps to problem solving process in planning care:

• Collects patient data in a systematic manner:
o Includes description of patients prehospital routines.
o Has information about the severity of illness.
o Has information regarding lab tests.
o Has information regarding vital signs.
o Has information from physical assessment, etc.
• States nurses diagnosis.
• Writes nursing orders.
• Suggests immediate and long-term goals
• Implements the nursing care plan
• Plans health teaching for patients
 • Evaluates the plan of care.
Advantages
• Can be used as a method of measurement in all areas of nursing.
• Scoring system is fairly simple.
• Results easily understand.
• Assess the work of all those involved in recording care.
• May be useful tool as a part of a quality assurance program in areas where
accurate records of care are kept.
Disadvantages
• Appraises the outcomes of the nursing process. So, it is not useful in areas
where the nursing process has not been implemented
• Many of the components overlap making analysis difficult.
• It is time consuming.
• Requires a team of trained auditors
• Deals with a large amount of information.
• Only evaluate record keeping. It only serves to improve documentation not
nursing care.
Hospital Accreditation System of India
• Indian Hospitals Association-IHA, 1993
• Bureau of Indian Standards-BIS, 1988
• National Accreditation Board for Hospitals and Healthcare Providers-ΝΑΒΗ

CONCLUSION
In conclusion, quality assurance in community health nursing is paramount for
ensuring the delivery of effective, safe, and patient-centered care. Continuous
monitoring, evaluation, and improvement of processes contribute to enhanced
healthcare outcomes and the overall well-being of the community. Adherence to
standards, collaboration among healthcare professionals, and a focus on
preventive measures are integral components of successful quality assurance in
community health nursing.
 BIBLIOGRAPHY
 Daksh B,A comprehensive textbook of Community Health Nursing,Jaypee
publication, 2ndedition,page no.829-857.
 Stanhope M, Lancaster J, Community Health Nursing, Process and
practice for promoting health, The C V mosby publisher, page no. 219-217.
 Brar n.p, Rawat hc textbook of advanced nursing practice, jaypee
publications, 1st edition. Page no. 76-90.
 Vati j, Principles and practice of nursing management and administration,
Jaypee brother medical publisher, page no. 94-97.
 Gulani k, Community health nursing, Kumar publishing house,3 rd edition,
page no. 717.
 Masih S, Essentials of nursing management, Lotus Publisher,2 ndedition,
page no.166-168.
 https://neltoolkit.rnao.ca/sites/default/files/Canadian%20Community%20
Health%20Nursing%20Standards%20of%20Practice%20mar08_english.p
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