scholarly journals Nurses’ perspectives of the nursing documentation audit process

2019 ◽  
Vol 24 ◽  
Author(s):  
Mokholelana M. Ramukumba ◽  
Souher El Amouri
Keyword(s):  
Evaluation Method ◽  
Clinical Audit ◽  
Abu Dhabi ◽  
Release Time ◽  
Audit Process ◽  
Nursing Documentation ◽  
Implementation Processes ◽  
Enhance Patient Safety ◽  
Group Interviews

Background: Nursing has an obligation to the public to develop measures for the quality of care to enhance patient safety and efficiency of the system. The first hospital to introduce the clinical audit of nursing documentation was in Abu Dhabi. The rationale was the recognition of the link between clinical audits and the quality of patient care and safety. This article recognises the importance of documentation audits in nursing practice and the role of nurses related to conducting audits in a selected hospital in Abu Dhabi. Many studies have shown the potential benefits of documentation audits to evaluate or assess the quality of recorded nursing assessments and care.Aim: The aim of this study was to explore nurses’ perspectives of the documentation audit process.Method: The study adopted an exploratory, descriptive qualitative approach using the evaluation method. Data were collected using three focus group interviews consisting of 4 informatics and 13 documentation link nurses involved in the implementation of the clinical audit on nursing documentation in the selected hospital. Thematic analysis was used to analyse the data.Results: Three major themes evolved from the research findings: implementation of documentation audit, evaluation of audit and measures to improve documentation audit. Strengths and weaknesses of the documentation audit were articulated by the nurses. Generally, nurses were satisfied with the audit process and made recommendations on improvements.Conclusion: Processes adopted by the team were reasonable and useful, and the preparation and planning for the clinical audit were regarded as areas of strength. Areas of weaknesses in the implementation processes identified included dissemination of findings and executing improvements. This could be improved with necessary support from the hospital management, especially with regard to release time to implement required changes. The complexity of auditing electronic versus paper-based nursing documentation is acknowledged.

Audit clinico sugli interventi di adenotonsillectomia in Regione Piemonte: un intervento multilivello

2021 ◽  
Vol 24 (7) ◽  
pp. 188-196
Author(s):  
Domenico Tangolo ◽  
Aldo Ravaglia ◽  
Alessandro Migliardi ◽  
Roberto Gnavi ◽  
Alberto Borraccino ◽  
...  
Keyword(s):  
Quality Of Care ◽  
Clinical Audit ◽  
Regional Scale ◽  
Sampling Procedure ◽  
Local Health ◽  
Audit Process ◽  
Health Authorities ◽  
Definition Of ◽  
Local Health Authorities

Background: Despite the dissemination of national and international clinical and organizational guidelines, adenotonsillectomy is still subject to a significant variability both at local and regional levels. To address the criticalities related to the different phases leading to adenotonsillectomy, the Department of Health in Piedmont engaged a multi-disciplinary team to carry out an intervention to improve the quality of care. To address the issue, the working group started a regional clinical audit. - Objective: To describe the approach and the process that involved more than one hundred professionals in the management of adenotonsillectomy within the 12 Local Health Authorities of the Piedmont Region in the period 2017-2019 as well as to discuss their main results. - Materials, methods and results: The activities that led to the implementation of the whole audit process were carried out considering both the development of a suitable set of measures and the definition of the sampling procedure for the selection of the patients’ medical files to be analysed. The methodology involved several professionals along the territory. The team was engaged in sharing the audit methodology, defining the evaluation procedures and selecting relevant indicators. All measured values showed an overall improvement that in some cases matched the identified quality standards. - Conclusions: The present research shows that the use of the clinical audit on a regional scale is a favourable tool for professional communities to improve the quality of care and can be used as a valuable participatory educational tool.

Improving the quality of medical reports to mental health review tribunals

2002 ◽  
Vol 26 (6) ◽  
pp. 215-218 ◽  
Author(s):  
Paul Egleston ◽  
Michael D. Hunter
Keyword(s):  
Mental Health ◽  
Clinical Audit ◽  
Clinical Implications ◽  
National Guidelines ◽  
Audit Process ◽  
Quality Of Reports ◽  
Medical Reports ◽  
Health Review

AIMS AND METHODWe aimed to determine, using clinical audit, the effect of implementing national guidelines on the quality of responsible medical officers' (RMOs’) reports to the mental health review tribunal (MHRT). We blindly assessed the quality of 50 consecutive reports concerning patients detained under Sections 3 and 37. Twenty-five reports were written before guidelines were circulated; a further 25 were written following the distribution of guidelines and a checklist with every request for a report.RESULTSThe quality of reports, as measured by our checklist, significantly improved following the circulation of guidelines.CLINICAL IMPLICATIONSIncreasing the awareness of guidelines by widespread circulation and the audit process is an effective way of improving the quality of RMOs' reports to the MHRT.

Is audit research? The relationships between clinical audit and social research

2005 ◽  
Vol 18 (4) ◽  
pp. 289-299 ◽  
Author(s):  
Rhidian Hughes
Keyword(s):  
Health Care ◽  
Social Research ◽  
Clinical Audit ◽  
Ethical Review ◽  
Audit Process ◽  
Ethical Considerations ◽  
Content Type ◽  
Multidisciplinary Working ◽  
Asking Questions

PurposeQuality has an established history in health care. Audit, as a means of quality assessment, is well understood and the existing literature has identified links between audit and research processes. This paper reviews the relationships between audit and research processes, highlighting how audit can be improved through the principles and practice of social research.Design/methodology/approachThe review begins by defining the audit process. It goes on to explore salient relationships between clinical audit and research, grouped into the following broad themes: ethical considerations, highlighting responsibilities towards others and the need for ethical review for audit; asking questions and using appropriate methods, emphasising transparency in audit methods; conceptual issues, including identifying problematic concepts, such as “satisfaction”, and the importance of reflexivity within audit; emphasising research in context, highlighting the benefits of vignettes and action research; complementary methods, demonstrating improvements for the quality of findings; and training and multidisciplinary working, suggesting the need for closer relationships between researchers and clinical practitioners.FindingsAudit processes cannot be considered research. Both audit and research processes serve distinct purposes.Originality/valueAttention to the principles of research when conducting audit are necessary to improve the quality of audit and, in turn, the quality of health care.

Effect of clinical audits of radiation use in one hospital district in finland

2009 ◽  
Vol 50 (4) ◽  
pp. 389-395 ◽  
Author(s):  
M. Hirvonen-Kari ◽  
S. Salo ◽  
K. Dean ◽  
L. Kivisaari
Keyword(s):  
Positive Impact ◽  
Clinical Audit ◽  
Diagnostic Procedures ◽  
Medical Procedures ◽  
Audit Process ◽  
Hospital District ◽  
Radiological Procedures ◽  
Radiation Use ◽  
Clinical Audits

Background: A clinical audit is a systematic, independent, and documented process to improve the quality of radiological processes and radiation safety for patients. Purpose: To evaluate the effect of an audit process by comparing the results of two consecutive audits at the same units. Material and Methods: Audits were carried out twice at each imaging unit in the southwest hospital district of Finland: first, at the end of 2003, and again in November 2007. Both evaluations were carried out in a similar way: by interviewing personnel and examining documents, independent experts from other hospital districts ensured that diagnostic medical imaging processes at each unit were carried out according to generally accepted standards for good medical radiological procedures. The results of the consecutive audits were compared in order to analyze the effects of the clinical audits. Results: The use of radiation was in accordance with the requirements and standards of good medical procedures at every audited unit during both evaluations. The list of audit criteria was fulfilled satisfactorily on both occasions at all of the audited units, and clearly better during the second run. In the first audit, the auditors made 80 recommendations for improving diagnostic procedures and, in the second audit, 53 recommendations. During the first audit, most of the recommendations (22/80) concerned instructions in the fundamental practice of examining a patient. During the second audit, most recommendations were in the category of radiation doses. Conclusion: The clinical audit had a positive impact on the practice of work procedures in radiological departments. Most of the recommendations made after the first audit had been taken into consideration by the time of the second audit.

scholarly journals Improving the Quality of Nursing Documentation at A Residential Care Home: A Clinical Audit

2020 ◽  
Author(s):  
Preben Søvik Moldskred ◽  
Anne Kristin Snibsøer ◽  
Birgitte Espehaug
Keyword(s):  
Residential Care ◽  
Clinical Audit ◽  
Care Home ◽  
Patient Records ◽  
Nursing Documentation ◽  
Nursing Assessment ◽  
Residential Care Home ◽  
Nursing Diagnoses ◽  
Quality Of Nursing

Abstract Background: Quality in nursing documentation holds promise to increase patient safety and quality of care. While high-quality nursing documentation implies a comprehensive documentation of the nursing process, nursing records do not always adhere to these documentation criteria. The aim of this quality improvement project was to assess the quality of electronic nursing records in a residential care home using a standardized audit tool and, if necessary, implement a tailored strategy to improve documentation practice.Methods: A criteria-based clinical audit was performed in a residential care home in Norway. Quantitative criteria in the N-Catch II audit instrument was used to give an assessment of electronic nursing records on the following: nursing assessment on admission, nursing diagnoses, aims for nursing care, nursing interventions, and evaluation/progress reports. Each criterium was scored on a 0 - 3 point scale, with standard (complete documentation) coinciding with the highest score. A retrospective audit was conducted on 38 patient records from January to March 2018, followed by the development and execution of an implementation strategy tailored to local barriers. A re-audit was performed on 38 patient records from March to June 2019. Results: None of the investigated patient records at audit fulfilled standards for recommended nursing documentation practice. Mean scores at audit varied from 0.4 (95% confidence interval 0.3 - 0.6) for “aims for nursing care” to 1.1 (0.9 - 1.3) for “nursing diagnoses”. After implementation of a tailored multifaceted intervention strategy, an improvement (p < 0.001) was noted for all criteria except for “evaluation/progress reports” (p = 0.6). The improvement did not lead to standards being met at re-audit, where mean scores varied from 0.9 (0.8 - 1.1) for “evaluation/progress reports” to 1.9 (1.5 - 2.2) for “nursing assessment on admission”.Conclusions: A criteria-based clinical audit with multifaceted tailored interventions that addresses determinants of practice may improve the quality of nursing documentation, but further cycles of the clinical audit process are needed before standards are met and focus can be shifted to sustainment of knowledge use.

scholarly journals Improving the quality of nursing documentation at a residential care home: a clinical audit

BMC Nursing ◽  
2021 ◽  
Vol 20 (1) ◽  
Author(s):  
Preben Søvik Moldskred ◽  
Anne Kristin Snibsøer ◽  
Birgitte Espehaug
Keyword(s):  
Residential Care ◽  
Clinical Audit ◽  
Care Home ◽  
Patient Records ◽  
Nursing Documentation ◽  
Nursing Assessment ◽  
Residential Care Home ◽  
Nursing Diagnoses ◽  
Quality Of Nursing

Abstract Background Quality in nursing documentation holds promise to increase patient safety and quality of care. While high-quality nursing documentation implies a comprehensive documentation of the nursing process, nursing records do not always adhere to these documentation criteria. The aim of this quality improvement project was to assess the quality of electronic nursing records in a residential care home using a standardized audit tool and, if necessary, implement a tailored strategy to improve documentation practice. Methods A criteria-based clinical audit was performed in a residential care home in Norway. Quantitative criteria in the N-Catch II audit instrument was used to give an assessment of electronic nursing records on the following: nursing assessment on admission, nursing diagnoses, aims for nursing care, nursing interventions, and evaluation/progress reports. Each criterium was scored on a 0–3 point scale, with standard (complete documentation) coinciding with the highest score. A retrospective audit was conducted on 38 patient records from January to March 2018, followed by the development and execution of an implementation strategy tailored to local barriers. A re-audit was performed on 38 patient records from March to June 2019. Results None of the investigated patient records at audit fulfilled standards for recommended nursing documentation practice. Mean scores at audit varied from 0.4 (95 % confidence interval 0.3–0.6) for “aims for nursing care” to 1.1 (0.9–1.3) for “nursing diagnoses”. After implementation of a tailored multifaceted intervention strategy, an improvement (p < 0.001) was noted for all criteria except for “evaluation/progress reports” (p = 0.6). The improvement did not lead to standards being met at re-audit, where mean scores varied from 0.9 (0.8–1.1) for “evaluation/progress reports” to 1.9 (1.5–2.2) for “nursing assessment on admission”. Conclusions A criteria-based clinical audit with multifaceted tailored interventions that addresses determinants of practice may improve the quality of nursing documentation, but further cycles of the clinical audit process are needed before standards are met and focus can be shifted to sustainment of knowledge use.

What is clinical audit’s purpose: quality assurance or quality improvement?

2011 ◽  
Vol 2 (2) ◽  
pp. 79-83
Author(s):  
Nancy Dixon
Keyword(s):  
Quality Assurance ◽  
Quality Improvement ◽  
Patient Care ◽  
Clinical Audit ◽  
Audit Process ◽  
Quality Improvement Process ◽  
Quality Assurance Process ◽  
Quality Of Patient Care ◽  
Assurance Process

Clinical audit has become a key activity for healthcare organisations and professionals in England. The clinical audit process is frequently described as a cycle of steps that includes making changes in practice. However, some evidence suggests that clinical audit is not effective in producing improvements in the quality of patient care. The explanation may be that clinicians and managers are seeing clinical audit as a quality assurance process, which implies making small adjustments in practice to conform to standards, rather than as a quality improvement process.

scholarly journals Improving nursing documentation for surgical patients in a referral hospital in Freetown, Sierra Leone: protocol for assessing feasibility of a pilot multifaceted quality improvement hybrid type project

2021 ◽  
Vol 7 (1) ◽  
Author(s):  
Nataliya Brima ◽  
Nick Sevdalis ◽  
K. Daoh ◽  
B. Deen ◽  
T. B. Kamara ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Quality Of Care ◽  
Sierra Leone ◽  
Referral Hospital ◽  
Audit And Feedback ◽  
Health System Strengthening ◽  
Theory Of Change ◽  
Improve Quality ◽  
Nursing Documentation

Abstract Background There is an urgent need to improve quality of care to reduce avoidable mortality and morbidity from surgical diseases in low- and middle-income countries. Currently, there is a lack of knowledge about how evidence-based health system strengthening interventions can be implemented effectively to improve quality of care in these settings. To address this gap, we have developed a multifaceted quality improvement intervention to improve nursing documentation in a low-income country hospital setting. The aim of this pilot project is to test the intervention within the surgical department of a national referral hospital in Freetown, Sierra Leone. Methods This project was co-developed and co-designed by in-country stakeholders and UK-based researchers, after a multiple-methodology assessment of needs (qualitative, quantitative), guided by a participatory ‘Theory of Change’ process. It has a mixed-method, quasi-experimental evaluation design underpinned by implementation and improvement science theoretical approaches. It consists of three distinct phases—(1) pre-implementation(project set up and review of hospital relevant policies and forms), (2) intervention implementation (awareness drive, training package, audit and feedback), and (3) evaluation of (a) the feasibility of delivering the intervention and capturing implementation and process outcomes, (b) the impact of implementation strategies on the adoption, integration, and uptake of the intervention using implementation outcomes, (c) the intervention’s effectiveness For improving nursing in this pilot setting. Discussion We seek to test whether it is possible to deliver and assess a set of theory-driven interventions to improve the quality of nursing documentation using quality improvement and implementation science methods and frameworks in a single facility in Sierra Leone. The results of this study will inform the design of a large-scale effectiveness-implementation study for improving nursing documentation practices for patients throughout hospitals in Sierra Leone. Trial registration Protocol version number 6, date: 24.12.2020, recruitment is planned to begin: January 2021, recruitment will be completed: December 2021.

Research on Reliability Evaluation Methods of Distribution System

2014 ◽  
Vol 672-674 ◽  
pp. 1441-1446 ◽  
Author(s):  
Yu Qiang Ou ◽  
Le Feng Cheng ◽  
Jian Zhong Wen ◽  
Xuan Yu Qiu ◽  
Tao Yu
Keyword(s):  
Distribution System ◽  
Evaluation Method ◽  
Network Reliability ◽  
Distribution Network ◽  
Reliability Evaluation ◽  
Evaluation Indexes ◽  
Specific Distribution ◽  
And Function ◽  
Meaning And Function

Research on reliability of distribution network has very important meaning and function to ensure the quality of power supply. This paper introduces some basic concepts of reliability in distribution network, including distribution network reliability definition, task and index. The classical reliability evaluation method was reviewed, and focused on specific distribution network, an example analysis was given, and specific reliability evaluation indexes were calculated. Finally, the future development of distribution network reliability evaluation was made a simple prospect.

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