- Email: [email protected]
JCAH patient care audit
Barbara J Mohr, RN, MSN
JCAH patient care audit Accountability for one’s performance is no longer a matter of choice as evidenced by recent mandates from various groups for quality assurance within patient-care settings. One important component of any quality assurance program is retrospective analysis of past professional performance. The need for a methodology to provide this analysis surfaced in 1971 when the Joint Commission on Accreditation of Hospitals (JCAH), in a reaffirmation of its original purpose to improve the quality of patient care, revised and expanded its standards for hospital accreditation. These standards require that specific evaluation methods be intituted so that all health professionals can be held accountable for the quality of care they provide. Now, in accordance with the most recent statement by the Board of Commissioners of the Joint Commission (December 1974), regard-
Barbara J Mohr, R N , M S N , is assistant director, nursing program, Quality Review Center, Joint Commission on Accreditation of Hospitals ( J C A H ) , Chicago. She is a graduate of St Louis University, S t Louis, Mo. M s Mohr described the JCAH audit at the 1975 A O R N Congress.
less of the type of evaluation procedure a hospital elects to use, some essential characteristics of a sound evaluation system must be included. These are the basic JCAH requirements for audit: 1. establishment of valid criteria that include a statement of expected patient outcomes 2. measurement of actual practice against these predetermined criteria in a manner that will provide reliable data 3. analysis of actual practice findings including identification of variations from criteria as well as the clinical justification of any acceptable variation 4. implementation of specific action to correct unjustified variations or deficiencies 5. followup of action to assure its implementation and effectiveness 6. report of audit results to those accountable (director of nursing, chief of medical staff, continuing education officer, and hospital governing body). To aid hospitals in satisfying these mandates, the Joint Commission has instituted nationwide educational programs to assist health care professionals participating in this evaluation-accountability process. Educational workshops
AORN Journal, August 1975, Vol 22, No 2
187
T
he audit can illustrate how care by nurses makes a difference
have been conducted for physicians, trustees, and administrators (TrusteesAdministrators-Physicians InstitutesTAP); medical record personnel (Medical Audit Team Seminars-MATS); and nurses (Nursing Workshops on Audit-NWA). Since March 1974, I have been a member of the national nursing team which teaches the Joint Commission on Accreditation of Hospitals’ Performance Evaluation Procedure ( P E P ) for Auditing and Improving Patient Care. (The team includes four fulltime JCAH registered nurses and about 20 clinical faculty members who have full-time jobs in hospitals around the country and are using PEP. Clinical faculty members travel with us about every six weeks. In essence, JCAH’s P E P methodology is a retrospective, systematic review of patient records to determine whether the care administered is consistent with predetermined criteria. If criteria established by health professionals are explicit, identification of variation charts (those that do not meet or conform to predetermined standards) is easily accomplished by medical record personnel. Thus, only variation charts must be reviewed by the peer group and corrective action taken only for true deficiencies as determined by the audit committee. By screening out for direct review by peers those records that may indicate that nursing care is less than
188
what is optimally achievable (the criteria statement), the nursing quality evaluation activity is made more efficient and productive. One of the major strengths of JCAH’s audit system is the use of criteria that primarily, but not exclusively, focus on expected patient outcomes. If nurses are willing to accept the challenge of demonstrating just how nursing care affects or alters the health and knowledge status of a patient, then an evaluation of patient outcomes or the end results of nursing intervention becomes of paramount importance. Is it so important to know that 99% of the time immobilized patients are being turned every two hours if the number of patients who develop decubitus ulcers or the incidence of atelectasis is unknown? The information obtained by asking the question, At discharge from the hospital, how many diabetic patients were able to test their own urine?, provides a more accurate measure of quality than the question, How many nurses instructed the diabetic patient to test his own urine? Asking about nurses’ instructions rather than patient knowledge assumes the patients have learned because they have been instructed. Clearly, this is a dangerous assumption. With the focus of audit criteria on patient outcomes, for the first time nurses have been given a n opportunity to answer with a resounding “yes” when
AORN Journal, August 1975, Vol22, No 2
a consumer asks the question, Did it really make a difference that I received nursing care while I was in the hospital? The theory of outcomes as validators of quality is not new. Florence Nightingale originated it in 1863 when she proposed keeping a log of the circumstances surrounding surgical procedures.’ Review of past performance with the intention of improving future performance is the heart of evaluation in almost every industry. The automobile industry evaluates the effectiveness of its assembly line by test driving its finished product. In education, the effectiveness of a teaching methodology is evaluated by the students’ ability to achieve certain objectives. Advertising uses sales as an indicator of success. In the health professions, nonconformance to a criterion or a less than desirable outcome, signals the audit committee that some aspect of patient care needs further investigation. Recognizing that in actual practice many variables may justifiably contribute to nonconformance to an established criterion, a panel of peers further scrutinizes each variation chart to identify those representing actual deficiencies. Once deficiencies in patient outcomes have been determined and consideration given to the type and cause of the problems identified, corrective action becomes goal directed and can be designed to specific needs. Necessary
changes in policies, procedures, staffing, and equipment can be pinpointed as well as supported when their relationships to an effect on the patient have been documented. Nursing processes that need monitoring can be identified. For instance, it is not necessary to observe the insertion of a Foley catheter if urinary tract infection in patients with retention catheters is not a problem in that setting. Inservice education programs become more relevant when the quality of nursing care is measured by its ability to achieve or contribute to certain patient outcomes. If new mothers are able to demonstrate the correct procedure for bathing their newborn before discharge from the hospital, it may not be appropriate to institute a hospital-wide education program on teaching the “how-tos” of basic infant care. The purpose of audit is to assist in identifying areas that need change so the overall pattern of patient care can be improved. Effective evaluation of the quality of patient care within an institution must be a collaborative venture. Comprehensive quality patient care is more than a “one-man show” and depends on the effective functioning of a diverse group of interdependent professionals. When one member of the health team fails, some aspect of patient care generally suffers. There is no better way to point
AORN Journal, August 1975, Vol 22, No 2
189
P
atient care suffers when one member of the health team fails.
out the interdependency of health professionals than to attempt to establish audit criteria relating to patient outcomes. For example, for a patient with pneumonia to be discharged from the hospital with a clear chest, not only must the physician order the administration of appropriate antibiotics, but rigorous respiratory toilet must be provided by nurses and inhalation therapists. Because outcomes are not achieved by one discipline acting alone, quality of care evaluation should be conducted by all who contribute to them. The operating room nurse is a significant contributor to the multi-disciplinary evaluation of patient care. For example, she influences whether or not a surgical patient goes home within a reasonable length of stay afebrile and with a clean wound. The analysis of an audit study that demonstrates a high incidence of postoperative wound infection could give direction to the identification of a problem in the operating room. In addition, the argument for including the operating room nurse on the audit committee is considerably strengthened when one remembers that audit results may be used as a basis for continuing education programs, purchase of needed equipment, or changes in hospital policies, procedures, or staffing patterns. OR nurses should have
190
input into these types of decisions. The challenge for the operating room nurse is to identify what unique contribution to the achievement of certain surgical patient outcomes is hers. What role does she play in the prevention of shock, thrombophlebitis, or wound infection? What responsibility does she have for ensuring the physical safety of the patient? How does the nurses’ responsibility for the OR environment affect patient outcomes? These are the kinds of questions operating room nurses will answer when they begin to have input into developing patient outcome criteria. To improve the provision of health care, it is essential that evaluation of care be conducted with a clear understanding and respect for what each health professional contributes to quality patient care. 0 Notes 1. Florence Nightingale, Proposal for Improved Statistics of Surgical Operations (London: Saville and Edwards, 1863).
AORN Journal, August 1975, Vol 22, No 2
JCAH patient care audit Accountability for one’s performance is no longer a matter of choice as evidenced by recent mandates from various groups for quality assurance within patient-care settings. One important component of any quality assurance program is retrospective analysis of past professional performance. The need for a methodology to provide this analysis surfaced in 1971 when the Joint Commission on Accreditation of Hospitals (JCAH), in a reaffirmation of its original purpose to improve the quality of patient care, revised and expanded its standards for hospital accreditation. These standards require that specific evaluation methods be intituted so that all health professionals can be held accountable for the quality of care they provide. Now, in accordance with the most recent statement by the Board of Commissioners of the Joint Commission (December 1974), regard-
Barbara J Mohr, R N , M S N , is assistant director, nursing program, Quality Review Center, Joint Commission on Accreditation of Hospitals ( J C A H ) , Chicago. She is a graduate of St Louis University, S t Louis, Mo. M s Mohr described the JCAH audit at the 1975 A O R N Congress.
less of the type of evaluation procedure a hospital elects to use, some essential characteristics of a sound evaluation system must be included. These are the basic JCAH requirements for audit: 1. establishment of valid criteria that include a statement of expected patient outcomes 2. measurement of actual practice against these predetermined criteria in a manner that will provide reliable data 3. analysis of actual practice findings including identification of variations from criteria as well as the clinical justification of any acceptable variation 4. implementation of specific action to correct unjustified variations or deficiencies 5. followup of action to assure its implementation and effectiveness 6. report of audit results to those accountable (director of nursing, chief of medical staff, continuing education officer, and hospital governing body). To aid hospitals in satisfying these mandates, the Joint Commission has instituted nationwide educational programs to assist health care professionals participating in this evaluation-accountability process. Educational workshops
AORN Journal, August 1975, Vol 22, No 2
187
T
he audit can illustrate how care by nurses makes a difference
have been conducted for physicians, trustees, and administrators (TrusteesAdministrators-Physicians InstitutesTAP); medical record personnel (Medical Audit Team Seminars-MATS); and nurses (Nursing Workshops on Audit-NWA). Since March 1974, I have been a member of the national nursing team which teaches the Joint Commission on Accreditation of Hospitals’ Performance Evaluation Procedure ( P E P ) for Auditing and Improving Patient Care. (The team includes four fulltime JCAH registered nurses and about 20 clinical faculty members who have full-time jobs in hospitals around the country and are using PEP. Clinical faculty members travel with us about every six weeks. In essence, JCAH’s P E P methodology is a retrospective, systematic review of patient records to determine whether the care administered is consistent with predetermined criteria. If criteria established by health professionals are explicit, identification of variation charts (those that do not meet or conform to predetermined standards) is easily accomplished by medical record personnel. Thus, only variation charts must be reviewed by the peer group and corrective action taken only for true deficiencies as determined by the audit committee. By screening out for direct review by peers those records that may indicate that nursing care is less than
188
what is optimally achievable (the criteria statement), the nursing quality evaluation activity is made more efficient and productive. One of the major strengths of JCAH’s audit system is the use of criteria that primarily, but not exclusively, focus on expected patient outcomes. If nurses are willing to accept the challenge of demonstrating just how nursing care affects or alters the health and knowledge status of a patient, then an evaluation of patient outcomes or the end results of nursing intervention becomes of paramount importance. Is it so important to know that 99% of the time immobilized patients are being turned every two hours if the number of patients who develop decubitus ulcers or the incidence of atelectasis is unknown? The information obtained by asking the question, At discharge from the hospital, how many diabetic patients were able to test their own urine?, provides a more accurate measure of quality than the question, How many nurses instructed the diabetic patient to test his own urine? Asking about nurses’ instructions rather than patient knowledge assumes the patients have learned because they have been instructed. Clearly, this is a dangerous assumption. With the focus of audit criteria on patient outcomes, for the first time nurses have been given a n opportunity to answer with a resounding “yes” when
AORN Journal, August 1975, Vol22, No 2
a consumer asks the question, Did it really make a difference that I received nursing care while I was in the hospital? The theory of outcomes as validators of quality is not new. Florence Nightingale originated it in 1863 when she proposed keeping a log of the circumstances surrounding surgical procedures.’ Review of past performance with the intention of improving future performance is the heart of evaluation in almost every industry. The automobile industry evaluates the effectiveness of its assembly line by test driving its finished product. In education, the effectiveness of a teaching methodology is evaluated by the students’ ability to achieve certain objectives. Advertising uses sales as an indicator of success. In the health professions, nonconformance to a criterion or a less than desirable outcome, signals the audit committee that some aspect of patient care needs further investigation. Recognizing that in actual practice many variables may justifiably contribute to nonconformance to an established criterion, a panel of peers further scrutinizes each variation chart to identify those representing actual deficiencies. Once deficiencies in patient outcomes have been determined and consideration given to the type and cause of the problems identified, corrective action becomes goal directed and can be designed to specific needs. Necessary
changes in policies, procedures, staffing, and equipment can be pinpointed as well as supported when their relationships to an effect on the patient have been documented. Nursing processes that need monitoring can be identified. For instance, it is not necessary to observe the insertion of a Foley catheter if urinary tract infection in patients with retention catheters is not a problem in that setting. Inservice education programs become more relevant when the quality of nursing care is measured by its ability to achieve or contribute to certain patient outcomes. If new mothers are able to demonstrate the correct procedure for bathing their newborn before discharge from the hospital, it may not be appropriate to institute a hospital-wide education program on teaching the “how-tos” of basic infant care. The purpose of audit is to assist in identifying areas that need change so the overall pattern of patient care can be improved. Effective evaluation of the quality of patient care within an institution must be a collaborative venture. Comprehensive quality patient care is more than a “one-man show” and depends on the effective functioning of a diverse group of interdependent professionals. When one member of the health team fails, some aspect of patient care generally suffers. There is no better way to point
AORN Journal, August 1975, Vol 22, No 2
189
P
atient care suffers when one member of the health team fails.
out the interdependency of health professionals than to attempt to establish audit criteria relating to patient outcomes. For example, for a patient with pneumonia to be discharged from the hospital with a clear chest, not only must the physician order the administration of appropriate antibiotics, but rigorous respiratory toilet must be provided by nurses and inhalation therapists. Because outcomes are not achieved by one discipline acting alone, quality of care evaluation should be conducted by all who contribute to them. The operating room nurse is a significant contributor to the multi-disciplinary evaluation of patient care. For example, she influences whether or not a surgical patient goes home within a reasonable length of stay afebrile and with a clean wound. The analysis of an audit study that demonstrates a high incidence of postoperative wound infection could give direction to the identification of a problem in the operating room. In addition, the argument for including the operating room nurse on the audit committee is considerably strengthened when one remembers that audit results may be used as a basis for continuing education programs, purchase of needed equipment, or changes in hospital policies, procedures, or staffing patterns. OR nurses should have
190
input into these types of decisions. The challenge for the operating room nurse is to identify what unique contribution to the achievement of certain surgical patient outcomes is hers. What role does she play in the prevention of shock, thrombophlebitis, or wound infection? What responsibility does she have for ensuring the physical safety of the patient? How does the nurses’ responsibility for the OR environment affect patient outcomes? These are the kinds of questions operating room nurses will answer when they begin to have input into developing patient outcome criteria. To improve the provision of health care, it is essential that evaluation of care be conducted with a clear understanding and respect for what each health professional contributes to quality patient care. 0 Notes 1. Florence Nightingale, Proposal for Improved Statistics of Surgical Operations (London: Saville and Edwards, 1863).
AORN Journal, August 1975, Vol 22, No 2