Quality Assurance:
Program-Specific Record Audits

New River Health District

implemented this best practice in February 1997

Qualifying under the Best Practices catalogue:
1 Establish Direction
12 Determine requirements
121 Evaluate current performance

Best Practice Summary
(how it works, how you measure it)

Quality assurance record audits are conducted in the District monthly or at least quarterly for one of the major public health programs administered by the Nursing/Health Care staff. This audit process includes a multi-disciplined team of public health care providers from each health department who participate in the program-specific record audits. Public health nurses, clinician, social worker, nutritionist, nutritionist assistants, nursing assistants, office services specialists, nurse managers, office service supervisor seniors, as well as the business manager exemplify the multi-discipline team. Team members are selected according to their major program assignments. Quality assurance record audit tools were developed and formal audits have been conducted for the following programs:

.BabyCare

.Family Planning

.Maternal Health

.Resource Mothers

.WIC

Audit tools have been developed for Communicable Disease, Immunization, and Tuberculosis Programs and will be implemented in the coming year. Prior to the review date, the nurse manager or nutritionist notifies the local health department of the number of records to retrieve and the methodology for selection. Following the actual review, the nurse manager or nutritionist compiles the data and prepares a written summary for the district as well as an individual summary for each health department. Local summaries are shared with the staff of the individual health department; the district summary is distributed and presented at the nursing/health care staff meeting. The Office Services Specialist Seniors attend this meeting and share the results with respective staff.

The measure of success for this method of record evaluation is two-fold: an increased sense of teamwork and improved documentation on the medical record. In years past, the medical record audits were the sole responsibility of the nursing/health care staff. All staff who contributes to the completion of the medical record is now involved. Improved documentation has been reflected in the audit summary reports which are standard in reporting the date of review, committee members, number of records reviewed, record selection methodology, audit tool used, evaluation parameters, results, areas for corrective action, and the plan of correction with time frames.

Impact on the Process Organizational Performance (OUTCOMES)

The multi-disciplined team approach to record audits has promoted teamwork by recognizing the value of peer review in the evaluation process, enhanced staff development of program and documentation requirements, emphasized the importance of evaluation as an important responsibility of staff at all levels rather than just a select few, provided clear standard program parameters for measuring efforts, improved overall documentation, and provided feedback to teams and management so that successes are celebrated and deficiencies are corrected.

Best Practice Qualification

The New River Health District recognizes and values the team approach to program planning, implementation, and evaluation. The quality assurance record audit process clearly demonstrates this philosophy. Further, the first record audit tools (Family Planning and Maternal Health Services) developed by the New River Health District to audit the new records implemented by the Documentation by Exception Method of Documentation were shared and adopted with modifications by the Virginia Department of Health Standards Committee for Utilization state-wide.

For Additional Information

New River Health Department
210 South Pepper Street
Suite A
Christiansburg, VA 24073

Brenda Burrus
(540) 381-7100, Extension 199
bburrus@vdh.state.va.us

J. Henry Hershey, M.D., M.P.H.
Director
New River Health District
jhershey@vdh.state.va.us

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