ORIGINAL ARTICLES

Understanding the audit in the family health strategy: exploratory research

Cristiano Caveião¹, Angelita Visentin¹, Willian Barbosa Sales¹, Ana Paula Hey¹, Nice Andreia de Moraes Lara¹, Tuany Costa¹

¹Autonomous University Center of Brazil (UniBrasil)

ABSTRACT
Aims: To identify and understand the skills required by nurses in relation to the audit of the services of the Family Health Strategy Unit of a municipality in the southern region of Brazil.
Method: exploratory, descriptive study, with a qualitative approach.
Results: the audit of health services performed by nurses can contribute as a tool to helping the management of finance and human resources; in the evaluation, monitoring procedures and processes, records, protocols, work processes; and quality of health services. Therefore, it is necessary to acquire some skills through training, continuing education and/or professional experience.
Conclusion: nurses recognize their responsibilities and the importance of surveys for the audit to be successful. It is considered essential to enable these professionals to improve and expand the quality of audit services at the local level, providing to the managers guiding subsidies of an awareness strategy directed to assistance granted.
Descriptors: Nursing Audit; Professional Competence; Quality of Health Care.

INTRODUCTION

Since the 20th century, the intensification of the analysis of medical records related to care has provided assistance to users of health services. It is a method that consists of a systematic and independent examination of an activity, element or system to verify that health actions and their results are consistent with the planned arrangements and the rules and laws in force in a country⁽¹⁾.

This method is called audit, whose word originates from Latin “audire” that means hear, and in Eenglish audit, meanings examine, correct and certify. The audit consists of a set of measures by which internal or external experts review the operational activities of certain sectors of the institution, in order to measure the quality of services provided. It could understood as a strategy to improve care through conducting previous surveys and disability identification in the organization and the assistance provided^(2,3).

In regard to the audit, it is divided into two types: retrospective and operational, or recurrent. The retrospective is performed after patient discharge and uses medical charts for evaluation. The operational or recurrent occurs during inpatient hospitalization or outpatient care. It can be classified in terms of intervention (internal and external); time (continuous and periodic); its nature (standard and specific) and its limit (full and partial)^(2,4). It consists of a systematic and independent examination of facts obtained through observation, measurement, test or other appropriate techniques, an activity element or system, which aims to verify the adequacy of the requirements recommended by the applicable laws and regulations and determine whether actions health and their results are consistent with the planned arrangements⁽⁵⁾.

The Unified Health System (SUS), the audit began in mid-1995 by Decree-Law No. 1,651/95. This decree regulates the National Auditing System (SNA), which aims to audit in the three spheres of government (federal, state and municipal) to fund transfers to the financing of the SUS, while seeking to associate the typical functions of audit with the quality assessment of management⁽⁵⁾. For the whole of this scenario involving the audit, nursing can be understood as that which manages, provides assistance, coordinates and audits all that relates to patient/customer care^(2,6).

With the evolution of health care, there is a need to acquire basic knowledge about audit for the professionals, especially nurses, being that, through this professional knowledge,  loss reduction, cost reduction and a reduction of rejections and waste can be achieved without losing customer service quality^(2,4).

Nurses should be aware of their responsibilities and capabilities as well as committed to the goals of your organization. Motivation is necessary to influence your team in order to follow the same path of commitment with the objectives of the institution, ethically and productively. However, the audit in nursing still seems to be viewed by some professionals as a detached function of focus area - the care.

The audit in health services has been seen as essential to achieving the goals of any organization. The nurse must have qualities (some possibly innate and other acquired through qualification and experience) that make a qualified and experienced professional, whose main ability is to motivate others to follow their ideas and ideals.

The justification of the study is that the labor market in this area has been expanding increasingly. And considering that there is a deficit of auditors’ nurses, it is necessary to understand the role of nurses in this scenario, especially in the Family Health Strategy Unit (UESF) that performs this activity, in order to improve and extend the quality of service audit at the local level, providing the management with guiding grants of an outreach strategy directed towards the assistance provided.

Thus, emerged the motivation to carry out the study, which was anchored in order to identify the comprehension and skills equired by nurses in relation to the audit of health services in UESF in a municipality in southern Brazil. To meet the goal, the following question have been drawn up: what skills and understanding are required by nurses in relation to the audit of services in UESF in a municipality in southern Brazil?

METHOD

This is a descriptive study with qualitative approach that, enables a closer relationship with the daily life and experiences of the research subjects themselves⁽⁷⁾.

The study was conducted in all UESF of a municipality in southern Brazil, totaling 11 units. They attended 11 nurse coordinators. They followed the inclusion criteria for: nurses coordinators working in the UESF of a municipality in the southern region of Brazil, those of both sexes and of all ages. The exclusion criteria applied to clinical nurses of UESF and those taking holidays in the data collection period.

To collect the information, we used the semi-structured interview technique and recorded the responses to, six open questions on the subject of study. The interview duration was approximately 20minutes for each participant in designated time by the same participant. Data collection took place in July 2014.

For the analysis of information, we have followed the steps of Bardin's Content Analysis Technique: pre-analysis, material exploration and treatment of results, inference and interpretation⁽⁸⁾.

Ethical principles were respected at all stages of the study according to Resolution No. 466/12, which deals with recommendations that regulate research involving human beings⁽⁹⁾. The study was approved by the Ethics Committee of the Integrated Faculties of Brazil in the opinion CAAE 28773214.5.0000.0095. Given the ethical aspects of research with human beings that must be taken into consideration in order to preserve the anonymity, it was decided to identify subjects with encodings E1, E2, E3 and so on.

RESULTS

Eleven USF coordinators nurses participated as study sample, 91% ⁽¹⁰⁾ female and 9% ⁽¹⁾ male, with an average age of 38.27 years. In regard to the training time, there was variation between 2 and 30 years, with an average of 12.6 years. The average time of employment in public health in UESF was 9.3 years. Among the coordinators nurses participants of the study, all had a broad sense course of specialization in various areas of knowledge, but 64% ⁽⁷⁾ had specialization in Family Health Strategy (FHS). Of the remainder, 26% ⁽⁴⁾ had expertise in other areas such as Occupational Health, Emergency Department, Pedagogy and Marketing.

Regarding the audit experience, one of the interviewees already exercised activities in the private sector, while 55% ⁽⁶⁾ felt qualified to conduct audits in public health services and 45% ⁽⁵⁾ did not feel qualified or suitable for the activity.

After the content analysis, it was possible to apprehend four categories.

1) The audit as tool to help in management: administrative, financial and of humans resources
Audit is considered by the interviewees as a tool that helps administrative management, cost reduction, inputs prediction and provision, human resources, assessment of medical records, data analysis and quality assessment, as presented in the speeches below:
... then comes to help the nurse in the administrative part, both in prediction and in the provision of inputs and even human resources. Serves to verify the medical records, survey reports, material purchase readjustment. (E1)

Assessing the quality of procedures and processes offered to the population [...] analysis of data monitoring and account analysis also, invoices, finally, for cost reduction. (E6)

Issue of human resources for checking frequency, attendance, punctuality of employees, frequency report being delivered to the human resources of health department. [...] Issue of excessive workload because we have few professionals, the number is insufficient of human resources to develop the unit's activities. (E9)

2) The audit in health services and nursing: evaluation, monitoring procedures and processes
In the nurses' speeches, it became clear that the audit in the health and nursing services contribute to evaluation and monitoring procedures and processes aiming at reducing costs and consequently ensuring good management. Monitors the achievement of health actions, enabling the analysis of medical records regarding the quality of information and data collection, while containing the costs of tests and procedures and perform inventory control, as shown in the following excerpts:
In Nursing is the verification of medical records to see if it was checked, if was carried out, if was suspended or not, and in health to see if the service is having unnecessary expenses or even a readjustment of the purchase of materials (E1).

Audit in the health services I see as a whole: audit in question to all services, tests, nursing procedures, everything that is executed in the unit. (E2)

On service are the data from procedures performed, data from consultations available to users, and based on these, you can raise and develop goals and action to improve services. (E4)

The service can be done in many areas, for example, here at the facility, the management issues, the issue of pharmacy, matter of inventory control, all materials and medicines we use, we can do an audit checking if they are being used in the right way, leveraging and reducing costs. (E7)

3) Activities of audit performed by nurse in ESF:: medical records, protocols, work and quality processes
The nurses refer to the activities they perform in auditing public health when conducting data collection in relation to vaccines, consultations, hospitalization, evaluation of medical records, testing quotas, requesting materials, and the evaluation of the service and processes. When finish the closing report they foward to the manager of managers of government spheres, as presented in the speeches below:
I do the data collection based on consultations and medical procedures performed, use for the monthly report a printed called Brazilian Registration of Occupation, to record the procedures in general and then are sent to both the municipal, state and federal level. Still do the lifting of the Hospitalization Authorization and also of specialized consultations and specialty procedures. (E4)

The audit here is based on APSUS (Primary Health Care / SUS) that comes from the state government and the 2nd Regional, which will change the entire work process here on the unit from the registration, monitoring, evaluation and data analysis. Also audit medical records, vaccine and evaluation of laboratory quota, and accounts evaluations, among others. (E6)

We have audited the medical records to verify that all issues related to the Protocol, whether municipal or ministerial, are being followed. (E7)

4) Skills acquired through training, continuing education and professional experience for the exercise of audits
The speeches of the coordinators denote some factors that contribute to knowledge about the audit process in public health services when reporting experience, capacity-building, qualifications and training, as evidenced in the speeches below:
A formation, a practical experience, also the use of multidisciplinary knowledge in the audit, administration, economy and even laws. (E1)

It's only have one capacity building, postgraduate; in fact some have a profile, and others have not. (E5)

A specific course is required for this or professionals hired only for this function, it would be all much better. [...] skills, abilities, attributes, I think it is a series of items that nurses must possess. So you must have an education, you must have experience, you must have a willingness. (E7)

DISCUSSION

Throughout the study, it was observed that the interviewees mentioned numerous times that the audit of health services aims to benefit the activities that they perform in UESF, especially with regard to monitoring health care costs. Therefore, it is necessary to understand the concept of audit, what it contributes to and what is the role of the nurse in using it as a practical tool in nursing.
The nurse is the professional most qualified to fulfil the audit function, but it requires knowledge of the area in their training, so he or she can develop a critical look at the care provided.⁽³⁾ What is noticeable in the speeches of the interviewees is that the tool has helped the nurses working both in UESF in administrative and financial management, and in human resources.

Audit contributes to an economic analysis of healthcare, assessing the principles of efficiency, effectiveness and economy in regard to the actions and services of public administration. Since the SUS unit, the theme of economy has been longstanding, being that there are critical points in the discussion, such as the lack of resources, rising costs, and the inefficiency and ineffectiveness of its use as a condition on quality of services in health⁽¹⁰⁾.

Regarding the role of the nurse in this scenario, it highlights the importance of engaging in actions that provide the acquisition of resources for the institution for which it performs its work activities. As such, it enables management to regulate, control, evaluate and audit the established actions and/or described in an operational plan established by a planning goals and actions to meet the Complementary Law No. 141/2012⁽¹¹⁾.

The audit is considered a systematic evaluation of nursing care, which can be verified by the notes/evolution in the medical records of patients and care given through records, reflecting in turn the quality of care⁽⁴⁾. In this scenario, it is understood that the audit function not only indicates the failures and problems, but also points to suggestions and solutions⁽⁶⁾. Besides, it provides an improvement to the technology of information for health as the needs of patients seeking services⁽¹²⁾.

However, to point to suggestions or solutions regarding the nursing care, the auditor nurse must have technical expertise, independence and impartiality, ethical behavior, caution and professional zeal and, above all, secrecy and description, in order to meet the principles of the Constitution Federal (art. 196)⁽¹³⁾.

In the nurses' speeches, it denotes the fact that the audit in the health and nursing services is in line with the proposal of the SNA created in 1995, which aims to improve care and access to actions to health services, monitoring and verifying the performance of SUS, so that the principle of the Constitution can be fulfilled^(5,13).

In accordance with the proposal of SNA, health care workers should not and cannot do their jobs without analysis, preparation and knowledge, as it demands the need for qualified professionals for this work. With this, the nursing audit meets this demand to diagnose, organize, control and measure the registration process ⁽²⁾. Therefore, is needed training/qualification of this professional in order to exercise the function.

In relation to a qualified professional, the nurse is considered manager of nursing care in their daily practice, while the Regional Nursing Council considers the role of the auditor nurse in the areas of Management Audit, Quality Audit and Assistance and Economic Quantum Audit (materials and medicine)^(14,15). These principles provide legal conditions for the performance of the auditor nurse in the scope related to health services.

It is understood that these are opportunities of specialization in the training of nurses, which can contribute to the quality of the records of the care actions reflecting the quality of care and labor productivity. Based on these records, it is possible to build better care practices permanently, and implement actions aimed at improvements on operational results^(2,6).

By mentioning the auditing activities that they perform in UESF, the interviewees state that they elaborate various reports sent to the spheres responsible for the collation of information. Such a process thus enables investigation of the quality of care, leading managers to reflect upon its educational nature and so ensure the improvement of care⁽¹⁶⁾.

We have denoted the coherence between the interviews and the literature on the subject. It is inferred, therefore, that the audit is adopted as a tool of control and regulation of the use of health services. In the case of services provided in the SUS, Law No. 141/2012 stipulates that accounts are provided to the public about the investments made in public health, aiming thus the transparency of transfers made between the spheres^(1,17).

This policy is therefore consistent with the nursing audit carried in health institutions, which aims to minimize waste materials, medicines, equipment and human resources. It emphasizes the importance of the nursing team record, fundamental to the audit process⁽²⁾.

In any case, there are many challenges ahead for the development of audit in nursing, such as the discovery of a professional identity⁽²⁾. However, before the scenario it is clear that nurses already practicing and/or performing the audit function in UESF when carrying out activities verbalized during the interview.

Moreover, amongst the speeches of the coordinators, noticed some factors that contribute to the knowledge about the audit process in public health services when reporting experience, capacity, qualifications and training.

In regard to the skills acquired, we may surmise that the constructs presented here by the interviewees may serve as a fulcrum for greater investment in the training of nurses focused on auditing. Again, regarding the relevant skills, it is necessary to grasp the knowledge produced on the subject of nursing audit in terms of its conceptual dimensions, methods, purpose and legislation, so as to appropriate a minimum theoretical background on the subject and thus indicate possibilities of the auditor nurse acting^(17,18).

We will highlight the auditor nurse profile in this case: one must have technical knowledge, know how to listen and be silent when necessary, always have confidence, discretion, autonomy and independence, professional judgment domain, impartiality and objectivity^(2,3,18). For the powers of the auditor nurse to develop, it is important that the coordinator has appropriate academic education, meeting the needs of career professionals. It is evident in reading the works that training competent nurses for the area of audit and management is still a big challenge⁽³⁾.

The fact is that the quality of a service is measured through various aspects, ranging from professional training and the quality of the records, to assistance in improving the customer's living conditions or the restoration of his health, when possible⁽¹⁹⁾. Therefore, the nursing contribution to the audit process is significant because, through these professionals, the practice gained in managing the assistance is able to act in evaluating the quality of service⁽⁵⁾.

Considering this scenario, the scientific literature on auditing in the field is still insufficient. For this practice to be sustained, it is necessary for their production to form scientific thought⁽²⁰⁾.
Therefore, it noted the need to empower nurses working in units providing health services, especially UESF, considering that the audit brings benefits such as development of care indicators, establishment of evaluation criteria and generation of new knowledge⁽²⁰⁾.

It is noticed that the need for the updating and training of nursing professionals in regarding the audits for health services is unquestionable, as they are present at every health care level. Thus, it is relevant that it is always in search of new knowledge and updates.

CONCLUSION

Note that the audit is related to a set of processes and has, as its main objective, to analyze how to develop the procedures performed within UESF so that they can assess whether the best traveled path should be followed.

The analysis of the interviews showed that the audit is used as the basis for the administrative, financial and areas related to human resources. It helps providing useful data so that they can reduce spending, organizing tasks, improve the development of daily activities and track employees in carrying out their duties, and helping them to follow the ideal route for quality in UESF.

The audit helps with assessing, monitoring procedures and processes, showing whether they are being carried out correctly, as well as pointing noncompliance. It also presents a survey of expenses, thus ensuring that financial planning is scheduled and no waste to public health expenditure occurs.

It is noted that the interviewee nurses recognized their responsibilities and the importance of surveys in order for the audit to be successful. The auditor nurses must have the conviction that their reports are the guiding basis for healthcare services to follow their course without leaving the main axis to meet the needs of users.

In order that those responsible for the audit to be carried out with greater clarity and certainty such surveys, it is essential and indispensable that they are capacitated regularly so that they can improve and increase the quality of auditing in local levels services, providing guiding subsides to managers sensitized to strategy and focused on the assistance provided.

Therefore, the audit contributes directly to the management of nurses in UESF. What is more, as one of their presented objectives they also point to suggestions and solutions for the improvement of nursing care, although they should always take into consideration that the auditor nurse must meet the principles of the Federal Constitution.

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Received: 04/09/2015
Revised: 01/18/2016
Approved: 01/25/2016