Date of Conferral

2021

Degree

Doctor of Nursing Practice (DNP)

School

Nursing

Advisor

Barbara Niedz

Abstract

Quality documentation is a foundational element in healthcare. This QI project was conducted to examine the extent to which the implementation of a standardized behavioral health audit tool influenced compliance with required documentation elements. The context, input, process, product evaluation model was used to support the need for documentation compliance in behavioral health. A new audit tool was developed and implemented. Retrospective audit data were gathered from 86 locations over a period of 3 years, reflecting quarterly corporate audits and monthly program self-audit results. The first five quarters exhibited the widest variation in scoring; 28 locations required action plans for compliance scores lower than 90%. To further examine the variability of the first five quarters of data a series of nonparametric tests were performed on the audit results. The Friedman test comparing the first five quarters showed a statistically significant increase in scores (X2 = 12.982; p =.011). A Wilcoxon signed ranks test showed the significance of the gap in scoring between the corporate and self-audit scores for 2018 (Z = –3.381; p = .001), 2019 (Z = –3.578; p = .001), and 2020 (Z = –5.809; p = .001). The audit subsections that exhibited the most improvement over the five quarters were individualized treatment planning and treatment team. In response to a staff perception survey, staff indicated highly valuing the corporate audits and that host hospital leadership feels the programs are regulatorily compliant. This project offers other disciplines of nursing practice the opportunity to use this same audit process approach with tools appropriate to their care environment, which could bring about positive social change by improving patient care and regulatory compliance.

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