Supervision of the professional practice of nursing: case study describing the “on-site inspection” sub-process

Fiscalización del ejercicio profesional de enfermería: estudio de caso describiendo el subproceso “inspección in loco”

ABSTRACT

Objectives:

to describe the “On-site inspection” sub-process of the macroprocess “Supervision” conducted at the headquarters unit of the Regional Nursing Council of São Paulo.

Methods:

an exploratory descriptive research, in a single case study modality using data reported by the Headquarters Unit Inspection Management leaders.

Results:

the description of the “On-Site inspection” sub-process, initial and return, showed how the activities/tasks pre-established in the inspection roadmap and inserted in the respective inspection terms need to be accurately and sequentially executed to comply with the current legislation and provided the identification of activities that add value to the inspection process.

Conclusions:

the results obtained give visibility to the activities/tasks developed by the inspectors and will provide the Inspection Management with subsidies for the rational allocation of the required human resources; and, to the technical managers and legal representatives of the inspected institutions, the knowledge of the activities developed during the performance of the sub-process “On-site inspection”.

Descriptors
Professional Review Organizations; Health Care Coordination and Monitoring; Organization and Administration; Workflow; Nursing Services

RESUMEN

Objetivos:

describir subproceso “Inspección in loco” del macroproceso “Fiscalización”, realizado en Unidad Sede del Consejo Regional de Enfermería de São Paulo.

Métodos:

investigación exploratoria-descriptiva, en modalidad estudio de caso único, cuyos datos obtenidos con líderes de la Gerencia de Fiscalización de la Unidad Sede.

Resultados:

descripción del subproceso “Inspección in loco”, inicial y de vuelta, evidenció como las actividades/tareas preestablecidas en el guión de fiscalización, inseridas en los respectivos términos de fiscalización, precisan ser ejecutadas, de manera secuencial y en detalles, objetivando al cumplimiento de legislaciones vigentes; y propició la identificación de las actividades que agregan valor al proceso de fiscalización.

Conclusiones:

resultados obtenidos confieren visibilidad a las actividades/tareas desarrolladas por fiscales y proveerán a Gerencia de Fiscalización subsidios para mejor ubicación de recursos humanos requeridos; y, a Responsables Técnicos y Representantes Legales de instituciones fiscalizadas, el conocimiento de las actividades desarrolladas durante la realización del subproceso “Inspección in loco”.

Descriptores
Organizaciones de Normalización Profesional; Regulación y Fiscalización en Salud; Organización y Administración; Flujo de Trabajo; Servicios de Enfermería

RESUMO

Objetivos:

descrever o subprocesso “Inspeção in loco” do macroprocesso “Fiscalização”, realizado na Unidade Sede do Conselho Regional de Enfermagem de São Paulo.

Métodos:

pesquisa exploratório descritiva, na modalidade de estudo de caso único, cujos dados foram obtidos com os líderes da Gerência de Fiscalização da Unidade Sede.

Resultados:

a descrição do subprocesso “Inspeção in loco”, inicial e de retorno, evidenciou como as atividades/tarefas preestabelecidas no roteiro de fiscalização, inseridas nos respectivos termos de fiscalização, precisam ser executadas, de maneira detalhada e sequencial, visando ao cumprimento das legislações vigentes; e propiciou a identificação das atividades que agregam valor ao processo de fiscalização.

Conclusões:

os resultados obtidos conferem visibilidade às atividades/tarefas desenvolvidas pelos fiscais e fornecerão à Gerência de Fiscalização subsídios para a alocação racional dos recursos humanos requeridos; e, aos Responsáveis Técnicos e Representantes Legais das instituições fiscalizadas, o conhecimento das atividades desenvolvidas durante a realização do subprocesso “Inspeção in loco”.

Descritores
Organizações de Normalização Profissional; Regulação e Fiscalização em Saúde; Organização e Administração; Modelagem do Processo; Serviços de Enfermagem

INTRODUCTION

According to Federal Law Nº 5,905 of July 12, 1973(¹), the Federal Nursing Council (COFEN) and the Regional Nursing Councils (CORENs) are disciplinary bodies of the professional practice, whose scope is to standardize, discipline, and supervise the professional practice of Nursing, intending to meet ethical and legal principles(²). The supervision of the professional training should emphasize the educational, preventive, and disciplinary conceptions, ensuring the quality and safety of nursing care, and unfolds in inspection, hearing, meeting, and lectures(²).

In the administrative process of supervision, the on-site inspection is a previously planned activity in which the designated supervisor travels to a health institution to inspect the Nursing Service (NS) to identify and prevent the occurrence of violations of the laws that regulate the practice of nursing professionals(²-³).

In 2012, the Supervision Management (GEFIS) of the Regional Nursing Council of São Paulo (COREN-SP) began restructuring of its work processes to improve the performance of these activities (inspection, hearing, meeting, and lectures), with the principal purpose of implementing the standards established by COFEN through Resolution N^o 374/2011(⁴).

Thus, thirty-six normative documents were prepared, entitled Standard Operating Procedures (POPs) and an Inspection Roadmap to direct the supervisors executing their activities and tasks before the NSs in health institutions. Over the years, these documents have been updated in accordance with new legislation and internal routines. In 2014, COREN-SP inspectors conducted an evaluation of the papers and requested the insertion of flowcharts in each document to facilitate the understanding of the actions and expedite their proper conduct.

So, the software bizagi^® was adopted for the creation of flowcharts because it is free and simple to understand, which uses a graphic notation to map and monitor the internal processes of an organization in a standardized way(⁵), focusing on continuous improvement.

The process mapping makes it possible to fully identify the current situation of each process (“AS IS”), counting on the involvement of the employees who perform it daily, with the main benefit of a mutual understanding of how the work is done. With this knowledge, it is possible to incorporate best practices into existing processes towards where you want to go (“to BE”). It provides the standardization of procedures, the significant reduction of errors and rework, and, consequently, the dynamization of work, directly reflecting on the quality of the service provided for the user(⁶-⁷).

Mapping processes contribute to their proper management, allowing to organize and structure of all stages, activities, and tasks that contribute to the achievement of the strategic objectives of the organization to ensure their correct execution(⁶).

However, due to the brevity in using the 36 POPs previously mentioned and the need to invest in the training of employees for their proper use, GEFIS chose to build the flowcharts based on the activities described in each normative document (POP).

However, in July 2016, Cofen Resolution N^o 518/2016(³) amended the annex to Cofen Resolution N^o 374/2011(⁴), entitled “predictable situations and behaviors to be adopted,” from the Cofen/Regional Nursing Councils Supervision Manual, which was named as “framework of irregularities and illegalities.” Thus, the documents to be drawn up at the end of the inspections were standardized based on the type of action performed and situation found on-site. Until then, each of the 27 CORENs had its internal regulations on the documentation used in the actions, considering the COFEN regulations.

Based on this COFEN recommendation, COREN-SP adopted the use of the following documents: notification, for initial inspections; complementary notification, for return inspections; Inspection Term (IT), when there were no notifications involved, and infraction order, issued when there were no unjustified measures to comply with the notification(⁸), and it was necessary to update the POPs and the forms used in the inspection process. The Inspection Roadmap has been improved, meeting the requirements of Cofen Resolution N^o 518/2016(³), and was later used by COFEN as a reference for designing the new IT.

With the new management in COREN-SP in 2018, a new update of the documents was conducted with the insertion of the flowcharts in the current POPs. However, on October 17, 2019, Cofen Resolution N^o 617/2019(²) updated the “irregularities and illegalities” table contained in the Cofen/CORENs System Inspection Manual. It also proposed changes in the methodology for the execution of the “On-site inspection” sub-process and standardization of the Terms (one for the initial inspection [IT] and another for the return [IT of return]), including the same items contained in these Terms in the Inspection Roadmap. Thus, instead of the taxman using two documents (an IT and a road map), he/she began to use only specific terms.

Based on this situation, GEFIS launched a task force to review and amend the POPs, forms, and terms, in addition to promoting the training of the inspection team. The restructuring of computerized systems and the reformulation of documents occurred in November and December 2019, resulting in 21 POPs, 13 printed, two terms, and nine administrative standards and investments in tax training from January 6-10, 2020.

The implementation of the changes in the modus operandi took place on 01/13/2020, and the sub-processes (Pre-inspection, On-site inspection, and Post-inspection) did not change until 03/13/2021 when the conjuncture of the COVID-19 pandemic required changes on an emergency basis.

Despite periodic and recurrent searches in the national and international literature, no studies were found that addressed the specific sequence performed in the “On-site inspection” sub-process. It highlighted the knowledge gap that needs to be valued and shared as well as verticalized through research developed by other CORENS, including the activities performed in on-site pre-inspection and post-inspection sub-processes. In this context, the present study was proposed.

OBJECTIVES

To describe the “On-site inspection” sub-process of the macroprocess “Supervision,” conducted at the headquarters unit of COREN-SP.

METHODS

Ethical aspects

The Research Ethics Committee of the proposing institution approved the study in 2021, and the authors fully respected Resolution Nº 466/2012 of the National Health Council(⁹).

Type of study

This is an exploratory-descriptive research, in the particular case study modality(¹⁰), conducted in accordance with the guidelines of the Equator Network’s CARE instrument.

The present study was conducted at GEFIS of the Coren-SP headquarters unit, from August 02 to 27, 2021. COREN-SP has 14 units that conduct the inspection process, with a headquarters unit and 13 subsections (Araçatuba, Botucatu, Campinas, Guarulhos, Itapetininga, Marília, Osasco, Presidente Prudente, Ribeirão Preto, São José do Rio Preto, São José dos Campos, Santo André and Santos), covering 654,129 professionals(¹¹).

The GEFIS team comprises the professionals allocated in the headquarters unit and the 13 subsections, with one executive manager, one manager, four inspection coordinators, thirteen technical heads, one administrative coordinator, one coordinator of the ethical process, eighty-two tax inspectors, four inspection assistants, forty-seven administrative agents, eight receptionists, one computer technician, and four young apprentices.

As recommended by the 2018/2020 management of COREN-SP, the executive manager, the manager and the four inspection coordinators, the administrative coordinator, the coordinator of the ethical process, 24 tax inspectors, two inspection assistants, 16 administrative agents, and four young apprentices worked in the headquarters unit. Of the 24 inspectors, two conducted dimensioning workshops aimed at the technical nurses responsible (TR); one assisted in the preparation of opinions in the Technical Chamber; one screened the complaints received, three made face-to-face, telephone and hearing calls, and 17 conducted inspections in health institutions.

In conclusion, GEFIS develops 1) internal activities - attendance of hearings, preparation of reports, meetings with professionals, technical opinions, analysis of processes (administrative, complaint, syndication), participation in training; and 2) external activities - inspections, lectures, participation in working groups and scientific committees, meetings with professionals and representatives of COREN-SP in national and international events.

Collection of data

The collection of data was conducted in the presence of GEFIS’s manager and the executive director, who authorized access to regulatory documents (POPs, regulations, and printed matter) located on the intranet “Improvement Platform,” at the address https://aprimoramento-gefis.coren-sp.gov.br/. As a result, an analysis of the documents and a detailed description of the “inspection” sub-process was conducted on-site, initial and return, using as a subsidy the normative documents of COREN-SP’s GEFIS, resolution 617/2019(2) and the expertise of one of the authors.

RESULTS

As previously mentioned, the “On-site inspection” sub-process is characterized by the investigation in the health institution, whether the professional practice of Nursing is in line with ethical and legal principles, contemplating the main activities listed in Figure 1, which summarizes the three sub-processes of the macroprocess “Supervision:”

Figure 1
Synthesis of the macroprocess “Supervision”, with emphasis on the “On-site inspection” sub-process and respective activities and tasks, elaborated by the authors, São Paulo, São Paulo, Brazil, 2021

The description with emphasis on the “On-site inspection” sub-process, initial and return, in the context of the macroprocess “Supervision of the professional practice of nursing,” demonstrates how the activities and tasks pre-established in the roadmap, inserted in the respective ITs, need to be performed sequentially, for compliance with current legislation.

Next, the survey will present the nine activities and tasks (indicated by letters) related to the items 3 and 4, performed in the initial “On-site inspection” sub-process by the inspector:

1. Upon arr ival at the institution, introduce yourself with the professional identity card.

2. Request the presence of the nurse RT to accompany the inspection; and, in the absence of this, ask that another nursing professional be designated.

3. Hold an initial meeting with the nurse RT or other nursing professional to explain the objectives of the inspection and request the communication of the inspector’s presence to the legal representative if he/she is not present. At this meeting, question:

   1. Whether the registration data of the institution, registered in the computerized system of COREN-SP, are correct;

   2. If there is a nurse in the entire working hours and/or on usual leave in the institution;

   3. On the existence of a nursing Ethics Committee, based on the number of professionals established in a specific norm;

   4. On the existence of quality and patient safety indicators related to nursing care;

   5. On the periodicity of conducting training and performance evaluation, with the knowledge of professionals (request proof).

4. Inspect the places/sectors where nursing professionals work, to verify:

   1. Whether there are environmental conditions conducive to the provision of safe nursing care and whether there is an appropriate resting place for nursing professionals, as well as to question the nurse RT whether there are adequate and sufficient materials and equipment;

   2. The monthly and daily nursing scale, considering the number of assistants, technicians, and nurses, workload, distribution of professionals, and activities conducted to comply with current legislation;

   3. The presence of nurses in all units where nursing activities are developed;

   4. The presence of a nursing professional with an expired professional identity card;

   5. The presence of workers who are not legally qualified and registered to conduct nursing activities;

   6. Whether the activities conducted are in line with current legislation and other resolutions/decisions of the COFEN/CORENs system, highlighting, as an example, the execution of private activities of the nurse by a person without legal qualification;

   7. The performance of the nursing process and the records of the assistance provided in medical records, and nursing documents, such as control of the emergency car and validation of the sterilization process of materials;

   8. Whether there are guiding documents for the management of NS work processes, such as internal regulations, standards and routines, protocols, POPs, calculation of personnel sizing, and Certificate of Technical Responsibility, and whether they are consistent with the ethical and legal precepts of the profession.

5. At the end of the survey, the inspector guides on the irregularities and/or illegalities identified, notifying the deadline for regularization and, if necessary, the proposal of educational actions, such as the elaboration of the nursing process and the calculation of nursing personnel sizing, according to the relevant legislation.

6. Solve possible doubts related to professional practice, working conditions, and other situations that interfere in the provision of nursing care to nursing professionals in a legal and safe way.

7. Document in the IT the information collected during the inspection in the sectors, in the verification of documents, and the meetings, in addition to indicating in the IT the non-conformities, with their respective notifications and deadlines for compliance, if any.

8. Guide the TR nurse, or other designated nursing professional, who followed the action on the items identified in the inspection, paralleling the current legislation.

9. Deliver the first IT copy to the nurse, the second to the legal representative, and attach the third to the documentation of the inspection process. Finish the On-site inspection, return to the headquarters unit and continue the “initial on-site post-inspection” actions.

After the expiration of the most prolonged period notified in the initial on-site inspection, the institution is again assigned for the on-site inspection of return, in which the inspector must conduct the seven activities listed below:

1. Upon arrival at the institution, introduce yourself with the professional identity card.

2. Request the presence of the nurse RT to accompany the inspection; and, in the absence of this, ask that another nursing professional be designated.

3. Hold an initial meeting with the nurse RT or other nursing professional to explain the objectives of the inspection and request the communication of the inspector’s presence to the legal representative if he/she is not present.

4. Check if there was an update in the institution’s register and in the staff informed in the initial on-site inspection.

5. Check whether previously reported irregularities have been regularized and whether there are new irregularities.

6. Finalize the inspection describing the notifications regularized, the non-regularized ones and of the new ones, if any, in the return IT, contemplating the pertinent guidelines, the due deadlines for regularization of the new notifications and inform the period of 15 days for manifestation on the non-regularized notifications.

7. Guide the RT nurse or designated nursing professional to send the documents for proof of regularization via the Contact Us channel, on the COREN-SP website, within the established deadlines.

DISCUSSION

The first inspection project of COREN-SP was implemented in 1976 and improved over the subsequent years. In 1990, there was a reformulation in the inspection procedure, initially focused on guidance and, later, on the application of sanctions(¹²). After 21 years, Cofen Resolution Nº 374/2011 was promulgated, which presented the first Cofen/Regional Nursing Council’s Inspection Manual, containing general guidelines for inspection procedures in the NSs, including irregularities that must be identified and relevant notifications to be applied(⁴).

The NS is one of the components of the organizational structure, having as scope the execution of actions concerning the managerial and care work processes, complex, and multifaceted; it is done through continuous nursing care with the increase of safe and evidence-based practices, conducted by legally qualified professionals and sized according to current legislation(¹³-¹⁸). Cofen Resolution Nº 509, of March 15, 2016, which updated the technical standard for annotation of technical responsibility for NS, defines, in Article 10, the duties of the TR nurse and how the NS should be structured, based on managerial actions(¹³).

It is relevant to recognize the different work processes (managerial, care, educational and investigative) of nurses to direct the supervision of the nursing professional practice. In this line, a study(¹⁹) developed with nurses who worked in Family Health Strategy identified that the development of the nursing work process went through the care (42%), managerial (38%), and educational (20%) dimensions. The Resolution Nº 573, of January 31, 2018(²⁰) of the National Health Council emphasizes the need for training of health professionals focusing on technical and political performance and the development of critical and reflective vision.

In the NSs, care and managerial work processes are predominant(²¹-²⁵). An observational study conducted with nurses of critical units aimed at pediatric and adult patients in a University hospital found this evidence: it identified that, of the 2,295 activities performed by nursing professionals, 61.1% were assistance and 18.3% managerial(²⁶).

During the initial and return on-site inspections, COREN-SP inspectors verified which are the management and care actions conducted by the nursing team, such as: Systematization of Nursing Care and guiding documents, especially the internal regulations, work plan, control instruments, monitoring of indicators, procedures manual, registration in papers of actions carried out related to care; personnel sizing and permanent education program, all focusing on compliance with legislation concerning the regulation of professional practice(³-⁴,¹⁴-¹⁵).

In the present study, the detailed description of the “on-site inspection” sub-process, the macroprocess “Supervision” and its respective activities and tasks, has the potential to assist the supervisor in its conduct and planning, giving visibility to the activities and tasks performed by this professional since there is a procedural rite to be followed. It enables TR nurses to understand the steps and developments of this sub-process to support the organization of their work processes and the nursing team to provide the information and documents requested by the supervisor. Finally, this description contributes to the understanding of the managers of COREN-SP itself about which activities and tasks can be excluded or changed, for the optimization of work and rational and efficient allocation of resources, without prejudice to quality, corroborating other studies(²⁷).

By describing the activities and tasks related to the “on-site inspection” sub-process, the study observed that the identification of the logical sequence of the component activities of the stages of a process helps in understanding the functioning in practice, ensuring its execution in the best feasible way. In addition, the study highlights which items need to be reformulated during execution(²⁸).

In that regard, research developed in a dental clinic demonstrated that the description of the activities of a process provided the manager with the knowledge of the logical sequence, facilitating the decision-making; and workers, the knowledge of steps that should guide the development of their work(²⁹).

Another example is a survey on the audit process, billing of accounts, and deduction resources in a hospital highlighted that the mapping and description of the processes complemented by flowcharts, help employees perform their tasks more efficiently, increasing the time spent on activities, minimizing non-conformities, and generating efficient financial results(³⁰).

Study limitations

As of 03/16/2020, the actions of the Inspection of COREN-SP were exclusively directly to the management of issues associated with the COVID-19 pandemic through strategies with institutions and public authorities to raise care risks and ensure the provision of personal protective equipment to nursing professionals. Due to this crucial situation, the regulatory inspection process until then was suspended; and the inspectors were destined to act exclusively on specific work fronts aimed at nursing professionals. Thus, it was not possible to send the description of the “on-site inspection” phase to the inspectors to jointly identify, based on their experience and professional practice, the priority activities and tasks to be maintained in the process of supervising the professional practice of Nursing and the actions that could be suppressed, without prejudice to the quality of the work performed, which would result in the mapping of said process.

Contributions to the field of Nursing

The results of this research will subsidize the identification of activities and tasks whether or not they add value to the “On-site inspection” sub-process,” initial and return, in the context of the macroprocess “Supervision” of GEFIS from COREN-SP. To that end, they can stimulate the reproduction of similar studies in CORENs of other states and, thus, direct the elaboration of strategies that increase the required resources, efficiently and effectively, including expanding the reach of the institutions to be supervised.

Research of this nature goes through the review of processes, through their description and mapping, considering the current situation (“AS IS”) and where it is intended to reach (“TO BE”), unfolding from the value chain. In addition, they make the understanding clear and unbureaucratized and assist managers in the elaboration of a change plan with the projection of opportunities for improvement and the allocation of specialized labor of the inspector in favor of the finalist activities.

CONCLUSIONS

The description of the “on-site inspection” sub-process in the macroprocess “Supervision” of the professional practice of nursing, conducted in the headquarters unit of COREN-SP, gave greater visibility to the performance of inspectors. It will provide GEFIS with subsidies for the rational allocation of human and financial resources involved in the work processes, increasing compliance with the resolutions of COFEN/COREN-SP; and will provide the TRs and legal representatives with knowledge about the activities and tasks developed during their achievement.

• FUNDING
  National Council for Scientific and Technological Development - CNPq.

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Edited by

EDITOR IN CHIEF: Antonio José de Almeida

ASSOCIATE EDITOR: Priscilla Valladares Broca

Publication Dates

• Publication in this collection
  17 Oct 2022
• Date of issue
  2022

History

• Received
  26 Nov 2021
• Accepted
  12 July 2022