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Principles for good healthcare auditing

CHKS Ireland Conference 24th November 2015

Geraldine Reynolds

greynolds@chks.co.uk

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The quality spiral

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PLAN: Definition

AUDIT – We might initially think of a financial audit. The Oxford

English Dictionary defines audit as ‘A systematic review or

assessment of something’.

In healthcare services we also are required to undertake

CLINICAL AUDIT The Irish Commission on Patient Safety and

Quality Assurance (2008) defined clinical audit as:

a clinically led, quality improvement process that seeks to

improve patient care and outcomes through systematic review of

care against explicit criteria and to act to improve care when

standards are not met

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PLAN: Definition cont….

Internal - managed perhaps by the organisations

quality or risk manager- top, middle and service/delivery

levels

External – undertaken by a third party and may be:

Voluntary - contracted by the organisation e.g. CHKS

Regulatory e.g. Health Information & Quality Authority

(HIQA), Health & Safety Authority or Health Products

Regulatory Authority (HPRA)

Statutory e.g. Financial

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PLAN: Definition cont….

Scheduled- noted on the annual audit plan

Unscheduled–

Voluntary – as a result of an incident report RCA

– as a result of a risk review

– as a result of a complaint

Unannounced/random – from perhaps Health

Information & Quality Authority (HIQA), Health & Safety

Authority or Health Products Regulatory Authority (HPRA)

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PLAN: Why bother?

Audit and clinical audit are an

essential and integral part

of good clinical governance.

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PLAN: Why bother? Cont.…

• To continually improve

• To deliver a safe, effective and quality service

• Check, monitor, trend, analyse, learn, change, progress

• To ensure what you are doing is of benefit to those

for whom you are doing it

• To be cost effective; to be efficient

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PLAN: The strategy

Where does audit fit in to the bigger picture?

Your KPI’s provide the basis for your strategic plan!

But – keep top level KPI’s focused, reasonable and

effective.

You plan your goals/targets for the day, week, month, year …

Inform staff Audit/ clinical audit strategy Audit policy

Agreed an annual audit schedule and responsibilities

Report CAPA’s review goals and targets …………….

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CHKS audit requirements

Key evidence at the time of your survey and surveillance

monitoring are your audit reports.

The survey team and your client manager, in their capacity as a

lead auditor, are checking that audits are undertaken and that the

results of audits and quantitative indicators are collated,

analysed, assessed and acted upon.

Your initial assessments for your external audit are therefore part

of your internal audit practices.

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DO: Getting started

What can be audited?

Anything!! For example-

• Outcomes from risk assessments

• Staff absenteeism rates

• Policies and procedures – clinical and non-clinical

• Hand hygiene practices

• Financial accounts

• Patient outcomes (The National Office of Clinical Audit

https://www.noca.ie/)

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What can be audited?

Required training - CHKS

Staff trained to undertake their various responsibilities e.g. use

of specialist equipment; e-prescribing; management &

leadership, staff performance management, budgeting, risk

assessment, root cause analysis, communications, conflict

resolution, audit, medicines management, security, handling &

changing medical gases.

In line with mandated national/clinical requirements- fire,

health & safety, child safety, vulnerable adults, COSHH,

HACCP, diversity, waste management, resuscitation, major

incident process.

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What can be audited? ‘Never event’ The term "Never Event" was first introduced in 2001 by Ken

Kizer, MD, former CEO of the National Quality Forum (NQF), in

reference to particularly shocking medical errors (such as wrong-

site surgery) that should never occur. Over time, the list has been

expanded to signify adverse events that are unambiguous

(clearly identifiable and measurable), serious (resulting in death

or significant disability), and usually preventable.

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Wrong site surgery

Wrong implant/prosthesis

Retained foreign object post-procedure

Wrongly prepared high-risk injectable

medication

Maladministration of a potassium-

containing solution

Wrong route administration of

chemotherapy

Wrong route administration of oral/enteral

treatment

Transfusion of ABO-incompatible blood

components

Transplantation of ABO incompatible

organs as a result of error

Air embolism

Severe scalding of patients

Ref: NHS, UK - The never events list; 2013/14 update

Intravenous administration of epidural

medication

Maladministration of Insulin

Overdose of midazolam during conscious

sedation

Opioid overdose of an opioid-naïve patient

Inappropriate administration of daily oral

methotrexate

Suicide using non collapsible rails

Entrapment in bedrails

Falls from unrestricted windows

Escape of a transferred prisoner

Misplaced naso- or oro-gastric tubes

Wrong gas administered

Failure to monitor and respond to oxygen

saturation

Misidentification of patients

Maternal death due to post partum

haemorrhage after elective caesarean

section

‘Never event’

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What can be audited?

Clinical supervision An Bord Altranais - Clinical Supervision can be defined as "an

exchange between practicing professionals to enable the

development of professional skills" (Butterworth & Faugier 1992, p.12).

CHKS- Clinical Supervision: a programme of professional review

carried out by a more clinically experienced member of staff to

develop and improve the performance of a less experienced

member of staff.

Clinical staff participate in a programme of clinical supervision.

Guidance

Supervision in this sense relates to time set aside for formal reflection on clinical practice, usually with a more experienced practitioner, or for senior clinicians, a peer practitioner. Time needs to be allowed for clinical staff to be involved in receiving and giving clinical supervision. The term clinician applies to all staff with a clinical role and not just doctors and nurses.

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DO: Getting started cont.…

Who can perform an audit?

Internal audits can be done by anyone really – some

knowledge/internal training; larger organisation should have staff

with formal training.

Preferably someone not directly involved in the service, area,

process for audit.

External audits require trained auditors. Where contracting 3rd

parties e.g. Financial, Healthcare or QMS providers ensure

registered.

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DO: Getting started cont.…

What can YOU do?

Know and understand the audit strategy

Know and understand the audit policy

Know and understand the audit schedule

Know your audit responsibilities

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DO: Getting started Cont.…

SAMPLE AUDIT SCHEDULE Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Audit lead Supporting policy KPI

Training Resus Training Due Due Due Due Resus trainer RP101 100% rolling

Hand hygiene Due Due Due Due IP&C CNS IPC45 90% rolling

Fire drill Due Due Due Due Fire Officer FP112 100% rolling

Manual handling Due Due Due Due MH trainer HR101 90% rolling

Risk H & S Assessments Ward

1

Ward

2

Caterin

g &

Laundr

y

Ward

3

Admin

& HR

OT &

Pharm

a

H&S manager HS555 >85%

Incident reports Q2 Q4 QM Q999

RP065

S,T & F >5% p.a.

Fire safety Fire Officer FP112

Environmental (e.g. Disability access/

reception

H&S manager HS123

Hygiene (e.g. General/ catering/ laundry/

waste.

Clinical No. of transfusions Q1 Q3 Year end report

No. sober one year post 28/7 Tx

No. of returns to theatre

No. of HAI’s

Clinical notes

Financial Stock

Assets

Accounts €50k profit at year end

External CHKS Due

HIQA (Disabilities) Due

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DO: Getting started cont.…

Prepare your audit tool – based on what it is you are going to

audit:

Use pre-existing e.g. HIQA hygiene audit tool

Ask others to share

Create your own on Word or Excel e.g.

Based on your ‘Prevention of slips, trips and falls’ policy falls in

hospitalized patients audit might require:

Audit guidelines/instructions

Manual data collection sheet

Manual data summary sheet

Data collection spreadsheet

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DO: Getting started cont.…

Audit guidelines/ instructions –

Inpatient Fall Audit Guidelines

Background

Falls prevention is a risk management challenge for our organisation. Based on recent studies for example Kolin et al (2010) and Cotter et al (2012), as per the Prevention of slips, trips and falls policy (RP065) our KPI is that we shall experience no more than 3 falls per 1000 bed nights (i.e. 0.30% fall rate). Measure definition This audit will determine the number of inpatients who have a documented account of a fall in their medical chart.

Sample determination Inpatient falls are known to increase in patients 65 years or older. All slips, trips and falls are also reportable events recorded on the internal incident reporting system. Based on the incident reports for the previous three month period the charts of all reported slips, trips and falls will be listed.

Instructions for conducting audit The audit is undertaken each quarter from a randomly select 25% of the patients drawn from the provided list. Using electronic and /or paper medical records, complete the attached audit tool (see example) for each selected medical chart, or use the Excel spreadsheet and complete each cell under each relevant heading (see example). After completing an audit tool or the spreadsheet for each individual chart, compile your results and complete the audit summary with your totals.

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DO: Getting started cont.…

Manual data collection sheet –

Inpatient Fall Audit Tool

Date of review

Patient ID Auditor Inclusion criterion:

Patient age 65 years as of ##/##/## Y N Patient hospitalized during 20## Y N

If no to either of the above, this file is ineligible for this audit Exclusion criterion

None

Verification of fall (check as applicable):

Documentation of fall in record of hospital stay

Record as noted in incident report

No documentation of fall

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DO: Getting started cont.…

Manual data summary sheet –

Inpatient Fall Audit Audit Summary

Date: ____________________ Auditor: ___________________________________ Total charts reviewed: ________ Number who:

a. Had documentation of fall in chart: _______ % b. Did not have documentation of fall in chart: _______ %

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DO: Getting started cont.…

Data collection spreadsheet –

Inpatient Falls Audit

20##

Excel Spreadsheet

Name M R # Age Fall Y/N No Fall Y/N

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DO: Audit report

AUDIT REPORT FORM

AUDIT DETAILS: AUDITORS/AUDITEES: AUDIT NON-CONFORMANCES

Audit reference: Area Audited: Date:

Auditor(s): Auditee(s):

Conformance rating:

Full (%) Partial (%) Non (%)

SECTION 1 AUDIT FINDINGS: In this section outline the audit process and include a description of the non-conformance(s) and recommendation(s):

Audit Process: Documents for audit:

~~~~~~ Supporting documentation: ######################

Audit Tool: Audit Summary: _____________________________________________ __________________________ Auditor(s) & Date Auditee(s) & Date

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CHECK: Review the findings

Are the findings in line with policy and KPI expectations?

Do results need to be flagged up to a higher level urgently?

Are any gaps, issues or concerns noted?

What corrective actions are required?

What preventative actions are required?

Does an incident report need to be raised?

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CHECK: Agree

Responsibilities for corrective and preventative actions

required

Timeline for completion of the corrective and preventative

actions

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ACT: Make it happen

Regular checks and sign off on completed corrective and

preventative actions

Report up to management

Agree if and when re-audit required

Loop outcomes and learnings into next system of checks.

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CHKS- evidence of audit

An audit strategy- linked to annual plan or strategy

An audit policy and procedure

An audit schedule (annual)

List of audits undertaken- to include unplanned

Examples of audit tools and reports

Examples of CAPA’s

Staff able to verbalise changes made as a result of audit

findings

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Useful resources

• Irish Joint Colleges Specialty National Quality Improvement

Programmes https://www.rcpi.ie/landing.php?locID=1.10.274

• Health Service Executive quality and audit section

http://www.hse.ie/eng/about/Who/qualityandpatientsafety/auditservic

es/

• The Health Information and Quality Authority www.hiqa.ie

• The National Office of Clinical Audit www.noca.ie

• Irish Society for Quality and Safety in Healthcare

http://www.isqsh.ie/