Reducing Variability and Duplication in Organisational Clinical Audit
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Reducing Variability and Duplication -Does an Organisational Clinical Audit Framework Work?
Ms. Stella KravtsovQuality Improvement Consultant – Clinical Audit and AccreditationMelbourne Health
• Serving more than 1 million Victorians
• Victoria’s first public hospital
• Provides local and tertiary/ quaternary academic health services
• Largest mental health service in Melbourne
• Services over 1.2 million Melburnians
• 30 sites
• Opened in 2013• Joint venture with the
University of Melbourne• World-class institute in
infection and immunity
Royal Park Campus
City Campus
Melbourne Health comprises
• 1,098 beds (acute, sub-acute, mental health and aged care)
• 86,926 people discharged (RMH 2014/15)
• More than 600,000 outpatient appts annually
• Averaging 5,000+ ED presentations monthly
• Around 25 helicopters each month
• Only accredited level 1 Trauma Centre
• Fastest emergency stroke treatment in Australia
• Annual operating budget over $900 million
• Service 40% of metro health services with supplies
• Over 9,000 staff and 400 volunteers
Melbourne Health
RMH Organisational Structure
2012 2013 2014 2015 2016
MH Clinical Audit
Framework
developed
Periodic
review
November
2013
Evolution of Clinical Audit at
Melbourne Health
Review of clinical
audit activity
MH Clinical
Audit
Schedule
developed
MH Clinical Audit
Procedure
developed
Electronic auditing
using Audit Angels
MH Evidence Portal
Organisation
Wide Survey
October 2015
Building capability
Sustainability
Evaluation
Dashboard App
development
Standards of
the Month
program
Leadership
WalkRounds
Setting the ‘standard’
•No single audit schedule or governance process
•Size and complexity of organisation
•Lack of standardisation of audit tools
•Increasing audit burden - no additional resources, staff overwhelmed
•Inconsistent transparency/reporting
•No central repository for audit
data
•Lack of time to identify and
follow-up improvement actions
Elements of a Clinical Audit program
Data collection
Opportunities for
improvement identified and
acted on
Evidence of implementation
of National Accreditation
Standards gathered
Reporting on audit outcomes
Improvements in quality and
safety of patient care
Clinical Audit Framework
• coordinated and planned approach to audit
• reflects the EQuIPNational audit requirements
• outlines purpose and outcomes of auditing, scope, governance and accountabilities
• supported by organisational procedure for Clinical Audit and Clinical Audit Reporting template
Clinical Audit Framework
• resources available to conduct audits used efficiently
• duplication and opportunity for error minimised
• Accurate and timely audit drives practice improvements
• central repository for audit results and action plans using an Evidence Portal accessible via the intranet
Clinical Audit Schedule
The Auditing Challenge
• Consistently capture, collate, validate and consolidate mandated clinical and observational audit data
• Use reports to develop action plans and measure / review on an ongoing basis
Standards in Action Program
Standard 10: Preventing Falls and Harm from
FallsApril
Standard 3: Preventing and Controlling
Healthcare Associated Infections
May
Standard 11: Service Delivery
Standard 12: Delivery of Care
June
Standard 4: Medication Safety July
Standard 5: Patient Identification and
Procedure Matching
Standard 7: Blood and Blood Products Aug
Standard 6: Clinical Handover Sept
Standard 8: Preventing and Managing Pressure
InjuriesOct
• Standardise and centralise resources and improve consistency of communication
• Ensure quality improvement activities align with the Standards
• Improve safety and experience of our patients/consumers in line with the organisational Safety First Strategy
Standards in Action Program
Standard of the Month
Launch
Local Gap Analysis, auditing
& education
Local & Divisional
Action Plans
Outcomes & Recommendations
via Standards Committees
Feedback and Continuous
Improvement
Current Gaps and
requirements,
Patient Stories
The Paradigm Shift
Paper and spreadsheets Hand held technology
1. Draw up Audit Tool on paper
2. Print paper based Audit Tool
3. Distribute paper Tool to auditors
4. Ensure only correct version
used
5. Auditors fill in Audits
6. Collect all audits from locations
7. Check for errors and lost audits
8. Define spreadsheet
9. Enter audits into spreadsheet
10. Check for errors and omissions
11. Save and secure data
12. Define spreadsheet report
13. Arrange report distribution
1. Select Audit Tool
2. Complete Audits
3. Submit data
4. Analysis completed by
provider
5. Customised Report at
designated frequency
6. Data transparency
using ‘real-time’
dashboard reporting
The Way Forward –principles
Real time
Change focused
Sustainable
Simple to use
Meaningful
Capable of benchmarking
Local ownership
Electronic
Predictive
Key Achievements5 org-wide electronic
audits developed
Reporting at organisational, divisional, professional and ward level
Audit Benefit
Royal Melbourne Hospital Interdisciplinary Documentation Audit
Multiple standards, trended data,compliance reporting accessible via intranet
Royal Melbourne Hospital Bedside – Nursing Practice Audit
Local area auditing and ownership
NorthWestern Mental Health Clinical Practice Audit Multiple standards - combinationof observational, documentationand consumer experience questions
Occupational Health and Safety Workplace Inspection Checklists
Local area compliance reporting and documentation of actions for follow-up
National Inpatient Medication Chart Audit Benchmarking
Moving from Compliance to Improvement
Bedside – Nursing Practice Audit -embedding local monitoring
Clinical Audit Webpage
IRIS driving safer care
Information
Safer care
ElectronicAccessible Intuitive GraphicalReal-timeReliable Comprehensive
11am
3pm9pm
Improving patient safety - FallsIdentifying contributing factors
Understanding falls incidents by:
• Ward• Outcome• Patient level
details• Age• Location• Activity• Time
Melbourne Health Accreditation Tool
Melbourne Health Accreditation Tool
Lessons learnt
“It takes us two clicks to access the information
we need”
“We are now
better able to
monitor quality
improvements”
“This approach
is better than
leaving things
to the last
minute”
• Embedding the Standards is everyone's responsibility
• Forward planning – staff awareness of audit schedules and
action plans
• Education and training is vital for managers to understand
how to audit and create sustainable action plans
• Engaging Medical staff requires a targeted focus
• Work doesn’t stop at the end of Accreditation - this is the
way we work every day
Future focus•Accessible audit tools at local level with timely and transparent reporting to drive improvement
•Strong executive leadership, effective governance systems and accountability (standard level/divisional level/professional level)
•Support and capability building for local level and organisational level initiatives to sustain change
•Regular monitoring and sustainability using SharePoint platform
•Evaluation of Clinical Audit Framework
•Reward and recognise improvement efforts
Acknowledgements
• Jill Exton – National Standards and Clinical Governance
Manager, Melbourne Health
• Customer Feedback Systems Australasia (CFS)
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