Natalie de Vos - Marie Stopes International - Development and Implementation of an Effective Clinical Audit Program
Natalie de Vos delivered the presentation at the 2014 Clinical Audit Improvement Conference. The Clinical Audit Improvement Conference explored the role of clinical audit in the new era of National Care Standards. For more information about the event, please visit: http://bit.ly/clinicalaudit14
Published on: Mar 3, 2016
Transcripts - Natalie de Vos - Marie Stopes International - Development and Implementation of an Effective Clinical Audit Program
Natalie de Vos
National Quality and Risk Manager
Marie Stopes International
Dr Marie™ is part of the not-for-profit Marie Stopes International (MSI) global partnership. We have 15 clinics throughout Australia.
Whilst in Australia we predominantly provide a termination service, we also provide contraceptive and reproductive health services.
Our global approach is to increase the uptake of long acting reproductive contraception. (LARC)
MSI works in over 40 countries around the world, mostly in third and developing world countries. The money generated in our Australian clinic network (Dr Marie) assists in the provision outreach programs in most of these countries.
Uptake of LARC is a KPI for all programs including Australia
Keep in mind the purpose of the audit
A tool for education
Assist in the continuous improvement process
Measure compliance to a policy, procedure or a standard
Identify service delivery gaps
Audit what we should be doing, not what we are currently doing.
Define area where auditing is require
Helpful to direct us to the recognised experts in the field.
Useful for some specific criteria.
Experience and Clinical Expertise
Useful for speciality areas
Known areas of risk
Utilise direct observation and retrospective documentation approach
Monthly audits for high risk areas and areas of known risk
Schedule 8 drug management
Completion of Mandatory Education
Alternate month audits
Bi annual audits
We look at compliance for each criteria
This helps identify components that need to be improved
Ensures important components of clinical practice are not missed.
We look at compliance for each set audited for example;
Each medical record
Each day for clinical waste audit –(10 days in audit period)
Each clinical area for PPE availability audit
Area of cleaning audit
Area of WH&S audit
We look at overall compliance
Only enter n for non compliance
We needed the process to be easy to complete
Experience with placing Y did not mean better completion of audit tool. Cut and past often used
Enter nafor not applicable criteria
Background formulas calculate compliance
Sections in some audits are given weightings.
This is so sections with fewer criteria do not negatively impact overall compliance.
We also use weighting if we think a section in the audit is higher risk egenvironmental audit for cleaning verses documentation audit of cleaning.
Weightings are used mainly in the medical record audit, where the audit tool has multiple sections.
Some audits allow for partial compliance.
These allow drilling down in certain areas
Eg. Client demographic details, contents of consultation notes.
The value of a partial compliance is determined by home many criteria in a section or part of the audit are meet verses how many are not met.
This is helps prevent undervalue or overvalue of a partial compliance, which occurs with the C=100%, P=50% and N=0% formula (traditional)
The P value affects the overall compliance value
This is mainly used in the medical record audit
Number ofmeet criteria
Value of P with traditional formula
Value of P Criteria Meetformula
Most complex audit tool we use.
We have utilises RACGP criteria with a few added extras for our surgical environment
Divided into 8 sections
Pt. 1 -General medical record requirements as well as less complex and lower risk documentation requirements or where singular auditing can be complete
Pt. 2 -Consultation Notes. Allows for 4 most recent consultation notes to be audited
Pt. 3 -Referral letters
Pt. 4 -Review of pathology results
Pt. 5 -Surgical Safety Checklist
Pt. 6 -Surgical Count documentation
Pt. 7 -Medication administration
Pt. 8 -PACU chart -(incorporates deteriorating client chart)
The Questions -If one or two criteria are missing, is it of value to give a P or Non compliance and how do we ensure consistency between the auditors.
Allows multiple entries in record to be audited in areas such as consultation notes, pathology report reviews, each with a set of criteria.
Our process is to audit 4 most recent consultations or received pathology results since last audit period
Overall compliance of parts 2-8 will give the P or C value on part 1 of the audit tool.
Allows for overall compliance and section compliance to be determined.
MSI_MedicalRecord Audit Tool_Template_2014 - 2015.xlsx
Instant result at site level. (provided data is entered correctly)
Gaps entered into site Quality Improvement tool, is risk rated and flags if not completed by due date
DRM_TM_GOV_SiteQuality Improvement Plan_Sample_Version1.0.xlsx
Trend improvement over time.
Discussed in Improving Performance meetings, local staff meetings and at SMT meeting
All site data is released monthly. This includes sites who did not complete
Understanding the criteria
Understanding the audit tools
Functionality of the audit tools
Overuse of not applicable function
Changing the corporate culture
Validation audits -commenced this year. Completed by Head office staff at site visit.
Observation audit for Time Out and Surgical Count.