DEVELOPMENTANDIMPLEMENTATIONOFANEFFECTIVECLINICALAUDITPROGRAM
Natalie de Vos
National Quality and Risk Manager
Marie St...
DRMARIE-MARIESTOPESINTERNATIONAL
Dr Marie™ is part of the not-for-profit Marie Stopes International (MSI) global partner...
SELECTINGAUDITCRITERIA
Keep in mind the purpose of the audit
A tool for education
Assist in the continuous improveme...
SELECTINGAUDITCRITERIA–CONT….
National Standards
Define area where auditing is require
Helpful to direct us to the r...
MSI APPROACH
Utilise direct observation and retrospective documentation approach
Monthly audits for high risk areas an...
AUDITTOOL
Multi focal
We look at compliance for each criteria
This helps identify components that need to be improve...
COMPLETION
Yellow sections
Only enter n for non compliance
We needed the process to be easy to complete
Experience...
CALCULATIONS
Background formulas calculate compliance
Sections in some audits are given weightings.
This is so secti...
CALCULATIONCONT…
The value of a partial compliance is determined by home many criteria in a section or part of the audit...
EXAMPLEUSING8 CRITERIA
The P value affects the overall compliance value
This is mainly used in the medical record audi...
MEDICALRECORDAUDIT
Most complex audit tool we use.
We have utilises RACGP criteria with a few added extras for our sur...
RATIONAL
The Questions -If one or two criteria are missing, is it of value to give a P or Non compliance and how do we e...
ADDITIONALCALCULATIONSFORMEDICALRECORDS
Overall compliance of parts 2-8 will give the P or C value on part 1 of the audi...
DATAANDRESULTS
Instant result at site level. (provided data is entered correctly)
Gaps entered into site Quality Impro...
CHALLENGES
Understanding the criteria
Understanding the audit tools
Functionality of the audit tools
Overuse of no...
NEXTSTEPS
Validation audits -commenced this year. Completed by Head office staff at site visit.
Observation audit for ...
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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
Published in: Business      
Source: www.slideshare.net


Transcripts - Natalie de Vos - Marie Stopes International - Development and Implementation of an Effective Clinical Audit Program

  • 1. DEVELOPMENTANDIMPLEMENTATIONOFANEFFECTIVECLINICALAUDITPROGRAM Natalie de Vos National Quality and Risk Manager Marie Stopes International Presenters Title
  • 2. DRMARIE-MARIESTOPESINTERNATIONAL 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
  • 3. SELECTINGAUDITCRITERIA 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.
  • 4. SELECTINGAUDITCRITERIA–CONT…. National Standards Define area where auditing is require Helpful to direct us to the recognised experts in the field. Useful for some specific criteria. Legislation WH&S requirements Medication management Experience and Clinical Expertise Useful for speciality areas Known areas of risk
  • 5. MSI APPROACH Utilise direct observation and retrospective documentation approach Monthly audits for high risk areas and areas of known risk Medical Record Schedule 8 drug management Hand Hygiene Completion of Mandatory Education Alternate month audits Quarterly audit Bi annual audits
  • 6. AUDITTOOL Multi focal 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 MSI_AditSchedule_Template_2014-2015_Version 1.0.xlsx
  • 7. COMPLETION Yellow sections 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
  • 8. CALCULATIONS 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.
  • 9. CALCULATIONCONT… 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)
  • 10. EXAMPLEUSING8 CRITERIA 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 1 50% 12.5% 2 50% 25% 3 50% 37.5% 4 50% 50% 5 50% 62.5% 6 50% 75% 7 50% 87.5% 8 50% 100%
  • 11. MEDICALRECORDAUDIT 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)
  • 12. RATIONAL 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
  • 13. ADDITIONALCALCULATIONSFORMEDICALRECORDS 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
  • 14. DATAANDRESULTS 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
  • 15. CHALLENGES Understanding the criteria Understanding the audit tools Functionality of the audit tools Overuse of not applicable function Changing the corporate culture
  • 16. NEXTSTEPS Validation audits -commenced this year. Completed by Head office staff at site visit. Observation audit for Time Out and Surgical Count.

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