evidence and learning from healthcare audit about … · 2019. 7. 5. · outline 1. about...

Evidence and Learning From Healthcare Audit about communications for patient

safety Cora McCaughan

Assistant National DirectorHealthcare Audit

Quality Assurance and Verification Division

NPSO Conference Dublin 2018

Outline

1. About Healthcare Audit (HCA)

2. Rapid appraisal of the HCA function (2017)

3. Evidence and learning from HCA about communications

4. Communications for sharing learning and for Q&S improvement

5. Bringing risk information together to develop HCA plans

1. About Healthcare Audit

QAVDHealthcare Audit

Chapter 9 of the HSE Code of Governance entitled:

“Accountability and Assurance”

states that Healthcare Audit –like Internal Audit – provides:

“Level 3 assurance”.

Source: Chapter 9. HSE Code of Governance https://www.hse.ie/eng/about/who/directoratemembers/codeofgovernance/hsecodeofgovernance2015.pdf

1. About Healthcare Audit

Source: Chapter 9. HSE Code of Governance https://www.hse.ie/eng/about/who/directoratemembers/codeofgovernance/hsecodeofgovernance2015.pdf

▪ 17 people

▪ Provide assurance

▪ Key role in assurance framework

▪ Provides valuable and reliable information to inform decision making

▪ Identify good practice for sharing across system

1. About Healthcare Audit

▪ Tests the effectiveness of internal controls

▪ Provides evidence for signing the statement of internal control

▪ A quality improvement activity

▪ 2018/9 plan include audits spanning every service and relate to key safety issues

1. About Healthcare Audit

Audits compliance against clinical and non-clinical standards across the entire health system.

What Healthcare Audit DOES:

1. About Healthcare Audit

▪ Does not audit compliance against financial or human resources standards

▪ Does not do national clinical audits

Healthcare Audit DOES NOT do:

1. About Healthcare Audit

1. About Healthcare Audit

1. About Healthcare Audit

1. About Healthcare Audit

1. About Healthcare Audit

2. Rapid Appraisal of HCA (2017)

2. Rapid Appraisal of HCA (2017)

Source:https://www.google.ie/search?q=HSE+Healthcare+Audit&rlz=1C1NHXL_enIE780IE781&oq=HSE+Healthcare+Audit&aqs=chrome..69i57j69i60l3j69i64l2.2819j0j7&sourceid=chrome&ie=UTF-8

Rapid appraisal of HCA function asked 46 key stakeholders:

1. What they thought of where HCA was in 2017

2. Where they thought HCA needed to go in the future

3. How they thought HCA needed to get there…

2. Rapid Appraisal of HCA (2017)Recommendations:

1. Engage service users in scheduling, designing and conducting HCAs

2. Implement a process of prioritising HCAs based on risk

3. Continue to improve methods, data integrity and usefulness

4. Increase the number and organisation-wide coverage of HCAs

5. Rapid audit response to emerging safety concerns

6. Tracking implementation of recommendations and linking audits to specific quality improvements and outcomes

2. Rapid Appraisal of HCA (2017)

=Recommendations (Cont’d):

7. Build capacity for local HCA enabling more sophisticated national HCA including validation audits.

8. Enhance the profile of HCA via reports, internet, E-zines, conferences.

9. Strategy

– Healthcare Audit Strategy– National Audit Strategy

3. Evidence from Healthcare Audit about communication

3. Evidence from HCA about communications

Audit of compliance with HSE Healthcare Records Management Standards:

1. Standard applicable to all sites including section 38 and 39’s

2. Implemented differently at different sites

3. Not implemented at some sites

4. Impossible to implement at some sites

5. Some ambiguous criteria

6. Some attempts to apply universal rule to something that was not universal

3. Evidence from HCA about communications

Audit of compliance with NCGs (No’s 5 & 11) for multidisciplinary clinical handover in maternity, acute , and children’s hospitals:

1. Good compliance with use of ISBAR

2. Issues with compliance with ISBAR3

3. Evidence of ISBAR being used in other scenarios

4. Communication for sharing learning and Q&S improvement

4. Communications for sharing learning and for Q&Simprovement

5. Bringing risk information together to develop audit plans

Healthcare Audit Plan

Risk Register

Analysis of incident

investigations

Analysis of complaints

Controls assurance

NPES

5. Bringing risk information together to develop audit plans

Source:https://www.google.ie/search?q=HSE+Healthcare+Audit&rlz=1C1NHXL_enIE780IE781&oq=HSE+Healthcare+Audit&aqs=chrome..69i57j69i60l3j69i64l2.2819j0j7&sourceid=chrome&ie=UTF-8

HCA Plan developed based on informationfrom:

1. HSE Risk register

2. Incident investigation reports

3. Complaint reports

4. Gaps in the controls assurance process

5. National Patient Experience Survey results

5. Bringing risk information together to develop audit plans

▪Detecting and responding to patient deterioration

▪Managing complex patients with multiple co-morbidities

▪Discharge planning

▪Medication safety

▪Healthcare Acquired Infection (HCAI) and Anti-microbial Resistance (AMR)

▪Continence and toileting

▪Hydration and nutrition

▪Falls

▪Pressure ulcers

▪Safeguarding vulnerable persons at risk of abuse

▪Emergency department delays

▪The prevention and management of violence and aggression

5. Bringing risk information together to develop audit plans

Source:https://www.google.ie/search?q=HSE+Healthcare+Audit&rlz=1C1NHXL_enIE780IE781&oq=HSE+Healthcare+Audit&aqs=chrome..69i57j69i60l3j69i64l2.2819j0j7&sourceid=chrome&ie=UTF-8

For more information about Healthcare Audit

For more information about Healthcare Audit

Summary reports of all audits which have been completed since 2013 are published to and accessible for you to read on the following HSE Website:

https://www.google.ie/search?q=HSE+Healthcare+Audit&rlz=1C1NHXL_enIE780IE781&oq=HSE+Healthcare+Audit&aqs=chrome..69i57j69i60l3j69i64l2.2819j0j7&sourceid=chrome&ie=UTF-8