developing an audit schedule to support accreditation compliance and performance -matthew soo -...
TRANSCRIPT
Developing an Audit Framework to Support Accreditation Compliance and Performance
Matthew Soo – Director, Risk Management
Developing an Audit Schedule to Support Accreditation Compliance and Performance
Audit problems and how we solved them
Audit Schedule Governance Communication
Introducing Northern Health
Developing an Audit Schedule to Support Accreditation Compliance and Performance
Organisation and Committee Structure
Directorate
Program
Department
Improvement CommitteeWorking Parties
Improvement CommitteesAligned to Standards 1-15
Clinical Council
Executive Committee
Developing an Audit Schedule to Support Accreditation Compliance and Performance
Performance Improvement Directorate
Performance Improvement Executive Director
Risk Management
Patient Experience &
Consumer Participation
Quality & Service
Improvement
Clinical Practice
Improvement
Developing an Audit Schedule to Support Accreditation Compliance and Performance
Our problem: Audits not making an impact
2013 2014 2015 2016
Accreditation Survey Mar-14
Periodic Review Sep-15
Effort for audit
Value from audit
Action 1.6.2 NM
Developing an Audit Schedule to Support Accreditation Compliance and Performance
What we needed: Audits make an impact
Performance information flows efficiently from the bottom-up and promotes a culture of accountability and continuous
improvement at the local level
Directorate
Program
Unit
The answer had to be simple, low cost and user friendly
Improvement Committees
Defined audit as a NH CEO priority
NH Score is 2.8 out of 5 as at June 2015
Clinical Audit Maturity Matrix published by the Healthcare Quality Improvement Partnership (HQIP) and Good Governance Institute (GGI) in the UK (2010).
Developing an Audit Schedule to Support Accreditation Compliance and Performance
Improving the Audit Schedule
Big Bedside Audit
Standards Audits
Local Audits
Standards Audits
Table 8
The NH Master Audit Schedule v3.0
1. Audit name2. Audit format*3. Reason for audit* / Standards reference4. Which service/department is audited*5. Who collects local data6. Who is central coordinator7. Committee(s) reported to8. Frequency of audit9. Frequency of reporting10. Calendar for auditing*Refinements since version 1.0
On Intranet under Audit and under
each Standards Page
Version for each department
Approved by Improvement
Committee
The NH Master Audit Schedule Example
Changes to our governance to improve audits
Programs – 1st line of defence – business operations – manage the risks & control in the business
Clarified roles based on 1st and 2nd lines of defence
Introduced standardised agendas for committees
Standardised audit action plan reports
Added layer of consolidated reporting to improve visibility
Audits repositioned as part of excellent care
Knowing How You’re Doing Boards
Knowing How You’re Doing Boards
Directorate Quality Data Wall
Developing an Audit Schedule to Support Accreditation Compliance and Performance
Audits are starting to make an impact
2013 2014 2015 2016
Accreditation Survey Mar-14
Periodic Review Sep-15
Value from audit
Effort for audit
Future improvements in 2016 to work towards our ideal state
Audit reports
for Board
Relook at Bedside
Audit
Real time self
service reporting
Partnering with unis
Analyse audits
with other data
Like what you see?Be part of our conversation.
informa.com.au
Join our e-newsletter