Moving-ON Audits ProgramIRT Indicator Database

Completing Audits & On-Line EntryLast updated: March 2011

How to complete Auditsand on-line entry

Residential and Community

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What is auditing about?

When we audit something, we are checking a process or a system against a pre-determined criteria.For example for an audit about fire systems and processes, we might be checking what our policy and the law says we should do (pre-determined criteria) about having an evacuation plan, then we audit our own area or service by checking to see what we actually say and do regarding our evacuation plan.

Audits at IRTAs well as the Moving ON Audits Program, IRT has

some audits that it does internally. Down the track these may be incorporated into the MOA program.

IRT believes compliance to laws and regulations are the minimum acceptable standard-we try and exceed this standard wherever possible.

Audits assist us to find ways to improve what we do, but are only one part of our Quality System.

There is no grey in auditingIn auditing, it is usually Yes or No. There are no boxes

for:Almost there¾ of the timeNearlyMaybe

If we say we have a process for doing something, we are really saying it happens the same way, all the time. Therefore when we find it is not happening the same way, all the time, we have some deficits in our system, and opportunities for improvement.

Why is this so important?The way we provide services to our customers, both

within and outside our service should be of a consistently high standard. Then our customers know:What to expectWhen to expect itAnd most importantly, have trust that we will do it, no

matter who is working at that time, or on that day.We are in a “people business” so it is hard to get

things right every time, but that should not be an excuse for not trying!

Tips for good auditing

1. Never assume!We don’t wish that something was happening the way it should when we audit a process or a system, we need to check that it is. This might mean:

Checking the IRT intranet to find a particular Policy, Procedure, Form or Plan.

Checking individual resident or client documentation. Asking our colleagues within and outside our own service Asking the people we work with how they do certain tasks. Observing they way things are done in our service Checking the information we provide to staff, residents, clients,

relatives and others.

Tips for auditing2. Knowledge should be shared

The more we learn about each other’s jobs and roles, the more we understand how important it is to work together, and we also keep our minds active and learning-which is important at any age.New people to IRT ask questions about things that we take for granted. They might find something that needs correcting that we had missed or assumed was working. The same goes for someone auditing an unfamiliar area. This is a great test of our systems and processes and can’t be taken for granted!

Tips for auditing3. Read, read and read the explanations

Audits in the MOA program have explanation sheets that provide information on: The purpose of the audit Links to relevant outcomes and standards where applicable Guidance on answering the questions (that is, if you say Yes, you

need to ensure x, y and z are in place) Resources for further information which can be used for

education sessions etcYou need to read audit explanations if you are co-ordinating that particular audit, and it might be a good idea to go over relevant sections with those who may be assisting you by completing Part B!

Tips for auditing4. Be honest

Use the audits as an opportunity to identify improvements, not as a tick and flick exercise.If the answer is No-it might not be an issue. With MOA Audits, some questions are written to promote best practice, rather than something that is mandatory.Some questions may not be applicable for a particular service. If an NA is available, this is usually an indication that the question is either best practice or is something that is not mandatory in all services within the program.

MOA Audit FormatMOA audits have 2-3 sections as follows:PART AIs completed once.This section is auditing the system, that is what we

say we are doing. Examples are:Evidence of policy, procedure or protocol that covers re

audit topic.Evidence such as a plan or a formal program.An example of a Part A is on the next page.

Note: Some audits have a PART A only. This will be indicated in the coversheet information.

MOA Audit FormatYour service’s

member number

Sheet Number-to assist with

data entry

Tick the appropriate box on your printed

sheet

The audit gives you hints on where to find the

information

MOA Audit FormatPART BThis section samples, or tests our system and

processes about what we are actually doing.Involves a sample of at least 10%, based on the

number of residents or clients you have. You do not have to calculate 10% each time, the

number of sheets you need to provide is already worked out.

If your service is less than 50 beds/packages, you will complete 5 sheets for Part B. Less than this is not a valid response for reporting requirements.

SamplingCheck out the section on how to randomly sample in

the MOA Continuous Quality Improvement Guide, located on the IRT intranet under MOA Resources.

MOA Audit FormatPart B may involve:

Checking a process in a resident/clients fileObserving staff practiceAsking residents their opinion about a service we provideAsking staff about their knowledge and/or opinion of a particular

processChecking the environment of a particular area.

HINT: You will need to write the initials or other reference on these sheets of those files

audited/people observed/surveyed so that you know where to follow up if there are any

issues.

You can also ADD sheets if you want to increase your sample size.

MOA Audit Format

Again, you are provided with guidance on

completing this section.

MOA Audit FormatSome audits (usually 2-3 in the year) have a Part C.

This might be for a particular area that needs extra attention, such as Infection Control. In such an example:

Part A-what we say we do-usually what is written or formal

Part B-what we do-staff practices- how we do itPart C-evidence of how we can see we do it

(environment)

Who completes auditsIt is recommended that the service team look at the

calendar of audits for the year and work out:Individual staff areas of knowledge, expertise and

responsibility.Areas where staff may wish to increase or test their

knowledge.Training/learning opportunities for staff identified by

their Manager.And don’t forget the value of new staff!

Timeframe for completion of AuditsAudits and indicators for each month need to be

completed and entered into the system before the 15th of the following month.

Failure to do so means that your data will not be included for the IRT, state-wide and national benchmarking reports that are completed by MOA.

Your service manager will also be asked to explain why this has occurred, as compliance to completing data entry is monitored closely by the Chief Operating Officer.

SoBe Prepared and don’t leave it too late!

Before entering the data on-lineHas the relevant Manager or designated person

reviewed the results of the completed sheets and made any conclusions? Don’t just wait for the report and your benchmark-look at what is happening inside your own service!

Are the sheets fully completed-any missed questions? If yes, then get the answers quickly!

“Wrong” responsesSometimes staff answer “no” and the answer is actually

“yes”.What does this tell you? Do you need to look at:

Their interpretation of the question-did they read the explanation sheet.

Their knowledge in the subject-did they go out and seek information to validate their response (most relevant for Part A)

Is this an indication that more training or education may be required.

The point is, it is okay, as long as your service management team explains how they have acted on this issue in your monthly analysis.

On-line entry of audits1. Log on with your logon name and password

provided by MOA and go to the MOA website via the IRT intranet and go to My MOA.

2. Go to the relevant service that you wish to enter the audit data for-make sure that the member number on the screen corresponds with the one on your data sheets if you enter for more than one service or unit.

3. Go to Data Entry (under Audit Program)4. Select the relevant month’s package5. Go to the Data Entry section at the top of the page

MOA on-line audit data entry

Select the audit that you

want.

This column shows you % completed. You can save the data entered

and come back to it later if you need to-this must

be 100% before you sign off the package,.

MOA on-line audit data entry

The program tells you how many sheets you

need to complete.

Clicking on All Parts lets you complete all sheets on the one screen and saves

time

MOA on-line audit data entryClick the yes or no button for each response . Go through

check when you have finished that what you have selected

matches your completed sheets.Click on the

question mark to get the explanation

of the question

Comments about the questions themselves can be made by clicking on the

star at the end of each question. This feedback goes straight to MOA and is

used to improve the audit for the following year.

MOA on-line audit data entry

Remember to click on save! It will take you

back to the beginning of the package

MOA on-line audit data entryOnce you have completed data entry for all of the audits,

AND the quality indicators you need to “sign-off” the package.

This tells the program that your data is ready to generate reports, and no more data till be entered.

If you “sign-off” accidentally and have not completed entering all of the information, or you want to change it, contact MOA to unlock the package-before the 15th of the month!

Signing off the package

Lets check what knowledge you have gained …

What are audits all about?Why do we do audits at IRT?Why is there no “grey” in auditing?What are the key tips for good auditing?What does an MOA audit look like?Why are there different sections to an MOA audit?

Lets check what knowledge you have gained …Who can complete an audit?When do they need to be completed by?What do I need to check before I enter completed

audits on time?How do I enter audits on-line?How can I provide feedback to improve an audit

question?Who can I contact if I can’t enter my data on-line?

Printing Audit ReportsIf you would like to watch the powerpoint

presentation for further instruction on Printing Reports, go to the MOA Resources page on the IRT Intranet.