Reducing Variability and Duplication -Does an Organisational Clinical Audit Framework Work?

Ms. Stella KravtsovQuality Improvement Consultant – Clinical Audit and AccreditationMelbourne Health

• Serving more than 1 million Victorians

• Victoria’s first public hospital

• Provides local and tertiary/ quaternary academic health services

• Largest mental health service in Melbourne

• Services over 1.2 million Melburnians

• 30 sites

• Opened in 2013• Joint venture with the

University of Melbourne• World-class institute in

infection and immunity

Royal Park Campus

City Campus

Melbourne Health comprises

• 1,098 beds (acute, sub-acute, mental health and aged care)

• 86,926 people discharged (RMH 2014/15)

• More than 600,000 outpatient appts annually

• Averaging 5,000+ ED presentations monthly

• Around 25 helicopters each month

• Only accredited level 1 Trauma Centre

• Fastest emergency stroke treatment in Australia

• Annual operating budget over $900 million

• Service 40% of metro health services with supplies

• Over 9,000 staff and 400 volunteers

Melbourne Health

RMH Organisational Structure

2012 2013 2014 2015 2016

MH Clinical Audit

Framework

developed

Periodic

review

November

2013

Evolution of Clinical Audit at

Melbourne Health

Review of clinical

audit activity

MH Clinical

Audit

Schedule

developed

MH Clinical Audit

Procedure

developed

Electronic auditing

using Audit Angels

MH Evidence Portal

Organisation

Wide Survey

October 2015

Building capability

Sustainability

Evaluation

Dashboard App

development

Standards of

the Month

program

Leadership

WalkRounds

Setting the ‘standard’

•No single audit schedule or governance process

•Size and complexity of organisation

•Lack of standardisation of audit tools

•Increasing audit burden - no additional resources, staff overwhelmed

•Inconsistent transparency/reporting

•No central repository for audit

data

•Lack of time to identify and

follow-up improvement actions

Elements of a Clinical Audit program

Data collection

Opportunities for

improvement identified and

acted on

Evidence of implementation

of National Accreditation

Standards gathered

Reporting on audit outcomes

Improvements in quality and

safety of patient care

Clinical Audit Framework

• coordinated and planned approach to audit

• reflects the EQuIPNational audit requirements

• outlines purpose and outcomes of auditing, scope, governance and accountabilities

• supported by organisational procedure for Clinical Audit and Clinical Audit Reporting template

Clinical Audit Framework

• resources available to conduct audits used efficiently

• duplication and opportunity for error minimised

• Accurate and timely audit drives practice improvements

• central repository for audit results and action plans using an Evidence Portal accessible via the intranet

Clinical Audit Schedule

The Auditing Challenge

• Consistently capture, collate, validate and consolidate mandated clinical and observational audit data

• Use reports to develop action plans and measure / review on an ongoing basis

Standards in Action Program

Standard 10: Preventing Falls and Harm from

FallsApril

Standard 3: Preventing and Controlling

Healthcare Associated Infections

May

Standard 11: Service Delivery

Standard 12: Delivery of Care

June

Standard 4: Medication Safety July

Standard 5: Patient Identification and

Procedure Matching

Standard 7: Blood and Blood Products Aug

Standard 6: Clinical Handover Sept

Standard 8: Preventing and Managing Pressure

InjuriesOct

• Standardise and centralise resources and improve consistency of communication

• Ensure quality improvement activities align with the Standards

• Improve safety and experience of our patients/consumers in line with the organisational Safety First Strategy

Standards in Action Program

Standard of the Month

Launch

Local Gap Analysis, auditing

& education

Local & Divisional

Action Plans

Outcomes & Recommendations

via Standards Committees

Feedback and Continuous

Improvement

Current Gaps and

requirements,

Patient Stories

The Paradigm Shift

Paper and spreadsheets Hand held technology

1. Draw up Audit Tool on paper

2. Print paper based Audit Tool

3. Distribute paper Tool to auditors

4. Ensure only correct version

used

5. Auditors fill in Audits

6. Collect all audits from locations

7. Check for errors and lost audits

8. Define spreadsheet

9. Enter audits into spreadsheet

10. Check for errors and omissions

11. Save and secure data

12. Define spreadsheet report

13. Arrange report distribution

1. Select Audit Tool

2. Complete Audits

3. Submit data

4. Analysis completed by

provider

5. Customised Report at

designated frequency

6. Data transparency

using ‘real-time’

dashboard reporting

The Way Forward –principles

Real time

Change focused

Sustainable

Simple to use

Meaningful

Capable of benchmarking

Local ownership

Electronic

Predictive

Key Achievements5 org-wide electronic

audits developed

Reporting at organisational, divisional, professional and ward level

Audit Benefit

Royal Melbourne Hospital Interdisciplinary Documentation Audit

Multiple standards, trended data,compliance reporting accessible via intranet

Royal Melbourne Hospital Bedside – Nursing Practice Audit

Local area auditing and ownership

NorthWestern Mental Health Clinical Practice Audit Multiple standards - combinationof observational, documentationand consumer experience questions

Occupational Health and Safety Workplace Inspection Checklists

Local area compliance reporting and documentation of actions for follow-up

National Inpatient Medication Chart Audit Benchmarking

Moving from Compliance to Improvement

Bedside – Nursing Practice Audit -embedding local monitoring

Clinical Audit Webpage

IRIS driving safer care

Information

Safer care

ElectronicAccessible Intuitive GraphicalReal-timeReliable Comprehensive

11am

3pm9pm

Improving patient safety - FallsIdentifying contributing factors

Understanding falls incidents by:

• Ward• Outcome• Patient level

details• Age• Location• Activity• Time

Melbourne Health Accreditation Tool

Melbourne Health Accreditation Tool

Lessons learnt

“It takes us two clicks to access the information

we need”

“We are now

better able to

monitor quality

improvements”

“This approach

is better than

leaving things

to the last

minute”

• Embedding the Standards is everyone's responsibility

• Forward planning – staff awareness of audit schedules and

action plans

• Education and training is vital for managers to understand

how to audit and create sustainable action plans

• Engaging Medical staff requires a targeted focus

• Work doesn’t stop at the end of Accreditation - this is the

way we work every day

Future focus•Accessible audit tools at local level with timely and transparent reporting to drive improvement

•Strong executive leadership, effective governance systems and accountability (standard level/divisional level/professional level)

•Support and capability building for local level and organisational level initiatives to sustain change

•Regular monitoring and sustainability using SharePoint platform

•Evaluation of Clinical Audit Framework

•Reward and recognise improvement efforts

Acknowledgements

• Jill Exton – National Standards and Clinical Governance

Manager, Melbourne Health

• Customer Feedback Systems Australasia (CFS)

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