CHHS17/303

Canberra Hospital and Health ServicesOperational ProcedureClinical Audit Development and Implementation Procedure Contents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – Clinical Audit Initiation............................................................................................2

Section 2 – Development..........................................................................................................3

Section 3 – Drafting the tool.....................................................................................................4

Section 4 – Submission and Endorsement of the Audit Tool....................................................4

Section 5 – Clinical Audit Tool Review.......................................................................................5

Section 6 – Audit Implementation............................................................................................6

Section 7 – Data and Reporting.................................................................................................6

Implementation........................................................................................................................ 6

Related Policies, Procedures, Guidelines and Legislation.........................................................7

References................................................................................................................................ 7

Definition of Terms...................................................................................................................7

Search Terms............................................................................................................................ 8

Attachments..............................................................................................................................8

Attachment 1: Audit Development Request Form................................................................9

Attachment 2: 1, 3, 5 Methodology....................................................................................10

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Purpose

This procedure outlines the process for development and release of clinical audit tools used to monitor clinical activities with the purpose of improving the safety and quality of care provided to consumers and patients.

This procedure provides a consistent approach to clinical audit development across ACT Health CHHS and is a key control in ensuring audit tools result in useable, meaningful and reliable data collection. Data collected from clinical audits is used to inform improvements to patient or consumer care as well as monitoring of compliance against policies and procedures. Where required, clinical audits are also used to demonstrate evidence of compliance with the 10 National Safety and Quality Health Service (NSQHS) Standards.

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Scope

This procedure applies to all ACT Health CHHS staff involved in the development, endorsement and use of clinical audit tools across the organisation.

Instruction on how to conduct a clinical audit is out of scope for this procedure.

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Section 1 – Clinical Audit Initiation

In order to confirm that a clinical audit tool is necessary, divisional and organisational requirements need to be assessed. Clinical audits should be used to support the following activities: Quality Planning, Quality Assurance and Quality Improvement improving the safety and quality of care provided to consumers improving the patient experience measurement of adherence to relevant clinical practices, policies and procedures assessing real or perceived risks or hazards aligning practice with government initiatives and/or ACT Health priorities ensuring compliance with relevant legislation evidence of compliance with the NSQHS Standards

Clinical audits should not be used as a substitute for ongoing quality control activities or in place of clinician/staff performance management frameworks.

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Procedure 1. Consult with your area about whether an audit tool is required and for what purpose.

Discuss with your line manager/s and staff. Ensure you have a clear purpose for the audit and know what you are going to do with the results. Consider if this is a short-term or continuing audit. For example: if the audit is part of a quality improvement activity, a short-term audit may be more suitable.

2. Research existing audit tools used by ACT Health and external audits. Look at the existing audits in the Audit Tool Library on SharePoint for similar tools either in topic or format. Also look at what might be available nationally or from other states and territories.

3. Complete an Audit Development Request form (see attachment 1). The form is available on the Quality Assurance Audit SharePoint site for download and located at Attachment A. Submit it to QualityData@act.gov.au.

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Section 2 – Development

The development phase is crucial to ensure the resulting audit tool aligns to relevant practice and will meet its intended purpose.

Procedure 1. Assemble a development team (if appropriate). A development team is a group of

subject matter experts and interested staff. Assembling a team can provide the author with support, advice and assistance throughout the audit development phase. The development team should have members from across the organisation (where appropriate) and be multidisciplinary. If your audit aligns with one of the 10 NSQHS Standards, the relevant Standard Committee should be consulted in the development of the audit tool to ensure it meets requirements and does not duplicate existing work.

2. Research and Analysis: Research must be conducted to ensure the audit tool is evidence-based and will meet its intended purpose. Research activities may include: searching and reviewing related audit tools – this could include ACT Health or other

health services, jurisdictions, national and/or international, as appropriate in order to identify current best available practice;

meeting with Standard Groups to inform alignment to the Standards (if appropriate);

consultation with subject matter experts; examination of existing data and statistics on the topic.

3. Sample size: Consideration of sample size should be undertaken during the development phase for each audit. As a general rule, audits used for quality assurance purposes should aim for ten audits per ward/area or 30% of the ward/area’s open bed numbers, whichever is greater. Should a different sample size be required, this will be communicated to the areas affected prior to undertaking the audit.

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4. Communication and implementation: During this stage of audit development you will also need to consider how the audit will be communicated to staff and implemented (including training of staff in using the audit tool).

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Section 3 – Drafting the tool

It is important that the audit tool is drafted on the appropriate template, flows logically, and will produce data for analysis that is easy to interpret.

Procedure 1. Start drafting the audit tool: The Quality Assurance Team can provide you with a

template upon acceptance of an approved Audit Development Request form. The Quality Assurance team can guide you through developing the tool on the appropriate template. Think about the questions, including the order and the possible response options. Keep the audit as simple as possible and consider reliability of use and the data it will

produce. An audit with simple Yes/No/Not Applicable answers is easier to complete and interpret than an audit with multiple responses, free text, or multiple pathways depending on what answer is chosen for each question. If your audit requires multiple pathways depending on what answer is chosen for each question, the Quality Assurance Team can assist in structuring these with the audit developers.

Consider the best platform for your audit tool, e.g. paper-based or electronic. Ensure consideration is given to staff and consumers where English is their second

language or there may be varying levels of literacy.2. Apply appropriate version control: As ongoing changes are made to a draft tool during

development, changes should be tracked/inserted as comments in the document throughout the process and the version number updated after every amendment. The Quality Assurance Team will consolidate all approved amendments and finalise the audit tool.

3. Seek Feedback on your audit / test the tool: When your draft is complete, it is important that your document is tested by end users completing the audit.Ask users of the audit tool to read the draft, to test it using 1, 3, 5 methodology (see Attachment 2) and provide you with feedback, including if it is working correctly, easy to follow/understand, and asks the right questions. Also consider the data the audit tool produces and check it is easy to interpret. If it isn’t, you may need to amend the question (e.g. is it asking more than one thing?) or response options (e.g. is an N/A box required to avoid users leaving it blank or inappropriately selecting Yes or No).

4. Finalise the draft: Once the audit tool has been tested and all feedback has been considered and actioned, provide the finalised tool to the Quality Assurance Team to coordinate endorsement where required.

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Section 4 – Submission and Endorsement of the Audit Tool

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Once the audit tool has been finalised, it needs to have divisional approval and be endorsed at the appropriate forum (if applicable).

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Procedure 1. Quality Assurance Team to liaise with the relevant Standard group/s If the audit aligns to evidence requirements for one of the NSQHS Standards, the Quality Assurance Team will confirm divisional approval has been provided and submit the audit tool to the relevant Standard group/s for their review and endorsement in their next scheduled meeting. It is possible that further changes may be requested by the Standard committee before the audit tool is approved. If the tool is endorsed, the Quality Assurance Team will coordinate deployment of your new audit tool to the desired audit platform and upload the audit to the Audit Tool Library on SharePoint. Approximate time frames will be provided at each stage.

If the tool is not related to evidence against the Standards, appropriate approval at the divisional level is required before the audit tool can be deployed and made available on SharePoint.

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Section 5 – Clinical Audit Tool Review

Clinical audit tools and any supporting material require annual review to ensure they retain their relevance and effectiveness. Changing a tool earlier than one year after implementation or last amendment is not recommended to ensure reliable, valid and comparable data is captured. It may be necessary to review some audit tools more frequently or prior to the allocated review timeframe if legislation, best practice, or ACT Health policy has changed.

Procedure 1. Confirm you are using the correct version of the audit tool: All audit tools are available

on SharePoint. The Audit Tool Library outlines the version number to assist in selecting the current tool. The Audit Tool Library should be the place you access the tool each time you use it if you are completing it as a paper tool. Avoid saving versions of audit tools to individual computers and shared drives as the tool may be amended and the saved version will no longer be valid.

2. Advise Quality Assurance if your audit is no longer required: Quality Assurance can then archive your tool to keep the Audit Tool Library up to date.

3. Record any issues or feedback that arises during your use of the audit tool: Any feedback or issues should be tracked so that when your audit is due for its annual review, these can be considered and resolved.

4. Quality Assurance Team manages the Audit Tool Library and amendment scheduling: The Quality Assurance Team is responsible for monitoring all audits on the Audit Tool Library and tracking due dates for review and re-endorsement. Contact the Quality Assurance Team if the audit requires any amendments outside of this review cycle, for example due to legislation or procedural change that will impact how the audit is completed before its next review date.

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Section 6 – Audit Implementation

Each new or revised audit tool must be communicated to those likely to be impacted by its introduction. During planning for implementation you will need to consider who will be affected by the audit tool and determine the most appropriate way of informing them.

Consider and make decisions about the following: identify who is responsible for conducting the audit communicate any recent updates or changes to the audit tool since the previous

audit resources required to implement the audit tool any training required for auditors in the use of the tool how and when the audit tool will be distributed how and when the audit will be conducted. Contact the Quality Assurance Team

to determine what other audits are taking place in ACT Health at the time you’re planning to audit so appropriate planning and coordination can occur.

timeframes for data collection on electronic devices or provision of completed paper-based audits

Methods for communication include: email face-to-face meetings/discussions (e.g. quality and safety meetings) team briefings by managers

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Section 7 – Data and Reporting

Data is collected in line with the platform it was entered on and coordinated by the Quality Assurance Team and Data Team within the Clinical Effectiveness Team. Data and reports are then distributed as per agreement with Quality Assurance Team either via SharePoint or directly to pre-determined staff. Assistance in data analysis and reporting may be provided if negotiated during the initiation phase of the audit development cycle.

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Implementation

This operational procedure/policy will be communicated to staff through an all staff DDG CHHS email, and through line managers at staff meetings.

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Related Policies, Procedures, Guidelines and Legislation

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Policies Clinical Audit Policy

Procedures Clinical Record Documentation SOP Clinical Records - Release or Sharing of Clinical Records or Personal Health Information

SOP

Guidelines ACT Public Service Code of Conduct Table 8: Summary of Actions that Require Data Collection for Audit or Review Australian

Commission on Safety and Quality in Health Care. Hospital Accreditation Workbook. Sydney. ACSQHC, 2012. p.36

Legislation Health Records (Privacy and Access) Act 1997 (ACT) Information Privacy Act 2014 (ACT) Human Rights Act 2004

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References

1. Australian Commission on Safety and Quality in Health Care. Hospital Accreditation Workbook. Sydney. ACSQHC, 2012

2. Australian Commission on Safety and Quality in Health Care (ACSQHC). Guide to the National Safety and Quality Health Service Standards for community health services. Sydney. ACSQHC. 2015

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Definition of Terms

Audit - A systematic review of clinical care against a pre-determined set of criteria 1

Clinical Effectiveness – Monitoring against evidence-based practice Data - information collected for reference, measurement and/or analysis Quality Planning - Preparing, adapting, innovating, supporting safe and reliable decision

making. Quality Assurance - Activities to assess compliance with systems and processes that

result in safe and reliable care. Quality Improvement - The combined and unceasing efforts of everyone — clinicians,

consumers and their families, researchers, payers, planners and educators — to make the changes that will lead to better consumer outcomes (health), better system performance (care) and better professional development.2

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Search Terms

Audit, Audit Tool, Clinical Audit, Data, Quality, Quality Assurance, Monitoring

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Attachments

Attachment 1 – Audit Development Request Form

Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Policy Team ONLY to complete the following:Date Amended Section Amended Divisional Approval Final Approval 19/12/2017 New Document Josephine Smith,

Director, CSQUCHHS Policy Committee

22/02/2018 Information pertaining to sample size included in section 2

Josephine Smith, Director, CSQU

CHHS Policy Committee Chair

This document supersedes the following: Document Number Document Name

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Attachment 1: Audit Development Request Form

Proposed Audit Tool Title:      Division Responsible:      Request Type:      Aim/Purpose of Audit Tool:      Where will the findings be presented?

     

Internal Research: Have you checked the Audit Library for similar audits?

Yes No (please state reason):      

External Research: Have you checked for suitable International or National external Audit Tools? If so, can the/se documents be used?

Yes Yes (with amendment)

Not Applicable No (please state reason):      

Alignment: What will your audit align with? (Select one or more). Please specify.

National Standard:       Legislation:      

Policy/Procedure:       Other:      

Scope:Who/where is being targeted by this audit?

Inpatient Outpatient

Community Other (please specify):      

Period and frequency of audit: From:       Until:      Frequency:      

Consultation: Identify key stakeholders to be consulted, these may include:• Aboriginal and Torres Strait Islander peoples (contact the aboriginal

and Torres Strait Islander Unit 620 79172)• People from culturally and linguistically diverse backgrounds

(contact the Multicultural Policy Unit on 620 51011)• Consumers (contact the patient experience section on 624 43014)

Please list potential key stakeholders:     

Exclusions from Audit?Consult the CHHS organisational chart.

Please specify who/where should not be included in the completing this audit:     

Responsible person/s: Who will be responsible for acting on the outcome of the data collected by this audit?

Please identify a person or area:     

Action Officer Details: Name:       Email:      Position:       Date:      

Approving Divisional Executive (ED/DON/DAH/CD/Professional Lead)(email approval acceptable, please attach with this request form)

Name:       Signature:(Email )

     

Position:       Date:      

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Attachment 2: 1, 3, 5 Methodology

1, 3, 5 methodology is a simple way to check the useability and reliability of the audit tool. It involves providing the draft audit tool to one person to complete a practice audit and seeking their feedback on the audit tool. Once the feedback from one person has been incorporated, provide the revised audit tool to three people to conduct more practice audits and seek their feedback. Finally, after the feedback from those three people has been incorporated, provide the revised audit tool to five people and seek their feedback. You should then be in a good place to finalise the audit tool and have confidence that it is useable and fit for purpose.

Feedback should be sought in relation to the following:- Does the audit tool flow logically?- Are the questions clearly worded and comprehensible – does the auditor understand

the question and where/what to look at to get the answer?- Do the audit questions capture the intended data?- Are there any gaps in the pathway/s the questions lead the auditor on?- Do all possible answers to each question appear on the audit tool?- Are some questions not applicable and is there an option to provide an N/A response to

these?- Is there space to make comments where appropriate?

If you have any queries in relation to testing your audit tool, please contact the Quality Assurance team at QualityData@act.gov.au

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