Clinical AuditClinical Audit

Dr. Shahram Yazdani

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Dr. S

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Terminology Terminology

►MeasurementMeasurement►AssessmentAssessment►EvaluationEvaluation►AuditAudit►AccreditationAccreditation

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مميزي باليني چيست؟مميزي باليني چيست؟

مميزي باليني يك فرآيند ارتقا كيفيت است كه به مميزي باليني يك فرآيند ارتقا كيفيت است كه به ►دنبال بهبود مراقبت از بيمار و نتايج آن از طريق دنبال بهبود مراقبت از بيمار و نتايج آن از طريق

مرور نظام مند خدمت در مقابل معيار هاي مرور نظام مند خدمت در مقابل معيار هاي روشن و اجراي تغيير مي باشدروشن و اجراي تغيير مي باشد

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مميزي باليني چيست؟مميزي باليني چيست؟

جنبه هائي از ساختار ، فرآيند و نتايج انتخاب مي جنبه هائي از ساختار ، فرآيند و نتايج انتخاب مي ►شود و به لحاظ رعايت استاندارد در هر شود و به لحاظ رعايت استاندارد در هر

يك ،مورد سنجش و قضاوت ارزشي و عيني يك ،مورد سنجش و قضاوت ارزشي و عيني قرار مي گيردقرار مي گيرد

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مميزي باليني چيست؟مميزي باليني چيست؟

به هنگام اقتضاي شرايط تغييرات در سطوح به هنگام اقتضاي شرايط تغييرات در سطوح ►فردي ، گروهي و يا خدمت اعمال مي گردد و فردي ، گروهي و يا خدمت اعمال مي گردد و پايش مجدد جهت كسب اطمينان از بهبود در پايش مجدد جهت كسب اطمينان از بهبود در

خدمت صورت مي گيردخدمت صورت مي گيرد

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مراحل مميزي بالينيمراحل مميزي باليني

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آماده شدن براي مميزيآماده شدن براي مميزي -1 -1

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آماده شدن براي مميزيآماده شدن براي مميزي

جز مي شود: جز مي شود:55شامل شامل در گير كردن استفاده كنندگان فرآينددر گير كردن استفاده كنندگان فرآيندانتخاب عنوانانتخاب عنوانبيان هدف مميزيبيان هدف مميزيفراهم كردن ساختار هاي ضروريفراهم كردن ساختار هاي ضروري شناسائي افراد و مهارت هاي مورد نياز براي شناسائي افراد و مهارت هاي مورد نياز براي

انجام مميزي و ترغيب اين افراد براي انجام مميزي و ترغيب اين افراد براي مشاركتمشاركت

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منابع بدست آوردن نظرات استفاده منابع بدست آوردن نظرات استفاده كنندگانكنندگان

مالحظات استفاده كنندگان از خدمات را از منابع ذيل مي توان مالحظات استفاده كنندگان از خدمات را از منابع ذيل مي توان بدست آوردبدست آورد

نامه هاي پيشنهادات و انتقاداتنامه هاي پيشنهادات و انتقادات►گزارشات وقايع مهم گزارشات وقايع مهم ►روايت و باز خورد هاي بيماران از فرآيند دريافت خدمتروايت و باز خورد هاي بيماران از فرآيند دريافت خدمت►مشاهده مستقيم مشاهده مستقيم ►مصاحبه مستقيممصاحبه مستقيم►شايعترين روش مورد استفاده پيمايش هاي رضايت سنجي شايعترين روش مورد استفاده پيمايش هاي رضايت سنجي ►

است و مداخله دادن مستقيم بيماران و دريافت نظرات و است و مداخله دادن مستقيم بيماران و دريافت نظرات و مباحث آنان كمتر مورد استفاده واقع مي شودمباحث آنان كمتر مورد استفاده واقع مي شود

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انتخاب يك عنوان: اولويت هاي مميزيانتخاب يك عنوان: اولويت هاي مميزي

آيا موضوع داراي هزينه ، حجم زياد يا خطر چشمگير براي آيا موضوع داراي هزينه ، حجم زياد يا خطر چشمگير براي ►استفاده كندگان يا ارائه كنندگان مي باشد؟استفاده كندگان يا ارائه كنندگان مي باشد؟

آيا شواهدي از يك مشكل مهم كيفيتي مثل شكايت زياد آيا شواهدي از يك مشكل مهم كيفيتي مثل شكايت زياد ►بيماران يا بروز زياد عوارض وجود دارد؟بيماران يا بروز زياد عوارض وجود دارد؟

آيا استاندادر هاي خوب و مستندي مثل راهنماهاي باليني ملي آيا استاندادر هاي خوب و مستندي مثل راهنماهاي باليني ملي ►يا مرور نظام مند وجود دارد؟يا مرور نظام مند وجود دارد؟

آيا امكان برطرف كردن مشكل وجود دارد؟آيا امكان برطرف كردن مشكل وجود دارد؟►آيا مشكل داراي ابعاد ملي يا سازماني است؟آيا مشكل داراي ابعاد ملي يا سازماني است؟►

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::بيان اهدافبيان اهداف

پروژه بدون بيان روشن اهداف به هيچ چيز نمي رسد پروژه بدون بيان روشن اهداف به هيچ چيز نمي رسد، درك روشني از هدف قبل از انتخاب روش مميزي ، درك روشني از هدف قبل از انتخاب روش مميزي

بايد ايجاد گرددبايد ايجاد گردد افعال زير ممكن است در تعريف اهداف مميزي افعال زير ممكن است در تعريف اهداف مميزي

كمك كنند:كمك كنند:بهبودبهبودافزايشافزايش كسب اطمينان كسب اطمينانتغييرتغيير

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::بيان اهدافبيان اهداف

:مثالهائي از شيوه بيان اهداف:مثالهائي از شيوه بيان اهدافبهبود فرآيند انتقال خون در بيمارستانبهبود فرآيند انتقال خون در بيمارستان افزايش نسبت بيمارن مبتال به پرفشاري خون كه افزايش نسبت بيمارن مبتال به پرفشاري خون كه

كنترل مي شوندكنترل مي شوند كسب اطمينان از دريافت واكسن هاي مهم توسط كسب اطمينان از دريافت واكسن هاي مهم توسط

ماهگي ماهگي 66كودكان در قبل ار كودكان در قبل ار

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فراهم كردن ساختارفراهم كردن ساختار

براي افزايش منافع حاصل از مميزي سازمان به اين براي افزايش منافع حاصل از مميزي سازمان به اين موارد نياز دارد:موارد نياز دارد:

برنامه ساختارمند مميزي ) ساختار كميته ، روش برنامه ساختارمند مميزي ) ساختار كميته ، روشهاي تعريف شده براي بازخورد و جلسات منظم هاي تعريف شده براي بازخورد و جلسات منظم

مميزي(مميزي(تيمي از افراد مميز واجد صالحيت كافيتيمي از افراد مميز واجد صالحيت كافي

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انتخاب معيارانتخاب معيار -2 -2

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معيارمعيار

معيار ها در واقع جنبه ها و حوزه هائي از خدمت معيار ها در واقع جنبه ها و حوزه هائي از خدمت ►مي باشند كه مورد سنجش قرار مي گيرندمي باشند كه مورد سنجش قرار مي گيرند

كميسيون مشترك اعتبار بخشي سازمانهاي كميسيون مشترك اعتبار بخشي سازمانهاي ►به عنوان مثال اين به عنوان مثال اين ( ( JCAHOJCAHO))سالمت در آمريكا سالمت در آمريكا

موارد را به عنوان حوزه هاي مورد بررسي در موارد را به عنوان حوزه هاي مورد بررسي در خدمات در نظر مي گيرد:خدمات در نظر مي گيرد:

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The JCAHO CriteriaThe JCAHO Criteria

: سهولت : سهولت Accessibility of careAccessibility of careدسترسي به خدمت دسترسي به خدمت ►دسترسي به خدمت براي بيمار وقتي كه به آن نياز دارددسترسي به خدمت براي بيمار وقتي كه به آن نياز دارد

: درجه هماهنگي ارائه : درجه هماهنگي ارائه Continuity of careContinuity of careاستمرار خدمت استمرار خدمت ►كنندگان و سازمان در ارائه بسته خدمت به بيماركنندگان و سازمان در ارائه بسته خدمت به بيمار

: درجه : درجه Appropriateness of careAppropriateness of careمناسب بودن خدمت مناسب بودن خدمت ►صحت خدمت دريافت شده توسط بيماران با توجه به علم صحت خدمت دريافت شده توسط بيماران با توجه به علم

موجودموجود :ميزان صحيح انجام :ميزان صحيح انجام Effectiveness of careEffectiveness of careاثربخش خدمت اثربخش خدمت ►

گرفتن خدمت ) بدون اشتباه و خطا بودن(گرفتن خدمت ) بدون اشتباه و خطا بودن( : درجه تاثير گذاري بالقوه خدمت : درجه تاثير گذاري بالقوه خدمت Efficacy of careEfficacy of careكارآمدي كارآمدي ►

در برطرف كردن واقعي نياز هاي بيماردر برطرف كردن واقعي نياز هاي بيمار

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The JCAHO CriteriaThe JCAHO Criteria

►Efficiency of careEfficiency of care درجه ايجاد اثرات مطلوب با كمترين تالش درجه ايجاد اثرات مطلوب با كمترين تالش ، هزينه يا اتالف منابع، هزينه يا اتالف منابع

: : Patient perspective issuesPatient perspective issuesرعايت مالحظات بيماران رعايت مالحظات بيماران ►درجه مداخله دادن بيمارن و خانواده آنان در تصميم گيري در درجه مداخله دادن بيمارن و خانواده آنان در تصميم گيري در

امور مربوط به سالمتي و ميزان رضايت آنان از خدمتامور مربوط به سالمتي و ميزان رضايت آنان از خدمت Safety of the care Safety of the careايمني محيط خدمت ايمني محيط خدمت ►

environmentenvironment درجه عاري بودن محيط از احتمال حادثه و :درجه عاري بودن محيط از احتمال حادثه و: خطرخطر

:ميزان ارائه :ميزان ارائه Timeliness of careTimeliness of careبه هنگام بودن خدمت به هنگام بودن خدمت ►خدمت در زماني كه بيمار به آن نياز داردخدمت در زماني كه بيمار به آن نياز دارد

مثال يك معيار مشخص: بهنگام بودن تشخيص بيمار مشكوك به مثال يك معيار مشخص: بهنگام بودن تشخيص بيمار مشكوك به ►سكته مغزيسكته مغزي

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معیار های متفاوتمعیار های متفاوت

معیار ها می توانند مربوط به یکی از حوزه های معیار ها می توانند مربوط به یکی از حوزه های ذیل باشند:ذیل باشند:

)ساختار ) آنچه شما نیاز دارید(ساختار ) آنچه شما نیاز دارید)فرآیند)آنچه شما انجام می دهید(فرآیند)آنچه شما انجام می دهید)نتیجه درمان ) آنچه شما انتظار دارید(نتیجه درمان ) آنچه شما انتظار دارید

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►Quality IndicatorsQuality Indicators شاخص های شاخص هایکیفیت کیفیت

شاخص های کیفیت وسائلی هستند که برای شاخص های کیفیت وسائلی هستند که برای ►افتراق بین کیفیت کم و زیاد ساختار ها ، افتراق بین کیفیت کم و زیاد ساختار ها ،

فرآیندها یا نتایج مراقبت های طبیمورد استفاده فرآیندها یا نتایج مراقبت های طبیمورد استفاده قرار می گیرند.یعنی به صورت یک کسر یا قرار می گیرند.یعنی به صورت یک کسر یا

نسبت ساخته می شوندنسبت ساخته می شوند

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نسبت بیماران مشکوک به سکته ) در یک نسبت بیماران مشکوک به سکته ) در یک ► 66 تا تا 22بیمارستان یا یک منطقه (که طی بیمارستان یا یک منطقه (که طی

ساعت بعد از اولین عالئم تشخیص داده شده ساعت بعد از اولین عالئم تشخیص داده شده اند به کل بیمارن مشکوک به سکته مغزی در اند به کل بیمارن مشکوک به سکته مغزی در

یک بیمارستان یا منطقهیک بیمارستان یا منطقه

►Quality IndicatorsQuality Indicators شاخص های شاخص هایکیفیت )مثال(کیفیت )مثال(

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آستانه عملکرد ) استاندارد(آستانه عملکرد ) استاندارد(

آستانه عملکرد شامل بازه هائی ) مقادیر آستانه عملکرد شامل بازه هائی ) مقادیر ►حداکثر و حداقل( از یک شاخص کیفیت حداکثر و حداقل( از یک شاخص کیفیت هستند که بر اساس آن یک محصول یا هستند که بر اساس آن یک محصول یا

خدمت در آن حوزه خوب یا پذیرفته تلقی خدمت در آن حوزه خوب یا پذیرفته تلقی می گرددمی گردد

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درصد بیماران با شک به درصد بیماران با شک به 8080بیش از بیش از ► ساعت از بروز ساعت از بروز 66 تا تا 22سکته مغزی بین سکته مغزی بین

اولین عالئم تشخیص داده شونداولین عالئم تشخیص داده شوند

آستانه عملکرد ) استاندارد( )مثال( آستانه عملکرد ) استاندارد( )مثال(

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Using guidelinesUsing guidelines

► Recommendations from clinical practice Recommendations from clinical practice guidelines can be used to develop criteria guidelines can be used to develop criteria and standards without substantial and standards without substantial additional work. Guidelines now often additional work. Guidelines now often include suggestions for criteria, a policy include suggestions for criteria, a policy that will be followed in guidelines published that will be followed in guidelines published by NICE.by NICE.

► As the development of good-quality As the development of good-quality guidelines depends on careful review of the guidelines depends on careful review of the relevant research evidence, the criteria relevant research evidence, the criteria suggested in such guidelines are likely to suggested in such guidelines are likely to be valid.be valid.

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III – Measuring PerformanceIII – Measuring Performance

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Planning data collectionPlanning data collection

► To make sure that the data collected are To make sure that the data collected are precise, and that only essential data are precise, and that only essential data are collected, certain details about what is to collected, certain details about what is to be audited must be established from the be audited must be established from the outset. These are:outset. These are: the user group to be included, with any the user group to be included, with any

exceptions noted exceptions noted the healthcare professionals involved in the the healthcare professionals involved in the

users’ careusers’ care the time period over which the criteria apply.the time period over which the criteria apply.

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Planning data collectionPlanning data collection

►Examples of statements )or ‘inclusion Examples of statements )or ‘inclusion criteria’( that define specific populations criteria’( that define specific populations for the purposes of particular auditsfor the purposes of particular audits All children under 16 years diagnosed with All children under 16 years diagnosed with

asthma and registered with the primary asthma and registered with the primary healthcare teamhealthcare team

All people with multiple sclerosis in a All people with multiple sclerosis in a hospitalhospital

All women receiving treatment for breast All women receiving treatment for breast cancer in Irancancer in Iran

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Collect Only Necessary DataCollect Only Necessary Data

► It is always tempting to collect more data It is always tempting to collect more data than necessary, but only the minimum than necessary, but only the minimum amount required by the objectives of the amount required by the objectives of the audit should be collected. audit should be collected.

► It is better to improve a single aspect of It is better to improve a single aspect of care than to collect data on 20 items and care than to collect data on 20 items and change nothing.change nothing.

► There is an inevitable trade-off between There is an inevitable trade-off between data quality and the costs and data quality and the costs and practicality of collecting data.practicality of collecting data.

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Sampling usersSampling users

► Once the group or population of users has been Once the group or population of users has been precisely defined by specifying the ‘inclusion precisely defined by specifying the ‘inclusion criteria’, it is time to decide on the records criteria’, it is time to decide on the records from which data will be collected.from which data will be collected.

► It may not always be practical or feasible to It may not always be practical or feasible to include each and every user, and in this case, a include each and every user, and in this case, a representative sample is usually chosen from representative sample is usually chosen from which inferences about the total population can which inferences about the total population can be made. be made.

► The number needed in the sample is The number needed in the sample is determined by two factors:determined by two factors: The degree of confidence wanted in the findingsThe degree of confidence wanted in the findings Resource constraints )time, access to data, costs(.Resource constraints )time, access to data, costs(.

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Handling data: Data sourcesHandling data: Data sources

►Existing record and information systems Existing record and information systems may already be adequate for clinical may already be adequate for clinical audit purposes, for example, audit purposes, for example, management information systems may management information systems may already collect the data required for already collect the data required for audit. audit.

► If the required data are not collected If the required data are not collected routinely, a specific paper or electronic routinely, a specific paper or electronic encounter sheet can be devised for encounter sheet can be devised for healthcare professionals to record healthcare professionals to record needed information during each needed information during each consultation.consultation.

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Audit of the management of Audit of the management of urinary incontinence: data urinary incontinence: data

collection form for an individual collection form for an individual user.user.

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Data abstraction toolsData abstraction tools

► Data collection forms must specify Data collection forms must specify precisely the information to be abstracted precisely the information to be abstracted from the record, and they should be clear from the record, and they should be clear and easy to use.and easy to use.

► It is good practice to pilot the data It is good practice to pilot the data collection form to enable any inherent collection form to enable any inherent problems to be detected and corrected.problems to be detected and corrected.

► It is essential that data collectors undergo It is essential that data collectors undergo training on the use of the data collection training on the use of the data collection form, so any confusing items are identified form, so any confusing items are identified and a clear policy is established on how and a clear policy is established on how data items should be recorded.data items should be recorded.

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Data analysisData analysis

► The type of analysis to be used should be The type of analysis to be used should be identified at an early stage, as it influence identified at an early stage, as it influence both the type and amount of data collected. both the type and amount of data collected.

► The analysis can range from a simple The analysis can range from a simple calculation of percentages, through to calculation of percentages, through to relatively sophisticated statistical techniques.relatively sophisticated statistical techniques.

► On most occasions, however, simple methods On most occasions, however, simple methods are preferable, and indeed, if the results are are preferable, and indeed, if the results are to stimulate change, the analysis must be to stimulate change, the analysis must be simple enough for everyone in the care simple enough for everyone in the care process to understand. process to understand.

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Concurrent data collection for the administration of Concurrent data collection for the administration of thrombolytic therapy )‘door-to-needle time’(thrombolytic therapy )‘door-to-needle time’(

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An example of a bar chart used in a An example of a bar chart used in a clinical auditclinical audit

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Example of a statistical control Example of a statistical control chart used in a clinical auditchart used in a clinical audit

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IV – Making ImprovementsIV – Making Improvements

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Changing BehaviorsChanging Behaviors

►Change can occur at organizational, Change can occur at organizational, group, or individual levels.group, or individual levels.

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Organizational ChangeOrganizational Change

►Organizations can be thought of as Organizations can be thought of as existing in a state of quasi-equilibrium, existing in a state of quasi-equilibrium, in which driving forces are opposed by in which driving forces are opposed by restraining forces, with the net effect restraining forces, with the net effect that changes in the organization are that changes in the organization are minimizedminimized

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Organizational changeOrganizational change

► Driving forcesDriving forces Patient pressurePatient pressure National policyNational policy Demands from referring general practitioners for Demands from referring general practitioners for

improved accessimproved access► Restraining forcesRestraining forces

IndividualsIndividuals► Fear of increased workloadFear of increased workload► Concern about staffing and mixConcern about staffing and mix► Loss of control over work patternsLoss of control over work patterns

OrganizationsOrganizations► Resistant cultureResistant culture► Lack of resourcesLack of resources► Rigid structureRigid structure

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Organizational ChangeOrganizational Change

► The status quo must be ‘unfrozen’ to allow The status quo must be ‘unfrozen’ to allow change to occur, followed by ‘refreezing’ to change to occur, followed by ‘refreezing’ to consolidate the new equilibrium. consolidate the new equilibrium.

► In order to create the imbalance between In order to create the imbalance between the driving and restraining forces that is the driving and restraining forces that is needed for unfreezing, the restraining needed for unfreezing, the restraining forces should be selectively removed or forces should be selectively removed or reduced. reduced.

► Merely increasing the driving forces will Merely increasing the driving forces will stimulate an increase in the number or stimulate an increase in the number or strength of the restraining forces.strength of the restraining forces.

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Individual changeIndividual change

► The trans-theoretical model, which was developed for The trans-theoretical model, which was developed for management of people with addictive behaviors, such as management of people with addictive behaviors, such as smoking )Robertson, 1999(, explains individual behavior smoking )Robertson, 1999(, explains individual behavior change as a transition through a series of five stages:change as a transition through a series of five stages: precontemplation – the individual has no intention of precontemplation – the individual has no intention of

changingchanging contemplation – change is regarded as a possibility in the contemplation – change is regarded as a possibility in the

near futurenear future preparation – explicit plans are madepreparation – explicit plans are made action – the change occursaction – the change occurs maintenance – the changed behavior is consolidated.maintenance – the changed behavior is consolidated.

► Progression through each stage is necessary if a change Progression through each stage is necessary if a change is to occur. No single strategy can encourage someone is to occur. No single strategy can encourage someone to progress from precontemplation to maintenance, and to progress from precontemplation to maintenance, and different strategies are required at each stage to help a different strategies are required at each stage to help a person move on to the next.person move on to the next.

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Identifying barriers to changeIdentifying barriers to change

► Interviews of key staff and/or usersInterviews of key staff and/or users►Discussion at a team meetingDiscussion at a team meeting►Observation of patterns of workObservation of patterns of work► Identification of the care pathwayIdentification of the care pathway►Facilitated team meetings with the use Facilitated team meetings with the use

of brainstorming or fishbone diagramsof brainstorming or fishbone diagrams

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Some methods of identifying Some methods of identifying barriers to changebarriers to change

► The required change is clearly defined, based on evidence, The required change is clearly defined, based on evidence, and is presented in a way that staff can easily understand.and is presented in a way that staff can easily understand.

► The barriers to change are identified, including those The barriers to change are identified, including those relating to professionals and to the healthcare organization.relating to professionals and to the healthcare organization.

► Implementation methods are chosen that are appropriate to Implementation methods are chosen that are appropriate to the particular circumstances, the change itself, and the the particular circumstances, the change itself, and the obstacles to be overcome. An understanding of selected obstacles to be overcome. An understanding of selected theories of behavior change may be used to inform the theories of behavior change may be used to inform the choice of methods.choice of methods.

► An integrated plan is developed for coordinated delivery An integrated plan is developed for coordinated delivery and monitoring of the interventions. The plan should and monitoring of the interventions. The plan should describe the sequence in which interventions will be made, describe the sequence in which interventions will be made, the staff and resources required to make them, and the the staff and resources required to make them, and the target groups.target groups.

► The plan is carried out, and progress is evaluated, with The plan is carried out, and progress is evaluated, with modifications to the plan or additional interventions being modifications to the plan or additional interventions being used as required.used as required.

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Promoting successful auditPromoting successful audit

► In a recent review of 93 studies concerned In a recent review of 93 studies concerned with a wide variety of clinical audits with a wide variety of clinical audits involving different professional groups, the involving different professional groups, the barriers to successful audit included:barriers to successful audit included: lack of resourceslack of resources lack of expertise in project design and analysislack of expertise in project design and analysis lack of an overall plan for auditlack of an overall plan for audit poor relationships between professional poor relationships between professional

groups or agencies and within teamsgroups or agencies and within teams organizational problems, such as lack of a organizational problems, such as lack of a

supportive relationship between clinician and supportive relationship between clinician and managersmanagers

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Promoting successful auditPromoting successful audit

►Hierarchical relationships, lack of Hierarchical relationships, lack of commitment from senior doctors and commitment from senior doctors and managers, poor organizational links managers, poor organizational links between departments, and lack of between departments, and lack of time and practical support can also be time and practical support can also be obstacles to those taking part in obstacles to those taking part in clinical audit and changing practiceclinical audit and changing practice

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Promoting successful auditPromoting successful audit

► Factors that promote the success of clinical Factors that promote the success of clinical audit include:audit include: sound leadershipsound leadership a conducive/supportive organizational a conducive/supportive organizational

environmentenvironment structures and systems to support audit, structures and systems to support audit,

including mechanisms to make data collection including mechanisms to make data collection easiereasier

a well-managed audit programa well-managed audit program addressing a range of issues important to the addressing a range of issues important to the

trust and individual clinicianstrust and individual clinicians giving adequate attention to all stages of auditgiving adequate attention to all stages of audit

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Structural aspects of Structural aspects of environment that promote environment that promote

clinical auditclinical audit► IndividualsIndividuals TimeTime Personal development plansPersonal development plans Access to advice about change managementAccess to advice about change management Access to a system for reporting concernsAccess to a system for reporting concerns Occupational health service availableOccupational health service available

► TeamsTeams LeadershipLeadership Clear and shared objectivesClear and shared objectives Effective communicationEffective communication Training in improvement methodsTraining in improvement methods Opportunities for the team to meet to share ideas and develop plansOpportunities for the team to meet to share ideas and develop plans

► OrganizationsOrganizations Explicit commitment to clinical audit within the organizationExplicit commitment to clinical audit within the organization Clear system for managing a clinical governance programClear system for managing a clinical governance program Staff with responsibility for audit are fully trained and encouraged to develop Staff with responsibility for audit are fully trained and encouraged to develop

new solutions to old problemsnew solutions to old problems Good systems for understanding the views of usersGood systems for understanding the views of users Good communication with other health and social care agenciesGood communication with other health and social care agencies

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Cultural aspects of Cultural aspects of environment that promote environment that promote

clinical auditclinical audit► IndividualsIndividuals Positive attitude to audit and improvementPositive attitude to audit and improvement Lack of fear – of change and of confronting less than desired or Lack of fear – of change and of confronting less than desired or

even poor performanceeven poor performance► TeamsTeams

Open to new ideasOpen to new ideas Focus on the user’s experienceFocus on the user’s experience Inter-professional respect and cooperationInter-professional respect and cooperation

► OrganizationsOrganizations Users’ perspectives genuinely regarded as the focus of quality Users’ perspectives genuinely regarded as the focus of quality

improvementimprovement Open to interest from external agencies in quality of Open to interest from external agencies in quality of

performance, and not afraid of inspectionperformance, and not afraid of inspection ‘‘No blame’ approach to errorsNo blame’ approach to errors Audit given a high priorityAudit given a high priority

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Thank You !Thank You !

Any Question ?Any Question ?