DEVELOPMENT AND IMPLEMENTATION OF AN

EFFECTIVE CLINICAL AUDIT PROGRAM

Natalie de Vos

National Quality and Risk Manager

Marie Stopes International

Presenters Title

DR MARIE - MARIE STOPES INTERNATIONAL

Dr Marie™ is part of the not-for-profit Marie Stopes International (MSI) global partnership. We have 15 clinics throughout Australia.

Whilst in Australia we predominantly provide a termination service, we also provide contraceptive and reproductive health services.

Our global approach is to increase the uptake of long acting reproductive contraception. (LARC)

MSI works in over 40 countries around the world, mostly in third and developing world countries. The money generated in our Australian clinic network (Dr Marie) assists in the provision outreach programs in most of these countries.

Uptake of LARC is a KPI for all programs including Australia

SELECTING AUDIT CRITERIA

Keep in mind the purpose of the audit

A tool for education

Assist in the continuous improvement process

Measure compliance to a policy, procedure or a

standard

Identify service delivery gaps

Audit what we should be doing, not what we are

currently doing.

SELECTING AUDIT CRITERIA – CONT….

National Standards

Define area where auditing is require

Helpful to direct us to the recognised experts in the

field.

Useful for some specific criteria.

Legislation

WH&S requirements

Medication management

Experience and Clinical Expertise

Useful for speciality areas

Known areas of risk

MSI APPROACH

Utilise direct observation and retrospective

documentation approach

Monthly audits for high risk areas and areas of

known risk

Medical Record

Schedule 8 drug management

Hand Hygiene

Completion of Mandatory Education

Alternate month audits

Quarterly audit

Bi annual audits

AUDIT TOOL

Multi focal

We look at compliance for each criteria This helps identify components that need to be improved

Ensures important components of clinical practice are not missed.

We look at compliance for each set audited for example; Each medical record

Each day for clinical waste audit – (10 days in audit period)

Each clinical area for PPE availability audit

Area of cleaning audit

Area of WH&S audit

We look at overall compliance

MSI_Adit Schedule_Template_2014-2015_Version 1.0.xlsx

COMPLETION

Yellow sections

Only enter n for non compliance

We needed the process to be easy to complete

Experience with placing Y did not mean better

completion of audit tool. Cut and past often used

Enter na for not applicable criteria

CALCULATIONS

Background formulas calculate compliance

Sections in some audits are given weightings.

This is so sections with fewer criteria do not negatively impact overall compliance.

We also use weighting if we think a section in the audit is higher risk eg environmental audit for cleaning verses documentation audit of cleaning.

Weightings are used mainly in the medical record audit, where the audit tool has multiple sections.

Some audits allow for partial compliance.

These allow drilling down in certain areas

Eg. Client demographic details, contents of consultation notes.

CALCULATION CONT…

The value of a partial compliance is determined

by home many criteria in a section or part of the

audit are meet verses how many are not met.

This is helps prevent undervalue or overvalue of

a partial compliance, which occurs with the

C=100%, P=50% and N=0% formula (traditional)

EXAMPLE USING 8 CRITERIA

The P value affects the overall compliance value

This is mainly used in the medical record audit

Number of meet

criteria

Value of P with

traditional

formula

Value of P

Criteria Meet

formula

1 50% 12.5%

2 50% 25%

3 50% 37.5%

4 50% 50%

5 50% 62.5%

6 50% 75%

7 50% 87.5%

8 50% 100%

MEDICAL RECORD AUDIT

Most complex audit tool we use.

We have utilises RACGP criteria with a few added extras for our surgical environment

Divided into 8 sections Pt. 1 - General medical record requirements as well as less

complex and lower risk documentation requirements or where singular auditing can be complete

Pt. 2 - Consultation Notes. Allows for 4 most recent consultation notes to be audited

Pt. 3 - Referral letters

Pt. 4 - Review of pathology results

Pt. 5 - Surgical Safety Checklist

Pt. 6 - Surgical Count documentation

Pt. 7 - Medication administration

Pt. 8 - PACU chart - (incorporates deteriorating client chart)

RATIONAL

The Questions - If one or two criteria are missing,

is it of value to give a P or Non compliance and

how do we ensure consistency between the

auditors.

Allows multiple entries in record to be audited in

areas such as consultation notes, pathology

report reviews, each with a set of criteria.

Our process is to audit 4 most recent

consultations or received pathology results since

last audit period

ADDITIONAL CALCULATIONS FOR MEDICAL

RECORDS

Overall compliance of parts 2-8 will give the P or

C value on part 1 of the audit tool.

Allows for overall compliance and section

compliance to be determined.

MSI_Medical Record Audit Tool_Template_2014 -

2015.xlsx

DATA AND RESULTS

Instant result at site level. (provided data is

entered correctly)

Gaps entered into site Quality Improvement tool,

is risk rated and flags if not completed by due

date

DRM_TM_GOV_Site Quality Improvement

Plan_Sample_Version 1.0.xlsx

Trend improvement over time.

Discussed in Improving Performance meetings,

local staff meetings and at SMT meeting

All site data is released monthly. This includes

sites who did not complete

CHALLENGES

Understanding the criteria

Understanding the audit tools

Functionality of the audit tools

Overuse of not applicable function

Changing the corporate culture

NEXT STEPS

Validation audits - commenced this year.

Completed by Head office staff at site visit.

Observation audit for Time Out and Surgical

Count.