Audit and Clinical Audit in Residential Care Facilities for Older People. .

1. Audit and Clinical Audit in Residential Care Facilities for Older People.. Eithne Ni Dhomhnaill, RGN., MSc., Director, Nursing Matters & Associates. www.nursingmatters.ie

2. Audit. • Audits can be used by the nursing home to identify areas for improvement; measure improvement and monitor improvements.

3. Types of Audit. There are a variety of types of audits that are routinely carried out in healthcare. These include: • Financial audits. • Internal audit of non-clinical activities and systems indirectly involved in the delivery of care for example ordering and supply of materials. • External organisational audits against standards eg ISO.

4. Types of Audit. • Collecting numerical information about certain activities such as number of admissions, discharges etc. • Routine outcome monitoring such as number of residents with a pressure sore; number of falls. These are often used as key quality indicators which allow us to monitor quality on a continuous basis. • Peer reviews.

5. Activities often confused with Audit. • Risk management activities such as adverse event monitoring; complaints monitoring which are an integral part of the risk management activities of the nursing home

6. Evaluation. • Evaluation / review of a service involves assessing the merits of a service such as identifying the strengths and weakness of a service from a number of perspectives. Different methods can be used depending on what you want to know. For example, you may have introduced a resident council and you want to find out how successful or otherwise it is.

7. Research. • Research is concerned with generating new knowledge which could be applied to other similar areas. Often, research is concerned with finding out what works well or what is best practice. Clinical audit on the other hand is concerned with quality and finding out to what extent we are complying with best practice.

8. Clinical Audit. • Clinical audit is one of many quality improvement tools that can be used to monitor the quality of care. It falls under the ‘audit’ umbrella, but not all audits are clinical audit. The words audit and clinical audit are often used interchangeably; however clinical audit involves a specific methodology.

9. Clinical Audit. • ‘‘Clinical Audit is a quality improvement process that seeks to improve patient care and outcomes through systematic review of careagainst explicit criteria and the implementation of change • NICE 2002.

10. How does Clinical Audit Differ from Audit? • An audit within the clinical setting is not necessarily a Clinical Audit project. • Clinical Audit is a specific form of audit that involves measuring clinical practice against agreed standards. • One important difference between Clinical Audit and these forms of audit is that the clinical audit process is (ideally) owned by healthcare professionals: they carry out the audit, they discuss results and make improvements to practice, etc. • All stages of the Clinical Audit Process must be completed. UBHT, 2005.

11. The Stages of Clinical Audit. Stage 1: Preparing for audit. Stage 2: Selecting Criteria. Stage 3: Measuring performance. Stage 4: Making improvements. Stage 5: Sustaining improvement.

12. The overarching aim of clinical audit is to improve the care and service provided to residents by continuously monitoring practice against standards and make improvements as required.

13. What should we audit? • Nursing homes should have an overall programme of audit in the facility. This should include audit of non clinical aspects of service and care delivery as well as clinical audits. Essentially you should audit structures, processes and outcomes related to care and all aspects of service delivery.

14. Structures. • Structures: Structures refer to ‘things’ that are required by standards and best practice. These may include organisational structures such as the environment; equipment; education; policies and procedures.

15. Processes. • Processes: Processes refer to how things are done. Providing care and services to residents involves numerous processes. These include how the facility is maintained, cleaned as well as the direct care processes carried out by healthcare staff. For example, medication management would include sub processes related to the prescribing, ordering and storage of drugs as well as how nurses administer drugs to residents.

16. Outcomes. • Outcomes: Outcomes are concerned with the results of care and service delivery to residents. Examples of outcomes include physiological measures such as behaviours; experience of pain; mobility as well as satisfaction outcomes such as the resident’s stated level of satisfaction with a service or intervention. Other outcomes that can be measured include numerical information such as the number of falls; complaints and so on.

17. Audit Programme. • The audit programme for the nursing home should be prioritised according to internal and external requirements. A simple form can be used to write up an annual programme of audit activities that will be carried out in the nursing home. The programme will contain a list of audit activities that have been prioritised for the facility for the coming year

18. How do We Identify Topics / Areas for Audit? (Where Do We Start?) • Is there evidence of any known serious quality problem in the nursing home? • Is there a wide variation in practice in any area? • Complaints or comments. • Feedback from the resident council or satisfaction surveys. • Incident / accident reports. • Medication errors / near misses. • Informal observation of practice. • Inspection reports from regulators. • Use of quality indicators (as mentioned previously).

19. Prioritising Audit Topics. • High Risk: Aspects of care / service delivery that are related to high risk. These might include environmental health and safety practices; medication management practices and so on. • High Volume: Aspects of care / service delivery that are regularly carried out. These may include activities that are carried out on a daily basis or more often. The rational behind this is that the more often an activity is carried out, the greater the chance of error. These might include medication administration; hand washing and so on.

20. Prioritising Audit Topics. • Error Prone Activities: This refers to activities that are known to have a high risk of mistakes / errors. Medication administration would also fall into this category. • External Priorities: This refers to audit activity that is required by legislation and standards or audits carried out to demonstrate compliance with regulation and standards.

21. Prioritising Audit Topics. • High Cost: This refers to aspects of care or service delivery in the nursing home that are associated with higher than average costs or could result in high costs if not provided properly. An example would be the use of specialised equipment / personal protective clothing.

22. Sample Priority Matrix for Audit Projects.

23. Conducting Audits. • Keep it simple. • Use existing audit tools (from a reliable /recognised source and adapt them for local use eg. SARI infection control audit tools; NHI Medication Management Audit tool. • Simple checklists are a good way to start.

24. Common areas to be included in an audit programme. • Medication Management. • Infection Control. • Records. • Falls assessment and prevention. • Pressure ulcer assessment and prevention. • Environmental health and safety audits. • Equipment audits. The programme will differ according to the nursing home.

25. Ethical Considerations for Clinical Audit Projects (1). • Confidentiality – anonymity/privacy • Consent – reviewing records do not require individual consent but patients should be aware of audit practice through info leaflets. Participation through interview/q’aire requires individual consent. • Effectiveness – given the significant use of resources, the need for audit should be clearly identified and standards based on best evidence. • Accountability – if the audit identifies areas for improvement, there is an ethical obligation on staff to make sure actions are implemented. Morrell and Harvey, 2003)

26. When in doubt about the ethical implications of collecting certain information, i.e. that of a sensitive nature, it is prudent to seek advice from local ethics committee / audit manager.

29. Findings. • A record of audits and findings should be kept. • Findings of audit should be used to inform improvements as part of clinical governance/continuous quality improvement. • Audits should be used with incident data; complaints; medication incidents and outcome measures for continuous quality improvement. • All staff should be encouraged to be involved in audit activity.

30. Thank You! Any Questions?