Assurance or Reassurance? The Internal Audit of Clinical Areas Forum

1. Assurance or Reassurance?The Internal Audit of Clinical Areas Forum

2. Agenda

3. Project Overview Nick Bush, CEO East Grampians Health Service Mario Santilli, Director Development and Improvement East Grampians Health Service

4. Background: • Health Services have a strong focus on external audit (Auditor General representation) and internal audit however the focus is on key risks, financial and compliance issues • The gap identified is the lack of clinical audit included in this framework • Currently the audit program for health services is led by accountants who are taught auditing and is fragmented and requires pulling together into one framework

5. Minister of Finance Standing Directions 2.5, Internal Audit a direction is given that: • “Each Public Sector Agency must, unless exemption has been obtained, establish and maintain an adequately resourced independent internal audit function appropriate to the needs of the Public Sector Agency.” • Standing Directions of the Minister for Finance under the Financial Management Act 1994, P 29 • Department of Treasury and Finance updated 2010

6. Currently EGHS has an internal audit program, like most public health services, that focuses on key financial compliance requirements and occasionally other operational activities (i.e. not primarily associated with core financial functions such as budgeting, payroll, accounts, purchasing and financial accounting) that provide exposure to high risk to the organisation.

7. EGHS believes that high risk clinical functions be exposed to the same discipline of internal audit to enable assessment of adherence, compliance and outcomes with standards for those identified high risk clinical areas.

8. A Risk Management Partnership Project with VMIA Underpinning – based on the International Standards for the Professional Practice of Internal Auditing. (Institute of Internal Auditors)

9. Key Principles Risk Based Proactive Independent High Level of Governance and Assurance Qualified Auditing Practitioners

10. Project Stages • Stage 1 International Literature Review • Stage 2 Development of a Framework • Stage 3 Development and testing of Guidelines • Stage 4 Pilot • Stage 5 Evaluation

11. Stage 2: Clinical Internal Audit Framework Paul Robertson and Wendy Malkiewicz INCITE information

12. Clinical Internal Audit Framework VHA & VMIA November 2013

13. Board needs not met by current risk management & assurance arrangements • internal audits often focus on low risk / low importance areas – do not address core business / high risk areas • clinical audits may not target areas of strategic risk - depend on the interests & concerns of clinical staff • accreditation processes may not be sufficiently exhaustive or in depth to address potential risk or improvement opportunities • incident reporting is reactive rather than proactive

14. An enhanced internal audit cycle • Internal audit of clinical areas • a systematic and proactive process • for Board (and senior management) • independent & objective • quality improvement advice and assurance • clinical risks to meeting strategic objectives are being managed

15. Vertical & horizontal integration

16. Governance arrangements

17. Internal Audit of Clinical Areas (3 yr flow)

18. Internal Audit of Clinical Areas (annual flow)

19. Wendy Malkiewicz wendy@inciteinformation.com.au 0409 851 025 Paul Robertson paul@inciteinformation.com.au 0432 685 204 Website: www.inciteinformation.com.au

20. Stage 3: Guidelines for the Internal Audit of Clinical Areas Alison Brown Consultant Australian Centre for Healthcare Governance

22. External Audit Regulators Board/ Audit Committee Senior Management 3rd line of defence 1st line of defence 2nd line of defence including: Risk Management Compliance Audit Quality Improvement Internal Audit Management Controls Internal Sources of Assurance External Assurance

25. In Clinical Areas

26. In Australia patients have a ‘one in two chance of receiving recommended care, a 1:10 likelihood of something going wrong in hospital and a 1:50 possibility of a health system-induced death or major disability’. (Braithwaite, 2010).

27. Sources of clinical risk information External data: • Claims data • Accreditation reports, • self assessment gap analysis • Peer review literature • policy directives, national safety goals, coroners reports, clinical registry reports Internal data • Areas of higher volume • Areas of higher risk • Consultation with clinical staff

30. Internal Audit Tool for Clinical Areas 4 sections • Quality Systems Evaluation • Clinical Process Evaluation • Clinical Data Review • Patient Record Review

31. Internal Audit Tool for Clinical 4 sections • Quality Systems Evaluation • Clinical Process Evaluation • Clinical Data Review • Patient Record Review

32. Internal Audit Tool for Clinical 4 sections • Quality Systems Evaluation • Clinical Process Evaluation • Clinical Data Review • Patient Record Review

33. Internal Audit Tool for Clinical 4 sections • Quality Systems Evaluation • Clinical Process Evaluation • Clinical Data Review • Patient Record Review

34. Internal Audit Tool for Clinical 4 sections • Quality Systems Evaluation • Clinical Process Evaluation • Clinical Data Review • Patient Record Review • General criteria for all patients • Specific criteria for high risk subpopulations e.g. for ED/UCC: • Altered conscious state • Acute coronary syndrome • Abdominal pain • Suicidal /self harm

39. From INCITE Information, 2012

40. Stage 3: Testing the Guidelines Findings of the EGHS Trial Audit of Urgent Care Centre Belinda Mitchell, Risk Consultant, VMIA Mario Santilli, EGHS

41. EGHS had been accredited only 12 days prior to the trial internal audit of the UCC. • Why review UCC • Project design to address high risk high claims areas • In line with VMIA reduce total cost of risk • EGHS high risk clinical area of concern

42. Findings of rating of controls • 4 unsatisfactory level of controls • 5 improvement opportunities Of the 4 unsatisfactory controls • 3 high priority • 1 medium priority

43. Quote from EGHS Board President relating to the value of the Clinical internal Audit. “As the President of the Board at EGHS the Clinical Internal Audit conducted on our Urgent Care Centre has provided a greater level of assurance with regards to clinical governance responsibilities and importantly provided valuable information with regard to risk exposure. I am now provided with assurance that risk is being managed and that further risk treatments will be implemented.” (Louise Staley EGHS Board President)

44. Stage 4 : Future Pilot Belinda Mitchell, Risk Consultant, VMIA Mario Santilli, EGHS Alison Brown, ACHG

45. Broad pilot to test the framework, guideline and tool • Seeking health services to participate in the pilot and conduct a clinical internal audit of their ED or UCC. • What will we get out of it - • the health service will get a clinical internal audit report • the project will get information from the participating health services that will help refine the framework, guidelines, tools and the implementation process.

46. Costs • EGHS experience that costs were approximately $9,000 to conduct the audit and produce the audit report. • The project team will provide support to the health service and provide consultation to the auditors to assist with scope, audit team requirements and report writing

47. What do you see as the barriers to implementing internal audit of clinical areas in your organisation? • Is any further information/support needed to discuss, at board/senior executive level, expanding the scope of internal audit to clinical areas? • Expressions of interest in a further pilot in emergency/urgent care centres?

48. For further information about the project please contact Mario Santilli, Director Development and Improvement, East Grampians Health Service Email: Mario.Santilli@eghs.net.au Belinda Mitchell Risk Management Consultant, VMIA Email: B.Mitchell@vmia.vic.gov.au