Healthcare Audit
ICHN Annual Conference Hilton Hotel Kilmainham
17th of May 2017
Cora McCaughan,
Assistant National Director, Healthcare Audit,
Quality Assurance and Verification Division.
Overview
1. Rapid appraisal of Healthcare Audit Function
2. Where Healthcare Audit is at the moment
3. Findings from Audit for ICHN Members
4. QI Response by ICHN members to Audit
5. Focus on Outcomes
1. Rapid Appraisal of Healthcare Audit
Function
1. Rapid Appraisal of Healthcare Audit
Function
Rapid Appraisal
Rapid Appraisal
Rapid Appraisal
2. Where Healthcare Audit is at the
Moment
QID/
RCPI
/SQI
QAVD
/HCA
Team
Service
Delivery
System
Internal
Audit
NOCA
2. Where Healthcare Audit is at the
Moment
•
•
•
•
•
•
Established 2010
Office of the CEO → QCCD → QPS →QID → QAVD
13 people
Provides assurance
Key role in assurance framework
Provides valuable and reliable information to
inform decision making
2. Where Healthcare Audit is at the
Moment
• Identifies good practice for sharing across system.
• Tests the effectiveness of internal controls.
• Provides evidence for signing the statement of
internal control.
• A quality improvement activity.
• 2017 operational plan include audits spanning every
Division and relate to key safety issues.
2. Where Healthcare Audit is at the
Moment
What we do:
We audit compliance against clinical and nonclinical standards.
2. Where Healthcare Audit is at the
Moment
What we DON’T do:
We do not audit compliance against financial
standards
2. Where Healthcare Audit is at the
Moment
Audits issued in 2016:
1.
Audit of compliance with implementation of the multidisciplinary clinical
handover in maternity services as per the National Clinical Guideline (2014)
2.
Audit of Implementation of Policies for Personal Assisted Care in Aiseanna
Tacaiochta
3.
Audit of incident reporting and learning in radiotherapy as outlined in section 3 of
the Medical Exposure Radiation Unit's (MERU) Patient Radiation Protection
Manual
4.
Audit of compliance with Theme 1, standard 1.3 and Theme3, standard 3.1 of the
National Standards for Residential Care Settings for Older People in Ireland
(HIQA,2016) in selected older person's services
5.
Audit of compliance of the management of serious incidents in the mental health
services with the HSE Policy for Safety Incident Management
2. Where Healthcare Audit is at the
Moment
Audits issued in 2016 (continued):
6.
Audit of evidence of compliance with the process by which a serious
reportable incident is reported, escalated, investigated and managed from
the point of occurrence/ identification to the senior most accountable
officer
7.
Audit of learning from adverse incidents and near misses in selected acute
hospital groups
8.
Audit of compliance with the implementation of recommendations listed
in the HIQA (2015) report Linking Learning to National Standards
9.
Audit of National Open Disclosure Policy in selected sites
10. Audit of the implementation of informed consent and supported decisionmaking practices as Part 1 of the National Consent Policy (2014)
3. Findings from Audit for ICHN Members
Healthcare Records/documentation
4. QI in response to Audit related to ICHN
Members’ work
• Dublin West Review of Documentation standards to
assess adults, child health, maternal health and wound
care
• Redesigned to support better assessment by adding
clinical screening tools such as:
– MUST tool
– Children and Family’s Child and Family Health Needs
Assessment S
– SKIN Bundle
Focus on Outcomes
Continuously
improving HCA’s
Team
Performance
Symbiotic
relationship
between NOCA,
HCA, SQI Audits
and Local
Clinical Audits
Enhanced data
from HCA’s
Generating the
most useful
possible HCA
data to deliver
the greatest
possible patient
safety
improvement
Triangulation of
HCA data with
data from other
sources
Enhanced local
Clinical Audit
Thank you