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HSE Codes of Practice for Healthcare Records Management & Integrated Discharge Planning. Guidance Notes for HSE Audit Tool.

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Guidance Notes for Audit Tool

Health Service Executive Codes of Practice for

Healthcare Records Management & Integrated Discharge Planning



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Reader Information

Directorate: Quality & Clinical Care Directorate (QCCD)

Title: HSE Codes of Practice for Healthcare Records Management & Integrated Discharge Planning

Document Purpose: Guidance Notes for Audit Tool

Author: Quality & Clinical Care Directorate (QCCD)

Publication Date: May 2010

Target Audience: All staff in the HSE who work in healthcare records management & integrated discharge planning

Description:

The Code of Practice is a guide to the standards of practice re-quired in the management of healthcare records & integrated discharge planning in the HSE, based on current legal require-ments and professional best practice

Superseded Docs: NHO HCRM Guidance Notes for Audit Tool 2009

Review Date: May 2011

Contact Details:

Winifred Ryan,

Quality & Clinical Care Directorate,

Health Service Executive,

Dr. Steevens,

Dublin

Ireland.

Email: [email protected]

Web: www.hse.ie



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Contents

Contents

Page

1. Introduction 4

1.1 Standards for healthcare records management and integrated discharge planning

1.2 Audit

1.3 Audit tool

1.4 Use of the audit tool

1.5 Levels of audit

1.6 Planning the audit programme

1.7 Carrying out the self-assessment

2. Guidelines for using the audit tool 7

2.1 Running the tool

2.2 Entering data against the Standard questions

2.3 Areas for improvement

2.4 Recording Quality Improvement Plans (QIPs)

2.5 Evidence of compliance

2.6 Good practice (and ‘benchmarking’)

2.7 Analysis

2.8 Aggregation sheets



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Introduction

1 Introduction

1.1 Standards for healthcare records management and integrated discharge planning

During 2006, Standards for healthcare records management were developed using a consistent methodology. A literature review was undertaken which included a search for all relevant guidance and evidence. Expert opinion was also sought for the Standards. A national consultation process was undertaken and feedback where appropriate, was incorporated into the final version of the Standards.

During 2008, the HSE Code of Practice for Integrated Discharge Planning was drafted

by members of the National Integrated Discharge Planning Steering Committee. The Code was prepared by utilising published guidance from expert bodies, and existing best practice guidance and Standards. Information was also drawn from various expert groups and reference sources. A national consultation process on the draft Code was undertaken and feedback, where appropriate, was incorporated into the final version of the Code.

An audit tool (based on the 'Safety and Health Audit Tool' for the Healthcare Sector)

was then developed to assist in the monitoring of each set of Standards. These audit tools and Standards have been reviewed, amalgamated and amended in line with the Quality, Safety and Risk Framework.

1.2 Audit

Audit is a function of all developing and progressive organisations. The outcome from an audit can facilitate an organisation to be knowledgeable about its areas of non-conformance and to identify and implement quality improvement plans where neces-sary.

1.3 Audit tool

The audit tool relates to the principles of healthcare records management and integrated discharge planning and includes: clear accountability arrangements, communication and consultation, integrated discharge planning process and clinical coding. The audit tool can be used to provide objective data on conformance with the standards within the HSE. Year-on-year data can assist in monitoring the effectiveness of healthcare records management and integrated discharge planning programmes and assist in strategic planning to meet long term healthcare records management and integrated discharge planning objectives.



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Introduction

1.4 Use of the audit tool

The audit tool is intended for use by the healthcare records management/integrated discharge planning committees (in conjunction with the clinical governance commit tee), staff with a demonstrated interest in healthcare records management/integrated discharge planning and trained audit personnel.

1.5 Levels of audit

There are two levels of audit against the Standards: self-assessment and peer review. Self assessment is a process whereby the healthcare organisation measures its

conformance against Standards. Each organisation will be asked to undertake a self-assessment exercise for its service against the Standards. This will be completed annually, signed by the manager/CEO and sent to the senior manager/director.

Peer review uses the same Standards to independently measure the healthcare organi-

sation through an on-site audit. The findings from the audit will be summarised in a written report.

1.6 Planning the audit programme

In addition to the annual self-assessment, it is envisaged that the healthcare records management/integrated discharge planning committees (in conjunction with the clini-cal governance committee), will develop an annual audit programme, based on a re-view of specific policies, results of previous self-assessments, in response to specific clinical incidents or to assist in monitoring quality improvement plans (QIPs). Thus the audit programme may include a number of self-assessments against all or some of the questions of the Standards throughout the year and will focus on monitoring the implementation of actions as outlined in the healthcare organisations quality improve-ment plans.

1.7 Carrying out the self-assessment

The Standards and thus the self-assessment are applicable at an organisational level. An ‘organisation’ is defined as a collection of services, departments and/or functions under the actual or assumed overall direction and control of a management team or governing body. In practical terms, this definition is intended to cover both statutory and voluntary hospitals together with local health offices (LHOs).

Both in hospitals and LHOs there are a range of services, departments and/or func-tions that ‘aggregate up’ to provide a picture of the whole organisation. In a hospital there are various services such as Accident and Emergency, Cardiology, Care of the Elderly, General Surgery, Paediatrics, Radiology and so on. Similarly, in an LHO there are various services such as mental health, disability services, primary care services, chil-dren and families, social inclusion, and so on.



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Introduction

Many of the Standards will require aggregation across the organisation to determine the overall question response (i.e. yes, high partial, medium partial, low partial, not applicable or no). Each healthcare organisation must collect and collate, where appro-priate, sufficient information at ‘lower levels’ within the organisation in order that a judgement can be made about the level of organisational compliance with each Stan-dard. For hospitals this may imply starting the self-assessment process at the level of service area or directorate and aggregating these results to achieve an overall hospital self-assessment result.



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Guidelines for using the audit tool

2.1 Running the tool

The tool is an Excel spreadsheet. Simply ‘double-click’ on ‘HSE Healthcare Records Management & Integrated Discharge Planning Audit Tool V3.0’ to run the tool. You will see the following introductory screen (Figure 1) , which contains basic instructions on how to operate the tool. There are several worksheets listed at the bottom, which cover ‘data entry’, ‘analysis’, ‘QIPs’ and ‘good practice’ etc. These are outlined in more detail below.

Figure 1

2.2 Entering data against the Standard questions

Click on the ‘Data Entry’ worksheet tab. A screen similar to Figure 2 appears.

Figure 2



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The Standard statements and associated questions have been entered for scoring and analysis purposes. Run your cursor over the ‘Question’ boxes with a small red triangle in the top right corner to reveal each question and over the ‘Comments’ boxes with a small red triangle in the top right corner to reveal each example of verification (see Figure 3 below).

Figure 3

For each question the auditor can indicate the method of verification used in trying to get an answer to the question. The auditor may have interviewed ( I ) an employee, observed ( 0 ) a particular work practice or reviewed a particular document ( D ). The auditor may have used all three methods and all three may be recorded on the work-sheet. You can enter a response, in the form of the number ‘1’, against each question to indicate the method of verification (see Figure 4 below).

Figure 4



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You must enter a response, in the form of the number ‘1’, against each question. There are six possible question responses— Yes, high partial (HP), medium partial (MP) low partial (LP), not applicable and no. The tool automatically assigns the following scores to your response: Yes=100%, HP=80%, MP=50%, LP=20% and No=0%. You must enter ONE response for each question. This can include a ‘not applicable’ (N/A) or a ‘don’t know’ (D/K) response.

Note: N/A implies that the Standard question does not apply in that particular circumstance. The D/K response should only be used in circumstances where the auditor does not have the required knowledge to allocate a score, however, this must be revisited and an appropriate score allocated prior to completion of the self-assessment.

One way to think about a high partial response is consider it a ‘yes, but…..’ i.e. you meet many of the requirements of the question, but are not quite there yet. Similarly, a low partial can be thought of as a ‘no, but…..’ i.e. there is little in place but you can point to evidence of some aspects of compliance. Medium partial implies that you are ‘half way there’.

Figure 5

If the ‘Check’ box is green then you have entered a response. If it is white you have yet to enter a response. If it is red, you have entered too many responses and it must be corrected to ensure only one response entered. If the ‘Action’ box is red, this flags up that you have not scored 100% on the question and action(s) may be needed.

Figure 6



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The ‘Count’ line simply counts the number of each type of response and this is then converted to a ‘Percentage’ response immediately below. Thus you can immediately get a ‘feel’ for the response profile in relation to the questions comprising the Standard. The ‘STANDARD SCORE (%)’ gives the overall score for the Standard, taking ac-count of any not applicable questions.

Figure 7

The scores are based on professional judgement made in relation to responding to the various questions in the DATA ENTRY worksheet. Scoring is relative and not abso-lute. The objective is to provide a profile not to suggest precision.



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2.3 Areas for improvement

Click on the ‘Areas for improvement’ worksheet tab. A screen similar to Figure 8 ap-pears.

Figure 8

Careful examination of self-assessment results and feedback will highlight the areas that need improvement and supply the evidence for change. Key to success is the in-volvement of staff and service users in identifying areas for improvement and develop-ing quality improvement plans.

The ‘Areas for improvement’ worksheet allows you to identify the areas for improve-ment in order of priority under each Standard heading. It is important to prioritise areas for improvement. It is better not to tackle everything at once, but stick to a few main priorities for action. The priority areas for improvement that must be dealt with during the current year should be transferred to the quality improvement plan (QIP) worksheet. Choose areas that show clear potential for improvement. If plans are too ambitious they may fail so it is important to be realistic and choose approaches that are likely to succeed. Small successes will help to keep the momentum going and en-courage continuous improvement.



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2.4 Recording Quality Improvement Plans (QIPs)

Click on the ‘QIPs’ worksheet tab. A screen similar to Figure 9 appears.

Figure 9

Agree the priorities and consider the appropriate interventions to encourage continu-ous improvement. Divide your quality improvement plans into manageable actions and achievable targets. Identify responsible persons and reasonable timescales for com-pleting each of the actions along with details of how and when progress will be meas-ured.

You can type in the relevant details under the various headings to build a comprehen-sive list of quality improvement plans in relation to compliance with the HSE Codes of Practice for Healthcare Records Management and Integrated Discharge Planning.

Each healthcare organisation must implement the appropriate interventions/actions identified in their quality improvement plans. Priority actions for healthcare records management/integrated discharge planning will also be identified by the Quality and Clinical Care Directorate on an annual basis for healthcare organisations to imple-ment.

Note 1: Please ensure you enter the 'Entry Date' (i.e. date that QIP is entered into the log), 'Due Date' (i.e. date that the QIP is due for completion), and, when appropriate, the 'Completed Date' (i.e. date that QIP has been fully implemented). The ‘QIPs STATUS’ information can be used to monitor the implementation of the QIPs as appropriate.

Note 2: ‘Late’ QIPs which had been identified during the previous annual self-assessment and which have not been completed by their ‘due dates’ should be reviewed in light of the current years self-assessment results and if considered to be still applicable, should be included in the healthcare organisations current self-assessment list of QIPs, with due dates for completion no later than the end of the next quarter.



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Evaluate

To identify if the priority actions are being implemented, an evaluation and monitor-ing process is required. This includes incorporating the 'Continuous Quality Improvement Cycle' outlined in Figure 10 (HSE 2009a). The Cycle is a four-step model for carrying out change and just as a circle has no end, the Cycle should be repeated again and again for continuous improvement. Evaluations should reflect the priority actions and the continuous quality improvement cycle described in Figure 10.

Progress against deadlines and milestones should be monitored on a regular basis. Meetings should be arranged to update everyone and assess how effective the changes are. This will help to maintain enthusiasm and interest. You need to know when you have achieved your objectives. Build mechanisms into your plan that will enable you to evaluate the impact of changes you make. Gathering further feedback will enable you to assess the impact of your work.

Figure 10



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i. When to use the Continuous Quality Improvement Cycle

• As a model for continuous improvement.

• When starting a new improvement project.

• When developing a new or improved design of a process, product or service.

• When defining a repetitive work process.

• When planning data collection and analysis in order to verify and pri-oritise problems or root causes.

• When implementing any change.

• The service user should be involved at all stages of the cycle.

ii. Procedure

1. Plan. Recognise an opportunity and plan a change.

2. Do. Test the change. Carry out a small-scale study.

3. Study. Review the test, analyse the results and identify what you’ve learned.

4. Act. Take action based on what you learned in the study step: If the change did not work, go through the cycle again with a different plan. If you were successful, incorporate what you learned from the test into wider changes. Use what you learned to plan new improvements, begin-ning the cycle again (ASQ Quality Tools 2010).



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2.5 Evidence of compliance

Click on the ‘Evidence of compliance’ worksheet tab. A screen similar to Figure 11 appears.

Figure 11

All evidence/data considered during the self-assessment should be given a document reference number and referred to within the data-entry worksheet. This information should be recorded on the ’Evidence of compliance’ worksheet (see above). The evi-dence can also be saved in a folder for that particular Standard/question and the folder hyperlinked to the comments box on the data entry worksheet (see Figure 12 below). Where no data/evidence is available please state this clearly. All written evi-dence/data submitted must be relevant to the questions in the self-assessment standard worksheets.

Figure 12



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2.6 Good practice (and ‘benchmarking’)

Click on the ‘Good Practice’ worksheet tab. A screen similar to Figure 13 appears.

Figure 13

The ‘Good Practice’ worksheet allows you to build a simple list of what you consider to be good practice in your healthcare organisation. You can then share this informa-tion, and your scoring information, with other healthcare organisations to build a learning sharing and benchmarking culture. This will help you improve quality, reduce risk and comply with the relevant requirements in the HSE Codes of Practice for Healthcare Records Management and Integrated Discharge Planning.

Note: The ’autofilter’ function (see Figure 13) can be used by clicking a cell in the range you want to filter (e.g. row 1 which contains the headings). On the Data menu, point to Filter, and then click AutoFilter. Click the arrow in the appropriate column and select the data that you want to filter.



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2.7 Analysis

Click on the ‘Analysis’ worksheet tab. A screen similar to Figure 14 appears (this par-ticular screen shows that some data has been entered).

Figure 14

Here you have four analysis ‘results’, each of which can be copied and pasted into, for example, a word processing package if you want to produce a report.

The first result is a table (top left) of responses and scores for each Standard.

The second result is a bar chart (top right) showing a profile of scores against each Standard.

The third result is a pie chart (bottom left) showing a breakdown of the methods of verification for all of the questions.

The fourth result is a pie chart (bottom right) showing a breakdown of the responses to all questions.



2.8 Aggregation sheets

Some of the Standards/questions may require aggregation across the healthcare organi-sation to determine the overall Standard compliance rating. Should you need to aggre-gate data for relevant questions, click on the ‘Aggregation’ worksheet. A screen similar to Figure 15 appears.

Figure 15

It is recommended that Standards (where appropriate) are audited at the section (ward/department/service area/directorate) level (as appropriate to your organisation) and the information is then aggregated so that a judgement can be made about the level of overall healthcare organisation compliance with each Standard/question.

In Standard 14 you must answer a separate list of questions for each chart audited. The answers for each chart can be recorded in the ‘Standard 14’ worksheet and the overall scores for each question are then transferred to the Aggregation or Data Entry worksheets.

Note: Because the information in the Aggregation worksheets will extend beyond the screen, it is recommended that the auditor clicks on the cell C7 and uses the ‘freeze panes’ facility as shown in Figures 15 and 16.

Figure 16

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Documents

Health Service Executive Codes of Practice for Healthcare ... · Audit is a function of all developing and progressive organisations. The outcome from ... assist in strategic planning