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IPAC Canada Audit Toolkit
Presented by:
Mandy Deeves - RN, BScN, MPH, CIC
Director, Programs & Projects
IPAC Canada
If at first you don't succeed, redefine success
Learning Objectives
• Explain the benefits, purposes and functions of audits
• Cover what is an audit
• Discuss how data gathered can be used and next steps
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• If it can’t be measured it can’t be improved!
• Objective measurements can be used as quality indicators
for Accreditation Canada/Ministry of Labour reviews etc.
• Timely feedback / recommendation / input / decision-
making on results involving key stakeholders is enhanced
• Highlights areas of good performance –
identifies a job ‘well done’
Why Audit?
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• Locates, eliminates, and prevents problems
– before the product/service reaches the client/patient
– improved outcomes
• Identifies opportunities for improvement e.g. to best
practices
• Facilitates consistency of IPAC practices between staff and
different facility areas
• Identifies deficiencies in building elements/equipment
Why Audit?
• Media/Public interest - Increasing prevalence of HAIs
• Public Confidence
• Patient Safety
• “Adding Value”!
• Being transparent at all levels in your facility
• Occupational Health & Safety
• Quality care at all levels to clients/patients
Why Audit?
Internal-focused Indicators • Surveillance indicators (process and
outcome indicators)
• Staff satisfaction surveys
• Staff absenteeism rates and benefit premium costs
• Work-related injury rates/WSIB claims costs
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• A sound understanding of IPAC principles is needed for auditing e.g. hand hygiene
• The CHICA audit tools can provide you with selected criteria/best practices to consider relevant to the specific audit tool
• Great tool to provide standardization of audits carried out by various staff
• Relevant audit criteria can be used to review facility policies and procedures etc.
• Practice develops your auditing skills!
The Audit Process
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• Accountability is defined for ___________practices and quality improvement activities?
• Manufacturer’s guidelines/department procedures are readily accessible and are being followed?
• Policies and procedures posted/readily accessible?
• Staff training parameters are met and training records are available?
Document Review
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• How is/are tasks being done, what equipment is being used, what are the potential IPAC risks etc.?
• What is the reporting process to report any IPAC problems?
• Do you have access to IPAC policies and procedures specific to the work you do? Where are they located?
• What __________training have you had and when did you last have it?
Staff Interviews
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• What equipment is being cleaned, disinfected or sterilized?
• Is the proper workflow for housekeeping and reprocessing happening?
• Are sterilized, clean and dirty supplies being stored properly?
• Is what staff say is happening really happening? e.g. hand hygiene etc.
• Are there activities going on that you were unaware of?
Observational Tours
Image Source: IPAC Canada
The Audit Process
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IPAC Canada Website
13 www.ipaccanada.org
IPAC Canada Audit Toolkit
14 www.ipaccanada.org
IPAC Canada Audit Toolkit
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www.ipaccanada.org
Closing the Loop
• An area of auditing where it is common to see gaps in resolution/communication about deficiencies!!
• Immediate “easy fixes” are readily dealt with, however more challenging issues get partially dealt with or “drop of the radar” altogether
• Need process to track and close ALL deficiencies identified e.g. any issues not readily addressed can be given a # and tracked on a log sheet 20120501 – dirty utility room sink install
The Audit Process
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Roles in the Audit Process
• Joint ‘walkabouts’
– Managers and IPAC
– OH&S and IPAC
– Environmental services and IPAC
– Other combinations (e.g. clinical personnel)
• Communication on differences in expectations
– makes these clearer
The Audit Process
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Roles in the Audit Process
• Self-evaluation and/or
coaching of others
• Health care worker
• Manager/Supervisor
• 3rd party auditor – public health/outside expert
for specific issue e.g. outbreaks, HVAC issue,
mold issue etc.
The Audit Process
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Audit Summary Report
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Impact & Likelihood Deficiency Review
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Risk Level Matrix
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Action Planning Form
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Action Planning Form
Complete the Audit
Action Planning Form
this form might not apply
to all audits
provides a useful method
of summarizing
deficiencies and follow-up
required
Audit Analysis Activity
Practice Activity You will be presented with 3 scenarios that represent
what you might see when carrying out an audit in a
hospital or nursing home.
Working with others at your table, follow the instructions
given to you.
Fill out the audit tool as you view the scenes that are
displayed on the screen, then complete the Audit
Summary Report.
Practice Scenario #1 The Scene: You are performing a PPE audit in a
nursing home.
As the auditor, complete the audit tool using the images
that represent what you see during your observational
audit.
Fill out the Audit Summary Report according to
instructions provided at your table.
Practice Scenario #1
Practice Scenario #1 Not wearing
gloves according to RP [7.1]
Failure to remove gloves after the task,
leading to cross-contamination [8.4]
Gloves must never be washed [7.3]
Appropriate use of gloves [7.1]
Gloves are pulled up over cuffs of gown appropriately
[7.8]
Practice Scenario #2
The Scene: You are performing a general unit
audit in a hospital.
As the auditor, complete the audit tool using the images
that represent what you see during your observational
audit.
Fill out the Audit Summary Report according to
instructions provided at your table.
Practice Scenario #2
Practice Scenario #2
Bedpans are not covered and
transported in a safe manner [4.16]
Lack of appropriate spatial separation [4.3],
lack of ABHR [4.9], inaccessible sharps
container [4.24]
Staff are not disposing of blood spills safely
[4.30]
Dedicated hand washing sink [4.5], PPE is available [4.10],
there is a stocked area for PPE used for AP [4.11]
Appropriate disposal of soiled linen [4.23]
Practice Scenario #3
The Scene: You are performing an audit of cleaning
practices for noncritical equipment.
As the auditor, complete the audit tool using the images
that represent what you see during your observational
audit.
Fill out the Audit Summary Report according to
instructions provided at your table.
Practice Activity #3
Practice Activity #3 Hand washing sink has
winged taps, disposable liquid soap and single-
use hand towels [3.10-3.13]
Missing facial protection according to
RP [4.3]
Unlabelled chemical product bottle [4.10],
overfilled sharps container [3.25]
There is an adequate supply of cloths
available for cleaning [3.22]
Overfilled, uncovered waste container [3.29]
• Done via consensus – get support for resolutions!
• Get the most appropriate, feasible and effective control measure based on collective experience!
• Someone else other than you likely has the accountability, responsibility and budget to resolve the issue!
• Reduces the risk of negative consequences as decisions will be based on collective experience!
Prioritize Deficiencies
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Action Plan
Present your findings:
Complete Audit Action Planning Form
Meet with area manager, clinical department head
and others who can facilitate improvements
Present scope of audit, audit findings, references
consulted and recommendations
Action Plan
Work with leaders to prepare an improvement action
plan that includes:
assigned authority for completion of corrective
action item(s)
timelines for completion
feedback from those impacted
Prioritize action items
“Closing the Loop”
Follow Up:
determine process for tracking completion of action item(s)
establish dates for follow-up audits
maintain records of audits and follow-up
report results to a wider audience e.g. IP&C Committee, departmental meetings
RE-AUDIT!!
Do this…. • Promote understanding in your facility about your role in the auditing
process
• Seek a repositioning of IPAC as the “clinical support” service to manage IPAC deficiencies rather than the sole “owner” of IPAC in your facility
• Support your managers and staff with guidance on how to:
– Be actively involved in the auditing process
– Be actively involved in decision making to address identified deficiencies in their departments
– Be actively involved in providing management with audit results, recommendations and follow-up actions taken on identified deficiencies
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Don’t Do This! • Taking-over what is another manager’s responsibility
(e.g. monitoring the performance of a specific individual)
• Overseeing the quality monitoring for a department (e.g. show how, not do, environmental marking for housekeeping)
• Compensating for the limitations of a department (e.g. lack of staff)
• Dictating practice – a collaborative approach should be used to work towards and achieving best practices (e.g. be nice unless it’s time not to be nice!)
• Doing all the “thinking”- act as mentor in the decision-making process that is involved in addressing IPAC deficiencies
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In Closing • Need to move away from where health care providers are
apprehensive about being involved in auditing
• Auditing procedures can facilitate involvement and decision
making/recommendations at all levels in the facility
• Leadership support and visibility is instrumental in changing
these perceptions
• Auditing – can seem tedious, but will tell you whether IPAC best
practices have been sustained or whether you need to make
another change
• Auditing may find deficiencies in another program area that needs
to be reported/addressed to the appropriate person
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In Closing • Staff engagement is key to success – frontline staff should be actively
involved in data collection, observational audits interviews, discussion on
changes needed and how to implement necessary changes
• Continuous leadership presence conveys the importance of the work being
done and helps to showcase the successes to a broader audience
• Deficiencies are learning opportunities!!!!
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