Leveraging Resources for Clinical Auditing

Catherine Li

Performance Review and Audit Coordinator, Fiona Stanley Hospital, WA

About Fiona Stanley Hospital

• Brand new tertiary hospital with 783 beds

• Fully commissioned in February 2015

• Four main clinical service streams with over 40 medical specialties

• Over 5700 staff counting by head

My Journey in Driving Clinical Audits…

1 2 8

48

70

94

135

165

212

255

302

1

6 5

16

22

3

18

9 8

7 7

0

5

10

15

20

25

0

50

100

150

200

250

300

350

Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov

GEKO submission

Edu & training

Submissions by Profession

49%

36%

7%

4% 4%

N&M

Medical

Pharmacy

Allied Health

Other

What’s being audited?

• Compliance with NSQHS Standards

• Concerns arising from clinical practice

• Participation in international prevalence survey

• Testing changes in processes/system

• Patient / consumer satisfaction survey

• Staff knowledge survey

Who can audit?

Whoever is motivated, interested!

A Couple of Milestones

• FSH Audit Presentation Afternoon: 10 presentations by medical and nursing staff, show case improvement activities

• FSH Diabetes Management Review Audit: one day point prevalence survey across the whole hospital for adult in patients:

18 volunteer auditors participated

21 wards audited

Data collection completed in 4 hours

How did this work?

Electronic quality system

• Introducing Governance, Evidence, Knowledge and Outcome (GEKO) system across the organisation

Systematic way to manage quality initiatives

Make quality improvement accessible to everyone

Facilitate communication

Identify accountabilities & responsibilities

Tracking performance & outcome

Governance structure

– 3-tiers

– Vision for clinician engagement

– Ownership

Processes

• Standardisation

• Remove common barriers

• Combination of bottom-up & top-down approach

• Integrate measurement framework with hospital governance framework

Relationships / Engagement

• Education and training: formal, informal

• Standard committee agenda item

• Feedback strategies

• Monthly open forum: Use of GEKO

Quality improvement principles

Clinical audit methodologies

New ideas

Supporting resources

• Available and accessible on hospital intranet

Hospital clinical audit improvement procedure

Governance processes

Guides for using the GEKO system

Guides for defining objectives/measures

Checklist for submissions and approvals

Resources to differentiate quality activities from research projects

Commonly used audit tools

Partnership

• Collaboration with education departments

• Clinical audit program with universities

• Resources from Department of Heath programs

Get to know the departments, know the people, and know their needs!

All in one 3-E Model

3-E model for QI

The model acknowledges the learning curve that staff need to go through and the evolving process required to embed the QI principles.

Thank you!

Like what you see?Be part of our conversation.

informa.com.au

Join our e-newsletter