Healthcare Audit ICHN Annual Conference Hilton Hotel Kilmainham

Healthcare Audit ICHN Annual Conference Hilton Hotel Kilmainham 17 th of May 2017 Cora Mc. Caughan, 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 (1) Where we are?

Rapid Appraisal (1) Where we are? (2) Where we need to go?

Rapid Appraisal (1) Where we are? (3) How do we get there? (2) Where we need to go?

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 Theme 3, 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