Presentation is loading. Please wait.

Presentation is loading. Please wait.

Assurance or Reassurance? The Internal Audit of Clinical Areas Forum 19 November 2013.

Similar presentations


Presentation on theme: "Assurance or Reassurance? The Internal Audit of Clinical Areas Forum 19 November 2013."— Presentation transcript:

1 Assurance or Reassurance? The Internal Audit of Clinical Areas Forum 19 November 2013

2 Agenda 10.00Welcome and introduction to project team 10.10Project Overview 10.30Clinical Internal Audit Framework 10.45Implementing the internal audit of clinical areas 11.10Morning tea 11.30Case study: the internal audit of an urgent care centre 12.00Future Implementation in the sector 12.30Summary and Close 12.45Lunch

3 Project Overview Nick Bush, CEO East Grampians Health Service Mario Santilli, Director Development and Improvement East Grampians Health Service

4

5

6

7

8 Underpinning – based on the International Standards for the Professional Practice of Internal Auditing. (Institute of Internal Auditors) A Risk Management Partnership Project with VMIA

9 Key Principles Risk Based Proactive Independent High Level of Governance and Assurance Qualified Auditing Practitioners

10 Project Stages Stage 1 International Literature Review Stage 2 Development of a Framework Stage 3 Development and testing of Guidelines Stage 4 Pilot Stage 5 Evaluation

11 Stage 2: Clinical Internal Audit Framework Paul Robertson and Wendy Malkiewicz INCITE information

12 VHA & VMIA November 2013 Clinical Internal Audit Framework

13 internal audits often focus on low risk / low importance areas – do not address core business / high risk areas clinical audits may not target areas of strategic risk - depend on the interests & concerns of clinical staff accreditation processes may not be sufficiently exhaustive or in depth to address potential risk or improvement opportunities incident reporting is reactive rather than proactive Board needs not met by current risk management & assurance arrangements 13

14 An enhanced internal audit cycle 14 Internal audit of clinical areas a systematic and proactive process for Board (and senior management) independent & objective quality improvement advice and assurance clinical risks to meeting strategic objectives are being managed

15 Vertical & horizontal integration 15

16 Governance arrangements 16

17 Internal Audit of Clinical Areas (3 yr flow) 17

18 Internal Audit of Clinical Areas (annual flow) 18

19 Paul Robertson Wendy Malkiewicz Website:

20 Stage 3: Guidelines for the Internal Audit of Clinical Areas Alison Brown Consultant Australian Centre for Healthcare Governance

21 Internal Audit Clinical Audit Examines clinical and non-clinical activity, systems and processes Examines clinical processes and outcomes Is carried out externally by independent professionals. Is clinically led, and may be carried out by healthcare professionals and / or clinical audit staff Selection of audit areas is risk basedSelection of audit areas may be driven by clinical interest and accreditation and only loosely related to significant risks Assesses mechanisms of internal risk control within an organisation and feeds back into risk plans. Measures clinical practice against agreed best practice standards Internal audit programs are established over the medium term (3-5 years) with work-plans agreed annually. May be an annual clinical audit program or audits may occur in response to an incident Consistent approach according to Internal Audit Standards Carried out in accordance with board approved clinical audit policy Recipient of audit findings is the boardRecipient of audit findings is often internal committees or other interested internal parties e.g. unit manager

22 External Audit Regulators 1st line of defence 3 rd line of defence 2nd line of defence Management Controls including: Risk Management Compliance Audit Quality Improvement Internal Audit Senior Management Board/ Audit Committee Internal Sources of Assurance External Assurance

23 1. Internal Audit planning 2. Preparing for an internal audit 3. Conducting an internal audit 4. Reporting and Monitoring

24 Developing a three year risk based program of internal audit Developing annual internal audit work plan 1. Internal Audit planning 2. Preparing for internal audit 3. Conducting an internal audit 4. Reporting and Monitoring

25 Developing a three year risk based program of internal audit- strategic clinical risk identified and prioritised Developing annual internal audit work plan - clinical expertise into clinical areas requiring internal audit 1. Internal Audit planning 2. Preparing for internal audit 3. Conducting an internal audit 4. Reporting and Monitoring In Clinical Areas

26 In Australia patients have a ‘one in two chance of receiving recommended care, a 1:10 likelihood of something going wrong in hospital and a 1:50 possibility of a health system-induced death or major disability’. (Braithwaite, 2010).

27 Sources of clinical risk information External data: Claims data Accreditation reports, self assessment gap analysis Peer review literature policy directives, national safety goals, coroners reports, clinical registry reports Internal data Areas of higher volume Areas of higher risk Consultation with clinical staff

28 Developing a three year risk based program of internal audit Developing annual internal audit work plan 1. Internal Audit planning Appointing the internal auditor Identifying/developing the internal audit tool/s Agreeing individual internal audit plan 2. Preparing for internal audit 3. Conducting an internal audit 4. Reporting and Monitoring

29 Developing a three year risk based program of internal audit- strategic clinical risks identified and prioritised Developing annual internal audit work plan - clinical expertise into clinical areas requiring internal audit 1. Internal Audit planning Appointing the internal auditor- appropriate audit team Identifying/developing the internal audit tool - clinical tool Agreeing individual internal audit plan –clinical managers 2. Preparing for internal audit 3. Conducting an internal audit 4. Reporting and Monitoring

30 4 sections 1.Quality Systems Evaluation 2.Clinical Process Evaluation 3.Clinical Data Review 4.Patient Record Review Internal Audit Tool for Clinical Areas

31 Internal Audit Tool for Clinical 4 sections 1.Quality Systems Evaluation 2.Clinical Process Evaluation 3.Clinical Data Review 4.Patient Record Review Internal Audit Criterion Evidence Required Individual scope of practice is periodically reviewed and defined The scope of practice of individual staff in ED/UCC is documented and there is evidence of regular review Risk identification and assessment occurs regularly The ED/UCC undertakes the identification and analysis of risks (including clinical)

32 Internal Audit Tool for Clinical 4 sections 1.Quality Systems Evaluation 2.Clinical Process Evaluation 3.Clinical Data Review 4.Patient Record Review Internal Audit Criterion Evidence Required Document/s support the prioritisation of patients in a timely manner There is a current policy/procedure for patient triage which addresses the requirements for:  A uniform approach to undertaking the assessment of triage category  How to document triage category  Triage competency requirements for staff  Orientation to triage for all new staff

33 Internal Audit Tool for Clinical 4 sections 1.Quality Systems Evaluation 2.Clinical Process Evaluation 3.Clinical Data Review 4.Patient Record Review Internal Audit Criterion Evidence Required Presentations/de mand data is collected and analysed in the ED/UCC Total presentations Presentation by date of week and hour of day Presentation by ambulance or self Unplanned re- attendances are monitored and analysed Percentage of ED patients who have unplanned re attendances within 48 hours

34 Internal Audit Tool for Clinical 4 sections 1.Quality Systems Evaluation 2.Clinical Process Evaluation 3.Clinical Data Review 4.Patient Record Review General criteria for all patients Specific criteria for high risk subpopulations e.g. for ED/UCC: Altered conscious state Acute coronary syndrome Abdominal pain Suicidal /self harm General Clinical Processes Criterion Frequency of monitoring occurred at reasonable time intervals (as appropriate to patient condition or as specified in ED/UCC protocol)? Record of Medication prescribed in discharge plan

35 Developing a three year risk based program of internal audit Developing annual internal audit work plan 1. Internal Audit planning Appointing the internal auditor Identifying/developing the internal audit tool Finalising individual internal audit plan 2. Preparing for internal audit Preliminary meetings Fieldwork Progress and End of Audit meetings 3. Conducting an internal audit 4. Reporting and Monitoring

36 Developing a three year risk based program of internal audit- strategic clinical risks identified and prioritised Developing annual internal audit work plan - clinical expertise into clinical areas requiring internal audit 1. Internal Audit planning Appointing the internal auditor- appropriate clinical expertise in audit team Identifying/developing the internal audit tool - clinical tool Finalising individual internal audit plan –clinical managers 2. Preparing for internal audit Preliminary meetings – with clinical managers Fieldwork -in unit with clinical staff Progress and End of Audit meetings – with clinical managers 3. Conducting an internal audit 4. Reporting and Monitoring

37 Developing a three year risk based program of internal audit Developing annual internal audit work plan 1. Internal Audit planning Appointing the internal auditor Identifying/developing the internal audit tool Finalising individual internal audit plan 2. Preparing for internal audit Preliminary meetings Fieldwork Progress and End of Audit meetings 3. Conducting an internal audit Draft report for management response Final report to board via audit committee Monitoring Implementation of recommendations 4. Reporting and Monitoring

38 Developing a three year risk based program of internal audit-strategic clinical risks identified and prioritised Developing annual internal audit work plan - clinical expertise into clinical areas requiring internal audit 1. Internal Audit planning Appointing the internal auditor- appropriate clinical expertise in audit team Identifying/developing the internal audit tool - clinical tool Finalising individual internal audit plan –clinical managers 2. Preparing for internal audit Preliminary meetings – with clinical managers Fieldwork -in unit with clinical staff Progress and End of Audit meetings – with clinical managers 3. Conducting an internal audit Draft report for management response- clinical managers Final report to board via audit committee Monitoring Implementation of recommendations- role of quality committee 4. Reporting and Monitoring

39 From INCITE Information, 2012

40 Stage 3: Testing the Guidelines Findings of the EGHS Trial Audit of Urgent Care Centre Belinda Mitchell, Risk Consultant, VMIA Mario Santilli, EGHS

41

42 Findings of rating of controls 4 unsatisfactory level of controls 5 improvement opportunities Of the 4 unsatisfactory controls 3 high priority 1 medium priority

43 Quote from EGHS Board President relating to the value of the Clinical internal Audit. “As the President of the Board at EGHS the Clinical Internal Audit conducted on our Urgent Care Centre has provided a greater level of assurance with regards to clinical governance responsibilities and importantly provided valuable information with regard to risk exposure. I am now provided with assurance that risk is being managed and that further risk treatments will be implemented.” (Louise Staley EGHS Board President)

44 Stage 4 : Future Pilot Belinda Mitchell, Risk Consultant, VMIA Mario Santilli, EGHS Alison Brown, ACHG

45

46 Costs EGHS experience that costs were approximately $9,000 to conduct the audit and produce the audit report. The project team will provide support to the health service and provide consultation to the auditors to assist with scope, audit team requirements and report writing

47 1.What do you see as the barriers to implementing internal audit of clinical areas in your organisation? 2.Is any further information/support needed to discuss, at board/senior executive level, expanding the scope of internal audit to clinical areas? 3.Expressions of interest in a further pilot in emergency/urgent care centres?

48 For further information about the project please contact Mario Santilli, Director Development and Improvement, East Grampians Health Service Belinda Mitchell Risk Management Consultant, VMIA


Download ppt "Assurance or Reassurance? The Internal Audit of Clinical Areas Forum 19 November 2013."

Similar presentations


Ads by Google