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Assurance or Reassurance? The Internal Audit of Clinical Areas Forum

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

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

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

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

4 Background: Health Services have a strong focus on external audit (Auditor General representation) and internal audit however the focus is on key risks, financial and compliance issues The gap identified is the lack of clinical audit included in this framework Currently the audit program for health services is led by accountants who are taught auditing and is fragmented and requires pulling together into one framework

5 Minister of Finance Standing Directions 2
Minister of Finance Standing Directions 2.5, Internal Audit a direction is given that: “Each Public Sector Agency must, unless exemption has been obtained, establish and maintain an adequately resourced independent internal audit function appropriate to the needs of the Public Sector Agency.” Standing Directions of the Minister for Finance under the Financial Management Act 1994, P 29 Department of Treasury and Finance updated 2010

6 Currently EGHS has an internal audit program, like most public health services, that focuses on key financial compliance requirements and occasionally other operational activities (i.e. not primarily associated with core financial functions such as budgeting, payroll, accounts, purchasing and financial accounting) that provide exposure to high risk to the organisation.

7 EGHS believes that high risk clinical functions be exposed to the same discipline of internal audit to enable assessment of adherence, compliance and outcomes with standards for those identified high risk clinical areas.

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

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 Clinical Internal Audit Framework
VHA & VMIA November 2013

13 Board needs not met by current risk management & assurance arrangements
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

14 An enhanced internal audit cycle
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

16 Governance arrangements

17 Internal Audit of Clinical Areas (3 yr flow)

18 Internal Audit of Clinical Areas (annual flow)

19 Website: www.inciteinformation.com.au
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 based Selection 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 board Recipient of audit findings is often internal committees or other interested internal parties e.g. unit manager

22 Board/ Audit Committee Internal Sources of Assurance
1st line of defence 3rd 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 Audit Regulators External Assurance

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

24 1. Internal Audit planning
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 In Clinical Areas 1. Internal Audit planning
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

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

31 Internal Audit Criterion
Internal Audit Tool for Clinical 4 sections Quality Systems Evaluation Clinical Process Evaluation Clinical Data Review 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 Criterion
Internal Audit Tool for Clinical 4 sections Quality Systems Evaluation Clinical Process Evaluation Clinical Data Review 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 Quality Systems Evaluation Clinical Process Evaluation Clinical Data Review Patient Record Review Internal Audit Criterion Evidence Required Presentations/demand 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 General Clinical Processes Criterion
Internal Audit Tool for Clinical 4 sections Quality Systems Evaluation Clinical Process Evaluation Clinical Data Review 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 1. Internal Audit planning
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 1. Internal Audit planning
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 1. Internal Audit planning
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 1. Internal Audit planning
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 Belinda Mitchell, Risk Consultant, VMIA Mario Santilli, EGHS
Stage 3: Testing the Guidelines Findings of the EGHS Trial Audit of Urgent Care Centre Belinda Mitchell, Risk Consultant, VMIA Mario Santilli, EGHS

41 EGHS had been accredited only 12 days prior to the trial internal audit of the UCC.
Why review UCC Project design to address high risk high claims areas In line with VMIA reduce total cost of risk EGHS high risk clinical area of concern

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 Broad pilot to test the framework, guideline and tool
Seeking health services to participate in the pilot and conduct a clinical internal audit of their ED or UCC. What will we get out of it - the health service will get a clinical internal audit report the project will get information from the participating health services that will help refine the framework, guidelines, tools and the implementation process.

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 What do you see as the barriers to implementing internal audit of clinical areas in your organisation? Is any further information/support needed to discuss, at board/senior executive level, expanding the scope of internal audit to clinical areas? 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


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