How to complete Audits and on-line entry Residential and Community

What is auditing about? When we audit something, we are checking a process or a system against a pre-determined criteria. For example for an audit about fire systems and processes, we might be checking what our policy and the law says we should do (pre-determined criteria) about having an evacuation plan, then we audit our own area or service by checking to see what we actually say and do regarding our evacuation plan.

Audits at IRT As well as the Moving ON Audits Program, IRT has some audits that it does internally. Down the track these may be incorporated into the MOA program. IRT believes compliance to laws and regulations are the minimum acceptable standard-we try and exceed this standard wherever possible. Audits assist us to find ways to improve what we do, but are only one part of our Quality System.

There is no grey in auditing In auditing, it is usually Yes or No. There are no boxes for: –Almost there –¾ of the time –Nearly –Maybe If we say we have a process for doing something, we are really saying it happens the same way, all the time. Therefore when we find it is not happening the same way, all the time, we have some deficits in our system, and opportunities for improvement.

Why is this so important? The way we provide services to our customers, both within and outside our service should be of a consistently high standard. Then our customers know: –What to expect –When to expect it –And most importantly, have trust that we will do it, no matter who is working at that time, or on that day. We are in a “people business” so it is hard to get things right every time, but that should not be an excuse for not trying!

Tips for good auditing 1.Never assume! We don’t wish that something was happening the way it should when we audit a process or a system, we need to check that it is. This might mean: Checking the IRT intranet to find a particular Policy, Procedure, Form or Plan. Checking individual resident or client documentation. Asking our colleagues within and outside our own service Asking the people we work with how they do certain tasks. Observing they way things are done in our service Checking the information we provide to staff, residents, clients, relatives and others.

Tips for auditing 2.Knowledge should be shared The more we learn about each other’s jobs and roles, the more we understand how important it is to work together, and we also keep our minds active and learning-which is important at any age. New people to IRT ask questions about things that we take for granted. They might find something that needs correcting that we had missed or assumed was working. The same goes for someone auditing an unfamiliar area. This is a great test of our systems and processes and can’t be taken for granted!

Tips for auditing 3.Read, read and read the explanations Audits in the MOA program have explanation sheets that provide information on: –The purpose of the audit –Links to relevant outcomes and standards where applicable –Guidance on answering the questions (that is, if you say Yes, you need to ensure x, y and z are in place) –Resources for further information which can be used for education sessions etc You need to read audit explanations if you are co-ordinating that particular audit, and it might be a good idea to go over relevant sections with those who may be assisting you by completing Part B!

Tips for auditing 4.Be honest Use the audits as an opportunity to identify improvements, not as a tick and flick exercise. If the answer is No-it might not be an issue. With MOA Audits, some questions are written to promote best practice, rather than something that is mandatory. Some questions may not be applicable for a particular service. If an NA is available, this is usually an indication that the question is either best practice or is something that is not mandatory in all services within the program.

MOA Audit Format MOA audits have 2-3 sections as follows: PART A Is completed once and is generally done by the Service Manager or Coordinator. This section is auditing the system, that is what we say we are doing. Examples are: –Evidence of policy, procedure or protocol that covers re audit topic. –Evidence such as a plan or a formal program. –An example of a Part A is on the next page. Note: Some audits have a PART A only. This will be indicated in the coversheet information.

MOA Audit Format Your service’s member number Sheet Number-to assist with data entry Tick the appropriate box on your printed sheet The audit gives you hints on where to find the information

MOA Audit Format PART B This section samples, or tests our system and processes about what we are actually doing. This section can be completed by a range of staff depending on the audit. Involves a sample of at least 10%, based on the number of residents or clients you have. You do not have to calculate 10% each time, the number of sheets you need to provide is already worked out. If your service is less than 50 beds/packages, you will complete 5 sheets for Part B. Less than this is not a valid response for reporting requirements.

Sampling Check out the section on how to randomly sample in the MOA Continuous Quality Improvement Guide, located on the IRT intranet under MOA Resources.

MOA Audit Format Part B may involve: –Checking a process in a resident/clients file –Observing staff practice –Asking residents their opinion about a service we provide –Asking staff about their knowledge and/or opinion of a particular process –Checking the environment of a particular area. HINT: You will need to write the initials or other reference on these sheets of those files audited/people observed/surveyed so that you know where to follow up if there are any issues. You can also ADD sheets if you want to increase your sample size.

MOA Audit Format Again, you are provided with guidance on completing this section.

MOA Audit Format Some audits (usually 2-3 in the year) have a Part C. This might be for a particular area that needs extra attention, such as Infection Control. In such an example: Part A-what we say we do-usually what is written or formal Part B-what we do-staff practices- how we do it Part C-evidence of how we can see we do it (environment)

Who completes audits It is recommended that the service team look at the calendar of audits for the year and work out: Individual staff areas of knowledge, expertise and responsibility. Areas where staff may wish to increase or test their knowledge. Training/learning opportunities for staff identified by their Manager. And don’t forget the value of new staff!

Timeframe for completion of Audits Audits and indicators for each month need to be completed and entered into the system before the 15 th of the following month. Failure to do so means that your data will not be included for the IRT, state-wide and national benchmarking reports that are completed by MOA. Your service manager will also be asked to explain why this has occurred, as compliance to completing data entry is monitored closely by the Chief Operating Officer. Be Prepared and don’t leave it too late!

Before entering the data on-line Has the relevant Manager or designated person reviewed the results of the completed sheets and made any conclusions? Don’t just wait for the report and your benchmark-look at what is happening inside your own service! Are the sheets fully completed-any missed questions? If yes, then get the answers quickly! IT IS NOT THE RESPONSIBILITY OF ADMINISTRATIVE STAFF TO INTERPRET RESPONSES. ANY UNCLEAR RESPONSES OR INCOMPLETE INDICATOR REPORTS ARE TO BE RE-DIRECTED TO THE MANAGER OR THEIR DELEGATE (Snr Care Coordinator / RN, etc).

“Wrong” responses Sometimes staff answer “no” and the answer is actually “yes”. What does this tell you? Do you need to look at: –Their interpretation of the question-did they read the explanation sheet. –Their knowledge in the subject-did they go out and seek information to validate their response (most relevant for Part A) –Is this an indication that more training or education may be required. The point is, it is okay, as long as your service management team explains how they have acted on this issue in your monthly analysis.

On-line entry of audits 1.Log on with your logon name and password provided by MOA and go to the MOA website via the IRT intranet and go to My MOA. 2.Go to the relevant service that you wish to enter the audit data for-make sure that the member number on the screen corresponds with the one on your data sheets if you enter for more than one service or unit. 3.Go to Data Entry (under Audit Program) 4.Select the relevant month’s package 5.Go to the Data Entry section at the top of the page

MOA on-line audit data entry Select the audit that you want. This column shows you % completed. You can save the data entered and come back to it later if you need to-this must be 100% before you sign off the package,.

MOA on-line audit data entry The program tells you how many sheets you need to complete. Clicking on All Parts lets you complete all sheets on the one screen and saves time

MOA on-line audit data entry Click the yes or no button for each response. Go through check when you have finished that what you have selected matches your completed sheets. Click on the question mark to get the explanation of the question Comments about the questions themselves can be made by clicking on the star at the end of each question. This feedback goes straight to MOA and is used to improve the audit for the following year.

MOA on-line audit data entry Remember to click on save! It will take you back to the beginning of the package

MOA on-line audit data entry Once you have completed data entry for all of the audits, AND the quality indicators you need to “sign-off” the package. This tells the program that your data is ready to generate reports, and no more data till be entered. If you “sign-off” accidentally and have not completed entering all of the information, or you want to change it, contact MOA to unlock the package-before the 15 th of the month!

Signing off the package

Problems with entering your data? Contact Kim Hancock on: – –Phone: MOA during business hours on: – –Phone: