assurance or reassurance? the internal audit of clinical areas forum 19 november 2013
TRANSCRIPT
Assurance or Reassurance?The Internal Audit of Clinical Areas Forum
19 November 2013
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
Project Overview
Nick Bush, CEO
East Grampians Health Service
Mario Santilli,
Director Development and Improvement
East Grampians Health Service
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
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
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.
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.
• Underpinning – based on the International
Standards for the Professional Practice of Internal
Auditing.
(Institute of Internal Auditors)
A Risk Management Partnership Project with VMIA
Key Principles
• Risk Based
• Proactive
• Independent
• High Level of Governance and Assurance
• Qualified Auditing Practitioners
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
Stage 2: Clinical Internal Audit Framework
Paul Robertson and Wendy Malkiewicz
INCITE information
VHA & VMIA
November 2013
Clinical Internal Audit Framework
• 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
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
Vertical & horizontal integration
15
Governance arrangements
16
Internal Audit of Clinical Areas (3 yr flow)
17
Internal Audit of Clinical Areas (annual flow)
18
Paul Robertson
0432 685 204
Wendy Malkiewicz
0409 851 025
Website: www.inciteinformation.com.au
Stage 3: Guidelines for the Internal Audit of Clinical Areas
Alison BrownConsultant
Australian Centre for Healthcare Governance
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
Ex
terna
l Au
dit
Re
gu
lato
rs
1st line of defence
3rd line of defence
2nd line of defence
Management Controls
including:Risk
ManagementCompliance
AuditQuality
Improvement
Internal Audit
Senior Management
Board/ Audit Committee
Internal Sources of AssuranceExternal
Assurance
1. Internal Audit planning
2. Preparing for an internal audit
3. Conducting an internal audit
4. Reporting and Monitoring
• 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
• 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
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).
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
• 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
• 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
4 sections
1. Quality Systems Evaluation
2. Clinical Process Evaluation
3. Clinical Data Review
4. Patient Record Review
Internal Audit Tool for Clinical Areas
Internal Audit Tool for Clinical
4 sections
1. Quality Systems Evaluation
2. Clinical Process Evaluation
3. Clinical Data Review
4. Patient Record ReviewInternal Audit
CriterionEvidence 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)
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 categoryHow to document triage categoryTriage competency requirements for staffOrientation to triage for all new staff
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/demand data is collected and analysed in the ED/UCC
Total presentationsPresentation by date of week and hour of dayPresentation by ambulance or self
Unplanned re-attendances are monitored and analysed
Percentage of ED patients who have unplanned re attendances within 48 hours
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
• Developing a three year risk based program of internal audit
• Developing annual internal audit work plan1. 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
• 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
• Developing a three year risk based program of internal audit
• Developing annual internal audit work plan1. 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
• 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
From INCITE Information, 2012
Stage 3: Testing the Guidelines
Findings of the EGHS Trial Audit of Urgent Care Centre
Belinda Mitchell, Risk Consultant, VMIA
Mario Santilli, EGHS
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
Findings of rating of controls
• 4 unsatisfactory level of controls
• 5 improvement opportunities
Of the 4 unsatisfactory controls
• 3 high priority
• 1 medium priority
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)
Stage 4 : Future Pilot
Belinda Mitchell, Risk Consultant, VMIA
Mario Santilli, EGHS
Alison Brown, ACHG
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.
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
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?
For further information about the project please contact
Mario Santilli,
Director Development and Improvement, East Grampians Health Service
Email: [email protected]
Belinda Mitchell
Risk Management Consultant, VMIA
Email: [email protected]