leveraging available resources for clinical auditing in a new tertiary hospital -catherine li -...
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Leveraging Resources for Clinical Auditing
Catherine Li
Performance Review and Audit Coordinator, Fiona Stanley Hospital, WA
About Fiona Stanley Hospital
• Brand new tertiary hospital with 783 beds
• Fully commissioned in February 2015
• Four main clinical service streams with over 40 medical specialties
• Over 5700 staff counting by head
My Journey in Driving Clinical Audits…
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GEKO submission
Edu & training
What’s being audited?
• Compliance with NSQHS Standards
• Concerns arising from clinical practice
• Participation in international prevalence survey
• Testing changes in processes/system
• Patient / consumer satisfaction survey
• Staff knowledge survey
A Couple of Milestones
• FSH Audit Presentation Afternoon: 10 presentations by medical and nursing staff, show case improvement activities
• FSH Diabetes Management Review Audit: one day point prevalence survey across the whole hospital for adult in patients:
18 volunteer auditors participated
21 wards audited
Data collection completed in 4 hours
Electronic quality system
• Introducing Governance, Evidence, Knowledge and Outcome (GEKO) system across the organisation
Systematic way to manage quality initiatives
Make quality improvement accessible to everyone
Facilitate communication
Identify accountabilities & responsibilities
Tracking performance & outcome
Processes
• Standardisation
• Remove common barriers
• Combination of bottom-up & top-down approach
• Integrate measurement framework with hospital governance framework
Relationships / Engagement
• Education and training: formal, informal
• Standard committee agenda item
• Feedback strategies
• Monthly open forum: Use of GEKO
Quality improvement principles
Clinical audit methodologies
New ideas
Supporting resources
• Available and accessible on hospital intranet
Hospital clinical audit improvement procedure
Governance processes
Guides for using the GEKO system
Guides for defining objectives/measures
Checklist for submissions and approvals
Resources to differentiate quality activities from research projects
Commonly used audit tools
Partnership
• Collaboration with education departments
• Clinical audit program with universities
• Resources from Department of Heath programs
Get to know the departments, know the people, and know their needs!
All in one 3-E Model
3-E model for QI
The model acknowledges the learning curve that staff need to go through and the evolving process required to embed the QI principles.
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