Certified Internal Auditor-NABH AHPI Certification Centre

AHPI Certification Centre Terms and definitions Audit/ Assessment: Systematic, independent and documented process for obtaining evidence and evaluating it objectively to determine the extent to which assessment criteria are fulfilled. Assessment Criteria: Set of policies, procedures or requirements. Assessment Findings: Results of the evaluation of the collected assessment evidence against assessment criteria. Assessment Plan: Description of the activities and arrangements for an assessment. AHPI Certification Centre

AHPI Certification Centre Assessment Scope: Extent and boundaries of an assessment. Auditor/Assessee: Organization being assessed Assessor: Person with the demonstrated competence and authority to conduct an assessment. Capability: Ability of an organization, system or process to realize a product that will fulfill the requirements for that product. Competence: Demonstrated personal attributes and demonstrated ability to apply knowledge and skills. AHPI Certification Centre

AHPI Certification Centre Continual Improvement: Recurring activity to increase the ability to fulfill requirements. Correction: Action to eliminate a detected non-conformity. Corrective action: Action to prevent re-occurance of a detected non-conformity or other undesirable situation. Customer: Organization or person that receives a product/ service. Customer satisfaction: Customer’s perception of the degree to which the customer’s requirements have been fulfilled AHPI Certification Centre

AHPI Certification Centre Effectiveness: Extent to which planned activities are realized and planned results achieved. Efficiency: Relationship between the result achieved and the resources used. Non-conformity: Non-fulfillment of a requirement. Preventive action: Action to eliminate the cause of a potential non-conformity or other undesirable potential situation. AHPI Certification Centre

AHPI Certification Centre Healthcare quality Good quality means providing patients with appropriate services in a technically competent manner, with good communication, shared decision making, with cultural sensitivity and with greatest efficiency. AHPI Certification Centre

AHPI Certification Centre Regulation An instrument mandated by the government to impose set of condition, which a healthcare organization must comply with, before and after it is permitted to operate in the country. It is based on the minimum standards, inspection, enforcement and public accountability. AHPI Certification Centre

AHPI Certification Centre Accreditation Public recognition of the achievement of accreditation standards by a healthcare organization, demonstrated through an independent external assessment of that organization’s level of performance in relation to the standard. AHPI Certification Centre

Basic Quality concepts Quality can be defined in the following ways: Based on customer’s perceptions of a product/services design and how wee the design matches the original specifications. The ability of a product/service to satisfy stated or implied needs. Achieved by conforming to established requirements within an organization. According to ISO 9000, Quality is defined as “The set of inherent characteristics that fulfills the requirements. Requirements are need which can be stated, implied, legal or obligatory. AHPI Certification Centre

AHPI Certification Centre Quality Evolution Up to 1950: INSPECTION 1950- 1965: QUALITY ASSURANCE (QA) 1965- 1980: TOTAL QUALITY CONTROL 1980 & beyond: TOTAL QUALITY MANEGEMENT AHPI Certification Centre

Quality Evolution (Four Levels) Total Quality Management .Continuous Improvement . Customer Orientation . Empowered Employees Total Quality Control . Corrective and Preventive Actions . Company wide QA . Extensive use of QE Tools Quality Assurance . Corrective Actions . Statistical Process Control . Process compliance using 4-M Inspection . Corrections . Grading, salvage . Post Production Exercise AHPI Certification Centre

AHPI Certification Centre About TQM We are engaged in an on going journey of continuous, measurable improvement championed by empowered individuals at all levels of the organization. Our leadership philosophy inspires teamwork, and a sincere trust & belief in people which results in an enjoyable and productive workplace, dedicated to the highest possible level of customer satisfaction. AHPI Certification Centre

Constituents of TQM Constituents of TQM Total Customer Delight QUALITY SYSTEM Total Customer Delight Leadership & Management Commitment Teamwork & Employee Involvement Continuous Improvement Tools & Techniques for AHPI Certification Centre

AHPI Certification Centre Audit Process Systematic , Independent and documented process for obtaining audit evidence and evaluating it objectively to determine the extent of which audit criteria are fulfilled. Note : Audit Criteria set of policies / procedures or Requirement . Audit Evidence: Statement of facts or information which are relevant to the audit criteria and verifiable. AHPI Certification Centre

AHPI Certification Centre Type of Audit INTERNAL AUDITS EXTERNAL AUDITS Internal Audits : Termed as first party audits . Conducted by or on behalf of the organization on its own system. It provides objective data to plan improvements. It is done for internal purposes AHPI Certification Centre

AHPI Certification Centre External Audits: Termed as Second party audit Third party audit Second Party Audits are performed by the client or its representative. Third Party Audits are performed by external and independent auditing agencies, generally against national or international standards. AHPI Certification Centre

Principles of Auditing Audits are an effective management tool to examine activities and processes. The result of an audit is information on which management can act; Objectivity, independence and systematic approach are core principles, which are essential for conducting effective and efficient audits; Audits are authorized, and authority may result from the decision of management, company policy, provisions of contract, the audit client, legislation or regulation; AHPI Certification Centre

Principles of Auditing Audit programs and audits are planned and managed to ensure that they are conducted in an effective and consistent manner and that the audit conclusions are credible; Audit should ensure that all elements that are being practiced and all the personnel are covered in each cycle of an Audit ; Audits are conducted using established methods and techniques to ensure that audit evidence and audit findings are relevant, reliable and sufficient, such that audit teams working independently from one another will reach similar audit conclusions; AHPI Certification Centre

Principles of Auditing The scope, objectives and audit criteria of each audit are clearly defined and agreed prior to commencing the audit; Audit team members and audit program managers are competent for the tasks they perform; Audit team members act with due professional care and adhere to a code of ethics which prescribes for example, auditor behavior, integrity, confidentiality and other attributes. Audit team members are free from bias and conflict of interest throughout their activities; AHPI Certification Centre

AHPI Certification Centre WHY- INTERNAL AUDITS A requirement of accreditation criteria of NABH standards Management wants to discover any weakness in the hospital’s systems before these are detected by external assessors, e.g. from NABH Internal audits are a powerful management tool to aid quality improvement Internal audits verify the effectiveness of corrective actions AHPI Certification Centre

Role of Accreditation Coordinator Planning of Audit Overseeing Audit Conduct Maintain Records of Audit Follow-up and close Appraise Management AHPI Certification Centre

AHPI Certification Centre AUDIT CYCLE The audit comprise the following four phases: Planning and preparation Conduct of audit Recording and reporting the audit findings Follow up and confirmation of corrective action The audit is considered to be complete only when corrective actions have been taken & auditor has verified. AHPI Certification Centre

AHPI Certification Centre AUDIT PLANNING List the activity you plan to audit Determine the period you need to complete the audit Ensure that each activity is covered. Take the help of check list Arrive at the total duration needed to complete the audit AHPI Certification Centre

AHPI Certification Centre AUDIT PLANNING Identifying the persons to be used for auditing Ensure their availability and properly coordinate with individual(s) of the section to be audited Decide to what extent sampling is to be done. Discuss it with individuals or hospital staff to be used for audit If negative findings are there, more sampling to be drawn to establish the fact that these are isolated cases or otherwise AHPI Certification Centre

AHPI Certification Centre Audit Checklist Checklist is a important tool for audit. Auditors need to be trained in usage of checklist by using good questioning technique. Checklist shall not be generic in nature. It shall be prepared using all applicable standards. There shall be no duplication and repetition, as it will slowdown the audit process AHPI Certification Centre

Advantage of usage of checklist It ensures that audit is conducted in a systematic and comprehensive manner . It provides structure and continuity to the audit. It ensure a consistent audit approach Act as a sampling plan and time manager Serve as a memory aid to ensure that the audit scope is followed and all the required standards are audited. It helps is gathering objective evidence and important information. AHPI Certification Centre

Sampling during Audit Process Data based on full populations gives the best indication of standard implementation but it is not possible due to constraint of resources and time . Sample audit can be a reasonable indicator, for full population. It is however important to control; Size of the sample Methodology to select the sample AHPI Certification Centre

AHPI Certification Centre Judgmental Sampling Judgmental sampling is a selection process where the auditor decides which services and areas shall be audited. It is not scientific and can render inconsistent and unreliable because it depends on auditors experience, knowledge and perception. AHPI Certification Centre

AHPI Certification Centre Statistical Sampling Types of sampling methods : SIMPLE RANDOM SAMPLING SYSTEMATIC SAMPLING STRATIFIED SAMPLING AHPI Certification Centre

AHPI Certification Centre AUDIT CONDUCT PROCESS Pre-audit team briefing Opening meeting On Site audit Final team meeting Closing meeting AHPI Certification Centre

Basic Approach to Audit conduct Vertical Audit Audit in depth of a particular function or department against all relevant requirements of the standard and organizational procedures. Internal Audit is generally the Vertical Audit Horizontal Audit Horizontal audit is done against one particular requirement of standard across the entire organization. AHPI Certification Centre

Vertical Audit Examples Area Accreditation Coordinator Functions Surgery Dept. Medicine OPD Procedure - I.A. -CQI (Quality assurance prog.) Hospital infection control (HIC) Human resource Management *Information management system AHPI Certification Centre

Horizontal Audit Examples Area Accreditation Coordinator Functions Surgery Dept. Kitchen Procedure - I.A. -CQI -COP Hospital infection control (HIC) *Care of patient *Human resource management *Information management system AHPI Certification Centre

AHPI Certification Centre Audit Methodology Tracer Individual System Document Review – Polices and procedures , Manuals etc. Closed Medical Record Review Human Resource Record Review Interview Process Staff Patient Senior leaders and Management AHPI Certification Centre

AHPI Certification Centre Tracer Methodology Tracer methodology is used in the healthcare set up to observe patients continuum of care , review systems of care and in talking to staff and patients about the care provided. During this process auditors are looking for how well healthcare providers deliver patient care. AHPI Certification Centre

Tracer Methodology Contd… Tracers can be conducted for Individual patient and systems and to determine how well a hospital has implemented its policies and procedures . It also assesses the compliance with the standard , legal requirements and regulations. AHPI Certification Centre

Individual Patient Tracers Auditors select active patients and trace their care through department or services of the hospital. Patients are selected usually using following criteria; Active Patients Patients with main specialties of the hospital Patients who have received multiple or complex services Patients related to system tracers, like infection , medication management etc. Number of samples depend on the size , complexity of the hospital and length of the audits. AHPI Certification Centre

Individual Patient Tracers Contd… Follows the patient from admission to discharge Follows the course of treatment and services provided to the patients. Assess the relationship, integration and coordination of distinct and related process, departments, services or units. Identify potential concerns in the related process AHPI Certification Centre

Individual Patient Tracers Contd… Tracers usually start from the point where the patient first entered the hospital systems . Review the record with the staff responsible for patient care Observation of direct patient care , medication process , infection control , care planning , Pain management etc. Observation of impact of the environment safety and role of staff in minimizing those environmental risks – example fall management AHPI Certification Centre

Individual Patient Tracers Contd… Observation of maintenance of medical equipment Review of the qualified personnel who is responsible for maintenance of the equipments . Interview the patient , family Review ancillary care areas like if the patient has received blood, visit blood bank. In case of nutritional issues interview the dietician. AHPI Certification Centre

Individual Patient Tracers Contd… Auditors may review few additional records to verify issues that have been identified during audit . Following criteria can be used in selecting additional records. Same diagnosis Same diagnosis but different physician. Same age / sex Patient going to be discharged AHPI Certification Centre

Individual Patient Tracers Contd… Interview with staff to get their views about; Flow of a process across the hospital , including identification of risk points , integration of key activities and communication among the staff / units involved in process. Strength and weakness in the process. Review/Revision of procedures if required. Identified issues can be verified during system tracers. AHPI Certification Centre

AHPI Certification Centre System Tracers System tracers explore process, sub processes and potential risk points . System tracers allow staff members and administrators to see how well a unit , department or facility is doing. Effective means for process improvement System tracers help to audit the process from start to end. Example : In medication process from medication procurement through monitoring the effects of medication. Participation of all the staff in the process AHPI Certification Centre

AHPI Certification Centre System Tracers Contd… System Tracers have three parts; Focused Tracers : visit areas relevant to the process Conference with the group of staff involved in the process. It may include policy review, evaluation criteria for the process and action taken to improve the process etc. Review of data i.e. “data related to medication error , ADR etc.” AHPI Certification Centre

AHPI Certification Centre System Tracers Example In medication Management tracers : Medication selection, procurement storage Order Entry, Transcription Preparation, Dispensing Reporting of errors / system breakdown / near misses Data Collection, Analysis, Performance Improvement Education for patient and staff Information Management Patient involvement AHPI Certification Centre

System Tracers – Facility Tour Physical facility Medical and Other equipment Patient visitors, staff safety and security Infection Prevention and Control Emergency Preparedness Hazardous material and waste Staff education and Training AHPI Certification Centre

Facility Tour- Documents Facility Management Plan Utility Back up Plan in case of failures or disruptions Risk Management Plan Emergency Management Plan Fire Safety Plan Safety and Security Plan Medical Equipment Management Plan AHPI Certification Centre

Facility Tour- Documents contd… Hazardous Material Plan Facility Audit Reports Safety Committee meeting Minutes Licenses, Documents complying with national/state Laws and Regulations Review of Inspection, Testing reports Third party audit reports and action taken reports. Approved Building Plan AHPI Certification Centre

AHPI Certification Centre Document Review Documents describe how the hospital systems comply with the required standards Some standards require written documented system. Document review orients the auditors to the structure of hospital and management. It provides an overview to the auditors what they shall expect to see in the actual practice during audit. AHPI Certification Centre

Closed Patient Medical Record Review It is done to assess the compliance with standards about what needs to be documented in the patients record . Usually 5 to 10 closed records are reviewed of the period as required by the audit. Audit shall be done as per the documented procedure. It includes the Interview of Medical Record staff and other staff as appropriate to validate the process. AHPI Certification Centre

Human Resource Records Human resource records are reviewed to ensure the implementation of required polices and procedures. It involves systematic review of all aspects of Human resource i.e. Verification process at the time of hiring, Orientation, Compensation, Performance Evaluation , Termination and exit , Job Descriptions, Training and education etc. It includes review of implementation of National and Local laws and Regulations. During this audit records are selected from all the categories of the staff. Auditors shall specify the time periods of the records required for the audit. AHPI Certification Centre

AHPI Certification Centre Patient Interview Review the patient medical chart to gather information about the patient illness , cultural and social background which will help in interview process. Introduce yourself and explain the interview process Normalize patient anxiety, Respect privacy Keep the conversation simple so patient can understand AHPI Certification Centre

AHPI Certification Centre Staff Interview Staff Interview is conducted to check the awareness of the staff about policies and procedures and to ensure the effective implementation of the processes Staff are interviewed during the patient in system tracers Choose the Staff from all the category to ensure the proper sampling while checking the awareness. During staff interview record the identity of the person interviewed End the interview by at least repeating the main point understood during the interview to avoid any conflict later. AHPI Certification Centre

Senior Leaders Interview Gather all information about governance and organization before starting the interview process . Prepare the checklist to keep the interview structured and able to gather the information required as per the audit standard Keep the communication clear . Ask open ended questions to gather more information. Keep the interview process controlled to ensure all the questions are asked during the interview. Ask the questions only related to leadership activity. Everyone present ( all senior Leaders ) shall participate in answering the questions AHPI Certification Centre

Interviewing in Assessments AHPI Certification Centre

Interviewing in Assessments Assessment involves an extensive and intensive exercise of finding facts and not faults. Important that the assessee is placed at ease and thus fulfill the purpose of assessment. This can be done by interviewing the HCO personnel in which questioning and asking for records and other evidences are involved. National Accreditation Board for Hospitals and Health Care Providers

National Accreditation Board for Hospitals and Health Care Providers How to go about? Purpose of asking questions Should always explain the purpose before putting a question. Strengthens the bond of communication between the Assessor and the Assessee. National Accreditation Board for Hospitals and Health Care Providers

National Accreditation Board for Hospitals and Health Care Providers Type of questions Direct or Open Questions General Questions Sarcastic Questions Multiple/ Chain Questions Probing Questions Closed Questions National Accreditation Board for Hospitals and Health Care Providers

National Accreditation Board for Hospitals and Health Care Providers Open questions "I keep six honest serving men, they taught me all I knew, their names are What and Why and When and How and Where and Who." Rudyard Kipling National Accreditation Board for Hospitals and Health Care Providers

National Accreditation Board for Hospitals and Health Care Providers Open questions Will elicit more than just Yes or No answers Takes longer to answer such a question than it does to ask auditor also gets some thinking time! Can control the tone of discussions to their advantage with the use of these questions since the questions demand meaningful answers. National Accreditation Board for Hospitals and Health Care Providers

National Accreditation Board for Hospitals and Health Care Providers Different types Themed questions Expansive questions Opinion questions Investigative questions Repetitive questions Hypothetical questions National Accreditation Board for Hospitals and Health Care Providers

National Accreditation Board for Hospitals and Health Care Providers Closed questions Have a ‘yes’ or ‘no’ response Should only be used in audits where the Yes and No answer can quite definitely be given because of what has gone before. Should be used to verify that the assessor has clearly understood what has been explained. Have their place in an assessment but the assessor must not rely on them. Let the assessee do the talking!! National Accreditation Board for Hospitals and Health Care Providers

When to Use ‘Open’ and ‘Closed’ Questions? Use ‘open’ questions to search and probe for the unknown. New practices Changes to existing processes Failures (or indeed successes) Use ‘closed’ questions to check known or expected facts such as: A stage in a procedure being complete Compliance with a standard National Accreditation Board for Hospitals and Health Care Providers

Interviewing in practice… Plan the sequence of your interviews. remember that what you find during the course of one interview may affect who you interview next Analyse the procedures to make sure that you are going to assess relevant personnel. Don’t barge in and start questioning! Put your assessees at ease Use a checklist to structure each interview Plan the sequence of your interviews. Decide: Who do you need to see Where is the best place to interview them? (Where will records be available?) What will you want them to talk about? National Accreditation Board for Hospitals and Health Care Providers

Interviewing in practice… Never get distracted with how you think something should be done Take one input to a procedure or process and follow it through Reassure them that non-conformances are just problems to be corrected. Make a good first impression! National Accreditation Board for Hospitals and Health Care Providers

Interviewing in practice Your assessees may have (or feel that they have) little time to spare. Keep their attention with short questions. Don’t let them distract you by their wanting to leave. Keep it focused. National Accreditation Board for Hospitals and Health Care Providers

Personality Types: Remote Don’t match the assessee’s style by remaining remote, get close! Be prepared to follow them if necessary, but get them to agree to sit down with you. Remind them that they have agreed to your appointment. As a last resort, reschedule the audit. National Accreditation Board for Hospitals and Health Care Providers

Personality Types: Antagonistic Assessees can be very antagonistic, seeing the assessor as an unnecessary invasion of their time or a threat to their authority. Let them do the shouting! Don’t be tempted to match their mood. Bring them back to earth by staying calm and explaining your objectives, more than once if necessary. National Accreditation Board for Hospitals and Health Care Providers

Personality Types: Reserved Sometimes assessees will want you to do the talking. Make them feel at ease; start with general questions (possibly not wholly focused on the assessment) and slowly focus on the important issues. Use open questions to guide the assessee’s side of the conversation. National Accreditation Board for Hospitals and Health Care Providers

National Accreditation Board for Hospitals and Health Care Providers

National Accreditation Board for Hospitals and Health Care Providers Exercise 15 Two participants are to volunteer as assessor and two as assessee. One of the assessee should act as if he is defensive even though his area of work is well managed while the other assessee should act as if he is irritated because of missing promotion for two years. The two assessors are to manage the situation. National Accreditation Board for Hospitals and Health Care Providers

IDENTIFYING NON-CONFORMITIES Related to the quality system Related to technical activities Failure to do some thing required Difference between work practices and documented instructions AHPI Certification Centre

EXPRESSING NON-CONFORMITIES Non-blaming statements of fact Based on objective evidence Directly related to specific documented requirement AHPI Certification Centre

AHPI Certification Centre Objective evidence THE OBSERVATIONS AND STATEMENTS OF FACT AND THE INFORMATION CONTAINED IN RECORDS THAT CAN BE VERIFIED AHPI Certification Centre

AHPI Certification Centre Objective evidence Evidence which exists Uninfluenced by emotions or prejudices Can be stated Can be documented Is about quality Can be verified AHPI Certification Centre

AHPI Certification Centre Objective evidence Objective evidence IF IT IS NOT WRITTEN DOWN IT DID NOT HAPPEN IF YOU CAN’T EXPRESS THE PROBLEM IN THE WORDS OF THE PROCEDURE / STANDARD THEN THERE IS NO NON - CONFORMANCE AHPI Certification Centre

ASSESSMENT TECHNIQUES Recognize limitations of sampling Examine as many as practicable Sample randomly or selectively? Evenly over time or clustered? Continuously evaluate findings AHPI Certification Centre

ASSESSMENT TECHNIQUES Questions to ask……open questions Who How What When Where Why AHPI Certification Centre

ASSESSMENT TECHNIQUES Questions not to ask self-answering Compound trick questions AHPI Certification Centre

ASSESSMENT TECHNIQUES Remember the “Titanic Principle” “What you see is just the tip of the iceberg” AHPI Certification Centre

AHPI Certification Centre ASSESSOR ATTRIBUTES professional qualifications technical knowledge assessment experience administrative skills personal attributes AHPI Certification Centre

AHPI Certification Centre HUMAN ASPECTS be a good listener focus on speaker avoid physical, mental distractions reassure verbally, visually maintain appropriate eye contact project appropriate body language AHPI Certification Centre

AHPI Certification Centre HUMAN ASPECTS keep assessment flowing systematic sequence avoid back-tracking orderly flow of questions avoid long periods of silence plan your approach AHPI Certification Centre

AHPI Certification Centre HUMAN ASPECTS professional approach preparation personal presentation/dress project right image stay on track thorough and persistent AHPI Certification Centre

Applying Internal Audit as Tool in “Maximizing Value for Hospitals” AHPI Certification Centre

AHPI Certification Centre Accreditation Accreditation relies on establishing technical competence of healthcare organisation in terms of accreditation standards in delivering services with respect to its scope. It focuses on learning, self development, improved performance and reducing risk. Accreditation is based on optimum standards, professional accountability and encourages healthcare organisation to pursue continual excellence. AHPI Certification Centre

Accreditation also means putting systems in place Systems are defined What, Who, How Systems are implemented understood & owned by stake holders Systems are Established / Institutionalized Transparent Dynamic Objective AHPI Certification Centre

AHPI Certification Centre Accreditation Management Logistics Nursing / Technician Physician Patient Safety Surgeon Paramedical AHPI Certification Centre

PATIENTS / ASSOCIATES CEO/HODs CONSULTANT / DOCTORS FRONT LINE STAFF PATIENT REGISTRATION DAY TO DAY MONITORING OPD ADMISSION OPD CONSULTATION DISCHARGE CERTIFICATE FEE COLLECTION FRONT LINE STAFF REGISTRATION ,PARAMEDICAL, NURSES, REDSIDENT CONSULTANT / DOCTORS EMPOWERMENT CEO/HODs AHPI Certification Centre

Football Vs Hospital Football GOAL KEEPER BACKS C MIDFIELD FORWARDS CONSULTANTS RESIDENTS NURSING PARA-MEDICAL AHPI Certification Centre

How to maximize gain from Internal Audit Internal Audits should be under the auspice of Top management. Results of Internal Audit Should be on agenda of Management Review. Follow-up on corrective actions is key to institutionalize improvements. Senior management should encourage the junior auditors, while being audited. AHPI Certification Centre

Benefits of Internal audit Internal Auditors are fully acquainted with the business of HCO and therefore are best suited to contribute towards improvements, especially when they are trained in the art & science of internal auditing. Internal Audits help in employees taking ownership of their processes. Internal Audit fosters teamwork. Internal audits provides excellent training ground for inculcating leadership qualities. Finally the Internal audits provide excellent framework for continuous improvement in providing effective (patient safety) and efficient (affordability) services to patients. AHPI Certification Centre

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