Audits in Infection Prevention and Control

Learning objectives Explain the relevance of audit in IP&C practice Identify audit tools and methods Describe the main principles of audits December 1, 2013

Time involved 40 minutes December 1, 2013

Key points Audit means checking practice against a standard Improves by providing information about practices Use for risk assessment, strategic planning, and root cause analysis Essential to have an audit team Results need to be known by decision makers December 1, 2013 Audit means checking practice against a standard. It examines the actual situation and compares it to written policies or another benchmark. Audit can help to improve health care service by providing a blame-free mechanism for changes in practice. It can also be used for risk assessment, strategic planning, and root cause analysis. An audit team is essential to carry out a proper audit through good planning, performance, and feedback of results. Audit results may be provided to others through various types of reporting.

Introduction Healthcare-associated infections (HAI) are due to multiple factors Prevention depends on surveillance and infection prevention and control (IP&C) practices Practices are outlined in guidelines, policies, and procedures December 1, 2013 Healthcare-associated infections are generally related to multiple factors. Prevention of these infections depends on daily vigilance and implementation of infection prevention and control (IPC) practices. These practices are outlined in written guidelines, policies, and procedures. Health care workers' compliance with infection prevention and control practices and principles is vital in preventing the spread of disease.

Audit objectives Reporting of noncompliance or issues of concern Identifying where improvement is needed Monitoring and evaluating the effectiveness of the organisation’s risk management process December 1, 2013 One tool to assess infection control practice in clinical areas is the infection control audit. Audit means checking actual practice against a standard; it should permit reporting of noncompliance or issues of concern by either healthcare workers (HCW) or the Infection Control Team (ICT). Providing results of the audit to staff enables them to identify where improvement is needed. The infection control audit is an opportunity to implement changes and to introduce remedial measures in collaboration with various departments and services. A standardized approach to the audit allows benchmarking of practices across the institution and enhances standards of care.

Risk Management Set objectives Identify, analyse and respond to risks that could impact the organisation Internal auditors can offer advice and help risks December 1, 2013 Risk management involves setting objectives then identifying, analysing, and responding to those risks that could potentially impact the organisation’s ability to realise its objectives. Internal auditors can offer advice and help identify emerging risks.

The PDSA cycle December 1, 2013 Internal auditing standards require the development of a plan of audit engagement (project) based on an annually updated risk assessment using the concept: Plan, Do, Study, Act (PDSA). The PDSA cycle guides the test of a change to determine if the change is an improvement. The PDSA cycle is shorthand for developing a plan to test a change (Plan), carrying out the plan (Do), observing and learning from the consequences (Study), and determining what modifications should be made (Act). Changes in processes often generate audit projects in addition to reviews of documents such as strategic plans. Plan: Identify what change you think will create improvement and then plan the test of the change. What is your objective in introducing the change? It is important to establish the scope of the change to be introduced, and how you are going to collect information about the differences that occur, how will you know whether the change made has 'worked' or not? Do: Put the plan into practice - test change by collecting the data. This stage involves carrying out the plans agreed in the Plan stage. It is important that the Do stage is kept short as possible. There may be changes that should only be measured over long periods. Record any unexpected events, problems and other observations. Start analysing the data. Study: Review and reflect. Complete the analysis of the data. Has there been an improvement? Did your expectations match the reality of what happened? What could have been done differently? Act: Make further changes or amendments after you have decided what worked and what didn't and collect data again. Carry out an 'amended' version of what happened during the Do stage and measure any differences.

The PDSA cycle December 1, 2013 The Plan-Do-Study-Act (PDSA) cycle is shorthand for testing a change in the real work setting — by planning it, trying it, observing the results, and acting on what is learned. The PDSA cycle guides the test of a change to determine if the change is an improvement. After testing a change on a small scale, learning from each test, and refining the change through several PDSA cycles, the team may implement the change on a broader scale — for example, for an entire pilot population or on an entire unit. After successful implementation of a change or package of changes for a pilot population or an entire unit, changes can be spread to other parts of the organisation. There is enormous scope for an audit in IP&C. The audit can lead to improvement of services because it provides a blame-free mechanism for changes in practice. The results of audit, when provided back to staff , can turn defects into improvements after appropriate changes are completed

Audit tools Templates to evaluate implementation of the standard Can focus on Procedures hand hygiene, isolation, cleaning, disinfection or sterilisation Practices personal protective equipment, insertion and care of intravascular, respiratory and urinary devices, hair removal, prophylactic antibiotic December 1, 2013 Audit tools are commonly referred to as “quality improvement tools”. They are templates for ICTs to evaluate implementation of standard procedures, such as hand hygiene, isolation precautions, environmental cleaning, disinfection or sterilisation of equipment, handling linen/waste/sharps/supplies, etc., in their facility. In addition, specific practices may be monitored, e.g., use of personal protective equipment, insertion and care of intravascular, respiratory and urinary devices, and wound care. Operating room observations for practices such as patient preparation, hair removal, surgical team scrub, and prophylactic antibiotic use, may also be included.

Audit Tools Audit tools must match the recommended practices and resources of the institution The audit can be performed by the IP&C team or other designated staff December 1, 2013 The audit can be performed by the IP&C team or other designated staff. The audit tool must match the recommended practices and resources of the health care setting.

Audit Method Select areas Report should include Focus on a few important ones Report should include Description of the physical layout Observation of practices Action taken/Practice changed Collection of local audit data Analysed audit data December 1, 2013 Initially it is probably worth selecting a few areas to audit, preferably those that are most important to the organisation. These may include high-risk areas highlighted through surveillance results or occurrence of outbreaks. An effective audit should include A description of the physical layout; review of traffic flow, protocols and policies, supplies and equipment; and observation of appropriate IP&C practice. Action taken / Practice changed. Collection of local audit data. Audit data analyzed and fed back to clinicians.

Audit plan December 1, 2013 The audit should take place over a defined time. A rapid audit cycle plan can be completed in a few days and the results provided very quickly. In addition to the rapid cycle plan, an annual plan may be useful. Link personnel and ward staff may assist with the Process improvement is needed.

Annual audit plan December 1, 2013 In addition to the rapid cycle plan, an annual plan may be useful. Link personnel and ward staff may assist with the process.

Preparation of Audit Team All staff must be included Need to understand its purpose is to improve practice Not punitive or to identify weaknesses Pre-audit meetings essential Consistence and anonymity Identify leaders in the area Knowledge assessment December 1, 2013 All HCWs and support staff must be included in preparing for an audit. They need to understand that its purpose is to improve IPC practice. It is in no way punitive or a search for weaknesses. Pre-audit meetings are essential to explain and discuss the goals and objectives of the audit, how it will be conducted, and how the results will be reported. Staff should understand that an objective approach will be maintained, that the audit will be performed consistently across the facility, and anonymity will be protected. The audit team must identify the leaders in the area being audited and continue communication with them. Management and other key decision makers (e.g., educators) need to support the audit team in any changes required post-audit. Knowledge Assessment - A questionnaire on employees’ knowledge of safe IP&C practice should be developed and distributed prior to any audit. The questionnaire can assist in determining what areas of practice should be audited. Respondents should be identified only by job title (e.g., nurse, physician, radiographer, cleaner, etc.). The questionnaire can be modified to suit the department or area being audited. A deadline must be provided so that questionnaires are returned on time. One person in each survey area should be asked to ensure that questionnaires are completed and kept securely for collection and tabulation by the audit team. The results will allow the IP&C team to determine where additional education is needed. Dissemination of results and discussion of the correct answers can be used as an educational tool.

Toolkits to Complete Audits Available from Community and Hospital Infection Control Association-Canada and World Health Organization Hand hygiene Standard precautions/routine practices Use of isolation/precautions Use of personal protective equipment Monitoring of sterilisation equipment And many others……….. December 1, 2013 Toolkits to carry out different types of audits in health care settings are available such The Community and Hospital Infection Control Association-Canada audit toolkit and World Health Organization audit toolkits. They include, but are not limited to: Hand hygiene (readiness and practice; supplies such as soap, paper towel, alcohol-based products). Use of standard precautions/routine practices. Use of isolation/precautions. Use of personal protective equipment. Monitoring of sterilisation equipment. Cleaning, disinfection, and sterilisation of reusable equipment and devices, such as bronchoscopes and surgical instruments. Health care environment cleaning. Haemodialysis practices, equipment, facility. Operating room IPC practices, asepsis and preoperative antisepsis, traffic control, patient skin preparation, hair removal, surgical scrub, and prophylactic antibiotics. Practice and medical device reprocessing in clinics and physician offices. Occupational health issues, such as, sharps injuries/needle sticks, vaccination rates. Outbreak management. Self-audit tool. More information: CHICA - http://www.chica.org/inside_products.php WHO toolkit for hand hygiene - http://www.who.int/gpsc/information_centre/en/ and Safe Surgery - http://www.who.int/patientsafety/safesurgery/en/index.html

Routine Reports Weekly reports Monthly reports Quarterly reports Rapid feedback on incidental issues Monthly reports Audit results, education, training, and consultations Quarterly reports Formal reports including recommendations and management Annual reports A summary of audits carried and the resulting improvement December 1, 2013 Audits in Infection Prevention and Control reviewed with management and key staff in the audit area before it is finalised and distributed. The report should include information on why the audit was performed, method used, findings, and recommendations. Compliance data should be included as appropriate. Reporting of audits could be in the form of: Weekly reports: Providing rapid feedback on incidental issues while they are still fresh (e.g., during outbreaks or after occupational sharp injuries). Monthly reports: A monthly report should include sections about surveillance, audit results, education, training, and consultations. Quarterly reports: These are formal reports including recommendations and management of issues. Annual reports: A summary of audits carried out during the year and the resulting improvement or changes during the rapid and annual audit plans, illustrated as appropriate with graphs.

Behavioural Change Behavioural theories and interventions insufficient Interventions must account for different levels Interdependence of factors, environmental constraints, and institutional climate taken into account Factors necessary for change Dissatisfaction with the current situation Perception of alternatives Recognition, of the ability and potential to change December 1, 2013 Review of prevailing behavioural theories and their application to health professions is recommended in an attempt to understand how to target more successful interventions. In hand hygiene, although behavioural theories and secondary interventions have primarily targeted individual workers, this might be insufficient to produce sustained change. Interventions must account for different levels of behavioural interaction. Thus, the interdependence of individual factors, environmental constraints, and the institutional climate must be taken into account in the strategic planning and development of programs, e.g., hand hygiene campaigns. Factors necessary for change include 1) dissatisfaction with the current situation, 2) perception of alternatives, and 3) recognition, both at the individual and institutional level, of the ability and potential to change.

Basic principles: Bundles Multi-model structured way of improving processes and outcomes Collection of processes needed to effectively and safely care for patients Interventions “bundled” together and when combined, improve outcomes Consists of small (3-5) set of procedures, determined by robust evidence Successfully completing each step is a straightforward process and can be audited December 1, 2013 A bundle is a multi-model structured way of improving processes of care and patient outcomes. It is a collection of processes needed to effectively and safely care for patients undergoing particular treatments with inherent risks. Several interventions are “bundled” together and, when combined, significantly improve patient care outcomes. Bundles are helpful and have been developed for ventilator-associated pneumonia, catheter-associated urinary tract infection, and central line-associated bloodstream infection. A bundle typically consists of a small (usually three to five) critical set of procedures, all determined by robust evidence, which when taken together create improved outcomes. Successfully completing each step is a straightforward process and can be audited.

Bundle pack A statement of commitment A cause-effect chart Standard operating procedures Data collection sheet Explanation for staff December 1, 2013 A bundle pack includes: A statement of commitment for the clinical team to sign. A cause-effect chart describing the evidence for optimal practice and used also for root cause analysis of non-conformities, in reference to the standards. Standard operating procedures for the bundle including specific criteria. A data collection sheet. Explanation of the bundle to the clinical staff (e.g., group discussion, slide presentation)

Cause and effect diagram December 1, 2013 A cause-effect chart describing the evidence for optimal practice and used also for root cause analysis of non-conformities, in reference to the standards. It is a tool that helps identify, sort, and display possible causes of a specific problem or quality characteristic. It graphically illustrates the relationship between a given outcome and all the factors that influence the outcome. This type of diagram is sometimes called an "Ishikawa diagram“ because it was invented by Kaoru Ishikawa, or a "fishbone diagram" because of the way it looks. It can be used to Identify possible root causes, the basic reasons, for a specific effect, problem, or condition. Sort out and relate some of the interactions among the factors affecting a particular process or effect. Analyse existing problems so that corrective action can be taken.

Guidelines Written guidelines for each procedure Updated, acceptable, practical An audit checks if guidelines are being followed December 1, 2013 IPC audits ensure that written guidelines are in place for each procedure. These guidelines must be current, acceptable and practical, and used in developing the IP&C program’s policies and procedures. An audit checks whether these guidelines are being followed in actual practice. This can be accomplished by auditing practices with “Staff Interviews” and “Observational Tours”.

Summary Data derived from audits used to inform the IP&C program The intent of audits is to promote good practice, improve patient care, and ensure safety A key person must be identified in each area to help facilitate implementation of any recommendations Auditing is relatively simple, but time-consuming Important to plan and develop an audit calendar December 1, 2013 The data derived from audits can be used to direct the IP&C program’s annual goals and objectives. It also assists in meeting the needs of the health care setting in relation to IP&C standards and safer health care practices. Staff must learn to appreciate that the intent of audits is to promote good practice, improve patient care, and ensure safety. A key person must be identified in each area to help facilitate implementation of any recommendations within a specified time. This latter form of auditing is relatively simple, albeit time-consuming. Developing an audit calendar for planning the audit cycle may be useful from a time management perspective.

References Millward S, Barnett J, Tomlinson D. A clinical infection control audit programme. J Hosp Infect 1993; 24: 219-232. Bryce EA, Scharf SL and Walker MM: Infection control practitioner audit form for patient/resident service units. Canadian J Infect Control 2002; 17:23-26. Yokoe DS, et al. A compendium of strategies to prevent healthcare associated infections in acute care hospitals, Infect Control Hospital Epidemiol 2008; 29 (Suppl 1): 12-21. December 1, 2013 Other tool web sites: http://www.infectioncontrol.co.nz/resources/audit-tools/ http://www.ascquality.org/EnvironmentalInfectionPreventionToolkit.cfm

Quiz Audits have demonstrated improvement in processes and outcomes. T/F An audit tool helps evaluate Practice against a standard Health care behaviour Surveillance Epidemiological investigation Regarding audits, it is incorrect that: The intent of audits is to promote good practice, improve patient care, and ensure safety. Audit means checking practice against a standard It is punitive There needs to be a plan December 1, 2013 True A 3. C

International Federation of Infection Control IFIC’s mission is to facilitate international networking in order to improve the prevention and control of healthcare associated infections worldwide. It is an umbrella organisation of societies and associations of healthcare professionals in infection control and related fields across the globe . The goal of IFIC is to minimise the risk of infection within healthcare settings through development of a network of infection control organisations for communication, consensus building, education and sharing expertise. For more information go to http://theific.org/ December 1, 2013