1. Healthcare Audit ICHN Annual Conference Hilton Hotel Kilmainham
17th of May 2017
Cora McCaughan,
Assistant National Director, Healthcare Audit,
Quality Assurance and Verification Division.

2. Overview Rapid appraisal of Healthcare Audit Function
Where Healthcare Audit is at the moment
Findings from Audit for ICHN Members
QI Response by ICHN members to Audit
Focus on Outcomes

3. 1. Rapid Appraisal of Healthcare Audit Function

4. 1. Rapid Appraisal of Healthcare Audit Function

5. Rapid Appraisal
(1) Where we are?

6. (1) Where we are?
(2) Where we need to go?
Rapid Appraisal

7. Rapid Appraisal (1) Where we are? (3) How do we get there?
(2) Where we need to go?
Rapid Appraisal

8. 2. Where Healthcare Audit is at the Moment
QID/ RCPI /SQI
QAVD/HCA Team
NOCA
Internal Audit
Service Delivery System

9. 2. Where Healthcare Audit is at the Moment
Established 2010
Office of the CEO → QCCD → QPS →QID → QAVD
13 people
Provides assurance
Key role in assurance framework 
Provides valuable and reliable information to inform decision making

10. 2. Where Healthcare Audit is at the Moment
Identifies good practice for sharing across system.
Tests the effectiveness of internal controls.
Provides evidence for signing the statement of internal control.
A quality improvement activity. 
2017 operational plan include audits spanning every Division and relate to key safety issues.

11. 2. Where Healthcare Audit is at the Moment
What we do: We audit compliance against clinical and non-clinical standards.

12. 2. Where Healthcare Audit is at the Moment
What we DON’T do: We do not audit compliance against financial standards

13. 2. Where Healthcare Audit is at the Moment
Audits issued in 2016:
Audit of compliance with implementation of the multidisciplinary clinical handover in maternity services as per the National Clinical Guideline (2014)
Audit of Implementation of Policies for Personal Assisted Care in Aiseanna Tacaiochta
Audit of incident reporting and learning in radiotherapy as outlined in section 3 of the Medical Exposure Radiation Unit's (MERU) Patient Radiation Protection Manual
Audit of compliance with Theme 1, standard 1.3 and Theme3, standard 3.1 of the National Standards for Residential Care Settings for Older People in Ireland (HIQA,2016) in selected older person's services
Audit of compliance of the management of serious incidents in the mental health services with the HSE Policy for Safety Incident Management

14. 2. Where Healthcare Audit is at the Moment
Audits issued in 2016 (continued):
Audit of evidence of compliance with the process by which a serious reportable incident is reported, escalated, investigated and managed from the point of occurrence/ identification to the senior most accountable officer
Audit of learning from adverse incidents and near misses in selected acute hospital groups
Audit of compliance with the implementation of recommendations listed in the HIQA (2015) report Linking Learning to National Standards
Audit of National Open Disclosure Policy in selected sites
Audit of the implementation of informed consent and supported decision- making practices as Part 1 of the National Consent Policy (2014)

15. 3. Findings from Audit for ICHN Members
Healthcare Records/documentation

16. 4. QI in response to Audit related to ICHN Members’ work
Dublin West Review of Documentation standards to assess adults, child health,  maternal health and wound care
Redesigned to support better assessment by adding clinical screening tools such as:
MUST tool
Children and Family’s Child and Family Health Needs Assessment S
SKIN Bundle

18. Focus on Outcomes
Enhanced data from HCA’s
Enhanced local Clinical Audit
Triangulation of HCA data with data from other sources
Symbiotic relationship between NOCA, HCA, SQI Audits and Local Clinical Audits
Continuously improving HCA’s Team Performance
Generating the most useful possible HCA data to deliver the greatest possible patient safety improvement

19. Thank you
Thank you.