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Overview
Complete
15 May 2019 / Intensive Care Quality Improvement / Astrid Declaro
Clinical Audit ChecklistConducted on15th May, 2019BySafetyCulture Staff
Inspection score
82.35%
Failed items
6
Created actions
0
Site
Sydney
Department
Intensive Care Quality Improvement
Healthcare Facility
East Rochester Hospital
Audit Lead
Astrid Declaro
Conducted on

15th May, 2019

3:09 PM +08

Failed items
6
Clinical Audit Checklist / Preparation, Planning & Selecting the Standards/Criteria
Does the clinical audit have a clearly-stated quality improvement aim and objectives?
No
Clinical Audit Checklist / Measuring Performance
Is the data set collected defined with reference to the audit standards?
No
Clinical Audit Checklist / Measuring Performance
Is the population of patients to be included in the audit defined with reference to the audit standards?
No
Clinical Audit Checklist / Measuring Performance
Is the audit sample size set, and the sample selected, in accordance with best practice guidance?
No
Clinical Audit Checklist / Measuring Performance
Are the findings presented in a way which gave a clearest possible picture of performance?
No
Clinical Audit Checklist / Implementing Changes
Do the findings show compliance with standards?
No
Clinical Audit Checklist
6
82.35%
Preparation, Planning & Selecting the Standards/Criteria
1
90.91%
Does the clinical audit have a clearly-stated quality improvement aim and objectives?
No
Does the audit measure performance against standards for process and outcomes that are based on the best available evidence?
Yes
Are the standards clearly referenced?
Yes
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Has a named clinician been identified to lead the clinical audit?
Yes
Is the named lead is a junior doctor working on rotation?
No
Is the audit to be undertaken in compliance with local governance arrangements?
Yes
Is it proposed and registered in accordance with local policy and protocols?
Yes
Are the sample identification, data collection and analysis, and all other aspects of the clinical audit cycle compliant with the law and best practice on information governance and data security
Yes
Are all members of the clinical audit committee engaged in the clinical audit cycle from the start and in delivering the service to be audited?
Yes
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Is a stakeholder group identified and engaged in the clinical audit?
Yes
Does this group include representatives of the clinical audit committee, other clinicians whose practice may be impacted by the findings of the audit, service managers responsible for the service to be audited, relevant service users, carers and lay representatives, and where appropriate, senior clinicians and managers, board members, commissioners, and others?
Yes
Are any ethical or information governance concerns identified?
No
Did the stakeholder group sign off the audit aim, objectives, standards and audit method before data collection began?
Yes
Measuring Performance
4
63.64%
Is the data set collected defined with reference to the audit standards?
No
Is any data collected that is not required to measure compliance with the audit standards?
Yes
Is the population of patients to be included in the audit defined with reference to the audit standards?
No
Is the audit sample size set, and the sample selected, in accordance with best practice guidance?
No
Is the rationale behind the sample size and selection method documented in the audit report?
Yes
Is any part of the data to be extracted from electronic health records?
Yes
Is the data extraction tested to ensure that the correct data source was being used, and the correct sample and data were being extracted?
Yes
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Is any part of the data to be collected from paper health records?
No
Is clinical audit data analyzed using appropriate statistical techniques to measure compliance with audit standards?
Yes
Are the findings presented in a way which gave a clearest possible picture of performance?
No
Are the clinical audit findings reported with the appropriate level of granularity?
Yes
Are full details of the clinical audit method documented to ensure that any necessary repeat data collection to measure the impact of interventions was carried out in exactly the same way?
Yes
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In the final report, are any unavoidable variations in the repeat data collection method documented and reported alongside the results?
Yes
Implementing Changes
1
87.50%
Are the results shared with the stakeholder group?
Yes
Do the findings show compliance with standards?
No
Are steps undertaken to establish the underlying causes for non-compliance?
Yes
Is an action plan developed to address the established underlying causes?
Yes
Is the action plan signed off by the stakeholder group and in accordance with local governance arrangements?
Yes
Is the action plan implemented?
Yes
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Is the impact of the implementation of the action plan monitored in an appropriate way?
Yes
Are any unforeseen negative impacts identified?
No
Has evidence been obtained to demonstrate that implementation of the action plan has resulted in an improvement in the quality of services?
Yes
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Sustaining Improvements
100.00%
Has the stakeholder group determined whether the audit needs to be repeated?
No
Has the stakeholder group determined whether refinements are required to the audit protocol and data collection tool for greater focus on shortfalls identified?
Yes
Have alternative approaches to ensuring that quality of service is maintained, such as some form of ongoing monitoring, been considered?
Yes
Have the results of the audit been documented and shared with key stakeholders, service users, the rest of the organization, and with the public?
Yes
Have learnings from the audit been shared with colleagues, both within the organization and across partner organizations, including commissioners, clinical networks and other professional groups?
Yes
Notes
yes, able to automatically generate and share the clinical audit report! saved so much time and effort! lets me focus on patients more
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Sign Off
Additional Recommendations
Improvement efforts can be maintained by integrating iAuditor in our regular checking mechanisms
Audit Lead Name & Signature
Astrid Declaro
16th May, 2019 7:44 AM +08
Sign Off / Clinical Audit Committee
Sign Off / Clinical Audit Committee / Clinical Audit Committee 1
Name, Department & Signature
Jennelyn Casacop, Clinical Improvement
16th May, 2019 7:45 AM +08
Sign Off / Clinical Audit Committee / Clinical Audit Committee 2
Name, Department & Signature
Dyan delos Santos, Intensive Care
16th May, 2019 7:52 AM +08
Sign Off / Clinical Audit Committee / Clinical Audit Committee 3
Name, Department & Signature
Luigi Mendoza, Clinical Engineering
16th May, 2019 7:47 AM +08
Sign Off / Clinical Audit Committee / Clinical Audit Committee 4
Name, Department & Signature
Jericho Coronado, Applications Systems Analyst
16th May, 2019 7:48 AM +08
Sign Off / Stakeholders
Sign Off / Stakeholders / Stakeholders 1
Name & Signature
Sigrid Geronimo
16th May, 2019 7:50 AM +08
Sign Off / Stakeholders / Stakeholders 2
Name & Signature
Karl Gochuico
16th May, 2019 7:51 AM +08
Sign Off / Stakeholders / Stakeholders 3
Name & Signature
Michelle dela Paz
16th May, 2019 7:58 AM +08
Sign Off / Stakeholders / Stakeholders 4
Name & Signature
Neil Daroing
16th May, 2019 7:55 AM +08
Sign Off / Stakeholders / Stakeholders 5
Name & Signature
Patrick Hagape
16th May, 2019 7:56 AM +08
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