Clinical Audit Toolkit - Safety And Quality

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Clinical HandoverClinical Audit Toolkit

AcknowledgementsThe Residential Aged Care Facility / Hospital Clinical Handover Project is managed through theAustralian Government Department of Health and Ageing and is funded by the AustralianCommission on Safety and Quality in Health Care.Support for this project was received from 20 of the 22 organisations managing the 70 RACFs in the Brisbane North district.We appreciate your support and trust in our ability to undertake this audit on your behalf and believe this report will bringimproved understanding, increased knowledge and confidence to change processes toward safer handover for residentstransferring to and from acute facilities.GPpartners LimitedSuite 2 Centro Lutwyche, 543 Lutwyche Road (PO Box 845)Lutwyche Qld 4030Phone 07 3630 7300 [email protected]

ContentsClinical Audit Toolkit . 1Acknowledgements . 1Introduction. 1What we did. 4Why did we choose the auditors in the way that we did . 4Steps to perform a clinical audit. 51.Identify need and rationale for audit . 52.Systems identification . 53.Identify key stakeholders – who to involve and how? . 54.Seek organisational support and ethics approval . 65.Using the audit templates. 86.Timeframe and scope of audit. 97.Recruiting Auditors. 108.Implementing the Audit . 119.Evaluating Findings. 1210. Identifying gaps and making recommendations . 13Reporting. 16Key Factors to undertake a clinical audit . 16Conclusion . 16References . 17Attachment 1 – Admission Information from Residential Aged Care . 18Attachment 2 – Discharge Information from Acute Facility . 21Attachment 3 – Guidelines for Admission Information . 24Attachment 4 – Guidelines for Discharge Information . 28Attachment 5 – Coding formula . 32Attachment 6 – Sample spreadsheet . 35Attachment 7 – Sample table format . 36Attachment 8 – Sample graphs: Information to Acute Facility from RACFs . 37Attachment 9 – Sample graphs: Information to RACFs from Acute Facility . 38

IntroductionContinuity of information is vital for the safety of our patients and clinical handover is one of the mostimportant issues to be considered when ensuring continuity of patient care.GPpartners’ aged care team, General Practitioners (GPs), Residential Aged Care Facilities (RACFs)and the Hospital in the Nursing Home staff of the Royal Brisbane and Women’s’ Hospital (RBWH)were concerned about the reports relating to the lack of discharge information being received byresidential aged care facilities.Conversely, medical and nursing staff of the Emergency Department expressed concern at thevariation in quality of information received with residents presenting to their departmentIn 2002 the General Practice Advisory Council (GPAC) held a multi-disciplinary StatewideDischarge Planning Forum with the aim of improving discharge planning across Queensland. The keyrecommendation from this forum was to provide a framework – a practical agreed set of directions foruse by all service providers involved in continuity of care planning in Queensland.In 2007 the Continuity of Care Planning Framework for Queensland came into effect. Theframework spells out ‘Key Activities in the Continuity of Care Process’ and Recommended ‘Data Sets’for ‘Documentation to Support Continuity of Care Planning’.This contains areas in relation to:1. Pre-admission (Admission Referral)2. Pre-admission/Admissions (Risk Screening Tool)3. In Patient (Care Pathway/Discharge Plan)4. Discharge (Discharge Summary/Referral)Key accountabilities have been described for District Managers, GPs, community service providersand patients / families. Resources and systems are discussed clearly outlining the need for astandardised paper based system with recommendations for an information technology platform,integrated with hospital and community (medium term). (Continuity of Care Planning framework forQueensland – Resource Manual GPA, 2004)The guidelines exist and processes to assist to rectify gaps in continuity of care have been developed.However, a 2007 Australian Catholic University survey of RACFs found that 84% of Queenslandrespondents continue to experience problems with resident’s information received back from hospitalsand that they have serious concerns about the risk to patients due to unsafe discharge processes.They were also concerned that their duty of care would be compromised by the lack of appropriateinformation from the hospitals. (McDonald, T., For Their Sake. Can we improve the quality and safetyof resident transfers from acute hospitals to residential aged care? Australian Catholic UniversityNational; September 2007)Page 1

In November 2002, a combined workshop was held with representatives from residential aged carefacilities (RACFs), the emergency departments of the Queen Elizabeth II Jubilee Hospital, the MaterPrivate Hospital (adult) and the Princess Alexandra Hospital and Brisbane South Community Health.The workshop discussed the issues around residents being transferred to Emergency Departmentsand noted that causal factors for presentation to Emergency Departments included falls requiring x-rayor examination to eliminate fractures, acute illness requiring antibiotics, GP not available or GPrequest transfer in lieu of attending residents on site and catheter or peg change.From the workshop a ‘Residential Aged Care Facility Clinical Resource Manual’ was developed and aproblem solving assessment flow chart designed to reduce transfers to acute facilities. The workshopalso identified issues that included (but were not limited to):1. Communication between the Emergency Departments and residential aged care wasinconsistent and/or inappropriate, and2. Discharge summaries sent / faxed to GPs from Emergency Departments without dischargeinformation being provided to RACFs.Communication tools were developed to improve these issues and made available to all RACFs forimplementation, including: an Aged Care Facility Resident Transfer form (the green form) adapted from a previous formused by the Sunshine Coast Aged Care Regional Forum, Nambour Hospital and Aged CareQueensland a Cognitive Impairment Information Form (orange) adapted from Alzheimer’s Australia’s FirstAlert Trial – Cognitive Impairment Information Form SA. an Aged Care Facility Transfer form (yellow) that is completed by the Emergency Departmentand returned to the RACF.It seems however, that these forms are not widely used. Some facilities have electronic systems thatenable printing of current health summary information, whilst others do not.However there is no discussion about the role or responsibility of GPs, as health team leaders, inproviding transfer information. There is little evidence that RACFs have processes to collect GPs’ inputor include GP input in transfer documentation and little evidence that GPs are offering this.The GPAC guidelines state that a key accountability for GPs is “provision of comprehensive, legiblereferral information to hospital for all planned admissions, and for referrals to Emergency Department(where relevant)”.Systems such as a shared electronic health records could be the answer to these questions.Undertaking a clinical audit enables knowledge that can identify issues local to the area and assist inmaking recommendations that can achieve safer, more effective and more responsive clinicalhandovers for residential aged care residents as they transfer to and from acute facilities.Page 2

GPpartners, funded by Department of Health & Ageing through the Australian Commission on Safetyand Quality in Healthcare, undertook to develop an audit tool, identify the audit process, andundertake an audit to collect evidence based information that can inform recommendations forprocess change.The audit enables organisations to clearly identify areas of concern and target these areas for a morein-depth review. The toolkit used to undertake these audits is presented in this workbook to enableother organisations to perform similar reviews that provide them with actual clinical data to informrecommendations for improvement.Page 3

What we didA Clinical Audit Toolkit (CAT) was developed for the purpose of this project. Audits on informationreceived at the Emergency Department from Residential Aged Care Facilities were performed by twoHospital based project officers. Audits on information received from the Hospital by the RACFs wereperformed by two General Practitioners who currently visit residents in Residential Aged Care.An initial one month audit was performed as a baseline to gather information on:1: How admission and discharge information is currently received2. What information is currently received?3. Possible impact on clinical outcomes.Information collated from this audit enabled us to target areas of concern. A second audit wasperformed three months after the initial audit. This time frame was extremely short so not all plannedinterventions were completed by the commencement of the second audit.The results of the two audits were collated and compared and recommendations on continued changehave been made.The toolkit used to undertake these audits has been completed to enable other organisations toperform similar reviews that provide them with actual clinical data to inform recommendations forimprovement.Why did we choose the auditors in the way that we didTo improve the access and acceptability of the audit within the acute facility and for the purposes ofequity, it was decided that the admission audit would be undertaken by staff of the acute facility.This ensured that the auditors were already covered by the Health Department’s code of ethics andhad the relevant security access to the areas needed to obtain the patients’ charts. Initially it wasdiscussed that a medical officer could undertake the audits, but due to workloads it was decided thatRegistered Nurses with current research experience and access to medical support would undertakethe audits. Two nurses based in the Internal Medicine Research Unit were employed under thesponsorship of the Assistant Nursing Director (Community Interface) Patient Flow Unit.To ensure that the audits being undertaken in the RACFs were consistent and to ensure that GPsvisiting RACFs were informed, it was decided to recruit two GPs to undertake the discharge audits inthe RACFs. Two GPs who currently visit RACFs were recruited to undertake this process.Page 4

Steps to perform a clinical auditNotes.1. Identify need and rationale for audit .Is there a perceived problem with transfer communication in yourlocal area?.How can you find this information?.oLiterature reviewsoLocal news storiesoLocal forums with appropriate health care workers, familymembers, residents.oComplaints systemsoAdverse Events ReviewoSurveys.oVerbal