type of auditing is therefore better termed financial ‘analysis’, as, to ensure services are really cost-effective, comparison of the costs of one or more interventions may be necessary. Each organisation will have its own financial advisers, normally situated in the company finance department, who can help with this type of audit.
priorities agreed with the purchaser (ideally contained in the service level agreement), elements of service raised by the professionals and any mandatory organisation-wide audits.
Deciding on the priority of activities to audit can present a challenge.
In the case of health professionals, one of the main priority areas will be the quality of care and advice given. It is widely recognised that there are currently inadequate written standards of clinical practice in occupational health care and as yet few are evidence based (Agius 1997).
Research has shown that occupational consultations and occupational rehabilitation have hardly been studied and that scientific evaluative research is needed to provide more evidence-based care (Hulstof et al.
1999).
Occupational health practice can be very diverse and exists over many different industries, creating a further problem for consistency of stan- dards of care and advice.
Identifying the objective of any audit can be problematic. This raises the question of whether audit is a control function only to evaluate standards or whether the information generated is going to be used to develop and improve standards. Most occupational health professionals would agree that audit should be a dynamic process, not just a control function, and that the indications for change should be acted upon as far as is possible.
Prioritising Quality Assurance Activity and Ethical Considerations
It is important to use any existing quality organisational framework as a starting point from which to base the way systems are used to control and develop quality. Audit activity in the occupational health service, defined as ‘observing practice and comparing it to a standard’ (Faculty of Occupational Medicine 1995 p. 9), should be steered by occupational health professionals, with company (purchaser) and employee input.
Priority areas for audit include the general organisational systems, ac- tivities where the occupational health staff have concerns over a shortfall in practice and areas where improvement is needed or changes in clinical practice are proposed. It is worth remembering that when prioritising audit activity, the values of individuals working in the team or buy- ing occupational health services can influence the subjects or methods chosen, as well as the interpretation of the results.
Menckel and Westerholm (1999 p. 207) recommend that a good starting point for any specific audit area is the question, ‘Which is- sues in this evaluation are ethical?’ This involves looking at ‘actions planned and undertaken, and in what ways their underlying motives involve the value criteria of beneficence, non-maleficence, respect and justice.’
Setting Standards and Criteria
The audit process starts with setting of standards. Standards need to be identified and it is useful to divide them between external standards that can be translated into operational standards and existing standards already in use.
External standards are those that have been formulated by in- ternational bodies, government, professional bodies or the organi- sation the service is contracted to. They include customer charters, health and safety legislation and codes of practice, guidance notes and classifications (see Chapter 2 for information on writing policies and procedures).
Some health and safety legislation contains statutory levels of com- pliance, while codes of practice and guidance notes describe best prac- tice. Other existing standards are the respective professional codes of practice, which describe standards, for example, on record keeping.
National clinical guidelines that are evidence based are available from different sources and include systematic worldwide literature reviews (e.g. www.library.nhs.uk/Default.aspx). Professional guidelines such as those published on the management of acute low back pain (Carter &
Birrell 2000) and the evidence-based guidelines for the prevention, iden- tification and management of occupational asthma (Nicholson et al.
2005) will be useful in any occupational health setting.
Examples of internal standards, developed within the occupational health service and already in existence, may be clinical procedures such as a vaccination policy, medication guidelines and response times to management or waiting times in the department.
If a new standard needs to be written, it should be:
r Agreed with professional or management colleagues.
r Desirable and appropriate to the customer base.
r Observable.
r Measurable.
r Relevant to the occupational health needs of the organisation (RCN 1999a).
Any standard written concerning clinical performance must include the minimum level of safe practice to be considered ethical.
Before a new standard is constructed there may need to be further data collection to help inform the level of practice. For example, it might be useful to carry out a user survey of occupational health customers and clients to understand current expectations before writing the standard of customer service. Other necessary standards may require more detailed research methods in order to gather data.
It is also worth noting that the jargon of audit may be confusing here. Some ‘audits’ are really methods of data collection, as they do not have a ‘standard’ to audit against. For example, collecting information
about a type of occupational health practice across a region is useful as a benchmarking exercise, which in turn can be used to help formulate standards, but for an ‘audit’ there need to be standards to audit against!
Benchmarking involves comparing practices with other occupational health services and adopting those considered to be the best. Once stan- dards are in place, the next step is to agree measurable criteria. Review criteria should clarify whether the standard is being met, so statements need to be formulated to achieve this. For example, the ‘if–then’ format is useful. To illustrate, if a manager refers a staff member for advice then they should be seen within the defined time standard for making appointments. Or if a client informs us they are working with blood then hepatitis B immunisation should be offered, as stated in the local policy.
The various approaches to audit described earlier are the main types in use and the majority start from the basis of a standard or target de- scribing the level of quality expected, and audit criteria to measure the standards. The AOHNP(UK) (1999) produced a general framework for auditing occupational health practice. This pathway or audit process starts with the ‘outcome’ or expectations, in terms of what is decided with the purchaser, and looks at setting standards, measurement and review. This framework is useful in any occupational health setting, but particularly in organisations that do not have general established quality assurance. Whatever audit tool and checklist is finally used to record the responses, it should be kept as simple as possible, with either yes/no, numerical figures or short responses systematically collected.
As a further simple example, the occupational health service may want to audit the response time to managers after a referral and will use as the standard the existing service statement, describing the level of service expected. Elements of the standard may be converted into mea- surable criteria, such as recording how quickly an appointment was sent, waiting times for an appointment and how long it took the oc- cupational health service to respond. The results can then be analysed by the team and compared against the agreed acceptable level of ser- vice, for example that each referral is offered an appointment within one working week and that the manager is informed in writing within five days. If this is not being met, the standard can be changed to, for example, contacting the manager by telephone within one working day to speed up communication.
This is a fairly simple retrospective audit but can still be time con- suming. It is therefore vitally important to ensure that relevant, logical measurement criteria are formulated to save time. Descriptive audits are the most commonly used; analytical types, usually to evaluate out- comes, require more detailed design. It may be more appropriate to un- dertake such an audit as a research project as outcomes may be difficult to measure. Analytical audits still need standards to measure against to avoid becoming pure data-collection or benchmarking exercises.
Other variables used to formulate measurement criteria are the data sources in the service, such as daily activity figures; historical data;
benchmarking data from other occupational health services; and na- tional statistics. Data should be from a reliable source, be as accurate as possible and be relevant to the population being audited. Internal policies, legal requirements, peer-reviewed research evidence, clinical practice guidelines and the experience of the occupational health pro- fessionals can all help in establishing measurable criteria, as well as in writing the standards in the first place.
Carrying Out the Audit
Who performs the audit will vary between organisations and types of audit. In most circumstances it should be a team effort, if there is an occupational health team, not only to aid in designing the audit and collecting data but to increase everyone’s experience and understand- ing. The audit leader or co-ordinator, normally the lead doctor or nurse, should have knowledge of the audit process and be competent and ex- perienced. This person will ensure that the audit tool design is practical, that a time frame is set and that the results are analysed, collated and communicated to the relevant people.
The collection of measurement data will either be retrospective or recorded during a procedure, depending on how the audit tool has been designed. This may entail information being collected at different times, perhaps to fit in with the department schedule, or at repeated intervals if procedures (or different aspects of a procedure) are being monitored over time. Sampling strategies may be required to ensure that, for example, when auditing records, a representative selection is chosen.
Internal auditors in the organisation may be involved, although issues of confidentiality must be remembered, and external auditors in the form of occupational health experts may be brought in to carry out the process. Donabedian (Donabedian and Rosenfield 1968) developed a model that separates audit activity into structure, process and outcome. Structural elements include clinical equipment, facilities, ref- erence materials, resources available and how the service is organised.
Process measures are procedures such as sickness absence management, pre-employment screening and health surveillance activity. Outcome measures are the results of occupational health interventions, for example advising on acute back pain, the number of clients identified with an occupational disease compared with previous data and the impact of a health promotion project. In practice these can be difficult to separate, but the sections provide a useful reminder when designing an audit tool.
Reviewing the Results
The results need to be compared with the standard under audit, if neces- sary using statistical analysis of the data collected, and any gaps or areas for improvement must be identified. Previous audits for the same stan- dard can provide comparison and help with prioritising recommenda- tions in practice. The standard can be adjusted or rewritten as necessary.
It is essential to show where and whether the standard is being met and to congratulate the team when they are delivering up to the standard.
The audit tool should also be examined to see if it was valid, if the right criteria were chosen, whether the data were captured effectively and whether the standard and measurement criteria were pragmatic.
Making Changes
This involves agreeing action plans to implement what has been high- lighted in the reviewing results stage and may involve parties outside the occupational health service. Deadlines and responsibilities should be made clear, with review dates. As with any process of change, commu- nication with the team and other stakeholders as required is important.
The audit process will continue with a further date for re-audit and review of further standards.
Communicating Results
It is important to use the results to improve the occupational health service, but why not share the knowledge? Sharing good practice and useful results is important. British Medical Journal editor Richard Smith says that ‘Those who work in quality improvement in health care have a poor record in publishing their articles.’ He goes on to recommend the structure introduced by the editors of the journal Quality in Health Care as a good format for communicating quality improvement reports (Smith 2000 p. 1428).
Conclusion
The preceding outline has given an overview of the audit process, the types of audit commonly used in practice and how this work can help measure progress and develop the quality of the service that is being offered. It is essential to grasp the difference between audit and data collection, which is only part of the process. The use of existing stan- dards, as described earlier, can be particularly useful when setting up a new occupational health contract or starting to introduce audit activity into practice. Careful planning of the audit process will save time and
resources in the long term. As more experience is gained, the team will be able to construct effective audits and re-audit standards with less time required for planning.
Audit is a useful marketing tool. From an external viewpoint, audit will be seen as an indication that the service is actively looking at con- tinuous improvement. This should be one of the ‘selling points’ and a marker for a proactive service. General outcomes of audit and actions taken should be included in the annual business plan and service report to the customers, including results of any specific audits agreed with the purchaser of the service. This information will help inform the customer about using the occupational health service or adjusting the service level agreement when reviewed. It should also help inform business cases for increasing occupational health services in the future.
The audit process should be incorporated when setting up any new occupational health contract, and time for audit activity must be built into any contract as an essential quality-control element. Well estab- lished audit systems can also help recruitment and encourage occupa- tional health students to undertake training placements in the service.
The quality and audit process must be integrated into practice and en- compass all elements that go towards delivering a ‘quality’ service. Help to set standards, formulate criteria and start audit activity may come from within the occupational health service, from the organisation’s experts in audit or from external experts brought in to advise. Logical thinking and consultation are needed to ensure priority areas are chosen for standard setting and audit and that there is a consistent approach.
Inability to demonstrate a quality service costs money. Customers may be lost, complaints may rise, recruitment and retention of occu- pational health staff may become difficult and time and effort will be wasted. The benefits of audit may not be obvious in the short term, es- pecially as some occupational health practice may not show results for a long time. Other areas, such as audit of administrative systems, may demonstrate that progress has occurred in a quicker time frame. Over- all, the quality assurance costs are repaid in quality staff and services, and satisfied customers and clients.
References and Further Reading
Agius R. (1997) Quality and Audit in Occupational Health, Health Environment
& Work, www.agius.com/hew/resource/quality.htm (accessed June 2007).
AOHNP(UK) (2000) A Quality Pathway for Occupational Health, Leicester:
AOHNP(UK) Publications & W. Mercer, available from PO Box 11785, Peterhead AB42 5YG.
Carter J.T. and Birrell L.N. (2000) Occupational Health Guidelines for the Manage- ment of Low Back Pain at Work: Principal Recommendations, London: Faculty of Occupational Medicine, Royal College of Physicians.
Donabedian A. and Rosenfield L.S. (1968) Criteria and Standards for Quality Assessment and Monitoring, Quarterly Review Bulletin 12, 1–6.
Everitt J. (2000) Evaluating Clinical Supervision, Nursing Times 96(10), 47–9.
Faculty of Occupational Medicine (1995) Quality and Audit in Occupational Health, London: Royal College of Physicians.
Hulstof C.T., Verbeek J.H., van Dijk F.J., van der Weide W.E. and Braam I.T. (1999) Evaluation Research in Occupational Health Services: General Principles and a Systematic Review of Empirical Studies, Occupational and Environmental Medicine 56, 361–77.
Jackson S. (1999) Exploring the Possible Reasons why the UK Government Com- mended the EQFM Excellence Model as the Framework for Delivering Gov- ernance in the NHS, International Journal of Health Care Quality Assurance 12(6), 244–53.
Lilley R. (2001) Clinical Governance Toolkit, Oxford: Radcliffe Medical Press.
MacDonald E.B. (1992) Audit and Quality in Occupational Health, Occupational Medicine 42, 7–11.
Menckel E. and Westerholm P. (eds) (1999) Evaluation in Occupational Health Practice, Oxford: Butterworth-Heinemann.
NHS Electronic Library, www.library.nhs.uk/Default.aspx.
Nicholson P.J., Cullinan P., Newman Taylor A.J., Burge P.S. and Boyle C. (2005) Evidence Based Guidelines for the Prevention, Identification and Manage- ment of Occupational Asthma, Occupational and Environmental Medicine 62, 290–9.
Parasuraman V., Zeithaml A. and Berry L.L. (1985) A Conceptual Model of Service Quality and its Implications for Future Research, Journal of Marketing 49 (Fall), 41–50.
RCN (1997) Clinical Guidelines: What You Need to Know, London: RCN.
RCN (1999a) Occupational Health Audit: a Practical Guide for Occupational Health Nurses, London: RCN.
RCN (1999b) Clinical Governance: How Nurses Can Get Involved, London:
RCN.
RCN (2003) Clinical Goverance: an RCN Resource Guide, London: RCN.
Smith R. (2000) Editorial: Quality Improvement Reports: a New Kind of Article, British Medical Journa1 321, 1428.
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