Many organisations now have a quality framework that encompasses the different systems working towards providing and developing qual- ity services. This is a way of organising the different departments to continuously improve together, to increase the effectiveness of the work and its results. The occupational health service will be expected to work within this management culture to develop the quality of its own ser- vices. Every organisation will use some or all of the following types of audit or self-assessment activity. The two broad main types of audit relevant to occupational health are, first, those where the framework standards have already been set (e.g. ‘top-down’ management audits or third-party audits) and, second, those where the occupational health team organises the audit itself, usually developing its own standards and criteria. There may be some overlap between the two types (Figure 4.2).
Audit Type 1: Standards Already Set
Organisational Management Audit An example of a self- assessment tool used to assess standards (and also used as a framework for quality) is the European Foundation for Quality Management (EFQM) business excellence model. This is gaining popularity, par- ticularly in the NHS, where the government has commended its use (Jackson 1999). Approaches for achieving ‘excellence’ (e.g. meeting tar- gets and national standards, comparing well with other organisations) are defined and then assessed and reviewed. The key components of the business excellence model contain further sub-criteria to address different areas in the organisation (Figure 4.3).
Type 1 Type 2
Audit framework standards already set Audit standards set by OH
EFQM Clinical audit
BS5750 User satisfaction
ISO 9000 Cost-effectiveness
Baseline service audit
Figure 4.2 Occupational Health Services: Examples of Types of Audit which may be Relevant
Results Enablers
People 9 %
Policy &
Strategy 8 %
Partnerships &
Resources 9 %
Processes 14 %
People Results 9 %
Customer Results
20 %
Society Results 6 %
PerformanceKey Results
15 % Leadership
10 %
Innovation and Learning Figure 4.3 A Diagramatic Representation of the EFQM Excellence Model
Source: EFQM (1999).c EFQM. The EFQM Excellence Model is a registered trademark
EFQM Business Excellence Model A summary of the model shows how all the elements of the organisation are included. The model starts with leadership. Commitment to continuously developing quality is con- sidered vitally important and leaders should be able to demonstrate by their behaviour that they are involving all staff, communicating to in- ternal and external customers, and recognising the input of motivating and supporting their staff.
People management follows, as the contribution and empowerment of staff is important to improving the service. Criteria include areas such as performance review, training and development, improving retention of staff and decreasing sickness absence rates.
Policy and strategy reviews the mission, values and strategic direc- tion of the organisation. Policy and strategy should be based on the present and future needs of stakeholders, using relevant information and research. These areas should also be regularly developed, updated, communicated and implemented effectively.
Resources looks at how the resources required to run the organisa- tion are managed, from financial resources to buildings, equipment and technology.
The processes element analyses the design and management of all activities to review how they can be improved. This includes all the pro- cesses involved in an occupational health service that incorporate clin- ical best practice, benchmarking standards and customer needs. Other
national standards can also be absorbed into the model within this com- ponent, for example the Investors in People Award.
The above elements are considered under the ‘enablers’ part of the model, which concentrates on running the organisation. The remain- der of the model looks at achievement, measurement and targeting of
‘results’.
People satisfaction examines achievements by measuring the percep- tions of staff and reviewing customer satisfaction, i.e. the perceptions of external customers.
Impact on society is monitored by looking at how the needs and ex- pectations of people affected by the organisation are met, for example, the impact of being a local employer.
Lastly, business results or key performance results measure what is being achieved by the organisation, comparing financial, non-financial and operational aspects with targets (Jackson 1999).
All these activities are linked and depend on networking and over- coming practical barriers. Building and developing a quality organi- sation means ensuring that the total quality ethos is at the heart of everything. It can take a long time for this ethos to be integrated into a company.
Other Examples of Organisational Management Audits Manage- ment audits tend to be formulated outside the occupational health ser- vice and use broad standards to review the organisation. These audits take a general look at systems and processes, including auditing occupa- tional health services and seeing how they interact with other services in the organisation. External auditors will periodically attend for planned audits, normally undertaken with representatives from the organisa- tion. The Health Quality Service Audit, previously known as the King’s Fund Audit, where it originated, is an example of an organisational, general accredited audit used in the NHS. There is a dedicated section on occupational health, as well as other core activities of a Trust. There is a checklist of standards, for example ‘Is there a health screening pol- icy in existence?’ and ‘Is there access to a qualified occupational health physician?’
A commonly used organisational audit is the internationally equiv- alent family of standards, ISO 9000. As with the NHS Health Quality Service Audit, the standards relate to broad management activities and are used as a marker to indicate that a system of monitoring and audit exists.
Health and Safety Audit Health and safety audit should be an in- tegral part of the organisation’s quality framework, rather than an iso- lated section. Regular audits, viewing the corporate health and safety system or separate individual parts of that system, are used to mon- itor and evaluate risk management standards as part of the general
management responsibilities. This involves working with health and safety colleagues to look at areas of potential overlap or dual respon- sibility, in particular the risk assessment and control process, health surveillance activity, accident/incident reporting, policy and procedure writing including review, first aid organisation, health and safety train- ing and the level of legislative compliance. As above, there may be an external organisational audit that has a health and safety section to monitor corporate activity, or this type of audit may be designed internally.
Audit Type 2: Occupational Health Staff Set the Standards
Baseline Occupational Health Service Audit This type of audit re- views the existing resources, facilities, equipment, procedures and poli- cies in a service and how they may be improved or reorganised. Such audits are performed when there is new management, the viability of the service is being questioned, or to adapt to major changes in the host organisation. Some companies use external occupational health experts for this, as they will give an objective look at a service.
There are professional standards available to help design this type of audit, for example, those from the Royal College of Nursing on setting up an occupational health service. Many occupational health service providers use this as a first step when taking over a service (for more details see Chapter 1).
User Satisfaction Audit The ‘users’ are either the company (pur- chasers of the service) or its employees. Each user will have a different concept of what quality means to them. The employees are not involved in payment for the occupational health service and will normally base their perception of quality on the advice and care they receive on a one- to-one basis or as part of a group. The company, however, will usually have a broader perspective on quality, such as wanting to ensure a range of services, value for money and accessibility.
One way in which to audit the users is to slot their perceptions of service received and their expectations into one of five ‘gaps’. Parasur- aman et al. (1985) developed a model of service quality based on inter- pretation of qualitative data from executive interviews and consumer focus groups. The study was not health care related but can be usefully adapted. The model identifies gaps in perceived service quality between the executives and consumers, i.e. service providers and service users.
The model is adapted to fit an occupational health service in Figure 4.4.
It provides a useful breakdown of the different gaps in customer service and could be used to formulate ‘bottom-up’ criteria against which to audit user satisfaction.
User expectation–management perception gap: Service quality expectation–service delivery gap:
Occupational health management may falsely believe that it understands the users’ expectations and without any feedback it will continue to do so.
A department may have established quality standards but it relies on all members of staff to maintain them; a shortfall in delivery will reflect on colleagues and the overall service.
Management perception–service quality expectation gap:
Service delivery–external communications to consumers gap:
Quality specifications are set by the occupational health managers without their understanding what the users’ priority is, for example the occupational health service allows several days for typing a detailed report to management, when the advice contained within the report could have been communicated by another means.
The standard of service delivery as
communicated to clients is not met, for example a sign in the waiting room informs clients that they will not be kept waiting longer than five minutes without being informed of the reasons but this is not put into practice.
Expected service–perceived service gap:
Users’ subjective expectations of service may not match that which is received and a single event may influence their views of the entire service.
Figure 4.4 Quality Model for an Occupational Health Service Source: Adapted from Parasuramanet al.(1985)
The occupational health service may adopt the organisational stan- dard on customer services and use measures such as encouraging feedback in structured questionnaires or reviewing the number of complaints received. Each service level agreement or contract the oc- cupational health service holds needs to specify how this area of cus- tomer satisfaction can be audited effectively. Appropriate measurement tools may need to be developed. It is important to remember that the employees need an opportunity to offer feedback as well as the em- ployers or managers, and an occupational health monitoring group can be established, allowing representatives from management and staff to give their views. A simple example of a questionnaire based on an in- ternal standard for customer service following referral is included in Figure 4.5.
Internal Occupational Health Audit This type of audit is to measure internal clinical and non-clinical standards in the occupational health service and involves looking at either a separate process or a group of processes that function together, for example the wider effects of how accessible the service is, or how the occupational health service communicates with managers.
Many occupational health services, particularly in the NHS, will fall within the organisation’s clinical audit process. Clinical audit involves all members of the occupational health team reviewing care in a sys- tematic way and assessing whether it meets standards. This means tak- ing part in clinical audit projects, which will need to be submitted and
Aim to evaluate how the occupational health service is meeting user needs 1. Have you come to occupational health today at the request of:
Your manager Self-referral
2. Were you offered an appointment date and time convenient to you?
Yes No
3. Was the service easy to find?
Yes No
4. Were you made to feel welcome?
Yes No
5. Were you seen within five minutes of your appointment time?
Yes No
6. Are you happy with the quality of advice and any actions planned by the nurse/doctor with you?
Yes No
Comments ...
7. Was this advice/action explained clearly?
Yes No
Comments ...
8. What was the most useful aspect of your appointment today?
9. What was the least useful aspect?
Please add any other comments/suggestions below.
...
...
Figure 4.5 User Satisfaction Survey
approved. Again it is important that the occupational health profession- als guide the project, with the help of internal audit experts if required.
In the occupational health context, this means auditing the quality of care to the client when assessing, treating or advising an individual and their manager. It may also require examining the outcome measures of the advice given.
Medical audit is the evaluation of care: diagnosis, treatment, re- sources and outcomes carried out by doctors. It is normally performed by doctors looking at their own work or that of medical colleagues.
Documentation Review This type of audit can be conducted as a joint effort, with doctors and nurses looking at a random sample of notes to see how the cases were handled. In occupational health there is normally only one set of notes for each service user, making audit much easier. One occupational health service has regular multi-disciplinary team audit meetings, and reviewing notes is one of the topics. Figure 4.6 presents a case study looking at record keeping following a referral.
Method: compare with internal clinical operating guideline standards on this subject by a retrospective review of a sample of records as follows:
r Selection of records made randomly within a set time frame.
r Audit questions formulated using measurable criteria, for example the standard states that all records must contain information concerning how and why the individual was referred, and that an appropriate assessment should be made, containing at least four essential areas of information.
r Audit questions such as:
r Do the notes contain the mode of referral? Response yes or no.
r Do the notes contain the reason for referral? Response yes or no.
r Do the notes contain information on the assessment made:
Present problem Occupational history Symptomatic review Clinical assessment
Responses to above: yes, no or not applicable.
Results and action points: if the results are not 100 % compliant with the standard this must be discussed and acted on. The fundamental details to be included in all records of an assessment may be adjusted as necessary after reviewing individual cases used in the audit.
Figure 4.6 Documentation Review of OH Case Notes Following Referral
Cost-Effectiveness Audit/Financial Analysis This type of audit, of- ten done in conjunction with other auditing approaches, is described as a means of justifying why any activity is being delivered and its financial cost (staff time costs, client time costs, equipment and other overheads), and looks at how to make the activity more economically efficient. It is also used to identify priorities for action, such as research activity. Our starting point for any audit is to observe practice compared with a stan- dard. The standard or outcome of any activity under audit can be set to satisfy specified requirements, but evaluating the actual health value in cost-effectiveness terms can be complex. There are methodologies for calculating costs, both direct and indirect, and the audit results depend on what method is used.
In auditing the cost-effectiveness of, for example, a back clinic that sees workers with back pain and provides preventive advice, the pa- rameters for cost analysis will include direct costs such as occupational health staff time, client time, drugs and equipment. Further indirect costs such as lost working time or intangibles like counselling costs required for an anxious worker whose back pain is continuing might also need to be included. A source of potential error in the results is disagreement over definitions, such as what should be included under the ‘back pain’
description.
Activities that have purely occupational causes are rare but are easier to audit, as opposed to activities that have multi-factorial elements. This
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.