Table 1

Tool for reflecting on the implementation and maintenance of an audit programme

STAGE

QUESTIONS TO CONSIDER


Stage 1:

Create awareness

• of problem (e.g. high PNMR)

• that something must be done

• of audit programmes that could be used

• What is the level of awareness of staff about the problem?

• How can we create or improve a general awareness of the importance of audit among staff?

• Do we have review meetings (e.g. perinatal review meetings) on a regular basis?

○ If no, how could we organise and institute these meetings?

○ If yes, how could we use the existing meetings to create better awareness of the importance of audit?

• Should a specific person at our facility be designated to find out about the programme (e.g. PPIP)?

• Could a representative of an institution using the audit programme or the owners of the programme (e.g. PPIP) be invited to come and tell staff about it?

• Are other facilities in our area/district using audit programmes?

○ If no, what role can our facility play in reaching out to create awareness of the problem and the importance of audit?


Stage 2:

Commit to implement audit

• More people commit to implement programme

• Can existing review meetings be used to facilitate commitment from more people?

○ How could we use this?

○ What needs to be done?

• Can existing communication channels be used to facilitate commitment from more people?

○ How could we use this?

○ What needs to be done?

• Are there specific persons whose commitment is required who need to be approached?

○ People at management level? Who? How?

○ IT officials? Who? How?

○ Clinicians? Who? How?

○ Government officials? Who? How?

○ Other? Who? How?

• What steps are needed to get the use of the programme approved in principle?

• What kinds of commitment are needed? (E.g. Who? What? Where? When? How?)

○ Written?

○ Verbal?


Stage 3:

Prepare to implement

• Practical aspects to get the programme up and running

• What do we expect of the driver(s) of the process?

• How will we identify the driver(s)? Who should be considered?

• What are the financial outlays for getting the programmes and necessary equipment?

○ Must the audit programme be purchased or is it free?

○ What will orientation and training in the use of the programme cost?

○ Do we have a dedicated computer for capturing audit data?

- Should more computers be made available?

• How do we get budget approval for the purchase of the programme and other equipment (if applicable)?

• What kind of support do we have from senior management on the practical aspects of the audit implementation process?

○ In what areas do we need additional support?

○ What else should we do to secure the necessary support?

• Has the software for the audit programme been installed?

• Who will be responsible for data entry?

○ Has this duty been negotiated with the assigned data capturer(s)?

- How well have they bought into the idea?

○ What kind of computer training do they need?

○ What kind of training do they need in the use of the software?

- How will that be organised?

○ What kind of support or incentives should be provided to the data capturers to make them aware of the value of their work?

• What kind of quality control will be exercised on the captured data?

• Who has been trained in interpreting the data and generating reports?

○ If no one, what should be done about it?

• Are all the responsible clinicians trained in the use of the computer hardware?

• Are all the responsible clinicians trained in the use of the software?

• How are facility information officers or IT officials involved in the establishment of the system?

○ How informed are they?

○ What kind of support will they be able to provide?

• What kind of support do we need from our outreach clinicians and other health department officials in our preparation for implementation?

○ How could these person(s) assist us in keeping the process on track or speeding it up?


Stage 4:

Implement audit

• Collection of the first data

• Analysis of the results

• Dissemination of results

• Have we started collecting data?

• How do we keep back-ups of data files?

○ Who is responsible for making back-ups?

○ How often are back-ups made?

○ How do we check that this is done regularly?

• Are all persons sharing the computer(s) aware of the programme? (To avoid unintentional deleting of files or programmes)

• How can accuracy and regular data entry be improved?

○ Are data always entered immediately?

○ Should refresher sessions on the use of the software be provided?

• How is/are the driver(s) of the implementation process coping with the tasks?

○ What kind of additional support do they need?

• How is feedback of results given at the review meetings?

○ How can we improve on this feedback?

• How good is the attendance of review meetings?

○ How can it be improved?

○ Are attendance registers kept for review meetings?

- If yes, how does it help us in what we are doing?

- How do we use the information to ensure that all relevant role-players are invited regularly and/or have the opportunity to attend?

• Is the usefulness of the audit programme (e.g. PPIP) evident at meetings?

○ If yes, how?

○ How can this be improved?

• Are minutes taken at review meetings?

○ If no, how will we get this process going?

○ If yes, how can we improve on what we are doing?

- How are the minutes used?

- How are recommendations noted in the minutes?

- Are timelines and the allocation of specific persons included in the recommendations?

• How are the recommendations incorporated into in-service training?

• How does the use of the results contribute to accountable behaviour of all relevant role-players?

• What kind of support do we need from our outreach clinicians and other health department officials in the implementation process?

○ How could these person(s) assist us in keeping the process on track or speeding it up?

• How can communication at different levels be improved?

○ Between providers at the coal face?

○ Between providers and their immediate managers?

○ Between managers and senior management?

○ Between the facility and the other levels of the health system?

○ Other?


Stage 5:

Integrate audit into routine practice

• Data collection

• Analysis of the results

• Dissemination of results

• Use of findings

Routine practice

• Are audit duties written into the job descriptions of relevant staff members?

• Is feedback on audit results regularly provided to all relevant service providers in the institution?

○ How can we improve on this?

• Is feedback on audit results regularly provided to senior management in the institution?

○ How can we improve on this?

• Is feedback on audit results regularly provided to higher levels in the health system (e.g. district, regional or provincial managers)?

○ How can we improve on this?

• How are the audit data interpreted?

○ How can we improve on this?

• What kinds of recommendations and improvements are suggested following the interpretation of data?

○ How can we improve this?

• How are we faring with the execution of the recommendations?

○ What are we doing well?

○ How can we improve on the things we are not doing so well?

• Does our facility need (more) visits from an outreach person or team to assist us with the institutionalisation of the audit programme?


Stage 6:

Sustain audit

• Data collection

• Analysis of the results

• Dissemination of results

• Use of findings

Sustained over a longer period of time

• How can the regular review meetings be improved and used more effectively?

• How often and to whom is feedback given?

○ Monthly? To whom?

○ Quarterly? To whom?

○ Six-monthly? To whom?

○ Annually? To whom?

• What are the gaps in our feedback procedures?

• How can the feedback to service providers and senior management in the facility be improved?

○ How can engagement in the audit process, the use of the findings and the application of recommendations be improved?

• How can the feedback to the higher levels of reporting be improved (e.g. district or provincial levels)?

○ How can involvement from these levels be improved?

• Who is responsible for keeping the audit system together?

○ One person?

○ A team?

• Who is leading the audit?

○ Who takes responsibility when the leader(s) is/are not there?

○ What kind of succession plan do we have?

• How do staffing issues such as rotations and turnovers influence the audit activities?

○ How can staff stability be improved?

• What is our facility's responsibility in reaching out to another facility or facilities to introduce and establish an audit programme (e.g. PPIP)?


Belizán et al. BMC Health Services Research 2011 11:243   doi:10.1186/1472-6963-11-243

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