The Health Information and Quality Authority (HIQA) is the statutory authority with responsibility for setting standards for health and social care services and for ensuring that such standards are met. HIQA is responsible for the registration and inspection of residential services for people with disabilities under the Health Act (2007). The Authority published National Quality Standards: Residential Services for People with Disabilities in 2009. There are regulations being developed at present which will give statutory strength to the standards, and which organisations will be measured against as part of the registration and inspection process. These regulations will also provide further detail to organisations on what is expected of them.
One of the requirements of the HIQA standards (Standard 17, criteria 17.12) is that organisations must have a process in place for auditing their service against the national standards. Furthermore (if the approach taken for disability services is similar to criteria 30-2 in the Older Persons’ Standards), services will need to carry out specific audits in areas such as:
- residents who have had moderate to severe pain within the previous week
- residents who have pressure sores
- residents who have been physically restrained within the previous week
- residents who have received psychotropic drugs (including sleeping tablets) within the last week
- residents who spent most of their time in bed or in a chair within the last week
- residents who have fallen within the last month
- residents who experienced significant weight loss over the last three months
- unexplained absences of residents
- significant events.
In our experience, services have approached quality in a range of ways:
- Some services have an internal quality process in place, where they self-assess against the standards.
- Some services buy into an external quality process or system.
- Some services carry out a range of audits over the course of the year (often sporadic).
- Some services do not have any structured approach to audit and quality improvement.
The introduction of the standards requires organisations to have a structured approach to auditing the standards themselves in core areas such as those referred to above. In essence, all organisations will need to have
- An annual structured schedule of audit that measures the service against the national standards, and
- A further range of audits of key issues within the organisation.
The organisational approach to quality and audit
In our experience, the most effective organisations are those that have a structured approach to quality and audit. Put simply, the current national standards provide a framework to audit all elements of an organisation. The standards are written in a manner that addresses all elements of a quality service—considering the broad themes of governance and management, the environment, staffing, development and health, rights, protection and quality of life.
From the above perspective, our view is that if the organisation puts a structure in place that enables a substantial and significant focus on quality and audit, then this can replace many of the traditional elements of organisational structure. A representative group (one which includes senior management of the service) should oversee and drive the approach to quality and audit within the organisation. This group should have very clear terms of reference, should have an annual quality and audit plan and should have very strong linkage with the strategic and service planning forums of the service. In our experience, the organisations that spend time properly establishing and bedding down this structure have a far better likelihood of being successful.
Audit cycle and process
Once the above structure has been established, it is crucial that the organisation establishes its audit function and begins the audit cycle and processes. There are a number of pitfalls that organisations can often encounter, such as:
- A lack of sufficiently skilled auditors
- A perception that if people have an audit tool, that they can automatically carry out audit effectively
- A dependence on internal audit and self-assessment, which can result in a biased effect
- A lack of understanding of the standards and, in some instances, applying a tick.the.box approach to testing against the standards, using personal judgement only. (This results in very subjective and inaccurate measurement of compliance against the standards.)
- Audits being completed and no root.cause analysis being conducted into reasons for non-or poor compliance.
- A lack of senior management buy.in, resulting in reports sitting on shelves, gathering dust.
- A lack of clarity on corrective action plans, negatively impacting on their implementation.
- The non-closure of the quality loop, where corrective actions have been identified, but not implemented or followed up.
Organisations need to be conscious of the above pitfalls and try to minimise these in implementing the audit function. Services need to:
- Ensure that the staff carrying out audits have, and continue to build, the necessary skills in conducting audits
- Ensure that it has a structured approach to quality and audit, with one representative group driving this across the organisation
- Have an audit schedule in place on an annual basis Balance the audit function with internal and external audits
- Use robust, well developed audit tools (Joe Wolfe & Associates have developed a suite of specific audit tools to this regard.)
- Ensure that the quality circle is completed, with an emphasis on monitoring the implementation of corrective action plans.