Audits for ongoing quality improvement

Point of Care audits  

Ensuring you select the most appropriate area-specific tool and that your audits are up-to-date and accurate is a crucial step in ongoing quality improvement.  

Top Tips:  

1. Make sure you select the correct audit, correct entity, and ensure all tabs are completed.
2. When you are ready to finalise Click ‘save’ and then ‘submit’.  

Clinical area managers (or their delegates) are required to conduct 11 Point of Care audits each month comprising of: 

• Part 1 – 10 audits, including patient questions and a medical record review. 
• Part 2 – 1 audit, including employee questions and a check of environmental safety. 

Remember, conducting an audit is only one step in successful quality improvement. It’s what you do with your results, and how you fix things, that really counts. 

What do I need to do? 

• Ensure this month’s audits have been completed
• Discuss with your team and record actions in your Quality Improvement Plan
• Implement the actions and
• Review effectiveness of the actions on your next audit 

To ensure we remain Accreditation-ready, we have set a target of 90% of areas to have completed all 11 audits each month. In April 65% of areas had completed all 11 audits.  

Infection Control Risk Assessments  

Review the last assessment undertaken in your unit. If you’re new to the role, contact Infection Prevention for a copy of the last audit undertaken in your area. What did the last risk assessment show? Have any ‘not mets’ been actioned or escalated? 

Quality Improvement Plan 

Each month, review all your audit results and themes from incidents and complaints. Celebrate your positive areas and discuss areas that are outliers and:  

• Develop an action plan to address any shortcomings 
• Make sure your QIP uses the current Quality Improvement Plan template  
•  Document the action plan in your Quality Improvement Plan and then upload your QIP to the intranet 
• Discuss results and strategies at ward governance, huddles, committees and involve all disciplines, including non-clinical areas, to assist in improvements.  

If you have any further questions or enquiries, please refer to the Point of Care audit procedure and the Quality Improvement Plan procedure or contact your Quality Partner or audit@monashhealth.org. 

Approved by Kate MacDermid, Director, Quality and Safety.