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Each team audited must have the opportunity to participate in the analysis and to study and comment on the results, express their opinions on the audit, identify causes for non-compliance and propose improvement actions. The team leader should generously acknowledge the contribution of all participants. At this stage, the team leader should be ready to provide a final validated report at the institution level. If a report is to be submitted for journal publication the active contributors should be properly recognised (R28 downloadable below).
Tables and graphs to present the results should be as simple as possible. Presentation should focus on the quality and completeness of participation and compliance with audit instructions (rate of non evaluable answers, etc.), identification of the major positive points and of the major points of nonconformity that will require improvement. It is important, at this stage, to propose a preliminary root cause analysis, in order to stimulate discussion among the participants; for each nonconforming item:
- Identify the nature of the problem
- Identify the possible causes for non-compliance
- Propose a classification to help build an action plan
- Propose an improvement action plan for consultation and agreement
(R28 downloadable below)
Search for improvement
Analysis of the audit results should define the improvements that can be proposed to the audited teams and to management. The action plan must define the objectives and the approaches to be used.
Examples
The plan may aim to improve deficiencies in the design of process or the resources that are revealed by the audit. This might involve developing or updating an SOP that is (Table 9.1) missing or out of date or correcting deficiencies in resources or training.
Table 9.1 Responding to audit findings. Examples: deficiencies in processes or resources
| Responding to audit findings – deficiencies in processes or resources | |
|---|---|
| Criterion | National and local guideline requires that hospitals have a validated procedure for provision of blood to patients in an emergency |
| Audit finding | Hospital does not have a major haemorrhage procedure |
| Corrective action | Take steps to ensure that staff who provide this service are supported by written procedures, effective training, and appropriate practises (fire drills) to test the procedures periodically |
| Criterion | Staff must receive appropriate training for their task(s) |
| Audit finding | Audits may uncover deficiencies in education and training in any area of practice |
| Corrective action | Develop and implement training programme |
| Criterion | National and local guideline requires perioperative monitoring of patients’ haemoglobin levels |
| Audit finding | Equipment for “near patient” measurement of haemoglobin concentration is not available |
| Corrective action | Operating departments must be supplied with suitable equipment |
Alternatively the audit may show that there are non-compliances even though all the appropriate procedures, personnel, training equipment, etc. are in place. (Table 9.2)
Table 9.2 Responding to audit findings. Examples: non-compliance
| Responding to audit findings – non-compliance | |
|---|---|
| Criterion | Guidelines require that patient records contain a record of the clinician’s reason for prescribing each red cell transfusion. |
| Audit finding | A doctor’s record of the reason for transfusing is found in only 20% of patients’ files. |
| Corrective action | Obtain the agreement of clinical staff to achieve a target of 90% documentation of the reason to transfuse and to participate in education on the importance of clinical accountability for transfusion and to a repeat audit. |
| Criterion | Guidelines require that all patients undergoing transfusion have observations of pulse, blood pressure, respiration and temperature recorded before and at specified time intervals during the transfusion. |
| Audit finding | These “routine observations” are performed incompletely or not at all in a substantial proportion of transfusion episodes. |
| Corrective action | Obtain the agreement of clinical staff to achieve a target of 90% documentation of patient observations according to the guidelines and to a repeat audit. To overcome the problem that nursing staff believe that they do not have time to perform the task, consider action such as:
|
| Criterion | EU Directive requires that the final fate of all blood components issued for recipients is recorded by the hospital blood bank. |
| Audit finding | Hospital blood bank does not have data on the final fate of all components |
| Corrective action | Obtain the agreement of clinical staff to achieve an initial target of 98%. Inform staff that monthly reports will be provided to senior nursing managers, identifying the clinical areas not meeting the agreed target. These mangers will be required to identify how non-conformance will be addressed. |
| Attachment | Size |
|---|---|
 28_NHSBT AUDIT GUIDE Audit presentation.pdf | 43.57 KB |
