76-441 / Patient safety audits

GOP Information
Organisation sharing the GOP
Related practices from PaSQ database
Galician Health Service


Quality indicators
Audit system

GOP Description
Implementation level
Clinical settings
Hospital sector – 100% of all hospitals belonging to the Galician Health Service
–    Acknowledge the degree of compliance with 25 indicators dealing with patient safety projects.

–    Identify strong points and improvement areas of each hospital in order to apply the necessary measures.

–    Share experiences with other health quality leaders by participating in the audits as observers.

–    Compare and share results with the rest of hospitals.

All hospitals in the Galician Health Service; a total of 15 hospitals.
–    Planning an external audit. A total of 25 indicators were chosen, dealing with patient safety. Of these, 15 indicators which involved leadership aspects, strategy, internal communication and procedures; 10 direct observational indicators in care units which involved patient identification, safe use of ClK, fall prevention and pressure ulcers, using Patient Safety Reporting and Learning System, pain management, revision and maintenance of crash carts and expiry control of drugs and perishable goods in care units.
–    Sending documentation to centers.
–    Elaboration of a schedule involving the interchange of quality leaders as audit observers.
–    The audit and revision of the documentation that was claimed. Visits to the care units for direct observation and conclusions meeting with hospital’s management staff.
–    Elaboration of the final report, including degree of accomplishment and improvement recommendations.
–    Benchmarking conference where results are presented and compared with the rest of hospitals in an anonymous fashion.
Timeframe implementation
–    Planning: 2 weeks

–    Visits: 6 hours (in large hospitals this timeframe was insufficient). Two five hour periods are recommended for large hospitals.

–    Elaboration and closing report: 1 or 2 working days per hospital.

Implementation tools available
–    Form with indicators regarding evaluation criteria.
–    Final report and results form.
Implementation cost
–    A doctor and a nurse in the Quality Department of the Galician Health Ministry were responsible for organizing and undertaking this audit in all 15 hospitals during a two month period.
–    Two health quality leaders which were present in each audit.
Method used to measure the results
All audits followed the same evaluation system, where two expert auditors in patient safety, analyzed all the data and evaluated all observational criteria in the care units, by means of material verification, interviews with health professionals and medical records revision.
Average accomplishment of all 25 indicators in the 15 hospitals was 64%.

Some indicators involving documented safety procedures such as safe use of ClK, Patient Identification, traceability of blood products or correct pain management were close to reaching 100%. Averages over 90% were reached in some indicators involving training in patient safety and the existence of communication channels on adverse events.

As to the 10 observational indicators, average accomplishment was of 56%. Best results were achieved in patient identification and as to the use of VAS scale for pain management.

Analysis of the results
1.    The evaluation of the degree of implementation of the different safety projects in hospitals of the Galician Health Service is a very strong knowledge and motivation tool.
2.    Those aspects which are monitored and where institutional rules exist, achieve a satisfactory degree of accomplishment (patient identification, pain, Patient Safety Reporting and Learning System, ClK, etc.)
3.    The audits allow us to detect those areas which are up for improvement in all hospitals and where an institutional approach would be beneficial (correct use of medication, expiry control, etc.)
Implementation barriers
Did you find implementation barriers?
Please describe implementation barriers
1.    There are important differences in safety culture from one hospital to another. In some hospitals, obtaining the documentation and its revision proved to be more complicated than in others.
2.    Some medical directors were reluctant to attend the audit meetings because they felt that these audits were intended for nursing staff.
3.    The time aspect and the distance to and from hospitals are aspects that should be kept in mind if this practice is to be implemented.
4.    Those quality leaders who had attended audits in other hospitals as observers had advantage over those who had not.
Describe the strategies used to overcome the barriers (If needed)
1.    Send information/documentation beforehand, detailing the evidence required. Before the visit, reconfirm date, time and documentation requested, with quality leaders.
2.    Audit team made up of a doctor and a nurse. In the initial documentation we specified that at least one person from the medical director´s office should be present. If this was not so, his or her presence was requested before beginning the audit.
3.    Adapt planning.
4.    Guarantee that quality leaders may participate as observers only after having their own hospital audited, in order to avoid being bias when comparing hospitals
Other information
Other information about the GOP that you would like to add (Link or attached document)
1.    This is not the first audit hospitals have had to face. We have been working directly and in a coordinated way with hospital quality leaders in terms of patient safety projects for the last four years, thus we are constantly in touch with them and there is a high degree of mutual trust and understanding.
2.    Continuous improvement is the main approach and so these methods are considered very useful sources of information for hospitals.
3.    The fact that Quality leaders from other hospitals act as observers in the audits, guarantees transparency and is a source of mutual knowledge.
4.    The presentation of a global report with results from all hospitals within a benchmarking session for all hospital management, proves to be a strong source of motivation for improvement.