Electronic audit Hospital using Tablet-pcs

Whipps Cross University Hospital NHS Trust, Clinical Risk and Audit Manager, Clinical Governance Facilitator , Clinical Governance Facilitator, Clinical Governance Facilitator, Clinical Risk Administrator

Introduction

The Clinical Risk and Audit team at Whipps Cross Hospital in North East London developed an innovative process for enabling local audits using Microsoft Tablet-pc's. At a difficult time, the introduction of initiative, innovation and team spirit resulted in an improved clinical audit process and prompted engagement in clinical audit from both clinical staff and patients. The technology, Microsoft Tablet-pc's (security encrypted) impressed staff and patients, and enabled improved engagement and timely response with local audits. The Trust is pleased with the audit process, a variety of audits are ongoing and nurses are using the technology to carry out audits.

Instigation:
In August 2006 the Trust "Turnaround" agenda resulted in the department being reduced by 50 per cent in line with other cuts that occurred around the Trust and other NHS establishments around the country. The clinical risk and audit staff researched alternative and innovative ways of carrying out audit, as this was still an essential requirement.

The Clinical Risk and Audit department had previously been involved in an initiative to support the maternity Clinical Risk Manager and clinical staff on the maternity ward to meet the CNST standards and carry out the Caesarean-section audit. An IT system dedicated to capturing CNST criteria was placed on the ward, and used to carry out the audit in Microsoft Access. Doctors were given generic passwords, received training, and test data was used to pilot the system. Results were immediately available and Doctors were able to discuss the information and request changes to meet the CNST standards and local improvements. Doctors were notably responsive to audit. Quarterly reports were generated more efficiently and areas to focus on were quickly identified.

Progression:
In August 2007, the Clinical Risk and Audit department carried out a four week pilot on five wards as part of a business case to purchase ten HP Microsoft tablet-pc's (a laptop with rotatable and interactive screen). The Director of Nursing was supportive of the idea and supported the business case for the funding. During the pilot, which formed part of the business case, the nurses received one to one training on how to use the tablets and the electronic audit forms. Written instructions were sent out to the nurses, with contact numbers of clinical risk and audit staff, and the Clinical Governance Facilitators visited the wards to note progression.

The first audit to use the new technology was the Essence of Care Nutrition Standard in April 2008. Following discussions with the Nutrition Action Team (NAT), the questionnaires were designed in Microsoft Access by the Clinical Governance Facilitators, using drop down boxes and yes or no fields. A variety of different data collection audit tools were designed; these included staff, patient, documentation, mealtime observation, speech and language, parenteral, and NG tube. Analysis was carried out in Microsoft Access and Excel. Ten wards participated.

On the day, the audit team comprised the NAT (including nurses, therapists, healthcare assistants and customer services) and nursing staff from the wards. An hour was devoted to training the audit team to use the tablet-pc's and electronic questionnaires before they went on to the wards to carry out the audit. At the end of the audit, the audit team met together for a debriefing session; this included the clinical risk and audit team. As well as the feedback on the audit results, the debriefing session included feedback on how the auditors felt about using the tablet-pc's and some constructive criticism on the design of the electronic questionnaires. The audit team were very positive about using the tablet-pc's, despite some apprehension during the training. There were a few minor problems, but these were quickly sorted out by the Clinical Governance Facilitators who went to the wards to support the staff. The staff carrying out the audit loved using the tablet-pc's and were keen to take part in the next audit!

At the end of the audit, the data was copied from the tablets' hard drives onto the departmental server and saved.

The huge learning curve for staff, combined with the manager's approach of allowing freedom and flexibility for the facilitators to be creative, contributed to the development of a strong team work ethos of working together, being supportive and sharing knowledge.

Nurses were really enthusiastic and welcomed the trust and investment in their being given the opportunity to use the tablets. The patient audit tool created an opportunity for nurses to sit with patients and interact, which both nurses and patients appreciated. They looked and felt more professional and effective. The nurses contributed significantly towards changes on the ward arising from the audit.

Previously, using paper forms, there had been a two month gap from data collection to results to allow for data entry and analysis: with the electronic audit tools and the tablets, the results were available to view the next day.

On the first day back in the office after the Essence of Care nutrition audit everyone was feeling very positive, which is not the usual emotion that audit evokes. Everyone was pleased and wanted to do more audit!
Further development:

The same technology has been used to develop an electronic audit questionnaire for the Nursing Quality Tool. Four questionnaires - documentation, observation, staff and patient - were developed; the audit criteria covered mental health, pain management, food & nutrition, record keeping, self care, respect and dignity, pressure ulcers, continence, communication, infection control and environment. Later, the audit tools were developed in Excel, as it was more easily accessible for nurses who needed to see the results straightaway.

The technology was also used for a Corporate Records and Information Audit in January 2009, and is currently being used for a Bed Rails audit. There are plans to use it for auditing Care Pathways within the Map of Medicine project.

The project involved a steep learning curve for all concerned, but staff feel invested in and have developed new skills. The technology and its use in the team has eliminated some techno-phobia as it is very user friendly. Neighbouring Homerton University Hospital NHS Foundation Trust has expressed interest in the systems.
Funding was agreed for advanced training in Microsoft Access and Excel for the department. The training has enabled the electronic audit tools to be developed and improved and has enabled more sophisticated databases to be designed.
Summary:

Apart from the cost of the tablets, the Trust has not purchased any commercial software to enable electronic audit to be carried out at Whipps Cross University Hospital Trust. We have used the software that is available to all NHS Trusts i.e. Microsoft Access and Excel. Overall, Clinical Audit is much more of a priority for clinical staff. Results are more readily available, meaning that tangible improvements to patient care can be identified and implemented swiftly.