AUDIT OUTLINE INFORMATION SUMMARY 1. External QA Each DAFNE centre will undergo an external audit visit every 3 years. The external audit visit will take place during a week that the centre being audited is delivering a DAFNE patient course. The cost of the 3-yearly audit visit is included in your annual central contribution. In the unlikely event that your centre requires a repeat audit due to issues identified at your initial audit, or required audit documentation, information and preparation not being completed by you ready for the audit visit, the cost of the repeat audit will unfortunately have to be charged to your centre. 2. Purpose of External QA 1. Check Educators (and Doctor Educators if applicable) are delivering sufficient courses (one every 26 weeks) to maintain skills. 2. Verify that ongoing internal QA taking place: Observing all sessions within 3 year period 3. Professional Development Plans (PDPs) current, updated and development objectives achieved. 4. Check external agreement with Core Skills, Audit Form A and PDP for Educators observed delivering sessions during the audit visit compared to documentation produced during internal observation of these Educators. 5. DAFNE curriculum being delivered using adult learning skills, DAFNE principles and philosophy. 6. Evidence of lesson planning. 7. Check all DAFNE Doctors and Level-1 DAFNE Advisors are maintaining dose adjustment skills (attending 1 dose adjustment session per year). 8. Embedding of DAFNE as part of your service s care pathway. The individual DAFNE Professional Development files provide the information required for points 2-3, whilst observing 2-3 sessions of the delivery of a patient course that enables the execution of points 4 through 8. The information collected during the external audit visit is recorded by the Auditor in the Auditor Questionnaire. The external audit visit is not about observing the skills of the individual DAFNE Educators at your centre but rather checking and collecting evidence that your centre: Has successfully implemented and embedded DAFNE into your service and look at organisational issues. Delivers DAFNE patient courses according to the DAFNE philosophy and principles. Delivers sufficient courses to ensure that the skills of your DAFNE Educators are maintained. Has implemented a robust system of ongoing internal QA. DAFNE F03.017, Version 7 April 2014 1 of 63
Has collected patient pre and post data and that these are accurately entered onto the DAFNE database. 3. Central DAFNE/DAFNE Executive Responsibilities Central DAFNE will: Inform centres 12-18 months in advance that they are due for external audit and request course dates. Confirm in writing the date of the audit visit. Identify an external Auditor. Sent in advance for completion during 3 year audit period Audit Form A: for each individual Educator / Doctor Educator to complete Audit Form D: Summary of Courses delivered for each individual Educator / Doctor Educator to complete Audit Form E: Doctor and Level-1 DAFNE Advisor Dose Adjustment Skills Maintenance for the Lead Educator to complete Supply the necessary paperwork (listed below) to the centre being audited: Centre Questionnaire: to be completed by Lead Dr/Educator Audit Form F: Timetable Audit for the Lead Educator to complete A copy of the Auditor Questionnaire for information only Central DAFNE will: Review all paperwork from the external audit visit. Prepare an outcome report for each centre audited. Present the key data: In an annual audit outcome summary which will be placed in the public domain (DAFNE Website). To the Collaborative at the next Collaborative meeting. 4. Centre Responsibilities during External Audit Ensure the Lead Educator has pre-agreed a time (minimum 1 hour) to meet with the Auditor. Ensure that there is a DAFNE patient course being delivered the week of the audit visit as confirmed by Central DAFNE. The audit will normally take place on the Wednesday of the course, depending on the timetable. Supply Central DAFNE the names of Educators delivering the course, at least 10 weeks prior to the visit. Ensure that the Centre Questionnaire is completed in full and returned, electronically, to Central DAFNE at least 2 weeks prior to the audit visit. Ensure all DAFNE Educators, including Doctor Educators, complete all sections of their Audit Form A and return, electronically, to Central DAFNE at least 5 weeks prior to the audit visit. Ensure all DAFNE Educators, including Doctor Educators, complete all sections of their Audit Form D and return, electronically, to Central DAFNE at least 5 weeks prior to the audit visit. DAFNE F03.017, Version 7 April 2014 2 of 63
Ensure Audit Form E is complete and returned, electronically, to Central DAFNE at least 2 weeks prior to the audit visit. Ensure Audit Form F is completed and returned to Central DAFNE, along with copies of the course timetable(s) for all usual course timetables delivered by the centre, at least 5 weeks prior to the audit visit. Provide a room / desk space for the Auditor to work. Ensure that all Educators, including Doctor Educators, DAFNE Professional Development (PDP) files are up to date, with documentation correctly filed, and made available to the Auditor during the visit (should be placed in the room where the Auditor will work). The Lead DAFNE Educator must be available during the audit visit to answer any queries that the Auditor may have and to provide information to enable the Auditor to complete the Auditor Questionnaire. Times can be arranged with the Auditor on the morning of the audit. Ensure that the Educators delivering the sessions that will be observed during the external audit visit make all their lesson plans available to the Auditor. Ensure that the two Educators who will be observed by the Auditor each deliver one session, plus Dose Adjustment session during the morning of the audit visit and that each Educator leads on session 6 (each leading on half of the group). Ensure that the two Educators who will be observed by the Auditor have a core skills form and session learning outcome forms completed for sessions which are being observed and in their PD files Ensure, if at all possible, that the Lead DAFNE Educator is not involved with the delivery of the patient course during the audit visit. In situations where this is not possible (i.e. centres with only 2 DAFNE Educators), the Lead Educator must provide the Auditor with times during the day when they are not delivering sessions of the patient course and ensure that these periods are allocated to the Auditor. 5. The Centre Audit Questionnaire (Appendix 1) This questionnaire covers the implementation and organisation of DAFNE in your service, i.e. the process; such as: Data being collected pre and post course. Data being entered onto the database - someone responsible for data entry (in job description). Recruitment. How often DAFNE teams meet and evidence of this (e.g. minutes). Venue suitability/accessibility. Number of courses delivered. Number of patients trained. Follow-up arrangements post course. Cascading of peer review skills to colleagues for internal peer review process. DAFNE F03.017, Version 7 April 2014 3 of 63
User involvement DAFNE re-united, feedback on course, follow-up and service etc. Outcome data (pre and post course) from the database. This is available as a download from the DAFNE database. However the quality of the data generated will rely entirely upon the centre collecting the pre course and on-going post course data on patients and entering this into the database accurately Running a Courses Delivered report from the database which will enable the centre to check accuracy of certain elements of the data, and make amendments as required. It is the joint responsibility of the Lead DAFNE Doctor and Educator to ensure that this questionnaire is accurately completed and returned to Central DAFNE no later than 2 weeks prior to date of Audit. 6. Audit Form A (Appendix 2) Each Educator and Doctor Educator will have received a copy of Audit Form A for completion during the 3 year audit period. It is the responsibility of the Lead Educator to ensure the forms are completed and sent, electronically, to Central DAFNE at least 5 weeks prior to the audit visit. 7. Audit Form D (Appendix 3) Each Educator and Doctor Educator will have received an electronic copy of Audit Form D. It is the responsibility of the Lead Educator to ensure the forms are completed and sent, electronically, to Central DAFNE at least 5 weeks prior to the audit visit. 8. Audit Form E (Appendix 4) It is the Lead Educator s responsibility to ensure that all DAFNE Doctors and Level- 1 DAFNE Advisors at their centre observe a minimum of one morning dose adjustment session each year (ideally the session should be from mid-week onwards for maximum dose adjustment opportunities), and record the date of observation on Audit Form E. Lead Educators must add the names of any Doctors and Level-1 DAFNE Advisors that train during the lifetime of each Form E. This form must be completed and returned, electronically, to Central DAFNE at least 2 weeks prior to the audit visit. 9. Audit Form F (Appendix 5) The information from Audit Form F is used in assessment of the centre s current status regarding course delivery during the audit period. It is the Lead Educators responsibility to ensure all parts of this form are completed and that the form is returned, electronically, to Central DAFNE at least 5 weeks prior to the audit visit. 10. Auditor Tasks Gathering evidence of a system of on-going internal QA (i) Observing sessions of a patient course (½ day) It is essential that the Auditor is present during either the morning/afternoon discussions of dose adjustment or at lunchtime, in addition to observing other sessions. DAFNE F03.017, Version 7 April 2014 4 of 63
The external QA visit involves cross referencing internal and external QA to validate the centre s internal QA programme. This is not about peer reviewing the DAFNE Educator(s) delivering the patient course observed during the external QA visit. The external QA process is site specific and not Educator specific. The Auditor will not feedback to the Educators delivering the course. The Auditor will compare the Core Skills and Session Learning Outcome forms they have completed during their observation with the forms completed during internal observation along with the PDPs in the Educator s DAFNE PDP files, to provide external agreement with the internal QA process. It is therefore essential that the Educators they observe have been internally observed delivering sessions that the Auditor will observe and that their PD files are up to date The Auditor must have access to the lesson plans belonging to the Educators delivering the sessions observed. If the Auditor s comments do not agree with those recorded during internal observation they will discuss the discrepancies with the Lead Educator to establish if there are obvious reasons for this. If the matter cannot be resolved, the discrepancies will be recorded and fed back to the DAFNE Executive Educator sub group to decide if further investigation or training is required with regard to Educator skills and/or the internal QA process. (ii) Completion / collection of documentation and Questionnaires and meeting with Lead Educator (½ day) The Auditor will complete an Auditor Questionnaire (Appendix 6) which enables the Auditor to confirm and gather evidence that the centre has a robust internal QA system in place and that each DAFNE Educator, including Doctor Educators, has an up to date and accurate DAFNE Professional Development file. The Auditor will compare completed Audit Form A s with the details provided against the PDPs and Peer Review documentation (Sections 3 and 5) of each Educator s DAFNE PDP file. The Auditor will then speak to the Lead DAFNE Educator and record the centre s policy to ensure that all DAFNE Educators maintain their status and achieve development objectives outlined in their PDPs and that new development objectives are set. 11. Audit Outcome Report All audit documentation completed by the centre, DAFNE Educators and Auditor will be returned to Central DAFNE, where a report will be produced. Central DAFNE will score against standardised criteria, the outcomes of the audit based on evidence gathered during the audit visit, provided in the completed electronic audit forms and Central DAFNE training records. The report will include action plans to remedy any problems identified. Key data will be presented at the annual Collaborative meeting. DAFNE F03.017, Version 7 April 2014 5 of 63
Appendix 1 Centre Questionnaire For information only F03.023,Version 4 Oct 2013 DAFNE F03.017, Version 7 April 2014 6 of 63
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Appendix 2 Audit Form A For information only DAFNE F03.017, Version 7 April 2014 17 of 63
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Appendix 3 Audit Form D For Information Only DAFNE F03.017, Version 7 April 2014 22 of 63
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Appendix 4 Audit Form E For information only DAFNE F03.017, Version 7 April 2014 25 of 63
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Appendix 5 Audit Form F For information only DAFNE F03.017, Version 7 April 2014 27 of 63
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Appendix 6 Auditor Questionnaire For information only DAFNE F03.017, Version 7 April 2014 30 of 63
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