OH audit: Health check

If you had the time or the inclination, you could probably have quite a good semantic discussion about whether occupational health (OH) should ever be considered a core business function. Yes, it may not physically be out there making widgets or sealing contracts, but arguably what could be more ‘core’ than a function that keeps people at work, operating at peak productivity, and gets them back to work quickly when they have been off sick, particularly in a recession?

Sadly, the nuances of such a debate are, for the time being, probably going to be lost on most hard-pressed management teams desperately looking to shave percentages off their bottom lines wherever they can. It is clear that, so far, spending on health and wellbeing has remained remarkably robust during this recession. Back in July, for example, the Chartered Institute for Personnel and Development’s annual absence survey of more than 600 firms found that just over a fifth planned to increase their spending on employee wellbeing in the coming year, which sounds good, although it compares with nearly four out of 10 in last year’s survey. Yet just 7% said they actually intended to cut back on spending, with nearly half expecting spending to remain relatively static.

Similarly, research by the Institute for Employment Studies in August argued that, for more than half of the employers it polled, wellbeing was now, if anything, more important to them in the current economic climate. Yet, perhaps unsurprisingly, there was a growing emphasis on improving absence management and “shoring up policies”, as well as “more systematic monitoring of any problems”, it concluded.

We are increasingly, therefore, seeing more scrutiny of how OH budgets are being spent, how departments and individuals operate and perform, whether providers are giving value for money, and whether employers feel they are getting an adequate return on investment. While this scrutiny can take many forms, one option becoming more common is to carry out an audit of the OH service – something that can often be a precursor to a wholesale reorganisation of the department, a change of contract provider, or even switching from in-house to outsourced provider.

What will an OH audit normally cover?

  • Key service objectives, processes and procedures, contractual arrangements

  • Key performance indicators, benchmarks, service-level agreements

  • Quality of clinical recommendations and any commercial application

  • People, IT systems, budgets

  • Integration within the business and understanding of the core business objectives

  • Whether it is profitable or generates external revenues

  • User feedback

  • Options for additional services or alternative delivery or providers.

Reasons for audits

“Often there is little sense that the people providing the OH service should be being treated like any other supply chain within their organisation,” points out Charlotte Bray, OH consultant at Aon Consulting, which launched an OH audit service in October 2008 and has seen demand for it growing ever since.

“Often the penny has not dropped that they should even be measuring the service, that they need to have service and contract levels, and potential financial penalties attached to not meeting them,” she adds.

But it is also important for OH practitioners to recognise that an audit may not always be a negative experience, she stresses. It might, equally, highlight good points or areas where more investment, modernisation or expansion is needed.

“It may not necessarily mean that roles are going to get lost. It may simply be that a service needs to update its technology or become more efficient in its metrics and measuring,” Bray suggests. “Quite often it is good for OH advisers to be challenged, and for the quality of their work or their reports to be reviewed.”

Nurse consultant Helen Kirk, managing consultant at HK Consulting, has audited about 40 firms, and argues the recession is not the only factor driving this increased scrutiny of service providers.

“Most often it has been driven by two things: first, to get value for money; and second, to transform OH working practices – to improve effectiveness and cost-effectiveness,” she explains.

“I’ve seen a trend towards organisations looking at how they can work together – audit is a good way to identify what is in place, and then decide how and if resources can be shared for mutual benefit. This often reduces the cost of the service.

“Some organisations are interested in investing the money they have back into the best possible OH service. Others face intense pressure to save money, so will reduce their investment in OH. This might be seen as a step backwards for OH, but in the longer term we’re more likely to persuade employers to invest more in OH if they see that money is being invested wisely and is showing a return,” she contends.

Standards agenda

Then there is the wider standards agenda, as set out by national director for health and work Dame Carol Black. Her drive, as outlined within her Working for a Healthier Tomorrow review of workplace health, to improve research into OH, set common standards of practice and benchmarks and even the accreditation of providers, all feeds into the employers’ desire to know that what they are paying for is what they are getting.

“OH service accreditation is just round the corner,” predicts Kirk. “Not everyone will welcome this, but it is what patients expect in the 21st century. We can complain about the large number of standards in healthcare, but people really do care about them.

“We should have just as high standards in OH as everywhere else in health services. In the future, and given the choice, I’d want my OH care from registered OH practitioners working in an accredited service. These things might not guarantee a good experience, but they let me know that some of the key things are in place,” she adds.

So, what should an OH audit cover, how should practitioners prepare for the experience, and how scared should they really be?

Audit areas

Taking what an OH audit should cover first, Mark Holt-Rogers, managing director of consultancy Wellbeing4business, suggests a good audit will probably need to look at six areas:

  • People – whether you have the right mix of people, the right training, clinical governance and corporate governance structures, the right mix of skills, expertise and abilities

  • Processes – what processes are in place, and how they can be improved, made more valuable and effective

  • IT systems – how new they are, whether they are ‘fit for purpose’, and whether they are being used to their full potential

  • Budgets – how is money being spent and allocated, what budgets there are for investment

  • Its integration within the business, within HR and more widely

  • Whether it is profitable or generates any external revenues.

“An audit is there to show positives and negatives. It is there to enlighten organisations about what is good with OH as well as what could be improved. Often what people find is actually how effective OH is being for them, and see what is actually working well,” Holt-Rogers stresses.

“Three things will tend to come out of an audit. First, what is the value of OH; second, what is its effectiveness; and third, how efficient is it?” Holt-Rogers adds.

Aon, in turn, says its OH audits will normally include:

  • A review of key service objectives against most pressing and changing business needs

  • A review of all policies, procedures and contractual arrangements

  • A review of all management information against key performance indicators, benchmarks and service-level agreements

  • Assessment of the quality of clinical recommendations and their commercial application

  • Comparison of user stakeholder feedback to assess overall efficiency and effectiveness of the service, and whether metrics are measuring the right things

  • Recommendations to optimise use of the existing OH resource and services and advice on exploration of additional services, including alternative delivery options and providers where appropriate.

Length of time

“I gather quantitative data using a very broad clinical governance framework. Perhaps more important is the qualitative work that goes with this – I use interviews and meetings not only to enrich the review but also to sow the seeds of change. In this regard, my auditing methodology is more like performance coaching,” adds Kirk.

How long an audit takes will inevitably depend on the complexity of the service and the organisation and what the audit is being tasked to look at, she suggests.

“There is no one timescale. This depends on what the commissioner wants to achieve. There is value in auditing single issues – such as clinical record-keeping – which might take half a day.

“My own work tends to take days to weeks – my passion is not for the audit but for coaching the team and transforming the service. Telling people that they can do things better counts for very little. Working alongside them to improve is far more rewarding,” Kirk says.

Positive experience

This need for there to be an educative as well as a scrutinising process is vital, agrees Holt-Rogers, as it is all too easy for the audit process, especially if it seen as a precursor to jobs being lost or roles redefined, to become a hostile or confrontational experience.

“There has to be education to ensure that the process is not seen as intimidating or hostile. And it has to be confidential so people can say what they want or need to say. There may be, for example, team or communication issues and complexities. Unless everyone buys into the process, it is not worth doing,” he explains.

“An audit can sometimes show that it is better to keep a service in-house rather than outsource it. But we are in a commoditised marketplace, and there is no benefit in anything unless it is put together,” he adds.

The message needs to be got across that this is about improvement, not ticking off or Big Brother, agrees Kirk.

“Getting the auditors in is intimidating and OH practitioners can feel resentful that their professionalism is being scrutinised. Others see it, as I do, as an opportunity to show off good practice, learn from their peers, and improve the service to patients,” she says.

Audit request

Often what happens is that a letter will be sent from the client to the provider asking them to participate in an audit, says Bray, normally of course a ‘request’ that the provider will be unable to refuse. Intriguingly, since the launch of the Aon service it has yet to audit an in-house OH service, with most of its work so far having been done with private providers, she adds.

As to how a practitioner should prepare for the potentially difficult experience of an audit, Bray argues that it will probably depend on the seniority of the practitioner and the sight they have of the service. It makes sense to check that you are adhering to your relevant standards, such as obtaining consent processes and so on, and not making any elementary errors. But for an OH auditor working on the ‘front line’, so to speak, it may be that, in reality, they have a relatively narrow view of the service and what is being provided, and therefore what can or cannot be improved.

“It can be quite difficult for an OH auditor to be thinking about things like a service redesign because they are not going to be in a position to be aware of how it could potentially be changed,” Bray points out.

Kirk agrees that it is hard to prepare for something that is supposed to be reviewing how you operate on a normal, day-to-day level.

“If there is some preparation then it should be that we look towards improving what we do all the time – let’s not wait for an auditor to tell us we’re not doing all we can to offer effective and cost-effective support to workers,” she suggests.

“Audits will look at every aspect of delivery of the OH service. What are the gaps between what the client wants and what is being provided?” agrees Les Smith, managing director of consultancy Health and Wellbeing UK. “Is it a real gap or just a perception gap, or something caused by misunderstanding? Then you may have to go back and re-engineer the service much more closely to meet the client’s needs. It is more than just rejigging the service; it is looking at much more focused delivery.”

Avoiding demotivation

And the key to prevent the process being seen as threatening or demotivating is simply constant communication and explanation, Kirk says.

“Service review isn’t a demotivating threat, but it might identify one. Sometimes an audit is instigated to measure a service requirement as a precursor to outsourcing, but it isn’t the reason for the outsource. In any case, outsourcing isn’t necessarily a bad thing. Sometimes it means that a long-­ignored service – ‘not core business’ – becomes part of an organisation that really cares about OH,” she points out.

“It’s not an inspection – there is no pass or fail. I have never come across an organisation that genuinely believed the service couldn’t improve. If, during the review, an issue is explored and it is clear that there’s a gap, then it is known at the time. Also I look for evidence from multiple sources – an observation is something seen once; a real finding is something found in different ways or at different times,” Kirk says.

“At one hospital, my audit was followed by an outsource. However, I was called in to address major service problems and confidence in the service was already very low. Although the OH service was transformed during the year, the battle to retain an in-house service was long since lost,” she adds.

“OH practitioners who aren’t part of a great service should feel threatened,” she stresses. “Why should anyone pay for the service if it isn’t making a great effort to be as good as it can be?”


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