Taking stock

Occupational health advisers need to audit their own services before their
employers do it for them. This was the message from DoH chief nursing officer
Sarah Mullally last month at the launch of guidance Occupational Health Audit.

So how do OH nurses approach the task? We set out an extract from the
guidelines, written by a working party from the RCN Occupational Health
Managers’ Forum and the RCN Society of Occupational Health Nursing, and look at
two cases of how OH nurses have met their goals. By Fiona Clapson, Anne
Kennaugh, Margaret Mercer and Carole Miller

Audit is good practice and is carried out in many areas within
organisations. It ensures activities meet set standards and targets. Auditing OH
services is the same as auditing any other area of an organisation. According
to Widtfeldt1, OH nurses must be part of the trend in measuring the quality of
products and services they deliver.

Further research2 states that audit is a mechanism for continuous
improvement in which four factors are necessary. These are awareness of the
need for improvement; a willingness to improve, measurements and a product

Standards need to be set for OH practice and should be evidence-based.
Recent research by Dr Stuart Whitaker3 highlights the lack of consistency in
establishing standards, guidelines and auditing within occupational health.
Audit provides ways of measuring effectiveness of actions against a standard.

Clinical effectiveness is essential for quality OH nursing services. This
means using the best available research-based knowledge and clinical expertise
to achieve optimum processes and outcomes of OH intervention for employers and
employees.

Audit can be used to look at a specific activity in OH, or to focus on the
whole range of OH services to see if they are meeting the business needs of an
organisation. It can be done as self-audit – for example, periodic auditing of
record keeping – or by peer review. It can also be done through an external
audit by outside professionals which Macdonald1 considers the toughest form of
audit.

Audit benefits OH nurses, the business and customers. It can be part of
personal professional development for the nurse, it is a requirement of
business-wide standards for excellence and it improves the quality of service
to customers.

OH services vary enormously in what they offer businesses and there is no
uniform way of auditing them. When planning an audit, it is important to
recognise the desired outcome – different types of audit will produce different
benefits.

Health and safety

Many organisations have formal health and safety auditing systems in place.
The organisation’s safety adviser typically oversees these, but often OH
specialists are closely involved. They need to work with safety advisers, as
many areas require an integrated approach.

Key health and safety areas involving OH staff include:

– hazard identification
– risk assessment
– risk control measures
– health surveillance
– reporting and recording procedures
– management of first aid
– policy writing
– standard setting, procedure writing
– legislative compliance.

First steps

It is possible to audit one or more separate activities within the service,
either as a discrete function, or as a process within the larger organisation.

For an OH nurse’s first audit, it may be best to start with a specific
department activity. The nurse can use defined standards and criteria to
measure against and use the results to make an action plan for improvement.
Once improvement is shown objectively, the benefits of auditing can be
highlighted.

At the other end of the spectrum, it is possible to audit all aspects of OH
within an organisation. Agius4 states those issues of quality and audit must
address occupational health throughout the whole organisation and not merely
within the service.

There are many models that can be used for this approach. This guide focuses
on one model5 which looks at the structure, the processes and the outcomes of
health care. This is used extensively in health care settings and is the model
advocated by the Faculty of Occupational Medicine in the book Quality and audit
in occupational health6.

Audit structure

It is possible to audit each section in isolation or to combine them to
audit all aspects of OH in an organisation.

The occupational health structure includes the resources, human and material
that are in place to allow OH to function effectively. These include having the
budget, equipment, clinical and information technology facilities, reference
materials, books, journals and databases and policies

Occupational health processes include all the steps that OH nurses and
management must do to practise effectively. The emphasis must be on auditing
the whole sequence. Processes include: pre-employment screening, pre-placement
screening, health surveillance, statutory screening, management referrals to
OH, ethics and confidentiality and sickness absence management.

The audit will determine whether the process meets the standards. For example,
clinical audit is a process audit. Clinical procedures that can be audited
include: lung function testing, audiometry and blood pressure testing

Occupational outcomes are probably the most difficult area to evaluate and audit.
It involves measuring the results – that is the success of OH interventions –
looking at whether the health of employees is improved. Outcome measures
include: sickness absence trends, work related ill-health and accident
incidence trends, civil claims experience, health needs assessment, comparisons
of serial general health questionnaires and success of health promotion
initiatives.

Baseline audit

This approach may be used when a new company is purchased by an
organisation, or an OH provider takes on a new contract.

It can involve auditing existing facilities, equipment, resources and
policies in relation to the health risks of the organisation. Results can be
used to develop targets and objectives to improve the service. A date can be
set to assess future progress against the plan.

Where no OH service exists, a baseline audit can determine what level of
service is appropriate.

Customer satisfaction audit

Such an audit can highlight differences between the expectations and
priorities of customers and OH staff.

OH customers may include employers, employees and others involved in the
process. Customers can be questioned to see whether the OH service is meeting
their needs. The questions should relate to the customers and their
expectations from the service. For example, line managers expect to receive a
prompt response when they refer someone to OH. The standard may be part of a
service level agreement, which sets a time for responses. This can produce
quantitative measurements. Other service delivery standards may elicit
qualitative measurements such as line manager’s opinions on the quality of the
reports.

Employees can be asked about waiting time for appointments, speed of results
for tests, confidentiality and privacy and professional approach.

Cost audit

OH nurses must periodically review costs and benefits of the services they
provide. This can help focus activities, prioritise actions and justify whether
more resources are needed. Questions include: why is this activity done? What
does it cost in OH time, employee time and money? What improvements can be
made? Can it be done more effectively? What are the benefits to the
organisation and to the business?

OH advisers involved in other areas that have financial implications for an
organisation, for example sickness absence management or ill-health retirement,
can audit these areas to ensure standards are met.

These guidelines do not provide all the answers to auditing OH services, but
intend to stimulate practitioners to appreciate the value of setting standards.
Audit is an important measuring device for occupational health and is essential
for continuous development of services.

References

1 Widtfeldt AK, 1992, Quality and Quality Improvement in Occupational Health
Nursing. AAOHN Journal, Vol 40, No 7, pp326-332

2 MacDonald EB, 1992, Audit and Quality in Occupational Health, Occupational
Medicine, Vol 42, pp7-11

3 Whitaker S,1999, Bridging the Theory-Practice Gap. RCN Society of
Occupational Health Nursing, Spring 1999

4 Agius R,1997, Quality and Audit in Occupational Health.
www.med.ed.ac/new/quality.htm

5 Donabedian A and Rosenfield LS,1968, Criteria and Standards for Quality
Assessment and Monitoring Quarterly Bulletin Vol 12 pp99-108

6 Faculty of Occupational Medicine,1995, Quality and audit in occupational
health London: Royal College of Physicians

Fiona Clapson is chief nursing officer at BT, Anne Kennaugh is operations
director, Marsh Health, Margaret Mercer is OH adviser at Unilever and Carole
Miller is regional OH manager for Cheviot Artus

Occupational Health Audit – a Practical Guide for Occupational Health
Nurses is available from the Royal College of Nursing on 020-7409 3333 or RCN
Direct on 0345 726100

Putting audit into practice: Unilever UK

Why? Unilever UK has audited its occupational health services since
1993. It was initiated after safety professionals, as part of health and safety
audits, started auditing its OH departments. The occupational health module
used did not give any indication of the quality of OH, but instead focused on
first aid and occupational hygiene, so it was decided to write an internal
audit.

The aim The Occupational Health Audit provides a structured process
for reviewing OH services and management systems on company sites. The aim is
to allow continuous improvements to be made to the business.

How? The evidence for the standards we use stem from: mandatory
legislative requirements, professional standards – UKCC, GMC, HSE, DoH, Faculty
of Occupational Medicine, RCN and industry specific groups – and company health
and safety standards.

Key elements of the audit include a workplace visit, survey of OH facilities
and equipment, review of documentation, customer evaluation and feedback of
information.

At the end of the audit, there is an informal feedback to management and OH
staff. The auditors then forward a written report. The recommendations enable
the site to produce an action plan to maintain or improve standards.

The audit has not been a static process. Various changes have been
incorporated over the years and when the sites start to score very high scores
then we have to raise the standards and hence we have continuous improvement.
At present we are reviewing the audit process to include it under the umbrella
of clinical governance.

Who? A senior OH nurse adviser and a senior OH physician conduct the
audit. It takes at least a full day and includes interviews with OH staff, site
management, safety advisors and users of the service.

Results The audit has been a very successful tool for raising the
profile of occupational health at senior level on sites. All site general
managers tend to be competitive and want their sites to have the best
occupational health department. At the end of the day, they want a score and if
it is not good they want to know why.

This is a powerful method to improve OH provision on-site.

Margaret Mercer is Unilever’s senior nursing adviser UK

Assessment following restructure

An organisation had benefited from a limited, in-house occupational health
service for more than 20 years. It had moved forward during the last three
years, since the appointment of a principal nursing adviser.

Due to market pressures, production processes within the organisation were
redefined, as were employee skills. With decentralisation, there were increased
pressures to reduce staff numbers and costs. Corporate results showed mixed
performance from the divisions. The historically paternalistic and caring
culture of the company was under threat from recent performance figures,
downsizing, reorganisation and the appointment of a new finance director, with
a ruthless remit to reduce costs.

OH overhaul

Soon after the nursing adviser was appointed, she decided to introduce some
formal performance measurement of the occupational health service operations
for management. In agreement with her manager, she decided upon four key
performance indicators:

– Review of OH services – delivery/range and frequency

– Sickness absence – incidence of illness and disease

– Accident rates

– Employee claims against the firm

A number of new OH services and policies were introduced including
non-statutory health screening for drivers, alcohol/drug and smoking policies
and stress management.

Measuring value

The need for audit was highlighted when, in the middle of the restructuring
process, the nursing adviser was questioned about scope for improvement in
service delivery. OH may be offering good programmes with an eye to best
practice, but does the customer value them?

The first aim is to set objectives for the service, which tie into the
business aims. It will then be possible to demonstrate achievement of quality
and value for money – performance measures the service’s efficiency,
effectiveness and economy.

So in this very competitive environment, has attention been given to the
specific needs of the business, the audit process, customer service skills and
the perceived cost of the OH service?

Carole Miller is regional manager of the Cheviot Artus

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