|Name of Health Department/Agency:
||Carson City Health and Human Services
||Internal auditing process
|| Fishbone Diagram, Histogram, Root Cause Analysis, Bone Diagram, Process Illustration
|Description of the process and intervention:
||The agency was using an outdated lab auditing tool that was working inefficiently. To ensure compliance with the lab licensing agency, to improve the flow of staff and clients through the lab, and to enhance lab efficiency and quality, the team decided to revise the quality assurance internal audit log for the onsite lab. Using a fishbone diagram, a root cause analysis revealed a lack of formal lab monitoring and follow- through. The goal was to ensure that 95% of components on the tool will pass the audit. The improvement theory was that if the internal lab audit yields consistently high marks, then the lab will be operating in a high quality manner and all external audits will be successful. To test this theory, the audit tool was revised and audits were conducted four times (one baseline and three audit trials). In each iteration, the team made changes to the tool and lab setting based on results from the previous audit. Data collection consisted of counting auditor changes.
||As a result of the new auditing process, data revealed that 89% of components on the tool passed the audit with only three items remaining in need of change.
||To meet the goal of having 95% of components on the tool to pass the audit, an additional audit will be conducted. After this audit, the tool will be finalized (pending that no additional changes are needed) and a quarterly audit process will be implemented.