Audit of the Sedation Practices and Procedures of a Health Care Facility - Research Paper Example

?Cover Page The National of Ireland Royal College of Surgeons in Ireland Institute of Leadership MSc in Healthcare Management Semester 1 Evaluation, Measurement & Research Student ID 13131796 Table of Contents Part A I. Introduction II. Literature Review III. Importance of Evaluation, Measurement and Research in Healthcare IV. Rational for Audit V. Best Practice in Sedation VI. The Audit Scope, Objective, Criteria and Standards VII. Audit Evaluation: Performance Indicators and Proposed Data Collection and Analysis VIII. JCIA, NICE and ASA standards on sedation IX. Audit Implementation Plan Part B I. Reflective Learning II. References Part A: Healthcare Research Audit Introduction This paper is a proposal for an audit of the sedation practices and procedures of a health care facility. Sedation is a process by which a patient’s irritability, pain and agitation are reduced using a special type of drugs. In many cases sedation is applied to accompany medical and diagnostic procedures. Among the common sedative drugs are ketamine, fentanyl and propofol. Among the procedures during which sedation is applied are minor surgeries, cosmetic surgeries and removal of teeth. Different methods of sedation are ideal for different medical conditions, treatment and diagnosis. The sedation methods are inhalation sedation, intravenous (IV) sedation and inhalation sedation. From the use and implications of sedation procedures, it is apparent that it is such an important medical or diagnostic procedures that health care practitioners ought to value. It is for these reasons that professional organisations such as the JCIA (Joint Commission International Accreditation), NICE (National Institute for Health and Care Excellence) and the ASA (American Association of Anesthesia) have come up with standards by which health care institutions, practitioners and governments can offer, evidence-based, patient- and results-oriented services may be provided. These standards are equally important for sedation procedures as they are for other practices in the health care fraternity (Brown et al., 90). To help governments, institutions and individual practitioners, NICE and the ASA carry out training; counseling and publication services for purposes of helping stakeholders improve health care quality, safety and efficiency. The other key function of the NICE and the ASA is to outline standards for health service facility accreditation. Thus, the core goals of NICE and the ASA are improvement of safety of high-alert medications, access to care and continuity of care, provision of ongoing care from multiple clinics, upholding of patient and family rights and patient assessment and quality improvement and patient safety. This paper proposes an audit of the sedation procedures of a health care facility. In this context, the evaluation, measurement and research of not only the sedation procedures but also entire health care management will be emphasised. The objectives of the audit are: to identify and promote good sedation practices, to achieve improvements in patient care, to avail information on the effectiveness of sedation services, to emphasise sedation problems and propose solutions and to improve team work and communication in the health care sector (Dartford & Gravesham 3). For quality and comfortable sedation procedures, NICE and the ASA expects institutions and individual health care practitioners to follow certain standards. The key goals of these standards are to ensure health and social care practitioners make decisions based on the latest evidence and best practices and to find information on quality services and health care. Third, the standards require health providers to quickly and easily examine their performance and their improvement standards. The other function of the standards is to assure clients that the services they receive are of the right quality, patient-centered and cost-effective. The NICE standards are contained in the new Clinical Commissioning Group Outcome Indicator Set (CCGOIS). Also to be used as the basis for the audit is the JCIA, which has also aligned its standards to those of NICE and ASA. The NICE and guidelines for sedation against which the audit will be compared provides standards for pre-sedation assessment, training of sedation personnel, drug misuse (opioid detoxification). The standards encompass several recommendations for healthcare professionals such as nurses, anaesthetists, doctors and dentists. Literature Review A review of past and current study reports and literatures explore the ideas of evaluation, measurement and research (EMR). In most, if not all of these literatures, the focus is on the need for health care facilities uphold or comply with the local, national, regional and international guidelines and standards on evaluation, measurement and research. Sedation is one medical practice about which standards must be adhered to if a facility has to remain compliant with standards set by professional and regulatory bodies such as NICE, JCI and the ASA and other accreditation standards set in their areas of operations. RCSI Consultancy Services assert that the first reason evaluation and measurement are essential in the successful implementation of health care services is that it ensures that only evidence-based practices are used in service delivery (RCSI Consultancy Services 12). Kousholt also adds that at the institutional and individual levels, evaluation and measurement help direct and support current and future success of health care units and services, more so with regards to viable initiatives. According to Sawyer (34), evaluation and measurement create and improve awareness, prioritization and coordination of efforts among health care stakeholders. He further states that through an evaluation or an analysis of research findings on diseases, treatment and their effects, health care practitioners are better placed to collect and aggregate data and model medical procedures such as sedation. Kousholt (45) supports this use of EMR by saying that the collected data may be used to estimate mortality and morbidity associated with the identified conditions and procedures. In the opinion of S World Bank Institute Sawyer, evaluation and measurement help in indicating to practitioners and regulatory bodies any changes in epidemics and consequences of diseases and medical or diagnostic procedures (Sawyer, 34). He adds that individual data from facilities and private practitioners in the health care industry can be best placed to track and coordinate their data and efforts even to the global levels, in the process acquiring and spreading emerging best practices, preventing duplication, and identifying additional resources and strategies (Sawyer, 34). Evaluation also helps in the assessment of the planning and implementation of financial strategies. Importance of Evaluation, Measurement and Research in Healthcare An apparent importance of evaluation and measurement discovered in the literatures reviewed is in their use to determine the appropriateness and effectiveness of a medical or diagnostic procedure or an intervention. This use is often more obvious in interventions that are still under experimental trials. Once used to assess the effectiveness of an intervention evaluation and measurement data can be used in planning, prioritization and operational interventions and programs (Sawyer, 34). According to the World Bank Institute, although program experimental trials are normally conducted in small scales, once such interventions are proved to be effective, the real interventions are conducted on large scale. It is at this stage that evaluation data can be used to monitor and predict the outcomes of large scale health programs (World Bank Institute 43). Of great importance to health care programs is on-going evaluation, which program implementers use for improvement purposes as well as to promote program sustainability. Research is the other practice in healthcare that is quite related to measurement and evaluation. In fact, all these aspects interconnect with regards to their application in proposing changes to different services offered to patients and their loved ones. In normal circumstances, researchers and auditors of healthcare services use the obtained results to improve service delivery. Formative and intervention research are the two common approaches to research used to collect data and outcomes for program improvement. According to Nicholson and Duncan, intervention research is important in the management of health care systems. They also opine that the main purpose of intervention audit and research is to assess a program’s effectiveness and reliability. In addition, they state that EMR is also used to examine a program’s efficacy, if all conditions, factors and forces are ideal and in real conditions. Intervention research also find use in the evaluation of the possible approaches to implement, adapt, scale up, and sustain over a given period of service delivery (Nicholson & Duncan 73). In particular, health care facilities conduct randomised trials with the objective of establishing the highest possible standards and conditions for intervention research and programs. From such trials, stakeholders are best placed to make rigorous and professional conclusions on the effects of a proposed intervention and their causal implications (Sawyer, 49). Given that randomised trials are not really feasible, other approaches to research are used in health care. These approached include interrupted time series, pre-post comparisons and waitlist comparisons (Sawyer, 78). Literatures have also largely explored the reasons that sedation and other medical procedures need to be evaluated. First reason, according to Potter is that program evaluation helps to ascertain whether the expected objectives are achieved or whether a program is on track towards the realization of both short- and long-term objectives (Potter, 67). That is, evaluations give program manages, owners and financiers a feedback for performance assessment and improvement purposes ((Sawyer, 34). Thus, organisations and individual stakeholders in health programs should form a habit of sharing and disseminating evaluation results and best practices so that the impacts of evaluation may reach all stakeholders (Harrison & Lock 22). Once the benefits of evaluation are recognized and appreciate, it would become easier for stakeholders to engage in rigorous preplanning and evaluation of programs, resulting in data that can be used in measurement systems for performance improvement (Sawyer, 118). An area that is not quite emphasised in literatures is the importance of measurement, research and evaluation in the assessment of patient needs. Instead, a lot of emphasis is on clinical guidelines and standards that practitioners have to follow or face fines or disapproval. Hence, more literatures and studies should focus not only on the current professional trends and efforts, capacities, health care infrastructure and priorities but also on the wellbeing and rights of patients, their families and carers (Young-Hoon 5). Rational for Audit Just like any other health care service, sedation procedures and practices require constant, if not periodic audit. First, in many jurisdictions, conducting an audit of a company or any other organisation is a requirement of the law. Thus, the relevant law enforcement agencies and other regulatory authorities may demand for an audit report of the sedation practices, services and procedures that a health care facility offers (Sawyer, 62). Second, an audit of the sedation practices of a facility would help confirm its claims on the quality of services it offers. Hence, it is highly recommended that the services of independent and fair auditors are sought for meeting such objectives. Moreover, a clear picture of the final status of a facility’s sedation services and the processes by which these services are offered is ascertained via an audit (Potter, 102). The other rationale for conducting the audit is for the benefit of investors and other shareholders who own the facility in one way or the other (RCSI IL Learning Resources 6). In many cases, some shareholders are not quite closely linked to a facility in its daily operations. Thus, an audit helps in giving such shareholders a clear and trusted opinion and picture of a facility’s services and processes. An audit would not only give an insight into how sedation processes in a facility ends but also how they are started and their movement through various stages to the final stage (Stufflebeam & Webster 19). The key approaches to evaluation to be applied in this audit include the objectivist approach, which uses the elite or managerial and the mass or consumer perspectives. Under the managerial approach, the methods that will include experimental research, management of information systems, testing of programs, using objectives-based questions and content analysis. Under mass or consumer perspective, accountability of the systems will be evaluated. While the former perspectives values best practice-driven decisions and policies, the former focuses on consumer-oriented practices. The other approach to be used is the subjectivist or institutionalist, which applies the elite/professional and the mass/participatory perspectives with client-centered services and accreditation as the key goals. Best Practice in Sedation In auditing its sedation practices and processes, it is of the essence that a health facility identifies and outlines the best practices in this area and uses these practices as the benchmark for the audit and future strategisation. The key areas in which best practice in sedation may be viewed are distress, fear, attention and pain. Stress is among the most important aspect of sedation that if managed well, results in a successful sedation. However, each o f the mentioned aspect of pediatric distress, which is fear, pain and attention, ought to be addressed. For proper fear management, health care providers ought to minimize the effects of patients’ lack of knowledge of what to expect, lack of control over the procedure, and the fear associated with physical vulnerability, all of which contribute to the heightened sense of fear associated with sedation. Best practices for reducing the sense of vulnerability are the use of minimal restraint. In such strategies, patients are placed on a pillow case, on an incline rather than on a flat surface against a table, a posture that restrains a patient’s arms but still allows for sufficient mobility. Thus, this position helps make patients feel less vulnerable. There are certain post-sedation practices that health care providers must apply to make a sedation experience less distressing. First, it is important to observe a patient until the peak of the effect of sedation occurs. That is, keen observation must be done until the pre-sedation consciousness is achieved. For children undergoing moderate to deep sedation, it is advisable that a parent or other adult accompanies the patient. The other best practice is the provision of a 24-hour contact number for patients who have undergone moderate to deep sedation. The Audit Scope, Objective, Criteria and Standards The proposed audit intends to cover all the aspects of sedation, including the range of patient responses to different sedative or analgesic agents. Second, the audit intends to explore the recommended procedures for clinician seeking to achieve moderate sedation. The other objective of the audit is to establish the knowledge base of the facility and its staffs in relations to the pharmacokinetic profiles of the sedative agents normally used in the facility (Reeve & Peerbhoy 32). The pharmacokinetic knowledge to be assessed encompasses area such as agent concentration, time, volume and elimination methods. Also to be assessed in the audit is the staffs’ abilities to undertake clinical estimations of the necessary sedation dosages. The audit will also test the staffs’ ability to allow for enough time to elapse between doses for the assessment of the effects of a drug prior to the subsequent administration of other doses (Rossi & Freeman 45). The audit scope will also cover the various patient factors that affect their response to sedation. These factors include morbidity and organ system abnormalities. The morbidity sub-factors are difficult airways, risks of aspiration, reduced tolerance and paradoxical reactions to standard sedatives. The organ system abnormalities could be short neck, reduced mouth opening, sleep apnea, obesity, large tongue and anatomical abnormalities. Other abnormalities are tobacco, alcohol, or substance abuse, allergies, neuropsychiatric disorder, drug interactions acute upper gastrointestinal bleeding, gastric outlet obstruction, delayed gastric emptying and achalasia. The audit will also cover aspects of sedation such as synergistic effects, onset of action, intravenous access, reversal agents and the use of supplemental oxygen. Among the post-audit indicators to be evaluated and reported are as in the table below Category Key Post-Audit Indicators Reported to Client satisfaction Reduced average sedation time Average post-audit occupancy CEO/Chief administrator Environmental Average resource consumption due to sedation Entire sedation team Finance Reduced contingency utilization of finances Chief finance officers and facility administrators Personnel Reduced accident rates All health care staffs Compliance 100% compliance with NICE standards Administrators Processes Progress within programme Reduced accidents Entire sedation personnel The clinical audit process will entail the submission of survey or questionnaire tool for approval and receiving inputs from service users, patients and carers via surveys for measuring compliance against NICE and the ASA. The other processes that will be undertaken include the identification of clinical concerns by collecting user views and complaints, unusual and risky incidents, near-miss reports, reports of critical incidents and the identification of priorities such as risks and costs. The following plan is proposed for the clinical audit. The cycle below summarises the audit activity to be followed (Dartford & Gravesham 3) Audit Evaluation: Performance Indicators and Proposed Data Collection and Analysis Health auditors normally seek to establish whether their audits have met the objectives. There are several metrics that can be applied to evaluate whether an audit is successful or a failure. The six key metrics or measuring sticks by which the success or failure of an audit may be established include: reduction in sedation-related malpractices, improved compliance, indicated by reduction in the cases of malpractices, disapproval, fines and enforcement actions. Other valid measuring sticks for audit evaluation are reduction in the number of audit findings, especially, high-risk audit findings and a reduction in the number of repeat audit findings. On-time closure of audits also indicates that it was successful. In fact, the latter metric is the most useful indication of the success of an audit exercise. The measures may be generally categorised as internal and external measures. The value of the proposed audit will be mainly ascertained by the improved compliance with NICE and ASA standards, as will be defined by the reduction in sedation-related malpractices, accidents, fines and enforcement actions from regulatory and accreditation organisations. This metric is particularly useful in scenarios where enforcement and fine are the main courses of action for malpractices. A reduction in the number of high-risk audit findings would also indicate that past audits were successful. That is, it is expected that the number of high-risk findings should reduce as a health facility is audited in subsequent times. The key performance indicators for the audit are established depending on the role of the various functions of the audit, more so as a catalyst for change in sedation practices and procedures. For the function of audit plan delivery, which is the number of audits delivered compared to the planned number of audits on the audit plan, the actual plan completion will be compared with the planned completion. For audit reporting after the completion of fieldwork, the percentage of draft reports issue within a specified period after completion of fieldwork. Regarding the issuance of final report, the issuance of the final report after the draft could also indicate the performance of the audit. Regarding quality, whether customers are satisfied or not will be evaluated. For instance, the target satisfied customers could be 80%. Second, the number of actions implemented by the due date could also indicate performance. Quality will also be measured by the number of extent of audit completed within the planned time budget. The audit’s KPIs will also be based on the improvements and savings accrued. That is, how much improvement, cost saving and risk reduction will have been occasioned the internal audit process and departments. Findings and observations, compared to previous years and repeat findings could also be indicators of performance. The other key KPI will be the objectives of the audit of effecting valuable change. In this regard, success will be measured from the perspective of the customer, not necessarily by the number of audits conducted or the time between audits, meetings and issuance of reports. For an illustration, many reports and recommendations do not necessarily result in value for customers. That is, the customers must see value in such reports and recommendations. The table below shows the NICE and JCIA standards that the audit we be based upon. JCIA, NICE and ASA standards on sedation Standard Description NICE Use of anaesthetic agents: ketamine, opioid combinations, propofol, sevoflurane Specialized anaesthetic equipment for sevoflurane, qualified personnel (doctors with relevant training) to administer sedation. Full details of training and competencies Airway rescue skills Formal and continuous training in airway management for moderate and deep sedation Development of accredited training programmes, training and assessment on airway complication management Sedation venue Deep sedation should not be done outside hospital environment, additional anaesthetic support must be availed at sedation venues Sedation committees A multidisciplinary approach is recommended The committee to define sedation limits and practices, review best-practices and lessons learnt from audit cycles JCI Qualification Qualified personnel must perform various modes of sedation, monitor patients and manage all the adverse effects, especially airway related issues Nurse and physician education program must be developed on sedation techniques, medications and responses Sedation location equipment and monitoring Pre-sedation assessment must be done Sedation venue and recovery room must be well equipped with monitoring and emergency resuscitation systems. Routine monitoring of heart rate, EKG, and pulse oximetry. Availing emergency equipment Documentation Informed consent must be obtained and procedural and recovery monitoring and documentation conducted Nurse and physician to conduct pre-sedation evaluation, assessment and documentation on medical history, current medication and history of adverse effects. The table below contains the measurable elements to be targeted by the audit Audit Implementation Plan The type of audit proposed is the horizontal audit. Since sedation is practised across different departments in a healthcare facility, the horizontal audit, which evaluates a process or activity across many departments within an organization, is quite appropriate. In addition, sedation is the same across departments, regardless of the nature of illness a patient suffers from. The reason this audit type was chosen is that it is appropriate for processes and activities that are similar across a number of departments. Hence, the audit would assess the effectiveness of the common approach used in a healthcare facility. Among the activities to be undertaken in the execution of the plan are: creating the audit in the facility’s system, attaching the audit checklist to the actual audit and contacting the lead auditor, searching for the last audit and its report, assigning a question list to the audit, the auditors record replies to the questions and note any deviations and problems. Then the lead auditor valuates the questions and determines whether or not any corrective and preventive actions are required. Then, the lead auditor will value the audit based on the valuations of the individual questions and, if required, will change the valuation proposed by the system. The lead auditor will then print the questions with replies and discuss the question list with all audit participants, and, in conjunction with the audited area, will determine corrective/preventive actions for the audit, if these are required. The people responsible and planned dates will then be entered for these actions. The lead auditor will then track the actions and complete them. The lead auditor will then rate the audit and establish the indicator “Subsequent Audit Required” if the overall assessment is “not satisfaction. [Organizational Logo Here] Audit Plan Type of Audit Clinical Audit Objective/Purpose To improve sedation care and outcomes via a systematic review, assessment and evaluation of NICE and the American Association of Anaesthesia’s explicit accreditation standards. To identify and appraise the existing evidence of best practices in sedation To promote the application of best practices in sedation To ensure the desired sedation outcomes are achieved Standard (Criteria) NICE and the American Association of Anaesthesia Accreditation standards Scope All aspects of sedation care Auditee & Location An outpatient health care facility Date of Audit Auditors Nursing staff and anaesthetists, auditors from different departments Language English Guidance documents NICE and the American Association of Anaesthesia Quality Improvement and Patient Safety (QPS), NICE and the American Association of Anaesthesia Prevention and Control Infection (PCI), Governance, Leadership and Direction (GLD), NICE and the American Association of Anaesthesia Anesthesia and Surgical Care (ASC), Medication Management and Use (MMU), Patient and Family Rights (PFR) Technical Expert clinical audit committee, clinical audit central office, clinical audit facilitators and conveners Activity Time Auditee 1 Opening Meeting 3 hours Nursing staff and anaesthetists, auditors from different departments 2 Selecting a topic 2 hours auditors from different departments 3 Agreeing on the standards of best practice or the audit criteria 5 hours auditors from different departments 4 Data collection 10 days Nursing staff and anaesthetists 5 Analysis of data based on the selected standards 5 days auditors from different departments 6 Feeding back outcomes 1 day auditors from different departments 7 Discussing possible changes 3 days auditors from different departments 8 Implementing the agreed changes No time limit anaesthetists 9 Allowing for change before re-audit No time limit anaesthetists 10 Closing Meeting 3 hours Nursing staff and anaesthetists, auditors from different departments Gantt Chart for the Audit Project task, stage, step or milestone Time Time Time Time Time Time 1 Opening Meeting 2 Selecting a topic 3 Agreeing on the standards of best practice 4 Data collection 5 Analysis of data based on the selected standards 6 Feeding back outcomes 7 Discussing possible changes 8 Implementing the agreed changes 9 Allowing for change before re-audit 10 Closing Meeting Part B Reflective Learning Gibb’s reflective cycle shown below is used in outlining the manner in which the module was delivered and how it has helped shape and change my learning experience. First, the principles and various concepts of evaluation measurement, and research (EMR) were explored. My feeling and thinking during learning was that EMR is rather important for appropriate and effective health care delivery. The integration and teamwork that characterised the learning process were particularly good. The learning processes really made sense of the usefulness of EMR. However, I would have done more research into the various forms and approaches to EMR. If another chance arose, I would adopt a more critical and analytical approach to the module. Learning this module was particularly important since it helped me improve my understanding of the integral role played by research, measurement and evaluation in health care service quality, safety and delivery. Through classroom work, homework and interactions with colleagues and lecturers, I managed to achieve all the learning outcomes as set by the lecturer and even managed to achieve some on my own. Furthermore, through the various assignments, including the current assignment, I have been better placed to understand and apply the principles of evaluation, research and measurement that I have learnt in class. In other words, the real-life application of the material, contents and context are now quite clear. During the learning of the module, different types of learning situations were observed. During this time, I tool quite a lot of educational and real-life situations and dimensions with regards to evaluation, measurement and research in health care. To start, the various concepts of measurement, evaluation and dimensions were explored in addition to their importance to best practice on health care delivery. In addition, the specific elements and principles of measurement, evaluation and research were covered during the module coverage. Throughout the module period, references were made to these elements of research, measurement and evaluation. Finally, the importance of this assignment to the attainment of module income cannot be overemphasized, as will be explained. During the module learning, several situations, scenarios and examples that highlight were presented. The core learning outcomes of the modules included to demonstrate a thorough understanding of critical reflection on the main concepts around measurement, research and evaluation. The second outcome was to critically demonstrate the manner of conducting an evaluation of quality improvement or change projects in health care organisations. The third learning outcome was to critique the key approaches to measurement, evaluation and research. Among the presented approaches to evaluation, measurement and research included performance indicators, audit and qualitative and quantitative methods. The other learning outcome was to critically evaluate health care management, quality and safety research reports. The final learning outcome for the module was to critically discuss the importance of measurement, evaluation and research in the management of safety and quality in healthcare. Learning this module has helped me become more critical and evaluative of health care procedures and practices undertaken in health facilities. In addition, I am better skilled and knowledgeable in different types of research and the most appropriate areas, disciplines and situations in which they should be applied. Thus, over the learning period for this module, I have grown in the area of creativity, critical thinking and having a wholesome view of health care quality, safety and appropriateness. I have also become more conversant with the types and processes of research, evaluation and measurement in health care and their applicability, appropriateness and effectiveness. Besides helping me academically, the module has empowered and prepared me for my professional and personal life pursuits. To meet the project or class goals, I strived to do all the group and individual assignments given by the tutor. Although I have developed skills such as group work, oral presentation, time management, note-taking, there are others in which I need improvement including creativity and critical thinking. The main academic areas in which I have evidently grown are writing and expression of my ideas, knowledge and thought, which have really improved in the time the module was offered. I am now better at putting my thoughts in coherent and correct formats more so in assignment and note-taking. I have also greatly sharpened my critical thinking and analysis skills. Rather than focus on proposed meanings of processes and terms, I have learned the importance of evaluation and research in unearthing and addressing the underlying issues in every situation or subject. Thus, I now delve deeper into issues through measurement, research and evaluation so that the true picture or state of affairs of a subject. The module also made me aware of how effective and powerful the processes of evaluation, research and measurement can be if they are planned and implemented well. That is, research, evaluation and audit results tell so much about the nature, weaknesses, strengths and future of a healthcare organisation and its services. That is, their reports tell about the life and conditions in a healthcare facility and could hasten the introduction of new policies and practices as well as past and forgotten practices that may have been dropped despite being effective and appropriate for patients. In case a situation that calls for sedation occurs, I will be better placed to deal with it as a professional and involve the people close to the patient such as parents, families and friends. In addition to using my versed knowledge and skills in ensuring best sedation practices, I will always work with other colleagues as a team. References Brown, T. B., Lovato, L. M., Parker, D. "Procedural Sedation in the Acute Care Setting." (2005). Am Fam Physician 71 (1): 90. Dartford & Gravesham. “Improving Patient Care through Clinical Audit: A How to Do Guide. Retrieved on January 8, 2013 from http://www.dvh.nhs.uk/EasysiteWeb/getresource.axd?AssetID=107264&type=full&servicetype=Attachmen Harrison, F. L., & Lock, D. Advanced Project Management: A Structured Approach. (2004). Gower Publishing, Ltd. Kousholt, B. Project Management – Theory and Practice. (2007). Nyt Teknisk Forlag. Nicholson, T., and Duncan, D. “Is Recreational Drug Use Normal?” (2002). Journal of Substance Use, 7, 116-123. Potter, C. Psychology and the Art of Program Evaluation." (2006). South African journal of psychology 36 (1): 82HGGFGYR–102. RCSI Consultancy Services. Best Practice Guide for Healthcare Audit Management. 2013. Retrieved on January 6, 2013 from http://vle.rcsi.ie/mod/resource/view.php?id=132524 RCSI IL Learning Resources. Example Extracts from Research Report Support Portfolio. Retrieved on January 6, 2013 from m http://vle.rcsi.ie/mod/resource/view.php?id=132524 RCSI IL Learning Resources. Example Extracts from Research Report. Retrieved on January 6, 2013 from m http://vle.rcsi.ie/mod/resource/view.php?id=132524 RCSI IL Learning Resources. Gibb’s (1988) Reflective Cycle: Guidance and Examples. Retrieved on January 6, 2013 from m http://vle.rcsi.ie/mod/resource/view.php?id=132524 Reeve, J., and Peerbhoy, D. Evaluating the Evaluation: Understanding the Utility aAnd Limitations of Evaluation a Tool for Organizational Learning. (2007). Health Education Journal 66 (2): 120–131. Rossi, P. H., and Freeman, H. E. Evaluation: A systematic Approach, Seventh Edition. (2004). Thousand Oaks: Sage. Sawyer, L. Sawyer's Internal Auditing, Fifth Edition, 2003. Institute of Internal Auditors. Stufflebeam, D. L., and Webster, W. J. "An Analysis of Alternative Approaches to Evaluation.” (1980). Educational Evaluation and Policy Analysis. 2(3): 19. World Bank Institute. Monitoring and Evaluation for Results Evaluation Ethics What to Expect From Your Evaluators. (2007). World Bank Institute. Young-Hoon, K. "A Brief History of Project Management. In: The Story of Managing Projects. (2005). Greenwood Publishing Group. Read More