Audit Compliance - How is it calculated?

Also see Case Ascertainment and Audit Compliance overview

The success of SSNAP depends on complete and timely data being submitted so that there is rapid turnaround of reporting to facilitate change. 

High audit compliance is a prerequisite to ensure that the data are complete, of high data quality and produced as close to the time the patients were admitted or discharged as possible. Individual teams are provided with a weighted audit compliance score to provide a context in which to interpret their process of care results and identify areas of improvement.

The audit compliance score includes measures of high usage of “unknown” data items, in particular the elements of the NIHSS. In response to feedback from post-acute teams, some measures of speed of data entry and data transfer have been added to ensure that these teams are able to complete their sections in a timely way so that the rapid turnaround of results can be maintained.

See a full breakdown of Audit Compliance scoring below:

Measure	Breakdown
NIHSS at arrival	1) NIHSS at arrival: 30% of score (team-centred 72h cohort)
NIHSS at arrival fully complete	Percentage of patients where NIHSS at arrival is fully complete
NIHSS 24h	2) NIHSS 24h: 20% of score (team-centred 72h cohort)
NIHSS 24h after thrombolysis is known	Percentage of patients where NIHSS 24h after thrombolysis is known
Transfers	3) Transfers: 10% of score  (team-centred 72h cohort and team-centred post-72h all teams cohort)
Records which are ready to transfer and have been transferred to next team	Percentage of records which are ready to transfer and have been transferred to next team (team-centred 72h cohort)
Number of days from patient transferred to next team to when the record is transferred on the webtool	Median number of days from patient transferred to next team to when the record is transferred on the webtool (team-centred post-72h all teams cohort) • A score of 100 is obtained if the median time is less than 7 days • A score of 75 is obtained if the median time is between 7 and less than 14 days • A score of 50 is obtained if the median time is between 14 and <21 days • A score of 25 is obtained if the median time is between 21 and <28 days • A score of 0 is obtained if the median time is 28 days or longer
Patients who were recorded as discharged with either ESD or CRT in Q7.7 or Q7.8, and transferred to an ESD or CRT on the webtool	Percentage of patients who have been transferred to an ESD or CRT out of those who have been recorded as discharged with ESD or CRT in Q7.7 or Q7.8 (team-centred post-72h all teams cohort)
Data Entry	4) Data Entry: 10% of score   (team-centred 72h cohort and team-centred post-72h inpatient discharge cohort)
Number of days from when patient is admitted/onset to when the record is started	Median number of days from when patient is admitted/onset to when the record is started (team-centred 72h cohort) • A score of 100 is obtained if the median time is less than 7 days • A score of 75 is obtained if the median time is between 7 and less than 14 days • A score of 50 is obtained if the median time is between 14 and <21 days • A score of 25 is obtained if the median time is between 21 and <28 days • A score of 0 is obtained if the median time is 28 days or longer
Number of days from when the patient is discharged from the team's care to when the record is locked to discharge	Median number of days from when the patient is discharged from the team's care to when the record is locked to discharge (not transferred) (team-centred post-72h inpatient discharge cohort) • A score of 100 is obtained if the median time is less than 7 days • A score of 75 is obtained if the median time is between 7 and less than 14 days • A score of 50 is obtained if the median time is between 14 and <21 days • A score of 25 is obtained if the median time is between 21 and <28 days • A score of 0 is obtained if the median time is 28 days or longer
All applicable scores in this section are added together and divided by the total number of applicable components to calculate the data entry score.
72h measures:	5) 72h measures: 15% of score (team-centred 72h cohort)
Ethnicity is known	Percentage of patients whose ethnicity is known
Reason for no swallow screen within 4h is known	Percentage of patients where reason for no swallow screen within 4h is known
Reason for no swallow screen within 72h is known	Percentage of patients where reason for no swallow screen within 72h is known
Reason for no OT assessment within 72 is known	Percentage of patients where reason for no OT assessment within 72 is known
Reason for no PT assessment within 72 is known	Percentage of patients where reason for no PT assessment within 72 is known
Reason for no SALT communication assessment within 72 is known	Percentage of patients where reason for no SALT communication assessment within 72 is known
Reason for no formal swallow assessment within 72 is known	Percentage of patients where reason for no formal swallow assessment within 72 is known
Post-72h measures:	6) Post-72h measures: 15% of score (team-centred post-72h cohorts)
Reason for no rehabilitation goals is known	Percentage of patients where reason for no rehabilitation goals is known (all teams cohort)
Development of urinary tract infection is known	Percentage of patients where development of urinary tract infection is known (7 day cohort)
Receipt of antibiotics for pneumonia is known	Percentage of patients where receipt of antibiotics for pneumonia is known (7 day cohort)
Reason for no urinary continence plan is known	Percentage of patients where reason for no urinary continence plan is known (7 day cohort)
Reason for no OT assessment by discharge is known	Percentage of patients where reason for no OT assessment by discharge is known (inpatient discharge cohort)
Reason for no PT assessment by discharge is known	Percentage of patients where reason for no PT assessment by discharge is known (inpatient discharge cohort)
Reason for no SALT communication assessment by discharge is known	Percentage of patients where reason for no SALT communication assessment by discharge is known (inpatient discharge cohort)
Reason for no SALT swallow assessment by discharge is known	Percentage of patients where reason for no SALT swallow assessment by discharge is known (inpatient discharge cohort)
Reason for no mood screening by discharge is known	Percentage of patients where reason for no mood screening by discharge is known (inpatient discharge cohort)
Reason for no cognition screening is known	Percentage of patients where reason for no cognition screening is known (inpatient discharge cohort)
Patients discharge home and living alone is known	Percentage of patients where discharge home and living alone is known (inpatient discharge cohort)
Number of social service visits is known	Percentage of patients where number of social service visits is known (inpatient discharge cohort)
All applicable percentages in this section are added together and divided by the total number of applicable components to calculate the post-72h measures score.
Where a team does not have the relevant results for a particular category, e.g. if the team has not thrombolysed any patients, the “NIHSS 24h after thrombolysis is known” result does not apply and therefore does not contribute to the audit compliance score. The score is therefore based on the remaining categories, with the weighting adjusted accordingly. Audit compliance bands Band A: 90 - 100 Band B: 80 - 89.9 Band C: 70 - 79.9 Band D: 50 - 69.9 Band E: 0 - 49.9 Click here to see how the SSNAP scoring is calculated and how audit compliance can cause negative adjustment