Audit & Monitoring Implementation

At KKBM, auditing is not just about checking logs — it is how we understand what happened, why it happened, and how to prevent it from happening again. We use CCMS audit capabilities in two ways: reactively when an incident or complaint occurs, and proactively to catch issues before they affect patients.

For what CCMS can audit technically, see the Audit Trail in CCMS↴ reference on CCMS-Wiki. For documentation errors and how we correct them, see Documentation Quality Implementation↴.

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1. How We Use Auditing at KKBM

Reactive Auditing

Investigating after an incident, complaint, or error is reported. We trace what happened, who was involved, and why.

Proactive Auditing

Regular monitoring to catch issues before they become incidents — data quality, flow compliance, and system usage.

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2. Reactive Auditing — When Things Go Wrong

These are real scenarios where KKBM has used CCMS audit capabilities to investigate and resolve issues.

Scenario	Description	How We Audited	Remarks
1. Patient misallocation	Patient registered for doctor's room but auto-allocated to procedure room, causing unnecessary wait and reallocation	SystmOne Patient Allocation audit + auto-allocation event log	2-identifier protocol↴ · Registration workflow review
2. Patient complaint — waiting time	Patient complains about excessive waiting time or flow disruption in the clinic	SystmOne allocation timestamps + room queue audit + rota history	Documentation Implementation↴ · SOP compliance check
3. Patient complaint — misallocation	Patient directed to wrong unit or room, causing confusion and delay	SystmOne allocation audit + user activity log for registration staff	2-identifier protocol↴ · Corrective coaching
4. Track back patient history	Need to verify what was documented, prescribed, or done during a previous visit	SystmOne patient record access history + clinical note revision log	Audit Trail Reference↴ · Full timeline retrieval
5. Medical practitioner issue	Allegation of mismanagement, missed documentation, or incorrect clinical action	SystmOne clinical note audit + prescription history + user activity for the session	Documentation Implementation↴ · Peer review process
6. Medication error	Wrong medication, dosage, or patient dispensed	SystmOne prescribing audit (who ordered what) + PHIS dispensing audit (who dispensed what)	Pharmacy SOPs↴ · Correction workflow
7. Wrong appointment	Patient booked for wrong date, time, or clinic session	SystmOne Appointments & Rotas audit + booking user activity	Documentation Implementation↴ · Staff retraining
8. Missing referral letter	Patient claims referral letter was not issued	SystmOne Communication & Letters audit + print history	Audit Trail Reference↴ · Reissue process
9. Missing prescription	Patient claims prescription was not given or printed	SystmOne prescribing audit + print history	Pharmacy SOPs↴ · Reprint / investigation

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3. Proactive Auditing — Preventing Problems

These are ongoing monitoring activities KKBM conducts to catch issues before they become incidents.

Monitoring Focus	What We Check	How We Do It	Status
1. Incomplete registration data	Missing ethnicity, address, or mandatory demographic fields causing underreporting in clinical reports	Clinical reporting dashboards + spot-check of registration records	Ongoing
2. Patient flow compliance	Whether patients are allocated and flow through units according to SOP	SystmOne allocation audit + timestamp comparison against expected flow	Ongoing
3. System usage tracking	Whether doctors use auto-allocation in SystmOne or rely solely on physical checklists	User activity audit for auto-allocation events vs. manual allocation patterns	Ongoing
4. Template compliance	Whether clinical staff use correct SystmOne templates rather than free-text journals	Documentation audit + template usage reports	Ongoing
5. Data quality monitoring	Duplicate records, wrong patient registrations, demographic inconsistencies	Registration audit + duplicate record detection	Ongoing
6. Login security	Failed login attempts, simultaneous logins, password lockouts	SystmOne User Access Activity report	Active

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4. How to Request an Audit

If you do not have direct access to audit reports, follow this process:

1

Identify the system involved

• SystmOne — clinical records, appointments, logins
• PHIS — medication dispensing
• iLAB — laboratory results

2

Gather basic details

• Date and time range of the incident
• Patient name / MRN (if applicable)
• Staff member involved (if known)
• Brief description of what happened

3

Contact the appropriate person

• SystmOne issues → Dr Azlan, Dr Fuad or ICT En Siva
• Medication issues → Pharmacy Unit
• Lab result issues → Laboratory Unit

4

Provide justification

• Audit requests must be tied to a specific operational need (complaint investigation, error tracing, training review)
• General browsing of audit logs is not permitted

5

Await response

• Turnaround depends on complexity and workload
• For urgent patient safety issues, escalate through the head of department

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5. What Can Be Audited

For reference, CCMS provides audit coverage across these systems. KKBM uses the capabilities relevant to primary care:

1. SystmOne CCMS: Authentication, registration, patient allocation, documentation, appointments, rota management, and administrative activity.
2. PHIS Integration: Prescribing history, amendments, print history, and dispensing records.
3. iLAB Integration: Test orders, amendments, and result audit.
4. MyVAS Integration: Appointment booking sources and modifications.

For detailed technical specifications of each audit capability, see Audit Trail in CCMS↴.

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6. Audit Practice Status

Practice	Status	Remarks
Reactive audit investigations	Active	Used regularly for complaints, errors, and patient history requests
Proactive data quality monitoring	Ongoing	Clinical reporting spot-checks and registration audits conducted monthly
Patient flow compliance checks	Ongoing	Allocation audits reviewed quarterly against SOP
System usage tracking (auto-allocation)	Ongoing	User activity patterns analysed to identify training needs
SystmOne audit report access	Available	Dr Fuad and ICT Syahirah have direct access
PHIS audit access	Via Pharmacy Unit	Clinic staff have no direct access; pharmacy manages dispensing audits
iLAB audit access	Via Laboratory Unit	Managed by laboratory staff
Routine scheduled audits	Not Started	No formal scheduled monitoring cycle at clinic level yet
Retention policy confirmed	Pending	Awaiting BKD KKM confirmation on official retention policy

Operational Reality

Audit monitoring at KKBM is functional but ad-hoc. Reactive audits are well-established. Proactive monitoring is growing but not yet formally scheduled. This is a known improvement area.