Clinical Audit Procedure

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1 SH NCP 7 Clinical Audit Procedure Summary: Keywords (minimum of 5): (To assist policy search engine) Target Audience: Clinical audit is the process of health professionals evaluating the quality of care they provide by comparing current practice against pre-determined best practice. This procedure details how audits topics are selected and will guide staff through the clinical audit process Clinical Audit, Standards, Audit Cycle, All SHFT staff who are required to participate in clinical audits Next Review Date: December 2020 Approved & Ratified by: Clinical Effectiveness Group Date of meeting: 25 October 2016 Date issued: Author: Helen Alger, Clinical Audit facilitator Sponsor: Julie Dawes, Director of Nursing and Quality Clinical Audit Procedure 1

2 Version Control Change Record Date Author Version Page Reason for Change 15/8/2016 Helen Alger 2 Scheduled policy & procedure review Reviewers/contributors Name Position Version Reviewed & Date Helen Alger Clinical Audit facilitator August 2016 Paula Hull Divisional Director of Nursing & AHP August 2016 Sara Courtney Acting Director of Nursing and Allied Health August 2016 Professionals Debra Moore Deputy Director of Nursing - MH, LD August 2016 Sara Constantine Consultant Psychiatrist, Psychiatry of Older August 2016 Adults Mayura Deshpande Clinical Service Director, Adult MH August 2016 Jennifer Dolman Clinical Director, Community Learning August 2016 Disability Team Peter Hockey Consultant Respiratory Physician and August 2016 Clinical Director Mary Kloer Interim Clinical Director Adult Mental Health August 2016 Juanita Pascual Clinical Director North and Mid Hampshire August 2016 Amanda Taylor Consultant Forensic Psychiatrist / Clinical August 2016 Service Director, Adult Mental Health Theresa Lewis Lead Nurse Infection Prevention and Control August 2016 Julia Lake Deputy Head of Professions, LNFH August 2016 Susanna Preedy Head of Nursing & Allied Health August 2016 Professionals, (Mid-West Hampshire) Caz Maclean Associate Director of Safeguarding August 2016 Patrick Carrol Integration Project Manager, Business August 2016 Development Neil Langridge clinical lead physiotherapist August 2016 Gina Winterbates Head of Nursing and AHP's, August 2016 Liz Taylor Associate Director for Nursing & AHP August 2016 Childrens Service John Stagg Associate Director of Nursing, AHP & August 2016 Quality (Learning Disabilities) Tracey Mckenzie Head of Compliance, Assurance & Quality August 2016 Sophie Tomkins Clinical Audit facilitator August 2016 Clinical Audit Procedure 2

3 CONTENTS Page 1. What is Clinical Audit 4 2. The Clinical Audit Cycle 4 3. Choosing an Audit Topic 5 4. Registering Clinical Audits 5 5. Involvement of Stakeholders 5 6. Setting Audit Standards 6 7. Considering Ethics, Patient Consent and Equality & Diversity Ethics Consent Equality and Diversity 7 8. Selecting an Audit Sample Sample Size Data Collection Data Sources Sampling Techniques 7 9. Planning and Carrying Out Data Collection Designing an Audit Data Collection Tool Types of Data Collection Piloting the Tool SNAP Audit Software Data Analysis Actions Plans Dissemination and Reporting 9 Appendix 1 Audit Proposal and Planning Form 10 Appendix 2 Case Code Recorder 13 Appendix 3 Equality Impact Assessment Tool 14 Appendix 4 Clinical Audit Report Template 15 Appendix 5 Clinical Audit Action Plan Template 17 Clinical Audit Procedure 3

4 Clinical Audit Procedure How to do Clinical Audit a brief guide 1. What is Clinical Audit? The National Institute for Clinical Excellence (NICE) has defined clinical audit as: A quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. Aspects of the structure, processes and outcomes of care are selected and systematically evaluated against explicit criteria. Where indicated changes are implemented at an individual, team or service level and further monitoring is used to confirm improvement in healthcare delivery. Principles for Best Practice in Clinical Audit NICE 2002 Clinical audit is the process of health professionals evaluating the quality of care they provide, as a team, by comparing current practice against pre-determined best practice. The results will show whether things are being done in accordance with best practice. 2. The Clinical Audit Cycle The component parts of clinical audit are: Selecting a topic Agreeing standards Comparing practice with standards Changing practice Re-audit to make sure practice has improved ( closing the loop ) Clinical Audit Procedure 4

5 3. Choosing an Audit Topic Topics for audit across Southern Health NHS Foundation Trust (hereafter known as The Trust) must be prioritised to accommodate organisational, local and national agendas whilst avoiding duplication of effort. As resources for carrying out audit are finite, care should be taken in identifying and prioritising suitable audit topics. When planning the audit programme and determining priorities, consideration will be given to: Trust s Strategic Objectives / Board Assurance Framework Commissioner quality contract requirements NICE Clinical guidance / National Service Frameworks (NSFs) National / Professional body led clinical audits New policies or guidelines implemented Trends from effectiveness data / clinical/quality indicators Concerns via complaints, surveys, letters, focus groups, patient stories Evidence for Care Quality Commission (CQC) Areas with variations in practice Team priorities / concerns Adverse events Claims / litigation Business plans Mortality / morbidity data Re-audit requirements Findings from inspections and investigations Staff who are interested in carrying out an audit but are unsure about appropriate topics should contact the Clinical Audit Team who will be able to advise them on key subjects in their clinical area. 4. Registering Clinical Audits The first stage in planning a local clinical audit is to complete an Audit Proposal and Planning Form which is available from the Clinical Audit Team and on the Trust intranet site (see Appendix 1). This form must be completed and returned to the Clinical Audit Team regardless of whether support is required. This enables all clinical audits to be registered on the central database. The Clinical Audit Team will review each proposal form. The team will check to see if a similar audit has already been undertaken in another area and how any previous tools or learning may be shared All requests for support will then be timetabled appropriately to take into account other clinical audit activity and priorities. 5. Involvement of Stakeholders If the audit has implications for disciplines or professionals other than those of the lead auditor it is important to consult these staff during the planning stage. If the audit is looking Clinical Audit Procedure 5

6 at the patient/service user journey across different care sectors it is also important to try and include staff representatives from these other organisations. Engagement by professionals is encouraged by the audit team to ensure a meaningful capture of data and team commitment to the implementation of change. 6. Setting Audit Standards Standards of best practice may exist locally or nationally in the form of guidelines or protocols. National standards are available for certain treatments and conditions in the form of NICE or Royal College / professional body guidelines and are also incorporated into large-scale service delivery documents such as the NSFs. If there are no recognised standards available from these sources, audit specific standards need to be developed by the clinicians undertaking the audit. The standards should relate to the audit objectives and should always be based on, the most up-to-date evidence of what constitutes best practice. A literature search will need to be undertaken to identify relevant evidence from which to develop the standards. There is no single way of writing a standard but any well-written standard should be specific and evidence should be readily accessible and available to indicate whether this standard has been met. Below is an example model of how standards may be written: Audit Criteria Target Exceptions Source of evidence Venous leg ulcers will be treated with graduated multilayer high compression bandaging 100% ABPI<0.8 RCN Management of Venous Leg Ulcers guidance 1998 It is normal to set the target at 100% as, if the standard is best practice; everyone is entitled to receive it. However, there are occasions when the target may be set lower than 100%. For example, the standard would be set at 0% if it is referring to something that will never be done 7. Considering Ethics, Patient Consent and Equality & Diversity 7.1 Ethics Unlike research, clinical audit projects do not need to be submitted to the Local Research Ethics Committee for ethical approval. However, clinical audit must always be conducted within an ethical framework. At a practical level this means ensuring patient confidentiality at all times by abiding by the Data Protection Act (1998) and the Caldicott Principles (1997). Audit data collected should be anonymised wherever possible, removing identifiers such as patient/service user name or other unique/semi-unique details such as post code, date of birth etc. Good practice in clinical audit states that when data is collected about a patient/service user a unique identification code should be assigned to that data. A case code recorder can be used and is available on the intranet (See Appendix 2) Any patient-identifiable clinical audit data must be kept secure, e.g. by locking audit proformas away in a filing cabinet; or password protecting electronic files. Once the audit has been carried out and written up, all completed audit proformas and patient identifiable data should be destroyed. Clinical Audit Procedure 6

7 7.2 Consent Where an audit requires information to be collected directly from patients, consent should be obtained verbally prior to asking them any questions and recorded on the data collection form. Consent is not required to access patient records for criterion-based clinical audit. 7.3 Equality and Diversity The process for determining choice of clinical audit projects, and the manner in which project patient samples are drawn up, should not inadvertently discriminate against any groups in society based on their race, disability, gender, age, sexual orientation, religion and belief. Therefore an equality impact assessment should be completed for all clinical audits (See Appendix 3). For further details on equality impact assessments please contact the Trust Equality & Diversity Lead. 8. Selecting an Audit Sample 8.1 Sample Size An audit usually involves a defined group of people who share certain characteristics such as the same medical condition or having received the same type of treatment. Ideally the care received by all the audit population should be audited, however this can be impractical. For most audits a snapshot sample will be sufficient this should be small enough to allow rapid data collection but large enough to represent the audit population and to ensure that senior clinicians / managers will be willing to implement change based on the audit findings. There are a number of guides available detailing how to choose sample sizes depending on these criteria. Advice on which is the best sample size for a specific audit can be sought from the Clinical Audit Team. 8.2 Data Collection It is important that only the minimum amount of data is collected and that it is precise. Prior to the audit the staff involved need to establish exactly what data needs to be collected, how it will be collected and over what time period the audit needs to be carried out. Data may be collected retrospectively, providing an indication of the care provided during a period in the past. Or, it can be collected concurrently to provide more immediate feedback on current practices. 8.3 Data Sources Data can be obtained from a number of sources. The hospital information system can be used to obtain data such as discharges, length of stay, age, diagnosis etc. Data can be collected from patient / service user records, surveys, questionnaires, interviews or observations. The tool must specify precisely the information which needs to be collected so that the auditor knows exactly what to look for. 8.4 Sampling Techniques Random sampling or whole population samples should be used wherever possible to ensure that data collection is representative and unbiased. The audit team can be contacted for further information and guidance on how to select a sample. Clinical Audit Procedure 7

8 9. Planning and Carrying Out the Data Collection 9.1 Designing an audit data collection tool There is no standardised way of designing a data collection form, however, below are some points to remember: Include the title and date of the audit for easy identification. Include instructions for completing and returning the form. Questions should be clear and unambiguous. Questions should be well spaced out and a font size should be selected which makes it easily readable. Allow space for auditors opinions and free-text. Make it as concise as possible 9.2 Types of data collection Clinical audit is usually concerned with gathering quantitative data ( e. g. counting how many times certain things were done and how often) and linking it to standards of best practice. It may also be necessary to collect some qualitative data, for example to establish why standards were not met or to capture patients subjective experiences. 9.3 Piloting the tool If at all possible take the time to pilot the audit before collecting all the data. This will enable the data collection form to be tested to make sure it works and the correct data is retrieved. The pilot may reveal that some of the questions were ambiguous or that the form was difficult to complete or simply that it is not retrieving the data required to meet the audit purpose. 9.4 SNAP audit software All audits supported by the Clinical Audit Team will be carried out using the SNAP software package. This is a web-based system on which data collection tools can be designed and staff can submit the data via the web. The Clinical Audit Team will work with the audit lead to design the tool as described above and on completion will the web-link out to staff with a guidance document on how to carry out the audit. 9.5 Data Analysis Once data has been collected it needs to be analysed to compare the results with the audit standards to establish compliance. Staff who choose to carry out their audit without the support of the Clinical Audit Team will be required to input and analyse their own data. All audits carried out in SNAP can be analysed within the system and the Clinical Audit Team can automatically download results/tables/graphs for the audit leads to analyse. 10. Action Plans All audit projects should have a SMART (Specific, Measurable, Achievable, Relevant, Timely) action plan that identifies What needs to be done Who is going to do it When (target dates) Clinical Audit Procedure 8

9 How it will be done When a re-audit will be carried out Appendix 5 shows the Action Plan Template 11. Dissemination and Reporting Once an audit is complete, an audit report must be written detailing what was done, the findings, any recommendations and action plans. The Clinical Audit Report Template should be completed and sent to the Clinical Audit Team for review and logging (See Appendix 4 for the Report Template). Audit results should be shared locally with stakeholders, and a copy of the audit report and action plan should be forwarded to the Clinical Audit Team. Progress against action plans should be monitored locally to ensure improvements are implemented and reported back to the Clinical Audit Team to be logged centrally. Clinical Audit Procedure 9

10 Appendix 1 Clinical Audit Team 6 Sterne Road, Tatchbury Mount Calmore, Southampton SO40 2RZ Tel : /4111/ AUDIT PROPOSAL AND PLANNING FORM Audit lead name: Job Title: Work base: Telephone number: address: Division: Please write your name here Please write your job title here For example, ward and hospital Please include your area code Please write your address here Mental Health/Specialised Services Learning Disability Children Services ISD West ISD East/OPMH Type of audit: Initial audit Re-audit Project title: Background / rationale (Why is the audit being done?) Please write the title of your audit / survey / service evaluation here. Aims & Objectives (What is the aim and purpose of the audit? How will it improve patient care?) Is this audit: National Trust-wide Area / locality-wide Regional Division-wide Local / service-specific Will patients/service users or carer be involved? YES NO If so, Please state How?

11 What are your inclusion criteria?(how will you choose who/what is included?) Estimated sample size: Type of data collection : Method of data collection: Retrospective Concurrent OTHER Interview Questionnaire Observational Other (please state) Data source (Please tick all that apply) Focus groups I.T. systems data Interviews Observation Other (please state) Patient records Peer review Questionnaire Telephone survey How do you plan to circulate your results? Presentation Report To Whom? (please state) When do you expect to undertake this audit? Anticipated Dates: Audit proposal agreed by: Line / Locality Manager Signature DATE: / / Declaration I understand that raw data from this audit (staff /patient/service user/carer) must be kept anonymous and is not to be taken outside this Trust. I understand that the results belong to the Trust, not myself. I agree to the results appearing in the Trust s clinical audit reports. I confirm that the information provided on this form is accurate to the best of my knowledge. By signing this form I agree to ensure that this project is completed, the results disseminated and a report and action plan given to both the Quality & Governance Team and Division. Audit lead: Date: (signature)

12 Appendix 1 Clinical Audit Team 6 Sterne Road, Tatchbury Mount Calmore, Southampton SO40 2RZ Tel: (023) / 4111 Fax: (023) IF KNOWN PLEASE COMPLETE AND RETURN THE STANDARDS OF CARE YOU WILL BE MEASURING. Clinical Audit Standards No Standard (Evidence of quality or care or service) Target % Clinical exceptions Definitions and instructions for data collection Audit Proposal Form

13 Appendix 2 CASE CODE RECORDER FOR CLINICAL AUDIT DATA COLLECTION 003 Please use the Case Code numbers listed below, i.e.( ) on all audit tools. Due to Data Protection regulations, patient numbers must NOT be written on audit sheets, but a record should be maintained independently and stored separately so that notes can be traced and checked if necessary. *PLEASE KEEP THIS FORM IN YOUR DEPARTMENT, DO NOT RETURN WITH AUDIT TOOLS* Audit Name: Date: Case Code No. Patient Number / Identifier Case Code No. Patient Number / Identifier Case Code No. Patient Number / Identifier Ref No: CA/A.FORM.009 Page 1 of 17 VERSION DATE: Jan 2011

14 Appendix 3 Equality Impact Assessment The Equality Analysis is a written record that demonstrates that you have shown due regard to the need to eliminate unlawful discrimination, advance equality of opportunity and foster good relations with respect to the characteristics protected by the Equality Act Stage 1: Screening Date of assessment: Name of person completing the assessment: Job title: Responsible department: Intended equality outcomes: Who was involved in the consultation of this document? Please describe the positive and any potential negative impact of the policy on service users or staff. In the case of negative impact, please indicate any measures planned to mitigate against this by completing stage 2. Supporting Information can be found be following the link: Protected Characteristic Positive impact Negative impact Age Disability Gender reassignment Marriage & civil partnership Pregnancy & maternity Race Religion Sex Sexual orientation Stage 2: Full impact assessment What is the impact? Mitigating actions Monitoring of actions

15 Appendix 4 NAME OF SERVICE NAME OF AUDIT RESULTS REPORT DATE OF REPORT Audit Details Clinical Lead: Audit Facilitator: Rationale: Objectives: Frequency: Date Collection Period: Method: Sample: Sample Size: Service Participation: Results: Action Planning: Name of Clinical lead Name of Audit Facilitator Brief outline of why the audit is being carried out. What will this audit achieve (include reference to quality improvement)? How often will this audit be completed; is it a re-audit? Month, year. How was data collected, e.g. from records using an audit tool, observing staff etc. How many cases are to be audited from what population? Number of cases audited, if applicable compared to the sample that should have been audited. Include details of the teams that did not participate and the sample that was audited. How will results be shared? Who will be responsible for identifying key actions? What will the process be for chasing and following up on implementation

16 Appendix 4 Results (Graphs or Tables) Please insert Good practice Identified Areas for improvement Key Actions/ learning Improvements from previous audit Author: Title: Date:

17 CLINICAL AUDIT ACTION PLAN Audit title: Service / Ward No 1 Area for improvement Action to be implemented Date to be implemented by Evidence of implementation (What evidence will there be that this action has been implemented? Staff member responsible Manager responsible Update (i.e. have you been able to implement it, any difficulties?) Audit lead signature Name (printed) Date Senior clinician/manager signature Name (printed) Date

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