Document Details Clinical Audit Policy

Transcription

1 Title Document Details Clinical Audit Policy Trust Ref No Main points this document covers This policy details the responsibilities and processes associated with the Clinical Audit process within the Trust. Who is the document aimed at? All staff who take part in Clinical Audit or who are responsible for staff who do so. Authors Dee Radford, Quality and Compliance Lead Michelle Bramble, Clinical Effectiveness Facilitator Approval Process Approved by Quality & Safety Delivery Group Approval Date 15/06/2016 Initial Equality Impact Screening No Full Equality Impact Assessment No Lead Director Executive Director of Nursing and Operations Category Clinical Sub Category Audit Review Date 15/06/2019 Distribution Who the policy will be distributed to All clinical staff Method Electronically Document Links Required by CQC No Required by NHSLA No Other Monitor Amendments History No Date Amendment 1 December 2011 Addition of introduction and amendments to comply with Trust Policy on Procedural Documents 2 January 2012 Minor changes and formatting. 3 February 2012 Changes following Internal Auditors comments 4 March 2012 Changes following DoN/Audit Team comments 5 April 2012 Changes made following NHSLA inspector comments 6 January 2013 Changes made following NHSLA inspection in July 2012 and internal audit review in December May 2014 Agreed by Quality and Safety Operational Group to extend review date to May July 2014 Amendments made to reflect new titles and slight amendment to governance process. 9 May 2016 Amendments made to reflect new titles and slight amendment to governance process Clinical Audit Policy Reviewed 2016 Datix Ref: Page 1 of 19

2 Clinical Audit Policy Page 1 Introduction 3 2 Purposes 3 3 Definitions Clinical audit National clinical audit Local clinical audit Clinical audit and research Clinical team Leads for clinical audit Clinical audit programme 5 4 Duties Duties within the Organisation 5 Process for developing and carrying out the Clinical Audit Programme including participation in national and local audits Developing the clinical audit programme Prioritising clinical audit work Information in the Clinical Audit Programme Monitoring of the Clinical Audit Programme Managing the Clinical Audit Programme Reporting on the Clinical Audit Programme 10 6 Process for carrying out clinical audits 10 7 Data protection requirements relating to clinical audit Informing patients about the use of personal health information Anonymisation of clinical audit data 12 8 Ethics and Consent 12 9 Dissemination of clinical audit activities/policy Support for implementation of this policy Monitoring compliance with this policy Consultation References 13 Appendices Appendix A Clinical Audit Proposal Template 14 Appendix B Clinical Audit Report Template 16 Clinical Audit Policy Reviewed 2016 Datix Ref: Page 2 of 19

3 1 Introduction Clinical Audit is seen by Shropshire Community Health NHS Trust (SCHT) as a key process for assessing, improving and assuring the quality of care and treatment against best available evidence e.g. NICE guidance. This may be achieved through a continuous process where healthcare professionals review systems, processes and patient care against agreed standards and make changes, where necessary, to meet those standards. Once learning outcomes from audit activity have been disseminated and implemented in practice, re audit should be undertaken to ensure that change has taken place and patient care improved as a result. In addition, the Trust encourages clinical audit undertaken jointly across professions and organisational boundaries. Partnership working will be encouraged where improvements to the patient journey may be identified through shared clinical audit activity. Clinical audit is an integral part of patient safety measures within the Trust by ensuring the highest standards of care and in doing so it provides a key source of assurance for the Board. Clinical staff are expected to take part in clinical audits as part of their professional practice - for medical practitioners this is a requirement of their post and a core part of their training and revalidation. The Care Quality Commission (CQC) requires that: Providers must have systems and processes such as regular audits of the service provided and must assess, monitor and improve the quality and safety of the service. These audits should be baselined against Regulations 4 to 20A of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and should, where possible, include the experiences of people who use the service (Ref A) Full information of the requirement under Regulation 17(2)(a) may be found at: n_meeting_the_regulations_final_01.pdf Support for clinical audit is provided by the Clinical Effectiveness Facilitator within the Directorate of Nursing and Quality and a review of clinical audits forms a mandatory element of the Trust s review of quality in its annual Quality Accounts (Ref B). 2 Purposes The purposes of this policy are to: Define a standardised approach to carrying out clinical audits to be followed by staff working in all professions and clinical specialties within SCHT consistent with current evidence of best practice in clinical audit in order to support the Clinical Governance agenda of the Trust. Facilitate an understanding of the purpose of clinical audit and the clinical audit process among all staff working in SCHT. Clinical Audit Policy Reviewed 2016 Datix Ref: Page 3 of 19

4 Ensure that SCHT has an active ongoing clinical audit programme that is made up of audits that are appropriate and effective and that support the Trust s commitment to continuously improve the quality and safety of care and services for patients and other service users. Facilitate the sharing and dissemination of good clinical practice as demonstrated through clinical audits across professions and services in SCHT. Ensure that professionals in training who work in SCHT meet requirements for the completion of clinical audits as part of their training. Inform staff carrying out clinical audits of their responsibilities relating to data protection requirements. Ensure that ethical issues in clinical audits are recognised and handled appropriately by Trust staff. Ensure that there are clear lines of accountability within the Trust for the execution of an ongoing clinical audit programme and a robust monitoring process for the recommendations and actions made as a result of the audit process. 3 Definitions 3.1 Clinical Audit NICE (2002) defines clinical audit as: A quality improvement process that seeks to improve patient care and outcomes through systematic review of care 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. (Ref C). Although this definition is now over a decade old, the Healthcare Quality Improvement Partnership (HQIP) still adheres to this definition stating: HQIP firmly believes that clinical audit is part of quality improvement. The audit cycle is about measuring, acting on changes, and measuring again. Making and assessing improvements is fully part of that cycle. People work in clinical audit because this definition is at the core of what they do and what they believe. Through audit we make care better (Ref D). 3.2 National Clinical Audit A national clinical audit is a clinical audit which has been set up across Trusts in England and Wales, enabling a large dataset to be created and comparisons to be made between Trusts. Participation in national clinical audits is strongly encouraged by the Department of Health and Monitor and Trusts are expected to report on their participation in national audits in their annual Quality Accounts. National clinical audit is designed to improve patient outcomes across a wide range of medical, surgical and mental health conditions. Its purpose is to engage all healthcare professionals across Clinical Audit Policy Reviewed 2016 Datix Ref: Page 4 of 19

5 England and Wales in systematic evaluation of their clinical practice against standards and to support and encourage improvement in the quality of treatment and care. 3.3 Local Clinical Audit A local audit is a more clinician led audit designed to meet a Trust or directorate priority or as part of a quality improvement initiative in a team or on a ward. 3.4 Clinical Audit and Research Research is related to but different from clinical audit. Research is about obtaining new knowledge that can be generalised: research studies generate hypotheses or test them out. Research identifies best practice and clinical audit ensures that best practice is being carried out. 3.5 Clinical Team For purposes of this process, a clinical team is a professional or specialty group. Such teams assume responsibility and accountability for the completion of clinical audits in the relevant specialty or service. 3.6 Lead(s) for clinical audits The lead(s) for a specific clinical audit is (are) the member(s) of staff who will do the work involved in carrying out that audit. The work involved in carrying out a specific clinical audit may be shared among members of staff or when some stages are completed, the audit may be handed over to other members of staff to continue the work. If the clinical audit covers more than one profession or specialty, the overall lead(s) must be agreed when the Clinical Audit Proposal is prepared and submitted for approval. 3.7 Clinical Audit Programme For purposes of this policy, a clinical audit programme is a document that identifies the following: The subjects of clinical audits to be carried out in SCHT over a specified year. The specific objectives for each clinical audit. The objectives should reflect how the clinical audit relates to the quality or safety of patient care, for example, confirm that best practice (as defined by a guideline, policy, protocol, etc) is being followed, or increase the percentage of patients who receive care that represents best practice. 4 Duties Duties within the organisation are: Chief Executive Clinical Audit Policy Reviewed 2016 Datix Ref: Page 5 of 19

6 The Chief Executive is ultimately responsible for the quality and safety of services provided by the Trust. Director of Nursing The Director of Nursing and Operations has executive responsibility for quality and safety in the Trust and joint responsibility with the Medical Director for clinical risk management and as such has the responsibility for ensuring there are effective systems and processes in place for clinical audit. Executive Directors, Clinical and Service Directors and Professional Heads/Clinical Leads Executive Directors, Clinical and Service Directors and Professional Heads/ Clinical Leads are responsible for ensuring that the staff they manage comply with the requirement to lead, participate or contribute information to clinical audits. They must also ensure that, through their governance structures, the results of clinical audits are reviewed and any action required are identified and action taken accordingly. Trust Board The Trust Board is responsible for ensuring that they are rigorous in demanding that the technical quality of clinical audit is high and that key issues that affect data quality have been addressed. The board should ensure that the full cycle of clinical audit, especially the quality improvement part, takes place to ensure that clinical audit does not simply measure, but does lead to real changes. Quality and Compliance Lead/Clinical Effectiveness Facilitator The Quality and Compliance Lead/Clinical Effectiveness Facilitator are responsible for ensuring that the processes identified within this policy are adhered to within the trust. All Staff All staff providing care in the Trust are expected to be aware of the clinical audit programme and to contribute to it as appropriate to their job role and as required by their managers and professional bodies. They are expected to learn from the results of clinical audits and make any necessary improvements to their practice that may be required as a result. Committees The Trust groups with the primary role in overseeing the development and delivery of the Clinical Audit Programme are the Service Delivery Group (SDG) Quality and Safety Groups. The Quality and Safety Delivery Group will require clinical audits to play a key role in assurance as to the quality of care and treatment provided by the Trust. The presentation of clinical audit reports will take place within the directorate and team clinical governance processes. Clinical Audit Policy Reviewed 2016 Datix Ref: Page 6 of 19

7 5. Process for developing and carrying out the Clinical Audit Programme including participation in national and local audits. The process for developing and carrying out SCHT s Clinical Audit Programme is as follows: 5.1 Developing the Clinical Audit Programme The Clinical Effectiveness Facilitator develops a Clinical Audit Programme from priority areas (below) and from consultation with each of the clinical divisions. This process commences in early January each year and the draft programme is completed by the end of February. The draft Clinical Audit Programme is presented to the SDG Quality and Safety Groups for review prior to submission to the Quality and Safety Delivery Group for approval. The final Clinical Audit Programme will be noted by the Quality and Safety Committee. Once approved, the Clinical Audit Programme will be disseminated across the Trust via SDG Quality and Safety Groups. The Clinical Audit Programme will be influenced by the following: National Requirements National Institute for Health & Clinical Excellence (NICE) National Clinical Audit/NCEPOD National Service Frameworks (NSFs) Guidelines from Royal Colleges Department of Health Standards National Audits Care Quality Commission Regulations Corporate Requirements Trends from clinical/ non-clinical incidents Information Governance requirements Requirements through contracts for the services we commission (CQUINS) Trends from complaints Issues identified from patient groups/service users/carers/pals Issues raised through Risk Management Standards Cost effectiveness and value for money Service Development, Internal and External audit Complaints/litigation identified by Corporate Services Manager Risk Register / Assurance framework identified by Corporate Risk Manager Service Requirements Prescribing incentive scheme Practice/ Service/ Team improvement plans Previous audit outcomes Proposals from clinical teams /Clinical Effectiveness Facilitator The Clinical Audit Programme is developed from a combination of the above managerial directives and service/ team issues with work prioritised as in section 5.2 below. Clinical Audit Policy Reviewed 2016 Datix Ref: Page 7 of 19

8 5.2 Prioritising Clinical Audit Work Priority 1 Must do projects Projects that are driven by commissioning and quality improvement are treated as the priority by the Trust. Example topics to include at this priority should be: New national targets and existing commitments NCAPOP/National clinical audits Audits demonstrating compliance with regulation requirements e.g. audits with the aim of providing evidence of implementation of NICE technology appraisals, clinical guidelines and public health guidance, NSFs and other national guidance such as that coming from NPSA alerts or NCEs CQUINS and other commissioner priorities DH statutory requirements, such as infection control monitoring External accreditation schemes, e.g. cancer peer review audit Re-audits of any of the above Priority 2 Internal must do projects Topics classed as Priority Two audits are those that fulfil the classic criteria of high risk or high profile identified by trust management or trust clinical effectiveness strategy documents. They may include national initiatives with trust-wide relevance but no penalties exist for non-participation. Many of these projects will emanate from trust governance issues or high profile local initiatives and will include: Clinical risk issues Serious untoward incidents/adverse incidents Organisational clinical priorities Priorities identified via Patient and Public Involvement initiatives Complaints Access Patient Safety Claims and other legal processes e.g. inquests Re-audits of any of the above Priority 3 Operational priorities Directorates are asked to suggest audits that are priority pieces of work and important to them local priorities. They may include DH initiatives and be directorate specific. Directorate priorities may include: Local clinical interest audit agreed by directorate as a priority National audits not part of NCAPOP, e.g. some Royal College initiated projects lie outside of NCAPOP Locally adopted clinical standards benchmarking e.g., Essence of Care Re-audits of any of the above Priority 4 Clinician interest The priorities set up above should not stifle audits that emerge during the year that contribute to improvements in care. Some of these audits registered later in the year will slot into one of the above categories. However, there will Clinical Audit Policy Reviewed 2016 Datix Ref: Page 8 of 19

9 be a number of audits that will not fall into any of the above priorities. It is fully recognised that there is a need to maintain a degree of locally initiated audits. These projects often cannot be determined at the outset of the financial year. They represent innovative ideas from clinicians and can provide valuable educational experience for junior staff. In the case of audits that do not fit into any of the above categories, it will be the responsibility of the relevant SDG Quality and Safety Group to determine the priority of the audit. In order to reflect projects that arise during the year, the Clinical Audit Programme will be updated at quarterly intervals throughout the year. 5.3 Information in the Clinical Audit Programme Information within the Clinical Audit Programme will include the following information: A unique number for each project The service in which the audit will be undertaken Links to NICE Guidance, CQC regulations, Quality regulations for each project The programme will be divided into: o National Audit/NCAPOP (Priority 1) o Contractual Requirement Audits (Priority 1) o National Guidance/Standards including NICE (Priority 1) o User Experience (Priority 2) o Locally Initiated Projects (Priority 3) 5.4 Monitoring of the Clinical Audit Programme The Clinical Effectiveness Facilitator will monitor completion of SCHT s Clinical Audit Programme, including checking if projects are being carried out in accordance with the planned timetable, and what interventions are needed, if any to keep the programme on schedule. This will be reported through the SDG Quality and Safety Groups. 5.5 Managing the Clinical Audit Programme The Quality and Compliance Lead/Clinical Effectiveness Facilitator are responsible for: Coordinating the annual clinical audit programme which will be approved by the Trust Board through the Quality and Safety Committee and the Audit Committee Developing and delivering local clinical effectiveness training and providing advice for staff undertaking improvement projects. Supporting clinicians in the process of carrying out improvement projects this will include advice and guidance regarding the clinical audit process, identifying cohorts and facilitating and assisting with data collection and data analysis. Maintaining a register of all clinical audit projects in the Trust and tracking progress of the clinical audit, prompting colleagues who may be falling behind timescales or plans. They will maintain a record of recommendations and implementations from completed audit projects with expected completion dates and report on a quarterly basis to the SDG Quality and Safety Groups with specific Clinical Audit Policy Reviewed 2016 Datix Ref: Page 9 of 19

10 reference to recommendations and actions that have not been completed within agreed timescales. Monitoring the completion of audit projects and reporting delays and problems to the SDG Quality and Safety Groups. This in turn will be reported via the regular report to the Quality and Safety Delivery Group where a decision will be made as to whether the delay requires escalation to the Quality and Safety Committee. They will produce regular progress reports against the programme to the Quality and Safety Delivery Group. They will produce an Annual Clinical Audit Report which will be presented to the Quality and Safety Committee and the Audit Committee and contribute to the Trust s Quality Accounts and they will report to the commissioners on clinical audit as required. 5.6 Reporting on the Clinical Audit Programme The Clinical Effectiveness Facilitator will prepare monthly reports to the SDG Quality and Safety Groups on the status of the Clinical Audit Programme including any requests for extensions of deadlines. 6 Process for carrying out clinical audits The process for carrying out a clinical audit in SCHT is as follows: At the beginning of each quarter, the Clinical Effectiveness Facilitator will all nominated audit leads for audits due to commence during that quarter to remind them that the audit is due and that a proposal form should be completed. A clinical team: Agrees to how the audit will be carried out, including the objective(s) of the audit, the population or sample to be included and the data collection strategy. Agrees to the precise measures of the quality or safety of patient care or service. The clinical audit measures may incorporate agreed national or local standards or evidence of good clinical practice, where available, or consensus among appropriate colleagues in the absence of agreed standards or evidence. Submits a Clinical Audit Proposal (Appendix A) to the appropriate SDG Quality and Safety group for approval. By completing and submitting a clinical audit proposal form the lead(s) for a specific clinical audit agrees to carry out the work involved in a clinical audit. This should be following discussion with and the involvement of the clinical audit team who will provide guidance and support throughout the audit process. The Clinical Audit Proposal will be considered as an item of business at the next meeting of the relevant governance group for the service where clinical audits are discussed. The following are the potential outcomes for an audit at this stage: Approved with no changes or additions required Clinical Audit Policy Reviewed 2016 Datix Ref: Page 10 of 19

11 Approved but with specific changes required by the group Rejected The decision relating to each audit proposal will be recorded in meeting minutes and the audit lead informed. Their actions relating to the audit will be recorded on the Clinical Audit database maintained by the Clinical Effectiveness Facilitator Uses the clinical audit measures as the basis for collecting data on day-today practice Evaluates the findings and any cases or events that did not meet patient care quality or safety expectations If the findings show that the clinical audit measures are being met, gives feedback on good practice to those involved and acts to maintain good practice If the findings show that the clinical audit measures are not being met: o o o analyses the problems revealed and finds their root causes takes action to eliminate or minimize the causes of the problems measures again when action is taken to see if practice is improved Upon completion of the work involved in the clinical audit, the lead(s) for the specific clinical audit should complete a report on the audit using the approved Trust template (Appendix B). In some cases this will be completed by a member of the Clinical Audit team and will have been agreed at the planning stage of the audit. Once agreed by the clinical team and recommendations and an action plan formulated, the report should be submitted to the Clinical Effectiveness Facilitator The audit lead(s) will be responsible for ensuring that the results of the audit are disseminated appropriately within individual services. The individuals receiving the report should take particular notice of the effectiveness of actions taken to achieve any improvements shown as indicated by the clinical audit and the need for further actions to be taken. It is the responsibility of the audit Lead with the assistance of the Clinical Effectiveness Facilitator to ensure that the report of the audit is presented at the appropriate governance group for the service. 7 Data protection requirements relating to clinical audit 7.1 Informing patients about the use of personal health information SCHT informs patients that their personal health information will be used for clinical audit and quality improvement purposes through reference to the subject in the patient information material about care in the Trust. 7.2 Anonymisation of clinical audit data Clinical Audit Policy Reviewed 2016 Datix Ref: Page 11 of 19

12 All data collected for clinical audit purposes in the Trust will be anonymised through the use of randomly assigned codes at the time of data collection. No patient or professional identifiable data will be reported for any clinical audit at any time. 8 Ethics and Consent One of the principles underpinning clinical audit is that the process should do good and not do any harm. Clinical audit should be carried out within the following ethical framework (Ref E): There is a benefit to existing or future patients or others that outweighs potential burdens or risks. Each patients right to privacy and confidentiality are preserved The activity is fairly distributed across patient groups. 9 Dissemination of clinical audit activities The Quality and Compliance Lead/Clinical Effectiveness Facilitator will be responsible for ensuring that the following are communicated to the staff working in SCHT: The Clinical Audit Programme and progress on carrying out the programme Findings of clinical audits, both of good practice and where improvements in practice need to be made Changes in practice being implemented as a consequence of clinical audits and evidence of the effectiveness of the changes in practice learned through repeating the data collection for clinical audits Good practice in clinical audit and how to carry out a clinical audit the right way This will be done via discussion at SDG Quality and Safety Group meetings and dissemination to clinical staff of the outcome of those discussions by service leads on the group. 10 Support for implementation of this policy The following forms of support will be provided to implement this policy: Clinical audit proposal, clinical audit report and clinical audit presentation templates for use by staff serving as leads for clinical audits Guidance on SCHT clinical audit programme and the clinical audit process as defined in this policy Training for staff to carry out the clinical audit process Technical assistance for staff carrying out clinical audits as required Clinical Audit Policy Reviewed 2016 Datix Ref: Page 12 of 19

13 11 Monitoring Compliance with this Policy Compliance with this policy will be monitored via the SDG Quality and Safety Groups on a monthly basis, the Quality and Safety Delivery Group on a quarterly basis and annually, by the Board via reports to Audit Committee and Quality and Safety Committee. 12 Consultation Consultation has taken place with the following members of staff: Deputy Directors of Operations, Heads of Nursing and Quality, Quality and Safety Compliance Lead, Corporate Risk Manager 13 References: A. Care Quality Commission (2015) Guidance for providers on meeting the regulations, London B. Department of Health (2010) Quality Accounts Toolkit , DH, London. C. National Institute for Clinical Excellence (2002), Principles for best practice in clinical audit, Radcliffe Medical Press, Abingdon. D. Healthcare Quality Improvement Partnership (HQIP) website: E. Heathcare Quality Improvement Partnership (undated) Template for Clinical Audit Policy, HQIP, London Appendix A Clinical Audit Policy Reviewed 2016 Datix Ref: Page 13 of 19

14 Audit Ref: CLINICAL AUDIT PROPOSAL FORM This form is for the use of all healthcare professionals who undertake any clinical audit activity within Shropshire Community Health NHS Trust as part of the agreed Clinical Audit Programme. Advice on completing the form is available from Michelle Bramble, Clinical Effectiveness Facilitator ( ) Both the clinical audit proposal and the associated data collection form should be approved by the relevant SDG Quality and Safety Group for the clinical area in which the audit is to take place prior to any audit work starting. A copy of the audit proposal and the data collection form must be sent to the Clinical Effectiveness Facilitator prior to audit work commencing for inclusion on the Clinical Audit Database. AUDIT PROPOSAL 1. Title of project: 2. Introduction/Background: The rationale for choosing the topic (e.g. problem identified through risk management, clinical incident reporting, patient complaint, availability of national clinical guidance [NICE, NSF], locally developed guidelines or new research evidence, What makes it a priority topic (e.g. high risk, high cost, area of concern, area where there is a need to set standards) 3. Audit project team: The team should be multi-disciplinary where possible and include those with authority to sanction any necessary changes. Please list all staff who will be involved in this audit Name Job Title Role within project (e.g. audit lead, supervisor) Please also ensure that any staff likely to be affected by the audit process or changes identified are notified at the start 4. Overall aim of the audit: The aim of the audit (what you want to achieve) e.g. to assess adherence to NICE guidance on the prescription of methylphenidate Clinical Audit Policy Reviewed 2016 Datix Ref: Page 14 of 19

15 5.Objective/s: Break the overall purpose down into smaller steps that need to be achieved e.g. 1) to identify the maximum daily dose of methylphenidate prescribed 6. Standards: Outline the standards to be used in the audit e.g. Treatment should be increased up to a maximum of 60mg per day; Source NICE Standard Source Any Exceptions 7. Sample Please state how you will identify cases (e.g.lorenzo, Graphnet), the time period to be audited and the number/estimated number of cases to be included 8. Data collection: Please give the method(s) of data collection to be used (double click on tick-box and select Checked ) Casenote Prospective data Data from Patient/staff review collection existing database(s) questionnaire Further details or other method: 9. Data analysis: State how the data will be analysed (e.g Microsoft Access, Excel) 10. Piloting the project: If possible, pilot the methodology - use your data collection form on a few cases. This will tell you whether your instructions were clear, you could get the data you needed, etc. Do you intend to do a pilot? Yes No If yes, please give details: 11. Deadlines: Proposed start of data collection: Anticipated date of project completion (i.e. data collected, analysed, audit report written and ready for presentation to SDG Quality and Safety Group: Clinical Audit Policy Reviewed 2016 Datix Ref: Page 15 of 19

16 Appendix B Title of Audit Audit Team: Clinical Audit Policy Reviewed 2016 Datix Ref: Page 16 of 19

17 Index Page 1.0 Background 2.0 Aim 3.0 Objectives 4.0 Standards 5.0 Sample 6.0 Data Sources and Methodology 7.0 Results 8.0 Findings 9.0 Recommendations and Action Plan Tables and charts: Appendices: References: Clinical Audit Policy Reviewed 2016 Datix Ref: Page 17 of 19

18 1.0 Background 2.0 Aim 3.0 Objectives 4.0 Standards 5.0 Sample 6.0 Data Sources and Methodology 7.0 Results 8.0 Recommendations Clinical Audit Policy Reviewed 2016 Datix Ref: Page 18 of 19

19 9.0 Action Plan Key Finding/Recommendation Action Required Person Leading Status/Timeframe Clinical Audit Policy Reviewed 2016 Datix Ref: Page 19 of 19