Clinical Audit Strategy 2015/ /18

Transcription

1 Audit Strategy 2015/ /18 Audit Strategy v8 Head of Integrated Governance Oct

2 CLINICAL AUDIT STRATEGY, 2015/16 to 2017/18 Executive East Cheshire NHS Trust sees clinical audit as a cornerstone of its arrangements Summary: for developing and maintaining high quality patient-centred services. It is expected that this Strategy will inform and enhance the process of improving clinical services. Supersedes: Audit Strategy 2011/15 Description of Amendment(s): This policy will impact on: All Trust Staff Financial Implications: This Audit Strategy has been fully rewritten to reflect the changes which have taken place in the field of clinical audit and to meet present day requirements Policy Area: Corporate Document ECT Reference: Version Version 8 Effective Date: 13 th October 2014 Number: Issued By: Julie Green, Director of Corporate Review Date: 13 th October 2018 Affairs and Governance Author: (Full Job title) Fiona Smith Head of Integrated Governance APPROVAL RECORD Committees / Group Date Consultation: Audit Research and Effectiveness Group Approval Committee: Ratified by Committee: Audit Research and Effectiveness Group 13 th October 2014 Safety Quality and Standards Committee November 2014 Audit Strategy v8 Head of Integrated Governance Oct

3 Table of contents Executive Statement Page 1 Chapter One: Organisational Context Page 2 Chapter Two: Scope Page 3 Chapter Three: Definition of clinical audit Page 5 Chapter Four: Strategic aim and objectives Page 6 Chapter Five: audit programme Page 7 Chapter Six: Action Plan Page 9 Appendix A: References & acknowledgements Page 14 Audit Strategy v8 Head of Integrated Governance Oct

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5 Executive Statement East Cheshire NHS Trust (the Trust) is committed to delivering effective clinical audit in the clinical services it provides. The Trust sees clinical audit as a cornerstone of its arrangements for developing and maintaining high quality patient-centred care. It is expected that this 3-year Audit Strategy, in line with the Trust s wider governance and assurance mechanisms will inform and enhance the process of improving clinical services. Dr John Hunter Interim Medical Director Julie Green Director of Corporate Affairs and Governance 1 P a g e E x e c u t i v e S t a t e m e n t

6 Chapter One: Organisational context 1. audit is an established, systematic review process with quality improvement at its core. 1 It is important that clinical audit is not seen as an isolated quality improvement activity but as one of a set of tools which teams and organisations can use to improve the quality of care that is delivered to service users and their families. It is also important to consider the links to the wider quality and governance frameworks that exist. 2. audit, as a body of work, should contribute to the delivery of East Cheshire NHS Trust s corporate objectives and its overall vision for: clinical governance - the framework through which NHS organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish 2 ; corporate assurance including the Care Quality Commission s registration standards, and related indicators; integrated governance - systems, processes and behaviours by which organisations lead, direct and control their functions in order to achieve organisational objectives, safety and quality of service and in which they relate to patients and carers, the wider community and partner organisations 3 ; quality, including quality accounts; patient engagement/involvement i.e. how organisations respond to the Duty to Involve as set out in Department of Health Guidance Real Involvement: working with people to improve services 4, which updates Section 242 of the NHS Act 2006; support for the implementation and evaluation of initiatives developed as part of the next generation care approach to service improvement within the organisation. 3. For East Cheshire NHS Trust, as a provider organisation, clinical audit activity should reflect commissioners requirements and aspirations, for example, by providing evidence for commissioning with regards to contractual requirements. Findings of any audit must be made available to the commissioner on request and the commissioner can appoint an auditor to audit quality and outcomes and recording and coding of clinical activity. 4. Other areas of consideration must include: information governance to ensure that clinical audit practice meets the requirements of information governance best practice; research and development - close working arrangements exist between clinical audit and research and development staff, with open communication to clarify details over projects e.g. where doubt exists about whether a project is audit, research or service evaluation. 2 P a g e C h a p t e r O n e O r g a n i s a t i o n a l C o n t e x t

7 Chapter Two: Scope 5. This strategy is targeted at all the clinicians and staff within East Cheshire NHS Trust who have responsibility for overseeing the direction and development of clinical audit. This will typically include the following: Trust Board The Trust Board is responsible for ensuring that the organisation consistently follows the principles of good governance applicable to NHS organisations. This includes the development of systems and processes for governance and risk management which support this strategy. Chief Executive The Chief Executive is the Accountable Officer of the Trust and as such has overall accountability and responsibility for ensuring it meets it s statutory and legal requirements and adheres to guidance issued by the Department of Health in respect of Governance. Medical Director The Medical Director has executive accountability for clinical effectiveness and is responsible for providing assurance to the Board on the implementation of this strategy via the appropriate Board Committee. Director of Nursing, Performance and Quality The Director of Nursing, Performance and Quality is responsible for organisational operational management of clinical services and the delivery of the Quality Strategy. The Director has executive responsibility for ensuring the Trust provides high quality care, which is supported by the effective implementation of clinical audit within Service Lines. Director of Corporate Affairs and Governance The Director of Corporate Affairs and Governance has accountability for governance and risk management across the Trust and for working in collaboration with Medical Director to ensure the Board and relevant committees receive appropriate assurance with regard to the implementation of this strategy. As Chair of the Audit Research and Effectiveness Group will develop the Audit Strategy with members of the meeting and oversee its implementation. Associate Medical Director for Effectiveness The Assistant Medical Director is the lead clinician accountable for the implementation of the Audit Strategy across the Trust. They provide clinical leadership across the organisation in respect of clinical audit. They are Vice Chair of CARE Group and work closely with members of the group and identified audit leads to support quality improvements. 3 P a g e C h a p t e r T w o S c o p e

8 Deputy Director Corporate Affairs & Governance The Deputy Director will lead and ensure mechanisms are in place to manage the governance processes related to the Audit Strategy in order to achieve best practice and continued improvement; this includes having accountability for the management of the Effectiveness Team. The Head of Integrated Governance The Head of Integrated Governance is responsible for the management of the clinical effectiveness team and development of the Audit Strategy. Effectiveness Team The Effectiveness Team is responsible for monitoring and reporting on the Trust clinical audit programme, ensuring that the requirement to provide assurance on compliance/ implementation of national, regional and local standards of practice is met. This includes audit of the implementation of NICE guidance including quality standards and technology appraisals. The team members will work with representatives of the Service Lines to prioritise audit activity which reflects the objectives of the organisation and provide support to ensure a programme of clinical audit and effectiveness activities is undertaken. Associate Director for Performance and Delivery The Associate Director for Performance and Delivery will lead (support) on governance performance issues throughout the Service Lines. Heads of Service Associate Directors are responsible for the local implementation of this strategy within their respective areas and for ensuring that Audit Leads and Service Line representatives on the Audit Research and Effectiveness Group fulfil their responsibilities for the delivery and monitoring of their clinical audit programme. Audit Leads Service Line Audit Leads are responsible for promoting and monitoring clinical audit activity within their area of responsibility, ensuring that evidence of changes in practice, where required, is available. Managers Managers are responsible for the local implementation of clinical audit and for ensuring staff adhere to the relevant clinical audit policy and procedures. All clinicians and healthcare professionals All clinicians and healthcare professionals are responsible for providing clinically effective care and treatment, which is supported through active participation in clinical audit and the implementation of improved practice as a result of learning. 6. All members of Trust staff should be aware of the strategy as its implementation will have an impact on the way they undertake their duties and the support the Effectiveness Team can provide in everyday clinical audit activities. 4 P a g e C h a p t e r T w o S c o p e

9 Chapter Three: Definition of clinical audit 7. Audit may be defined 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. 5 This is the definition provided and endorsed by the National Institute for Health and Care Excellence, and the one to which East Cheshire NHS Trust works. 8. audit is often shown as a cycle. This cycle can have many stages, and appear quite complex. A simplified version of this cycle is shown below for information. Audit within East Cheshire NHS Trust will follow this model. It is of particular importance to note the stages of improve practice and re-audit. This will support the Trust to demonstrate demonstrable improvements in the quality of care that we deliver. Select Topic Re-audit Appraise Evidence Improve Practice Audit Cycle Develop Standards Peer Review Design Data Collection 5 P a g e C h a p t e r T h r e e D e f i n i t i o n o f C l i n i c a l A u d i t

10 Chapter Four: Strategic aim and objectives Strategic aim 9. The aim of this strategy is to ensure that there is clarity over the use of clinical audit as a process to embed clinical quality at all levels within East Cheshire NHS Trust over the next three years. It will deliver demonstrable improvements in patient care through the development and measurement of evidence-based practice. Objectives 10. The above strategic aim is supported by a number of service objectives, i.e., the areas of clinical audit practice that the Trust is committed to developing. By definition, these objectives are likely to vary in their specificity, however all objectives will be supported by SMART actions: Specific Measurable Achievable Relevant Time-based 11. For 2015/16 to 2017/18 the key objectives for East Cheshire NHS Trust are: to ensure that all clinical audits undertaken within the Trust support, the organisation s objectives and reporting requirements; to ensure a uniform approach across the organisation to clinical audit activity and clinical lead engagement; to ensure that all clinical staff have the necessary competency, support and time to participate in clinical audit; to ensure that the Trust has a robust clinical audit programme and mechanism to report to the Board; to ensure that mechanisms are in place to support the monitoring of the achievement of audit action plans supporting improvements in practice within stated timescales; to ensure organisational compliance with the Care Quality Commission and statutory and mandatory Audit requirements imposed on healthcare providers who work in the NHS in England. to ensure that where appropriate audit is a multi-professional activity. 6 P a g e C h a p t e r F o u r S t r a t e g i c A i m & O b j e c t i v e s

11 Chapter Five: audit programme 12. East Cheshire NHS Trust will produce an annual clinical audit programme which will outline details of the specific clinical audit projects to be carried out. The programme will be developed in consultation with members of senior clinical and non-clinical management within the organisation. It is expected that managers will ensure that there is an opportunity for staff at all levels within the organisation to feed into the development of the core programme. 13. The choice of clinical audit topics will also support other key streams of governance and quality activity, for example: clinical effectiveness and evidence-based practice; clinical risk management/patient safety (e.g., choosing audit topics in response to concerns highlighted by patient safety incidents); complaints and other forms for patient feedback (e.g., themes from this source of information intelligence should be used to propose topics for clinical audit); other benchmarking activities as appropriate 14. This clinical audit core programme will, each year, make provision to highlight or support (as appropriate) various core projects. As a minimum the programme will consider or include: National Confidential Enquiries into Patient Outcome and Death 6 ; National Patient Safety Agency guidance; National Audit; National Service Frameworks; Statutory and Mandatory Audit requirements; Care Quality Commission standards; National Institute for Health and Care Excellence guidance (in all its forms). 7 P a g e C h a p t e r F i v e C l i n i c a l a u d i t p r o g r a m m e

12 15. The annual work that the Effectiveness Team supports must also take into consideration each of the following areas: the development of the Service Lines within the Trust, particularly in respect of those clinical staff who work in a community setting or outside of an acute hospital setting; the appraisal and revalidation of consultants and other doctors, together with enabling all clinicians to comply with their professional codes of conduct; service user involvement; national initiatives, including Quality Accounts, Commissioning for Quality and Innovation (CQUINS), Patient Reported Outcome Measures (PROMS) which some teams will be coordinating work for as part of their clinical audit function. the annual Statement of Internal Control for the Trust (the contribution of clinical audit to the process by which an organisation gains assurances about the quality of its services and the effective management of risk). 8 P a g e C h a p t e r F i v e C l i n i c a l a u d i t p r o g r a m m e

13 Chapter Six: Action Plan 16. An action plan reflecting the objectives listed in Chapter 4 has been developed and is shown below. To ensure that they are achieved and delivered in a timely manner, this plan will be reviewed bi-annually by the Trust s Audit Research and Effectiveness Group (CARE) - which is accountable to the Safety, Quality and Standards Committee, a committee of the Trust s Board. Progress against this plan will be reported as part of the Effectiveness quarterly report to the Trust Safety, Quality and Standards Committee. Outcome Lead Action Objective 1 - To ensure that all clinical audits undertaken within the Trust support the organisation s objectives and reporting requirements To ensure Trust Board objectives are considered in the audit planning process. Head of Integrated Governance Relevance of audits to Trust Board objectives to be made at planning/ registration stage. Engagement of clinical supervisors/clinical audit leads to ensure quality and consistency of clinical audit reports. Service Line s Safety Quality and Standards Groups audit results to be documented in the Trust Audit report template, to ensure consistency. Objective 2 - To ensure a uniform approach across the organisation to clinical audit activity and clinical lead engagement To support clinical audit and mortality review groups in the Service Lines providing a multidisciplinary approach, measurable changes to practice, and regular meetings. To improve the opportunities available to trainee doctors within the organisation to participate in audits which are of value to the organisation. There will be a Head of Integrated Governance Service Line s Safety Quality and Standards Groups Head of Integrated Governance Audit Research and Effectiveness audit and mortality review groups will meet monthly in each of the following Service Lines: Surgical Specialties Support & Diagnostics Women s and Children s Urgent Care Medical Specialties Allied Health Services Integrated Care It may be appropriate for Service Lines to have joint clinical audit and mortality review groups and joint accountability will be clear within the terms of reference where this occurs. Provision of a structured plan for audits available to trainee doctors through the Trust s annual audit programme. Supervisors/ 9 P a g e C h a p t e r S i x A c t i o n P l a n

14 Outcome Lead Action structured format of projects to complete or contribute to. Projects will link into the Trust core programme. There will be an increased level of ownership by supervisors and teams of clinical audit reporting and findings, with an improved level of change following audit. Education to highlight the importance of reaudit will be provided and evidence of change to practice will be monitored. Group Service Line s Safety Quality and Standards Groups Audit Leads to oversee audit to ensure quality and consistency of audit reporting Liaison with Service Line clinical audit leads, through Audit Research & Effectiveness Group membership. Objective 3 - To ensure that clinical staff have the necessary competency, support and time to participate in clinical audit To review the training that the clinical audit department provides to ensure it is fit for purpose: that it is appropriate to the needs of the organisation that an appropriate number of sessions are being delivered to ensure that sessions are being delivered to meet the needs of differing ability groups to ensure training is available both face to face and electronically when systems allow. Head of Integrated Governance Review of training to ensure that information is up-to-date and accessible to all staff and will be available electronically when systems allow. Review of content of sessions delivered to teams and individuals. Plan for annual training to be delivered which should include sessions at multiple locations, and available on a planned and drop in session. To ensure a clear framework is in place within clinical effectiveness to provide clarity of roles, to enable best practice to be applied in supporting all clinicians in clinical audit. Conduct annual appraisal sessions for clinical effectiveness staff to identify training needs To ensure that the Trust obligations towards clinical audit within revalidation for doctors, and other health professionals, are met. Associate Medical Director for Effectiveness Associate Medical Director for Revalidation Heads of Service Inclusion of clinical audit or other quality improvement activities, as appropriate, within the supporting professional activities (SPAs) undertaken within the Trust. Involvement in appropriate audit activity, and completion of the audit cycle, will be recorded and scrutinised during the annual appraisal and 10 P a g e C h a p t e r S i x A c t i o n P l a n

15 Outcome Lead Action then will form part of the evidence used for revalidation. This will take into account recommendations by the General Medical Council and other organisations such as the Royal Colleges. The effectiveness department will identify and develop as necessary (within the financial constraints present) supporting measures which can be provided to staff undertaking clinical audits. For those who register their audit activity and submit reports of the completed audit, the effectiveness Department will provide certificates of completion. These will outline the stages of the audit cycle that individual clinicians have been involved in. These can form part of the individual s appraisal portfolio. To provide comprehensive evidence of involvement by clinical staff of clinical audit and other quality improvement activities to enable publication within the Quality Accounts. Educational Supervisors Service Line Audit Leads That evidence is available through minutes of audit meetings, appraisal portfolios, supervision records, or audit project reports. Directors Director of Nursing Continued on the next page 11 P a g e C h a p t e r S i x A c t i o n P l a n

16 Outcome Lead Action Objective 4 - To ensure that the trust has a robust clinical audit programme and mechanism to report to the Board There will be an annual clinical audit programme developed for East Cheshire NHS Trust detailing specific clinical audit projects that will be carried out. The programme will be developed in consultation with members of senior clinical and non-clinical management within the organisation. It is expected that managers will ensure that there is an opportunity for staff at all levels within the organisation to feed into the development of the core programme. There will be an evidence trail for this involvement, including meeting minutes, or s. Progress by teams against the programme will be monitored through Service Line scorecards, and reported in the clinical effectiveness quarterly report to the Trust Safety, Quality and Standards Committee. audit of National Institute for Health & Care Excellence guidance will be incorporated into the clinical audit annual programme. The Institute s guidance will be prioritised for audit in terms of which topics are selected, and how they will be audited. This will be in liaison with the Audit Research & Effectiveness Group to ensure that there is broad input into this process. Audit of National Institute for Health & Care Excellence topics will feed into the core programme. Head of Integrated Governance Associate Medical Director for Effectiveness Audit Leads Service Line Safety and Quality Standards Groups Audit Research and Effectiveness Group Audit Leads Audit Research and Effectiveness Group A clinical audit programme will be produced, in consultation with the Service Line Safety Quality and Standards Groups, and this will be ratified by the Audit Research and Effectiveness Group. There will be an evidence trail for this involvement, including meeting minutes, or s Liaison with Service Line audit leads, through Audit Research and Effectiveness Group membership to ensure that National Institute for Health and Care Excellence guidance is prioritised as a topic for audit. Objective 5 - To ensure that mechanisms are in place to support the monitoring of the achievement of audit action plans within stated timescales This is achieved through RAG rating the audit scorecards, supporting Service Line audit leads in ensuring that audit plans lead to changes in practice within stated timescales Utilisation of DATIX to record audit activity from registration to Head of Integrated Governance Audit Leads Service Line Safety and Quality Standards Groups Service Lines and the Audit Research and Effectiveness Group have a systematic approach to monitor that the audit cycle is completed within stated timescales. Concise monitoring of audit action plans and audit trail to 12 P a g e C h a p t e r S i x A c t i o n P l a n

17 completion Outcome Lead Action evidence actions completed and improvements to care implemented. Objective 6 - To ensure organisational compliance with the Care Quality Commission and Statutory and Mandatory Audit Requirements To provide comprehensive evidence of involvement by staff with clinical audit and other quality improvement activity. Audit Leads Educational Supervisors Evidence provided from team meeting minutes, appraisal portfolios and audit projects Audit Research & Effectiveness Group audit of policies and their implementation will be incorporated into the Service Line s clinical audit annual programme. Audit Leads Service Line Safety & Quality Standards Committees Evidence from the audits that policies are being adhered to. Policy Governance Group Audit Research & Effectiveness Group Implementation of Governance Self Serve Head of Integrated Governance Effectiveness Team The introduction of Governance Self Serve will enable all users to access electronic templates and examples of best practice The Trust must participate in the National Audit and Patient Outcomes Programme (NCAPOP) audits which are relevant to the services we provide and make national clinical audit data available, to support the publication of consultant level outcomes. Audit Leads The national audits will be monitored via the Effectiveness team and included in the Annual Quality Accounts report. 13 P a g e C h a p t e r S i x A c t i o n P l a n

18 Appendix A: References and Acknowledgements References The following documents, publications and / or websites have been referenced in this Strategy: 1. A simple guide for NHS Boards and Partners ( -Audit-Simple-Guide-online1.pdf) 2. Scally G, Donaldson LJ. governance and the drive for quality improvement in the new NHS in England. BMJ 1998;317: Deighan M, Bullivant J. Integrated Governance Handbook: A Handbook for Executives and Non-executives in Healthcare Organisations. London: Department of Health; Real Involvement: working with people to improve services Guidance ( web archive. 5. National Institute for Excellence. Principles for Best Practice in Audit. Abingdon: Radcliffe Medical Press; 2002, p The National Confidential Enquiry into Patient Outcome and Death ( the Confidential Inquiry into Maternal and Child Health (CEMACH) ( and the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (CISH) ( /nci). Acknowledgements The strategies of the following organisations were reviewed as part of the development of this Strategy: Dartford and Gravesham NHS Trust NHS Plymouth NHS Sheffield Salisbury NHS Foundation Trust South Devon Healthcare NHS Foundation Trust Taunton and Somerset NHS Foundation Trust University Hospitals Coventry and Warwickshire NHS Trust 14 P a g e A p p e n d i x A R e f e r e n c e s

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20 East Cheshire NHS Trust Trust Headquarters Macclesfield District General Hospital Victoria Road Macclesfield Cheshire SK10 3BL Copyright East Cheshire NHS Trust, 2014