Clinical Audit Policy

Clinical Audit Policy Clinical Audit Policy Page: Page 1 of 24

Recommended by Approved by Executive Management Team Quality Committee Approval date July 2017 Version number 3.0 Review date July 2019 Responsible Director Responsible Manager (Sponsor) For use by Medical Director Senior Clinical Quality Manager All Trust Employees This policy is available in alternative formats on request. Please contact the Corporate Governance Office on 01204 498400 with your request. Clinical Audit Policy Page: Page 2 of 24

Change record form Version Date of change Date of release Changed by Reason for change 0.1 March 2008 April 2008 Draft document 1.0 April 2008 April 2008 Final document 1.1 October 2010 October 2010 NHSLA Monitoring 0.2 April 2011 Document Review 0.3 May 2011 NHSLA Review Feedback 2.0 July 2011 July 2011 S. Barnard Trust Board Approval 0.4 April 2012 M Peters NHSLA Feedback & amendment of performance improvement process 2.1 May 2012 May 2012 Final document 0.5 September 2014 Senior Clinical Quality Manager Document Review 2.2 December 2014 January 2014 Final Document 0.6 July 2015 2.3 October 2015 October 2015 0.7 June 2017 3.0 August 2017 Senior Clinical Quality Manager Senior Clinical Quality Manager Senior Clinical Quality Manager Senior Clinical Quality Manager Document Review Final Document Document Review Final Document Clinical Audit Policy Page: Page 3 of 24

Clinical Audit Policy Contents 1. Introduction... 5 2. Purpose of Policy... 5 3. Duties and Responsibilities... 7 4. Selection and Prioritisation of Audits... 9 5. Clinical Audit Register... 10 6. Clinical Audit Methodology... 10 7. Quality Improvement Methodology... 12 8. Further Information & Support... 12 9. Policy Review... 12 10. Equality Impact Assessment Statement... 13 11. Bibliography and References... 13 Appendix 1: Key Principles: CLEAR Vision Matrix for 2017... 14 Appendix 2: Patient and Public Involvement Guidance and Legislation... 16 Appendix 3: Clinical Audit Priority Identification... 17 Appendix 4: Clinical Audit Proposal Form... 18 Appendix 5: Clinical Audit Cycle... 21 Appendix 6: Clinical Audit Report Pro-forma... 24 Clinical Audit Policy Page: Page 4 of 24

1. Introduction 1.1 What is Clinical Audit? Clinical Audit is 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. (NICE 2002) Put more simply, Clinical Audit is all about measuring the quality of care and service against agreed standards and making improvements where necessary. 2. Purpose of Policy The purpose of this policy is to develop and sustain a culture of best practice within the Trust through the clinical audit process. The policy sets out a framework of key principles for staff undertaking clinical audit projects within North West Ambulance Service NHS Trust and should be referred to when organising clinical audit activity. The policy seeks to underpin the Patient Care Strategy objectives for the Trust through the clinical audit processes through an accessible quality improvement tool. The key aims and objectives of this policy are: To ensure that NWAS has an active on-going audit programme focussing and addressing national priorities and key clinical concerns aligned with the assurance and accountability measurement of the Patient Care Strategies, using the Clear Vision Framework. Ensure that there is clarity over the use of clinical audit as a process to embed clinical quality at all levels within North West Ambulance Service NHS Trust. Promotes continual development and sustains a culture that supports quality improvement, best practice and learning. To enable health professionals and service users to evaluate and measure practice and standards. To assure the Trust Board that systems are in place to develop an audit programme that meets organisational needs for robust information and reports which are received on a regular basis. Clinical Audit Policy Page: Page 5 of 24

2.1 Clinical Audit as a source of board assurance The Trust supports the view that clinical audit is a tool that is used in strategic management as part of the broader quality improvement programme. It plays an important role in providing assurance to the board about the quality of service and is a vital component of the clinical governance arrangements. 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 the organisation can use to improve the quality of care that is delivered to patients. There is scope to maximise the assurance provided by the clinical audit function through considering how the audit programme can be best aligned to the Trust Patient Care Strategy CLEAR vision framework. A high level overview of the relationship between the key principles of the patient care strategy is described in figure 1 below. Following this framework it will demonstrate a commitment to improving the care of patients that fall within the identified NWAS clinical priorities areas. The Clear vision framework: Key Principle matrix for 2017 is located in appendix 1. Figure 1: Patient Care Strategy Key Principles The CLEAR vision framework elements can be described as follows: Clinical and systems Leadership Education, innovation and clinical practice development Accountability for quality improvement and assurance Responsibility to collaborate and improve Clinical Audit Policy Page: Page 6 of 24

2.2 Background If applied correctly, clinical audit as a performance measurement system will help; provide assurance that clinical protocols and guidance are being adhered to, highlight areas of good or poor performance and identify problems within systems, structures or processes. Clinical audit can also help measure the effectiveness of clinical protocols by linking actions and processes to outcomes. This will also help create an evidence base to inform the review and development of future protocols or guidance. Taking healthcare to the patient: transforming NHS ambulance services' (DoH 2005) re-enforces this by stating: that measures of patient outcomes and experience should be used to promote evidence based practice and to assess how far ambulance services are delivering high quality care. Clinical audit was cited as the principle activity to support this. 2.3 Involving Patients and the Public Patients and carers often assess quality of care in different ways to healthcare professionals: they can provide a unique perspective based on their personal experience and can help design services around patient needs. The ambulance service is a gateway for many people with a range of health problems and the information about people s experiences of care, and the outcomes of that care, can be invaluable in improving quality. The Trust is committed to the involvement of patients, their families and the wider public in the whole clinical audit process. Appendix 2 lists some of the guidance and legislation for patient and public involvement. 3. Duties and Responsibilities The Chief Executive has a statutory responsibility for the quality of care provided to patients. The Medical Director is the Executive Director lead for clinical audit. The Chief Consultant Paramedic has corporate responsibility for ensuring that clinical staff participate, and are actively engaged, in clinical audit. This will include the provision of educational support to ensure that they have the relevant competencies. Clinical Audit Policy Page: Page 7 of 24

Senior Clinical Quality Manager is responsible for the corporate development, implementation and performance management of an annual clinical audit plan, including the production of any policies or procedures to support clinical audit across the different areas of the Trust. The Head of Clinical Education is responsible for the development and provision of education and training to support clinical staff to undertake clinical audit. The Clinical Quality Manager is responsible for supporting the service delivery and clinical leaders in the day to day management of clinical audit, supporting the Trusts clinical audit plan. The Clinical Quality Officer is responsible for providing day to day support and advice for clinical audit. They are responsible for advising the service delivery and clinical leaders with best practice methods of data collection, communication and quality improvement aspects of audit. The Consultant Paramedics with the Sector Managers within Service Delivery are responsible for supporting the operational implementation and performance management of the annual clinical audit plan and any related policies and procedures. The Advanced Paramedics (APs) within Service Delivery are responsible for the development, implementation, data collection analysis, reporting and quality improvement actions of specific AP led audits within the annual clinical audit plan. APs are responsible for supporting all clinical staff within the organisation to be engaged with clinical audit processes. It is the responsibility of all clinical staff to support clinical audit within the organisation and to be actively engaged wherever possible. It is the responsibility of the Trust Clinical Governance Management Group to: Recommend the annual clinical audit plan to the Audit Committee Receive clinical audit reports, consider and approve recommendations for improvements change; ensuring learning occurs wherever possible. Review the Trust Clinical Audit Policy and other related polices or procedures. Clinical Audit Policy Page: Page 8 of 24

It is the responsibility of the Trust Audit Committee to: approve the annual clinical audit plan It is the responsibility for the Trust Quality Committee to: Provide assurance to the Trust Board in relation to clinical audit activity. Provide assurance to the Trust Board in relation to clinical audit activity by reviewing progress against the plan twice a year. It is the responsibility of Emergency Service Quality Board Group (ESQBG) to: Identify any local clinical audits required Identify learning outcomes and support communication of quality improvement programmes and audit results. 4. Selection and Prioritisation of Audits Each year the Trust develops its clinical audit plan, which consists of the Trusts priorities and key drivers for the year. The clinical audit plan is taken to the Audit Committee for approval. The audit plan is compiled by a process of identification of clinical audit priorities (appendix 3) considering both bottom up via clinical staff and top down via Trust committees, performance groups or external requirements. All clinical audits should be supported by a proposal form (appendix 4) that guides the clinician to define the audit as clearly as possible. The clinical audit plan provides an outline of the National programme of work and key clinical audit activity for the Trust. All Clinical Audit activity will be registered on the clinical audit tracker and a quarterly report will be produced by the Clinical Quality Officer and be presented at the Clinical Governance Management Group. A full breakdown of annual clinical audit activity will be finalised at year end and documented in the Annual clinical audit report. Each audit is classified in terms of their priority as follows: Priority 1 (P1): External Must Dos: National audit requirements mandated through organisations such as the Department of Health, Care Quality Commission, or other national audit programmes. Clinical Audit Policy Page: Page 9 of 24

Priority 2 (P2): Internal Must Dos: Internal audits mandated through the quality contract with the ambulance service lead commissioners. Priority 3 (P3): External Discretionary: Usually large scale audits commissioned through an external source not mandated through any national programme of audit. Priority 4 (P4): Internal Discretionary: usually but not always small scale locally commissioned audit not mandated through any formal programme of audit commission. The annual audit calendar clearly indicates the priority of the audit. 5. Clinical Audit Register The Trust will maintain a register of clinical audits undertaken within the organisation. This will support good governance of all audit projects; ensuring that the rationale for the audit is appropriate and also that the principles of the policy and guidance are adhered to. The register will also enable sharing of good practice and avoid any duplication of efforts. The Trust Clinical Quality Officer will manage the register. 6. Clinical Audit Methodology All audits undertaken should reflect the process for a good quality audit as outlined in Appendix 5. The Trust uses a selection of audit methods to allow us to understand the care that we are providing to our patients across the North West; each has their own specific purpose. Clinical Audit audit against agreed standards of best practice, a larger end sample size to warrant implementation of change based on findings. Snapshot Audit (PDSA) a process based audit that will enable you to measure whether processes are being followed, this is a more frequent audit with a smaller sample size. Clinical Performance Indicator Care Bundle Audit - A high level audit process that could be undertaken locally, by clinicians, at an Clinical Audit Policy Page: Page 10 of 24

operational level on a monthly basis. The Trust performs a monthly audit in the form of the Clinical Performance Indicator Care Bundle Audit. A bundle is a structured way of improving the processes of care and patient outcomes: a small, straightforward set of evidence-based practices generally three to five that, when performed collectively and reliably, have been proven to improve patient outcomes http://www.ihi.org/topics/bundles/pages/default.aspx (last accessed 21/07/2017) Peer Review Audit - A periodic review, to identify any lessons that can be learned that may affect others in the future. A selection of case studies that are selected for detailed analysis and form the basis for suggesting future improvements. Observational Audit a series of observations are made over a period of time to allow us to evaluate the service and give direction for improvement and development. Patient Reported Experience Measures (PREMs) A patient experience questionnaire that patients complete and return to allow for analysis. This will allow for an understanding of what the patient thinks of the process of care that they have received. 6.1 Clinical Audit Projects All clinical audit projects undertaken within the Trust must be developed and registered in accordance with the agreed clinical audit procedure. Each audit project should ideally have a topic that falls within the identified Patient Strategy priorities. The project lead is responsible for ensuring all involved are aware that the audit project is being undertaken and data collected; they are responsible for overseeing the audit process. The Trust has an approved format for all audit reports. It is expected that the audit reports, other than the CPI Care Bundle reports, will follow the same format to include methodology, conclusion and action plans (Appendix 6). Clinical Audit Policy Page: Page 11 of 24

7. Quality Improvement Methodology NWAS has developed a Quality Improvement Strategy the actions of which correspond with the Care Quality Commission s (CQC) key lines of enquiry (KLOE) as follows (CQC KLOE reference in brackets): Promote a safety culture, whilst seeking to reduce harm (Safe) Provide the best information and intelligence to support staff and achieve the highest standards of safe, reliable and effective care (Effective) Propagate a listening and learning culture that responds to what matters most to our patients and staff (Responsive) Promote the use of improvement methodology, human factors principles and an appreciative inquiry approach to optimise individual performance and help deliver safe-care-closer-to-home in partnership with local health and social care (Well Led) The use of Quality Improvement methodology, Human Factors thinking and Appreciative Inquiry techniques will support the delivery of the improvements to patient care identified as required through clinical audit. Our quality improvement ambitions are described in more detail in the NWAS quality improvement strategy. 8. Further Information & Support Practical Clinical Audit Handbook; www.cgsupport.nhs.uk/downloads/practical_clinical_audit_handbook_v1_ 1.pdf Principles for Best Practice in Clinical Audit; www.nice.org.uk/nicemedia/pdf/bestpracticeclinicalaudit.pdf 9. Policy Review The NWAS Clinical Audit Policy will be reviewed every three years; however, should national guidance or legislation change then the policy may be reviewed earlier. As part of the policy review process, the effectiveness of the policy and its application will be assessed. Information and results from audit systems, adverse incidents, user feedback and external audits/reviews will be used to inform this assessment. Clinical Audit Policy Page: Page 12 of 24

10. Equality Impact Assessment Statement It was found that the Clinical Audit framework has a positive assessment, as it supports the public health agenda. 11. Bibliography and References Chambers, R. and Boath, E (2001) Clinical Effectiveness and Clinical Governance Made Easy, (2nd edn), Radcliffe Medical Press Ltd. Dhaya et al (2005) Informing clinical practice through audit: theory into practice, Clinical Governance Bulletin, Vol. 6, No.1, 2005 Department of Health (2002) Learning from Bristol: the Department of Health s Response to the Report of the Public Inquiry into Children s Heart Surgery at the Bristol Royal Infirmary 1984 1995, London: The Stationery Office. Department of Health (2004) Standards for Better Health, London: HMSO Department of Health (2005) Taking Healthcare to the Patient: Transferring Ambulance Services, London: HMSO NHS Executive (1999) Clinical Governance: Quality in the New NHS, London: HMSO NICE (2002) Principles for Best Practise in Clinical Audit, Oxford, Radcliffe Medical Press Ltd Ranade, W. (1997) A Future for the NHS? Health Care for the Millenium, (2 nd edn), London: Addison Wesley Longman Limited Clinical Audit Policy Page: Page 13 of 24

Appendix 1: Key Principles: CLEAR Vision Matrix for 2017 CLEAR Framework Before the Call Answer my Call Understand my Need(s) Respond to my Need(s) Direct Me to the Right Place Clinical and Systems Leadership Lead networks to reduce common presentations to services. Ensure as many users are able to understand NWAS mission statement and use our services as appropriate. Embed making every contact count and use opportunities for public health advice. Understand the impact of service reconfigurations & transformations regionally and locally. Effective telephony and triage platform. Embedded Clinical leadership embedded support all call centre activity. Remote access to clinical specialities to encourage hear & treat via virtual integrated clinical hub. Develop a comprehensive scheme of clinical delegation that covers all aspects of NWAS as an organisation. Ensure those who require H&T receive it. Ensure local health systems are organised to receive right care referrals from NWAS clinicians. Access to summary care records Embed systems of observation, peer review and 360 reviews. Clinical supervision will be a normal function at all levels of practice and will include volunteers and third sector agencies. Access to summary care records. Influence the networks to provide direct access to specialities in the community or hospital bypassing traditional pathways (ED & GP) Clinical leadership to support & encourage alternative care pathway use. Clinical Audit Policy Page: Page 14 of 24

CLEAR Framework Before the Call Answer my Call Understand my Need(s) Respond to my Need(s) Direct Me to the Right Place Education, Innovation and Clinical Practice Development Research the changing epidemiology of ambulance users at a population level using linked data. Develop NWAS staff as prevention practitioners. Trust wide involvement in promoting prevention. Invest in leadership across call centres by developing knowledge and skills. Commission research to improve efficiency and safety of call centre operations. Develop, strengthen and diversify the role of traditional ambulance practice with the support of educational partners to align practice against the nature of calls attended. Develop robust & evidence based care pathways. Develop system to review evidence of new best practice and guideline developments. Normalise simulation to test new practice, guidelines & equipment before operational implementation. Continue to invest in education to support patient centred & shared decisions to determine where care can be best delivered. Accountability for QI and Assurance Further develop metrics to identify high intensity users. Use trend data following interventions to establish their effectiveness. Develop suite of safety-based metrics with the granularity to allow practitioners to compare their performance with each other and their teams. Develop metrics to determine if the clinician with the right skill set was sent to the right patient. Further develop metrics to determine consistent delivery of right treatment. Develop Quality Improvement methodologies to enable care to advance safely. Develop safety metrics and mortality based data. Develop patient reported outcome measures. Responsibility to Collaborate and Improve Collaborate with partner agencies to reduce call volume or flatten known peaks in demand. Develop multi-agency preventative strategy. Develop national learning networks to improve the call experience through patient and participant involvement as well as system experts in the UK and globally. Encourage participation in ambulance care by alternative providers and practitioners to complement NWAS skill-set and bring the right care to our patients. Collaborate to develop the right care in the community away from hospital wherever possible. Maximise the opportunities to provide definitive care closer to the point of contact through collaboration with partner agencies. Use linked outcome data to collaborate with partners to provide innovative solutions to where care can be delivered. Clinical Audit Policy Page: Page 15 of 24

Appendix 2: Patient and Public Involvement Guidance and Legislation Care Quality Commission, Guidance for providers on meeting the Health and Social Care Act 2008 (Regulated Activities) Regulations, 2014 (Part 3) (as amended) Care Quality Commission, March 2015, Regulation 17: Good governance: As part of their governance, providers must seek and act on feedback from people using the service, those acting on their behalf, staff and other stakeholders, so that they can continually evaluate the service and drive improvement. NHS Standard Contract 2016-17, Service Conditions, SC12 Communicating with and involving Service Users, Public and Staff: The Provider must actively engage, liaise and communicate with Service Users (and, where appropriate, their Carers and Legal Guardians), Staff, GPs and the public in an open and clear manner in accordance with the Law and Good Practice, seeking their feedback whenever practicable. Department of Health, GOV UK, The NHS Constitution, 26 March 2013: Sets out the NHS Values, including a commitment to quality of care, and places responsibilities upon patients and the public to give feedback about NHS services. Department of Health, GOV UK, Liberating the NHS: No decision about me without me, 2010 Monitor, GOV UK, Well-led framework for governance reviews, April 2015 Policy on Clinical Audit Page: Page 16 of 12

Appendix 3: Clinical Audit Priority Identification Clinical audit projects will be prioritised in a systematic way, taking into consideration the following issues: Is the topic a priority for the organisation? Is there evidence of a serious quality problem identified through systems such as complaints or incident reporting? Is the topic relevant to national policy or guidance initiatives (e.g. NSFs, NICE etc)? Is the topic related to an area of high cost, high volume or high risk to patients and/or staff? Is there good evidence available to inform standards such as systematic reviews or national clinical guidelines? Is there a requirement to be involved in a national audit? Is there a requirement to audit a particular service or clinical area from external organisations such as the Care Quality Commission or NHSLA? Is the topic related to improvement of pathways across several organisations? Policy on Clinical Audit Page: Page 17 of 24

Appendix 4: Clinical Audit Proposal Form Project Lead Name Job Title Directorate Project Title Reasons for Audit? Main aim / objective of the Audit (What are you trying to achieve, your expectations?) Objectives (what aspects of care or practice are to be examined?) Which of the below Patient Care Strategy Key Principles does the audit meet? (Please place an X for all that apply) CLEAR Framework Before the Call Answer my Call Understand my Need(s) Respond to my Need(s) Direct Me to the Right Place Clinical and Systems Leadership Education, Innovation and Clinical Practice Development Accountability for QI and Assurance Responsibility to Collaborate and Improve Policy on Clinical Audit Page: Page 18 of 24

Project Design: How do you propose to collect the data? Sample size (indicate how this was calculated and whether any advice was sought in calculating it?) Method of analysis Who is going to collect the data? Timescale (to collect the data, to analyse the data?) Details of costs/resource implications (if applicable) Please confirm that you have attached the following documents: (Delete as appropriate) Background research undertaken (i.e. Literature review) Information about patient involvement in the study (in the study design) Arrangements for obtaining informed consent & identifying participants Questionnaires or surveys to be used Risk assessment Strategy for dissemination Y/N Y/N Y/N Y/N Y/N Y/N Policy on Clinical Audit Page: Page 19 of 24

Please confirm that you are familiar with: (Delete as appropriate) The Data Protection Act and other legal provisions/guidance The Incident Reporting Process The Trust Clinical Audit Policy Y/N Y/N Y/N Proposed study start date Proposed study finish date Expected date of final report Policy on Clinical Audit Page: Page 20 of 24

Appendix 5: Clinical Audit Cycle Figure 2 provides an overview of the clinical audit cycle including some of the factors or activities that should be considered. Figure 2: The Clinical Audit Cycle (NICE 2002) The cycle can be divided into four clear steps, plan, do, revise and review. This is reflected in figure 3. REVISE Identifying changes/ make things better PLAN What are we trying to achieve? Define criteria and standards REVIEW Assess performance against standards. Why are we not achieving it? DO Data Collection Are we achieving it? Figure 3: Plan-Do-Review-Revise model and the Clinical Audit Cycle Policy on Clinical Audit Page: Page 21 of 24

PLAN Audit Proposal Purpose of the audit is clearly defined. The expectations of the audit are clear. An appropriate methodology has been selected. Ethical issues are addressed. Where applicable the costs and resource implications are identified and quantified. The proposed timescale for the project and its reporting is achievable. Information with regard to the audit participants identification process; taking into account the data protection act, and their level of involvement in the design and details of the project, and arrangements for obtaining informed consent is supplied. A risk assessment for the audit has been completed. A strategy for dissemination of the audit has been identified. Appraising the evidence available A literature search on best evidence and national guidance should be undertaken. This should include a review of similar projects conducted in other organisations. Current Trust guidance or current standards of practice should also be consulted. A series of standards or criteria should be produced to conduct the audit against. Determining audit details DO A detailed audit template and data collection and collation process should be developed. The final audit process should be clarified and agreed with all individuals involved. Communication of the audit and the data collection method should be undertaken. Carrying out the project Where possible, pilot audits should be undertaken for larger scale audits. Audit data should, wherever possible, be collected from existing sources of information to minimise any duplication of effort. The audit should be undertaken as per the agreed methods and timescales. Interim monitoring, reports and communication should be undertaken. Any delays, adverse events or unexpected results should be reported to all relevant stakeholders. A final audit report must be produced. Policy on Clinical Audit Page: Page 22 of 24

REVIEW The audit report should be reviewed to determine Trust performance in relation to the defined standards. The review process should focus on both learning and quality improvement. Quality Board Group area level meetings and patient groups should be utilised to ensure full engagement with staff and patients. The review process should identify whether there are systemic changes required (changes in current guidelines, procedures or standards) or if individual and organisational performance requires improving against existing standards. A series of recommended actions should be produced as a result of the review process. Any additional costs or resources required should be specified as part of the review process. The Trust Clinical Governance Management Group is responsible for the review and approval of any recommended actions. The audit report and recommendations should be communicated to all relevant areas of the organisation. REVISE An action plan should be produced from the agreed recommendations, including agreed timescales and lead persons. Where necessary, a change management strategy should be considered to support the action plan process. Progress against the action plans should be monitored through the Trust Clinical Governance Management Group; where appropriate sits with Emergency Quality Board Group. The effectiveness of any changes made and the need for re-audit should also be considered. Policy on Clinical Audit Page: Page 23 of 24

Appendix 6: Clinical Audit Report Pro-forma Audit Title: Audit Lead: BACKGROUND: AIM AND OBJECTIVES: CRITERIA AND STANDARDS : METHODOLOGY: FINDINGS: RECOMMENDATIONS: CONCLUSION: Policy on Clinical Audit Page: Page 24 of 24