SECTION: 15 RISK MANAGEMENT POLICY & PROCEDURE NO: 15.02 NATURE AND SCOPE: SUBJECT: POLICY AND PROCEDURE TRUST WIDE CLINICAL AUDIT This policy sets out the framework of good practice and the principles underpinning this when conducting Clinical Audit DATE OF LATEST RATIFICATION: 24 FEBRUARY 2016 RATIFIED BY: PATIENT SAFETY AND EFFECTIVENESS COMMITTEE IMPLEMENTATION DATE: 05 APRIL 2016 REVIEW DATE: MARCH 2019 ASSOCIATED TRUST POLICIES 7.06 Clinical Records Management 10.15: Public Interest Disclosure (Whistle Blowing) Policy and Procedure 15.01 Reporting of Accidents, Incidents & Near Miss Situations including Serious Incidents (SIs) 15.11 Being Open When Patients are Harmed 7.06 Clinical Records Management Relevant local Divisional Clinical Audit Procedures ISSUE 4 APRIL 2016 1
1.0 Introduction NOTTINGHAMSHIRE HEALTHCARE NHS FOUNDATION TRUST 2.0 National Context/Policy Principles 3.0 Definition of Clinical Audit 3.1 Locally Accepted Definition 4.0 Purpose of this Policy 4.1 Scope/Statement of Purpose 5.0 Implementation UCLINICAL AUDIT POLICY AND PROCEDURE UCONTENTS 6.0 Process for Monitoring Compliance and Effectiveness 6.1 Monitoring the Effectiveness of the Policy 6.2 Assurance and Monitoring 7.0 Duties and Responsibilities 7.1 Corporate Responsibilities 7.2 Divisional Responsibilities 7.3 Individual Responsibility 8.0 Commitment to Stakeholder Engagement, Collaboration and Partnership 8.1 Involving Patients and the Public Clinical Audit 15.02 8.2 Multi-Disciplinary and Multi-Professional Audit, and Partnership Working with other Organisations 9.0 Clinical Audit Programme 9.2 Agreeing an Annual Programme of Activity 9.3 Audits of Serious Incidents 10.0 Governance of Clinical Audit 10.1 Systems for Registering and Approving Audits 10.2 The Use of Criteria and Standards in Clinical Audit 10.3 Information Governance, Collection, Storage and Retention of Data and Confidentiality 10.4 Confidentiality Agreements 10.5 Clinical Audit Data 11.0 Ethics and Consent 12.0 Reporting and Dissemination of Results 12.1 Reporting 12.2 Dissemination 12.3 Publication of Audit Reports Outside of the Trust 12.4 Project Management Database 12.5 Clinical Audit Annual Report 13.0 Action Plans and Improvement 13.1 Action Plans ISSUE 4 APRIL 2016 2
13.2 Action Plans: Format 13.3 Re-Audit 13.4 Risk Registers 14.0 Training and Development 14.3 Provision of Clinical Audit Training 15.0 Target Audience 16.0 Review Date 17.0 Equality Impact Assessment 18.0 Consultation 19.0 Champion and Expert Writer 20.0 Reference and Source Documents Appendix 1 Example Confidentiality Agreement Appendix 2 Record of Changes Appendix 3 Employee Record of Having Read the Policy ISSUE 4 APRIL 2016 3
1.0 INTRODUCTION NOTTINGHAMSHIRE HEALTHCARE NHS FOUNDATION TRUST UCLINICAL AUDIT POLICY AND PROCEDURE Clinical Audit 15.02 1.1 Under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, providers of care are required to ensure that systems and processes are in place to assess, monitor and improve the quality and safety of the services provided. 1.2 Clinical Audit is a continuous cycle of topic selection, measurement against standards, making improvements and sustaining them. It links to the Trust Quality Strategy, proving a mechanism for both defining what quality looks like, measuring quality and then regulating for quality improvements. 1.3 Nottinghamshire Healthcare NHS Foundation Trust sees Clinical Audit as a key element of clinical governance, enabling it to promote and measure its commitment to providing high quality clinical services. It links to the Quality Strategy, proving a mechanism for both defining what quality looks like, measuring quality and then regulating for quality improvements. 2.0 NATIONAL CONTEXT/POLICY PRINCIPLES 2.1 The expectation for healthcare professionals to participate in regular Clinical Audit was first established in the 1989 Government White Paper, Working for Patients. Clinical Audit has since become widely recognised as a quality improvement tool within the NHS. 2.2 In recent years Clinical Audit has been re-invigorated and set as a priority by the Department of Health, with High Quality care for all recognizing the crucial value of Clinical Audit in assessing the quality of clinical care and maintaining high quality professional performance. 2.3 The Francis Inquiry report into Mid-Staffordshire NHS Foundation Trust (The Mid Staffordshire NHS Foundation Trust Independent Inquiry; February 2010) identified a serious deficiency in the performance and resourcing of Clinical Audit at least in some areas of activity. This report recommended that The Board should institute a programme of improving the arrangements for audit in all clinical departments and make participation in audit processes in accordance with contemporary standards of practice a requirement for all relevant staff. The Board should review audit processes and outcomes on a regular basis. It further recommended that: Clinical Audit should be adopted in accordance with national standards in each area of activity. Resources should be made available to enable proper audit processes to be followed. Clinicians should be allocated specified time in the working month in which they are required to engage in audit and related activities. Compliance with the requirement to engage in audit should be monitored by the Board on a regular basis and the extent of participation reported to the public in the Trust s quality account, a statutory obligation from 2010. The Board should also consider publishing the outcomes of the audit process. 3.0 DEFINITION OF CLINICAL AUDIT 3.1 ULocally Accepted Definition Clinical audit is a quality improvement cycle that involves measurement of the effectiveness of healthcare against agreed and proven standards for high quality, and taking action to bring practice in line with these standards so as to improve the quality of care and health outcomes. New Principles of Best Practice in Clinical Audit (HQIP, January 2011) ISSUE 4 APRIL 2016 4
Clinical Audit is described as a cycle. The concept of Clinical Audit is as a cyclic process which suggests at the end of each level of audit, the quality of care should be improved and therefore is an important tool in enabling the Trust to meet its objectives. The Audit Cycle 4.0 PRINCIPLES/PURPOSE OF THIS POLICY 4.1 UScope/Statement of Purpose 4.1.1 This policy covers all Directorates/Services within the Local Services Division, the Forensic Division and Health Partnerships Division of Nottinghamshire Healthcare NHS Foundation Trust. It is applicable to all staff. 4.1.2 The purpose of this policy is to set out a framework for the conduct of Clinical Audit within the Trust and to provide guidance for all staff participating in Clinical Audit activities. It includes the organisations procedures and expectations for registering and approving Clinical Audit project proposals. 4.1.3 This policy sets out the Trust s expectations in relation to conduct and participation in Clinical Audit. 4.1.4 The policy outlines the process that should be followed when developing and designing Clinical Audit projects and the support that is available from the Clinical Audit Teams within Local and Forensic Services and from the Nursing, Quality and Patient Experience Team in Health Partnerships. ISSUE 4 APRIL 2016 5
4.1.5 The policy aims to develop and sustain a culture of best practice in Clinical Audit and clarify the roles and responsibilities of all staff engaged in Clinical Audit activities. 5.0 IMPLEMENTATION 5.1 Implementation of this policy will be through Divisional Clinical Governance structures. 6.0 PROCESS FOR MONITORING COMPLIANCE AND EFFECTIVENESS 6.1 UMonitoring the Effectiveness of the Policy 6.1.1 The implementation of this policy will be monitored through the Patient Safety and Effectiveness Group. 6.2 UAssurance and Monitoring 6.2.1 Where appropriate, Clinical Audit Groups within the Trust will be tasked with monitoring audit activity and progress of any Division wide actions coming from these audits, ensuring that re-audit is conducted within a reasonable timescale. Where Directorate specific recommendations have been made these will be monitored at the appropriate Directorate Clinical Governance Group where applicable. 6.2.2 The Divisions are also required to provide Trust level assurance on the progress of its Clinical Audit programme. This will be provided to the Patient Safety and Effectiveness Group; annual reports will also be provided. 7.0 DUTIES AND RESPONSIBILITIES 7.1 UCorporate Responsibilities The Executive Medical Director has overall responsibility for Clinical Governance incorporating Clinical Audit. The Patient Safety and Effectiveness Group is the corporate committee tasked with overseeing the Trust s Governance and Audit programmes. 7.2 UDivisional Responsibilities The Executive Directors of Local Services, Forensic Services and General Managers of Health Partnerships have overall responsibility for Clinical Governance within their Divisions. The Associate Medical Directors for Local Services and Forensic Services and the Associate Director (Nursing, Quality and Patient Experience) within Health Partnerships will take a lead role for both Clinical Governance and Clinical Audit. There is a Head of Governance for Local and Forensic Services and a Head of Quality Risk and Patient Safety for Health Partnerships, all of whom have operational responsibility for the Divisional Clinical Audit processes including developing a local procedure and ensuring that this is followed. 7.3 UIndividual Responsibility Professional staff are individually accountable for ensuring that they audit their own practice as defined by their Codes of Conduct. 8.0 COMMITMENT TO STAKEHOLDER ENGAGEMENT, COLLABORATION AND PARTNERSHIP 8.1 UInvolving Patients and the Public ISSUE 4 APRIL 2016 6
8.1.1 The Trust is committed to the principle of involving patients/carers in the Clinical Audit process where appropriate. This may include the use of patient surveys/questionnaires/other feedback mechanisms. 8.1.2 The Trust will expect that all Clinical Audit projects consider the involvement of Service Users/Carers and ask that Directorate Service User/Carer Groups are involved in developing divisional audit programmes and are able to recommend where and how Clinical Audits would benefit from Service User/Carer involvement. 8.2 UMulti-Disciplinary and Multi-Professional Audit, and Partnership Working with other Organisations 8.2.1 Multi-disciplinary and cross-organisational working are hallmarks of good Clinical Audit practice. 8.2.2 The Trust encourages Clinical Audit undertaken jointly across professions and across organisational boundaries. Partnership working with other local and regional organisations will be encouraged where improvements to the patient journey may be identified through shared Clinical Audit activity. 9.0 CLINICAL AUDIT PROGRAMME 9.1 External Drivers for Clinical Audit activity may come from the following areas: Care Quality Commission Essential Standards for Safety and Quality/regulations and reports National Institute for Health and Care Excellence (NICE) Guidance National Service Frameworks 11TNational Clinical Audit and Patient Outcomes Programme11T (11TNCAPOP/HQIP11T) Recertification/revalidation for relevant clinical staff NHS England Strategy for Nursing Midwifery & Care Staff: Compassion in Practice 6 C s National Inquiries CQUIN targets and Quality Framework Trust and Divisional Risk and Assurance programmes Local areas of clinical priority and interest Policies and Procedures Information Governance Toolkit Trust/Divisional Action Plans National Confidential Enquiries Commissioners Directorates/Localities/Services/Teams Re-audits Central Alerting System (CAS) Alerts Prescribing Observatory for Mental Health (POMH) 9.1.1 It is important also to ensure that the views of users, clinical staff, support staff and managers are represented in the selection process for topics of local interest. 9.1.2 The process for the identification of Clinical Audit priorities will be a combination of bottom up via clinical staff and top down via the Trust Patient Safety and Effectiveness Group on behalf of the Quality and Risk Committee or external requirements. 9.2 UAgreeing an Annual Programme of Activity 9.2.1 At the start of every financial year, each Division will agree an appropriate planned programme of Clinical Audit activity. This programme must meet the Trust s corporate requirements for assurance and will therefore be scrutinised by the Patient Safety and Effectiveness Group on behalf of the Quality and Risk Committee to ensure that Trust wide priorities are being met. The programme must also be owned by clinical services. ISSUE 4 APRIL 2016 7
9.2.2 The Trust is committed to supporting other locally determined Clinical Audit activity and recognises this as a significant contributor to the continuous process of service improvement. It is acknowledged that individual clinicians may initiate a Clinical Audit project on the basis of personal interest, personal development or as part of an educational or training programme. It is important that these are registered with the Division and reported through existing clinical governance structures to maximise organisational learning. 9.2.3 It is expected that the proposed annual programme will be ratified by the Trust Patient Safety and Effectiveness Committee. 9.3 UAudits of Serious Incidents: 9.3.1 Clinical Audits or Root Cause analyses will be undertaken following serious incidents as outlined in Trust Policy 15.01 Reporting of Accidents, Incidents & Near Miss Situations including Serious Incidents (SIs) and will be monitored by the Divisional Governance Groups. 10.0 GOVERNANCE OF CLINICAL AUDIT 10.1 USystems for Registering and Approving Audits All Clinical Audit activity must be registered in line with the Divisional Clinical Audit Procedure 10.1.1 For each Clinical Audit project that is undertaken, an Audit Registration Form must be completed by the project lead and reviewed by the relevant group, this will be: Team and Directorate audits Directorate Clinical Governance Group Divisional Level Audits Divisional Clinical Audit Group(s) Trust Level Audits Patient Safety and Effectiveness Committee Templates for Registration are included in Local Divisional Procedures (Divisional procedures are available on the intranet) 10.2 UThe use of criteria and standards in Clinical Audit 10.2.1 Clinical Audit involves measuring clinical practice against predetermined criteria for best practice, by definition this excludes those activities which do not measure against predetermined criteria. 10.2.2 The Trust has limited resources to support Clinical Audit activities (within the Clinical Audit Teams and in directorates) it therefore needs to ensure that the audit activities that it does undertake are of high quality. To ensure this any audit activity must have, as part of its planning process, identified criteria and where possible quantified standards to enable the measurement of the criteria. 10.3 UInformation Governance: Collection, Storage and Retention of Data and Confidentiality 10.3.1 All Clinical Audit activity must take account of the Data Protection Act (1998) and the Caldicott Principles (1997). This means, for example, that data should be: adequate, relevant and not excessive accurate processed for limited purposes held securely ISSUE 4 APRIL 2016 8
not kept for longer than is necessary. 10.3.2 The Trust has accepted guidance here provided in the Department of Health publication Records Management: NHS Code of Practice (2006) which requires audit records to be retained for a period of five years. 10.3.3 Best practice in Clinical Audit must always direct those involved to ensure that all patient information is made anonymous unless there is a compelling reason not to do so. In these circumstances, Clinical Audit activity must conform to the requirements of the NHS Confidentiality Code of Practice (2003) which states that Patients must be made aware that the information they give may be recorded, may be shared in order to provide them with care, and may be used to support local Clinical Audit (page 21). If patients have been so informed, Section 60 of the Health and Social Care Act 2001 makes provision for the collection of patient identifiable data for the purposes of Clinical Audit. 10.3.4 It must also be clear that Clinical Audit needs to exist within a blame free culture to be successful, it is therefore reasonable for staff to also expect confidentiality in respect of disclosure about discussions which take place at Clinical Audit meetings. 10.3.5 It is also standard practice for Clinical Audit reports to be made anonymous, i.e. not mentioning the names of patients 10.3.6 Where audit findings indicate practice that is of particular high risk or of particular concern, this should be highlighted in accordance with Trust Policy 10.15: Public Interest Disclosure (Whistle Blowing) Policy and Procedure 10.4 UConfidentiality Agreements 10.4.1 There may be occasions when the Division engages individuals in its Clinical Audit activities who are not directly employed by the Trust, e.g. staff who are on honorary contracts, students, volunteers, patients and the public. It is important that these groups understand the principles which apply to the practice of Clinical Audit. It is also recommended that individuals in this situation sign a confidentiality agreement (example provided as Appendix 1). The responsibility for the completing this lies with the local manager and documentation should be retained locally. 10.5 UClinical Audit Data 10.5.1 Clinical Audit data should not be reviewed by non-trust staff. This can only take place when a duty of confidentiality has been put in place, for example by the signing of an honorary contract, this applies equally to students on placements within the Trust. 10.5.2 Any data collected should be made anonymous, removing identifying information such as name, address, date of birth etc. All patient-identifiable data must be kept secure, ensuring that only relevant persons are able to access this data. This can be done by storing data collection forms in a locked filing cabinet, password protecting electronic files or keeping them on a secure, restricted access server. 10.5.3 Under NHS Information Governance Toolkit any device which holds Patient Identifiable information must be encrypted and this includes flash drives/memory sticks. 10.5.4 When data about a patient is required, a unique number should be assigned to each data collection form, which matches the patients details held on a separate sheet. The data collection form cannot then be matched to the patient without this sheet and so these items should be stored separately. This also applies to data held on databases. ISSUE 4 APRIL 2016 9
10.5.5 Data must only be collected for the stated purpose of Clinical Audit and only that which you need to answer your audit objectives keeping in mind the Data Protection Principle Adequate, relevant and not excessive. 11.0 ETHICS AND CONSENT 11.1 Each Division will have mechanisms in place to ensure that ethical considerations are made for all audit activity carried out. 12.0 REPORTING AND DISSEMINATION OF RESULTS 12.1 UReporting 12.1.1 Clinical Audit reports should be provided for all Clinical Audit activity. Templates for reporting are available on the Intranet and should be used where possible. Audit reports may contain for example: Summary Background Aims/Objectives Methodology, Sample and Limitations Criteria and Standards Findings Discussion Recommendations and Actions Dissemination key individuals and forums should be identified References (where required) 12.1.2 Executive summary should describe the work undertaken and should include summary or highlight information. 12.2 UDissemination 12.2.1 Details of completed audits should be presented at Clinical Audit Groups or Directorate Governance Groups where the findings should be discussed, action plans agreed and where relevant, a commitment to re-audit made in a designated time. Regular summary reports, together with recommendations should be communicated widely within Divisions and key lessons shared across the Trust through existing Clinical Governance Structures. 12.2.2 Copies of all reports should be provided to the Clinical Audit Teams who will ensure that reports, together with recommendations, are included on the Trust s Clinical Audit intranet site. 12.3 UPublication of audit reports outside of the Trust 12.3.1 If auditors wish to publish clinical audit findings outside the Trust, they must notify the Divisional Audit Lead and the relevant Divisional Clinical Director or Senior Service Manager prior to submitting any material for publication. 12.3.2 This requirement is stated on the clinical audit registration form and by signing the form auditors state they understand this requirement and are responsible for ensuring permission is granted. Clinical audit material must not be submitted for publication externally until explicit approval has been given. 12.4 UProject Management Database ISSUE 4 APRIL 2016 10
12.4.1 The Divisional Clinical Audit Teams will hold a database of audit activity and an additional database which tracks action plans associated with Clinical Audit. 12.4.2 All Clinical Audit projects will be entered onto the project database. In addition the Clinical Audit Teams will request a completed report from all registered projects along with a copy of the audit tool used. 12.4.3 The Clinical Audit Teams will provide Directorate Clinical Governance Groups with a quarterly report listing all known audit activity for the Directorate. 12.5 UClinical Audit Annual Report 12.5.1 The Clinical Audit Teams will provide an annual report for Clinical Audit which will include a summary of audits conducted throughout the year and which will focus on change or improvements in quality as a result of Clinical Audit. 13.0 ACTION PLANS AND IMPROVEMENT 13.1 UAction Plans: 13.1.1 The main purpose of Clinical Audit is to deliver improvements in clinical practice. Where the results of a Clinical Audit indicate sub-optimal practice, an action plan should be produced. It is important that progress of action plans from audit is reviewed and assurances received on action taken, the group tasked with reviewing action plans will reflect the scope of the audit: 13.2 UAction plans: Format Team and Directorate audits Directorate Clinical Governance Group Divisional audits Divisional Clinical Audit Group(s) Trust Level Audits Patient Safety and Effectiveness Group. 13.2.1 Action points should be specific, measurable and achievable/realistic. They should have clear implementation timescales with identified leads for each action. Action plans should also have been approved by the relevant head of service or department (as relevant). 13.2.2 Not all Clinical Audits will require an action plan e.g. where an audit shows that standards are being met or guidance followed. For such audits there should be an explicit statement saying no further action required in the audit summary report and a reason given for no re-audit. 13.2.3 A template for action plans is included in the local Divisional Clinical Audit Procedure and is also available on the intranet. 13.3 URe-Audit 13.3.1 The Trust considers that where appropriate re-audits should take place. Re-audit is important to determine whether agreed actions have been implemented according to the action plan. 13.3.2 Re-audit need not be the same scale/size as the initial audit. Its purpose is to confirm/provide assurance that the agreed actions have been implemented. It is therefore usually reasonable to reduce sample sizes to reflect this. 13.4 URisk Registers 13.4.1 It is important that any activity reviewed through Clinical Audit identified as causing particular concern is highlighted on and monitored through the Directorate s Risk ISSUE 4 APRIL 2016 11
Register. This will allow any clinical activity which is particularly concerning to be considered within the Risk Register processes and therefore inform the Trust Risk Register and the Board Assurance Framework. 14.0 TRAINING AND DEVELOPMENT 14.1 Improvements in Clinical Audit education and training are important in promoting Clinical Audit activities that are led by healthcare professionals. In addition, specific aspects of Clinical Audit require specialist skills to enable successful Clinical Audit, for example using the correct Clinical Audit methodology. 14.2 Improvements in Clinical Audit training will have the additional benefit of raising the profile of Clinical Audit and building capacity and capability of all staff involved in Clinical Audit, providing an additional driver for quality improvement. 14.3 UProvision of Clinical Audit Training 14.3.1 The Trust s Clinical Audit Teams will make available Clinical Audit Training which will be tailored to meet the needs of those accessing it Bespoke training will be provided to individual teams and Clinical Audit Project Groups, aimed at ensuring that individual projects are conducted appropriately. Training materials and a guide to Clinical Audit will be provided on the Clinical Audit Intranet site and will be available to all involved in Clinical Audit. 15.0 TARGET AUDIENCE 15.1 This policy is aimed at and applies to anyone engaged in Clinical Audit activity under the auspices of Nottinghamshire Healthcare Trust, including students, volunteers and patients, as well as staff. 16.0 REVIEW DATE 16.1 This policy will be reviewed in 3 years from the date of ratification or in light of organisational or legislative changes. 17.0 EQUALITY IMPACT ASSESSMENT 17.1 The Equality Impact Assessment was reviewed and updated using new Trust template. In particular, the policy has been screened in order to identify whether the policy may have a differential and adverse impact on any identified minority groups, providing an opportunity to promote equality. 18.0 CONSULTATION 18.1 This policy has been sent out for consultation to the Local Services LS Quality & Risk Group; Clinical Effectiveness, Clinical Audit & NICE Group for HP and has been sent out to Forensic Services Management Group 19.0 CHAMPION AND EXPERT WRITERS 19.1 The Champion of this policy is Julie Hankin, Executive Medical Director. The Expert Writers are Julie Smith, Clinical Audit Manager (Forensic Services), Amy Barksby, Audit Facilitator (Health Partnerships) and Alma Gallagher, Specialist Practitioner in Audit & Quality (Local Services) 20.0 REFERENCES AND SOURCE DOCUMENTS ISSUE 4 APRIL 2016 12
Health and Social Care Act 2008 Trust Quality Strategy Working for Patients Government White Paper (1989) Healthcare for All - NHS Next Stage Review Final Report (2008) Trust Quality Report New Principles of Best Practice in Clinical Audit (HQIP, January 2011) Data Protection Act (1998) The Caldicott Principles (1997) Records Management: NHS Code of Practice (2006) NHS Confidentiality Code of Practice (2003) NHS Information Governance Toolkit Clinical Audit Strategy The Francis Inquiry report into Mid-Staffordshire NHS Foundation Trust (The Mid Staffordshire NHS Foundation Trust Independent Inquiry; February 2010) HQIP website: http://www.hqip.org.uk/ Clinical Audit 15.02 ISSUE 4 APRIL 2016 13
APPENDIX 1 UEXAMPLE CONFIDENTIALITY AGREEMENT This declaration must be signed by any person who is not employed by the [name of organisation], or deemed an honorary employee through association with the appropriate department of the [academic body], who will be reviewing patient-related information for the purposes of Clinical Audit. Declaration I hereby declare that I fully understand that all patient-related information to which I have access, whether held on computer or in written form or given to me verbally, is confidential and I undertake never to divulge information to anyone without the authority of a senior member of administrative staff. I understand that this includes the divulging of information to the police. I also understand that the names, addresses and details of patients contained in any documents or indexes are confidential and must not be accessed or divulged for personal interest or gain, or any other purpose other than healthcare business. By signing this form I accept that I have been informed that under the provisions of the Data Protection Act 1998, unauthorised disclosure of data may result in personal prosecution. Name Project title: Post: Department: Email address: Mobile/telephone no: Signature and date: Witnessed by and date: ISSUE 4 APRIL 2016 14
APPENDIX 2 Policy/Procedure for: CLINICAL AUDIT Issue: 04 Status: Author Name and Title: APPROVED Julie Smith, Clinical Audit Manager (Forensic Services), Amy Barksby, Audit Facilitator (Health Partnerships) and Alma Gallagher, Specialist Practitioner in Audit & Quality (Local Services) Issue Date: 05 APRIL 2016 Review Date: MARCH 2019 Approved by: Distribution/Access: PATIENT SAFETY AND EFFECTIVENESS COMMITTEE Normal RECORD OF CHANGES DATE AUTHOR POLICY DETAILS OF CHANGE Oct 12 Apr 2013 Oct 2015 M Smith/ J Gleaden M Smith/ J Gleaden J Smith/ A Barksby/ A Gallagher 15.02 Minor changes throughout the document 15.02 15.02 Minor changes to Sections:- 3.1, 10.1.2, 10.2.1, 11.1.1 (bullet point 3) 14.1 (bullet point 3) to reflect changes in the structure of Trust committees and name changes to other referenced policies. Updated to reflect changes to job roles and titles. Current Governance structures updated to reflect reporting processes. Reference to Foundation Trust status change. Refreshed to reflect more recent Policy Drivers. Addition of Section 12.3 to cover publication of audit findings outside the Trust. Removal of Action Plan and Registration Document Appendices these are now located within Local Procedures only. Under section 7.2 Health Partnership responsibilities included. ISSUE 4 APRIL 2016 15
APPENDIX 3 EMPLOYEE RECORD OF HAVING READ THE POLICY UTitle of Policy/ProcedureU: Clinical Audit I have read and understand the principles contained in the named policy/procedure. 0BPRINT FULL NAME SIGNATURE DATE ISSUE 4 APRIL 2016 16