Report to Trust Board of Directors Date of Meeting: 24 June 2014 Enclosure Number: 11 Title of Report: Clinical Audit Plan for 2014/15 Author: Executive Lead: Responsible Sub- Committee (if appropriate): Executive Summary: Sue Brown Clinical Audit and Effectiveness Manager Dr Jeremy Rushmer, Medical Director Safety and Quality Committee This report outlines to the Trust Board the overall Clinical Audit Programme for 2014/15. The programme is based on the national requirements as well as locally driven priorities. The Safety and Quality Committee continue to receive and scrutinise the quarterly reports and seek further assurance on specific items as required. The draft plan for 2014/15 was discussed at the Safety and Quality Committee in May 2014. The Audit Committee has also identified clinical audit as a key priority for 2014/15 in relation to the robustness of the system for clinical audit and the assurance the Board gets from this important function. The Trust continues to make progress with delivering clinical audit across the Trust, however it is important to note that further work is required to truly embed clinical audit across the organisation. Whilst locally driven priorities have been identified from the Clinical Business Units, the delivery of the National Audit Programme and the Trust wide Audits remain the priority areas for full delivery in 2014/15. The goals for clinical audit for 2014/15 include: 100% achievement of the national audit programme. 100% achievement of the Trust priority audits, including CQC compliance. Risk assessments to support prioritisation of NICE guidance to be audited to be completed by all clinical business units.
Board Assurance Framework Reference: Risk Rating (high, medium, low risk) and any recommended changes to risk rating: Compliance, legal and national policy regulatory requirements: Financial Implications: 2.3, 2.4 Medium. The Trust is required to ensure its Clinical Audit Plan delivers the nationally mandated audits as defined by the Healthcare Quality Improvement Partnership (HQIP). None. Actions required by the Board: To approve: To note: For information: Discussion and decision Where the Board is made aware of key points but no decision required For reading and consideration and for discussion by exception only The Board is requested to APPROVE the Clinical Audit Plan for 2014/15. NOTE the continued developments to embed clinical audit across the Trust. Data quality: Source: Clinical Audit Team Validated by: Sue Brown Clinical Audit and Effectiveness Manager & Acting Director of Governance Date: 16/06/2014
Clinical Audit Programme 2014 / 15
Contents 1. Introduction... 5 2. Roles and Responsibilities... 5 3. Update from 2013/14 Programme... 6 3.1 Key Developments... 6 3.2 Clinical Audit Activity... 8 4. Prioritised Audits for 2014/15... 9 4.1 National Audits... 9 4.2 Trust Wide Audits... Error! Bookmark not defined. 4.3 Local Audits... 9 5. Reporting Arrangements... 15 For further information about clinical audit contact: Email: AcuteClinicalAudit@ncuh.nhs.uk Intranet: http://nww.staffweb.cumbria.nhs.uk/safety-and-quality/clinical-audit/index.aspx
1. Introduction North Cumbria University Hospitals Trust is committed to delivering an effective and coordinated clinical audit programme covering all of the clinical services it provides. Clinical audit is a key quality improvement tool within the Trust to continually monitor and improve the quality of care provided to patients. It also contributes towards the wider quality, safety, assurance and governance frameworks that are in place across the organisation. This document outlines the details of the Trust s corporate Clinical Audit Programme for 2014/15. It comprises of the individual Clinical Audit Plans developed and formally approved by each of the individual Business Units via their respective governance structures. Full details of the prioritised audits for 2014/15 are given in each of the Business Unit Clinical Audit Plans in the Appendices: Child Health Clinical Audit Plan - Appendix 1 Clinical Support and Cancer Services Clinical Audit Plan - Appendix 2 Emergency Surgery and Elective Care Clinical Audit Plan Appendix 3 Emergency Care and Medicine Clinical Audit Plan Appendix 4 This is a live programme and further clinical audits will be added during the course of the year in response to identified organisational, service and specialty needs. 2. Roles and Responsibilities The Board is ultimately responsible for ensuring that the Trust has a robust Clinical Audit Programme in place and receives regular updates on the status and outcomes of clinical audit activity. The Safety and Quality Committee has delegated responsibility from the Board for monitoring the status of the Clinical Audit Programme and receives a quarterly report on progress. Page 5 of 15
Business Unit Directors are responsible for ensuring that their Business Unit has an agreed and prioritised Clinical Audit Plan in place which covers the range of services in the Business Unit. They need to ensure that clinical audits are appropriately approved, registered, allocated, prioritised and resourced. Clinical Audit Leads are responsible for ensuring that their audit project is registered with the Clinical Audit Team, is conducted within the identified timescales, is written up and reported to the respective Business Unit governance group, and to the Clinical Audit Team via the Clinical Audit Summary and Improvement Plan. Business Unit Staff are responsible for identifying and proposing areas for audit and participating in audits as appropriate. Clinical Audit Team are responsible for providing advice and support on all aspects of clinical audit and monitoring the status of Business Unit Clinical Audit Plans and providing regular reports back to the Business Units. Clinical Audit and Effectiveness Manager is responsible for coordinating the corporate Annual Clinical Audit Programme and providing regular reports to the Safety and Quality Committee. 3. Update from 2013/14 Programme 3.1 Key Developments During 2013/14 there have been a number of developments which have strengthened the clinical audit arrangements in the Trust. These include: Business Units have reviewed and strengthened their governance arrangements around clinical audit ensuring a clearer focus on approving and reviewing audit activity. The clinical audit facilitators produce regular reports for their business units on progress against the agreed plan and the completion of action plans. Page 6 of 15
The policies for clinical audit and implementation of NICE are reviewed against Northumbria to ensure clinical standards and audit are measured and acted on in the same way. Reporting on progress against delivery of the clinical audit plan and compliance with NICE guidelines is a quarterly item reported to the Safety and Quality committee. There is greater alignment between clinical audit and the arrangements for reviewing serious untoward incidents (SIs). Internal processes for the registration, monitoring and reporting of clinical audits across the Trust have been reviewed and updated. The Clinical Audit webpages on the Trust intranet have been refreshed and updated including access to all relevant guidance pertaining to the registration, summary/improvement/action plan and clinical audit database. Also links to external sources of advice and support. The Trust has introduced new Quality Panels where the performance of individual services are scrutinised against the new CQC domains of safe, effective, caring, responsive and well-led. Local and national audit findings form part of the information set that is used to assess the performance of different services. 3.2 Key Goals for 2014/15 The goals for clinical audit for 2014/15 include: 100% achievement of the national audit programme. 100% achievement of the Trust priority audits, including CQC compliance. Risk assessments to support prioritisation of NICE guidance to be audited to be completed by all clinical business units. Page 7 of 15
3.3 Clinical Audit Activity During 2013/14, 201 local clinical audits were completed across the different Business Units and reported to the Safety and Quality Committee, and the Trust participated in 36 national audits. Figure 1 illustrates the number of completed audits by Business Unit: Figure 1 Completed Local Audit during 2013/14 by Business Unit 100 90 80 70 60 50 40 86 95 30 20 10 17 12 0 Child Health Clinical Support Medicine Surgery Findings and actions for improvement from these audits have been shared through each Business Unit s respective Governance Groups and reported to the Safety and Quality Committee. Page 8 of 15
NCAPOP? Eligible? Participating? Corporate Clinical Audit Programme 2014/15 4. National Audits 2014/15 4.1 National Audits HQIP identified 52 national audits for 2014/15. The Business Unit leads have identified the Trust is eligible for 39 audits and intends to participate in 39. Table 1 HQIP 2014/15 National Audits Title of Audit Business Unit 1. Adult community acquired pneumonia Medicine 2. Case Mix Programme Medicine 3. Medical and surgical clinical outcome review programme: National confidential enquiry into patient outcome and death Surgery & Medicine 4. National Audit of Seizures in Hospitals Medicine 5. National emergency laparotomy audit Surgery 6. National Joint Registry Surgery 7. Non-invasive ventilation - adults Medicine 8. Pleural procedures Medicine 9. Severe trauma (TARN) Medicine 10. National Comparative Audit of Blood Transfusion programme Clinical Support 11. Bowel cancer Clinical Support, Surgery & Medicine 12. Head and neck oncology Surgery 13. Lung cancer Medicine 14. Oesophago-gastric cancer Clinical Support & Surgery 15. Prostate Cancer Surgery 16. Acute coronary syndrome or Acute myocardial infarction Medicine 17. Cardiac Rhythm Management Medicine 18. Congenital heart disease (Paediatric cardiac surgery) - 19. Coronary angioplasty Medicine Page 9 of 15
NCAPOP? Eligible? Participating? Corporate Clinical Audit Programme 2014/15 Title of Audit Business Unit 20. National Adult Cardiac Surgery Audit - 21. National Cardiac Arrest Audit Medicine 22. National Heart Failure Audit Medicine 23. National Vascular Registry Surgery 24. Pulmonary hypertension - 25. Adult Bronchiectasis Audit Medicine 26. Diabetes (Adult), includes National Diabetes Inpatient Audit Medicine 27. Diabetes (Paediatric) Child Health 28. Inflammatory bowel disease Medicine 29. National Chronic Obstructive Pulmonary Disease Audit Programme Medicine 30. Renal replacement therapy Medicine 31. Rheumatoid and early inflammatory arthritis Medicine 32. Mental health clinical outcome review programme: National - Confidential Inquiry into Suicide and Homicide for people with Mental Illness 33. Prescribing Observatory for Mental Health - 34. Falls and Fragility Fractures Audit Programme 1 Surgery 35. National Audit of Dementia Medicine 36. Parkinson's disease Medicine 37. Sentinel Stroke National Audit Programme Medicine 38. Elective surgery Surgery 39. National Audit of Intermediate Care 40. Adherence to British Society for Clinical Neurophysiology and Association of Neurophysiological Scientists Standards for Ulnar Neuropathy at Elbow testing - 41. Fitting child (care in emergency departments) Medicine 42. Mental health (care in emergency departments) Medicine 43. Older people (care in emergency departments) Medicine 1 This audit is divided into 3 components. The Trust is intending to participate in 2 components but Medicine have stated that the Trust does not have a Fracture Liaison Service and so does not intend to participate in this third component. Page 10 of 15
NCAPOP? Eligible? Participating? Corporate Clinical Audit Programme 2014/15 Title of Audit Business Unit 44. Epilepsy 12 audit (Childhood Epilepsy) Child Health 45. Maternal, Newborn and Infant Clinical Outcome Review Programme Surgery 46. Neonatal intensive and special care Child Health 47. Paediatric intensive care - 48. Paediatric pneumonia Child Health 49. Chronic kidney disease in primary care - 50. Specialist rehabilitation for patients with complex needs - TBC by HQIP 51. Ophthalmology - TBC by HQIP 52. Familial hypercholesterolaemia - Cancelled by HQIP There are also a number of other national audits identified within the Business Unit clinical audit plans that the Trust will participate in (these are not included on the HQIP list but the Business Units consider to be best practice and beneficial to participate in). Title of Audit Business Unit 1. Medical Emergency Team Hospital Outcomes after a Day (METHOD) study - Bangor Hospital, Wales Medical 2. Global Rating Scale (JAG approval) Medical 3. National Audit of Cardiac Rehabilitation (NACR) Medical 4. Clinical Variation in Practice of Laparoscopic Cholecystectomy and Surgical Outcomes: a multi-center, prospective, population-based cohort study. Surgery 5. Read cell usage - NHSBT National comparative audit Clinical Support 4.2 Trust Wide Priority Audits Page 11 of 15
In addition to the national requirements, the Trust has identified the following priority audits for all Business Units. Table 1 lists the identified Trust wide clinical audits for 2014/15: Table 1 Trust wide Clinical Audits Title of the Audit Aim of the Audit 1. Weekly Mortality Case Audits To review all deaths in accordance with the Hogan Rating Scale in order to learn from all patients who die whilst in our care. 1. Serious Incidents To ensure specific actions identified in the SI action plan are completed and compliance demonstrated 2. Never Events To ensure specific actions identified in the SI action plan are completed and compliance demonstrated 3. Care Quality Commission outcomes (see 4.2.1 below) To monitor compliance of CQC outcomes 4. Patient Harm To identify where harm may have been caused due to omission of treatment /treatment given by reviewing selected patient casenotes. 5. 90 day Thrombosis/Root Cause Analysis To identify any root causes which may/may not have contributed to the patients VTE/PE by reviewing identified patient casenotes. 6. Care Bundles To monitor the use of care bundles for identified medical conditions 7. NEWS/MEOWS/PEWS To ensure algorithms are being followed to identify and effectively manage deteriorating patients 8. Record Keeping audit To Monitor the multidisciplinary performance against the Record Keeping standards. 9. Patient Safety Alerts To ensure specific actions identified in the alert are completed and compliance demonstrated 10. Hospital Associated Infections- Clostridium Difficile, Saving lives, Hand Hygiene To monitor and aim for Zero tolerance on Hospital associated Infections Page 12 of 15
4.2.1 Auditing Compliance with the CQC Essential Safety and Quality Outcomes Clinical audit forms a key part of the assurance to support compliance with the CQC essential outcomes. The table below summarises the audit programmes in place to demonstrate ongoing compliance: Outcome Audits Source 1 Monthly ward health check Auditr Clinical Indicators Essence of Care 2 Consent audits from each specialty Clinical audit team 4 PEWs audits Clinical audit team NEWs audits Auditr Derby audits Mattress audits Wristband audits Medicines management Cannulation audits Bedrail assessments VTE audits Single Sex accommodation 5 Derby audits Auditr 6 Discharge and transfer audits Clinical audit team 7 Safeguarding, children and adults referral process. Clinical audit team 8 Patient equipment cleaning audit Auditr Urethral catheter insertion audits IV audits Mattress audits Commode audits Hand hygiene audits Antibiotic audits Saving lives 9 Meds reconciliation audit CD check Meds Management Clinical Indicators Annual prescription chart audit Antibiotic prescribing audits Resus trolley check (part of monthly ward health check) Pharmacy Pharmacy Auditr Pharmacy Pharmacy Auditr 10 Single sex accommodation audits Auditr 11 Medical Devices training audits Medical Devices Education Co-ordinator 12 Audit of staff person files (pre-employment checks) Anne Hayton 16 National audits Clinical audit team Local audits NICE audits 21 Record keeping standards from each specialty Clinical audit team Page 13 of 15
4.3 Local Clinical Business Unit Plans As part of continuing to develop our clinical audit arrangements, each of the Clinical Business Units have also developed their own clinical audit plans. These plans include the national and trust wide priority audits but also include local priority areas such as NICE guidelines. The identified audits are diverse spanning the different specialties including clinical audits which focus on: the achievement of clinical outcomes; to what extent correct process and procedure is followed in the management of a patient s condition auditing against national guidance or a local clinical protocol; and those which assess standards based on feedback from patients in terms of level of satisfaction with different aspects of care, and the impact they perceive care and treatment to have had on their quality of life. The identified programme includes re-audits, audits that have been identified in response to complaints or incidents, and audits against external recommendations such as NICE guidance or Quality Standards. Page 14 of 15
5. Reporting Arrangements Quarterly clinical audit status reports will be presented to the Trust s Safety and Quality Committee by the Clinical Audit Team. Each Business Unit will also receive a minimum of quarterly status reports at their respective governance groups from the Clinical Audit Team. Each Business Unit also has an assigned Clinical Audit Facilitator from the corporate Clinical Audit Team who can be contacted for updates and support in-between formal reports. All members of staff participating in clinical audit are required to report the outcomes of their audit to the corporate team by completing a Clinical Audit Summary and Improvement Plan which is returned to the Clinical Audit Department. Outcomes from audits are also reported in the annual Trust Quality Account. The internal reporting arrangements around clinical audit activity and outcomes are illustrated in Figure 3: Figure 3 Corporate Clinical Audit Reporting Arrangements Trust Board Safety and Quality Committee Clinical Audit Team Child Health Clinical Support & Cancer services Emergency surgery & Elective care Emergency care & Medicine Sub Specialty Meetings Page 15 of 15