Clinical Audit Strategy

Clinical Audit Strategy

Clinical Audit Strategy 2012/15 Document Type Strategy Unique Identifier CL-016 Document Purpose To map out the strategic direction of Clinical Audit within the Trust for the next three years Document Author Samantha Whitby Target Audience All staff Responsible Group Clinical Audit and Group Date Ratified Expiry Date Date Equality Impact Assessment Completed This validity of this policy is only assured when viewed via the Worcestershire Health and Care NHS Trust website (hacw.nhs.uk.). If this document is printed into hard copy or saved to another location, its validity must be checked against the unique identifier number on the internet version. The internet version is the definitive version. If you would like this document in other languages or formats (i.e. large print), please contact the Communications Team on 01905 760020 or email communications@hacw.nhs.uk 20111223-Clinical Audit Stratgey-SW-V3 Page 1 of 11

Version History Version Circulation Date Job Title of Person/Name of Group circulated to 2 06.12.12 Group Brief Summary of Change Accessibility Worcestershire Health and Care NHS Trust has a contract with Applied Language Solutions to handle all interpreting and translation needs. This service is available to all staff in the trust via a free-phone number (0800 084 2003). Interpreters and translators are available for over 150 languages. From this number staff can arrange: Face to face interpreting Instant telephone interpreting Document translation British Sign Language interpreting Training and Development Worcestershire Health and Care NHS Trust recognises the importance of ensuring that its workforce has every opportunity to access relevant training. The Trust is committed to the provision of training and development opportunities that are in support of service needs and meet responsibilities for the provision of mandatory and statutory training. All staff employed by the Trust are required to attend the mandatory and statutory training that is relevant to their role and to ensure they meet their own continuous professional development. 20111223-Clinical Audit Stratgey-SW-V3 Page 2 of 11

Introduction The Trust is committed to delivering effective clinical audit in all the clinical services it provides. The Trust sees clinical audit as a cornerstone of its arrangements for developing and maintaining high quality patient-centred services. This Strategy describes how the Trust intends to develop and support Clinical Audit over the next three years, underlining the requirement for Clinical Audit to be fully integrated with care processes. Clinical Audit needs to be at the heart of clinical practice, something that all health practitioners should be engaged in. It is about continuing evaluation and improvement by health professionals working towards delivery of a better experience for patients, service users and their carers, and is a key element of Quality and Safety. Patients, service users and carers need to be involved in both the identification of what they expect from a service (standards) and to be assured those expectations have been met. Clinical Audit is about tripartite arrangements between health professionals, patients and the organisation. Health professionals need to own the process that drives the continual improvement of their practice. The organisation needs to support this by: Enabling development of the necessary competence, and facilitating training Allowing the time Providing technical support and expertise Ensuring access to the evidence base Promoting a supportive culture in which change can take place Purpose of document The aim of this strategy is to use clinical audit as a process to embed clinical quality at all levels in the organisation and to deliver demonstrable improvements in patient care over the next three years, creating a culture that is committed to learning and continuous organisational development: To overcome barriers to healthcare staff participating in clinical audit To develop a partnership approach to clinical audit To ensure that staff have the necessary competency, support and time to participate in clinical audit To ensure that the trust is fully compliant with the requirements of the National Clinical Audit and Patient Outcomes Programme To link clinical audit to appraisal and revalidation To ensure organisational compliance with the Care Quality Commission s Essential Standards for Quality and Safety (Outcomes 14 & 16) To ensure organisational compliance with Standard 5 Criterion 1: Clinical Audit of the NHSLA Risk Management Standards To demonstrate the benefits of clinical audit 20111223-Clinical Audit Stratgey-SW-V3 Page 3 of 11

Definitions Clinical audit is 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. National Institute for Clinical and Healthcare Excellence (NICE, 2002) Scope This policy applies to all staff with responsibility for clinical quality and safety. Clinical Audit, as a body of work, contributes to the delivery of the organisation s corporate objectives and its overall vision by supporting: clinical quality and safety corporate assurance (including the Care Quality Commission registration standards) patient engagement/involvement commissioning for quality and innovation (CQUINs) 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) Care Programme Approach consultant appraisal and revalidation/enabling clinicians to comply with their professional codes of conduct information governance (ensuring that clinical audit practice meets the requirements of IG best practice) National Patient Safety Agency guidance National Service Frameworks NHS Litigation Authority standards NICE guidance (in all its forms) service evaluation Training/Competencies Worcestershire Health and Care NHS Trust is committed to ensuring its workforce is confident, competent and capable. The Training and Development Unit develop a yearly training prospectus which describes the courses on offer, to whom they are aimed, how often they need to be updated and how to make a booking. All training offered in support of this policy can be accessed via the training prospectus which can be accessed via the intranet and internet. 20111223-Clinical Audit Stratgey-SW-V3 Page 4 of 11

Responsibilities and duties Group The Group is responsible for developing and supporting implementation of the clinical audit strategy. It will assist in the development and delivery of high quality clinical care through the incorporation of Evidence Based Practice, audit and training in audit. Related Work Groups Work Groups with a remit for identifying and directing relevant Clinical Audit programmes include: Clinical Risk Group - gives assurance that the organisation has set a clear strategic direction with regard to clinical risk and that work plans are in place to take this forward. Medicines Management & Safety Sub Committee (MMSSC) as the Trust s medicines safety committee, responsible for policy framework around safe custody of medicines and their provision. Their remit also includes supporting cost effective and evidence based prescribing through guideline development which is responsive to national drivers such as NICE, NPSA and local needs. Records Management Group has the responsibility for developing a framework for clinical record keeping and management within the Trust in line with controls assurance and other national guidance, ensuring the sharing of good practice, training, audit and evaluation. Director Leadership The Director of Quality and the Medical Director lead Clinical Audit at the highest level in the Organisation, and are supported by Service Delivery Unit and Clinical Leaders who also have responsibility for the quality of their Clinical Services. Service Delivery Unit and Professional Leadership Service Delivery Unit leadership is exercised at all levels; it is a responsibility of all clinicians to ensure the care they and their peers provide is of a consistently high standard. In order for each service to achieve and maintain the greatest improvement in care of patients, decisions made about the provision and delivery of services must be informed by regular clinical audit of all aspects of the service. Each part of the service should have the skills, knowledge and resources to identify, commission and/or carry out clinical audit. This will be achieved through the services regular quality and safety meetings where the Service Delivery Unit Lead will decide, in negotiation with clinicians, cognisant of current local and national policies, and of the strengths and development areas of their service, which audits need to be carried out with the appropriate level of resource commitment. Each service should have an agreed forward programme, and process for developing audit proposals. They should have the skills and time allocated to undertake the audit 20111223-Clinical Audit Stratgey-SW-V3 Page 5 of 11

cycle, and activity should be systematically (every quarter) reported to the Clinical Audit and Group. The Group will be responsible for supporting practitioners in this process. Each practitioner within the Trust should have the accessibility and responsibility to be effective and promote changes in practice. The Quality and Safety Team will be responsible for implementing a system which is transparent, practical and meaningful. Offering electronic proforma, advice and resources to signpost practitioners and to develop a culture where Clinical Audit is seen as integral to practice. Partnership/Multi-Agency Leadership Where partnership arrangements are in place there shall be evidence of joint governance and audit. Partnership may vary in the level of joint and collaborative working. Some partnerships may result in fully integrated services involving joint management, pooled budgets and totally integrated service provision. Joint governance objectives and clinical audit programmes will therefore be relative to the degree of partnership between the agencies involved. Effective Clinical Audit owned and directed through partnership arrangements, can help to support and inform service commissioning. Audit results may help confirm value for money and assist in furthering local delivery planning processes, thus influencing the future direction of services/service models. At a national level there is a responsibility to ensure that clinical audit is an integral part of the quality improvement and quality and safety strategies. NICE provides guidance on clinical audit within its guidelines and as part of its clinical governance reviews. The Care Quality Commission monitors organisations engagement with NICE directed audit. The Trust will become involved in appropriate national/regional audits such as speciality audits conducted by Royal Colleges, National/Regional clinical practice benchmarking initiatives, and those on the National Clinical Audit Patient Outcome Programme (NCAPOP). The local identification of needs and determination of services to meet those needs is a shared process between the different agencies involved. Although different organisations/agencies have their own priorities for audit (often based on local health priorities which reflect national targets, implementation of National Service Frameworks, Health Improvement Plans, NICE guidance and appraisals) there are also shared audit objectives. Therefore, just as there is a need to effectively collaborate with partners to ensure a co-ordinated approach to service delivery, there is also a need for co-ordination in reviewing the quality of the care provided. Shared learning will result from partners working together to ensure that there is systematic implementation and follow-up of audit findings. Equality impact assessment All policies require an equality impact assessment, and where that assessment identifies equality issues an action plan, to ensure the Trust meets its requirements within equalities legislation. 20111223-Clinical Audit Stratgey-SW-V3 Page 6 of 11

References Care Quality Commission (2010) Essential standards of quality and safety National Institute for Clinical Excellence (2002) Principles of Best Practice in Clinical Audit, Radcliffe Medical Press NHS Litigation Authority (2011) NHSLA Risk Management Standards for NHS Trusts providing Acute, Community, or Mental Health & Learning Disability Services and Independent Sector Providers of NHS Care 20111223-Clinical Audit Stratgey-SW-V3 Page 7 of 11

Appendices Operational action plan Objective Action Lead Timescale Progress 1.0 To overcome barriers to staff participating in clinical audit Agree a structured three year rolling clinical audit programme within and across the Service Delivery Units A&RCE Manager/ Quality Leads 31.03.12 1.1 Provide appropriate levels and types of clinical audit training, support and facilitation Quality and Safety Team N/A Continuous programme 2.0 To develop a partnership approach to clinical audit - working with patients and/or carers - working across organisations Monitor and report on partnership working via a quarterly report to Quality and Safety Committee, and via the Clinical Audit Register report to Clinical Audit & group A&RCE Manager Every quarter: Jan 2012 April 2012 July 2012 Oct 2012, onwards 2.1 Identify and report levels of patient and/or carer involvement in clinical audit via a quarterly report to Quality and Safety Committee, and via the Clinical Audit Register report to group A&RCE Manager Every quarter: Jan 2012 April 2012 July 2012 Oct 2012, onwards 2.2 Promote staff awareness of the need to involve patients and carers in clinical audit Group, Quality Clinical Audit Strategy 2012/15

2.3 Work with partners to promote joint clinical audit wherever appropriate 2.4 Support cross-locality, cross-service, and cross-organisational clinical audit 3.0 To ensure that staff have the necessary competency, support and time to participate in clinical audit Monitor on a 6 monthly basis the uptake of Clinical Audit training and evaluate its effectiveness via the evaluation feedback forms & professional Leads SDU Leads, Quality & professional Leads SDU Leads, Quality & professional Leads Quality & Safety Team Jun 12 & Jan 13 onwards 3.1 Ring-fence time to undertake clinical audit work. This should be part of the annual audit planning process 4.0 To ensure that the Trust is fully compliant with the requirements of the National Clinical Audit and Patient Outcomes Programme 5.0 To link clinical audit to staff appraisal and revalidation for medics All requests to participate in NCAPOP* audits are discussed at the Clinical Audit & working group, where a decision to participate/decline will be agreed and communicated to the Chief Executive and NCAPOP *National Clinical Audit Patient Outcome Programme HQIP on behalf of DoH Encourage and support medics and trainees, as per the Clinical Audit Policy SDU Leads/ Quality & Professional Leads Chief Executive/ Director of Quality/ Medical Director/A&RCE Manager/ Group Group/ Quality & Safety Team At planning stage On receipt of request letters Clinical Audit Strategy 2012/15

6.0 To ensure organisational compliance with CQC s Essential Standards of Quality and Safety Outcome 14 Supporting workers and Outcome 16 Assessing and monitoring the quality of service provision Ensuring staff at all levels within the Organisation recognise and understand their Clinical Audit responsibilities, via email circulations/ training/ intranet pages 6.1 Engage staff in the development of the 3 year Clinical Audit Forward Programme through the local quality groups 6.2 Communicate to the Trust the priorities and expectations for clinical audit through the Group, Quality & Safety Team and Junior Doctors Teaching Programme 6.3 Facilitate individuals and teams to effectively communicate their clinical audit needs/performance/achievements via the working group Group/ SDULs/ Quality & Professional Leads A&RCE Manager/ SDUs/ Quality & Professional Leads Group/ A&RCE Manager/ Clinical Tutors Group/ A&RCE Manager 6.4 Promote and maintain staff awareness and involvement in clinical audit Group/ A&RCE Manager 6.5 Identify and share good practice in regard to Clinical Audit via the circulation of new tools/ information e.g. new tools developed by HQIP/ NICE etc Group/ A&RCE Manager 31.03.12 Clinical Audit Strategy 2012/15

6.6 Review, update and approve the Clinical Audit Strategy/ policy ensuring they document the process for ensuring that all clinical audits are undertaken, completed and reported on in a systematic manner that is implemented and monitored 7.0 To ensure organisational compliance with Standard 5 Criterion 1: Clinical Audit of the NHSLA Risk Management Standards Review, update and approve the Clinical Audit Strategy/ policy ensuring they document the process for ensuring that all clinical audits are undertaken, completed and reported on in a systematic manner that is implemented and monitored Group/ A&RCE Manager/ Director of Quality & Medical Director Group/ A&RCE Manager/ Director of Quality and Medical Director April 12 April 12 Clinical Audit Strategy 2012/15