Clinical Audit Policy DOCUMENT CONTROL Version: 5 Ratified by: Quality Assurance Group Date ratified: 3 July 2017 Name of originator/author: Clinical Quality Lead Senior Clinical Audit Facilitator Name of responsible Clinical Quality Group committee/individual: Date issued: 18 August 2017 Review date: July 2020 Target Audience All staff who in their course of their work undertake duties in relation to Clinical Audit.
Section CONTENTS Page No 1 INTRODUCTION 4 1.1 Defining Clinical Audit 4 1.2 The purpose of Clinical Audit 4 1.3 Clinical Audit as a source of Board Assurance 4 1.4 The Trust Clinical Audit Programme 5 2 PURPOSE 5 3 SCOPE 6 4 RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES 6 4.1 Board of Directors 6 4.2 Audit Committee 6 4.3 Chief Executive 7 4.4 Director of Nursing and Quality 7 4.5 Deputy Director of Nursing and Quality 7 4.6 Designated Associate Nurse Director 7 4.7 Clinical Quality Lead 8 4.8 Senior Clinical Audit Facilitator 8 4.9 Clinical Audit Facilitator 9 4.10 Care Group Associate Nurse Directors/Associate Medical Directors and Senior Managers / Clinical Leads in other services 4.11 Service Lead / Managers 10 4.12 Clinical Audit Lead 10 4.13 Quality & Safety Sub Committee (Quality Assurance Group) 4.14 Clinical Quality Group 11 4.15 Other Trust Groups 12 5 PROCEDURE/IMPLEMENTATION 12 5.1 Process for setting priorities for the Clinical Audit Programme, including participation in local and national clinical audits and approved process for audit 5.2 Process for ensuring appropriate standards of performance are audited 5.3 Involving medical students and Junior Doctors 13 5.4 Involving service users and carers 13 5.5 Process for disseminating clinical audit results/reports 13 9 11 12 13 Page 2 of 30
Section CONTENTS 5.6 Format for all clinical audit reports i.e. methodology, conclusions, action plans etc Page No 5.7 Process for making improvements 15 5.8 Process for monitoring action plans and carrying out reaudits 5.9 Route for escalation of concerns 16 5.10 Clinical Audit Project Update 17 6 TRAINING IMPLICATIONS 17 7 MONITORING ARRANGEMENTS 17 8 EQUALITY IMPACT ASSESSMENT SCREENING 18 8.1 Privacy, Dignity and Respect 18 8.2 Mental Capacity Act 19 9 LINKS TO ANY ASSOCIATED DOCUMENTS 19 10 REFERENCES 19 11 APPENDICES 19 Appendix 1 - Clinical audit: Ten simple rules for NHS Boards Appendix 2 - Clinical Audit Work Request and Registration Form Appendix 3 - Submission of Clinical Audit Work Request Form to the Clinical Audit Team Appendix 4 - The Audit Process/Cycle 26 Appendix 5 - Clinical Audit Summary Results 27 Appendix 6 - Format for all Clinical Audit Reports 28 Appendix 7 - Clinical Audit Checklist 29 14 15 20 21 25 Page 3 of 30
1. INTRODUCTION 1.1 Defining Clinical Audit The universally accepted definition for both national and local clinical audit as defined by the National Institute for Health and Clinical Excellence (NICE) in their Principles for Best Practice in 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. NICE, 2002 1.2 The Purpose of Clinical Audit The purpose of clinical audit is to improve patient care which should be seen as a continuous cycle of improvement: Identifying which topics to audit Measuring care delivered against standards and evidence based practice Acting on the findings making improvements and changes Sustaining improvements, including re-audit where appropriate Clinical Audit: Needs to be a strategic priority for boards as part of their clinical governance function. Is one of the key compliance tools at a board s disposal and has an important role within the assurance framework. Has Ten simple rules for NHS Boards (Healthcare Quality Improvement Partnership, [HQIP] 2010) Appendix 1. Is a key element of Clinical Governance. Supports compliance with the Care Quality Commission s Fundamental Standards of Quality and Safety and with the NHS Litigation Authority Risk Management Standards. 1.3 Clinical Audit as a Source of Board Assurance The aim of a Trust s clinical audit programme is to ensure that effective clinical audits are planned and undertaken to measure and improve the effectiveness and safety of healthcare across the Trust, in addition to providing assurance to the Board of Directors via the Board Assurance Framework (BAF). The programme should be aligned to the Trust s individual risks as well as taking account of national priorities. Page 4 of 30
For example, if local complaints or surveys illustrate specific, persistent and/or local concerns, the clinical audit programme can be designed to include the monitoring of standards related to those concerns. Clinical audit can also be used as a systematic tool to address issues which arise about care and treatment priorities from a strategic rather than a more limited local clinical interest. Clinical audit is a key element of the Trust s Risk Management Strategy. 1.4 The Trust Clinical Audit Programme The Trust Clinical Audit Programme will deliver a programme of clinical audit activity over 1 year. It is devised to take into account: - Commissioning for Quality and Innovation (CQUIN) - National / Local Indicators - Incidents, complaints and claims themes - Lessons learned from external investigations at other NHS organisations - National Institute for Health and Care Excellence (NICE) Guidance - Prescribing Observatory for Mental Health UK (POMH UK 2yr programme) - National Service Frameworks (NSFs) - The Trust Risk Registers and Board Assurance Framework (BAF) - Areas highlighted as below average by inspection/performance data - Identified Trust strategies and policies - Relevance to Care Group priorities The delivery of the clinical audit programme will be planned and prioritised against the available staff resources, with each audit allocated within a specified quarter. Proposed changes to the clinical audit plan will be approved subject to prioritisation and available resources following approval from the Clinical Quality Group. 2. PURPOSE The purpose of this policy is to set out the Trust s arrangements and processes for ensuring that all clinical audits are undertaken, completed and reported on in a systematic manner, that is implemented and monitored. The Trust promotes a commitment to the principle of involving service users and carers where appropriate in the clinical audit process as part of its patient engagement strategy. Page 5 of 30
The Trust encourages clinical audit activity undertaken jointly across professions and across organisational boundaries. Partnership working with other local and national organisations will be encouraged where improvement to the patient journey may be identified through shared clinical audit. 3. SCOPE This policy applies to all clinical staff that, in the course of their work are expected to contribute to clinical audit as a means of reviewing and improving patient care and their own practice; and, to any non-clinical staff involved in the clinical audit process. This includes staff working directly in clinical services as well as those working in a range of corporate services, including finance and contracting, performance and assurance, human resources and learning and development. 4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES 4.1 Board of Directors As Trusts are regulated and performance managed against their participation in clinical audit and the findings, the Board of Directors requires assurance that there is a clinical audit policy in place that meets their strategic objectives. The Board s role is to ensure that clinical audit is strategic; it happens regularly; is clinically and cost effective; and, is linked to the Quality, Innovation, Productivity and Prevention (QIPP) agenda. The Board will achieve this through the governance structures and ultimately via the report from the Quality Assurance Group. The Board of Directors has overall responsibility for the monitoring of clinical quality as a whole within the context of clinical or integrated governance. It has a role in driving quality assurance, compliance, internal audit and closing the loop. Clinical audit provides a mechanism through which the quality of clinical care can be measured and improved, and as such has a key relationship to the Board Assurance Framework (BAF). 4.2 Audit Committee The role of the Audit Committee in relation to clinical audit as set out in its terms of reference is: In reviewing issues around clinical risk management, the Audit Committee will wish to satisfy themselves on the assurance that can be gained from the clinical audit function (via reviews commissioned from internal audit). Page 6 of 30
4.3 Chief Executive The Chief Executive is responsible for the statutory duty of quality and takes overall responsibility for this policy. 4.4 Director of Nursing and Quality The Director of Nursing and Quality is the board lead for clinical audit and is responsible for: Gaining assurance that clinical audit is relevant, focussed and complete through the results being shared, acted on, reviewed and sustained. A process for consultation with key stakeholders in the setting of priorities for the Trust Clinical Audit Programme, including participation in local and national clinical audits. Assuring that all identified risks are added to the relevant risk register (care group or corporate directorate). Where the risk is initially scored as extreme (risk score 15 or more) the risk is reported to the Executive Management Team for moderation and acceptance onto the extreme operational risk register - and therefore would require separate reporting on to the relevant Committee and Board of Directors The recommendations of clinical audits being actioned, by seeking assurance that improvement in care have been made. This lead role is undertaken in close liaison with the Medical Director. This will be as part of the overall quality framework and will be reported in the Trust s Quality Account. 4.5 Deputy Director of Nursing and Quality Deputy Director of Nursing and Quality is responsible for assuring that the process for Clinical Audit is robust, timely and effective, to enable and sustain improvement and achieve best practice. 4.6 Designated Associate Nurse Director The Associate Nurse Director is the operational lead for clinical audit, supported by the Clinical Quality Lead and the Senior Clinical Audit Facilitator. The Associate Nurse Director will: Agree the Clinical Audit Programme in consultation with Care Groups and other services and present the programme for approval to the Quality Assurance Group. Their role includes the ethical oversight of clinical audit, in consultation with other Associate Nurse Directors and relevant others as necessary. Page 7 of 30
4.7 Clinical Quality Lead The Clinical Quality Lead will support the Associate Nurse Director with the operational management of the Clinical Audit Programme. They will also support the Senior Clinical Audit Facilitator and Audit team by implementing the escalation process, to ensure timely completion of audits. He/she will work with the Senior Clinical Audit Facilitator to develop the annual Clinical Audit programme. 4.8 Senior Clinical Audit Facilitator The Senior Clinical Audit Facilitator is responsible for: Planning and prioritising the delivery of the Clinical Audit Programme against the available staff resource. Ensuring that all Clinical audits are measurable against recognised guidelines/criteria ie. NICE/National/Trust priorities. Utilising the Healthcare Quality Improvement Partnership (2012) Criteria and indicators of best practice in clinical audit as a framework to define the markers or indicators of good quality clinical audit. Presenting the annual clinical audit work programme to the Clinical Quality Group. Making available the Clinical Audit Programme to the Care Groups/other Services The circulation of final reports to the relevant Care Group/s. Implementing the prioritised Clinical Audit Programme, scheduling the individual audits and allocating Clinical Audit Facilitator support to each audit topic within the available resource, re-prioritising as required Checking that all clinical audits are registered and that teams are completing the clinical audit cycle (See Appendix 5) Ensuring that the Clinical Audit Facilitators adhere to the Clinical Audit Policy and processes that are in place Maintaining clear records and schedules for re-audits required, allocating resources as above. Assuring that the Clinical Audit team members provide the results of clinical audits in a timely manner to the Care Groups /other Services for discussion, and action planning. Preparing audit update reports on a monthly basis on the progress and outcomes of the Clinical Audit Programme to the Clinical Quality Group. Managing the request and approval process (including adding additional topics to the approved Trust Clinical Audit Programme) from the Care groups and other Services and reporting on this to the Clinical Quality Group. Providing clinical audit awareness sessions on request, to clinical teams and individuals. Facilitating and monitoring the dissemination of clinical audit Page 8 of 30
reports and results to a range of identified groups. Following best practice standards when planning, developing, and analysing clinical audit findings and use all clinical audit procedural documentation as outlined in this policy. 4.9 Clinical Audit Facilitator Clinical Audit Facilitator is responsible for: Supporting the Senior Clinical Audit Facilitator in the delivery of the responsibilities set out above. Taking the lead role on identified clinical audits with responsibility for implementing and managing the audit process through to completion within agreed timescales on the Clinical Audit Checklist, ensuring any reasons given for delays are recorded. (Appendix 7) Overseeing the collection of data, completes data analysis, interprets the findings and produces the audit report. Providing support to identified clinical audit leads for any additional not already included on the Clinical Audit Programme. Assisting them with implementing and managing the audit process through to completion within the agreed timescales. Providing guidance/advice on clinical audit and quality improvement methods and practices. Providing Clinical Audit Awareness Sessions on request to clinical teams and individuals subject to audit staff resources. Escalating any urgent risks identified at any point during the audit process immediately to the relevant person(s). 4.10 Care Group Associate Nurse Directors/Associate Medical Directors and Senior Managers/Clinical Leads in other Services Responsibilities: Promoting clinical audit within their services as a key element of clinical governance; as a quality improvement process that seeks to improve patient care; and, as a Continuing Professional Development (CPD) activity. Service development and delivery being underpinned by clinical audit. Identifying clinical audit priorities and feeding these through to the Clinical Audit Programme, whilst ensuring that these are measurable against recognised guidelines/criteria ie. NICE/National/Trust priorities. Ensuring that all clinical audit activity within their Care Group is registered centrally through the Clinical Audit Team, regardless of whether support from the Team is required. Allocating staff resources to undertake clinical audit. Fully considering and acting on the results of clinical audit, Page 9 of 30
feeding identified risks through to the risk register and completing action plans and re-audits as required to make improvements. Ensuring that any additional Clinical audits not included on the work programme have a Clinical Audit Work Request and Registration Form submitted to the Clinical Audit Team. (Appendix 2) and follow the Submission of Clinical Audit Work Request Form process (Appendix 3). 4.11 Service Leads/Managers Managers of Clinical Services are responsible for: Participating in and engaging their staff in clinical audit as a key quality improvement activity and as part of their CPD. Including Clinical audit activity in the objectives of individual staff as part of their annual Performance and Development Review (PDR) process and any identified learning and development needs reflected in their Personal Development Plan. Utilising the clinical audit programme as the source of clinical audit topics for all staff and trainees undertaking clinical audit activity. Disseminating clinical audit results within their teams and using them to drive local quality improvement strategies. Completing, reporting and producing evidence on clinical audit action plans to the Clinical Audit Team. 4.12 Clinical Audit Leads Are responsible for: Ensuring that audits are being undertaken against clear guidelines/criteria i.e. NICE/ National/Trust priorities. Discussing and agreeing on a viable sample size and methodology, to support reliable and robust clinical audit results. Being involved in the development of the audit questions / criteria before any data collection takes place to ensure questions are valid, objective and based on agreed standards. Supporting the Care Group Triumvirate and clinical services to develop action plans ensuring that SMART (Specific, Measurable, Achievable, Realistic and Timely) principles are utilised. Following guidance from the Clinical Audit team ensuring action plans are designed to deliver the recommended quality improvements. Keeping the Service Lead(s) updated on progress and to jointly agree the recommendations and action plan and feedback to the Clinical Audit Facilitator. Sharing results initially with the Care Group Director /Associate Nurse Directors/Medical Director /Lead Consultant. Clearly identifying (inc. name and title) individuals responsible for implementing/closing assigned actions, for audit team monitoring Page 10 of 30
purposes. Ensuring that the required communication has been undertaken to support the identification of appropriate named action leads and that consequently they are aware of this prior to the action plan being distributed/shared. Ensuring that the Clinical Audit Work Request and Registration Forms are fully completed for any audits not included in the annual Clinical Audit programme. Assuring that they (or a deputy) attend relevant meetings as requested to feedback on their report ie Care Group, Clinical Quality Group Meeting Keeping colleagues in the service up to date with results, issues and quality improvements as the audit progresses. Working in collaboration with the Clinical Audit Facilitator to provide confirmation that the final report is agreed. 4.13 Quality & Safety Sub Committee The Quality & Safety Sub Committee (QSSC) assures that there is an appropriate process in place to monitor and ensure compliance with clinical standards and guidelines, including, but not limited to Clinical Audit. QSSC will provide assurance on the high standards of care delivered by the Trust across the three domains of quality: clinical effectiveness, patient safety and patient experience. This group is authorised by the Board of Directors to act within its terms of reference and ensure all statutory elements of clinical governance are adhered to and will receive summary reports on all completed audits. The group is responsible for overseeing the Trust s clinical audit activities and will: Receive reports, quarterly and by exception on the progress and outcomes of the Clinical Audit Programme from the Associate Nurse Director. Contribute to, receive and approve the annual Clinical Audit Programme, ensuring it is consistent with the quality improvement priorities of the Trust. Ensure there is an appropriate mechanism in place for action to be taken in response to the results of clinical audit and the recommendations of any relevant external reports. 4.14 Clinical Quality Group The Clinical Quality Group is responsible for: The delegated responsibility from the QSSC for the process of monitoring Clinical audit. Receiving and reviewing proposals for clinical audits for inclusion onto the Clinical Audit Programme. Page 11 of 30
Monitoring progress with clinical audit action plans. Act as a forum for sharing the results of clinical audits and any related actions and recommendations. 4.15 Other Trust Groups As well as the formal progress reports provided to the Clinical Quality Group monthly, clinical audit outcomes will be discussed as appropriate by: Identified Care Group meetings. Medicines Management Committee. Other groups, including the Operational Management Meeting (OMM) Listen to Learn, etc. 5. PROCEDURE/IMPLEMENTATION 5.1 Process for setting priorities for the Clinical Audit Programme, including participation in local and national clinical audits and requirements to follow the approved process for audit This will include discussions at/with: - The Clinical Quality Group where each Care Group is represented. - Care Group /other meetings and via e-mail. - Corporate level with relevant Directors. - Commissioners. The Clinical Quality Group will agree the Clinical Audit Programme and recommend it for approval to the Quality Assurance Group, through the responsible Associate nurse Director. The programme will be responsive to identified risks, Care Group or other priorities, internally and externally. New topics may be added to the Clinical Audit Programme following receipt of the Clinical Audit Work Request and Registration Form. These will be taken to the Clinical Quality Group Meeting for discussion where a decision will be made whether it will be added to the Clinical Audit Programme or not depending on priorities of the Trust and staff resources in Clinical Audit. A record will be maintained by the Clinical Audit Team of clinical audit proposals which are not approved and the reasons fed back to the proposer. The Clinical Audit Programme will provide a source of topics for staff and trainees wishing to participate in audit activity and is shared with Page 12 of 30
Junior Doctors at their induction to the Trust via email / paper copy of the programme. Identified Care Group meetings may be utilised to provide a key forum where staff from the range of professional groups can come together to discuss, present and debate clinical audit findings. All audits supported by a Clinical Audit Facilitator must be conducted in line with the approved process for audit. (appendices 3 & 4) 5.2 Process for ensuring appropriate standards of performance are audited Clinical audits will be designed and agreed with Care groups/other services by the Clinical Audit Team in order to ensure that quality standards are selected or new standards are developed which meet Trust/ Care Group priorities. 5.3 Involving Medical Students and Junior Doctors Medical students and Junior doctors will be will be encouraged to be involved in clinical audit wherever possible as part of their learning and development. Their audits will be monitored by their supervising Consultant and follow the same process as all other audits. 5.4 Involving service users and carers Service users and carers often assess quality of care in different ways to healthcare professionals; can provide a unique perspective based on their personal experience; and, can help design services around service user needs. Involvement may range from passive input e.g. the Trust may decide to audit an issue highlighted by complaints, to active engagement e.g. direct involvement of service users in any or all aspects of the clinical audit process. 5.5 Process for disseminating clinical audit results/reports Draft Audit Reports will be sent out by the Clinical Audit Facilitator to the audit Lead (Service/Care Group) to be placed on the agenda of their Care Group meetings for presentation, discussion and action planning. Each report contains a distribution list and the reports are disseminated via e-mail by the Senior Clinical Audit Facilitator to each of the individuals identified on this list once the report and action plan has been approved by the Clinical Quality Group Meeting. Please see below for generic distribution list: Director of Nursing and Quality Page 13 of 30
Deputy Director of Nursing and Quality Care Group Director Associate Nurse Director Associate Medical Director / Lead Consultant Head of Service Ward Manager Ward Sister Ward Matron Clinical Quality Lead Audit Lead Any named staff as lead for audit actions 5.6 Format for all clinical audit reports i.e. methodology, conclusions, action plans etc. A streamlined user friendly audit report format and summary results on a page using the What? So What? Now What? Format is utilised (appendix 6). The overall rating for the audit will be determined by the Audit Facilitators and rated as one of the following (CQC Judgement Framework): Outcome Rating Outstanding Good Requires Improvement Inadequate Rationale 100% all standards 75% to 99.9% most standards 50 74.9% most standards or mixed results 49.9% or below for most standards The outcome rating is calculated by working out the overall percentage achieved taking into account the Numerators and Denominators for each criteria. It should be noted that there may be occasions when the rating may be altered if any criteria is rated Red and when utilising clinical judgement is deemed to be a patient/staff risk. For example, if the overall rating is good it may mean that the rating will be changed to Requires Improvement where the risk is seen as high and will automatically become a re-audit. This decision will be made by the Clinical Quality Group Meeting where the Clinical Audit Lead is presenting their report. Audit reports will evidence improvements in patient care through the development and measurement of evidence based practice supported by SMART actions:- o Specific o Achievable o Timely o Measurable o Realistic Page 14 of 30
All audits undertaken will have a standard approach. Mechanisms will be in place to support the monitoring of achievements via existing meeting structures (e.g Clinical Quality group) and confirm and challenge (by peers) of audit actions in order to support improvement in practice within stated timescales. This will ensure that the audit action plans lead to change in practice within the stated timescales. A Change Status Key is incorporated within the report for audit actions to determine the progress and status upon reporting: o Recommendation agreed but not yet actioned o Action in progress o Recommendation fully implemented o Recommendation never action (state reasons) o Other (provide supporting information) A format which is to be used for all clinical audit reports is provided in Appendix 6. The use of this format will promote consistent and comprehensive reporting and will support reporting on the outcomes of the clinical audit programme Trust wide. 5.7 Process for making improvements Clinical audit results will be used to inform improvements where the need is identified. The action plan will state what action is required against the criteria, by whom and when the action will be completed. Action plans are monitored to completion by the Clinical Audit Team feeding into the Clinical Quality Group and learning shared within the group which has Trust wide service membership. 5.8 Process for monitoring action plans and carrying out re-audits All action plans are entered onto the Clinical Audit Department s action plan log by the Clinical Audit Team. Due dates for the actions are clearly recorded and the status of the action is recorded. The spread sheet is reviewed monthly by the Senior Clinical Audit Facilitator for any due actions. Any actions which are due are followed up by the process below: - The Clinical Audit Facilitator will email the relevant lead(s) responsible for completion, asking them to confirm if the action has been completed and to provide evidence of what has been Page 15 of 30
done in response to the action. A response time of 2 weeks is allocated. - If no response is received the Clinical Audit Facilitator will follow up with a 1 week deadline for response. - If no response it is escalated in the first instance to the Senior Clinical Audit Facilitator who will contact the relevant audit lead with a 1 week response. - If no response is forthcoming this will then be escalated to the Clinical Quality Lead who will contact the audit lead primarily with a 1 week deadline for response. - If no response the Clinical Quality Lead will escalate to the relevant Associate Nurse/Medical Director of the service with a 1 week deadline for response. The action plan log is updated with the comments received and the status revised accordingly. Re-audits are also monitored through the Summary of Audits document by the Senior Clinical Audit Facilitator and are scheduled into the Clinical Audit Programme. The action plan log is monitored by the Clinical Quality Group on a monthly basis. The results of all clinical audits will be risk rated by the relevant Care Group and added to the risk register as required by the Associate Nurse Director. Risk is reported to the Quality Assurance Group. These will then be worked through via an action plan by the relevant Care Group Director to mitigate the risks. Monthly reviews of risk registers are undertaken by each Care Group. 5.9 Route for Escalation of Concerns The Senior Clinical Audit Facilitator will be the first point of contact for the escalation of concerns, raised by the Clinical Audit Team. These concerns may be about the clinical audit process, findings or any other related issues. The Senior Clinical Audit Facilitator will in turn discuss concerns with the Clinical Quality Lead as appropriate and follow up accordingly. In the event of the concerns relating to none or poor compliance with data submission deadlines, an e-mail will be sent to the relevant Service Manager with the Associate Nurse Director copied in. This e-mail will provide a final date for data submission and make it clear that if the data is not provided to the audit department by that date a none submission Page 16 of 30
will be documented in the final audit report. In the event of the concerns relating to none completion of Action Plans within the audit reports, the Clinical Audit Facilitator will escalate this in the first instance to the Senior Clinical Audit Facilitator who will, if necessary, then escalate to the Clinical Quality Lead. If no response is received the matter will then be taken to the Clinical Quality Group for a decision to be made on the way forward with the audit. 5.10 Clinical Audit Project Update The Clinical Audit Project Update spread sheet is an internal resource of the Clinical Audit Team and holds details of all Clinical Audits for monitoring and assurance purposes. The Clinical Audit Team uses a spread sheet to record and monitor the current status of all clinical audit work in progress. The spread sheet is used by the Clinical Audit team to retrieve appropriate information about projects to support the evidencing and reporting of work and its progress. 6. TRAINING IMPLICATIONS There are no specific training needs in relation to this policy, but clinical staff will need to be familiar with its contents and any other individual or group with a responsibility for implementing the contents of this policy. As a Trust policy, all staff need to be aware of the key points that the policy covers. Staff can be made aware through a variety of means such as: Trust wide mail drop Team meetings One to one meetings / Supervision Posters CPD sessions Trust wide email Group supervision Practice Development Days Local Induction The clinical audit team will hold 1:1 and group awareness sessions on request to clinical teams and individuals. 7. MONITORING ARRANGEMENTS Area for monitoring How Who by Frequency Reported to How the organisation sets priorities for clinical audit Clinical audit programme Responsible Associate Nurse Director, Clinical Quality Lead and Annual Clinical Quality Group Page 17 of 30
Area for monitoring How Who by Frequency Reported to including local and national requirements Requirement that audits are conducted in line with the approved process for audit How audit reports are shared Report Progress Ongoing monitoring of clinical audit reports, new work requests and action plans the Senior Clinical Audit Facilitator Senior Clinical Audit Facilitator Monthly Monthly Clinical Quality Group Clinical Quality Group Format for all audit reports, including methodology, conclusions, action plans etc How the organisation makes improvements How the organisation monitors action plans and carries out re-audits Action plan log Senior Clinical Audit Facilitator Monthly Clinical Quality Group 8. EQUALITY IMPACT ASSESSMENT SCREENING The completed Equality Impact Assessment for this Policy has been published on this Policy s webpage on the Trust Policy Website 8.1 Privacy, Dignity and Respect The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi s review of the NHS, identifies the need to organise care around the individual, not just clinically but in terms of dignity and respect. Indicate how this will be met No issues have been identified in relation to Page 18 of 30
As a consequence the Trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided). this policy. 8.2 Mental Capacity Act Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals capacity to participate in the decision making process. Consequently, no intervention should be carried out without either the individuals informed consent, or the powers included in a legal framework, or by order of the Court Therefore, the Trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act. For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act 2005 to ensure that the interests of an individual whose capacity is in question can continue to make as many decisions for themselves as possible. Indicate how this will be met All individuals involved in the implementation of this policy should do so in accordance with the Guiding Principles of the Mental Capacity Act 2005. (Section 1) 9. LINKS TO ANY ASSOCIATED DOCUMENTS Risk Management Framework 2016-2019 10. REFERENCES NICE (2002) Principles for Best Practice in Clinical Audit Healthcare Quality Improvement Partnership (2010) Clinical Audit: A simple guide for NHS Boards and Partners Healthcare Quality Improvement Partnership (2012) Criteria and indicators of best practice in clinical audit 11. APPENDICES Appendix 1 - Clinical Audit: Ten Simple Rules for NHS Boards Appendix 2 - Clinical Audit Work Request and Registration Form Appendix 3 - Submission of Clinical Audit Work Request Form to the Clinical Audit Team Appendix 4 - The Audit Process/Cycle Appendix 5 - Clinical Audit Summary Results Appendix 6 - Format for all Clinical Audit Reports Appendix 7 - Clinical Audit Checklist Page 19 of 30
CLINICAL AUDIT: TEN SIMPLE RULES FOR NHS BOARDS Appendix 1 1. Use clinical audit as a tool in strategic management; ensure the clinical audit strategy is allied to broader interests and targets that the board needs to address. 2. Develop a programme of work which gives direction and focus on how and which clinical audit activity will be supported in the organisation. 3. Develop appropriate processes for instigating clinical audit as a direct result of adverse clinical events, critical incidents and breaches in patient safety. 4. Check the clinical audit programme for relevance to board strategic interests and concerns. Ensure that results are turned into action plans, followed through and re-audit completed. 5. Ensure there is a lead clinician who manages clinical audit within the trust, with partners/suppliers outside, and who is clearly accountable at board level. 6. Ensure patient involvement is considered in all elements of clinical audit, including priority setting, means of engagement, sharing of results and plans for sustainable improvement. 7. Build clinical audit into planning, performance management and reporting. 8. Ensure with others that clinical audit crosses care boundaries and encompasses the whole patient pathway. 9. Agree the criteria of prioritisation of clinical audits, balancing national and local interests, and the need to address specific local risks, strategic interests and concerns. 10. Check if clinical audit results evidence complaints and if so, develop a system whereby complaints act as a stimulus to review and improvement. Source: Healthcare Quality Improvement Partnership (HQIP), 2010 Page 20 of 30
Appendix 2 Clinical Audit Work Request & Registration Form (Form to be completed when the audit is in addition to the agreed RDaSH Clinical Audit Work Programme) Audit Title: Audit Lead(s): Titles(s): Tel No: Email Address: Care Group: Rotherham Doncaster North Lincs Children s Service: Adult Community Adult Inpatient MH Older People MH Drug and Alcohol CYP+F CAMHs Medical/Pharmacy Learning Disabilities DCIS Corporate Services Forensic Will this be a Trust wide or locality specific audit? Trustwide Locality Specific Locality to be involved: If the project is not to be undertaken Trustwide (i.e. throughout all adult inpatients services), please indicate the reasons why: Type of Work: Clinical Audit Clinical Effectiveness Clinical Assurance Category: Safety Patient Experience Effectiveness Reason for the Audit: National Audit Identified on Risk Register Complaint / Incident Other, please state: CQC, state N o : Quality Marker Contractual / Commissioner Requirement CQUIN Performance Indicators Area of Concern NHSLA Risk M. Standards NICE Guidance, state N o : Re-audit Page 21 of 30
Main Aims/Objectives for the audit: (what do you want to achieve or assess?): What criteria and standards are you going to measure, i.e. what is the aspect of care that you are going to examine and what target are you going to set? Criteria Criteria Standard (%) Number 1 2 3 4 5 Continue on separate sheet if necessary Audit Methodology: Prospective Retrospective Concurrent Prevalence (held on one specific day) Data collection Method: Data collection proforma Questionnaire Interview Other please specify: Data source: Patient records Patient experience Computer held information Staff experience Observation Other please specify: Stakeholders: Have key people been made aware of this audit (ie people who will be providing services covered by this audit)? Yes No It is essential that anyone who will be providing services covered by this audit are made aware of the audit at the start to ensure where any changes are required at the end that they fully understand why these are necessary. Page 22 of 30
Please state the expected START date of the audit/project: Please state the expected COMPLETION date of the audit/project: Do you require any support from the Clinical Audit Team? Yes No If yes, please state what support you require from the Clinical Audit Team: Advise on how to conduct the audit Data input Data analysis Typing of tables / graphs for presentation of results Support with completing the audit report Other please specify: PRIORITISATION SCORE SHEET Please complete the following prioritisation scoring sheet to establish the level of priority for the project. Following your submission of the work request form, the Clinical Quality Group will consider the appropriateness of the project in order to identify available resources within the Clinical Audit Team. Projects scoring a medium/high will be considered for support. Projects scoring low will be considered a low priority and therefore, support from the Clinical Audit Team may not be approved. If you require any assistance in completing the work request form / prioritisation score sheet, please contact the department on 01302 796728. Audit Title Score Maximum allowed Reason for undertaking this audit project Max = 38 Compliance with national and local clinical priorities Max = 11 National clinical guidance e.g. NICE, New Horizons 2 Identified by the Care Quality Commission (CQC) 2 Fundamental Standards for Healthcare CQUIN 2 Commissioner Request/Requirement 2 Quality Marker / Performance Indicator 2 Local Care Group identified audit 1 Management of risk Max = 5 Problem identified through clinical incident 1 reporting/significant event analysis Problem identified through patient complaint/complaint 1 monitoring Topic through risk management process e.g. NHSLA 1 Issue identified through litigation/risk of litigation 1 Identified though the risk register 1 Page 23 of 30
Other Max = 5 Relates to strategic goals/objectives 2 Patient/carer feedback 2 Need for re-audit of previous topic 1 Area of Clinical Practice Max = 4 One of high volume 1 One associated with high costs 1 One of concern (i.e. outcomes/practice could be improved 1 One where there has been a change in practice requiring 1 evaluation Evidence based Guidelines / Standards Max = 9 NICE 2 CQC Standards 2 Royal College 1 Other Professional bodies 1 Policy 1 Locally developed clinical guidelines 1 Locally adopted clinical standards e.g. Essence of Care 1 Involvement of agencies / disciplines / users Max = 4 Multi Organisational e.g. GP s 2 Multidisciplinary 1 Identification / development of audit topic by service user 1 Project Total (max = 38) Key: 0-13 = Low 14-26 = Medium 27-39 = High Has this audit been discussed and approved by your Care Group YES NO Has this audit been discussed and approved by your Governance Group? YES NO Who has approved this audit? Care Group Director Date: please print name: Associate Nurse Director Date: please print name: Consultant Date: please print name: Signed: Job title: Date: Please return this form by post to: Clinical Audit Team Chestnut View, Tickhill Road Site, Doncaster Or email: clinicalaudit@rdash.nhs.uk CLINICAL AUDIT TEAM USE ONLY: Date received: / / Date approved by The Clinical Quality Group:.. /.. /.. Clinical Audit Facilitator: Submission Year: Page 24 of 30
Appendix 3 SUBMISSION OF CLINICAL AUDIT WORK REQUEST AND REGISTRATION FORM TO THE CLINICAL AUDIT TEAM (CAT) Audit Lead obtains approval for their audit from their Care Group / Governance Group and either their: Care Group Director / Associate Nurse Director / Consultant Obtain Clinical Audit Work Request and Registration Form from the CA Department Complete work request form and ensure: Audit has approval from Care Group Signature of Manager/Consultant Signature of Associate Director Audit Lead (AL) to submit Audit Request Form to the CA Department or email: clinicalaudit@rdash.nhs.uk Resources required from CA Department Audit request to be taken to the CQG (monthly by the Senior Clinical Audit Facilitator (SCAF) for approval Resources NOT required from CA Department (submitted for information purposes only) Audit registered with the CA Department APPROVED Audit registered with CA Department and Clinical Audit Facilitator (CAF) assigned to support Audit Lead CAF to contact Audit Lead to progress with audit SCAF to feedback to Audit Lead regarding outcome: APPROVED / NOT APPROVED NOT APPROVED SCAF or CAF to offer advice to Audit Lead Audit Lead completes Clinical Audit Report template Audit Lead to feedback report to colleagues to agree actions to be taken Audit Lead to send Audit Report to CA Department for SCAF to feedback to the CQG meeting who will forward any comments made by the CQG members (if applicable) CAF / SCAF to send an Audit Certificate to Audit Lead (if requested) Page 25 of 30
Appendix 4 THE AUDIT PROCESS / CYCLE Choose Audit Topic Re-audit. Establish Aim(s) Recommendations for change / action plan Define Criteria Analyse the results against criteria and standards Decide on methodology Collect data Page 26 of 30
Appendix 5 Clinical Audit Summary Results Audit Title: Area Audited: Care Group: What? So What Now What? Page 27 of 30
Appendix 6 FORMAT FOR ALL CLINICAL AUDIT REPORTS CONTENTS Page No 1. Front Page a. Clinical Audit Title b. Care Group c. Care Group Clinical Audit Lead d. Clinical Audit Facilitator e. Date 2. Clinical Audit Summary Results: a. What? b. So What? c. Now What? 3. Background 4. 5. Aims of the Audit Objectives of the Audit 6. Criteria and Standards 7. Method: Sample and Population Data Collection Data Analysis 8. Results 9. Observations 10. Recommendations and Actions 11. Re-Audit 12. Distribution List 13. Appendix Page 28 of 30
Appendix 7 Clinical Audit checklist for Audits on the Work Programme (to be completed at first meeting with audit lead) Date of Meeting with Audit Lead:.. /. / Name of Audit Lead: Date of Commencement of Audit:.. / /. Name of CA Facilitator: Phone number for Audit Lead:. Predicted Date of Completion of Audit:... /. /... Actions following initial meeting with Audit Lead: Timescale: By Whom: Record reasons for any delays on timescale set: DRAFT protocol and audit tool to be developed DRAFT protocol to be shared with Senior CA Facilitator DRAFT protocol and audit tool to be shared with Audit Lead Audit lead to confirm if happy with protocol and audit tool Audit lead to pilot the audit tool (where appropriate) Data collection to be carried out Data input to be carried out Data analysis to be carried out DRAFT Audit Report emailed (TEMPLATE B) to the Audit Lead for them to complete: recommendations action plan table (including clear name and title of action lead) suggested re-audit date (if applicable) the distribution list for the report CA Facilitator CA Facilitator CA Facilitator Audit Lead Audit Lead Audit Lead (& CA Facilitator if appropriate) CA Facilitator CA Facilitator CA Facilitator Page 29 of 30
Actions following initial meeting with Audit Lead: Timescale: By Whom: Record reasons for any delays on timescale set: DRAFT report to be sent to the CA Facilitator for final checks by CA Facilitator and the Senior CA Facilitator FINAL report to be scheduled on the next Clinical Quality Group Meeting (if amendments required to the actions - an agreement of approval of the report subject to amendments being made to prevent any delays) Feedback to be given to assigned CA Facilitator by the Senior CA Facilitator following the CQG meeting FINAL report to be circulated to all concerned with email (TEMPLATE D) Audit Lead Senior CA Facilitator Senior CA Facilitator Senior CA Facilitator Page 30 of 30