SUPPORTING PAPER (FOR INFORMATION) TRUST BOARD

Transcription

1 SUPPORTING PAPER (FOR INFORMATION) TRUST BOARD Date of meeting: Thursday, 28 th July 2011 Title of paper: Presented by: Executive Summary: Self Assessment Maturity Matrix Briefing Paper Head of Clinical Care and Patient Safety The has rated NEAS using the Matrix for its use of clinical audit in strategic, quality and performance management and answers have reflected an understanding of clinical audit within the Trust. The results demonstrate that developments can be made to improve clinical audit within the Trust and strengthen the s engagement in clinical audit. Recommendations: The is asked to review the findings of the task and to consider the recommendations made. CQC Essential Standards of Quality & Safety: Involvement and Information Personalised care, treatment and support Safeguarding and safety Quality and management Legal Issues: None identified Author: Jay Duckett Date: 16 th July 2011

2 NORTH EAST AMBULANCE SERVICE NHS TRUST SELF-ASSESSMENT MATURITY MATRIX BRIEFING PAPER REPORT BY: Head of Clinical Care & Patient Safety Introduction The Clinical Audit Self-Assessment Maturity Matrix took each of the 10 key elements from Clinical audit: a simple guide for NHS s and partners (HQIP, 2010) and broke them down into 5 statements, each statement reflecting different stages of progression; from basic level to exemplar. The key elements can be found in Appendix A. members were asked to rate NEAS using the Matrix for its use of clinical audit in strategic, quality and performance management and answers reflected an understanding of clinical audit within the Trust. The Matrix had been shared with both the Clinical Audit Steering Group () and the and the following key points have been extracted: The suggested that NEAS is developing in using clinical audit as a tool in strategic management. Each of the clinical audits in the programme have now been mapped to the strategic vision and the intentions from the Assurance Framework in order to align clinical audit with the s objectives. Both groups under-scored the Clinical Audit Programme and how each audit is allocated the correct resources and skills. Both groups underestimated NEAS involvement in cross-organisational audits. Only one person from each group said there was an expectation and commitment from the to see action plans. Suggestion was made by the to share the Clinical Audit Programme with the on an annual basis. Patient involvement received the lowest rating with the majority feeling that we could directly involve patients more in clinical audit Both groups believed clinical audit was particularly useful for planning and performance management and this received the highest possible score by both groups Further resources will be required in order to move clinical audit forward Recommendations for Improvement The is to be given the opportunity for greater involvement in the Clinical Audit Programme content and prioritising clinical audits. It is proposed that the Programme is presented on an annual basis with each audit being clearly strategically linked to the s objectives.

3 The is asked, through greater knowledge of the Programme and activity, to challenge the in terms of choice of audits and completion of action plans, in order to strengthen clinical audit within the Trust. The Clinical Projects Officer will continue to explore how patient involvement can be developed further in clinical audit. Please refer to Appendix B for full results and a comparison of the and the s views. Jay Duckett July 2011

4 Appendix A: Clinical Audit: Ten Simple Rules for NHS s Appendix B: Results of the Clinical Audit Self-Assessment Maturity Matrix

5 NEAS use clinical audit as a tool in strategic management. NEAS develop an annual programme of work.

6 NEAS instigate clinical audit as a direct result of mortality ratios, adverse clinical events, critical incidents & breaches in patient safety. NEAS ensure the clinical audit programme is relevant to board strategic interests and concerns.

7 NEAS ensure there is a lead clinician who manages clinical audit within the trust, with partners / suppliers outside. NEAS ensure patient involvement is considered in all elements of clinical audit.

8 NEAS build clinical audit into planning, performance management and reporting. NEAS ensure with others that clinical audit crosses care boundaries and encompasses the whole patient pathway.

9 NEAS agrees the criteria of prioritisation of clinical audits. NEAS confirm that clinical audit is leading to improved outcomes.