Clinical Audit Strategy 2011/ /14

Transcription

1 Audit Strategy 2011/ /14

2 CLINICAL AUDIT STRATEGY, 2011/12 to 2013/14 Executive East Cheshire NHS Trust sees clinical audit as a cornerstone of its arrangements Summary: for developing and maintaining high quality patient centred services. It is expected that this Strategy will inform and enhance the process of improving clinical services. Supersedes: Audit Strategy (Version 6) Description of Amendment(s): This policy will impact on: All Trust Staff Financial Implications: This Audit Strategy has been fully rewritten to reflect the changes which have taken place in the field of clinical audit and to meet present day requirements Policy Area: Corporate Document Reference: Version Version 7 Effective Date: 14 th November 2011 Number: Issued By: Dr S Knight Associate Medical Review Date: 14 th November 2014 Director for Author: Margaret Perry (Full Job title ), Research & Development Manager APPROVAL RECORD Committees / Group Date Consultation: Audit Research and Group Approval Committee: Ratified by Committee: Audit and Research Group 14 th November 2011 Safety Quality and Standards Committee 17 th January 2012

3 Table of contents Executive Statement Page 1 Chapter One: Organisational Context Page 2 Chapter Two: Scope Page 3 Chapter Three: Definition of clinical audit Page 4 Chapter Four: Strategic aim and objectives Page 5 Chapter Five: Action plan Page 6 Chapter Six: audit programme Page 10 Appendix A: References & acknowledgements Page 12

4 [Page Left Deliberately Blank]

5 Executive Statement East Cheshire NHS Trust (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. It is expected that this 3 year Audit Strategy, in line with the Our Developing Strategy: Transforming Health Care in Partnership and the Trust s wider governance and assurance mechanisms will inform and enhance the process of improving clinical services. Dr Robert Stead Medical Director Julie Green Director of Corporate Affairs and Governance 1 Page Executive Statement

6 Chapter One: Organisational context 1. It is important that clinical audit is not seen as an isolated quality improvement activity but as one of a set of tools which teams and organisations can use to improve the quality of care that is delivered to service users and their families. It is also important to consider the links to the wider quality and governance frameworks that exist. 2. audit (as a body of work) should contribute to the delivery of East Cheshire NHS Trust s corporate objectives and its overall vision for: clinical governance (the framework through which NHS organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish) 1 ; corporate assurance (including the Care Quality Commission s registration standards, and related indicators); integrated governance (systems, processes and behaviours by which organisations lead, direct and control their functions in order to achieve organisational objectives, safety and quality of service and in which they relate to patients and carers, the wider community and partner organisations) 2 ; quality (including quality accounts); patient engagement/involvement (i.e. how organisations respond to the Duty to Involve set out in Section 242 of the NHS Act 2006); support for the implementation and evaluation of initiatives developed as part of the next generation care approach to service improvement within the organisation. 3. For East Cheshire NHS Trust, as a provider organisation, clinical audit activity should reflect commissioners requirements and aspirations, for example, by providing evidence for commissioning with regards to contractual requirements. 4. Other areas of consideration must include: information governance (to ensure that clinical audit practice meets the requirements of information governance best practice); research and development (close working arrangements exist between clinical audit and Research and Development staff in the, Research and Development Team with open communication to clarify details over projects e.g. where doubt exists about whether a project is audit, research or service evaluation. 2 Page Chapter One Organisational Context

7 Chapter Two: Scope 5. This strategy is targeted at all the clinicians and staff within East Cheshire NHS Trust who have responsibility for overseeing the direction and development of clinical audit. This will typically include the following: Trust Board The Trust Board is responsible for ensuring that the organisation consistently follows the principles of good governance applicable to NHS organisations. This includes the development of systems and processes for governance and risk management which is supported by this strategy. Chief Executive The Chief Executive is the Accountable Officer of the Trust and as such has overall accountability and responsibility for ensuring it meets it s statutory and legal requirements and adheres to guidance issued by the Department of Health in respect of Governance. Medical Director The Medical Director has executive accountability for clinical effectiveness and is responsible for ensuring assurance with regard to the implementation of this strategy is provided to the Board and relevant committees. Director of Nursing, Performance and Quality The Director of Nursing, Performance and Quality is responsible for organisational operational management of clinical services for the delivery of the Quality Strategy. The Director has executive responsibility for ensuring the Trust provides high quality care, which is supported by the effective implementation of clinical audit within Business Groups. Director of Corporate Affairs and Governance The Director of Corporate Affairs and Governance has accountability for governance and risk management across the Trust and for working in collaboration with Medical Director to ensure the Board and relevant committees receive appropriate assurance with regard to the implementation of this strategy. Associate Medical Director for The Associate Medical Director is the lead clinician accountable for the implementation of the Audit Strategy across the Trust and chairs the Audit Research and Group, providing clinical leadership to Business Group representatives and Audit Leads. Deputy Director Corporate Affairs & Governance The Deputy Director will lead and ensure mechanisms are in place to manage the governance processes related to the Audit Strategy in order to achieve best 3 Page Chapter Two Scope

8 practice and continued improvement; this includes having accountability for the management of the Team. The Manager and Team The Manager is responsible for monitoring and reporting on the Trust clinical audit programme, ensuring that the requirement to provide assurance on compliance/ implementation of national, regional and local standards of practice is met. This includes audit of the implementation of NICE guidance, quality standards and technology appraisals. The wider team members will work with representatives of the Business Groups to prioritise audit activity which reflects the objectives of the organisation and provide support to ensure a programme of clinical audit and effectiveness activities is undertaken. Associate Directors Associate Directors are responsible for the local implementation of this strategy within their respective areas and for ensuring that Audit Leads and Business Group representatives on the Audit Research and Group fulfil their responsibilities for the delivery and monitoring of their clinical audit programme. Audit Leads Business Groups Audit Lead are responsible for promoting and monitoring clinical audit activity within their area of responsibility, ensuring that evidence of changes in practice, where required, is available. Managers Managers are responsible for the local implementation of clinical audit and for ensuring staff adhere to the relevant clinical audit policy and procedures. All clinicians and healthcare professionals All clinicians and healthcare professionals are responsible for providing clinically effective care and treatment, which is supported through active participation in clinical audit and the implementation of improved practice as a result of learning. 6. All members of Trust staff should be aware of the strategy as its implementation will have an impact on the way they undertake their duties and the support the Team can provide in everyday clinical audit activities. 4 Page Chapter Two Scope

9 Chapter Three: Definition of clinical audit 7. Audit may be defined as 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. 3 This is the definition provided and endorsed by the National Institute for Health and Excellence, and the one to which East Cheshire NHS Trust works. 8. audit is often shown as a cycle. This cycle can have many stages, and appear quite complex. A simplified version of this cycle is shown below for information. Audit within East Cheshire NHS Trust will follow this model. It is of particular importance to note the stages of improve practice and re audit. This will support the Trust to show demonstrable improvements in the quality of care that we deliver. Select Topic Re audit Appraise Evidence Improve Practice Audit Cycle Develop Standards Peer Review Design Data Collection 5 Page Chapter Three Definition of Audit

10 Chapter Four: Strategic aim and objectives Strategic aim 9. The aim of this strategy is to ensure that there is clarity over the use of clinical audit as a process to embed clinical quality at all levels within East Cheshire NHS Trust over the next three years. It will deliver demonstrable improvements in patient care through the development and measurement of evidence based practice. Objectives 10. The above strategic aim is supported by a number of service objectives, i.e., the areas of clinical audit practice that the Trust is committed to developing during 2011/12 to 2013/14. By definition, these objectives are likely to vary in their specificity, however all objectives will be supported by SMART actions: Specific Measurable Achievable Relevant Time based 11. For 2011/12 to 2013/14 the key objectives for East Cheshire NHS Trust are: to ensure that all audits undertaken within the Trust reflect, and support, the organisation s objectives; to ensure a uniform approach across the organisation to clinical audit activity; to ensure that clinical staff have the necessary competency, support and time to participate in clinical audit; to ensure that the Trust has a robust clinical audit programme; to ensure that mechanisms are in place to support the monitoring of the achievement of audit action plans supporting improvements in practice within stated timescales; to ensure organisational compliance with the Care Quality Commission and NHS Litigation Authority Standards (or the most recent equivalent). to ensure that where appropriate audit is a multi professional activity. 6 Page Chapter Four Strategic Aim & Objectives

11 Chapter Five: Action Plan 12. An action plan reflecting the objectives listed in Chapter 4 has been developed and is shown below. To ensure that they are achieved and delivered in a timely manner, this plan will be reviewed bi annually by the Trust s Audit Research and Group (CARE) which is accountable to the Safety, Quality and Standards Committee, a committee of the Trust s Board. Progress against this plan will be reported as part of the Annual Report. 13. The progress of the plan has been awarded a RAG status (red, amber, green), which translates as: Red: timescale for completion has passed. Amber: key challenges identified that may impact on delivery of milestones. Green: actions on target for completion within timescale. Action Supported by Expected Outcome Status (R/A/G) Objective 1 To ensure that all audits undertaken within the Trust reflect, and support, the organisation s objectives To introduce a system whereby Trust Board objectives are considered in the audit planning process. Manager Business Group Safety Quality and Standards Groups Identification of relevance of audits to Trust Board objectives to be made at planning/ registration stage of audit. Green Nov 2011 Objective 2 To ensure a uniform approach across the organisation to clinical audit activity To develop a set of tools that can be used by teams and individuals for planning, implementation and dissemination of clinical audits. To introduce clinical audit groups to areas where they do not currently exist in particular the Community Health Business Group and the Families & Well Being Business Group, supporting a multidisciplinary approach, measurable changes to practice, and regular meetings. Manager Manager Business Group Safety Quality and Standards Groups Tools for: Planning Report Presentation Action plan audit groups will meet on a regular basis in each of the following Business Groups: Acute Adult Care Community Health Families & Well Being Green Amber Nov 2011 April Page Chapter Five Action Plan

12 Action Supported by Expected Outcome Status (R/A/G) To improve the opportunities available to trainee doctors within the organisation to participate in audits which are of value to the organisation. There will be a more structured format of projects to complete or contribute to. Projects will link into the Trust core programme. There will be an increased level of ownership by supervisors and teams of findings, with an improved level of change following audit. Re audit as evidence of change to practice will be increased. Manager Audit Research and Group Business Group Safety Quality and Standards Groups Provision of a structured plan for audits available to trainee doctors. Liaison with Business Group clinical audit leads, through Audit Research & Group membership. Amber Objective 3 To ensure that staff have the necessary competency, support and time to participate in clinical audit To review the training that the clinical audit department offers to ensure: that it is appropriate to the needs of the organisation that an appropriate number of sessions are being delivered to ensure that sessions are being delivered at various levels to ensure training is available both face to face and electronically To ensure that the Trust obligations towards clinical audit within revalidation for doctors, and other health professionals as appropriate, are met. Manager Associate Medical Director for Associate Medical Director for Revalidation Review of training to ensure that information is up to date and accessible to all staff and will be available electronically when systems allow. Review of content of sessions delivered to teams and individuals. Plan for annual training to be delivered which should include sessions at multiple locations, and available on a planned and drop in session. Inclusion of clinical audit or other quality improvement activities, as appropriate, within the supporting professional activities (SPAs) undertaken within the Trust. Involvement in appropriate audit activity, and completion of the audit cycle, will be recorded, scrutinised during annual appraisal and will form part of the evidence used for revalidation. This will take into account recommendations by the General Medical Council and other organisations such as Royal Colleges. The Team, working with Education Amber Amber Aug 2012 Nov 2012 Jan Page Chapter Five Action Plan

13 Action Supported by Expected Outcome Status (R/A/G) and Training department, will identify and, as necessary develop (within financial constraints), supporting measures which can be provided to staff undertaking clinical audit. For those who register their audit activity and submit reports of the completed audit the Team will provide certificates of completion these will outline the stages of the audit cycle that individual clinicians have been involved in. They can form part of the individual s appraisal portfolio. There is comprehensive evidence of involvement by staff within clinical audit and other quality improvement activity Educational Supervisors Business Group Audit Leads That evidence is available through minutes of audit meetings, supervision records, or audit project reports. Amber April 2012 Continued on the next page 9 Page Chapter Five Action Plan

14 Action Supported by Expected Outcome Status (R/A/G) Objective 4 To ensure that the trust has a robust clinical audit programme There will be an annual clinical audit programme developed for East Cheshire NHS Trust detailing specific clinical audit projects that will be carried out. The programme will be developed in consultation with members of senior clinical and non clinical management within the organisation. It is expected that managers will ensure that there is an opportunity for staff at all levels within the organisation to feed into the development of the core programme. There will be an evidence trail for this involvement, including meeting minutes, or s. Progress by teams against the programme will be monitored through Business Group scorecards, and reported in the clinical effectiveness annual report. audit of National Institute for Health & Excellence guidance will be incorporated into the clinical audit annual programme. The Institute s guidance will be prioritised for audit in terms of which topics are selected, and how they will be audited. This will be in liaison with the Audit Research & Group to ensure that there is broad input into this process. Audit of National Institute for Health & Excellence topics will feed into the core programme. Manager Associate Medical Director for Audit Leads Business Group Safety Quality and Standards Groups Audit Research & Group Audit Leads Audit Research & Group A clinical audit programme will be produced, in consultation with the Business Unit Safety Quality and Standards Groups, and this will be ratified by the Audit Research and Group. There will be an evidence trail for this involvement, including meeting minutes, or s Liaison with Business Group audit leads, through Audit Research and Group membership to ensure that National Institute for Health and Excellence guidance is prioritised as a topic for audit. audit of National Institute for Health & Excellence guidance will be incorporated into clinical audit annual programme. Green Green Objective 5 To ensure that mechanisms are in place to support the monitoring of the achievement of audit action plans within stated timescales This will be achieved through RAG rating one of the sections on the audit scorecards, supporting Business Group audit leads in ensuring that audit plans lead to changes in practice within stated timescales Manager Audit Leads Business Group Safety Quality and Standards Groups Business Groups and the Audit Research and Group will have a systematic approach to monitoring that the audit cycle is completed within stated timescales. Green April 2012 April 2012 April 2012 April 2013 April Page Chapter Five Action Plan

15 Action Supported by Expected Outcome Status (R/A/G) Objective 6 To ensure organisational compliance with the Care Quality Commission and NHS Litigation Authority Standards audit of policies and their implementation will be incorporated into the clinical audit annual programme. Trust policies relating to National Health Service Litigation Authority standards will be prioritised for audit. Audit Leads Business Group Safety Quality and Standards Committees Policy Governance Group Risk Manager NHSLA Project Plan will include review of policies against Level 1 standards. Rolling audit will be undertaken provide evidence from live records of practice compliance with standards. Non compliance will be identified and actions implemented to address areas for improvement. Amber March 2012 Feb 2013 Audit Research & Group There will be a process developed for electronic registration of clinical audit projects. All audits will then be entered onto scorecards which facilitate electronic, real time monitoring, and support examination by the Audit & Research Group and Business Group Safety Quality and Standards Committees. Manager Improved process of registration, making it easier for staff to register projects, and scorecards also support ownership of audits by the Business Groups. Amber Sept Page Chapter Five Action Plan

16 Chapter 6: audit programme 14. East Cheshire NHS Trust will produce an annual clinical audit programme which will outline details of the specific clinical audit projects to be carried out. The programme will be developed in consultation with members of senior clinical and non clinical management within the organisation. It is expected that managers will ensure that there is an opportunity for staff at all levels within the organisation to feed into the development of the core programme. 15. The choice of clinical audit topics will also support other key streams of governance and quality activity, for example: 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); complaints and other forms for patient feedback (e.g., themes from this source of information intelligence should be used to propose topics for clinical audit); other benchmarking activities as appropriate 16. This clinical audit core programme will, each year, make provision to highlight or support (as appropriate) various core projects. As a minimum the programme will consider or include: National Confidential Enquiries into Patient Outcome and Death; National Patient Safety Agency guidance; National Audit; National Service Frameworks; NHS Litigation Authority standards (including audits of the quality of patient case notes); Care Quality Commission standards; National Institute for Health and Excellence guidance (in all its forms). 12 Page Chapter Six Audit Programme

17 17. The annual work that the Team supports must also take into consideration each of the following areas: the development of the Business Groups within the Trust, particularly in respect of those clinical staff who work in a community setting or outside of an acute hospital setting; the appraisal and revalidation of consultants and other doctors, together with enabling all clinicians to comply with their professional codes of conduct; service user involvement; national initiatives, including Quality Accounts, Commissioning for Quality and Innovation (CQUINS), Patient Reported Outcome Measures (PROMS) which some teams will be coordinating work for as part of their clinical audit function. the annual Statement of Internal Control for the Trust (the contribution of clinical audit to the process by which an organisation gains assurances about the quality of its services and the effective management of risk). 13 Page Chapter Six Audit Programme

18 Appendix A: References and Acknowledgements References The following documents, publications and / or websites have been referenced in this Strategy: 1. Scally G, Donaldson LJ. governance and the drive for quality improvement in the new NHS in England. BMJ 1998;317: Deighan M, Bullivant J. Integrated Governance Handbook: A Handbook for Executives and Non executives in Healthcare Organisations. London: Department of Health; National Institute for Excellence. Principles for Best Practice in Audit. Abingdon: Radcliffe Medical Press; 2002, p The National Confidential Enquiry into Patient Outcome and Death ( the Confidential Inquiry into Maternal and Child Health (CEMACH) ( and the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (CISH) ( /nci). Acknowledgements The strategies of the following organisations were reviewed as part of the development of this Strategy: Healthcare Quality Improvement Programme (HQIP) Dartford and Gravesham NHS Trust NHS Plymouth NHS Sheffield Salisbury NHS Foundation Trust South Devon Healthcare NHS Foundation Trust Taunton and Somerset NHS Foundation Trust University Hospitals Coventry and Warwickshire NHS Trust 14 Page Appendix A References

19 [Page Left Deliberately Blank]

20 East Cheshire NHS Trust Trust Headquarters Macclesfield District General Hospital Victoria Road Macclesfield Cheshire SK10 3BL Copyright East Cheshire NHS Trust, 2011