Policy: Clinical Audit

Transcription

1 Policy: Exec Director lead Author/ lead Feedback on implementation to Exec Medical Director Associate Medical Director for Quality and Governance Head of Integrated Governance Date of draft December 2015 Consultation period December 2015 February 2016 Date of ratification 11 February 2016 Ratified by Executive Directors Group Date for review April 2017 Target audience Directors and Senior Clinical Staff for Cascade This is Version 2 of the Policy reflecting changes in local and national guidance and practice. Original policy drafted March 2011, reviewed in March 2013 and in March This policy will require on-going review and modification in 2016/17 to reflect the Trust s developing governance structures and new services The policy is available through the Trust Intranet and website Policy Page 1 of 19

2 Contents: Section Page Flowchart 1 Introduction 4 2 Definitions 5 3 Purpose of this policy 6 4 Duties 6 5 Scope of this policy 7 6 Specific details Setting priorities for the annual clinical audit programme Developing the clinical audit programme Ensuring appropriate standards of performance are audited and 8 data quality is good 6.4 Registering audit projects Format for audit reports Dissemination of audit results and reports Process for making improvements Monitoring action plans and carrying out re-audits Reporting and monitoring the clinical audit process 12 7 Dissemination, storage and archiving 12 8 Training and other resource implications for this policy 13 9 Audit, monitoring and review Implementation plan Links to other policies, standards and legislation Key Contacts References 16 Appendix A Equality impact assessment form 17 Appendix B Human rights act assessment checklist 18 Appendix C Development and consultation process 19 Policy Page 2 of 19

3 Flowchart Identification of audit topic Application to Register Audit via Audit Registration Portal checks audit registration request against: Priority ( must do ) audit plan (National/NICE/Stakeholder required audit). checks audit request against current audit activity for duplication, YES Is audit topic is duplicating work stream? NO YES Does audit topic meet required (Priority) audit need? NO forwards registration request to appropriate Clinical Director identifying how audit meets required work stream (or may be adapted to meet required work stream) forwards registration request to appropriate Clinical Director identifying audit does not meet required work stream. Clinical Director to consider if audit meets local Ad Hoc work stream 1. Clinical Director agrees audit topic. 2. Clinical Director suggests revisions to audit topic to meet National/Local audit priorities. Topic meets Priority Audit Criteria: 1. Audit Registrant linked to Leads for priority audit (e.g. NICE Implementation Group) by. 2. Audit Activity Commences 3. Clinical Effectiveness Group and Clinical Directorate sent copy of audit outcome (may review action plans) 4. sent copy of audit outcome YES NO Clinical Director declines audit topic Topic meets needs for Directorate local Ad Hoc Audit: Audit Activity Commences 1. Clinical Effectiveness Group and Clinical Directorate sent copy of audit outcome (may review action plans) 2. sent copy of audit outcome Audit Registration declined: 1. Registrant invited to resubmit alternate topic. 2. ensures registrant aware of hot audit topics Policy Page 3 of 19

4 1. Introduction is seen by Sheffield Health and Social Care NHS Foundation Trust (SHSC) as a key process for assessing, improving and assuring the quality of care and treatment. The Quality Improvement and Assurance Strategy 2015 describes the Trust s vision, systems and processes for quality and how clinical audit fits in. Clinical audit is an integral part of performance management, assessing the effectiveness and delivery of treatments or the quality of care. It is a key source of assurance for the Board and forms a key part of the of the Trust s Quality Framework (available on the Trust website Clinical staff are expected to take part in clinical audits as part of their professional practice; for medical practitioners this is a requirement of their post and a core part of their training. Support for clinical audit is provided by the Integrated Governance Department. The Trust is commissioned by Sheffield CCG to deliver a clinical audit programme annually. It reports to the commissioner quarterly and at year end on the delivery of the programme. A review of clinical audits forms a mandatory element of the Trust s review of quality in its annual Quality Accounts (Quality Accounts toolkit, Department of Health 2010) The Care Quality Commission (CQC) emphasises the patient safety aspects of clinical audit and states that all registered NHS providers will: Use the findings from clinical and other audits, including those undertaken at a national level, and national service reviews, to ensure that action is taken to protect people who use services from the risks associated with unsafe care, treatment and support. (Essential Standards of Quality and Safety; Outcome 16; Assessing and monitoring the quality of service provision (CQC 2010). The Trust has an agreed annual process for prioritising topics in relation to clinical audit. This includes both national and local audits and is in line with Healthcare Quality Improvement Partnership guidance (2012) that annual audit plans should prioritise (required) National Audits and local audits from stakeholders (e.g. CCG and CQC) over local ad hoc audit. The Trust collaborates with partner organisations in the local health and social care community to deliver audits of care pathways which cut across organisational boundaries. This policy describes the clinical audit process in the Trust including: The clinical audit cycle Setting priorities for the annual clinical audit programme Developing the annual clinical audit programme Ensuring appropriate standards of performance are selected for audit and data quality is good Registering audit projects The format for audit reports Data quality in clinical audit Processes for making improvements Monitoring actions plans and carrying out re-audits Reporting and monitoring of the clinical audit process Staff training and development in clinical audit Policy Page 4 of 19

5 2. Definitions 2.1. Clinical audit Clinical audit is defined as systematically looking at the procedures used for diagnosis, care and treatment, examining how associated resources are used and investigating the effect care has on the outcome and quality of life for the patient (Department of Health, 1993). In simplistic terms, the use of resources and the resulting quality of life for the service user.' In 2009, the Healthcare Quality Improvement Partnership (HQIP) proposed the following: Put more simply: clinical audit is all about measuring the quality of care and services against agreed standards and making improvements where necessary.' (Healthcare Quality Improvement Partnership 2009) Clinical audit should be seen as a three dimensional process comprising of the clinical audit cycle and the audit spiral in which having measured quality or practice our outcomes lead to on-going and measureable (by further audit) outcomes: Diagram 1: The Cycle Observe current practice Implement change Set standards of care Compare practice with standards Diagram 2: The Audit Spiral National clinical audit Policy Page 5 of 19

6 A national clinical audit is a clinical audit which has been set up across Trusts in England and Wales, enabling a large dataset to be created and comparisons to be made between Trusts. Participation in national clinical audits is strongly encouraged by the Department of Health and Monitor: Trusts are expected to report on their participation in national audits in their Annual Quality Accounts (Quality Accounts toolkit 2010.) National clinical audits are designed to improve patient outcomes across a wide range of medical, surgical and mental health conditions. Its purpose is to engage all healthcare professionals across England and Wales in systematic evaluation of their clinical practice against standards and to support and encourage improvement in the quality of treatment and care. Local clinical audit A local audit is a more bottom up audit designed to meet a Trust or directorate priority or as part of a quality improvement initiative in a team or on a ward. Specific or focused local audit may also be requested by stakeholders e.g. CCG The difference between clinical audit and research Research identifies best practice and clinical audit ensures that best practice is being carried out. 3. Purpose of this Policy The purpose of this policy is to set out the Trust s approach to establishing clear structures and processes for clinical audit, to ensure best practice is followed. It describes how clinical audit fits into the Trust s governance and assurance systems and how it helps to improve the quality and safety of care It supports the Trust in achieving a key strategic priority: 4. Duties Quality improvement and system improvement reviews Trust Annual Plan 2015/16 The Chief Executive is ultimately responsible for the quality and safety of services provided by the Trust. The Executive Director for Nursing and Quality has executive responsibility for risk management and patient safety in the Trust and as such has the responsibility for ensuring there are effective systems and processes in place for clinical audit. The Head of Integrated Governance is responsible for co-ordinating the work of the Integrated Governance team and ensuring they provide the support needed for the clinical audit process in the Trust. The and governance team is responsible for developing the annual clinical audit programme and making sure it follows the agreed priorities. They will develop local audit training and provide advice for staff undertaking clinical audits. They set up and run a register of all clinical audit projects in the Trust and will support and direct clinical teams to ensure required audit is prioritised in line with HQIP guidance. They track progress on the clinical audit programme and prompt colleagues who may be falling behind timescales or plans. They produce quarterly progress reports for the Quality Assurance Committee. An Policy Page 6 of 19

7 Annual Report is also produced and this contributes to the Trust s Quality Accounts. Quarterly reports are also sent to the commissioners on clinical audit. The Medical Director, other Executive Directors, Clinical and Service Directors and Professional Heads/Leads are responsible for ensuring that the staff they manage comply with the requirement to lead, participate or contribute information to clinical audits. They must also ensure that, through their governance structures, the results of clinical audits are reviewed and any action required are identified and action taken accordingly. All staff providing health and social care in the Trust are expected to be aware of the clinical audit programme and to contribute to it as appropriate to their job role and as required by their managers and professional bodies. They are expected to learn from the results of clinical audits and make any necessary improvements to their practice that may be required as a result. The Trust Committee with the primary role in overseeing the development and delivery of the clinical audit programme is the Executive Directors Group (EDG). The Executive Directors Group recognise that clinical audits to play a key role in assurance as to the quality of care and treatment provided by the Trust. There is now an Audit Steering Group that monitors clinical audit activity across the Trust. The presentation of clinical audit reports will take place at the Trust Quality Improvement group (QIG). In addition directorates will present and review clinical audits within the directorate and team clinical governance processes. A quarterly report on audit activity is also submitted to the Quality Assurance Committee (QAC). 5. Scope of this Policy within the Trust This is a Trust wide policy which applies to all directorates and services without any exceptions. This policy also applies to staff that work in Sheffield Health and Social Care NHS Foundation Trust services but are not employed by the Trust. Where staff employed by the Trust work in services provided by other organisations, they have a duty to follow the policies of the organisation they are working in, and comply with their process for clinical audits. 6. Specific Details of the Process 6.1 Setting priorities for the annual clinical audit programme. The Trust will participate in both national and local clinical audits, and address both local and national issues and interests. The criteria for selecting priorities for clinical audit in the trust are as follows: 1. All audits must all be relevant to the Trust and to assessing, improving and assuring the quality of care and treatment 2. Audit topics should based on issues that are high risk, high volume or high cost 3. They will fall within the following categories: National Audits list (obtainable from the Healthcare Quality Improvement Partnership (HQIP) on ) Policy Page 7 of 19

8 National Institute for Health and Clinical Excellence (NICE) guidance Audits linked to Care Quality Commission Reviews or Visits, or to recommendations from other regulators Audits linked to serious incidents or complaints (e.g. to provide assurance that an action plan following a serious incident has been implemented and has had the desired impact in improving safety.) Audits linked to the implementation of the Trust s quality objectives and areas for improvement as described in the annual quality accounts or annual plans Audits linked to local directorate business priorities and quality improvement priorities Audits linked to Trust CQUIN programme 6.2 Developing the clinical audit programme The develops a clinical audit programme from the priority areas above, a list of clinical audits given by the Commissioner as part of the contract, and from consultation with each of the clinical directorates. The Commissioner s list will include both national priorities and local priorities for the city. The will meet clinical directorate senior management team members, present the national and Trust must-bedones and review the directorate s improvement priorities, to generate a directorate list of clinical audits. The draft Programme is presented to the Clinical Effectiveness Group. Further consultation may then take place and a final Programme for the year will be approved by the same committee. Once approved, the programme will be disseminated across the Trust using cascade via clinical directorates. It is the responsibility of clinical directorates to manage clinical audit within each directorate. Where audit programmes cross directorates the clinical directors (knowing their local priorities) must liaise to ensure audit programmes are managed in a timely and coherent manner. 6.3 Ensuring appropriate standards of performance are audited and data quality is good Guidance on appropriate standards and data quality can be found in the HQIP publication Guide to Ensuring Data Quality in. By definition, clinical audit involves measuring clinical practice against predetermined standards of best practice. Standards should have validity i.e. they should be capable of giving a true picture of what is being audited. They should have sensitivity i.e. they should pick up problems. They should flag all or almost all cases in the audit for which there is a problem with the quality of care provided and not miss cases where care was poor. The Guide to Ensuring Data Quality in provides further guidance on how to test for validity, sensitivity and specificity of standards. The Guide defines data quality in clinical audit as data that is: accurate available or accessible complete Policy Page 8 of 19

9 fit for purpose relevant reliable timely and valid It provides very useful guidance on the selection of the right cases, finding the right data, ensuring the data collection processes produce reliable data, and how to validate data collection and data collation. Staff are recommended to refer to this document for guidance on these issues. Clinical audit practice must take account of equality and diversity issues. For example, the process for determining the choice of clinical audit projects and the choice of service user samples should not inadvertently discriminate against any groups in society based on age, disability, gender reassignment, marital status and civil partnership, pregnancy and maternity, race, religion and belief, sex, sexual orientation. It is recommended that equality data is collected as part of clinical audits, to determine whether any particular groups of service users are experiencing variations in practice. All clinical audit activity must take account of the Data protection Act (1998) and the Caldicott Principles (2013.) Data should be: adequate, relevant and not excessive accurate processed for limited purposes held securely disposed of securely and not held for longer than necessary Clinical audit activity must comply with the NHS Confidentiality Code of Practice (2003) which states that: Patients must be made aware that the information they give may be recorded, may be shared in order to provide them with care, and may be used to support local clinical audit. It is standard practice for clinical audit reports to be anonymous and confidential i.e. not mentioning the names of service users or clinicians. All clinical audit data must be stored securely, and anonymous and confidential e.g. by use of Insight or NHS numbers rather than names of patients. The Trust has a set of policies relating to information governance, records management, data security, confidentiality etc. They can be found on the Trust website and are listed at the end of this Policy. 6.4 Registering audit projects All clinical audit projects must be registered on the central Register by applying via the survey portal (Audit register). Applications will be reviewed against National, Local required audits and other current audit activity prior to submission to clinical directorates by Policy Page 9 of 19

10 the trusts audit manager. Audit must not commence until written approval is received. The register is kept on a secure electronic database. 6.5 Format for audit reports and action plans Audit reports All clinical audit reports should ideally include the following headings: Title Date Lead Author Name, Job Title, Team, Directorate/Service Collaborators Name, Job Title, Team, Directorate/Service Introduction Standards to be audited Objective Methodology o Description of method used o Data collection (NB a survey is a data collection device and not an audit in its own right) o Data analysis Results (measured against standards) Conclusions Recommendations Action Plan (see below) A number of projects are presented at audit forums therefore it may not always be necessary to have all the above detail in a presentation. Where possible, the report should give a distribution list and say who will be responsible for developing any action plans, and which group or committee will monitor the delivery of the action plan. A copy of the completed (final version including action plans) must be submitted to the who maintains a central record. Action plans Where the results of a clinical audit suggest that practice is below the required standard, an action plan should be produced, implemented and monitored. Action plans must be agreed at directorate level prior to finalisation The action plan should include: Name and date of audit Lead author of audit Name, Job Title, address Author of action plan Name. Job Title, address Person responsible for implementing action plan Name, Job Title, address It should indicate Which team, service or directorate it applies to. Which director is accountable and Which group or committee will be responsible for monitoring delivery The action plan must be SMART i.e. Specific Measurable Achievable Policy Page 10 of 19

11 Resourced Timely The headings for the columns in the action plan should include: Area identified for action Action needed/change to be implemented Lead for action Timescale Progress (to be updated on review of the action plan) Expected outcome The expected outcome is the target for improvement. Staff are encouraged to set specific, measurable success criteria e.g. a 5% improvement in compliance to the standard. The action plan must be copied to the managers and lead clinicians of the teams / services / directorate where it applies. Presentation of audit reports and action plans The presentation and discussion of results is an important part of building commitment to change and changing practice. The person presenting should try to make the presentation clear, accessible and authoritative, being mindful of the target audience. A clinical audit presentation should provide the audience with an account of the design of the audit how the quality of care was measured the results of data collection and analysis what the audit has found conclusions and recommendations what action has been taken or is being planned to address any problems found The presentation should also have an educational and developmental purpose, to remind staff of the expected standards of best practice, and provide an opportunity for reflection on the quality of their own work. Policy Page 11 of 19

12 6.6 Dissemination of audit results and reports Following the completion of a clinical audit project, a copy of the completed audit report will be stored by the to make them readily accessible: The results and reports will also be disseminated through the appropriate meetings, committees or groups e.g. Quality Assurance Committee (QAC) Quality Improvement Group Team governance meetings Directorate governance meetings Forums such as the Inpatient Forum, Recovery Forum A brief summary of some audit findings may be posted on the Trust website (intranet and Internet At a local level, audit reports and results are fed back to team and form an important part of the team governance process. Teams are expected to report back on clinical audit results, findings and any action taken in their local team governance reports. Results of the national clinical audits and key local audits are reported in the Trust s annual Quality Account, which is posted on the Trust website and the NHS choices website. Results are also shared with the Commissioners and partner organisations in the City. 6.7 Process for making improvements The key components for making improvements are: Staff that are having their practice audited should be involved from the very beginning Making sure the results are fed back to the people who need to know the teams whose practice was audited Clinical staff have reported how motivating it can be to see the impact and effectiveness of their work assessed by audits. It is good to be able to celebrate good practice, and it also helps to see if performance is not meeting the expected standards. The more critical feedback can motivate staff to reflect on their practice and seek to make improvements. Seeing the results of a re-audit of a problem area and being able to see the progress made can be extremely motivating for staff, managers and service users. So can seeing the results of your team compared with those of another, similar team. Involving service users and carers, members and governors in the clinical audit improvement process Involving service users and carers can also help to stimulate change. Service users, carers and governors often attend directorate governance events and value the opportunity to see the results of clinical audits, and what changes are taking place as a result. The action plan provides clarity and a focus for change. It also enables the clinical team to monitor progress and whether the actions they are taking are having an impact. Developing a sound action plan and making sure it is implemented, monitored and reviewed is the main process for making improvements after a clinical audit. Policy Page 12 of 19

13 Tools and techniques for service and quality improvement Support is available from a number of sources for staff who want to learn more about quality and service improvement techniques and processes. A number of staff in the Trust have undergone leadership for quality improvement training and can offer advice and support to colleagues. Staff in the Integrated Governance department Directorate can offer advice to teams on Data analysis Presenting results in reports and on posters How to identify key areas for improvement (using Root Cause Analysis, fishbone diagrams, Five Whys etc) How to map and analyse care pathways or service user journeys How to look at things differently and generate creative and different solutions (e.g. Six thinking hats.) 6.8 Monitoring action plans and carrying our re-audits The action plans developed in response to clinical audits must be monitored and updated by the teams or directorates concerned in local governance meetings or groups such as NICE implementation groups. The updated action plans should be copied or ed to the Clinical Audit. There is an expectation that action plans will be updated quarterly. Review and updating of actions plans should consider the impact of the action taken as well as whether the agreed task has been completed. An effective way of doing this is through a repeat audit or re-audit. All national audits and all commissioned clinical audit projects are expected to be re-audited to show improvements in performance against the standards. This is the clinical audit cycle in action. If the results of a local clinical audit show significant and sustained improvement, then teams should consider moving on to another topic. 6.9 Reporting and monitoring the clinical audit process The clinical audit process itself is monitored within the Trust by the Clinical Effectiveness Group which reports to the Executive Directors Group and Quality Assurance Committee. Because the Board sees clinical audit as a key assurance tool to assess the quality of care and treatment and performance against best practice, Board members have played an active role in reviewing and suggesting improvements to the clinical audit process and reports. They scrutinise the programme, the Annual Report and receive quarterly updates of progress on clinical audit projects. The clinical audit process and its outcomes are also monitored by Sheffield CCG. Random audits from the Trust database of audit projects are reviewed by the Commissioner quarterly. 7 Dissemination, storage and archiving Policy Page 13 of 19

14 Dissemination, storage and archiving of clinical audit reports and data is described in Section 6 (above). This policy will be disseminated via the Sheffield Health and Social Care NHS Foundation Trust intranet and be made available to all staff. The Integrated Governance Department is responsible for the storage and dissemination of this policy. The Head of Integrated Governance is responsible for making sure the new policy is inserted on the Trust intranet in the policies section. An All SHSCT staff alert should be sent to all staff telling them of the new policy and where to find it. Clinical and Service Directors are responsible for ensuring that all staff in their directorates are aware of new policies and know where to find them. Additional promotion of the new policy will take place through further publicity such as articles in Sheffield Health and Social Care Trust newsletters. In particular, it will be promoted to targeted staff at meetings where reports are presented e.g. QIG. Many teams have paper policy files or archives for easy reference. It is the responsibility of the team manager to ensure that paper policy files are kept up to date and comprehensive, and that staff are made aware of new or revised policies. Older versions should be destroyed to avoid confusion. It is the responsibility of the team manager to make sure the latest version of a policy is available to all staff in the team. It is the responsibility of the Integrated Governance team to maintain an archive of previous versions of policies, and to make sure that the latest version is the one which is posted on the Trust intranet. They will circulate a list of all Sheffield Health and Social Care Trust policies at least annually to team managers and directors throughout the Trust. 8. Training and other resource implications This policy is designed to describe a process which is already in existence. Training in clinical audit is already provided by the and colleagues both in formal sessions and through informal advice. An e-learning package in clinical audit is available which assesses knowledge of the audit process at the end of the learning session. It is anticipated that these requirements can be met within current resources of available clinicians time and the time of staff in Integrated Governance Department who support the process. 9. Audit, monitoring and review This policy describes a clear process for the audit, monitoring and review of clinical audit reports and the clinical audit process. This includes both internal and external monitoring. Policy Page 14 of 19

15 NHSLA Risk Management Standards - Monitoring Compliance Template Minimum Requirement Process for Monitoring Responsible Individual/ group/ committee Duties Supervision Head of Integrated Governance (HIG) How the organisation sets priorities for audit including local and national requirements Requirements that audits are conducted in line with the approved process for audit How audit reports are shared Format for all audit reports, including methodology, conclusions, action plans etc How the organisation makes improvements How the organisation monitors action plans and carries of re-audits Commissioner and Quality Assurance Committee (QAC) Snap shot check of sample reports Snap shot check of sample reports Snap shot check of sample reports Annual report reviews Annual report reviews this 10. Implementation plan Dissemination, storage and archiving of policy Audit steering group / clinical audit manager Frequency of Monitoring Review of Results process (e.g. who does this?) Responsible Individual/group/ committee for action plan development Yearly HIG HIG HIG Quarterly Commissioner Commissioner QAC Yearly Yearly Yearly Yearly Yearly, QAC, QAC, QAC, QAC, QAC Responsible Individual/group/ committee for action plan monitoring and implementation Commissioner QAC, QAC, QAC, QAC, QAC, QAC Objective Task Lead Responsibility Timescale Post on Trust intranet Head of Integrated January Governance 2016 All SHSC staff alert Chief Operating January Officer/Chief Nurse 2016 Team managers to ensure all staff have All within areas of From access to latest version of this policy, operational January and the previous guidance is removed responsibility 2016 and destroyed Refresh and revise Quality section on website to include new guidance on clinical audits and more links to audit reports from the site Head of Integrated Governance January Links to other policies Policy Page 15 of 19

16 Risk Management Strategy and Policy Trust Quality Framework Trust Annual Plan 2015/16 Policy for Responding to National Confidential Inquiries and Other National Inquiries and Reviews Policy for Implementation of NICE Guidance and other Best Practice Policy for Management of External Agency Visits, Inspections and Accreditation Information Governance Policy Information Quality Assurance Policy Information Sharing Protocol Information Security Policy Interpreting and Translation Policy Records Management Policy Research Strategy 12. Key Contacts (NB Corporate organogram should be checked for current names) Title Chief Executive Medical Director Caldicott Guardian Executive Director for Nursing and Quality Deputy Chief Execs Head of Integrated Governance manager 13. References Clinical audit - A simple guide for NHS Boards and partners (Healthcare Quality Improvement Partnership (HQIP) 2010) Guide to Ensuring Data Quality in (Healthcare Quality Improvement Partnership (HQIP) 2010) Ethics and and Quality Improvement (Healthcare Quality Improvement Partnership (HQIP) 2010) NHSLA Risk Management Standards Standard 2 Criterion 2.1: Quality Accounts toolkit, (Department of Health, 2010) Essential Standards of Quality and Safety (Care Quality Commission, 2010) Data Protection Act (HMSO 1998) Caldicott Report (Caldicott Committee, Department of Health (2013) Policy Page 16 of 19

17 Appendix A Equality Impact Assessment Form To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval. Yes/ Comments 1. Does the policy/guidance affect one group less or more favourably than another on the basis of: Race The Policy includes a guidance on using clinical audit to Ethnic origins (including gypsies and travellers) assess equality Nationality Gender Culture Religion or belief Sexual orientation including lesbian, gay and bisexual people Age Disability - learning disabilities, physical disability, sensory impairment and mental health problems 2. Is there any evidence that some groups are affected differently? 3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? 4. Is the impact of the policy/guidance likely to be negative? 5. If so can the impact be avoided? 6. What alternatives are there to achieving the policy/guidance without the impact? 7. Can we reduce the impact by taking different action? If you have identified a potential discriminatory impact of this procedural document, please refer it to Head of Service User Engagement together with any suggestions as to the action required to avoid/reduce this impact. For advice in respect of answering the above questions, please contact Head of Service User Engagement. Policy Page 17 of 19

18 Appendix B Human Rights Act assessment checklist To enable the Trust to fulfil its obligations to maintaining clinical quality Insert here 1.2 All clinical and governance staff and other groups related to the delivery of quality services 2.1 Will the policy/decision engage anyone s Convention rights? 2.2 YES NO Flowchart exit The Policy describes how confidentiality of staff and service users will be protected NO 3.1 YES YES 3.2 NO 4 The right is a qualified right NO 3.3 YES YES YES NO BUT Get legal advice Policy Page 18 of 19

19 Appendix C Development and consultation process This policy will be updated in line with: NICE Guideline development where the guidance is applicable to SHSCFT National Requirements by NHS oversight organisations Local Requirements as a result of commissioning processes Trust Board and other Trust Executive level requirements Areas of development identified in CQC action plans Policy Page 19 of 19