The National Clinical Effectiveness and Network Marketing Commission (NCEC)

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1 Prioritisation and Quality Assurance Process for National Clinical Audit Consultation Submission Report 8 th September

2 Table of Contents Glossary 1. National Clinical Effectiveness Committee Introduction to consultation on Prioritisation and Quality Assurance Process for National Clinical Audit Themes arising and NCEC responses... 4 Appendix 1 Issues raised beyond the scope of the consultation... 6 Glossary: CSP HIQA HSE NCA NCAGC NCEC NOCA QAVD QA Clinical Strategy and Programmes Health Information and Quality Authority Health Services Executive National Clinical Audit National Clinical Audit Governance Committee National Clinical Effectiveness Committee National Office for Clinical Audit Quality Assurance and Verification Division Quality Assurance 1

3 1. National Clinical Effectiveness Committee The National Clinical Effectiveness Committee (NCEC) is a Ministerial committee established as part of the Patient Safety First Initiative. The NCEC role is to prioritise and quality assure National Clinical Guidelines and National Clinical Audit so as to recommend them to the Minister for Health to become part of a suite of National Clinical Guidelines and National Clinical Audit. NCEC Terms of Reference: 1. Provide strategic leadership for the national clinical effectiveness agenda. 2. Contribute to national patient safety and quality improvement agendas. 3. Publish standards for clinical practice guidance. 4. Publish guidance for National Clinical Guidelines and National Clinical Audit. 5. Prioritise and quality assure National Clinical Guidelines and National Clinical Audit. 6. Commission National Clinical Guidelines and National Clinical Audit. 7. Align National Clinical Guidelines and National Clinical Audit with implementation levers. 8. Report periodically on the implementation and impact of National Clinical Guidelines and the performance of National Clinical Audit. 9. Establish sub-committees for NCEC workstreams. 10. Publish an Annual Report. Information on the NCEC is available at: 2. Introduction to consultation on Prioritisation and Quality Assurance Process for National Clinical Audit The National Clinical Effectiveness Committee (NCEC) in 2015 gave consideration to establishing the processes for prioritisation and quality assurance for National Clinical Audit as per its Terms of Reference. The development of these processes was informed by international literature, Irish requirements, expert advice 1 and NCEC members considerations. The NCEC launched a public consultation on its proposed processes for prioritisation and quality assurance for National Clinical Audit on 22/6/2015, closing on 31/7/2015. This consultation was placed on the Department of Health website and circulated to key stakeholders via the NCEC committee, alerts and reminders to contact lists. A number of twitter notices were also circulated. Thirteen responses were received see Table 1. Respondents were asked to consider four questions in relation to the proposed new National Clinical Audit prioritisation and quality assurance processes. 1 Ms Fiona Cahill & Ms Marina Cronin (NOCA), Dr Edwina Dunne (HSE QAVD), Dr Siobhan Kennelly (HSE CSP), Dr Mairin Ryan (HIQA). 2

4 1. Feedback in relation to the proposed prioritisation streams 2. Feedback in relation to the proposed prioritisation criteria 3. Feedback in relation to the proposed quality assurance criteria 4. Any general or specific feedback on the document This report details the main themes that arose in the consultation submissions. Individual responses are not identifiable in the report. Specific minor issues, such as typographical errors, grammatical changes, suggested modifications in terms or formatting are not included in this report but have been considered in adapting the document. In addition to commenting on the Prioritisation and Quality Assurance for National Clinical Audit Consultation document, some submitters used the opportunity to highlight other issues. While this feedback was beyond the scope of the consultation and is not included in detail in this report it will where appropriate be considered in other NCEC deliberations. Appendix 1 provides a summary related to these issues. Table 1 Responses to NCEC Public Consultation Prioritisation and Quality Assurance of National Clinical Audit Association of Occupational Therapists of Ireland Health Information and Quality Authority Health Services Executive collated by Quality Improvement Division Health Services Executive Health and Wellbeing Division Health Services Executive Quality Assurance and Verification Division Health Services Executive National Diabetes Programme Hospital Pharmacists Association of Ireland Irish Society of Chartered Physiotherapists Nursing and Midwifery Board of Ireland Pharmaceutical Society of Ireland Specialty National Quality Improvement Programmes in Histopathology, GI Endoscopy and Radiology managed by RCPI St Patrick s Mental Health Services University College Dublin Office for the Vice President for Health Affairs Submitters welcomed the opportunity to respond to the consultation and, in the main, were positive about the document. The document is very comprehensive is a very necessary and timely addition to a decision-making process in terms of clinical audit. It is clear, transparent, evidence-based and the framework flows well with the narrative. 3

5 3. Themes arising and NCEC responses 5 main themes emerged as follows: - Theme 1 Clarity and readability of the document - Theme 2 Reviewers for planned processes - Theme 3 Sources of NCA - Theme 4 Using the criteria - Theme 5 Criteria content Theme 1: Clarity and readability of the document The scope of the document should be emphasised. RESPONSE: Remove questions concerning National Clinical Guidelines from Purpose section. Place detail on clinical effectiveness processes of clinical practice guidance and National Clinical Guidelines in appendix. Emphasise that the planned criteria are for prioritisation and quality assurance of National Clinical Audit as per the NCEC s Terms of Reference. Greater clarity in relation to some of the terminology used in the document. RESPONSE: Amendments and further details in the glossary on audit proposal, full audit, NCAGC, horizon scanning Further detail is required in relation to some of the processes and statements, for example: the NCEC will not operationalise NCA at this time the NCEC is not recommending a weighting of criteria for prioritisation Indicative timeframe for completing the various stages. appeals mechanism on decisions. RESPONSE: The NCEC will publish a Framework of Endorsement of National Clinical Audit which will outline its processes and provide further detail and information as appropriate. It should be noted that a developmental approach will be taken as the NCEC progresses its role in National Clinical Audit; such that applicants will be given feedback at each stage in the process and the opportunity to address gaps or deficiencies that reviewers identify when using the published criteria. The Framework of Endorsement of National Clinical Audit will also outline a formal appeals process. Theme 2: Reviewers for planned processes More detail on the selection of external national reviewers for the prioritisation process including the criteria for selection, process for volunteering, access to subject expert if necessary and potential inclusion of international review at prioritisation stage. Consideration of outlining the membership of review teams categorised by role and including academics, consideration of continuity of review by the same team performing prioritisation and quality assurance reviews. RESPONSE: The NCEC considers that international review for prioritisation stage would be heavily dependent on the international individual s knowledge of the Irish context and therefore may be of limited benefit. However, the NCEC considers that, where additional expertise is required, international input to the quality assurance stage would add rigor to the process. The forthcoming Framework of Endorsement of National Clinical Audit will outline NCEC processes in this area and provide further detail and information as appropriate. 4

6 Theme 3: Sources of NCA Regarding the description of sources of National Clinical Audit, some submissions found this clear and sensible; others sought more clarity. Only one Stream 1 audit commissioned per year was viewed as limiting as service providers come under increased regulatory compliance scrutiny. RESPONSE: A visual diagram will be added to assist understanding. NCEC will be added where appropriate to references to commissioning in order to delineate from any other potential commissioners. To aid clarity some rewording will occur in this section and additional text elsewhere: It is intended that not all clinical audit will be submitted for national endorsement Services should to adhere to Standard 2.8 of HIQA s National Standards for Safer Better Healthcare (June 2012) and its relevant clinical audit subsections. Theme 4: Using the criteria Is there a threshold/minimum score? Response: Whilst acknowledging the merit in stating a threshold or minimum score, the NCEC considers that at this stage of development, it is premature to set such a score. The issue will however, be revisited at annual review when processes can be reviewed, amended and updated as the process matures. Submissions showed mixed views on (potential) weighting of criteria. The recommendation for not recommending a weighting was sought; prioritisation criteria 4&5 were viewed as potential criteria to be weighted; Response: Following on from its learning in relation to National Clinical Guidelines, a weighting system was not recommended by NCEC at this stage of criteria development. However, considering these are evolving processes, the issue of weighting will be revisited at annual review which will allow the processes to be reviewed, amended and updated as the process matures. The scoring system example should be fully worked Response: Amended as suggested. Theme 5 Criteria Content Additional yes/no prioritisation criteria on Audit is a recommendation of a major national review/report Response: Not required as Stream 1 would be the pathway for such an audit topic and therefore proceeds directly to NCEC commissioning. This may now be clearer for readers with the diagram. Consider stand-alone criteria on the evidence-base for the standards for measurement at the QA stage Response: Prioritisation Criteria 3 focuses solely on this issue and NCEC commissioning (see 5.2 Stream 1) will ensure evidence-based standards for any Stream 1 clinical audits. Suggest overall question for each of the eight QA criteria with subcategories Response: Amended accordingly. Prioritisation Criteria 2 : Whilst acknowledging that cost-burden is contained in Criteria 5 (Economic Impact), consider adding cost burden to Criteria 2. Response: At this stage of development of the criteria and in order not to confuse reviewers, cost-burden will remain a sub-subsection of Criteria 5 only. Consider broadening Patient dissatisfaction to patient experience. Response: Whilst acknowledging that patient experience may itself warrant audit, the National Patient Experience Survey that is being developed as a partnership between the Department, HIQA and HSE and will be managed by HIQA may precede any audit on this area. 5

7 Prioritisation Criteria 4 : How is variability in practice assessed findings from audits, self assessment? Response: Assessment of variability in practice may draw on a number of sources including existing audit, health management reports, health professional and patient views. It is likely to include a mix of sources. Prioritisation Criteria 7 and QA Criteria 1: Comment that these criteria are very similar and should occur only in prioritisation. Response: Inclusion of these criteria in prioritisation and quality assurance stages is taken from the international literature. As Stream 1 audits go straight to NCEC commissioning, there is a need for certain issues to be reviewed again in the QA part of the process. QA Criteria 8 (from expert advice): Consider inclusion of management regarding uncovering significant patient risk Response: Add The NCAGC develops appropriate escalation protocols and can demonstrate their use to Criteria 2 Governance. QA Criteria 5: Suggest scope and purpose is too narrow add plan Response: Agreed and amended QA Criteria 7: Suggest add an agreed reporting process Suggest add clarity regarding update reports Response: Agreed and added QA Criteria 8: Who is responsible for the implementation of the recommendation of the audit? What happens if they are not addressed sufficiently within a reasonable timeframe? Response: Add with explicit responsibilities assigned to ensure implementation to criterion subcategory. The escalation policies in Criteria 2 Governance should address the second question. Appendix 1 Issues raised beyond the scope of the consultation Use of online tool for reviewers Response: An online reviewer tool is currently in development for NCGs with potential to extend for NCA. Publishing successful audits and the IP of final audit documents. Response: See Term of Reference 8 for NCEC. A statement, similar to that used for NCEC National Clinical Guidelines, will be created and published for National Clinical Audit. Responses did show some confusion regarding audit in the current contextual instability. Queries were raised concerning relationships of various bodies, how clinical audit at national level is currently established/commissioned, specifically how NOCA fits in, how the public can raise issues etc. Response: NCEC will work with other stakeholders to communicate to the health system and public the various functions, roles and relationships for National Clinical Audit as these get bedded down. Support to services regarding compliance particularly with regard to data collection and analysis. Will regulators (HIQA and MHC) use to benchmark services and inspection practice adjust accordingly? Response: Standard 2.8 HIQA (2012) National Standards for Safer Better Healthcare addresses clinical audit. Is NCEC responsible for the standard of audit included in National Clinical Guidelines? Response: In National Clinical Guidelines, the Guideline Development Group suggest which recommendations are suitable for audit purposes at any level, BUT recommendations are not written as clinical standards that must be audited. 6

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