CLINICAL AUDIT STRATEGY

St Helens & Knowsley Teaching Hospitals NHS Trust CLINICAL AUDIT STRATEGY Recommending Committee: Approving Committee: Signature: Designation: Clinical Standards and Patient Focus Council Trust Governance Board. Chair of Council Version Number: 02 Date: February 2008 Review Date: January 2011 Responsible Officer: Research & Development/Clinical Audit Manager

Contents Purpose and Scope 2 Page Aim of Strategy 2 Background and Context 2 Strategic Objectives 3 Conclusion 4 References 5 Related Guidance 5 Appendices A Audit Facilitators Committee Terms of Reference 6 B Audit Weighting Criteria 8 C Process for Registration / Support of Audit Projects 9 D Health Care Commission Criteria/Standards 10 Page 2 of 10

1. Purpose and Scope 1.1 This document sets out the Trust Strategy for Clinical Audit to ensure the provision of high quality, clinically effective care in line with the Government agenda for Health Service Reform and the Governance Framework. 1.2 The Strategy outlines how the Trust will maximise and co-ordinate the use of resources to ensure that key priorities and organisational objectives are identified, communicated and met within the context of a large District General Hospital, working in partnership with other agencies to improve health care across the whole health community in a modernised NHS. 2. Aim of Strategy 2.1 To ensure that the strategic direction of clinical audit within the Trust is robust, effective and links with governance and risk management strategies to provide assurance on the governance aspects of internal audit. 2.2 To assure the Trust Board that systems are in place to develop an audit programme within a quality framework that ensures projects are safe, ethical, of high scientific quality and meet organisational needs for robust information on which to base decisions and improve services. 2.3 To ensure that systems are in place to identify and report emerging priorities from robust local information to the Trust Board for appropriate action. 3. Background and Context 3.1 Clinical audit is 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 specific criteria. Where indicated, changes are implemented at an individual, team or service level and further monitoring is used to confirm improvement in health care delivery. 2 3.2 Clinical audit is an essential pillar of clinical governance and integral to the core business of the organisation. This strategy is written in the context of the Trust commitment to the underlying principles, both implicit and 1, 2, 3 explicit, in the Government Strategic Direction for Health Reform. 3.3 A crucial element of clinical governance is the ability to detect, analyse and learn from relevant experiences. This is facilitated through an effective audit programme, integrated with Research and Development, to ensure access to and dissemination of evidence based information. Page 3 of 10

3.4 It is recognised that performance targets are an important component of a fully integrated clinical audit programme to assess the quality and safety of patient care using appropriate review criteria. If desirable performance measures are set according to appropriate criteria, the attainment of these targets should result in improved care. In contrast if quality of care is assessed against inappropriate criteria, attainment of targets may not effect any improvement in care and resources may be wasted in ineffective quality improvement activities. 7 3.5 The Trust is a major provider of health care with an overall budget of 191 million with just under a 1000 inpatient beds. Services are provided on two sites, Whiston Hospital and St Helens Hospital. Funding to directly support clinical audit activity is provided by the Strategic Health Authority via Knowsley PCT. 3.6 The Trust has robust systems and processes in place to support and manage high quality clinical audit. The Audit Facilitators Committee (Appendix A) reports to the Governance Clinical Standards and Patient Focus Council and Trust Governance Board to ensure that key priorities and organisational objectives are identified and communicated appropriately, providing a two-way forum for discussion and forward planning of corporate and multi-professional clinical audit activity. 3.7 The process for the registration and approval of clinical audit projects is shown in Appendix B and priority weighting criteria in Appendix C. 3.8 The Trust has demonstrated year on year improvements in the quality and impact of clinical audit. Further information on audit activity and the use of resources is available in more detail in the Trust Clinical Audit Annual Report. 4. Strategic Objectives 4.1 The Trust will continue to develop a comprehensive clinical audit programme and Trust Annual Audit Plan to facilitate clinically effective care and the information requirements for good governance and the provision of evidence in support of the Trust position against national quality and risk management standards 1, 2, 4, 5. 4.2 The Clinical Audit Annual Plan will support assessment of compliance with existing, new and emerging National Service Frameworks, NICE guidance and facilitate Trust achievement against the five NHSLA standards, Governance, Competent and Capable Workforce, Safe Environment, Clinical Care and Learning from Experience. 4.3 Develop and consolidate collaborations with information and health communities to fulfil the requirement for all Trusts to participate in both local and national specialty and sub specialty clinical audit providing comparative risk adjusted clinical audit data on the quality of clinical services 6. Page 4 of 10

4.4 Ensure that systems are in place to monitor, record and quality control all clinical audit activity, providing central skilled support from the Clinical Governance Audit and Research Resource Department (C-GARRD) in the planning and conducting of clinical audit projects, dissemination of the outcome and impact on practice. 4.5 Ensure optimum use of resources to support clinical audit including the provision of training and skills-sharing through workshops delivered by C- GARRD to promote capability and capacity building, enabling staff to evaluate their practice. 4.6 Ensure that communication processes are robust and transparent, demonstrating effective liaison between clinical audit, risk management and complaints and claims management. 4.7 Identify areas of activity for interface audit with primary care or regional/national projects agreed in collaboration with partner organisations. 4.8 Actively promote user involvement in all aspects of clinical audit activity in liaison with the Trust Patient and Public Involvement Officer and Patient Advice and Liaison Service. 4.9 The Trust Clinical Audit Annual Plan will reflect the Trusts integrated approach to clinical effectiveness also taking into account the Public Health Strategy and Local Health Improvement Programme. 5. Conclusion 5.1 The Trust Strategic Direction is clearly defined and provides a framework for further development. Systems are in place to facilitate dissemination of best practice and the implementation of changes in practice to improve the quality of care given to patients/clients. 5.2 The Trust has a comprehensive portfolio of clinical audit integrated with research and survey activity and looks forward to further expansion of collaborative working with partner organisations to improve care across the health community. Page 5 of 10

References 1 DOH (2004) Standards for Better Health Health Care Commission 2 DOH (2004) National Standards, Local Action - Health and Social Care Standards and Planning Framework. 3 DOH (2005) Health Reform for England Update and Next Steps 4 NHS (2007) Risk Management Standards for Acute Trusts - NHS Litigation Authority 5 CNST (2007) Clinical Negligence Scheme for Trusts Maternity Risk Management Standards NHSLA 6 NCASP (2007) National Clinical Audit Support Programme NHS Information Centre 7 DOH 2002 Health Technology Assessment (HTA) Programme A study of the methods used to select review criteria for clinical audit HTA 6: 1 Related Guidance NICE (2002) Principles for Best Practice in Clinical Audit WALSHE, K. & SPURGEON, P. (1997) Clinical Audit Assessment Framework Health Services Management Centre (HMSC). University of Birmingham Page 6 of 10

APPENDIX A AUDIT FACILITATORS COMMITTEE - TERMS OF REFERENCE 1. Audit Facilitators are the key champions of clinical audit within the Care Groups and clinical specialties who network with clinical staff and the Clinical Governance, Audit and Research Resource Department (C-GARRD) to plan, oversee and disseminate the results of completed audit projects. 2. As members of the Committee, Audit Facilitators are accountable for ensuring that Trust wide priorities for clinical audit are identified and put in to an operational Clinical Audit Plan that addresses evidence of effectiveness and monitors the implementation of effective clinical practice. 3. In liaison with C-GARRD, the Committee will formulate The Trust Annual Clinical Audit Plan to facilitate the information requirements for good governance and the provision of evidence of the Trust position against national quality and risk management standards 1 5. The Annual Clinical Audit Plan will include topics of local clinical relevance, evaluation of clinical outcomes and dissemination of findings to promote evidence based care and sharing of best practice across the organisation. 4. Audit Facilitators have a responsibility to liaise with clinical staff and with the support of operational managers within their Care Group/Specialty agree audit priorities and ensure that all audit activity is notified to C-GARRD for central registration and monitoring. 5. C-GARRD will provide central skilled support to staff in conducting approved clinical audit projects that are agreed with the Audit Facilitator and meet required quality criteria 2 6. The Audit Facilitators Committee reports to the Governance Clinical Standards and Patient Focus Council from where issues are raised at Trust Governance Board and then Trust Board. This ensures that key priorities and organisational objectives are identified and communicated appropriately, providing a two-way forum for discussion and forward planning of corporate and multi-professional clinical audit. 7. The Trust Board Lead for clinical audit is the Director of Nursing, Midwifery and Governance, Deputy Chief Executive. 8. Membership includes the Trust Head of Governance and senior clinicians from each Care Group and major sub specialty. 9. Meetings are held quarterly and are considered quorate if there are 50% of members present, including the Chair or Vice Chair and at least one representative from each Care Group. Page 7 of 10

AUDIT FACILITATORS COMMITTEE MEMBERS Dr M Lynch Medical Director (Chair) B Thompson R&D/Audit Manager (Vice Chair) Carole Whewell Head of Governance J Ratcliffe Lead Audit Officer, CGARRD J Feeney Lead Audit Officer, CGARRD J McIlwain Clinical Risk Manager Audit Facilitator Clinical Specialty Care Group Surgical Care Dr A Wong / Dr K Levshankov Anaesthetics Mr S Liew Burns & Plastics Mr A Daud Ear Nose & Throat Mr S Poonawala General Surgery Mr H Hamed / A Edgerton Obstetrics & Gynaecology Mrs L McCloskey Ophthalmology Mr P Mobbs Orthopaedics Mr B K Jha Urology Dr J Ball Ms G Rogers Dr A Elbadri Dr F Andrews Dr J Woods Dr M Al-Jubouri Dr O Harris Ms J Love Ms T Thornton General Medicine Cardiorespiratory Paediatrics Critical Care ED Critical Care ICU/HDU Laboratory Services Radiology Dietetics Pharmacy Medical Care Clinical Support Other personnel may be co-opted on to the Committee as necessary. References 1 Trust Clinical Audit Strategy (2008) 2 Trust Audit Weighting Criteria (2006) Background Footnote: The Audit Facilitators Committee was established in 1994 in response to EL (93) 34, EL (93) 59, of which the key elements were to promote the use of clinical audit as part of the purchasers role in contracting and within 5 years for audit to be largely multidisciplinary as part of a hospital wide quality management programme. Managers must respond to the resource implications of the findings of audit and support a culture of continuous quality improvement across the unit. APPENDIX B Page 8 of 10

AUDIT WEIGHTING CRITERIA A scoring system, based on the criteria below, will be used when selecting projects and allocating support from within C-GARRD. In addition to the existing annual audit plan, the Trust Board will direct individual topics to be audited as an immediate priority as deemed necessary. This may be in response to needs identified from performance monitoring against the Trust governance assurance measures or other key information. Where the audit agenda is full and resources limited, the projects identified by the Trust board will take precedence. Where it is necessary to defer audit work the scoring criteria will be applied and projects of low impact/score identified. Decisions to postpone/reject proposals will be discussed with the appropriate Audit Facilitator. A good audit proposal will have a number of the following characteristics: Assess compliance with: - National Service Frameworks National Institute for Clinical Excellence (NICE) Guidelines Recommendations/Actions from the National Confidential Enquiries Address an area of high volume/high risk/high cost/high resource use Address a known quality issue Address an area of clinical consensus/certainty Have an achievable objective Involve audit of the clinical lead s own practice Relate to St Helens & Knowsley Health Improvement Programme in secondary (acute) care or in collaboration with primary/social care as interface audit. Be multi-professional Comply with commissioner quality specifications Be well planned from the outset within a clear, agreed time-scale. AUDIT ASSESSMENT FRAMEWORK (HSMC 1997) REASONS for audit: are they clear? Have they been critically examined? Does the audit take into account the above characteristics? Has the audit topic been discussed and agreed with the clinicians involved? IMPACT of the audit: will it result in agreed action plan - improvement in health care process, structure or outcome, change in culture or quality of environment? COSTS of audit: in staff time, consequences of resulting change. USE OF EVIDENCE to underpin the investigation: literature search, expert opinion. PROJECT MANAGEMENT: team identified, planned time scale, record of progress. Emphasis has now moved from the number crunching exercises of the past to assessment of the overall quality of care, efficiency and effectiveness of services. Ratified by Governance Standards & Patient Focus Council 2006 APPENDIX C C-GARRD Page 9 of 10

Process Flow Chart for Registration and Accessing Support of Audit Projects Audit Proposal completed by Clinician Screened against Corporate / Directorate priorities Agreed by Facilitator (Signature essential See Page 5) Proposal sent to C-GARRD Initial proposal review in the 1st + 3rd week of the month. Reviewed against Audit Weighting Criteria. IF ACCEPTED Lead Audit Officer agrees allocation of project to Audit Officers: All aspects discussed with audit officer Project is transferred to main audit projects board Audit Officer initiates Practical Planning Meeting with clinicians To be discussed / agreed on Planning Log Sheet: Audit tool / Time scales / Resources required If applicable: Location of notes incl. Location Code on CFL & personnel designated to receive and dispatch notes. Lead Clinician to liaise directly with assigned Audit Officer from this point. NB: Clinical input is essential and meetings should be agreed in advance when possible. Provisional time-scales should be amended if necessary. Any potential changes to presentation dates should be notified to audit facilitators and lead audit officer. Following presentation: - Feedback sheet is to be completed by the presenting clinician/team and returned to C-GARRD. The Audit Officer will supply the form. Final Report to Audit Facilitator and Clinical Directors (Lead clinician in conjunction with audit officer). APPENDIX D Page 10 of 10

Health Care Commission Criteria for Assessing Core Standards Second domain: Clinical and cost effectiveness Domain outcome: patients achieve healthcare benefits that meet their individual needs through healthcare decisions and services, based on what assessed research evidence has shown provides effective clinical outcomes. Core standard C5 Healthcare organisations ensure that: a) They conform to National Institute for Health and Clinical Excellence (NICE) technology appraisals and, where it is available, take into account nationally agreed guidance when planning and delivering treatment and care. b) Clinical care and treatment are carried out under supervision and leadership. c) Clinicians * continuously update skills and techniques relevant to their clinical work. d) Clinicians participate in regular clinical audit and reviews of clinical services. Elements 1. The healthcare organisation conforms to NICE technology appraisals where relevant to its service. 2. The healthcare organisation can demonstrate how it takes into account nationally agreed best practice as defined in national service frameworks (NSFs), NICE clinical guidelines, national plans and nationally agreed guidance, when delivering services, care and treatment 1. Appropriate supervision and clinical leadership is provided to staff involved in delivering clinical care and treatment in accordance with guidance from relevant professional bodies 1. Clinicians from all disciplines participate in activities to update the skills and techniques relevant to their clinical work. 1. Clinicians are involved in prioritising, conducting, reporting and acting on clinical audits. 2. Clinicians participate in reviewing the effectiveness of clinical services through evaluation, audit or research * Professionally qualified staff providing care to patients Page 11 of 10