CLINICAL AUDIT POLICY - Sfh-tr.nhs.uk
CLINICAL AUDIT POLICYPOLICYReferenceGV/003Approving BodyDate ApprovedIssue DateVersionSummary of Changes fromPrevious VersionSupersedesPatient Safety and Quality Group9th October 2019January 2020V2Entire RevisionDocument CategoryConsultation UndertakenCorporateClinical Audit and Effectiveness GroupDivisional Governance Groups30th September 2019Date of Completion of EqualityImpact AssessmentDate of Environmental ImpactAssessment (if applicable)Legal and/or AccreditationImplicationsV130th September 2019Not applicableTarget AudienceAll staff undertaking Clinical AuditReview DateNovember 2021Sponsor (Position)Director of Culture and ImprovementAuthor (Position & Name)Trust Lead for Clinical AuditLead Division/ DirectorateCorporateLead Specialty/ Service/DepartmentPosition of Person able to provideFurther Guidance/InformationCulture and ImprovementClinical Audit Policy – V1Associate Director of Service ImprovementA summary of the information or guidance that hasbeen used to develop the policy is as follows: Healthcare Quality Improvement Partnership(HQIP) – www.hqip.co.uk New Principles of Best Practice in Clinical Audit– 2011 Robin Burgess Data Protection Act (1998) HMSO Caldicott Report (1997). Department of Health GDPR May 2019January 2020Page 1 of 26
Associated Documents/ InformationDateAssociatedDocuments/Informationwas 32.0POLICY STATEMENT43.0DEFINITIONS/ ABBREVIATIONS54.0ROLES AND RESPONSIBILITIES65.0SCOPE OF POLICY86.0APPROVAL87.0DOCUMENT REQUIREMENTS98.0MONITORING COMPLIANCE AND EFFECTIVENESS189.0TRAINING AND N1912.0IMPACT ASSESSMENT2213.0EVIDENCE BASE (Relevant Legislation/National Guidance) 23AND RELATED SFHFT DOCUMENTSAPPENDICES2314.0APPENDICIESAppendix IFlow Diagram of Clinical Audit Process24Appendix IIEquality Impact Assessment25Clinical Audit Policy V1January 2020Page 2 of 26
1INTRODUCTIONThis policy is issued and maintained currently by the Medical Director, and from 2020 bythe Director of Culture and Improvement on behalf of the Trust, and supersedes andreplaces the previous Clinical Audit Policy from 2017.The policy sets out Clinical Audit work-streams within Sherwood Forest Hospitals NHSFoundation Trust (the Trust) and the way in which they are implemented and monitored.This Clinical Audit Policy gives staff within the Trust comprehensive guidance in relation toall Clinical Audit activity.This policy describes the practice required for all stages of the Clinical Audit process, withthe aim of ensuring that Clinical Audits are undertaken in a robust and systematic mannerand provides specific information in relation to the following:1. How the Trust sets priorities for audit, including ensuring that both local and nationalrequirements are met2. How audits should be conducted in line with the approved Clinical Audit process3. Information about how audits are shared4. How national confidential enquires are managed5. The format for audit reports, including methodology, conclusions and action plans,etc6. How the Trust make improvements as a result of audits7. How risks and shortfalls are managed and addressed8. How the Trust monitors actions plans and carries out re-audits9. How the Trust monitors the documented process and monitors compliance with all ofthe above10. The roles and responsibilities of staff across the Trust including Specialty ClinicalAudit Leads.The specific purpose of this policy is to set out the framework for the conduct of ClinicalAudit within the Trust. It provides standards and guidance for all staff participating inClinical Audit activities; which includes the Trust’s procedures and expectations forregistering and approving Clinical Audit project proposals and for developing anddesigning Clinical Audit projects.When carried out in accordance with best practice standards, Clinical Audit: provides assurance of compliance with clinical standards; identifies and minimises risk, waste and inefficiencies; improves the quality of care and patient outcomes.The importance which the Department of Health (DH) and healthcare regulators attach toeffective Clinical Audit is shown by the extent to which participation in national and localClinical Audit is now a statutory and contractual requirement for healthcare providers.Clinical Audit Policy – V1January 2020Page 3 of 26
In addition to this contractual requirement, the regulatory framework operated by the CareQuality Commission (CQC) requires registered healthcare providers to regularly assessand monitor the quality of the services provided. They must use the findings from clinicaland other audits, including those undertaken at a national level, and national servicereviews to ensure that action is taken to protect people who use services from risksassociated with unsafe care, treatment and support. They must also ensure thathealthcare professionals are enabled to participate in Clinical Audit in order to satisfy thedemands of the relevant professional bodies.The Board is required by NHS Improvement to certify that they have effectivearrangements in place for the purpose of monitoring and continually improving the qualityof healthcare provided to patients, and must therefore ensure they have in place systems,processes and procedures to monitor, audit and improve quality.2POLICY STATEMENTThe purpose of this policy is to set out a framework for the conduct of Clinical Audit withinthe Trust. It provides standards and guidance for all staff participating in Clinical Auditactivities. It includes the Trust’s procedures and expectations: For registering and approving Clinical Audit project proposals For developing and designing Clinical Audit projectsIt sets out the support that is available from the Improvement and Audit team. All ClinicalAudit activity undertaken in the Trust must comply with the requirements of this policy.The purpose of this Clinical Audit Policy is to maintain and support a culture of bestpractice in the management and delivery of Clinical Audit within the Trust. The policyclarifies the roles and responsibilities of all staff engaged in Clinical Audit activities.The Trust will ensure that Clinical Audit is recognised as an effective mechanism forimproving the quality of patient care within the context of organisational strategicgovernance at Board level. The Trust Board has a role in driving quality assurance,compliance and continuous improvement and Clinical Audit seeks to ‘close this loop’.The Trust supports the view that whilst Clinical Audit and participation in NationalConfidential Enquiries into Patient Outcomes and Death (also known as NCEPOD) isfundamentally a quality improvement process, it also plays an important role in providingassurances about the quality of services and patient care. Clinical Audit has beenendorsed by the DH in strategic documents as a significant way in which the quality ofclinical care can be measured and improved. This policy also applies when Clinical Auditis undertaken jointly across organisational boundaries. This may involve working withother NHS Trusts or healthcare providers.Clinical Audit PolicyJanuary 2020Page 4 of 26
Objectives1. To develop Clinical Audit so that every activity can be linked to improving patient care(and sustaining these improvements).2. To develop the Clinical Audit support provided to a level where excellent practice iscommonplace.3. To adhere to the principles of Healthcare Quality Improvement Partnership (HQIP) andensure that the Trust’s Clinical Audit processes meet the requirements of “HQIP’s NewPrinciples of Best Practice in Clinical Audit”.4. To overcome barriers to participation in Clinical Audit by providing appropriate trainingand support to healthcare professionals at all levels, including the development ofClinical Audit for junior doctors and revalidation.5. To establish a robust system for reporting the outcomes of Clinical Audit activity, and toescalate to the Patient Safety and Quality Group, when required.6. To ensure that the Trust meets regulatory and national requirements includingparticipation in national audits and external best practice.Equality Impact AssessmentThe Trust is committed to ensuring that none of its policies, procedures and guidelinesdiscriminate against individuals directly or indirectly on the basis of gender, colour, race,nationality, ethnic or national origins, age, sexual orientation, marital status, disability,religion, beliefs, political affiliation, trade union membership, and social and employmentstatus.3DEFINITIONSClinical Audit is a quality improvement process that seeks to improve patient care andoutcomes through systematic review against explicit criteria (typically % compliance orachievement) and the subsequent implementation of change. Clinical Audit is aboutmeasuring the quality of care and services against agreed standards and makingimprovements as a result.Additionally, the Trust registers ‘baseline audits’. This is when the service is measuredagainst ‘best practice’ criteria but without a % measurement. The organisation may needto assess where it is in respect of its activity, and to go on to benchmark itself against otherproviders or make improvements as a result.Definitions for specific terms used in the policyThe TrustStaffClinical Audit PolicyMeans the Sherwood Forest Hospitals NHS Foundation Trust.Means all employees of the Trust including those managed by athird party organisation on behalf of the Trust.January 2020Page 5 of 26
CQUINClinical OutcomeReview Programmes(previously NationalConfidential Enquiries)National Clinical Auditsand Patient OutcomeProgramme4Commissioning for Quality and InnovationThe main Clinical Outcome Review Programmes: National Confidential Enquiry into Patient Outcome and Death(NCEPOD) Confidential Enquiry into Suicide and Homicide by People withMental Illness (NCISH) Maternal New-born and Infant Programme (MBRACE) Child Health Programme (CHP) – winter 2014 National Review of Asthma Deaths (NRAD) Children’s Head Injury ProjectThe Healthcare Quality Improvement Partnership (HQIP) hosts thecontract to manage and develop the National Clinical Audit andPatients Outcomes Programme (NCAPOP). Trust participation inNCAPOP audits is mandatory as it forms part of the NHS StandardContract.ROLES AND RESPONSIBILITIESQuality CommitteeThe Quality Committee will receive assurance, via the Patient Safety and Quality Group,that Clinical Audit systems and process are properly governed and monitored.Patient Safety and Quality GroupThe Patient Safety and Quality Group (PSQG) will receive monthly information, updatesand reports from Divisions on audit activities, and will receive quarterly reports from theTrust Clinical Audit Lead on Trust-wide themes and progress.Clinical Audit and Effectiveness GroupThe Clinical Audit and Effectiveness Group (CA&EG) will be re-named the ‘Improvementand Clinical Audit Group’ and its purpose will be to provide a forum to share good practicein Improvement and Audit (including regular reports and presentations on the outcomes ofClinical Audit and NCEPOD) and to collectively improve key themes that emerge. Thisgroup will also review, and ensure the dissemination of any policy related to Clinical Audit.The future focus of the group will be on improvement, and shared learning from projectsundertaken across the Trust.The group will receive regular reports and presentations of the outcomes of Clinical Auditand NCEPOD.Clinical Audit PolicyJanuary 2020Page 6 of 26
Divisional and Specialty Governance MeetingsTrust Divisions and Specialties should take responsibility for reviewing the appropriatenessof all Clinical Audits, and ensures that the Trust is participating in all it mandatory nationalaudits and NCEPOD studies. Each Clinical Audit registration should be assessed by theDivision / Specialty at their Governance meetings under the agenda item ‘Clinical Audit’.The minutes of these meetings will show evidence that the audit has been considered andwhether the Clinical Audit project is viable and worthwhile. The meetings will keep a log ofall Clinical Audit activity and will monitor each stage of the audit; data collection, reporting,action planning and more importantly changes required as a result of the audit to improvepatient care. The Divisional / Specialty meetings will also take full responsibility forreviewing their national audit / local audit / NCEPOD compliance and ensuring that auditsare undertaken within the outlined timescales and that they can evidence learning as aresult of every audit activity undertaken.Chair of Clinical Audit and Effectiveness Group/ Improvement and Clinical AuditGroupThe Chair of the CA&EG/ Improvement & Clinical Audit Group’ will: Coordinate and monitor the Trust-wide rolling programme for Clinical Audit and ensurethat any exceptions are escalated to the Patient Safety and Quality Group. Receive appropriate reports, as specified in the ICAG Terms of Reference, and shareaudit outcomes and associated risks. Ensure that there is a Trust-wide process to monitor progress against standards, and toidentify Trust-wide opportunities for improvement activities.Clinical Audit StaffingThe Clinical Audit staff provide central support, training and advice to enable clinical staffto undertake relevant and effective Clinical Audits on behalf of the Trust. This includes: Taking responsibility for the day-to-day processing of Clinical Audits, advice andguidance on registration, management of the current audit system and providingreports on participation on local Clinical AuditsEscalating issues of risk and participation, supporting clinicians in gap analysis andaction planning, and reporting appropriately on issues of compliance.Providing an effective Trust-wide knowledge platform to capture that the ClinicalAudit cycle loop is closed and that the Trust can demonstrate how practice haschanged and improved patient care as a result of Clinical Audit and improvement.Specialty Clinical Audit LeadsEach clinical Specialty will have a named Speciality Clinical Audit Lead, nominated by theService Lead. The key tasks of the speciality audit leads are:Clinical Audit PolicyJanuary 2020Page 7 of 26
To ensure that their services have comprehensive and effective Clinical Audit plans inplace.To report progress of all Clinical Audits within their area against agreedtimescales/standards.To monitor the quality and consistency of final audit submissions and action plans.To ensure that Clinical Audits are discussed and results presented at regular meetingsfor the Division / Specialty. This could be at a dedicated Clinical Audit meeting or partof a wider meeting, such as clinical governance forums.To facilitate, along with the Clinical Audit Sponsors, feedback, discussion,implementation of change and service developments/improvements (through businessplans and the link to Divisional risk registers) as and when the need is identified viaClinical Audit reports.Clinical Audit Lead the person submitting the registration and undertaking the audit To seek approval for individual Clinical Audits from the specialty Clinical Governancemeetings, prior to registering a formal request. If approved, submit details of proposedaudits, using the Trusts Clinical Audit registration process. Provide a valid data collection form with their audit registration submission. Once approval has been given within the registration process, undertake data collectionfor the audit via the current Audit system. The Clinical Audit Lead is responsible forensuring the security and confidentiality of Clinical Audit data. Ensure that the audit project is completed to the reporting and action plan stage,including SMART action planning (specific, measureable, achievable, realistic,timebound) using the templates provided by the Clinical Audit team. Share Clinical Audit results with relevant peer groups via the appropriate Specialtygovernance arrangements, or where applicable, higher level Trust wide committees Submit a copy of the final Clinical Audit report to the Clinical Audit & Improvement team,using the Trust Audit templates. The Clinical Audit status will only be formally completed once all of these steps havebeen followed, and ‘proof of completion’ has been provided. This includes havingSMART action plans in place.Clinical Audit Sponsor the Senior Manager or Consultant authorising the projectundertaken by the Clinical Audit Lead on behalf of the clinical area/ speciality: To ensure that the Clinical Audit project has clear objectives, and has an achievabletime scale. To ensure that the Clinical Audit is completed and that the Audit Lead disseminatesand presents findings to appropriate staff groups / meetings as well as to the Audit andImprovement team. In the event of a Clinical Audit Lead leaving their post before a project is completed, theSponsor will allocated the project to another member of staff for completion. Following the completion of a Clinical Audit, they will ensure that structures are in placeClinical Audit PolicyJanuary 2020Page 8 of 26
5to ensure any actions are reviewed and progressed, and that further audit cycles areplanned according to the findings.For audits where training of junior staff is an important component, the Clinical AuditSponsor may wish to include the Clinical Audit Lead in the action planning stage.However, the responsibility for developing and implementing action plans lies with boththe Clinical Audit Lead and the Audit Sponsor.SCOPE OF POLICYThis document will apply to all staff employed by the Trust and to any non-employed staff,including students and trainees in any discipline and patients, carers, volunteers andmembers of the public, undertaking Clinical Audits on behalf of the Trust / Divisions /Specialties. Those non-employed staff will have to apply for an honorary contract for theduration of the Clinical Audit and as such, will be subject to the same data protection,confidentiality and ethical standards as Trust staff. A senior member of clinical staff withinthe area wishing the non-employed staff to undertake the audit will have to undertakeclinical supervision of the non-employed person.6APPROVALA formal process for consultation and approval is required for both the initial productionand subsequent reviews of this policy. The following individuals and Trust groups /committees have been consulted in the review and update for this policy: Divisional Clinical Governance Meetings: October 2019 Clinical Audit and Effectiveness Group – October 2019 Patient Safety and Quality Group – October 20197DOCUMENT REQUIREMENTSAgreeing the programme of activityThe Trust Lead for Clinical Audit will take responsibility to ensure that, through the ClinicalAudit Team, all areas of Clinical Audit activity is monitored, either via the rolling audit planor another mechanism.The Trust operates a rolling audit programme. This means that the audit plan is flexible toincorporate audits that are registered at any point throughout the year. As a result, theClinical Audit plan will not remain static.Prior to the start of every financial year, the Trust will agree the appropriate ‘known about’planned programme of Clinical Audit activity. This will include: Eligible National Clinical Audits NCEPOD studies Trust wide Clinical AuditsClinical Audit PolicyJanuary 2020Page 9 of 26
Anything that has been rolled over from the previous year (as it is still in progress)Topics selection and prioritisationPrioritisation: Clinical Audit projects should contribute to the overall priorities of theorganisation and be clear about how patient care will be improved. However, as resourcesare finite; both in terms of clinician time and central support function, this places a limit onthe number of Clinical Audits that can be carried out over the course of a year andtherefore some degree of prioritisation is necessary. The rationale behind prio
Clinical Audit Policy January 2020 Page 5 of 26 Objectives 1. To develop Clinical Audit so that every activity can be linked to improving patient care (and sustaining these improvements). 2. To develop the Clinical Audit support provid
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