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Peninsula Community Health<br />

<strong>Clinical</strong> <strong>Audit</strong> Policy<br />

Title:<br />

<strong>Clinical</strong> <strong>Audit</strong> Policy<br />

Procedural Document Type:<br />

Policy<br />

Reference:<br />

CGP46<br />

Version:<br />

V1<br />

Ratified by:<br />

CIOS Community Health Services Board<br />

Date ratified: 27 th January 2011<br />

Freedom of Information:<br />

This document can be released<br />

Name of originator/author:<br />

Sally Shipley<br />

Name of responsible team:<br />

Governance<br />

Review Frequency:<br />

3 Years<br />

Review date: 27 th January 2014<br />

Target audience:<br />

All staff<br />

Exec Signature (Hard Copy Only):<br />

V1 Page 1 of 16 6-Aug-12


<strong>Clinical</strong> <strong>Audit</strong> Policy<br />

Contents<br />

1 Introduction ........................................................................................................ 3<br />

2 Definitions .......................................................................................................... 3<br />

3 Equality Impact Assessment .............................................................................. 4<br />

4 Good Corporate Citizen...................................................................................... 5<br />

5 Duties................................................................................................................. 5<br />

6 Commitment to Stakeholder Engagement, Collaboration and Partnership 7<br />

7 Process for Setting Priorities for a <strong>Clinical</strong> <strong>Audit</strong> Programme Including<br />

Participation in National and Local <strong>Audit</strong>s 7<br />

8 Process for Ensuring Appropriate Standards of Performance are <strong>Audit</strong>ed 8<br />

9 Format for All <strong>Clinical</strong> <strong>Audit</strong> Reports 8<br />

10 Process for Disseminating <strong>Audit</strong> Results / Reports 9<br />

11 Process for Making Improvements 9<br />

12 Process for Monitoring Action Plans and Carrying out Re-audits 9<br />

13 Data Protection 9<br />

14 Ethics and Consent 10<br />

15 Training 10<br />

16 Risk Management Strategy Implementation..................................................... 10<br />

16.1 Implementation ................................................................................... 10<br />

16.2 Training and Support .......................................................................... 10<br />

16.3 Dissemination ..................................................................................... 11<br />

16.4 Storing <strong>the</strong> Procedural Document....................................................... 11<br />

17 Process for Monitoring Effective Implementation ............................................. 11<br />

18 Associated Documentation............................................................................... 11<br />

19 References....................................................................................................... 11<br />

Appendix A <strong>Clinical</strong> audit proposal form 13<br />

Appendix B <strong>Clinical</strong> audit report template 15<br />

Please Note <strong>the</strong> Intention of this Document<br />

“This policy provides guidance for all staff participating in clinical audit activities. It includes<br />

<strong>the</strong> organisations procedures and expectations for registering and approving clinical audit<br />

project proposals”.<br />

V1 Page 2 of 16 6-Aug-12


<strong>Clinical</strong> <strong>Audit</strong> Policy<br />

1. Introduction<br />

The expectation for healthcare professionals to participate in regular clinical audit was first<br />

established in <strong>the</strong> 1989 Government White Paper, ‘Working for Patients’. This has been<br />

reinforced and extended by a succession of key national publications, including:<br />

The New NHS — Modern Dependable (Department of Health, 1997)<br />

A First Class Service (Department of Health, 1998)<br />

<strong>Clinical</strong> Governance — Quality in <strong>the</strong> NHS (Department of Health, 1999)<br />

Learning from Bristol: <strong>the</strong> report of <strong>the</strong> public inquiry into children’s heart surgery at<br />

Bristol <strong>Royal</strong> Infirmary 1984–1995 [<strong>the</strong> ‘Kennedy Report’] (Department of Health, 2002)<br />

Good Medical Practice (General Medical Council, 2001)<br />

National Standards, Local Action (Department of Health 2004)<br />

Good Doctors Safer Patients (Department of Health, 2006)<br />

<strong>Trust</strong> Assurance & Safety (Department of Health, 2007)<br />

<br />

The NHS Next Stage Review Final Report, High Quality Care For All [<strong>the</strong> ‘Darzi Report’],<br />

(Department of Health, 2008).<br />

Essential Standards of Quality and Safety (Care Quality Commission, 2009)<br />

Equity and Excellence, Liberating <strong>the</strong> NHS (Department of Health, 2010)<br />

Essential Standards of Quality and Safety outcome 16 states that organisations are required<br />

to regularly assess and monitor <strong>the</strong> quality of <strong>the</strong> services provided.<br />

NHS LA Risk Management Standards: standard 5, criterion 1 has been developed as a pilot<br />

for clinical audit for 2010/11.<br />

Peninsula Community Health expects all qualified health care professionals to participate in<br />

clinical audit as part of a structured programme of work including <strong>the</strong> annual record keeping<br />

audit<br />

The organisation supports <strong>the</strong> view that whilst <strong>Clinical</strong> <strong>Audit</strong> is fundamentally a quality<br />

improvement process, it also plays an important role in providing assurances about <strong>the</strong><br />

quality of services.<br />

2. Definitions<br />

2.1 <strong>Clinical</strong> audit<br />

<strong>Clinical</strong> <strong>Audit</strong> may be defined as “a quality improvement process that seeks to improve<br />

patient care and outcomes through systematic review of care against explicit criteria and<br />

<strong>the</strong> implementation of change. Aspects of <strong>the</strong> structure, processes, and outcomes of<br />

care are selected and systematically evaluated against explicit criteria. Where indicated,<br />

changes are implemented at an individual, team or service level and fur<strong>the</strong>r monitoring is<br />

used to confirm improvement in healthcare delivery”.<br />

V1 Page 3 of 16 6-Aug-12


<strong>Clinical</strong> <strong>Audit</strong> Policy<br />

2.2 Difference between clinical audit and research<br />

<strong>Clinical</strong> audit measures existing practice against evidence-based clinical standards.<br />

Research is about obtaining new knowledge and finding out what treatments are <strong>the</strong><br />

most effective<br />

<strong>Clinical</strong> audit is about quality and finding out if best practice is being practised. Research<br />

tells us what we should be doing. <strong>Clinical</strong> audit tells us whe<strong>the</strong>r we are doing what we<br />

should be doing and how well we are doing it.<br />

2.3 National <strong>Clinical</strong> <strong>Audit</strong> Advisory Group (NCAAG)<br />

The National <strong>Clinical</strong> <strong>Audit</strong> Advisory Group (NCAAG) has been established to drive <strong>the</strong><br />

reinvigoration programme and provide a national focus for discussion and advice on<br />

matters relating to clinical audit. The NCAAG also provides strategic advice and<br />

guidance to <strong>the</strong> Department of Health’s National <strong>Clinical</strong> <strong>Audit</strong> & Patient Outcomes<br />

Programme (NCAPOP), and in particular on proposals for new national clinical audits<br />

and for discontinuing existing ones<br />

2.4 Healthcare Quality Improvement Partnership (HQIP)<br />

The Healthcare Quality Improvement Partnership (HQIP) was established in April 2008<br />

to promote quality in healthcare, and in particular to increase <strong>the</strong> impact that clinical audit<br />

has on healthcare quality in England and Wales. It is led by a consortium of <strong>the</strong><br />

Academy of Medical <strong>Royal</strong> Colleges, <strong>the</strong> <strong>Royal</strong> College of Nursing and National Voices<br />

(formerly <strong>the</strong> Long-term Conditions Alliance).<br />

HQIP is contracted by <strong>the</strong> Department of Health to deliver a programme of activity to<br />

reinvigorate clinical audit<br />

HQIP hosts <strong>the</strong> contract to manage and develop <strong>the</strong> National <strong>Clinical</strong> <strong>Audit</strong> and Patient<br />

Outcome Programme (NCAPOP)<br />

2.5 National <strong>Clinical</strong> <strong>Audit</strong> and Patient Outcome Programme (NCAPOP)<br />

National clinical audit is designed to improve patient outcomes across a wide range of<br />

medical, surgical and mental health conditions. Its purpose is to engage all healthcare<br />

professionals across England and Wales in systematic evaluation of <strong>the</strong>ir clinical practice<br />

against standards and to support and encourage improvement and deliver better<br />

outcomes in <strong>the</strong> quality of treatment and care.<br />

The programme comprises more than 25 clinical audits that cover care provided to<br />

people with a wide range of medical, surgical and mental health conditions and will be<br />

extended to o<strong>the</strong>r areas of healthcare that are considered a priority by <strong>the</strong> National<br />

<strong>Clinical</strong> <strong>Audit</strong> Advisory Group (NCAAG) and <strong>the</strong> Department of Health.<br />

3. Equality Impact Assessment<br />

Peninsula Community Health aims to design and implement services, policies and measures<br />

that meet <strong>the</strong> diverse needs of our service, population and workforce, ensuring that none are<br />

placed at a disadvantage over o<strong>the</strong>rs.<br />

V1 Page 4 of 16 6-Aug-12


<strong>Clinical</strong> <strong>Audit</strong> Policy<br />

As part of its development, this strategy and its impact on equality have been reviewed in<br />

consultation with trade union and o<strong>the</strong>r employee representatives in line with <strong>the</strong> Equality<br />

and Diversity Policy. The purpose of <strong>the</strong> assessment is to minimise and if possible remove<br />

any disproportionate impact on employees on <strong>the</strong> grounds of race sex, disability, age, sexual<br />

orientation or religious belief. No detriment was identified.<br />

The Equality Impact Assessment Tool has been used to help consider <strong>the</strong> needs and assess<br />

<strong>the</strong> impact of this policy and has been completed alongside this document.<br />

4. Good Corporate Citizen<br />

As part of its development, this policy was reviewed in line with <strong>the</strong> Good Corporate Citizen<br />

Action Plan. The implementation of this strategy promotes good governance.<br />

5. Duties<br />

5.1 Chief Executive<br />

The Chief Executive is responsible for <strong>the</strong> statutory duty of quality and takes overall<br />

responsibility for this policy.<br />

5.2 Peninsula Community Health Services Board<br />

The <strong>Cornwall</strong> & Isles of Scilly Community Health Services Board has delegated<br />

overall responsibility for clinical audit to <strong>the</strong> Integrated Governance Committee. The<br />

board will act on <strong>the</strong> recommendations contained in ‘<strong>Clinical</strong> audit: A simple guide for<br />

NHS boards (2009) including <strong>the</strong> Board Engagement Matrix (2010)’ available at<br />

www.hqip.org.uk.<br />

5.3 <strong>Clinical</strong> Quality and Safety Committee<br />

Responsibility for clinical audit has been delegated by <strong>the</strong> board to <strong>the</strong> Integrated<br />

Governance Committee.<br />

The committee is responsible for:<br />

<br />

<br />

<br />

Agreeing <strong>the</strong> organisations priorities for clinical audit<br />

Approving <strong>the</strong> annual clinical audit plan<br />

Ensuring participation in all relevant audits contained in <strong>the</strong> National<br />

<strong>Clinical</strong> <strong>Audit</strong> and Patient Outcome Programme<br />

Ensuring all high contracted clinical audits (CQUINs, quality clinical<br />

audit plan) are undertaken and completed.<br />

Receiving summaries of completed clinical audit projects including<br />

taking appropriate action where necessary<br />

5.4 Director of Nursing and Professional Practice<br />

The Director of Nursing and Professional Practice provides board leadership<br />

for clinical audit<br />

5.5 Senior Managers / Service leads<br />

V1 Page 5 of 16 6-Aug-12


<strong>Clinical</strong> <strong>Audit</strong> Policy<br />

Senior managers and service leads are responsible for:<br />

<br />

Maintaining <strong>the</strong> services local clinical audit programme<br />

Ensuring <strong>the</strong> organisations priorities for clinical audit are met in <strong>the</strong><br />

first instance.<br />

<br />

<br />

<br />

<br />

Approving clinical audit proposals from staff within <strong>the</strong>ir service<br />

Forwarding all clinical audit proposal forms to <strong>the</strong> clinical effectiveness<br />

manager<br />

Ensuring all local clinical audit activity is completed in accordance with<br />

this policy<br />

Ensuring all clinical audit reports are sent to <strong>the</strong> clinical effectiveness<br />

manager<br />

5.6 <strong>Clinical</strong> Effectiveness Manager<br />

The <strong>Clinical</strong> Effectiveness Manager is responsible for:<br />

<br />

Developing, implementing, supporting and monitoring progress of <strong>the</strong><br />

annual clinical audit plan.<br />

Ensuring clinical audit (CQUINs, quality clinical audit plan) targets<br />

contained in <strong>the</strong> Community Health Services contract are included in<br />

<strong>the</strong> clinical audit plan and progress reported via <strong>the</strong> contract<br />

monitoring process<br />

<br />

<br />

<br />

Developing and reviewing Peninsula Community Health clinical audit<br />

policy.<br />

Providing advice and support in all aspect of clinical audit for all staff<br />

employed by Peninsula Community Health s<br />

Providing training in clinical audit including developing suitable<br />

guidance / leaflets and tools taking into account guidance developed<br />

by HQIP<br />

Ensuring PCH are aware of national clinical audit arrangements /<br />

initiatives and relevant clinical audits.<br />

<br />

<br />

Acting as <strong>the</strong> organisations contact point for all national clinical audits<br />

Maintaining systems for co-ordinating all clinical audit activity across<br />

<strong>the</strong> organisation.<br />

5.7 All clinical staff<br />

All staff involved in <strong>the</strong> provision of care, treatment and support for patients<br />

should participate in clinical audit.<br />

All clinical staff undertaking clinical audit must:<br />

<br />

Ensure all clinical audit activity is approved by <strong>the</strong>ir relevant service<br />

lead and registered with <strong>the</strong> <strong>Clinical</strong> Effectiveness Manager.<br />

V1 Page 6 of 16 6-Aug-12


<strong>Clinical</strong> <strong>Audit</strong> Policy<br />

<br />

Undertake clinical audit in accordance with this policy and guidance<br />

obtained from <strong>the</strong> <strong>Clinical</strong> Effectiveness Manager<br />

6. Commitment to Stakeholder Engagement, Collaboration and<br />

Partnership<br />

6.1 Involving Patients and <strong>the</strong> Public<br />

Patients and <strong>the</strong> public are usually involved in clinical audit / quality<br />

improvement initiatives via patient surveys and o<strong>the</strong>r patient experience<br />

methods. Where a patient survey is undertaken to determine whe<strong>the</strong>r clinical<br />

standards are being met, <strong>the</strong> project should be treated as any o<strong>the</strong>r clinical<br />

audit project. If <strong>the</strong> patient survey asks questions about patient satisfaction<br />

and experience <strong>the</strong> project should be registered with <strong>the</strong> <strong>Clinical</strong> Quality and<br />

Patient Experience Manager<br />

6.2 Multi-disciplinary and Multi-professional <strong>Audit</strong>, and Partnership<br />

Working with o<strong>the</strong>r Organisations<br />

The organisation supports collaboration on multi-professional clinical audits of<br />

interest to o<strong>the</strong>r parts of <strong>the</strong> local health economy, both within and outside of<br />

<strong>the</strong> NHS e.g. primary/secondary care, local authorities, social services etc<br />

7. Process for Setting Priorities for a <strong>Clinical</strong> <strong>Audit</strong> Programme<br />

Including Participation in National and Local <strong>Audit</strong>s<br />

Effective <strong>Clinical</strong> <strong>Audit</strong> is not a simple task and <strong>the</strong> pressure of incorporating complex<br />

requirements into an ever increasing workload presents yet ano<strong>the</strong>r demand on clinical time.<br />

It is <strong>the</strong>refore important for Peninsula Community Health to demonstrate a systematic<br />

approach to audit topic selection, taking into account any organisational priorities and new<br />

government initiatives toge<strong>the</strong>r with any local needs. This will ensure time is spent efficiently<br />

by concentrating on well-structured audit projects that produce effective results and<br />

highlights areas of practice requiring change. The aim is to increase audit activity across<br />

Peninsula Community Health and to reduce <strong>the</strong> number of poorly conducted audits that are<br />

often unsupported, carried out under pressure, and on occasions never completed.<br />

The <strong>Clinical</strong> <strong>Audit</strong> Plan will be determined by <strong>the</strong> <strong>Clinical</strong> Quality and Safety Committee<br />

based upon <strong>the</strong> four categories below:<br />

1: External ‘must do’ audits: Failure to participate or deliver on <strong>the</strong>se externally driven<br />

audits may carry a penalty for PCH (ei<strong>the</strong>r financial or in <strong>the</strong> form of a failed target or<br />

non-compliance). These are externally monitored and assessed by <strong>the</strong> CQC and in<br />

some areas by <strong>the</strong> local PCT commissioner.<br />

National <strong>Clinical</strong> <strong>Audit</strong> & Patient Outcome Programme (NCAPOP)<br />

<strong>Audit</strong>s demonstrating compliance with regulation requirements e.g. NICE<br />

guidance, NSFs, NPSA alerts<br />

CQUINS and o<strong>the</strong>r commissioner priorities<br />

<br />

<br />

DH statutory requirements, e.g infection control monitoring<br />

External accreditation schemes, e.g., NHS Litigation Authority (NHSLA),<br />

Information Governance Toolkit (IGT)<br />

2: Internal ‘must do’ audits: Priorities reflective of organisational objectives for clinical<br />

audit as outlined in <strong>the</strong> local clinical audit strategy or strategic objectives<br />

<strong>Clinical</strong> risk issues<br />

V1 Page 7 of 16 6-Aug-12


<strong>Clinical</strong> <strong>Audit</strong> Policy<br />

<br />

<br />

<br />

<br />

<br />

<br />

Serious untoward incidents/adverse incidents<br />

Organisational clinical priorities<br />

Priorities identified via Patient and Public Involvement initiatives<br />

Complaints<br />

Access<br />

Patient Safety First Campaign<br />

3: Business Unit / Service priorities<br />

<br />

<br />

<br />

Local clinical interest audit agreed by business units/services as a priority<br />

National audits not part of NCAPOP, e.g. some <strong>Royal</strong> College initiated projects<br />

that lie outside of NCAPOP<br />

Locally adopted clinical standards benchmarking e.g., Essence of Care<br />

4. Clinician interest<br />

8. Process for Ensuring Appropriate Standards of Performance<br />

are <strong>Audit</strong>ed<br />

All clinical audit activity must be registered with <strong>the</strong> <strong>Clinical</strong> Effectiveness Manager giving<br />

details of <strong>the</strong> guideline / policy / protocol to be audited. This will ensure that projects that do<br />

not measure compliance e.g. patient satisfaction surveys, research, and baseline<br />

assessments are managed by <strong>the</strong> appropriate departments<br />

Guidance developed by <strong>the</strong> <strong>Clinical</strong> Effectiveness Manager will describe how to develop<br />

measurable audit criteria<br />

The <strong>Clinical</strong> Effectiveness Manager is part of <strong>the</strong> consultation process for all procedural<br />

documents to ensure appropriate monitoring arrangements.<br />

9. Format for All <strong>Clinical</strong> <strong>Audit</strong> Reports<br />

All clinical audit reports will follow an agreed format. A template can be found in Appendix B<br />

<br />

<br />

<br />

<br />

<br />

<br />

<br />

<br />

Introduction / Background<br />

Policy / guideline audited<br />

Methodology<br />

Summary / Conclusions<br />

Recommendations<br />

Action plan<br />

Results<br />

Appendices<br />

10. Process for Disseminating <strong>Audit</strong> Results/Reports<br />

All clinical audit reports should be discussed at <strong>the</strong> relevant service team meetings and<br />

circulated to all staff affected by <strong>the</strong> results.<br />

V1 Page 8 of 16 6-Aug-12


<strong>Clinical</strong> <strong>Audit</strong> Policy<br />

A summary will be taken by <strong>the</strong> <strong>Clinical</strong> Effectiveness Manager to <strong>the</strong> <strong>Clinical</strong> Quality and<br />

Safety Committee for information / action. The committee will take appropriate action where<br />

indicated. This could include adding to <strong>the</strong> risk register, requesting a formal response,<br />

attendance at <strong>the</strong> next meeting.<br />

11. Process for Making Improvements<br />

All clinical audit reports must include recommendations and actions before <strong>the</strong> audit can be<br />

classed as ‘final’<br />

Action plans should be specific, measurable and achievable/realistic. They should have clear<br />

implementation timescales with identified leads for action. Action plans should also have<br />

been approved by <strong>the</strong> relevant head of service or department.<br />

A summary of each audit including recommendations and actions will be taken to <strong>the</strong> <strong>Clinical</strong><br />

Quality and Safety Committee by <strong>the</strong> <strong>Clinical</strong> Effectiveness Manager<br />

Final reports will be added to <strong>the</strong> Peninsula Community Health intranet site by <strong>the</strong> <strong>Clinical</strong><br />

Effectiveness Manager.<br />

12. Process for Monitoring Actions Plans and Carrying out Reaudits<br />

Re-audit is important to determine whe<strong>the</strong>r agreed actions have been implemented<br />

according to <strong>the</strong> action plan.<br />

The monitoring of action plans will be undertaken by <strong>the</strong> <strong>Clinical</strong> Quality and Safety<br />

Committee.<br />

The <strong>Clinical</strong> Effectiveness Manager will follow up actions resulting from clinical audit reports<br />

on a 6 monthly basis. Concerns will be taken to <strong>the</strong> <strong>Clinical</strong> Quality and Safety Committee<br />

for action.<br />

Re-audits will be undertaken as required and where indicated by <strong>the</strong> initial results included in<br />

<strong>the</strong> action plan. Advice should be sought from <strong>the</strong> <strong>Clinical</strong> Effectiveness Manager<br />

13. Data Protection<br />

All clinical audit activity must take account of <strong>the</strong> Data Protection Act 1998 and <strong>the</strong> ‘Caldicott<br />

principles’ (Caldicott Committee, 1997). This means, for example, that data should be:<br />

<br />

<br />

<br />

<br />

<br />

adequate, relevant and not excessive<br />

accurate<br />

processed for limited purposes<br />

held securely<br />

not kept for longer than is necessary.<br />

All clinical audit data must be anonymised in accordance with <strong>the</strong> Peninsula Community<br />

Heath Pseudoanonymisation Policy (2010) once <strong>the</strong> patient sample has been identified. Any<br />

records containing patient identifiable data must be destroyed as soon as <strong>the</strong> audit has been<br />

completed.<br />

V1 Page 9 of 16 6-Aug-12


<strong>Clinical</strong> <strong>Audit</strong> Policy<br />

<strong>Clinical</strong> audit records should be stored and retained for a period of 5 years in accordance<br />

with <strong>the</strong> Peninsula Community Health Records Management Policy and Procedure.<br />

The NHS Confidentiality Code of Practice (DH, 2003, p.21) states that “patients must be<br />

made aware that <strong>the</strong> information <strong>the</strong>y give may be recorded, may be shared in order to<br />

provide <strong>the</strong>m with care, and may be used to support local clinical audit”. Peninsula<br />

Community Health makes provision for this in its leaflet entitled ‘Protecting Your Data, How<br />

we use your health records’. This allows patient identifiable data to be collected for clinical<br />

audit purposes as agreed in section 60 of <strong>the</strong> Health and Social Care Act 2001<br />

14. Ethics and Consent<br />

By definition, clinical audit projects should not require formal approval from a Research<br />

Ethics Committee. However one of <strong>the</strong> principles underpinning clinical audit is that <strong>the</strong><br />

process should do good and not do harm. <strong>Clinical</strong> audit must always be conducted within an<br />

ethical framework that considers whe<strong>the</strong>r<br />

<br />

<br />

<br />

<br />

<strong>the</strong>re is a benefit to existing or future patients or o<strong>the</strong>rs that outweighs<br />

potential burdens or risks;<br />

each patient’s right to self-determination is respected;<br />

each patient’s privacy and confidentiality are preserved;<br />

<strong>the</strong> activity is fairly distributed across patient groups.<br />

15. Training<br />

All clinical staff should be involved in clinical audit activities in order to develop <strong>the</strong>ir own<br />

capability around audit and effectiveness and to proceed with making clinical audit part of<br />

routine practice.<br />

The <strong>Clinical</strong> Effectiveness Manager will provide training in clinical audit to enable clinical<br />

staff to undertake clinical audits with minimal support.<br />

Training will be provided on an ad-hoc basis by <strong>the</strong> <strong>Clinical</strong> Effectiveness Manager when<br />

requested.<br />

The <strong>Clinical</strong> Effectiveness Manager will develop and make available clinical audit guidance<br />

materials.<br />

16. Risk Management Strategy Implementation<br />

16.1 Implementation<br />

The <strong>Clinical</strong> Effectiveness Manager will be responsible for <strong>the</strong> implementation of<br />

this policy.<br />

The policy will be circulated to all members of <strong>the</strong> <strong>Clinical</strong> Quality and Safety<br />

Committee, Professional Practice Forum and all service/ business leads, within 2<br />

months of <strong>the</strong> date of ratification<br />

16.2 Training and Support<br />

Training and support for <strong>the</strong> implantation of this policy and clinical audit in general<br />

will be provided by <strong>the</strong> <strong>Clinical</strong> Effectiveness Manager<br />

V1 Page 10 of 16 6-Aug-12


<strong>Clinical</strong> <strong>Audit</strong> Policy<br />

16.3 Dissemination<br />

Once ratified this policy will be loaded to <strong>the</strong> intranet (read only)<br />

Staff will be made aware of its existence through <strong>the</strong> daily briefing email and <strong>the</strong><br />

fortnightly Team Briefing.<br />

Confirmation of receipt is not required for this procedural document.<br />

16.4 Storing <strong>the</strong> Procedural Document<br />

The signed procedural document will be stored (hard copy) centrally, as will <strong>the</strong><br />

digital (soft copy) version.<br />

17. Process for Monitoring Effective Implementation<br />

The effective implementation of this policy will be monitored by <strong>the</strong> <strong>Clinical</strong> Quality and<br />

Safety Committee.<br />

An annual clinical audit report will be produced by <strong>the</strong> <strong>Clinical</strong> Effectiveness Manager<br />

outlining compliance with <strong>the</strong> annual clinical audit programme and <strong>the</strong> policy.<br />

The <strong>Clinical</strong> Effectiveness Manager will monitor <strong>the</strong> use of appropriate standards at <strong>the</strong> time<br />

of initial project registration and again once <strong>the</strong> final report has been produced.<br />

The clinical audit programme includes details of which committee and <strong>the</strong> date <strong>the</strong> audit<br />

results were presented. The programme is updated on a monthly basis by <strong>the</strong> <strong>Clinical</strong><br />

Effectiveness Manager and taken to <strong>the</strong> <strong>Clinical</strong> Quality and Safety Committee for<br />

monitoring. Where it is identified that audits haven’t been presented, <strong>the</strong> service lead will be<br />

contacted to expedite matters.<br />

18. Associated Documentation<br />

This document references <strong>the</strong> following supporting documents which should be referred to in<br />

conjunction with <strong>the</strong> document being developed.<br />

Records Management Policy and Procedure 2010<br />

Pseudonymisation Policy 2010<br />

19. References<br />

Health and Social Care Act 2001. London: The stationary Office. Available at<br />

www.opsi.gov.uk<br />

Healthcare Quality Improvement Partnership: clinical audit guidance and support, Available<br />

at http://www.hqip.org.uk/guidance-support/<br />

National Institute for <strong>Clinical</strong> Health and Excellence. Principles for Best Practice in <strong>Clinical</strong><br />

<strong>Audit</strong>. Abingdon: Radcliffe Medical Press; 2002, p. 1.<br />

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<strong>Clinical</strong> <strong>Audit</strong> Policy<br />

Appendix A<br />

File ref: __________<br />

(<strong>Audit</strong> use only)<br />

<strong>Clinical</strong> <strong>Audit</strong> Proposal Form<br />

All clinical audit projects should be registered with <strong>the</strong> <strong>Clinical</strong> <strong>Audit</strong> Department for inclusion<br />

in <strong>the</strong> annual <strong>Clinical</strong> <strong>Audit</strong> Plan. This form should be completed for all clinical audit projects<br />

you wish to undertake. Please return completed forms to:<br />

<strong>Clinical</strong> Effectiveness Manager, Sedgemoor Centre, St Austell, PL25 5DS<br />

Title of Project:<br />

Your Details: (<strong>Audit</strong> Project Lead)<br />

Name:<br />

Address:<br />

Position / Job Title:<br />

Contact Tel No:<br />

E-mail Address:<br />

Priority: See guidance on page 2.<br />

Please delete as appropriate<br />

Rationale: e.g. Contract requirement, NICE, SUI,<br />

Service Priority<br />

1 2 3 4<br />

Guidelines, Policies, Protocols to be audited:<br />

Why are you undertaking this audit and what are your objectives?<br />

Start date:<br />

Completion date:<br />

For fur<strong>the</strong>r information and assistance please contact Tim Bowler<br />

on 01726 627643<br />

Peninsula Community Health <strong>Clinical</strong> <strong>Audit</strong> Plan will be determined by <strong>the</strong> <strong>Clinical</strong><br />

Quality and Safety Committee based upon <strong>the</strong> four categories below:<br />

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<strong>Clinical</strong> <strong>Audit</strong> Policy<br />

1: External ‘must do’ audits: Failure to participate or deliver on <strong>the</strong>se externally driven<br />

audits may carry a penalty for PCH (ei<strong>the</strong>r financial or in <strong>the</strong> form of a failed target or noncompliance).<br />

These are externally monitored and assessed by <strong>the</strong> CQC and in some areas<br />

by <strong>the</strong> local PCT commissioner.<br />

National <strong>Clinical</strong> <strong>Audit</strong> & Patient Outcome Programme (NCAPOP)<br />

<strong>Audit</strong>s demonstrating compliance with regulation requirements e.g. NICE<br />

guidance, NSFs, NPSA alerts<br />

CQUINS and o<strong>the</strong>r commissioner priorities<br />

<br />

<br />

DH statutory requirements, e.g infection control monitoring<br />

External accreditation schemes, e.g., NHS Litigation Authority (NHSLA),<br />

Information Governance Toolkit (IGT)<br />

2: Internal ‘must do’ audits: Priorities reflective of organisational objectives for clinical audit<br />

as outlined in <strong>the</strong> local clinical audit strategy or strategic objectives<br />

<strong>Clinical</strong> risk issues<br />

Serious untoward incidents/adverse incidents (SUIs)<br />

Organisational clinical priorities<br />

Priorities identified via Patient and Public Involvement initiatives<br />

Complaints<br />

Access<br />

Patient Safety First Campaign<br />

3: Business Unit / Service priorities<br />

Local clinical interest audit agreed by business units/services as a priority<br />

National audits not part of NCAPOP, e.g. some <strong>Royal</strong> College initiated projects<br />

that lie outside of NCAPOP<br />

Locally adopted clinical standards benchmarking e.g., Essence of Care<br />

4. Clinician interest<br />

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<strong>Clinical</strong> <strong>Audit</strong> Policy<br />

Appendix B<br />

Report Title<br />

Author<br />

Department<br />

Date<br />

V1 Page 14 of 16 6-Aug-12


<strong>Clinical</strong> <strong>Audit</strong> Policy<br />

<strong>Audit</strong> Title<br />

Date Range<br />

CQC Essential standards of quality and safety<br />

This report supports<br />

Domain:<br />

Outcome:<br />

Background/Introduction<br />

This should be a paragraph outlining <strong>the</strong> background information and expected benefits, ie.<br />

what <strong>the</strong> process is that you are auditing (remember, this report will be read by people<br />

outside your service). What was <strong>the</strong> problem? What were you hoping to achieve? If you<br />

undertook a literature search, say what you found giving a short description of good practice.<br />

Aims/Objectives<br />

State explicitly <strong>the</strong> specific objectives of <strong>the</strong> project (why did you do <strong>the</strong> project)?<br />

Guidelines, Protocols etc.<br />

An audit report should always be measuring against standards, guidelines or benchmarks of<br />

some sort; you need to state what <strong>the</strong>se are and where <strong>the</strong>y come from (references/<br />

bibliography). If <strong>the</strong> intention is to set standards at <strong>the</strong> end of <strong>the</strong> project, say so and state<br />

which aspects of care those standards pertain to.<br />

Methodology<br />

A short sequential list of steps that you took to carry out <strong>the</strong> audit (written in paragraph form)<br />

including any assumptions or limitations on methods. You should state your chosen<br />

population for this study (e.g. “patients referred to <strong>the</strong> one-stop breast clinic for suspected<br />

cancer”), go on to say how <strong>the</strong> sample was selected ie. “a sample of all patients seen at <strong>the</strong><br />

clinic during 1999”, in which case you would need to state <strong>the</strong> size of your sample and how it<br />

has been calculated or agreed upon. Say how you collected your data, e.g. “Data was<br />

collected from patients’ case notes using an audit tool (see Appendix)”. The method of data<br />

analysis may be mentioned briefly.<br />

Summary / Conclusions<br />

These should be written in line with <strong>the</strong> results making sure <strong>the</strong> conclusions relate to <strong>the</strong><br />

aims and objectives of <strong>the</strong> audit.<br />

Recommendations<br />

Ensure you give specific recommendations, improvements in methods and specifications for<br />

design.<br />

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<strong>Clinical</strong> <strong>Audit</strong> Policy<br />

Action Plan<br />

After <strong>the</strong> report has been written <strong>the</strong> project lead should write an action plan saying who will<br />

be responsible for carrying out changes and a time-scale in which <strong>the</strong>y will do it. What has to<br />

change, who has to change or is affected by <strong>the</strong> change and who is responsible for<br />

implementing that change. When will <strong>the</strong> change take place and how will <strong>the</strong> change be<br />

monitored.<br />

1<br />

Action Date Lead<br />

2<br />

3<br />

4<br />

5<br />

6<br />

7<br />

8<br />

9<br />

References<br />

List any references that you have quoted from and include titles, names of authors/editors<br />

and year of publication and any o<strong>the</strong>r details to help o<strong>the</strong>rs find source of information if<br />

necessary<br />

Results<br />

When analysing your data you need to state what your compliance rate is with <strong>the</strong> standard<br />

you are measuring against e.g 95% of records were legible<br />

Appendices<br />

V1 Page 16 of 16 6-Aug-12


Equality Impact Assessment Tool – <strong>Clinical</strong> <strong>Audit</strong> Policy<br />

To be completed and attached to any procedural document when submitted to <strong>the</strong><br />

appropriate committee for consideration and approval.<br />

Yes √<br />

No X<br />

Comments<br />

1. Does <strong>the</strong> document/guidance affect one<br />

group less or more favourably than ano<strong>the</strong>r<br />

on <strong>the</strong> basis of:<br />

Race X<br />

Ethnic origins (including gypsies and<br />

travellers)<br />

X<br />

Nationality X<br />

Gender X<br />

Culture X<br />

Religion or belief X<br />

<br />

Sexual orientation including lesbian, gay,<br />

transgender and bisexual people<br />

X<br />

Age X<br />

Disability - learning disabilities, physical<br />

disability, sensory impairment and mental<br />

health problems<br />

2. Is <strong>the</strong>re any evidence that some groups are<br />

affected differently?<br />

3. If you have identified potential<br />

discrimination, are <strong>the</strong>re any exceptions<br />

valid, legal and/or justifiable?<br />

4. Is <strong>the</strong> impact of <strong>the</strong> document/guidance<br />

likely to be negative?<br />

X<br />

X<br />

N/A<br />

X<br />

5. If so, can <strong>the</strong> impact be avoided? N/A<br />

6. What alternative is <strong>the</strong>re to achieving <strong>the</strong><br />

document/guidance without <strong>the</strong> impact?<br />

7. Can we reduce <strong>the</strong> impact by taking<br />

different action?<br />

N/A<br />

N/A<br />

If you have identified a potential discriminatory impact of this procedural document, please<br />

refer it to <strong>the</strong> Equality and Diversity lead, toge<strong>the</strong>r with any suggestions as to <strong>the</strong> action<br />

required to avoid/reduce this impact.<br />

For advice in respect of answering <strong>the</strong> above questions, please contact <strong>the</strong> Equality and<br />

Diversity lead.<br />

V1-0 Page 1 of 1 6-Aug-12

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