Clinical Audit Procedure Manual
Ref CORP-0053-001-v2
Status: Ratified
Document type: Procedure
Contents
1
Purpose....................................................................................................................... 3
2
Related documents ..................................................................................................... 3
3
Key.............................................................................................................................. 3
4
Procedure 01 - Development of Annual Clinical Audit Programmes ............................ 4
5
Procedure 02 – Clinical Audit Registration (for Programmed Audits) ........................... 6
6
Procedure 03 – Clinical Audit Registration (Ad Hoc and Trainee Doctor) .................... 9
7
Procedure 04 Audit Tool – Development, Completion and Submission ..................... 12
8
Procedure 05 – Data Entry ........................................................................................ 13
9
Procedure 06 – Data Analysis ................................................................................... 14
10
Procedure 07 – Draft Report .................................................................................. 15
11
Procedure 08 – Final Report and Action Plan ........................................................ 19
12
Procedure 09 - Compliance ................................................................................... 20
13
Procedure 10 - Dissemination ................................................................................ 23
14
Procedure 11 – Implementation of Action Plan Procedure ..................................... 24
15
Procedure 12 - Tracking, Monitoring and Reporting of Clinical Audit Activity ......... 25
16
Document control................................................................................................... 26
No: CORP-0053-001.v2
Clinical Audit Procedure Manual
2
March 2014
1 Purpose
Following this procedure will help the Trust to achieve the integrated approach to quality
improvement defined within the Clinical Audit Policy.
2
Related documents
This procedure must be read in conjunction with the following policy:
Clinical Audit Policy CORP-0053
3 Key
Clinical audit procedures
Directorate/divisional procedures
No: CORP-0053-001.v2
Clinical Audit Procedure Manual
3
March 2014
4 Procedure 01 - Development of Annual Clinical Audit
Programmes
Purpose
To highlight external and internal factors influencing the development of Clinical Audit
Programmes.
Process
A structured programme of clinical audit activity is agreed annually for all relevant
directorates and divisions. These programmes will include national and local clinical audit
priorities and will be based on key quality and risk issues.
The procedure for developing annual programmes is as follows:
1. Horizon scan of national and local priorities to be undertaken annually by the Clinical
Assurance & Registration Team. This includes consideration of the following:
National Drivers:
Local Drivers:






Commissioning Framework Priorities
National Clinical Audit Priorities
- National Clinical Audit Patient
Outcome Programme (NCAPOP)
- Royal College of Psychiatrists
Prescribing Observatory for Mental
Health (POMH-UK)
CQC clinical quality review topics and
themes of investigations
NICE and other national best practice
guidance publications including
- National Strategies
- NICE Quality Standards
- NICE Guidance
NHSLA priorities
Clinical Outcome Review Programmes
(national confidential inquiries)






Directorate and divisional risk register
priorities
Annual Quality Account priorities,
Annual / Business Planning priorities
Themes from serious untoward
incidents and risk incidents
CQUIN targets
Service developments
Priorities identified by service users
and carers
- National and local patient survey
results, Essential Standards of
Quality & Safety, Patient and Carer
Group feedback, themes of
complaints and PALS contacts
2. Categorisation of priorities into mandatory, high priority and desirable (using Trust
matrix*
3. Calculation and programme allocation of approximate capacity required for each
audit.
4. Discussion of identified national and local priorities with relevant divisional Service
Development Managers and Directorate representatives
5. Clinical Assurance & Registration Team draft outline clinical audit programmes
6. Draft clinical audit programme priorities considered/ agreed by relevant Divisions and
Directorates
7. Approval of clinical audit programmes by the Quality & Assurance Committee
(designated Board sub-committee) and the Audit Committee
In the event of newly emerging quality and risk issues these will be considered for
inclusion within clinical audit programmes by relevant Committees and Groups with
acknowledgement that high risk priorities may need to be incorporated to facilitate rapid
quality assurance / improvement.
No: CORP-0053-001.v2
Clinical Audit Procedure Manual
4
March 2014
Changes to the scheduled clinical audit programmes will be reviewed and authorised by
the Clinical Effectiveness Group.
The following prioritisation matrix demonstrates how priorities are derived and categorised
within the Trust:
Prioritisation Category
Mandatory Priority
These audits are compulsory
requirements for the Trust and
must be undertaken as agreed
by appropriate Trust Committees.
These high level requirements
may pose significant risk to
patient safety, clinical
effectiveness or patient
experience.
Care Quality
Commission
CQUIN
Audits for inclusion
National Clinical Audit
and Patient Outcome
Programme
(NCAPOP)
NPSA Alerts
Monitor Request
NHSLA
Quality Account
Indicators
Commissioner Quality
Assurance Framework
Mandated Statements
(QAF)
Divisional/Directorate Risk Register Priorities
High Priority
High Level Enquiries
These audits are of precedence
to the Trust. Good practice
indicates that these areas are
audited to mitigate potential high
risk to patient safety, clinical
effectiveness or patient
experience
Desirable Priority
NICE Quality Standards and Guidance
National Strategies
Emerging, repeating themes from SUIs and
complaints
Other National initiatives (e.g. Professional Body
Initiatives)
These audits are of lower priority
and do not pose significant risk to
Other Directorate Issues
patient safety, clinical
effectiveness or patient
Local Initiatives
experience
Clinical audit priorities identified from a risk register are categorised according to the
individual risk rating.
No: CORP-0053-001.v2
Clinical Audit Procedure Manual
5
March 2014
5 Procedure 02 – Clinical Audit Registration (for Programmed
Audits)
Quality Check
Safety Precaution
Standard Work in Progress
PURPOSE: To assist the Clinical Assurance and Registration Department and staff involved in audits.
Who Must Adopt This Procedure:
Clinical Assurance and Registration Member/ Clinical Services/
Staff participating in audit
Time Taken: Variable
GOAL: List key quality and lean targets
STEP
OPERATOR
TASK DESCRIPTION
1.
Audit Lead
2.
Audit Lead
3.
Audit Lead
Complete registration form
4.
Clinical Audit
Team
5.
Clinical Audit
Facilitator
Check registration form to
ensure all fields are complete.
Include use of appropriate
evidence based criteria and
standards and audit tool
attached.
Check programmes to identify
if audit is part of a scheduled
audit programme.
6.
Clinical Audit
Facilitator
7.
Clinical Audit
Facilitator
8.
Clinical Audit
Facilitator
9.
Clinical Audit
Facilitator
Ref CORP-0053-001.v2
Clinical Audit Procedure Manual
Identify and research evidence
base for audit topic
Establish criteria and
standards for audit
If on audit programme, ensure
registration form is discussed
and approved or rejected at
Assurance & Registration
Steering Group Meeting
(approval procedure)
If declined, add to log and
inform audit lead and SDM.
If approved, add to database
and obtain an audit number,
update relevant clinical Audit
Programme, add to Visual
Programme and add to VCB.
Send standard email to Audit
Lead informing them of the
outcome of registration.
Page 6 of 26
TOOLS/SUPPLIES
REQUIRED
Guidance documents,
general articles etc.
Guidance documents,
general articles etc
Registration Form
Clinical Audit Lead
Registration Form
Clinical Audit Tool
Clinical Audit Programme
Registration Form
Declined Log
Registration Form
Standard e-mail template
Clinical Audit Database
Clinical Audit Programme
Registration Form
Visual Control Board
Standard e-mail template
Approval date
CYCLE
TIME
REGISTRATION FORM FOR CLINICAL AUDITS
PROJECT TITLE:
PROJECT LEAD DETAILS:
Surname:
Job Title:
First Name:
Base:
Contact Telephone Number:
Service:
AMH
MHSOP
C&YPS
Pharmacy
Offender
Care
Forensics
LD
Substance Misuse
PROJECT TEAM: (state all members of staff to be involved in the audit, including job title. Please note most
clinical audits should involve members of the multi-disciplinary team):
PROJECT DETAILS
Locality:
Teesside
Durham & Darlington
Forensic Services
North Yorkshire
Location of Project: (provide a list of all Wards/ Teams involved in the audit)
Proposed Start Date of Project:
(dd/mm/yy)
Proposed Completion Date of Project:
(dd/mm/yy)
(usually no longer than 3 months )
Aims: (The specific goal or purpose of the Audit)

Objectives:
(Specific, Measurable, Achievable, Realistic, Timely)


Methodology:


Evidence Base
Standards
Criteria
(Evidence based statement)
e.g. All patients should have their NHS number recorded on
PARIS
Ref CORP-0053-001.v2
Clinical Audit Procedure Manual
Page 7 of 26
(including RAG rating)
e.g. 100% patients
should have their NHS
number recorded on
PARIS
e.g. NICE or other
National/local best
practice guidelines, local
policies/ procedures,
literature search/research
findings
Approval date
Data Collection Tool Attached:
ASSISTANCE REQUIRED
Yes
No
(If your audit forms part of a Trust Clinical Audit Programme the following
assistance is available. (Please tick all assistance you require. If your audit does
not appear on the Trust Clinical Audit Programme we can only provide advice.)
No support required
General project advice only
Data collection tool design
Initial drafting of audit report
Data analysis
Dissemination advice
AGREEMENT AND AUTHORISATION
You should ask an appropriate senior clinician or manager to sign below in support of your project.
Project Lead: By signing this form I agree to ensure that this project is completed, the results
disseminated, and a report and action plan given to the Clinical Assurance & Registration Department. I
understand that non-anonymised (staff/patient) audit data must not be taken outside the Trust. I
understand that audit results belong to the Trust and that the audit report may be made available to
anyone who requests it.
Signature of Project Lead
Name (printed)
Date
Senior Clinician/Manager: By signing this form I confirm that this project has been agreed as part of
the Specialty/Division audit programme and that I will give my full support to it. I will ensure the
dissemination of audit results and lead on the development and implementation of an action plan in order
to obtain improvements in the quality of care provided.
Signature of Senior Clinician/Manager
Name (printed)
Date
Registration form approved by Clinical Assurance and Registration Department
Date
Thank you for completing this form.
Please wait for approval of the project from the Clinical Assurance & Registration Department
before starting. If this project is approved, the information on this form will be entered onto the
Clinical Audit database and you will be contacted via e-mail to confirm registration.
All reports and action plans will be sent to relevant Heads of Service. Heads of Service will verify
implementation of action plan.
All areas of the form must be completed or your form will be returned.
Please send your completed form to
Clinical Assurance & Registration Department, Tarncroft, Lanchester
Road Hospital, Lanchester Road, Durham, DH1 5RD
Tel: 0191 333 3557 Email: [email protected]
Ref CORP-0053-001.v2
Clinical Audit Procedure Manual
Page 8 of 26
Approval date
6 Procedure 03 – Clinical Audit Registration (Ad Hoc and
Trainee Doctor)
Quality Check
Safety Precaution
Standard Work in Progress
Purpose: To assist the Clinical Assurance and Registration Department and staff involved in audits.
Who Must Adopt This Procedure:
Clinical Audit Facilitators
GOAL: List key quality and lean targets
OPERATOR TASK DESCRIPTION
STEP
1.
Audit Lead
2.
Audit Lead
3.
Audit Lead
5.
Clinical Audit
Facilitator
6.
Clinical Audit
Facilitator
7.
Clinical Audit
Facilitator
8.
Clinical Audit
Facilitator
Ref CORP-0053-001.v2
Clinical Audit Procedure Manual
Identify and research evidence
base for audit topic
Establish criteria and standards
for audit
Complete registration form and
send to Clinical Assurance and
Registration Department
Registration Form discussed
and approved (or declined) at
Assurance & Registration
Steering Group Meeting (or
where necessary relevant
divisional group).
If declined, add to log and inform
audit lead (and Medical Director)
using a standard e-mail.
If approved, add to database
and obtain an audit number and,
update relevant Audit
Programme.
Send standard email to Audit
Lead (cc. Medical Educational
supervisor if Trainee Dr)
informing them of the outcome
of registration and attach Trust
standard clinical audit report
template.
Page 9 of 26
Time Taken: Variable
TOOLS/SUPPLIES
REQUIRED
Guidance documents,
general articles etc.
Guidance documents,
general articles etc
Registration Form
Registration Form
Declined Log
Registration Form
Standard e-mail
Template
Clinical Audit Database
Clinical Audit
Programme
Registration Form
Standard e-mail
template.
Trust standard clinical
audit report template.
Approval date
CYCLE
TIME
TRAINEE AUDIT REGISTRATION FORM
PROJECT TITLE:
PROJECT LEAD DETAILS:
Surname:
First Name:
Job Title:
Grade:
Base:
Contact Telephone Number:
Service:
AMH
MHSOP
(e.g. F1, CT1, ST1, LAC etc)
C&YPS
Pharmacy
Offender
Care
Forensics
LD
Substance Misuse
College Tutor’s Name:
Placement Start Date:
Educational Supervisor’s Name:
Placement End Date:
PROJECT TEAM: (state all members of staff to be involved in the audit, including job title. Please note most
clinical audits should involve members of the multi-disciplinary team):
PROJECT DETAILS
Locality:
Teesside
Durham & Darlington
Forensic Services
North Yorkshire
Location of Project: (provide a list of all Wards/ Teams involved in the audit)
Proposed Start Date of Project:
Proposed Completion Date of Project:
(dd/mm/yy)
(dd/mm/yy)
(usually no longer than 3 months )
Aims: (The specific goal or purpose of the Audit)

Objectives:
(Specific, Measurable, Achievable, Realistic, Timely)


Methodology:


Evidence Base
Standards
Criteria
(Evidence based statement)
e.g. All patients should have their NHS number recorded on
PARIS
Ref CORP-0053-001.v2
Clinical Audit Procedure Manual
Page 10 of 26
(including RAG rating)
e.g. 100% patients
should have their NHS
number recorded on
PARIS
e.g. NICE or other
National/local best
practice guidelines, local
policies/ procedures,
literature
search/research findings
Approval date
Data Collection Tool Attached:
Yes
No
AGREEMENT AND AUTHORISATION
You should ask an appropriate senior clinician or manager to sign below in support of your project.
Project Lead: By signing this form I agree to ensure that this project is completed, the results
disseminated, and a report and action plan given to the Clinical Assurance & Registration Department. I
understand that non-anonymised (staff/patient) audit data must not be taken outside the Trust. I
understand that audit results belong to the Trust and that the audit report may be made available to
anyone who requests it.
Signature of Project Lead
Name (printed)
Date
Signature of Supervising Consultant
Name (printed)
Date
Registration form approved by Clinical Assurance and Registration Department
Date
Thank you for completing this form.
Please wait for approval of the project from the Clinical Assurance & Registration Department
before starting. If this project is approved, the information on this form will be entered onto the
Clinical Audit database and you will be contacted via e-mail to confirm registration.
All reports and action plans will be sent to relevant Heads of Service. Heads of Service will verify
implementation of action plan.
All areas of the form must be completed or your form will be returned.
Please send your completed form to
Clinical Assurance & Registration Department, Tarncroft, Lanchester
Road Hospital, Lanchester Road, Durham, DH1 5RD
Tel: 0191 333 3557 Email: [email protected]
Ref CORP-0053-001.v2
Clinical Audit Procedure Manual
Page 11 of 26
Approval date
7 Procedure 04 Audit Tool – Development, Completion and
Submission
Quality Check
Safety Precaution
Standard Work in Progress
Purpose: To assist the Clinical Assurance and Registration Department and staff involved in audits.
Who Must Adopt This Procedure:
Audit Lead
Time Taken: Variable
GOAL: List key quality and lean targets
STEP
1.
2.
TASK DESCRIPTION
Audit Lead/
Clinical Audit
Facilitator
Clinical Audit
Facilitator
Design audit tool (e.g.
questionnaire)
Audit Tool
Approve audit tool via
Assurance & Registration
Steering Group (and relevant
clinical audit subgroup where
appropriate).
Read, understand and check
audit tool (mistake proof).
Audit Tool
Read, understand and check
guidance notes for the audit.
Mistake proof (review & amend)
guidance notes.
Identify data source/
methodology (e.g. PARIS, CRS,
Clinical Record (hard copies),
Observation, etc
Distribute Audit Tool and
guidance notes if required.
Audit Tool & Guidance
Notes
Respond to all questions by
completing audit tool fully
Audit Tool
PARIS
Submit completed audit tools to
Clinical Assurance and
Registration Team (Tees, Esk &
Wear Valleys NHS Foundation
Trust) or designated lead for
analysis.
Retain a copy of all completed
audit tools in a secure place until
audit cycle complete (completed
report received)
Audit Tools
3.
Audit Lead
4.
Audit Lead
5.
Audit Lead
6.
Audit Lead
7.
Audit Lead/
Clinicians/
Auditors
Audit Lead
8.
9.
TOOLS/SUPPLIES
REQUIRED
OPERATOR
Audit
Lead/Clinical
Audit
Facilitator
Ref CORP-0053-001.v2
Clinical Audit Procedure Manual
Page 12 of 26
Audit Tool
Audit Tool
Clinical Audit shared
Drive
Approval date
CYCLE
TIME
8 Procedure 05 – Data Entry
Quality Check
Safety Precaution
Standard Work in Progress
Purpose: To assist the Clinical Assurance and Registration Department.
Who Must Adopt This Procedure:
Clinical Audit Facilitators
Time Taken: Variable
GOAL: List key quality and lean targets
STEP
OPERATOR
TASK DESCRIPTION
1.
Clinical
Audit
Facilitator
Clinical
Audit
Facilitator
Clinical
Audit
Facilitator
Clinical
Audit
Facilitator
Clinical
Audit
Facilitator
Ensure complete dataset
TOOLS/SUPPLIES
REQUIRED
Audit Tools
Separate and sort completed audit
tools
Audit Tools
Files
Design spreadsheet using Excel
Microsoft Excel
Populate spreadsheet, numbering
each fully inputted tool
Microsoft Excel
Audit Tools
Check inputted data against
completed audit tools to ensure
accuracy
Microsoft Excel
Audit Tools
2.
3.
4.
5.
Ref CORP-0053-001.v2
Clinical Audit Procedure Manual
Page 13 of 26
CYCLE TIME
Approval date
9 Procedure 06 – Data Analysis
Quality Check
Safety Precaution
Standard Work in Progress
Purpose: To assist the Clinical Assurance and Registration Department.
Who Must Adopt This Procedure:
Clinical Audit Facilitators
Time Taken: Variable
GOAL: List key quality and lean targets
STEP
OPERATOR
TASK DESCRIPTION
1.
Clinical Audit
Facilitator/
Service
Development
Manager
Clinical Audit
Facilitator
Identify how data will be
reported (e.g. by locality, clinical
team, etc)
2.
3.
Clinical Audit
Facilitator
4.
Clinical Audit
Facilitator
Analyse data using appropriate
data package for data type. E.g.
Excel – pivot tables.
Populate data analysis/results
section of draft report with
statistical data
Interpret data and add to draft
report.
Ref CORP-0053-001.v2
Clinical Audit Procedure Manual
Page 14 of 26
TOOLS/SUPPLIES
REQUIRED
-
CYCLE TIME
Microsoft Excel
Audit Tools
Microsoft Excel
Standard Report
Template
Audit Tools
Microsoft Excel
Standard Report
Template
Approval date
10 Procedure 07 – Draft Report
Quality Check
Safety Precaution
Standard Work in Progress
Procedure: To assist the Clinical Assurance and Registration Department.
Who Must Adopt This Procedure:
Clinical Audit Facilitators
Time Taken: Variable
GOAL: List key quality and lean targets
TOOLS/SUPPLIES
REQUIRED
Standard Trust Clinical
Audit Report Template
STEP
OPERATOR
TASK DESCRIPTION
1.
Clinical
Audit
Facilitator
Senior
Team
Member
Populate all sections of standard
clinical audit report template.
Proof read draft clinical audit
report (including validation of
small data sample).
Draft audit report
Clinical
Audit
Facilitator/
Audit Lead
Email draft report to Clinical Audit
Lead for checking and to add
further interpretation of data.
Draft audit report
Standard e-mail template
2.
3.
Ref CORP-0053-001.v2
Clinical Audit Procedure Manual
Page 15 of 26
CYCLE TIME
Approval date
Clinical Audit of
Project Lead
Project Team
1
Background
1.1
2
Criteria and Standards
2.1
3
Methodology
3.1
4
Audit Tool
4.1
Data Analysis/Results1
5
5.1
6
Areas of Good Practice
6.1
7
Mitigation of Emerging Risks / Lessons Learnt
7.1 This section should include how any areas of non compliance with standards or emerging risks
identified by the audit will be addressed. Please note that this does not necessarily need to
become an action point within the action plan, it may be documenting existing work streams or
TEWV QIS activity which are addressing this issue.
8
Sustained Improvements
8.1
1
The figures included in this report have been rounded.
Ref CORP-0053-001.v2
Clinical Audit Procedure Manual
Page 16 of 26
Approval date
9
References
CQC Essential Standards of Quality and Safety relevant to this audit are as follows: (Please delete
as appropriate)
Care and welfare of people who use services
Assessing and monitoring the quality of service provision
Safeguarding people who use services from abuse
Cleanliness and infection control
Management of medicines
Meeting nutritional needs
Safety and suitability of premises
Safety, availability and suitability of equipment
Respecting and involving people who use services
Consent to care and treatment
Complaints
Records
Requirements relating to workers
Staffing
Supporting workers
Co-operating with other providers
Ref CORP-0053-001.v2
Clinical Audit Procedure Manual
Page 17 of 26
Approval date
Clinical Audit Action Plan
COMPLIANCE LEVEL:
TITLE OF CLINICAL
AUDIT:
PROJECT LEAD:
AUDIT NUMBER:
AUDIT DATE:
NO.
RECOMMENDATION/FINDING
INTENDED
OUTCOME/RESULT
ACTION
ACTION
OWNER
TARGET DATE
FOR ACTION
COMPLETION
EVIDENCE
(TO BE
RETAINED
BY ACTION
OWNER)
PROGRESS
UPDATE
1
2
3
4
5
6
7
ACTION PLAN OWNER:
Please record individual with overall responsibility for
ensuring delivery of actions.
PLAN AGREED BY:
Ref CORP-0053-001.v2
Clinical Audit Procedure Manual
DATE:
DATE:
Page 18 of 26
Approval date
11 Procedure 08 – Final Report and Action Plan
Quality Check
Safety Precaution
Standard Work in Progress
Procedure: To assist the Clinical Assurance and Registration Department and staff involved in audits.
Who Must Adopt This Procedure:
Clinical Audit Facilitator
Time Taken: Variable
GOAL: List key quality and lean targets
STEP
OPERATOR
TASK DESCRIPTION
1.
Clinical Audit
Facilitator /
Audit Lead
and SDM
Clinical Audit
Facilitator
Agree content of draft report
3.
Audit Lead /
QuAG
4.
Audit Lead/
Clinical Audit
Facilitator
Clinical
Assurance
Assistant
Agree action plan with relevant
directorate and/or division(s) at
divisional clinical audit subgroup
meeting.
Submit final report and action
plan to Clinical Assurance and
Registration Team
Peer review action plan to
ensure objectives are SMART.
2.
5.
Request Clinical Audit Lead
develops action plan
Ref CORP-0053-001.v2
Clinical Audit Procedure Manual
Page 19 of 26
TOOLS/SUPPLIES
REQUIRED
Standard Trust Clinical
Audit Report Template
CYCLE TIME
Final Report
Standard action plan
template
Action Plan
Clinical Audit Subgroup
meeting
Final Report & Action
Plan
Action Plan
Approval date
12 Procedure 09 - Compliance
Quality Check
Safety Precaution
Standard Work in Progress
Purpose: To assist the Clinical Assurance and Registration Department.
Who Must Adopt This Procedure:
Clinical Audit Facilitators
Time Taken: Variable
GOAL: List key quality and lean targets
OPERATO
STEP
TASK DESCRIPTION
R
1.
Clinical
Peer review of final report
Assurance
(including content of action plan,
Assistant
checking for errors, omissions,
additions and rates compliance
using RAG system).
2.
Clinical
Complete Quality Assurance
Assurance
Checklist.
Assistant
3.
Clinical
Add final report and action plan to
Audit
the agenda for the Assurance &
Facilitator
Registration Steering Group
4.
Clinical
Audit
Facilitator
5.
Clinical
Audit
Facilitator
Complete administrative tasks,
including database, audit
programme, VCB, file audit tools
and update action plan monitoring
spreadsheet (audits prior to April
2012).
Produce an A4 summary of audit
using standard A4 summery
template to highlight key points.
Also summarize the audit report
and complete Team Performance
report template.
Ref CORP-0053-001.v2
Clinical Audit Procedure Manual
Page 20 of 26
TOOLS/SUPPLIES
REQUIRED
Final Report & Action
Plan
CYCLE TIME
Quality Assurance
Checklist
Final Report & Action
Plan
Agenda for Assurance &
Registration Steering
Group
Clinical Audit Database
Clinical Audit Programme
File
Visual Control Board
Action Plan Monitoring
Spreadsheet
Clinical Audit Report
A4 Summary Template
Team Performance
Report
Approval date
Methodology to support compliance assessment
Compliance assessment is the process undertaken when an audit is completed and
reported. It involves allocating a RAG rating (red, amber or green) as a visual indication of
the standards achieved within the audit.
Rating
Red
Amber
Green
Average practice
standards
demonstrated
1 - 49 %
50 -79%
80 -100 %
Compliance Assessment
Poor compliance
Moderate compliance
Good compliance
Compliance may be assigned to individual audit criteria or more commonly use a global
compliance assessment against all key criteria. Assignment of compliance level will,
therefore, be undertaken on an individual project basis.
Clinical audits which assess criteria where compliance standards must be set at a particular
level (e.g. 100%) due to level of potential associated risk (patient safety clinical
effectiveness, patient experience) will have this established during the initial audit
development processes.
On assessing compliance, consideration should be given to the following:-
Target compliance standard(s) to be achieved for key audit criteria
The degree to which standards are achieved.
The extent to which compliance with the expected standards affects patient safety and
quality of clinical care and treatment.
The potential risks posed by low compliance with criteria in respect of patient safety and
clinical effectiveness.
Indication of the severity of patient safety, clinical effectiveness and/ or patient experience
risks may be considered using the following matrix to support the decision regarding
compliance if required:
Patient Safety Risks
Clinical
Effectiveness
Risks
Low
Medium
High
Ref CORP-0053-001.v2
Clinical Audit Procedure Manual
Page 21 of 26
Medium
High
Patient Experience
Risks
Low
Approval date
Escalation of Significant Audit Findings
For audits where all of the following criteria apply, findings will be escalated for immediate
consideration and action by senior managers within relevant Clinical Divisions / Directorates

Red compliance standards.
Significant risk associated with compliance level achieved in respect of patient safety,
clinical effectiveness, patient experience (Darzi quality domains) or organisational risk
issues.
Formal reporting mechanisms will be utilised to escalate such findings. The Clinical Assurance
& Registration Team will inform the Executive Director of Nursing and Governance and findings
will be highlighted to relevant Trust Committees and Groups. Timescales for actions to be
taken may be determined for any clinical audit as stipulated by relevant Trust Committees and
Groups.
Ref CORP-0053-001.v2
Clinical Audit Procedure Manual
Page 22 of 26
Approval date
13 Procedure 10 - Dissemination
Quality Check
Safety Precaution
Standard Work in Progress
Purpose: To assist the Clinical Assurance and Registration Department and staff involved in audits.
Who Must Adopt This Procedure:
Clinical Audit Facilitator
Time Taken: Variable
GOAL: List key quality and lean targets
TOOLS/SUPPLIES
REQUIRED
Standard E-mail
Template
Final Report & Action
Plan
A4 Summary
STEP
OPERATOR
TASK DESCRIPTION
1.
Clinical Audit
Facilitator
E-mail final report, action plan,
and A4 Summary, Service
Development Manager/ Audit
Lead/ Individual team managers
where appropriate.
2.
Service
Development
Manager or
Clinical Audit
Facilitator
Team
Managers
Directorate/division
dissemination of report and
action plan
Final Report & Action
Plan
Divisional QuAG/ Clinical
Audit Subgroup/ DMT
Team level discussion of report.
Record action plan in minutes
Minutes of Meetings
SDM/ Head
of Service/
Chair/ Clinical
Audit Lead
Provide confirmation of
dissemination to Clinical
Assurance and Registration
Team.
E-mail
3.
4.
Ref CORP-0053-001.v2
Clinical Audit Procedure Manual
Page 23 of 26
CYCLE TIME
Approval date
14 Procedure 11 – Implementation of Action Plan Procedure
Quality Check
Safety Precaution
Standard Work in Progress
Purpose: To assist the Clinical Assurance and Registration Department and staff involved in audits.
Who Must Adopt This Procedure:
Clinical Audit Facilitators
Time Taken: Variable
GOAL: List key quality and lean targets
TOOLS/SUPPLIES
REQUIRED
Action Plan
STEP
OPERATOR
TASK DESCRIPTION
1.
QuAG/Service
Development
Manager or
DMT
Service level monitoring of action
plan implementation will be
undertaken by Directorate QuAGs
(including documented evidence)
2.
QuAG/Service
Development
Manager or
DMT
Service
Development
Manager or
DMT
Confirmation from QuAG/LMGB/
SDM/ Audit Lead that all actions are
implemented.
E-mail (electronic
confirmation)
Clinical Audit Action Plans to be
categorized by:
Clinical Audit Action Plan
3.

Actions implemented

Action implementation
ongoing (with deadline)

Action superseded (with
rationale).
3.
Clinical Audit
Facilitator
Re-audit scheduled if identified by
Division or Directorate
Clinical Audit Programme
4.
Clinical Audit
Facilitator
Clinical audit database to be
completed with dates of when
actions are due / achieved / updated.
Database
5.
Clinical Audit
Facilitator
Monthly report produced from
database identifying when action
plan implementation is due. Follow
up actions due with relevant leads
and retain submitted assurance
evidence.
Database
Team Meeting Agenda
6.
Head of
Assurance
and
Effectiveness
Performance reporting outstanding
actions to QuAC and other relevant
committees/groups.
Performance report
Ref CORP-0053-001.v2
Clinical Audit Procedure Manual
Page 24 of 26
Approval date
CYCLE TIME
15 Procedure 12 - Tracking, Monitoring and Reporting of
Clinical Audit Activity
Purpose
To highlight methods adopted to track, monitor and report clinical audit activity.
Process

Annual Division and Directorate specific clinical audit programmes will be the primary
mechanism used to track and monitor clinical audit activity

Individual clinical audit reports will be reported using the Trust standard template.

Throughout the financial year clinical audit programmes and other clinical audit activities will
be tracked and monitored for quality assurance and quality improvement purposes
(including sharing of lessons learned). This will be formally reviewed and reported by the
following strategic and operational Forums and Services:
-
Board
Quality & Assurance Committee
Clinical Effectiveness Group
Locality Management and Governance Board (LMGB)
Speciality Development Group (SDG)
Clinical Assurance and Registration Team
Divisional Quality & Assurance Groups (QuAGs)
Directorate Management Teams / Forums

The Trust Clinical Audit Database will capture all scheduled and reported clinical audit
activity.

The Clinical Assurance and Registration Team will publish an annual clinical audit report
(this will be a component of the scheduled QuAC report).

Trust clinical audit activity will be a component of the annual Quality Account (which is made
publicly available and accessible to service users and carers).
Ref CORP-0053-001.v2
Clinical Audit Procedure Manual
Page 25 of 26
Approval date
16 Document control
Date of approval:
05 March 2014
Next review date:
05 March 2017
This document replaces:
CORP/0053/01.v1
Lead:
Name
Title
Leanne McCrindle
Head of Assurance And
Effectiveness
Members of working party:
Name
Title
This document has been
agreed and accepted by:
(Director)
Name
Title
Chris Stanbury
Director of Nursing and
Governance
This document was approved
by:
Name of committee/group
Date
Quality Assurance Group
06 February 2014
Name of committee/group
Date
Executive Management
Team
05 March 2014
This document was ratified
by:
An equality analysis was
completed on this document
on:
May 2012
Amendment details:
Feb 2012 – Minor changes re titles of governance groups and
job titles
Ref CORP-0053-001.v2
Clinical Audit Procedure Manual
Page 26 of 26
Approval date