Clinical Audit Procedure Manual Ref CORP-0053-001-v2 Status: Ratified
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
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