Clinical Audit Dr Richard Morgan Trust Clinical Audit Lead Jayne - - PowerPoint PPT Presentation

Clinical Audit

Dr Richard Morgan Trust Clinical Audit Lead Jayne Porter Clinical Audit Team Leader

July 2015

Who we are and where we are

Dr Richard Morgan - Trust Clinical Audit Lead Cherith Haythornthwaite - Clinical Improvement & Effectiveness Manager Alison Bowes

• Clinical Audit & Effectiveness Manager

Jayne Porter

• Clinical Audit & Effectiveness Team Leader

Kathy Ballard

• Clinical Audit & effectiveness Facilitator

Rosemary Williamson - Clinical Audit & effectiveness Facilitator Lee Kane

• Clinical Audit & effectiveness Facilitator

Vikki Gowens

• Clinical Audit & effectiveness Facilitator

James Abbotts

• Clinical Audit & effectiveness Support Assistant

We all reside in the Clinical Quality Centre, First Floor Offices , Via Main Entrance

Clinical Audit

What is it?

Clinical Audit

‘The Evaluation of Performance Against Established Standards’

Clinical Audit

‘A quality improvement process that seeks to improve patient care against explicit criteria and the implementation of change. Aspects of the structure, processes and

• utcomes of care are selected and

systematically evaluated against explicit

• criteria. Where indicated changes are

implemented at an individual, team or service level and further monitoring is used to confirm improvement in health care delivery’ (N.I.C.E. 2002)

Select an audit topic Identify best practice/stan dards Agree criteria & standards Submit completed proposal form – gain approval Collect Data Analyse Data Present findings to Department & Division Agree action plan Write report and submit completion form

Clinical Audit

Clinical Audit Process

Multidisciplinary & Cross Speciality Audit

 Multidisciplinary - Doctors, nurses,

physiotherapists, etc; i.e. the ‘whole team’ auditing any aspect of service provision within departments or specialities

 Cross Speciality - Any mix of team members

auditing an aspect of service provision between divisions, departments or specialities; e.g. fractured neck of femur care pathway includes medical, nursing and AHP staff in A&E, Orthopaedics, Anaesthetics & Theatre)

What is not Clinical Audit

 Comparison of treatments and or interventions  Outcomes of novel treatments or interventions  Outcomes of novel service developments  Pure research or service evaluation  Census work  Measurement of activity alone

Audit, Research or Service Evaluation?

 Research

• Aims to evaluate & define ‘best practice’

 Service Evaluation

• Aims to evaluate and critically appraise

current service provision

 Audit

• Aims to evaluate how close local

practice is to ‘best practice’

Clinical Audit – Why Bother?

 A clinical governance requirement (corporate,

divisional, departmental & speciality)

 A training requirement for junior doctors  An appraisal and re-validation requirement for

consultants and NCCG staff (CPD)

 A potentially powerful instrument for maintenance

• f and improvement in standards of clinical service

provision

• Speak to the Clinical Audit Lead within your Division/Speciality
• Speak to staff in the Clinical Audit Department
• Identify your team of auditors including the senior supervisor
• Complete the audit proposal form (version 7.0)

What Do You Need To Do?

Identify what the aims and objectives are, what the relevant standards are and what your target standards are

HOW TO PROCEED

Completing the proposal form (v 7)

This can be found on the clinical audit SharePoint site on the intranet . If you require any help completing the form please call into the department. A Consultant must be named as the lead auditor (senior supervisor). Make sure all sections of the form are completed – failure to complete all sections will cause delay in the approval of your audit.

HOW TO PROCEED



Completing the proposal form (v 7)



Data collection must not be started until approval from the audit department has been received.



The form must be signed by the speciality audit lead (not the lead auditor for the project although this could be one and the same in theory)



Take the proposal form to the audit department along with the guidelines & standards you are auditing against and a copy of the data collection proforma.



Wait for confirmation that your audit has been approved before beginning data collection

Clinical Audit Proposal Form v 7.0

What Else Do You Need To Do?

 If you require case notes the patient list can be

passed to the audit manager. If you don’t already have a patient list then advise the clinical audit manager of the patient diagnostic group and a list will be requested on your behalf.

 Begin data collection once case notes are available

with a target of completion within the agreed timescale (as per date recorded on the proposal form)

 Inform the Clinical Audit Department when data

collection is complete

What Else Do You Need To Do?

 Analyse the data and develop a presentation/report  Present your findings at speciality and/or divisional

governance meeting

 The relevant divisional director or head of department

should sign off an action plan, identify who is to be responsible for implementing each of the changes and by when (this has to be a specific date).

 Send a copy of your report/presentation to your audit

facilitator along with your recommendations for action.

What Else Do You Need To Do?

If you require a certificate to confirm participation in a given audit please ask your facilitator and they will organise this for you. Please remember there hundreds of audits on our annual work plan, all of which we have to track ….. you have only one so please keep the audit department updated and make sure you complete the ‘full’ audit cycle at least to the point of presentation of results and recommendations

Where To Find Information

 Clinical Audit Department  Clinical Audit Podcast  Trust Intranet – Document Library – Audit  CORP/PROC/561 – Undertaking Clinical Audit  http://bfwnet/departments/policies_procedur

es/dept_docs.asp?respID=96

 Templates Provided: Presentations & Reports

Clinical Audit Good Luck!