Enclosure 21 - Clinical and Non Clinical Audit Policy - ES–

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Enclosure 21 Trust Board Meeting Agenda Item: 9.2Wednesday, 25 May 2005 Sunderland Teaching Primary Care Trust Clinical and Non-Clinical Audit Policy Executive Summary 1. Introduction Sunderland Teaching Primary Care Trust is committed to implementing an inclusive organisational wide approach to audit. The Clinical and Non Clinical Audit Policy outlines the overall plan to strengthen the evidence base of clinical and non clinical audit activity. The registration process and systems around Audit Control will ensure quality assurance. 2. Recommendation The process of audit approval is conditional as part of Sunderland Teaching Primary Care Trust employees carrying out audit. The Research and Audit Committee has the responsibility to provide validation of audit registration and the quality assurance processes. The Trust Board is asked to endorse the policy. Bev Atkinson Director of Nursing SUNDERLAND TEACHING PRIMARY CARE TRUST CLINICAL AND NON-CLINICAL AUDIT POLICY APRIL 2005 CONTROL INFORMATION DOCUMENT NAME: CLINICAL AND NON- CAL AUDIT POLICY DOCUMENT REFERENCE NUMBER: AUTHOR: KATH LOWERY SIGNATURE OF RATIFYING OFFICER: DATE OF FIRST ISSUE: APRIL 2005 DOCUMENT HISTORY: ISSUE NUMBER: AMENDED DATE OF DOCUMENT: RE-ISSUE DATE: APRIL 2008 TRAINING IMPLEMENTED: AUDIT POLICY / PROCEDURE DATE: ...

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• Publié par: Mizir
• Nombre de lectures: 23
• Langue: English

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Enclosure 21   Trust Board Meeting Agenda Item: 9.2 Wednesday, 25 May 2005     Sunderland Teaching Primary Care Trust     Clinical and Non-Clinical Audit Policy   Executive Summary   1. Introduction   Sunderland Teaching Primary Care Trust is committed to implementing an inclusive organisational wide approach to audit. The Clinical and Non Clinical Audit Policy outlines the overall plan to strengthen the evidence base of clinical and non clinical audit activity. The registration process and systems around Audit Control will ensure quality assurance.     2. Recommendation     The process of audit approval is conditional as part of Sunderland Teaching Primary Care Trust employees carrying out audit.   The Research and Audit Committee has the responsibility to provide validation of audit registration and the quality assurance processes.   The Trust Board is asked to endorse the policy.           Bev Atkinson Director of Nursing        

                SUNDERLAND TEACHING PRIMARY CARE TRUST                 CLINICAL AND NON-CLINICAL AUDIT POLICY                     APRIL 2005  

CONTROL INFORMATION      DOCUMENT NAME: CLINICAL AND NON-   CLINICAL AUDIT POLICY     DOCUMENT REFERENCE NUMBER:      AUTHOR: KATH LOWERY       SIGNATURE OF RATIFYING OFFICER:      DATE OF FIRST ISSUE: APRIL 2005       DOCUMENT HISTORY:       ISSUE NUMBER:       AMENDED DATE OF DOCUMENT:      RE-ISSUE DATE: APRIL 2008       TRAINING IMPLEMENTED:      AUDIT POLICY / PROCEDURE DATE:      PERSON RESPONSIBLE FOR AUDIT:          

  Sunderland Teaching Primary Care Trust   Clinical and Non-Clinical Audit Policy

 

    Brief Summary   This policy outlines the guiding principles for proceeding with audit in the Teaching Primary Care Trust to both strengthen the evidence base of clinical audit and non-clinical audit activity and explicitly demonstrating the quality of care/service being delivered. Clearly this document will also be shared with wider primary care for adoption and access to audit support and facilitation. Within this document the term audit will be utilised and this refers to both clinical and non-clinical audit. The term non-clinical audit is to encourage individual departments across the organisation assessing whether their identified activities are achieving standards for example the recruitment process, outcomes for training, it does not refer to the work of the Audit Committee which addresses financial and internal audit.   A process of validation will be carried out by the Research and Audit Committee to ensure;   •  quality of the project and a complete audit cycle; •  identify that service and corporate objectives in relation to audit are being achieved; •  identify dissemination and sharing of good practice approach; •  an appropriate centralised information resource to support the use of information; •  encouragement of staff to undertake and participate fully in the audit process with the right level of support.   Aims and Objectives   The overall aim of this policy is to deliver clear concise requirements for directly employed Teaching Primary Care Staff to follow when undertaking any audit activity.   The key objectives of this policy are to:   •  achieve a strong centralised evidence base of Teaching Primary Care Trust audit activity; •  to provide an accessible information resource to frontline staff sharing good practice; •  to ensure the quality of clinical service and practice is demonstrable;

•  identify and address gaps in the organisation audit work programme; •  utilise audit outcomes to progress service and clinical practice developments.   Introduction    Sunderland Teaching Primary Care Trust is committed to implementing an inclusive, organisational wide approach to audit. This policy provides clear guidance for all employed staff on the Trusts audit registration and approval procedure. Within the principle of good practice Sunderland Teaching Primary Care Trust share their policies and procedures with wider primary care for adoption this policy will also be shared and its application encouraged.   The term audit is often used in healthcare organisations. Publications and guidance from the Department of Health (DOH), The Commission for Audit and Inspection (CHAI) and the National Institute for Clinical Excellence (NICE) all outline the importance and usefulness of audit, as a result audit is now high on the agenda in many areas. All areas of healthcare not only the clinical side should be aware of the benefits of audit; all staff receive the same support from the audit team and are required to follow the same audit registration/approval process.   The principles of audit and the subsequent methodology can be applied equally across the healthcare sector. Audit is the objective assessment of areas of interest or concern; it can be carried out in all departments by staff of all levels. Audit is an important tool to review the overall quality of the work we do, it can demonstrate the protocols/procedures we use are satisfactory and that the information we need is recorded and dealt with to a high standard. Audit findings can be used to influence organisational development and lead to the improvement of services, it is therefore essential that all audits both clinical and non-clinical are undertaken in all departments and that the results of those audits are disseminated appropriately.   Principles of Good Practice   Audit will not usually require formal ethical approval and the Research and Audit Committee will advise on this matter. As we all in our everyday working adhere to ethical principles guided by our professional bodies, personal and or organisational ethos, staff will be advised to consider:   •  Is it necessary to collect the information - is the information/data not already available? •  Consent issues  where patients are involved how will you ensure that consent has been given? Have audit subjects been given the option to opt out?

•  Vulnerable groups  if the audit involves collecting data from vulnerable groups do they understand what is expected from them? Will parents or carers have to be informed? •  Sensitive information  will you be collecting sensitive information? Will this cause unnecessary distress? What support is available? •  Confidentiality  is the data you are collecting anonymous? •  Methods  methodologies employed should cause minimal possible disruption to staff/patients. •  Making use of information  any data collected must be used to improve services.   Implementing an Inclusive Approach to Audit   The Trust has the following in place:   •   Research and Audit Committee -The committee is a collective forum with membership from across the Trust and wider primary care team to influence and drive forward research and audit. It will play a key role in ensuring quality of audits through the registration process. Having a robust registration process in place will enable the tracking of audit activity, the re-audit cycle, the dissemination process and a centralised source of information for both frontline staff and corporate bodies to enable informed service and practice developments.   •   Audit Registration/Approval System   Audit taking place (by directly employed staff, students, and medical students or outside agencies) must be registered via the audit registration form (appendix 1) to gain approval. You also need to obtain the agreement of your line manager who is also required to sign the registration form.   •   Audit Database  The audit registration form will be used to develop and constantly update a database of audit activity going on throughout the Trust in order to share good practice across the City. This database will be the responsibility of the Clinical Governance, Research and Audit Department.   •   Audit Training   It is essential that all staff are competent and confident in carrying out audit, in order to train staff in the process of the audit cycle and audit methodology, audit workshops are offered on a monthly basis to all staff via the OD & Teaching Department.   Data Protection  - All Trust staff are expected (whether directly employed or holding honorary contracts) to be familiar with confidentiality and data protection policies and procedures. All audits must be reviewed for Data Protection issues. The eight principles of the Data Protection Act 1998 are outlined below.  

 

 Data must be fairly and lawfully processed 9 9  Personal data shall be obtained only for one or more specific and lawful purposes 9  Personal data shall be adequate, relevant and not excessive in relation to the purpose (s) for which they are processed.  Personal data shall be accurate and where necessary kept up to 9 date 9  Personal data processed for any purpose shall not be kept for longer than is necessary for its purpose. 9 Personal data shall be processed in accordance with the rights of   data subjects under the 1998 Data Protection Act 9  Appropriate technical and organisational measures shall be taken against unauthorised or unlawful processing of personal data and against accidental loss or damage to personal data 9  Personal data shall not be transferred to a Country outside the EEA, unless that country or territory ensures an adequate level of protection.   Caldicott Approval   In 1997 the Caldicott committee made a number of recommendations aimed at improving the way that the NHS handles and protects patient information. Audits using patient identifiable information must follow the Caldicott principles at all times and all audits must be reviewed for Caldicott issues. The six principles of Caldicott are outlined below. 9   Justify purpose(s)  - Individuals, departments and organisations must justify the purpose for which information is required. 9   Do not use patient identifiable information unless it is absolutely necessary  Information flows and uses must be assessed, patient identifiable information must be removed unless a genuine case can be made for its inclusion and there is no alternative. 9   Use the minimum necessary patient identifiable information  where patient identifiable information is considered essential, each individual item of information should be justified with the aim of reducing identifiable information. This includes the use of NHS number. 9   Access to patient identifiable information should be a strict need to know basis  Only those individuals who need access to patient identifiable information should have access to it and they should only have access to the items they need to see. 9   Everyone should be aware of their responsibilities   Action should be taken to ensure that those handling patient identifiable information (clinical and non clinical staff) are aware of their responsibilities and obligations with respect to confidentiality. 9   Understand and comply with the law  Such as Data Protection Act 1998, Access to Medical Records Act 1998.

  Audits involving the use of patient identifiable information may need Caldicott approval from the Trusts Caldicott Guardian.   •   Honorary Contracts   Audits being conducted by non NHS staff (e.g. drug companies) will require an honorary contract. Students (medical or non medical) will not require honorary contracts as universities must take responsibility of their students.   •   Dissemination of audit/audit results  - Details of all audits will be disseminated to all staff via the intranet, newsletters, clinical governance bulletin and the quarterly and annual audit reports. Key findings of audits will be fed to the Research and Audit Committee, the Clinical Governance Action Group, the Developing Excellence, Education and Learning Group, the Professional Executive Committee and the Board in order to act on any recommendations that have fallen out of the audit.   Responsibilities     It will be the responsibility of the Research and Audit Committee to provide validation of the audit registration proformas to provide a clear quality assurance process in relation to approved audits ensuring that the auditor/s are complying with the legal and quality issues.   The clinical audit facilitators have a clear responsibility to support and advise the auditor/s through the process of their audit and advise the committee of progress and seek their advice as appropriate. They will also be required to provide the committee of an annual audit trail demonstrating the effectiveness if the policy.   The lead auditor has a responsibility to register their audit and comply with the approval process.   This policy will be disseminated throughout the trust via Chief Executives Bulletin TPCT e-mail, inclusion in induction pack, clinical governance bulletin and intranet website as well as key directorate meetings.   Monitoring and Evaluation   On an annual basis line managers will be requested to identify all audits undertaken in their area and this will be mapped against those registered to identify compliance issues. An audit trail will identify the effectiveness of the policy to centralise information and dissemination.   Reference: http://www.healthcarecommission.org.uk/InformationForServiceProviders/Nation alClinicalAudit/AboutClinicalAudit/  

 

  http://www.hmso.gov.uk/acts/acts1998/19980029.htm    Mann T (1996) Clinical Audit in the NHS using Clinical Audit in the NHS: A position statement. Department of Health. Crown Stationery.   NICE (2002) Principles for best practice in Clinical Audit. National institute for Clinical Excellence. Radcliffe Press. Oxon.          

Appendix 1 Audit Registration Form     Please complete this form and return it to the Clinical Governance Department, Sunderland TPCT, Pemberton House, Colima Avenue, Sunderland Enterprise Park, Sunderland, SR5 3XB Audit Proposal    ..................     Audit Lead (name and contact details)      

Proposed Start Date Duration  .     Is this an Audit or a Baseline (no standards to measure against)?   Audit Baseline     Objectives of Audit / Baseline (aspects of care to be examined and measured)           Standards (what you will measure against)        

Will you be accessing patient records?   Yes No       Will you be collecting patient identifiable information?   Yes No     If you require assistance from the Clinical Audit Team what assistance is required?   Methodology Sampling Analys   Report writing Presentation Dissem nation     Key Milestones and projected time frame:    .     Dissemination and Sharing of final project:    .             Audit Lead Signature       Line Manager Signature