Enclosure 13 - Clinical Audit Strategy - ES&Paper - BA

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Enclosure 13 Trust Board Meeting Agenda Item 5.10Wednesday, 28 January 2004 SUNDERLAND TEACHING PRIMARY CARE TRUST Draft Interim Clinical Audit Strategy Executive Summary 1. Introduction It is incumbent on the TPCT to ensure that it provides safe, effective and high quality services to its population. Arguably Clinical Audit not only provides the bedrock to clinical governance but also is a key mechanism to identify and exemplify quality of care. Therefore it is crucial to have a clear and workable strategy, which will embed Clinical Audit both within the TPCT and the wider primary care team. Supporting the continued development of the Clinical Audit work will be a Research and Audit Committee who will contribute to an annual Clinical Audit work plan informed by Corporate Objectives, results from Local Patient Surveys and recommendations from relevant sources (which include the Clinical Governance Action Committee, Risk Management Committee, Developing Excellence and Learning Committee, Primary Care and National Audit requirements). The Clinical Audit Strategy will make a significant contribution to the overarching Clinical Governance Strategy. 2. Content of the Draft Strategy Document The attached draft strategy has been developed to provide clear process and protocols to embed quality clinical audit ...

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• Publié par: Viej
• Nombre de lectures: 30
• Langue: English

Extrait

1

Enclosure 13

Trust Board Meeting

Wednesday, 28 January 2004

Agenda Item 5.10

SUNDERLAND TEACHING PRIMARY CARE TRUST

Draft Interim Clinical Audit Strategy

Executive Summary

1.

Introduction

It is incumbent on the TPCT to ensure that it provides safe, effective and

high quality services to its population. Arguably Clinical Audit not only

provides the bedrock to clinical governance but also is a key mechanism

to identify and exemplify quality of care. Therefore it is crucial to have a

clear and workable strategy, which will embed Clinical Audit both within

the TPCT and the wider primary care team. Supporting the continued

development of the Clinical Audit work will be a Research and Audit

Committee who will contribute to an annual Clinical Audit work plan

informed by Corporate Objectives, results from Local Patient Surveys

and recommendations from relevant sources (which include the Clinical

Governance

Action

Committee,

Risk

Management

Committee,

Developing Excellence and Learning Committee, Primary Care and

National Audit requirements). The Clinical Audit Strategy will make a

significant contribution to the overarching Clinical Governance Strategy.

2.

Content of the Draft Strategy Document

The attached draft strategy has been developed to provide clear process

and protocols to embed quality clinical audit in the TPCT and wider

primary care team. The processes provide a means to centralise clinical

audit activity information and the sharing of the outcomes of audit

activity. Importantly it also describes the establishment of a Research

and Audit Committee. Whilst the strategy will continue to be developed,

this should not compromise the adoption of this document in its current

format.

3.

Conclusions and Recommendations

The Trust Board is asked to consider and comment on the draft Interim

Clinical Audit Strategy and agree to adopt this interim strategy and the

establishment of a Research and Audit Committee. The Trust Board is

requested to endorse the strategy.

2

Bev Atkinson

Kathleen Lowery

Director of Nursing

Service Lead

Clinical Governance,

Research and Audit Service Lead

3

SUNDERLAND TEACHING PRIMARY CARE TRUST

DRAFT

INTERIM CLINICAL AUDIT STRATEGY

Introduction

Developing a co-ordinated and cohesive approach to clinical audit will help

Sunderland Teaching Primary Care Trust develop a comprehensive audit culture,

which will engage all staff as well as develop clinical audit programmes. Integral to

the successful implementation of Clinical Governance, this Clinical Audit Strategy

will ensure the successful delivery of clinical audits from topic selection to

dissemination of results. It addresses the provision of appropriate support and

direction for all professional groups in carrying out a clinical audit to demonstrate

and develop effective clinical care.

Background

What is Clinical Audit?

Clinical audit is defined as:

‘A quality improvement process that aims to improve patient care and outcomes by

carrying out a systematic review and implementing change. Aspects of patient

care including structure, processes and outcomes are selected and evaluated

against explicit criteria and, where necessary, changes are implemented at an

individual team or service level. Further monitoring can then be used to confirm

the improvements in healthcare delivery’

(Principles of Best Practice in Clinical Audit, NICE 2002)

‘Clinical audit involves systematically looking at the procedures used for diagnosis,

care and treatment, examining how associated resources are used and

investigating the effect care has on the outcome and quality of life for the patient.’

(Department of Health 1993)

Why is clinical audit important?

As an intrinsic part of clinical practice clinical audit provides the means to both

demonstrate and improve the quality of patient care in a collaborative and

systematic way. When conducted well, clinical audit provides an objective review

of the quality of care delivered, whether multi-disciplinary or profession specific,

and may subsequently lead to timely and effective development with appropriate

supportive mechanisms.

4

As part of local arrangements for clinical governance, all NHS organisations are

required to have a comprehensive programme of quality improvement activity that

includes clinicians participating fully in audit.

Clinical audit provides the

mechanisms for reviewing the quality of everyday care provided to patients. It

builds on a long history of healthcare professionals seeking ways to serve their

patients better and addresses quality issues systematically and explicitly, providing

reliable information. By doing these things, it can confirm the quality of clinical

services and highlight the need for continuous quality improvement. Clinical audit

is therefore vital for underpinning the success of services to patients.

Aims of the TCPT Clinical Audit Strategy

For clinical audit to become an important component of how we manage our

services the Trust needs to make a commitment to support audit as a mainstream

activity. Sunderland Teaching Primary Care Trust is committed to developing a

comprehensive clinical audit programme as part of its clinical governance

responsibilities.

To become

achievable and workable

, the Clinical Audit Strategy aims to:

•

Introduce an efficient, effective and clear process of clinical audit

throughout the Trust;

•

Ensure that the wider Primary Care Team are included in the Trust’s

clinical audit programme;

•

Encourage commitment to working in multi-disciplinary teams whilst

recognising single disciplinary audits will take place;

•

Ensure compliance with national mandatory audits (on request);

•

Consider outcomes of national audits and health priorities in Sunderland

to inform future areas for clinical audit;

•

Establish an audit committee to lead and influence clinical audit agenda;

(see appendix 1)

•

Continue supporting and commissioning audit with partner organisations

City Hospitals, Sunderland and South of Tyne and Wear Mental Health

to evidence standards of care for the people of Sunderland;

•

Enable the GP practices to contribute to City Wide audit related to

national priorities and NSF standards through disease registers and

coding templates.

The success of the above relies on effective and

inclusive communication

processes

, which will be underpinned by:

5

•

Key links across the TPCT to clinical governance/audit leads;

•

Effective communications regarding clinical audit projects and

outcomes using established mediums e.g., the intranet, Clinical

Governance Bulletins (CGB), local forums, publication and the

promotion of a local annual conference;

•

Effective communication regarding key developments or publications

and how they impact on the clinical audit agenda e.g. NICE

guidelines, NSFs, through the intranet site and CGB;

•

Collaboration

with

partner

organisations

through

reciprocal

membership of pertinent committees and forums;

•

Collaboration with Lead for Patient and Public Involvement City wide

to establish a process of public/patient involvement;

•

Collaboration of Disease Register Facilitators with coding and

template group to enable city wide communication of standard data

templates.

To support

an effective training programme

the strategy will promote:

•

The augmentation and dissemination of a robust clinical audit-training

programme for all Trust staff, and the wider workforce (involving

collaboration with the OD and training department with specific

targets);

•

Awareness of the clinical audit agenda through the work of Clinical

Audit Facilitators who will provide Trust wide support at an

organisational, team and individual level.

•

A workforce within the Trust and wider Primary Care Team who are

confident and competent in clinical audit;

•

The continued professional development of Clinical Audit Facilitators;

•

The application of coding templates in GP practices by Disease

Register Facilitators.

6

To enable

quality and planning

the clinical audit team, in line with their role, will:

●

Introduce a project registration process to the TPCT and wider Primary

Care Team.

●

Advise where required on the process and methodology to deliver robust

clinical audits.

•

Promote understanding of data quality and standardisation of data

collected;

●

Support and work towards patients and carers being engaged/consulted

from the design and planning stage of clinical audit in the TPCT.

•

Create and maintain a register/database of all clinical audits to:

o

Enable appropriate support and advice to be offered to all projects

within the healthcare professional community.

o

Locate and network the workforce and their evolving expertise

and experience.

o

Inform the training plan and capacity of the clinical audit team.

The strategy will promote the use of Information Technology

to enable, record

and disseminate

Clinical Audit by means of:

•

Online registration and paper registration recorded centrally and

available to staff;

•

Completed clinical audits accessible on the intranet site as a process of

dissemination (in tandem with the Clinical Governance Bulletin and such

Clinical governance events as the annual conference);

•

An on-line register of clinical audit leads and support identified by

expertise and available to staff;

•

Training materials available on the intranet (as well as in paper versions)

where required by Clinical Audit Facilitators and Disease Register

Facilitators.

•

Disease Register Facilitators maintaining the template website.

The process of achieving these aims in the first instance will be addressed in the

work plan (see appendix 2).

7

The Role of the Audit Team

TPCT clinical audit structure and related committees

The principal needs of the TPCT/Wider Primary Care Team will be addressed by

developing a competent and confident work force that carries out its own audits,

and by facilitating audits that are city wide. Two Clinical Audit Facilitators will be

responsible for training development and promoting confidence and competence

among staff. A city wide audit of specific disease areas, however, requires data to

be collected in a standard form. Two disease register facilitators will make this

possible by working closely with all GP practices and the coding team, and by

applying the standard coding template with an understanding of data quality and

consistency.

Research and Audit

Committee (see

appendix 1)

Service Lead for Clinical Governance

Research and Audit

Kath Lowery

Disease Register Facilitators

Nancy Davison

Jackie Storey

Clinical Audit

Facilitators

Claire Kelly

Joanne Moss

Clinical Governance

Action Committee

8

Appendix 1

Research and Audit Committee

The committee is being developed to provide a collective forum across the TPCT

and wider Primary Care to influence and drive forward the Research and Audit

Agenda. The purpose of the committee is to plan the annual work and support the

implementation of research and audit in practice.

The committee will be made up of a wide range of practitioners to include:-

¾

Professor Greg Reubin (Chair)

¾

Non Executive Director

¾

Service Lead Clinical Governance Research and Audit

¾

Research Facilitator

¾

Clinical Audit Facilitator

¾

Organisational Development Team

¾

Information Technology Team

¾

Wider Primary Care – GP’s, Dentist, Pharmacist and Optometrist

¾

Service Co-ordinator, Patient Carer and Public Involvement

¾

Trust Librarian

9

Appendix 2 Provisional Workplan January 04-April 05

Aim

Action

Timescale

Development

1. Introduce an efficient, effective and clear

process of clinical audit throughout the

Trust

(a-e)

.

2. Ensure that the wider Primary Care Team

are included in the Trusts clinical audit

programme

(c,d)

.

3. Encourage commitment to working in

multi-disciplinary

teams

whilst

recognising single disciplinary audits will

take place

(d,e)

.

4. Ensure

compliance

with

national

mandatory audits on request

(e)

.

5. Consider outcomes of national audits and

health priorities in Sunderland to inform

future areas for clinical audit

(g)

.

6. Establish

an

audit

committee

(see

appendix 1) to lead and influence clinical

audit agenda

(c,d,f)

.

7. Continue supporting and commissioning

audit with partner organisations City

Hospitals Sunderland and South of Tyne

and Wear Mental Health to evidence

standards of care for the people of

Sunderland

(d)

.

8. Enable the GP practices to contribute to

City

Wide

audit

related

to

national

priorities and NSF standards through

disease registers and coding templates.

a.

Establish a registration system in order to

keep a record of all audits taking place in the

Trust.

b.

Promote an infra-structure within the Clinical

Governance department to support audit.

c.

Identify

key

links

with

local

clinical

governance leads from all disciplines.

d.

Establish key links with audit staff from

partner organisations and extend across

partnership audits.

e.

Liaise with clinical leads from NSF’s to

identify

compliance

with

National

Audit

programmes for inclusion in annual research

and clinical audit plan.

f. Establish an audit and research committee.

g. Liaise with Clinical Leads eg NSF’s, TPCT

and Primary Care Team in order to ascertain

status of both national and local audits and

incorporate this within the STPCT clinical

audit plan.

a. February 2004

b. Ongoing

c. January 2004

d.

January 2004

e.

March 2004

f. Completed

g. March 2004

10

Communication

a. Set up key links across the TPCT to

clinical governance/audit leads

(a)

.

b. Support

effective

communications

regarding

clinical

audit

projects

and

outcomes using established mediums

e.g. the intranet, Clinical Governance

Bulletins (CGB), local forums, publication

as well as setting up a local annual

conference

(b,c,d,e)

.

c. Raise awareness of key developments or

publications and how they impact on the

clinical

audit

agenda

e.g.

NICE

guidelines, NSF’s, through the intranet

site and CGB

(a-f)

.

d. Promote

collaboration

with

partner

organisations

through

reciprocal

membership of pertinent committees and

forums

(h)

.

e. Collaborate with Lead for Patient and

Public Involvement to establish a process

for public/patient involvement

(a,e,g)

.

f. Disease Register Facilitators to liaise and

work with coding and template group to

enable

city

wide

communication

of

standard data templates.

a. Establish key links between the clinical

governance/audit facilitators and the clinical

governance leads for all areas across the

TPCT.

b. Provide regular reports and feedback to

clinical governance committees within the

TPCT.

c. Institute a clinical audit section on the clinical

governance homepage to inform all staff of

the Trusts policies regarding clinical audit.

d. Utilise Clinical Governance Bulletin to raise

awareness of NSFs/NICE etc.

e. Establish an audit and research committee.

f. Report back and provide feedback on audits

to relevant professionals in the area.

g. Work with the public and patient involvement

lead to establish mechanisms to encourage

public and patient inclusion and introduce

patient forums.

h. Establish key links with audit staff from

partner

organisations

in

extend

across

partnership audits.

a. January 2004

b.

Ongoing process

c.

January 2004

d.

January 2004

e.

Completed

f.

Ongoing

g.

Ongoing

h.

January 2004

11

Training

1. Augmentation and dissemination of a

robust clinical audit-training programme

for

all

Trust

staff,

and

the

wider

workforce, (involving collaboration with

the OD and training department with

specific targets)

(a-e)

.

2. Awareness of the clinical audit agenda

through

the

work

of

Clinical

Audit

facilitators who will provide Trust wide

support

(a-e)

.

3. Develop a workforce in the trust and

wider Primary Care Team who are

confident and competent in clinical audit

(a-e)

.

4. Support

the

continued

professional

development

of

the

Clinical

Audit

Facilitators

(f,g)

.

5. The application of coding templates in GP

Practices

by

Disease

Register

Facilitators.

a. Clinical audit facilitators will offer support in

the form of education, training and advice to

teams and individuals who are taking part in

the audit process.

b. Provide workshops in order to train all staff in

audit

methodology

and

clinical

audit

techniques on a regular basis. Firstly on a

basic level, progressing to intermediate and

advanced levels at a later stage.

c. Liaise with department heads to ensure that

each department has a trained member of

staff who can help with the undertaking of

audits and cascade audit information to the

rest of the team.

d. Develop a clinical audit advice pack which will

be available on-line and on hard copy for staff

who don’t have intranet access (appendix 3).

e. Facilitate mentorship programme enabling

staff who have undertaken audit to share their

experiences.

f. Combined

working

programmes

and

attendance of relevant conferences in order

to increase awareness of current audit

procedures.

g. Network with other audit facilitators.

a. Ongoing

b. Basic- February 2004

Intermediate– Aug 2005

Advanced– Feb 2006

c. February 2005

d. February 2004

e.August 2004 and ongoing

f. Ongoing

g. Ongoing