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

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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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