3-4. CLinical Audit Policy (2013-2016) · 1.1 The target audience The policy applies to anyone...

Doc Number :- CO-POL-82 Version 1 Status : Ratified

Clincial Audit Policy

Type of document : Policy CO-POL-82 Authorisation Groups: Clinical Audit Steering Group;; Quality Committee; Ratified by:

Quality Committee

Date Ratified:

10th January 2013

Date Processed:

25th September 2014

Review Date:

October 2014

Document Author:

Clinical Audit Manager

Document Owner:

Director of Clinical Care & Patient Safety

Authorised Signatory:

Signature of owner

Authorised Staff: All staff

Clinical Audit Policy



Contents

Section Page

1. Scope of Policy 1

2 Roles and Responsibilities 2

3. Policy Content 5

4 Equality and Diversity Statement 17

5. Consultation, Approval and Ratification Process 18

6 Review and Revision Arrangements 18

7. Dissemination and Implementation 18

8 Document Control Including Archiving Arrangements 19

9 Monitoring Compliance With and the Effectiveness of Procedural Documents 19

Appendix 1: NEAS Patient Information and Confidentiality leaflet 21

Appendix A: Version Control Sheet 22



1. Scope of Policy

1.1 The target audience

The policy applies to anyone engaged in the clinical audit process under the auspices of the

organisation and may include internal staff, students, external NHS and non-NHS staff and patients.

Clinical audit is a key feature of a well governed organisation and is a key tool for identifying

opportunities to change practice and to improve the quality of patient care.

Clinical audit underpins several quality improvement areas for the North East Ambulance Service

NHS Foundation Trust (NEAS), particularly:

Managing risk

Clinical governance

Benchmarking

Quality indicators for contracts and commissioning

Quality improvement of provider services

Staff development

The current accepted definition appears in Principles for Best Practice in Clinical Audit (National

Institute of Clinical Excellence, 2002):

“Clinical audit is a quality improvement process that seeks to improve patient care and outcomes

through systematic review of care against explicit criteria and the implementation of change. Aspects

of the structure, process and outcome 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 healthcare delivery”.



2 Roles and Responsibilities

The Clinical Care and Patient Safety directorate are responsible for the management of clinical audit

but other Trust employees also contribute through clinical practice review, direct patient care and/or

training, for example. Other organisations may also collaborate with NEAS by undertaking interface

clinical audits (clinical audits across more than one organisation).

Highlighted in sections 2.1 and 2.2 are the roles and responsibilities of those involved in clinical audit;

internal and external to the Trust.

2.1 North East Ambulance Service NHS Foundation Trust

2.1.1. Chief Executive

The Chief Executive is responsible for the statutory duty of quality and takes overall

responsibility for the standard of patient care that NEAS delivers to patients.

2.1.2 Board

According to the Healthcare Quality Improvement Partnership(HQIP) guidance document,

Clinical audit: a simple guide for NHS Boards and partners (2010) ‘the board’s role is to

ensure that clinical audit is strategic; it happens regularly; is clinically and cost effective; and is

linked to the Quality, Innovation, Productivity and Prevention (QIPP) agenda.’

The Board is responsible for ensuring that the Annual Clinical Audit Programme is aligned with

the Corporate Objectives. The Board receives presentations on the content of the Programme

and the Trust’s current operational clinical performance. The Board may interrogate the

quality and integrity of clinical audit data as well as seek assurance that action will be taken to

implement change, make and sustain improvements.

2.1.3 Audit Committee

The Audit Committee provides the Board with assurance that the final Clinical Audit

Programme, governance arrangements and effectiveness of the clinical audit function are all

fit for purpose. The Audit Committee are expected to sign-off the Clinical Audit Programme.

2.1.4 Quality Committee

The Clinical Audit Steering Group is directly accountable to the Quality Committee which is

responsible for ratifying this policy and reviewing the Clinical Audit Strategy. The Quality

Committee provides assurance to the Board that it is monitoring clinical care and patient

safety robustly through clinical audit and quality improvement. The Quality Committee also



challenges the clinical audit function to ensure the clinical audit policy is adhered to and the

strategy is delivered effectively.

2.1.5 Clinical Advisory Group

The Clinical Advisory Group provides assurances to the Quality Committee that best evidence

is applied in clinical protocols, guidelines and practices and uses clinical audit data to support

and influence decisions.

2.1.6 Clinical Audit Steering Group

The Clinical Audit Steering Group (CASG) is the corporate group tasked with overseeing the

Trust’s clinical audit activities. Any concerns raised by this Group are escalated to the Quality

Committee which feeds in to the Board. The CASG is responsible for reviewing this policy

either on an annual basis or following amendments made by the Clinical Audit Manager. The

CASG Terms of Reference can be located at: http://neasintranet.neas.northy.nhs.uk/clinical-

care-patient-safety/quality/terms-of-reference.aspx

2.1.7 Director of Clinical Care and Patient Safety

The Director of Clinical Care and Patient Safety provides overall assurance that the directorate

is fulfilling the internal and external requirements of clinical audit, drives quality assurance and

ensures that the recommendations of reviews and clinical audits are actioned by seeking

assurance that improvements in care have been made. The Director of Clinical Care and

Patient Safety also takes the responsibility of being the Caldicott Guardian for the Trust and

must approve any applications requiring Caldicott approval before the project can be

undertaken. The Director takes ownership of this policy and must ensure that the content

remains accurate and up to date.

2.1.8 Head of Clinical Care and Patient Safety

The Lead Clinician who manages clinical audit within the trust is the Head of Clinical Care and

Patient Safety and is strategically linked to the organisation’s mission and vision, with high

level leadership skills. The Lead Clinician has a national as well as a local profile, and

networks to drive integrated clinical audit.

2.1.9 Medical Director

The Medical Director provides support, guidance and direction to the Clinical Audit Steering

Group ensuring that the Clinical Audit Programme is relevant, audits are completed thoroughly

and any clinical issues are highlighted and reported to the Clinical Advisory Group.



2.1.10 Clinical Audit Manager

The Clinical Audit Manager is responsible for the overall management of clinical audit projects.

These include national, regional, local and interface audits. The Clinical Audit Manager is

responsible for every aspect of the clinical audit cycle, including the creation of the audit tool,

the analysis of data, the identification and dissemination of quality improvement initiatives and

the presentation of the projects. The Clinical Audit Manager also updates this policy to ensure

it remains valid and current.

2.1.11 Clinical Audit Assistants

The Clinical Audit Assistants are responsible for the provision of PRFs and other relevant

clinical records for clinical audit samples.

2.1.12 Quality Improvement Officers

The Quality Improvement Officers clinically review patient records to ensure that the standard

of care delivered is in accordance with Joint Royal College Ambulance Liaison Committee

(JRCALC) standards. The Quality Improvement Officers are responsible for driving the

standard of care delivered to patients through the implementation of quality improvement

initiatives. They provide support to operational staff and encourage engagement in clinical

audit and quality improvement.

2.1.13 Operational Staff

Operational paramedics are individually accountable for ensuring they audit their own practice

as defined by their codes of conduct. In section 2c: Critical evaluation of the impact of, or

response to, the registrant’s actions, of the Health and Care Professions Council (HCPC)

Standards of Proficiency for Paramedics (2007), it clearly states that:

‘Registrant Paramedics must:

- 2c.1 be able to monitor and review the ongoing effectiveness of planned activity and modify it

accordingly

- 2c.2 be able to audit, reflect on and review practice.’

Advanced Technicians are responsible for ensuring their knowledge and practice meets the

clinical standards required within their scope of practice.

2.1.14 Operational Team Leaders

The Operational Team Leaders are responsible for ensuring that service development and

delivery is underpinned by clinical audit and forms part of Continuing Professional

Development. Team Leaders are expected to feedback performance directly to individuals



and identify individual training needs, reinforce clinical guidelines and best practice and make

recommendations for quality improvement.

2.1.15 Divisional Operational Managers

The Operational Managers are responsible for ensuring that the Operational Team Leaders

are participating in clinical audit and are engaging their staff in the clinical audit process.

2.1.16 Lead Quality and Performance Officer

The Lead Quality and Performance Officer is responsible for the overall provision of call taker

audits including dissemination of work to auditors. The Lead provides a report to the CASG

on a bi-monthly basis which details staff performance and action plans arising from individual

audit performance.

2.1.17 Quality and Performance Officers

The Quality and Performance Officers undertake audits which are allocated to them by the

Lead and are responsible for managing their own workload. They are required to benchmark

the calls against the agreed NHS Pathways (NHSP) license criteria.

2.1.18 Information Governance Manager

The Information Governance Manager provides support and advice in the initial stages of

gaining Caldicott approval for external projects.

2.2 External to the Trust

2..2.1 The Project Lead

The Clinical Audit Lead is the person named as the Project Lead on the ‘Study Expression of

Interest’ form. They will liaise closely with the NEAS Clinical Audit Manager and will take full

responsibility for the project. The Project Lead must ask permission from the NEAS Clinical

Audit Manager before sharing any NEAS data or including information in journal articles. The

Project Lead must sign the Information Security and Confidentiality Agreement and adhere to

the Trust’s policies and procedures at all times.

3. Policy Content

National context

3.1 Key policy drivers



Clinical audit is driven by the political environment, the external, regulatory environment and public

demand for better health. Department of Health (DoH) White Papers and guidance provided by the

Healthcare Quality Improvement Partnership (HQIP) have helped shape clinical audit at NEAS.

Clinical audit has been reinforced and extended by a succession of key national publications,

including:

Taking Healthcare to the Patient: Transforming NHS Ambulance Services

(DoH, 2005)

Trust Assurance & Safety (DoH, 2007)

The NHS Next Stage Review Final Report, High Quality Care For All [the

‘Darzi Report’], (DoH, 2008)

The Healthy NHS Board ‘Principles for Good Governance’ (National

Leadership Council, 2010)

Equity and Excellence: Liberating the NHS (DoH, 2010)

Clinical Audit: A Simple Guide for NHS Boards and Partners (HQIP, 2010)

The Power of Information: Putting all of us in control of the health and care information we need

(DoH, 2012)

Regulators such as the Care Quality Commission (CQC) and Monitor, as well as assessors,

monitor the quality of care delivered to patients by NEAS employees.

3.1.1 Care Quality Commission

The Care Quality Commission (CQC) is the regulator of health and social care in England, and

make sure that people receive care which meets the Essential Standards of Quality and

Safety. National clinical audit results feed into the Quality and Risk Profile (QRP) which the

CQC uses to gather all the information it has about NEAS into one place. The CQC expect

changes to be made to care or treatment to reflect findings of clinical audits where necessary

(Regulation 10C).

According to ‘Clinical audit: a simple guide for NHS Boards and partners (HQIP, 2010)’, ‘the

CQC will look for professional engagement in clinical audit and assess whether the local

environment, created by the Board, enables participation in clinical audit activity to ensure that

organisations are embracing the full potential of these methods in informing service delivery’.



3.1.2 Monitor

Monitor is the independent regulator for NHS Foundation Trusts and uses a risk-based system

of regulation to inform them of the level of monitoring needed. One of the key conditions of the

Authorisation between Monitor and NEAS is that the Trust is required to put, and keep in

place, and comply with, arrangements for the purpose of monitoring and improving the quality

of healthcare provided by and for the Trust. An NHS Foundation Trust’s Authorisation is based

around good systems of finance and governance as well as clinical care and ‘commissioner

requested services’.

3.2 Purpose of this policy

3.2.1 Statement of purpose

The purpose of this policy is to set out a framework for the conduct of and participation in

clinical audit within the Trust. The policy also clarifies the roles and responsibilities of all staff

engaged in clinical audit activities, along with the processes and procedures to be followed,

both within the audit cycle and within the organisation and that appropriate change in practice

is made.

3.3 Definition of clinical audit

3.3.1 Locally accepted definition

Clinical audit can be described as a method of evaluating care through systematic review,

implementing best practice, encouraging professional development and assuring quality. At the

North East Ambulance Service (NEAS), both paper and electronic copies of the Patient Report

Forms (PRFs) are regularly audited against local and national standards to ensure that

documentation reflects best clinical practice and to provide assurance that patient safety is being

monitored.

All call operators including 999 and 111 staff are audited on a monthly basis against an evidence

based tool which is aligned to the NHS Pathways triage assessment system.

3.3.2 1Improvement and assurance

The Trust supports the view that whilst clinical audit is fundamentally a quality improvement

process, it also plays an important role in providing assurances to the Board and key

stakeholders about the quality of services.

3.4 Commitment to stakeholder engagement, collaboration and partnership



3.4.1 Involving patients and the public

NEAS promotes a commitment to the principle of involving patients in the clinical audit process

both directly to Governors, the Local Involvement Networks (LINks) Forum, and the

Experience, Complaints, Litigation, Incidents and PALS (ECLIPs) Group and indirectly through

the use of patient surveys and questionnaires.

The Clinical Audit Manager invites suggestions from LINks members and Governors to the

Annual Clinical Audit Programme. Up to two audit topics are added to the Programme as

‘Public Priority’ audits. Presentations are delivered by the Clinical Audit Manager to the public

representatives, informing them of the content of the Clinical Audit Programme and updating

them on national and local operational clinical performance.

Patients are involved in the development of the annual Quality Account which is informed by

clinical audit results and also participate in local and national patient satisfaction surveys in

order to continually improve the standard of patient care and the patient experience.

3.4.2 Multi-disciplinary and multi-professional audit, and partnership working with other

organisations

The Trust encourages clinical audit undertaken jointly across professions and across

organisational boundaries. Partnership working with other local and regional organisations will

be encouraged where improvements to the patient journey may be identified through shared

clinical audit activity. The Trust also encourages a multi-professional audit of clinical records

across all specialties to be regularly undertaken.

3.4.3 Involving Operational Staff

Quality improvement is an important aspect of clinical audit and it is essential that Operational

Management work in partnership with the Clinical Care and Patient Safety directorate in order

to use clinical audit findings to drive the quality of care.

3.4.4 Involving Medical Students

NEAS has a commitment to collaborative working with local academic bodies. For example,

Year 4 medical students may choose clinical audit for their SSC (Student Selected

Component) study module. Where this is the case, the Clinical Care and Patient Safety

directorate identifies a selection of clinical audit projects which are of local priority and asks

the medical students to choose which project they wish to undertake. However, in some

cases NEAS may have complete control over the choice of project, for example to re-audit an

area which may be overdue on the Clinical Audit Programme.



It is the responsibility of the medical students to identify the project aims and objectives, create

the audit tool and undertake the sampling, data collection and analysis. The students work

closely with the NEAS Clinical Audit Manager, the Quality Improvement Officers and are

asked to present their findings and recommendations to the Clinical Care and Patient Safety

directorate and members of the Education and Training team.

3.4.5 Working with commissioners

NEAS will continue to work proactively with commissioners in respect of clinical audits. The

audit programme will be developed in line with requirements and will endeavour to incorporate

specific audit requests from commissioners. Results and outcomes from clinical audits will be

shared with commissioners where they are requested and in line with national guidance.

NEAS and commissioners will work in collaboration to develop a CQUIN scheme. Where the

CQUIN scheme requires clinical audits to take place this will be developed into the overall

clinical audit programme and results of which will be shared with commissioners.

3.5 Choosing topics and planning projects

3.5.1 Agreeing an annual programme of activity

Prior to the start of every financial year, the Trust will agree an appropriate planned

programme of clinical audit activity. This programme meets the Trust’s corporate requirements

for assurance, and is owned by the Clinical Care and Patient Safety directorate. The proposed

annual programme is developed by the Clinical Audit Steering Group and ratified by the

Quality Committee before being reported to the Board. The previous programme is also

reviewed at the CASG to confirm that all audits have been undertaken and necessary

remedial action completed. If any audits are outstanding, the plan is reviewed and, if

necessary, is added to the next year’s programme as high priority audits.

The Annual Clinical Audit Programme considers both ‘bottom up’ (via clinical staff, patients,

etc.) and ‘top down’ (via commissioners and external bodies) requirements and is developed

to reflect national, regional and local priorities and also addresses local risks and concerns.

The National Clinical Performance Indicators (NCPIs), Ambulance Quality Indicators (AQIs)

and National Confidential Enquiries/Inquiries must be undertaken as high priority audits in

order to meet external regulatory requirements (HQIP Clinical Audit Programme Guidance

Tool, 2009).



3.5.2 Choosing and prioritising clinical audit topics

The NCPIs are agreed by Chief Executives, Directors of Clinical Care, Clinical Audit Leads

and other members of the National Ambulance Services Clinical Quality Group (NASCQG).

The AQIs were developed by Peter Bradley, National Ambulance Director, and Professor

Matthew Cooke, the National Clinical Director for Emergency Care and implemented in April

2011. They have been designed to look at the whole patient care pathway and promote a

culture of continuous improvement involving clinicians, managers and commissioners.

NEAS treats all national audits as ‘external must-do’ (high priority) audits and adopted the

Quality Impact Analysis (QIA) system for grading the priority of local clinical audit projects.

The Programme is informed by issues arising from incidents, patient complaints/compliments

or by direct involvement of patients (represented by Governors, LINks and ECLIPs members).

The Clinical Audit Manager also invites suggestions from all stakeholders during the third

quarter of each year to ensure the Programme is varied, unbiased and owned by all of its

stakeholders.

The Clinical Audit Manager must ensure that the resources and timeframe available can

satisfy the amount of audits proposed in the Programme and the Head of Clinical Care and

Patient Safety must provide sufficient resources in the clinical audit department to fulfil the

Programme.

Individual clinicians may initiate a clinical audit project on the basis of personal interest,

personal development or as part of an educational or training programme.

3.5.3 Audit Tools

Audit tools and technical manuals are provided by East Midlands Ambulance Service to help

guide and undertake the sampling and data collection of national audits.

For local audits, the Clinical Audit Manager will design and implement the most appropriate

tool for the audit and advises External Audit Leads on the best tool and method for

undertaking the audit project.

3.6 Governance of clinical audit

3.6.1 Systems for registering and approving audits

All clinical audit activity must be registered with the Clinical Care and Patient Safety directorate

irrespective of the level of facilitation being requested of the Department.



Proposals from other organisations must be supported with the Study Expression of Interest

form. The NEAS Clinical Audit Manager then assesses the project to identify for example its

purpose, relevance and the potential impact it may have on NEAS’ resources. If the Clinical

Care and Patient Safety directorate agree that the project will lead to benefits in patient care

through either quality assurance or quality improvement then the project will be informally

approved.

The project may require approval from the Information Governance Manager and the Caldicott

Guardian if it involves the use of patient identifiable information. In such cases, the project may

not commence until full Caldicott approval has been granted following completion of the

Caldicott Approval form.

The Clinical Audit Steering Group are informed of the projects and updated at every meeting.

Once the Group approve the project, details of the audit are then added to the Annual Clinical

Audit Programme to complete registration. It is customary for the Project Lead to present the

audit findings to the Group upon completion and also inform of re-audit plans.

3.6.2 Clinical Audit Checklist

To ensure the process for undertaking clinical audit projects is consistent, a clinical audit

checklist is completed for every clinical audit undertaken. The checklist ensures the Project

Lead is undertaking the audit in line with the approved process for audit as outlined in this

policy.

3.6.3 NHS Pathways

NHS Pathways capacity management system (NHSP) is a clinical content suite, uniquely

designed for use in the emergency or urgent care assessment telephone access point setting.

NHSP has been in operation at NEAS since 2006 and the NHS Pathways End User License

Agreement must be adhered to. (NHS Pathways, 2010)



3.6.4 The use of standards (or criteria) in clinical audit

Every clinical audit undertaken will be measured against standards that have been set either

nationally (based upon the best available evidence) or locally (agreed by the stakeholders, such

as the Medical Director or Head of Clinical Care and Patient Safety, which in the absence of

empirical evidence may be based on expert opinion supported by the NEAS Clinical Advisory

Group (CAG)).

The standards are expressed in a form that enables measurement, i.e. specific, measurable,

achievable, relevant and theoretically sound. The quality of patient care can then be measured

against the criteria and standards and performance can be expressed as a percentage against

these standards and if possible, against the previous audit results.

Under the terms and conditions of the NHSP license agreement, a minimum of 1% of the total

number of calls taken by the individual call handlers must be audited on a monthly basis. The

audits are targeted against the continuous quality improvement data (CQI) that identify actual

individual call taker performance against NEAS desired performance criteria in both the 999 and

111 contact centres.

The documentation of the patient records reflect the standard of care delivered to the patients.

It is therefore necessary to perform regular audits on the accuracy of record keeping since this

is used to inform the standard of clinical practice. The criteria cover legibility, attributability and

timeliness of entries. The results of the Data Quality Audits are presented to the Clinical Audit

Steering Group and the Data Quality Assurance Group.

3.7 Information governance: collection, storage and retention of data and

confidentiality

All clinical audit activity will be conducted in line with the Principles of the Data Protection Act

1998 (please refer to Data Protection Policy) in addition to the Caldicott Principles 1997 (please

refer to Caldicott Procedure).

This means, for example, that data shall be:

adequate, relevant and not excessive

accurate and where necessary, kept up-to-date

processed fairly and lawfully and in accordance with the specified purposes

managed and maintained securely



not kept for longer than is necessary.

In order to ensure that only the minimum necessary person-identifiable information is used,

NEAS will only collect records that are required for the audit. The Trust will also ensure that

access is on a restricted basis only and copies of the patients records are made so that the

Trust’s original copy is not removed. When collecting the data, audit tools are piloted and

validated and the specific criteria and standards are attached. Audit material is stored at

Headquarters in a locked cupboard with restricted access.

Clinical audit activity also conforms to the requirements of the NHS Confidentiality Code of

Practice (2003) which states that “Patients must be made aware that the information they give

may be recorded, may be shared in order to provide them with care, and may be used to

support local clinical audit”. At NEAS, patients are informed through the ‘Patient Information

and Confidentiality’ leaflet (see Appendix 1). Section 60 of the Health and Social Care Act 2001

makes provision for the collection of patient identifiable data for the purposes of clinical audit.

The leaflet also allows the patient to opt out of any involvement in clinical audit.

Clinical audit data collection sheets are anonymised and pseudonymised where possible (use

of random coding), so no personal data is disclosed. NEAS staff involved in clinical audit are

cleared by the Disclosure and Barring Service, have undertaken Information Governance

annual training and are made fully aware of the Confidentiality Code of Practice.

Any patient identifiable information that must be taken outside the Trust must receive Caldicott

and Information Governance approval, which in most cases requires information to be stored on

encrypted removable devices and destroyed following completion of the audit.

3.7.1 Confidentiality agreements

There may be occasions when an organisation engages individuals in its clinical audit activities

who are not directly employed by that organisation, e.g. staff who are on honorary contracts,

volunteers, patients and the public. It is important that they understand the “rules” which apply

to the practice of clinical audit, so training is an important consideration. It is also recommended

that individuals in this situation sign the Information Security and Confidentiality Agreement.

3.8 Clinical Audit Strategy: Operational Action Plan

Objectives are laid out in the Clinical Audit Strategy which describes the areas of clinical

practice that NEAS is committed to developing during 2011-2015. The operational action plan

develops each of the objectives to include an action, an action lead, the expected outcome



and the aspirations for the next 4 years. The operational action plan is a standing agenda

item on the Clinical Audit Steering Group and members are updated on the progress to date in

the delivery of the objectives.

3.9 Ethics and consent

Clinical audit is conducted within an ethical framework and considers the following four principles:

1. There is a benefit to existing or future patients or others that outweighs potential burdens or

risks.

2. Each patient’s right to self-determination is respected.

3. Each patient’s privacy and confidentiality are preserved.

4. The activity is fairly distributed across patient groups.

(HQIP Review of Ethics Issues related to Clinical Audit and Quality Improvement Activities,

2009)

3.10 Training and development

3.10.1 Overall organisational approach

NEAS is committed to the training and professional development of its staff and members of

the clinical audit team are encouraged and supported to undertake clinical audit training.

3.10.2 Provision of clinical audit training

Specific aspects of clinical audit require specialist skills to enable successful clinical audit, for

example using the correct clinical audit methodology and NEAS ensures that all clinicians and

other relevant staff conducting and/or managing clinical audits are given appropriate time,

knowledge and skills to facilitate the successful completion of the audit cycle.

NEAS will offer clinical audit training to those involved in the area, and external courses vary

from basic level to Post-Graduate.

The Clinical Audit Manager acts as an advisor to anyone wishing to undertake a clinical audit.

The Clinical Audit Manager will also make recommendations to staff wishing to undertake a

clinical audit related course to develop their skills.



The Quality Improvement Officers deliver clinical audit and quality improvement workshops to

all Operational Team Leaders.

3.10.3 Employment and development of clinical audit staff

The Trust will employ a team of suitably skilled clinical audit staff to support its programme of

clinical audit activity. The Trust will also ensure that staff have access to further relevant

training in order to maintain and develop their knowledge and skills.

3.10.4 Training Needs for Call Operators

All call taking staff must pass on average 80% of the total audits, if a call taker fails two or

more call audits per month a course of action is decided at the Audit Review Meeting, the

action relating specifically to the areas identified in the audits. The Team Leaders are

responsible for implementing the action plan with the individual call taker and carrying out any

additional audits required. The pass rate is 80% and failure to achieve this will result in the

individual being managed under the probation/capability procedures laid down by NEAS in line

with the Probationary Period Policy.

3.11 Reporting and dissemination of results

3.11.1 Reporting

On completion of the audit, a report is produced detailing the aims and objectives,

methodology, results, conclusions, recommendations and action plan and some reports may

contain additional sections. Form is a clinical audit report template.

The audit results are reported to all stakeholders including various groups and operational

management. Should an audit identify an element of risk or concern, a member of the audit

team will inform the relevant person e.g. Safeguarding Lead or Head of Clinical Care and

Patient Safety for appropriate action/escalation.

3.11.2 Dissemination

Clinical audit reports are shared and debated at the Clinical Audit Steering Group and action

plans are agreed along with a commitment to re-audit in a designated time frame. The reports

are also presented to the Clinical Advisory Group and/or Quality Committee. Other methods

of communication include face-to-face dissemination with Operational Team Leaders at Team

Leader Days and station visits, the NEAS intranet, the NEAS newsletter, Patient Care

Updates and email.



The Team Leaders in the contact centres are responsible for providing individual audit

feedback of call operator audits, this is carried out on a monthly basis and all feedback is

documented to provide evidence of feedback and to facilitate on-going performance

management.

3.11.3 Clinical audit annual report

The clinical audit annual report is produced and disseminated to the Quality Committee and the

Board at the end of each financial year and contains a summary of all the audits undertaken

along with quality improvement initiatives, their effectiveness and re-audit details.

3.12 Feedback, Action Plans and Re-audit

3.12.1 Feedback

Clinical audit facilitates the learning and development of operational staff. The Quality

Improvement Officer will identify where there has been a failure to provide the recommended

Bundle of Care which will be fed back to the individual directly, with the Team Leader notified

for information purposes.

The Quality Improvement Officers will identify where there has been a failure to provide the

recommended Bundle of Care which will be fed back to the individual directly, with the Team

Leader notified for information purposes.

3.12.2 Action plans

Where the results of a clinical audit indicate sub-optimal practice, an action plan is produced.

This plan includes details of the action required, the staff member responsible, the target date

for completion and the routes of escalation if difficulties in implementation are encountered.

NEAS ensures that action plans are specific, measurable and achievable. They have clear

implementation timescales with identified leads for each action. Action plans are approved by

the Head of Clinical Care and Patient Safety and in some cases by the Head of any additional

directorate that the action plan may involve.

Not all clinical audits will require an action plan e.g. where an audit shows that standards are

being met or guidance followed. For such audits an explicit statement saying ‘no further action

required’ in the audit summary report is recorded and a reason given for no re-audit.



The Clinical Audit Steering Group will monitor the implementation of actions relating to

operational clinical performance or call-taker performance. The Infection Prevention and

Control Group and the Medicines Management Group will monitor the action plans for their

associated audits. Each Group will then feed in to the Quality Committee and provide

assurances that action plans have been completed, and will monitor whether service

improvements have resulted.

Following the discussion of the national audit results at the Clinical Audit Steering Group, any

actions arising are logged in the Register of Outstanding Actions. These actions are then only

closed out once the Chair is satisfied that these have been completed. Actions arising from

local audits are logged in the ‘Action Plan Tracker’. This is a standing agenda item at the

Clinical Audit Steering Group meetings and again, actions are only closed out following the

Chair’s approval. If any actions exist on the Register of Outstanding Actions or Action Plan

Tracker which exceed 12 months these should then be reviewed, by exception only.

The Quality Improvement Officers also maintain an Annual Quality Improvement Plan to

organise and track quality improvement initiatives for the year. Any issues arising from clinical

audit will inform the Plan allowing the Officers to focus on specific clinical areas or target

particular stations.

3.12.3 Re-audit

NEAS believe that all first audits with a corresponding action plan should lead to re-audit in

order to identify if quality improvement initiatives have been successful, issues have been

resolved and the level of clinical care has not deteriorated. Local clinical audits are re-audited

until the standard of care reaches the local trajectory or if no trajectory has been set until the

Medical Director is satisfied that this audit can be replaced with a different topic and revisited in

24 months’ time.

3.13 Acknowledgements This policy has been guided by the Healthcare Quality Improvement Partnership (HQIP)

‘Template for Clinical Audit Policy’.

4 Equality and Diversity Statement

The Trust is committed to providing equality of opportunity, not only in its employment

practices but also in the services for which it is responsible. As such, this document has been

screened, and if necessary an Equality Impact Assessment has been carried out on this

document, to identify any potential discriminatory impact. If relevant, recommendations from



the assessment have been incorporated into the document and have been considered by the

approving committee. The Trust also values and respects the diversity of its employees and

the communities it serves. In applying this policy, the Trust will have due regard for the need

to:

Eliminate unlawful discrimination

Promote equality of opportunity

Provide for good relations between people of diverse groups

For further information on this, please contact the Equality and Diversity Department.

5. Consultation, Approval and Ratification Process 5.1 Consultation

This policy has been discussed with the Clinical Audit Steering Group.

5.2 Approval

This policy has been submitted to the Policy Review Group for approval.

5.3 Ratification

This policy has been approved by the Policy Review Group and submitted to the Quality Committee

for ratification.

6 Review and Revision Arrangements

The Policy will be reviewed annually or earlier if necessary as determined by local and

national changes to clinical audit.

The Quality Committee has overall responsibility for ratifying the Policy.

The Version Control of this Policy is outlined in Appendix A as per NEAS Policy and

Procedures.

7. Dissemination and Implementation

7.1 Dissemination

7.1.1 This Policy will be added to the Document Quality Control System of which all staff have

access to. Earlier versions of the document will be archived in the quality system.

7.1.2 All staff will be notified of new or revised documents via internal communications systems.



7.1.3 This document will also be included in the Publication Scheme for NEAS in compliance with

the FOI Act 2000.

7.2 Implementation

7.2.1 Information about this policy and changes to this will be communicated by the Clinical Care

and Patient Safety directorate and any other relevant Trust members.

7.2.2 The Policy will also be monitored through the Information Governance Toolkit (IGT).

7.3 Training

Training will be as outlined in section 3.10.

8 Document Control Including Archiving Arrangements

8.1 Register / library of procedural documents

All documents shall be held within the Trust Quality System and will be managed in line with

quality standards.

8.2 Archiving arrangement

Archiving of documents will be in line with the Records Management Policy.

9 Monitoring Compliance With and the Effectiveness of Procedural Documents

9.1 Monitoring the effectiveness of clinical audit activity

Clinical audit activity is monitored by the Clinical Audit Steering Group (CASG) who ensure

that the action plan has been achieved and the audit cycle completed. The Group also

monitor whether the Programme has been fulfilled for the year and if not, explore these areas,

such as additional resources. The Clinical Audit Manager reports progress into the Quality

Committee to provide assurance to the Board.

The CASG Annual Report details the main areas of work and main achievements in clinical

audit which demonstrates how effective clinical audit activity has been each year. The clinical

audit activity is also directly related to the CQUIN and the annual Quality Account.

The clinical audit department is audited internally through the NEAS Quality Management

System and externally by the World Quality Assurance (WQA) and Sunderland Internal Audit

Services whereby processes and procedures are audited and recommendations made to

ensure that clinical audit is being undertaken effectively within the service.



9.1.1 Monitoring the effectiveness of the policy

The effectiveness of the policy will be monitored internally through the Quality Management

System by the Quality Assurance Assistant and by the annual audit undertaken by the World

Quality Assurance (WQA) to ensure that clinical audit is being carried out exactly how it

should.

This policy is developed by the CASG and proposed for ratification to both the Policy Review

Group and the Quality Committee. The policy is reviewed on a biennial basis but may be

updated as and when required.

The Quality Committee will ensure that the following actions are undertaken:

its lead group for clinical audit is discharging its responsibilities

staff are receiving training

there is a rigorous system for determining what goes into the Annual Clinical

Audit Programme

stakeholders are being involved

projects are approved and registered

project are standards-based

projects are meeting data protection and confidentiality guidelines

results are being reported and disseminated

action plans are being agreed and implemented

timely progress reports are being sent to commissioners/key stakeholders.



Appendix 1: NEAS Patient Information and Confidentiality leaflet



Appendix A: Version Control Sheet

Version Date Author Status Comment

001 Sept 2011


Final

002 January 2013


Final

003 July 14 Clinical Audit Manager

Final

Did you print this document yourself?

Please be advised that the Trust discourages the retention of hard copies of policies and can only

guarantee that the policy on the Trust website is the most up-to-date version.

Document Location

The source of the document will be found in the Trust Quality System.

Freedom of Information Act 2000 Access

This document will be available via the NEAS Publication Scheme.

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