+ All Categories
Home > Documents > A Policy Statement from the Department of Health, Launched on July 2, 1993

A Policy Statement from the Department of Health, Launched on July 2, 1993

Date post: 01-Jan-2017
Category:
Upload: vananh
View: 213 times
Download: 0 times
Share this document with a friend
3
542 Clinical Audit A Policy Statement from the Department of Health, Launched on July 2, 1993 Clinical audit is widely recognised as the systematic and critical analysis of the quality of clinical care, including the procedures used for diagnosis, treatment and care, the associated use of resources and the resulting outcome and quality of life for the patient. This paper sets out the Department of Health’s policy for the development of multi- professional clinical audit, building on the existing systems of uni-professional audit introduced into the National Health Service in England as part of the NHS reforms. The term ‘clinical audit’ embraces the audit activities of all health care professionals, including nurses, doctors and other health care staff. General Principles The fundamental principles associated with audit are that it should: 0 Be professionally led. @Be seen as an educational process. 0 Form part of routine clinical practice. 0 Be based on the setting of standards. @Generate results that can be used to improve outcome of quality care. 0 Involve management in both the process and outcome of audit. 0 Be confidential at the individual patientklinician level. 0 Be informed by the views of patientslclients. Audit forms a central part of overall quality programmes and what consititutes quality of care is based on the values of individual professions, patients and communities. Such values set priorities and the tone and culture of the clinical environment, and determine how patients and their relatives ultimatelyjudge the outcome of their care. Background Medical audit is not new. The Confidential Enquiry into Maternal Deaths, for example, was established in 1952. The medical audit proposals in ‘Working for Patients’ sought to make systematic audit, undertaken by all doctors, a routine part of professionalpractice. This was a requirement for critical examination by peer review of local performance against accepted standards generated locally or nationally, followed by a change in practice where appropriate. To date more than €160 million has been invested in the development and implementation of medical audit in hospitals and community health services (HCHS) in England. Although the nursing and therapy professions (for example, physiotherapists and occupational therapists) have been involved in standard setting for many years, formal audit is relatively new. In 1991, following the introduction of the NHS reforms, the Department of Health set up a three-year programme to establish a framework for audit in each provider unit. To date a total of €18 million has been spent on the programme, to assist the professions in the development of their audit tools and mechanisms with the objective of improving the quality and outcome of patient care. Each Family Health Service Authority (FHSA)was required to set up a Medical Audit Advisory Group (MAAG) by April 1991, with the remit of encouragingevery practitioner to become involved in audit activity. MAAGs have adopted a variety of methods: assistance with practice audits; audit protocols; training for audit; local GP audit meetings. To date €42 million has been invested in this programme. Funding Since the introduction of medical and nursing and therapy audit programmes, funding for audit has been provided from ‘top sliced’ moneys and allocated by the Department of Health through Regional Health Authorities and the Royal Colleges. Audit funding eilocatlons (f million) Medical Primary Nursing/ HCHS care m@WY Total ~ ~~~~ 1989-91 28.0 5.0 - 33.0 1991-92 48.8 12.5 2.3 63.6 1992-93 42.1 12.5 7.2 61.8 1993-94 41.9 12.2 8.2 62.3 Totals 160.8 42.2 17.7 220.7 NB: f3.2 million has been provided in 1993/94 to ‘pump-prime’ multi-professional clinical audit. Central funds for medical audit in the HCHS are currently distributed through Regionsand Special Health Authorities (SHAs) based on whole time equivalent (wte) consultant numbers. FHSAs receive funding through their general administrative allocation to support the activity of the MAAGs. A central sum is retained for allocations to Royal Colleges and centrally funded projects of national significance. Physiotherapy, August 1993, vol79, no 8
Transcript
Page 1: A Policy Statement from the Department of Health, Launched on July 2, 1993

542

Clinical Audit A Policy Statement from the Department of Health, Launched on July 2, 1993

Clinical audit is widely recognised as the systematic and critical analysis of the quality of clinical care, including the procedures used for diagnosis, treatment and care, the associated use of resources and the resulting outcome and quality of life for the patient.

This paper sets out the Department of Health’s policy for the development of multi- professional clinical audit, building on the existing systems of uni-professional audit introduced into the National Health Service in England as part of the NHS reforms. The term ‘clinical audit’ embraces the audit activities of all health care professionals, including nurses, doctors and other health care staff.

General Principles The fundamental principles associated with audit are that it should: 0 Be professionally led. @Be seen as an educational process. 0 Form part of routine clinical practice. 0 Be based on the setting of standards. @Generate results that can be used to improve outcome of quality care. 0 Involve management in both the process and outcome of audit. 0 Be confidential at the individual patientklinician level. 0 Be informed by the views of patientslclients.

Audit forms a central part of overall quality programmes and what consititutes quality of care is based on the values of individual professions, patients and communities. Such values set priorities and the tone and culture of the clinical environment, and determine how patients and their relatives ultimately judge the outcome of their care.

Background Medical audit is not new. The Confidential Enquiry into Maternal Deaths, for example, was established in 1952. The medical audit proposals in ‘Working for Patients’ sought to make systematic audit, undertaken by all doctors, a routine part of professional practice. This was a requirement for critical examination by peer review of local performance against accepted standards generated locally or nationally, followed by a change in practice where appropriate. To date more than €160 million has been invested in the development and implementation of medical audit in hospitals and community health services (HCHS) in England.

Although the nursing and therapy professions (for example, physiotherapists and occupational therapists) have been involved in standard setting for many years, formal audit is relatively new. In 1991, following the introduction of the NHS reforms, the Department of Health set up a three-year programme to establish a framework for audit in each provider unit. To date a total of €18 million has been spent on the programme, to assist the

professions in the development of their audit tools and mechanisms with the objective of improving the quality and outcome of patient care.

Each Family Health Service Authority (FHSA) was required to set up a Medical Audit Advisory Group (MAAG) by April 1991, with the remit of encouraging every practitioner to become involved in audit activity. MAAGs have adopted a variety of methods: assistance with practice audits; audit protocols; training for audit; local GP audit meetings. To date €42 million has been invested in this programme.

Funding Since the introduction of medical and nursing and therapy audit programmes, funding for audit has been provided from ‘top sliced’ moneys and allocated by the Department of Health through Regional Health Authorities and the Royal Colleges.

Audit funding eilocatlons (f million)

Medical Primary Nursing/ HCHS care m@WY Total

~ ~~~~

1989-91 28.0 5.0 - 33.0

1991-92 48.8 12.5 2.3 63.6

1992-93 42.1 12.5 7.2 61.8

1993-94 41.9 12.2 8.2 62.3

Totals 160.8 42.2 17.7 220.7

NB: f3.2 million has been provided in 1993/94 to ‘pump-prime’ multi-professional clinical audit.

Central funds for medical audit in the HCHS are currently distributed through Regions and Special Health Authorities (SHAs) based on whole time equivalent (wte) consultant numbers. FHSAs receive funding through their general administrative allocation to support the activity of the MAAGs. A central sum is retained for allocations to Royal Colleges and centrally funded projects of national significance.

Physiotherapy, August 1993, vol79, no 8

Page 2: A Policy Statement from the Department of Health, Launched on July 2, 1993

543

Nursing and therapy audit moneys are allocated to Regions and SHAs based on a Department of Health revenue formula, with a small amount held centrally for funding projects of national significance.

Accountability and Monitoring At present Regions are required to submit plans and provide annual reports to the National Health Service Management Executive (NHSME) on progress with medical and nursing and therapy audit programmes. Where appropriate reports are expected to cover: 0 Finance. 0 Progress with previous year’s plans. 0 Audit activity. 0 Audit support staff. 0 Regional initiatives. 0 Forward plan for coming year.

NHSME approval of annual reports is required before moneys for the forthcoming year are released. From 199W94 onwards a single clinical audit report will be required. Reports are also required from those Royal Colleges receiving central funding for audit projects or work.

MAAGs are accountable to their FHSA.

Networking/inf rastructure Medical audit coordinators are employed on a Regional basis. A national committee, the Regional Medical Audit Coordinators Committee (RMACC) has been formed, which has links to the Department of Health. A similar group, the Regional Nursing and Therapy Audit Co- ordinators Committee, also meets regularly, both groups providing valuable fora for resolving practical problems including communication between Regions, establishment of a common data set and policy implementation. FHSAs have established MAAGs, which have adopted a variety of approaches to developing audit acitivity. MAAG members and support staff network locally, regionally and nationally by means of meetings, newsletters and journals.

Training for MAAG staff is organised on a local and national basis. Audit can identify training needs in practices and in some places there are close links with postgraduate education.

Most Royal Colleges have medical audit or quality of care committees to supervise the medical audit work. A Conference of Colleges Audit Subcommittees also meets to monitor and develop crosscollege audit activity. Links now exist between that body and the Regional coordinators group.

Collectively these groups form a comprehensive national network providing information exchange, a problem- solving arena and a system for promulgating good practice. They also contribute to the development of the role of audit in the new purchaserlprovider relationship forming a bridge for discussion between the professions and management.

Clinical audit relies on inputs from all its constituent groups in order to develop standards, manage the peer review process (either together or in unidisciplinary groups)

and to develop cross-specialty and interdisciplinary links. It either has or needs to develop close links and interactions with: 0 Management - including such aspects as resource management, risk management, quality assurance and total quality management (TQM). 0 Research and development (R&D) - to establish the effectiveness of intervention and in conjunction with national professional bodies to develop good practice standards, guide lines and protocols for local application.

0 Education - to develop audit methodologies and awareness as well as include good practice as part of the continuing education programme.

A key component of demonstrating quality of clinical care is identifying the benefit of care in terms of improved health, patient satisfaction and reassurance and improved quality of life, ie clinical outcome. Clinical outcome usually reflects the consequence of the collective efforts of a number of professionals, consequently while it was necessary, initially, to set up the audit programme on a uni-professional basis, there is now a need to move to a more integrated approach to audit. Therefore while uni-professional audit will continue to be essential, where a mix of professionals is involved in the care of patients, multi-professional audit has already become established, eg accident and emergency, psychiatry and medicine for the elderly, as audit on any other basis would have been of limited value.

Clinical Outcomes Group To give strategic direction to the development of multi- professional clinical audit, the Clinical Outcomes Group (COG) was established.

The COG, which is chaired jointly by the chief medical officer (CMO) and the chief nursing officer (CNO) held its first meeting in November 1992. Its membership is based on potential personal contribution and embraces a diverse range of disciplines and interests. Subjects now under consideration by sub-groups of the COG include the implications of multi-professional audit, management aspects of clinical audit, production of a clinical audit handbook, development of good practice guide lines and a national clinical quality centre, and the development of audit in primary care.

The public needs to be adequately represented in the audit process and therefore the COG membership includes two lay members.

The COG has been established to advise the CMO and CNO on the strategic direction of clinical audit and the development of methodologies to identify and achieve improved outcomes. The review of the future organisation and funding of clinical audit are part of the COG’S remit. The composition and terms of reference of the group will be reviewed towards the end of 1993.

Management implications Providers The chief executives of provider units have overall responsibility for the quality of care provided for patients and must therefore have confidence in the local audit

Phyrlotherapy, August 1993, vol79, no 8

Page 3: A Policy Statement from the Department of Health, Launched on July 2, 1993

544

programme. They must be assured that appropriate action is being taken in response to audit findings. Managers need therefore to be actively involved in the audit process, this being particularly important as deficiencies revealed by audit relate more often to the running of the organ- isation than to poor quality professional practice. The more managers are involved in the audit process and its organisation the more likely they will be committed to securing the necessary improvements in care.

For their part managers must recognise that some aspects of audit are best carried out in complete confidence by the professions concerned, thus ensuring that more sensitive issues are not avoided.

Purchasers Clinical audit should be the major plank in the complete quality assurance that purchasers require of the unit with which they place contracts. Purchasers have a right to know the arrangements in units and trusts for clinical audit, and level of participation by professional staff, the topics examined and improvements generated.

Production of robust outcome data is very important to both purchaser and provider managers, linked to the definition of standards and guide lines of care. Clinicians must therefore be directly involved in discussions between purchasers and providers.

Future Direction 1993194 will be the final year in which there will be separate central medical and nursing and therapy audit programmes, although the organisation and practice of professional audit may continue to be separate at unit and practitioner level. With the imminent move from single programmes, joint working and integration of the Regional

Medical Audit Co-ordinators Committee and the Nursing and Therapy Co-ordinators Committee is essential and membership will need to be broadened to take on expertise from within other professional groups.

In the longer term: 0 Audit will become largely multi-professional and part of a wider quality management programme that spans all aspects of care in hospitals and the community. 0 The management contribution to clinical audit will be enhanced. Generation of outcome data will be of little value unless that can be integrated into management processes.

0 Clinical audit must remain clinically led and educ- ationally based. The move to multi-professional working should take place at a pace which participants at local level find consistent with the development and acceptance of uni-professional standards and values. 0 The practice of audit remains a professional activity. Purchasers of health care, health service managers and patients however will increasingly influence the audit programme. 0 The general result of clinical audit will increasingly inform service development and contracting. 0 By continuing to prove its effectiveness, audit will become part of routine practice for all health care professionals and a normal expectation of those who commission and finance health care. 0 Understanding of the effectiveness of interventions will improve with increasing sophistication of outcome measurement and information systems.

OAudit will become an integral part of basic, under- graduate, postgraduate and continuing education.

Conclusions Over the past three years great energy and activity have been directed at the development of medical, nursing and therapy and primary care audit programmes. Effective harnessing of this energy into multi-professional clinical audit programmes will contribute greatly to continuing improvement in the quality of patient care.

The outcome, resulting from combining separate audit programmes, will be far greater than that achievable through the individual component parts.

A clinical audit approach, based on clear definitions, with emphasis on outcomes and quality of care, will provide a powerful multi-professional incentive to set the direction for purchasers and providers alike.

1993/94 is the last year in which separate central medical and nursing and therapy programmes will run. With the transfer of ‘top sliced’ moneys to the NHS general allocation from 1994/95 and the changing role and structure of Regions, it is essential that clinical audit continues to progress. The NHSME expects Regions to maintain and develop clinical audit and they will be held accountable in this area. Significant progress has been made during the first three years of the programme, but much remains to be done.

Physiotherapy, August 1993, vol79, no 8


Recommended