Promoting quality for better health services

Best practice for laying the groundwork

Introduction

We know that undertaking national clinical audit, and making changes locally to improve care, poses specific challenges for organisations, clinicians and clinical audit staff.

If you participate in a national clinical audit you should be prepared to act on the results when they are published....

Creating the right environmentKey documents:

– Clinical audit policy – the rules of the game

– Clinical audit strategy – how you are going to win the game

– Clinical audit programme – the fixture list

Organisation and committees

– Roles and responsibilities

– Discussion and reporting

Motivation

– Clinical engagement

– Multidisciplinary working

– The Trust Board

Clinical Audit Policy

Should set out the principles, roles and responsibilities and practices you will follow

– How you plan and prioritise the programme

– What happens when things go wrong

Should be reviewed regularly to reflect best practice and national policy

Should be followed by everyone (NHSLA standard 2.1)

Should therefore be known about and understood by everyone

Implementation and effectiveness should be monitored

Clinical Audit StrategyShould describe how you will implement your policy,– to use clinical audit to improve the quality of services which you

provide,– and to meet the demands of healthcare regulators, healthcare

commissioners, patients and others.

Should set time-limited aims and objectives

Should connect clinical audit with your governance and assurance systems

Should take into account your corporate objectives and organisational risks

Progress in delivery should be monitored and reported to the Trust Board

Clinical Audit Programme

A working document or database under constant review

A prioritised list of ALL clinical audit activity in the trust

Tracking every audit from proposal to completion

– Completion includes implementation of actions and re-audit

It makes it possible to:– monitor the progress in completing the programme

– monitor the quality of clinical audit activity

– monitor the impact of the programme.

– meet the requirements for external monitoring

Engagement: the board

‘Clinical audit needs to be a strategic priority for board as part of their governance function’

‘Boards have a role in driving quality assurance, compliance…..and ‘closing the loop’

‘Trusts will be regulated and performance managed against their participation in clinical audit and the findings’

http://hqip.org.uk/assets/Guidance/HQIP-Clinical-Audit-Simple-Guide-online1.pdf

Engagement: the board cont.

Non- executive directors (NEDS)

One-day workshops which will cover the NED’s role in Quality Improvement and the use of clinical audit at board and audit committee level.

e-learning developed in association with MIAA

http://www.hqip.org.uk/guidance-support/clinical-audit-for-non-executive-directors.html

Engagement: other key stakeholders

Senior clinicians, managers and frontline clinical staff need to be involved at the start to promote commitment to national audit and have ownership of national audit projects.

Roles and responsibilities of the committees/groups that are involved in the prioritisation for participation in national audit ,and decisions about local audit and subsequent review of reports and re-audits should be documented.

Key messages

Planning is essential – ‘to fail to prepare is to prepare to fail’

Engage senior clinicians, board, managers and frontline clinical staff at the start to promote commitment to national audit and ownership of national audit projects.

Local best practice

Introduce local guest speaker

On your tables..Taking five minutes please:

introduce yourself

your role

the part you play in clinical audit

and using ‘post-it’ notes describe:

what is happening locally

the challenges you face

how you overcome them

what works well!!