Clinical Audit Plan: 2011-2012 – Updated 27/02/2012
Domain
Quality and
Management
Essential standards of quality and safety
Outcome
Comments
Outcome 16: Assessing and monitoring the quality of The Peninsula Community Health (PCH) Clinical Audit Plan
service provision
will be determined and monitored via the Clinical Quality &
Safety Committee based upon the four categories outlined on
page 2. It should be understood however that all clinical audits
undertaken by PCH staff should provide evidence for one or
more of the outcomes contained in Essential standards of
quality and safety (CQC 2010).
Introduction
The reinvigoration of clinical audit has been set as a priority by the Department of Health. In 2006 the Chief Medical Officers report ‘Good Doctors,
Safer Patients’ called for the reinvigoration of clinical audit to enable it to reach its potential as a rich source of information to support service
improvement, better information for patients and other activities such as the revalidation if clinicians. In February 2007 the White Paper ‘Trust
Assurance and Safety and in 2008 the Next Stage Review, ‘High Quality Care For All’ also recognised the crucial value of clinical audit in
assessing the quality of clinical care and maintaining high quality professional performance. In December 2009 (updated March 2010), the Care
Quality Commission (CQC) published Essential Standards of Quality and Safety to support the new registration regulations; Health and Social
Care Act 2008 (regulated activities) regulations 2009. These standards describe the essential standards of quality and safety the people who use
health and adult social care services have a right to expect.
Clinical Audit is defined as “A quality improvement process that seeks to improve patient care and outcomes through the systematic review of
care against explicit criteria and the implementation of change. Aspects of the structure, processes and outcomes of care are selected and
systematically evaluated against specific criteria. Where indicated, changes are implemented at an individual, team or service level and further
monitoring is used to confirm improvement in health care delivery”. (Principles of Best Practice in Clinical Audit – NICE 2002)
This plan is designed to be a working document and as such will be subject to amendments and additions throughout the year to reflect changes
to the organisation as well as changes to local and national priorities.
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Clinical Audit Plan 11/12
Development of the Clinical Audit Plan
Effective Clinical Audit is not a simple task and the pressure of incorporating complex requirements into an ever increasing workload presents yet
another demand on clinical time. It is therefore important for Peninsula Community Health to demonstrate a systematic approach to audit topic
selection, taking into account any organisational priorities and new government initiatives together with any local needs. This will ensure time is
spent efficiently by concentrating on well-structured audit projects that produce effective results and highlights areas of practice requiring change.
The aim is to increase audit activity across Peninsula Community Health and to reduce the number of poorly conducted audits that are often
unsupported, carried out under pressure, and on occasions never completed.
The Clinical Audit Plan will be determined by the Clinical Quality & Safety Committee based upon the four categories below:
1: External ‘must do’ audits: Failure to participate or deliver on these externally driven audits. These are externally monitored and assessed by
the CQC and in some areas by the local PCT commissioner.
• National Clinical Audit & Patient Outcome Programme (NCAPOP)
• Audits demonstrating compliance with regulation requirements e.g. NICE guidance, NSFs, NPSA alerts
• CQUINS and other commissioner priorities
• DH statutory requirements, e.g infection control monitoring
• External accreditation schemes, e.g., NHS Litigation Authority (NHSLA), Information Governance Toolkit (IGT)
2: Internal ‘must do’ audits: Priorities reflective of organisational objectives for clinical audit as outlined in the local clinical audit strategy or
strategic objectives
• Clinical risk issues
• Serious untoward incidents/adverse incidents
• Organisational clinical priorities
• Priorities identified via Patient and Public Involvement initiatives
• Complaints
• Access
• Patient Safety First Campaign
3: Service priorities
• Local clinical interest audit agreed by business units/services as a priority
• National audits not part of NCAPOP, e.g. some Royal College initiated projects that lie outside of NCAPOP
• Locally adopted clinical standards benchmarking e.g., Essence of Care
4: Clinician interest
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Clinical Audit Plan 11/12
KEY
Numbering system
Year / Priority / Audit number
G
Completed Projects
A
Projects underway but not completed
R
Projects over due / No information
received
Project cancelled/deferred
B
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Clinical Audit Plan 11/12
Service: Community Hospitals
Title
Clinical Record Keeping Audit- Nursing records
Lead(s)
Matrons
Clinical Record Keeping Audit- Doctors records
Matrons
Audit to demonstrate compliance with 28 days dispensing for
discharge, including medicines management and planning
Audit to provide evidence that all prescribing adheres to the locally
agreed joint formulary- in line with NPSA Alerts reviewed missed Doses
and quality of when required prescribing following recommendations
after CQC visit.
Audit to demonstrate the prudent and appropriate use of antibiotics in
line with the joint formulary
Audit to demonstrate compliance with and adherence to standard
operating procedures for controlled drugs
Audit of antipsychotic drug prescribing for patients in Community
Hospitals
Nursing Metrics
Ros Palmer / Matrons
Complete
Ros Palmer / Matrons
Complete and report finalised.
Action plan in place.
Prescription charts
Ros Palmer / Matrons
To reduce avoidable death, disability and chronic ill health from
Venous-thromboembolism (VTE) through risk assessment
Injectable Medicines (Alert 20)
Safe & Secure handling of medicines
Resuscitation equipment
Hand Hygiene -local
Anita Cornelius
Hand Hygiene -IPC nurses
Central Lines
Kitchen audit
Progress
Ros Palmer / Matrons
Ros Palmer / Matrons
Complete and report finalised
Ros Palmer / Matrons
Matrons
Ros Palmer
Ros Palmer
Hazel Renals
Sue Wright /
Matrons
Sue Wright /
Matrons
Sue Wright /
Matrons
Sue Wright /
Matrons
Complete and report finalised.
Action plan in place.
Complete
Complete
Complete
Complete
Complete
Complete
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Clinical Audit Plan 11/12
PPE audit
Cardiac arrest
Sue Wright /
Matrons
Sue Wright /
Matrons
Sue Wright /
Matrons
Sue Wright /
Matrons
Sue Wright /
Matrons
Karen Phillips / matrons
Do Not Attempt Resuscitation/Allow Natural Death documentation audit
Karen Phillips
Mattress audit
Sharps audit
Urinary catheters audit
Linen audit
Complete
Complete
Complete
Complete
Complete
Service: MIU units
Title
Clinical Record Keeping Audit
Lead(s)
Dee Hore
Progress
Complete
Title
Clinical Record Keeping Audit
Lead(s)
Val Derks
Progress
Complete
Hand Hygiene inspection
Sue Wright /
Val Derks
Sue Wright /
Val Derks
Sue Wright /
Val Derks
Sue Wright /
Val Derks
Sue Wright /
Val Derks
Sue Wright /
Val Derks
Complete
Service: District Nursing
Hand Hygiene observation
Hand Hygiene glow box
Central Lines
PPE audit
Mattress audit
Complete
Complete
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Clinical Audit Plan 11/12
Sharps audit
Sue Wright /
Val Derks
Sue Wright /
Val Derks
Urinary catheters audit
Complete
Service: Intermediate Care - CATS/RATS
Title
Clinical Record Keeping Audit
Lead(s)
Nicky Harvey / Sue Rogers
Progress
Complete
Intermediate Care National Audit
Nicky Harvey
Complete
Service: Cardiac Rehabilitation and Heart Failure Nurses
Title
Clinical Record Keeping Audit
Lead(s)
Gill Payne / Debbie Welsh
Progress
Complete
Service: Primary Care Liaison Nurses
Title
Clinical Record Keeping Audit
Lead(s)
Debbie Rees
Karen Clark
Sharon Ashby
Samuel Edwards
Alison Webb
Victoria Treddenick
Progress
Complete
Lead(s)
Nicci Kimpton
Progress
Complete
Service: Tissue Viability
Title
Clinical Record Keeping Audits
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Clinical Audit Plan 11/12
Service: Continence Specialist Nurses
Title
Clinical Record Keeping Audits
Continence Care
Enuresis Alarms
Lead(s)
Sharon Eustice
Sharon Eustice
Sharon Eustice
Progress
Complete
Complete
Complete
Title
Clinical Record Keeping Audits
Lead(s)
Deirdre Denn
Progress
Complete
COPD
Deirdre Denn
Service: Respiratory Nurses
Service: Diabetic Liaison Nurses
Title
Clinical Record Keeping Audits
Lead(s)
Caroline Dunstan
Progress
Complete
Lead(s)
Catherine Aitkenhead
Progress
Complete
Lead(s)
Joy Mulliner
Ally Hardman
Ally Hardman
Progress
Complete
Complete
complete
Lead(s)
Matt Englefield
Progress
Complete
Service: Health for the Homeless
Title
Clinical Record Keeping Audits
Service: Macmillan Nurses
Title
Clinical Record Keeping Audits
Preferred Place of Care
Liverpool care pathway After death analysis
Gold Standards Framework
Service: Acute Care at Home
Title
Clinical Record Keeping Audits
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Clinical Audit Plan 11/12
Service: Stroke Care Co-ordinators
Title
Clinical Record Keeping Audits
Lead(s)
Maggie Scott
Progress
Complete
Title
Clinical Record Keeping Audits
Lead(s)
Jax Dobell
Progress
Complete
Older people’s experiences of therapeutic
exercise
Jax Dobell
Complete
Service: Falls co-ordinators
Service: Parkinson’s Disease Specialist Nurses
Title
Clinical Record Keeping Audits
Parkinson’s referrals to therapy services
Parkinson’s Occupational Therapy
Parkinson’s Physiotherapy
Lead(s)
Lynne Osborne
Lynne Osborne / Katharine Stone
Julie Smith
Julie Smith
Progress
Complete
Complete
Complete
Complete
Service: Speech and Language (Adults)
Title
Clinical Record Keeping Audit
Lead(s)
Margaret Ray
Progress
Complete
To establish GP understanding of ASLT
service
Margaret Ray/Fran Brewer
Complete
Lead(s)
Julie Smith
Progress
Complete
Service: Occupational Therapy
Title
Clinical Record Keeping Audit
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Clinical Audit Plan 11/12
Service: Physiotherapy
Title
Clinical Record Keeping Audit
Lead(s)
Roz Collins
Progress
Complete
Title
Clinical Record Keeping Audits
Audit of nail re growths post nail surgery
with chemical ablation.
Referrals to podiatry specialist
musculoskeletal clinics
Hand hygiene – inspection; all clinics
Lead(s)
Tracey Willshee / Steve Enoch
Edwina Bottone
Progress
Complete
Complete
Beverly Bowring
Complete
Sue Wright / Steve Enoch
Ongoing
Hand hygiene – observation; RCHT clinics
Hand hygiene – observation; all other
clinics
PPE; all clinics
Sue Wright / Steve Enoch
Sue Wright / Steve Enoch
Ongoing
Ongoing
Service: Podiatry
Sue Wright / Steve Enoch
Service: MSK Interface Service
Title
Clinical Record Keeping Audits
Lead(s)
Progress
Complete
Lead(s)
Caroline Davey
Progress
Complete
Service: Elective Orthopaedics
Title
Clinical Record Keeping Audits
Service: TB nurses
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Clinical Audit Plan 11/12
Title
Lead(s)
Progress
Clinical Record Keeping Audits
Alison Blake
Complete
Lead(s)
Iona Loh
Progress
Ongoing not yet finalised
Lead(s)
Catherine Aitkenhead
Progress
Not complete for 2011-12.
Service: Dental
Title
Clinical Record Keeping Audits
Service: Acute GP Service
Title
Clinical Record Keeping Audits
Service: Musculoskeletal physiotherapy
Title
Clinical Record Keeping Audits
Staff Rapid Access to Physio Scheme
Lead(s)
Roz Collins
Maria Stickland / Lesley Pallett
Progress
The appropriateness of XR Ordering in an
Outpatient Physiotherapy Department
Jane Mitchell
Ongoing
Lead(s)
Karen Roach
Maggie Scott
Progress
Complete
Service: Stroke Therapy
Title
National Sentinel Stroke Audit
Stroke NICE Quality Standards
NHS Cornwall & Isles of Scilly – commissioning led audits affecting PCH services
Title
Stroke Improvement National Audit
Programme (SINAP)
Dementia
Lead(s)
Maggie Scott/Richard Barret (RCHT)
Progress
Bev Chapman / Kate Mitchell
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Clinical Audit Plan 11/12