Clinical Audit for Board
Assurance
Anne H Lawson
Director of Governance – HDFT
Visiting Fellow – Loughborough University
NHSFT Code of Governance
Directors are ultimately and
collectively responsible for all
aspects of the performance of the
Trust
How can they know?
The Balance
• Assurance or detailed knowledge
• Too much or too little
• Strategic or operational
• TRUST
• CHALLENGE
Role of Internal Audit
• Advising the Board of the adequacy and
effectiveness of overall arrangements
• Provide a coordinating role on assurance
issues
• Work closely with other reviewers
INTERNAL AUDIT
• Provides the Audit Committee with an
• “opinion on the overall adequacy and
effectiveness of the organisation’s risk
management, control and governance
processes”
WHY FOCUS ON CLINICAL AUDIT?
• The Audit Committee should consider
• “…how best to engage with clinical audit to meet its own
needs for assurance…”
• “..expect to see regular reports of the outcomes of Clinical
Audit work”
•
Audit Committee Handbook
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January 2010
SHOULD THE AUDIT COMMITTEE CONSIDER CLINICAL
GOVERNANCE ISSUES?
• “consider clinical objectives and risks in the
Assurance Framework”
•
Audit Committee Handbook
•
January 2010
Changes to the Audit committee
focus
• Challenging for non-execs who may have no
health background
• Challenging for trust clinical effectiveness and
audit staff.
Why do we carry out Audit?
Local Audit
Outcomes
against
standards
Learning for
staff
Comparison
with peers
Clinical
audit
local
Process
against
policy
Other
surveys
Patient
experience
surveys
National audit
Benchmarking of
organisational attributes
Audit of action
planning
Benchmarking of process
Clinical
audit
national
Gap
analysis
Benchmarking of outcomes
Assurance
CQC
External
Audit
NHSLA
Internal
Audit
HSE
regulation
Others
CPA
Monitor
HTA
Board of Directors
Assurance
CQC
Sub groups of
Board
Change
and reaudit
External
Audit
NHSLA
Internal
Audit
HSE
regulation
audit
Others
CPA
Monitor
Outcomes
against
standards
Learning for
staff
Benchmarking
of
organisational
attributes
Comparison
with peers
Clinical
audit
local
Audit of
action
planning
Process
against
policy
Other
surveys
Patient
experience
surveys
HTA
Gap
analysis
Clinical
audit
national
Benchmarking of
process
Benchmarking
of outcomes
Outcomes of audits
• For assurance
• Measure performance against a known
standard and facilitate improvement
• Benchmark performance against other
organisations
• To teach the practice/art of auditing (junior
doctors)
There is real gain to be realised
from Internal audit and clinical
audit working together although
each will always have their
particular remit.
Challenges
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We use different languages
We have different purposes for doing an audit
We report differently
We need to recognise diversity
We have different expected outcomes
Challenges
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Self assessment
Clinical Outcomes
Compliance
Evidence base
standards
• Independent view
• Systems and Controls
Levels of assurance
• Description of
compliance
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Full
Significant
Limited
None
Perceptions
• Board are nervous of limited assurance
• If worry area should expect gaps – make clear
expectation at start
• Re-audit WILL be for assurance purposes
• Do not drive the issues underground
False Assurance
If we have no limited assurances we have not
prioritised the correct areas
We can only ‘measure’ what we can measure.
Sources Of Assurance
examples
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Internal
Internal Audit
Clinical Audit
Assurance Framework
Governance Annual report
Robust reporting and
accountability structures
Performance Indicators
Self assessmentsresearch/information
governance, child protection
Complaints/incidents/claims
External
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NHSLA
National Audits
Audit Commission
Regulator – CQC/Monitor
Audit Office
College Visits
Deanery Visits
Cancer Peer Review
Performance Indicators
Benchmarking
Patient and Staff surveys
Standards to enable comparisons
DH & related Standards
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CQC
CQC reviews and reports
Independent reviews
Monitor
NICE Guidelines etc.
NHSLA Risk Management
Standards
Patient Safety Alerts
Health Service Circulars
Managers Code of Conduct
Other DH Standards e.g. Internal
Audit, IWL, etc.
Other ‘arms length’ bodies e.g.
National Patient Safety Agency,
MHRA, NHS Estates, etc.
National Confidential Enquiries
Other
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Independent reviews
Parliament - laws and regulations
Royal Colleges
Other professional organisations e.g.
IHM
Other UK health department related
e.g. Scottish Inter-Collegiate Network
(SIGN)
Regulatory bodies e.g. HSE
British & International Standards (BSI
& ISO)
Accreditation e.g. HQS, Trent,
Laboratories, etc.
Other independent healthcare
organisations e.g. ECRI
Investors in People (IIP)
Trade associations
Local policies etc.
Effectiveness and Outcomes
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CQUINS
Mortality rates– now on Choose and Book
CQC measurables
Safety measurables
Specialty audits
National audits
Nice
Other recommendations
Trust objectives
Assurance framework
• Used to let the Board know status of
organisation
• Informs the annual governance statement
• Identifies gaps in assurance
• Is a dynamic document used to update the
Board as to actions.
Assurance Framework
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Highest level for Board Assurance
Identify resource for gaps
Revisit it at Board after 6 months
Action Plan for leads
Should drive the working of the Board
Cross Check against progress
Evidence for Audit, CQC and Commissioners
Consultation
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Int audit set programme
Directors
Directorates
Clinicians
Regulation
Worry areas
Local interest
Planning the audit programme
• Must dos for external and internal audit – systems
and processes – for assurance
• Assurance framework and risk registers
• Gap analyses from national audits etc – audit to
determine progress
• Quality improvement work streams
• Regulators – CQC, Monitor
• NHSLA/CNST
• Worry areas where we do not exactly know the
problem
• Local – very clinical audit – for learning
Structuring the programme
• Pure Internal audit
• Joint Audits
• Pure clinical audits
– Trust wide
– Local
Prioritisation of audit
• Not
– When you know exactly what is wrong
– To gain investment
– To highlight an area
Joint audits
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Different starting points
Different language
Assurance versus other
Measures of success different
Challenges for reporting and scoring
Set the brief very carefully
Structure in HDFT
Board of Directors
Audit Committee
Quality and
Governance
Group
Standards Group
Clinical Effectiveness and Audit Group
Complaints and Risk
Management
(CORM)
Chief Executive
Director team
Standards
Group
Corporate Risk
Review Group
Clinical Effectiveness and
Audit Group
Clinical Effectiveness and Audit
Group
• Input from Specialty Leads for clinical team
and to support junior doctors
• Prioritisation of audit support
• Data-base of Audits
• Teaching of Audit methods
• Ensuring Change
• Sharing Good practice
Standards group
• Minutes from CEAG
• Clinical Audit report
• Gap analyses from National audits and national
recommendations/HLEs/ Confidential Enquiries
• Action Plan monitoring including CAS alerts and SUIs
• External visits and accreditations
• National data submissions
• Prioritisation of audit support to standards audits
• Audit Plan with CEAG
Audit Committee
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Minutes for standards
Internal audits and action plans
Standards report
Clinical audit report
Joint Audit plan – who and when
Corporate Risk register
Assurance framework and updates