Meeting national
standards for clinical
audit
NHS Litigation Authority
Level 3 NHS Trust
Shared learning objectives
• Policy on procedural documents
• Audit plan
• Clinical effectiveness strategy
• Clinical effectiveness roles
• Evidence
Surprises
• Internal audit
• On the day
Audit plans
• Board level engagement: Audit & assurance committee; Trust
board
• Links with policy, strategy and is reflected in annual
publication of audit plan guidance
• Mid-year and end year review to check we were on track
across the organisation
• Audit report template adapted to form a standardised
template for policy monitoring
• Hospital transfusion committee
• Resuscitation committee
Clinical effectiveness strategy
Clinical audit policy: clear processes;
Governance team / policy monitoring
Education Agenda
Informs
National Guidance
Confidential enquiries
Clinical
Effectiveness
Activity
Higher quality
care
Improved outcomes
Lessons learnt from NCE and Audit
Informed
by
Risk
R&D
Care improved by Pathways and Guidelines
Risks reduced, changes in process
Clinical effectiveness roles
Director,
Clinical
Effectiveness
Central
Clinical
Effectiveness
Team
Divisional
and Care
Group
Management
Team
Clinical
Effectiveness
Leads /
Champions
Divisional
Governance
Manager
Internal audit
• Action plan from each audit
• Audit completion
• Audit proposal form completion
• Rationale behind clinical audits
• Review of audit results and dissemination of audit results
Evidence
• Audit reports
• Other records (minutes / agendas etc)
• Emails
• Newsletters (actions)
• Intranet
• Familiarity with policy monitoring requirements
Wash-up
Celebrate