Clinical Audit Annual Report
2006 - 2007
August 2007
Sophie Wiggins
Clinical Audit Lead
1.
Introduction
The Royal National Orthopaedic Hospital Trust is committed to delivering high
quality, evidence based care to its patients, and views Clinical Audit as a
valuable tool in achieving this.
For the majority of 2006/7, Clinical Audit support was limited. However,
following the appointment of a Clinical Audit Lead at the end of the financial
year, the Trust is making real improvements with Clinical Audit and it is hoped
that this will be reflected in the next annual report.
This report details the position of Clinical Audit during 2006/7, details plans for
2007/8, and gives details of some of the Trust wide audit carried out during
the year.
2.
Work Plan
2.1 Clinical Audit Database and Audit Registration
2006/7:
A central database of audit projects was designed in February and is now in
use. At the end of the year there were 23 registered projects, however it is
expected that this number will continue to rise significantly throughout the next
financial year as more medical audit activity is captured.
Key Targets for 2007/8:
 Accurate database of clinical audit activity
 Audit policy detailing need for clinicians to ensure that all projects are
registered on this database
 Copy of the findings of all audit projects is kept in a central location
 Redesigned, readily accessible project registration form
2.2 Reestablishment of Steering Group
2006/7:
The Clinical Audit Steering Group, a subgroup of the Clinical Governance
Board, has been inactive during the year. However the group was in the
process of being re-established, with core members identified and a meeting
scheduled to agree membership and terms of reference.
Key Targets for 2007/8:
 To approve Terms of Reference
 Act on behalf of the Clinical Governance Board to oversee clinical audit
strategy and policy
 Implement a Trust Clinical Audit Programme
2.3 Clinical Audit Strategy
2006/7:
There is currently a Strategy in place dating from 2003 which needs to be
updated in line with the Trusts current goals and objectives.
Key Targets for 2007/8:
 Strategy approved and implemented
2.4 Clinical Audit Policy
2006/7:
There is a policy detailing the processes for carrying out audit dating from
2003, however the policy no longer reflects practice within the Trust.
Key Targets for 2007/8:
 Clear and efficient audit structure supported by a formal audit policy
 Policy drafted and approved
 Implementation of policy
2.5 Clinical Audit and Research Presentations
2006/7:
Bi-monthly Clinical Audit and Research Presentations were carried out
throughout 2006/7. Topics included PACS, Child Protection, and Patient
Pathways.
Plan for 2007/8:
 Work will be undertaken to ensure the attendance of junior medical
staff at the presentations
2.6 NICE Guidance
2006/7:
The NICE database was updated this year to ensure that NICE guidance is
being adequately monitored, and work has also taken place in Pharmacy to
this end.
Plan for 2007/8:
 Policy drafted and approved
 Implementation of policy
3.
Trust Wide Audits 2006/7
3.1
Nursing Audit of Core Standards
Between January and March 2007 the Trust completed a nursing audit of core
standards. The audit aimed to improve the standard of care provided by the
Trust, and to create a set of standards by which ward managers can manage
the performance of their wards/areas in line with Standards for Better Health.
The audit report concluded that the Trust is currently at least partially
compliant with all of the domains and key standards in the toolkit, and shows
high compliance in one area: Safety A1 (Environment, Kitchens, Linen,
Waste, Sharps, Pt. Equipment, Hand Hygiene, Clinical Practice, Protective
Equipment)
Several areas of concern were highlighted. Three individual standards
received notably low scores, these were:


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The clinical area has an improving working lives action plan
Staff have access to washing facilities
There is a log of all staff signatures of multidisciplinary staff who make
an entrance into the health records: nurses, medical and AHP’s
There was also a generally low level of compliance with standards relating to
patient involvement. Improvements should initially focus on these areas.
Key Targets for 2007/8:


3.2
Develop and make changes to the audit tool
Look at combining the nursing audit with Essence of Care, the NSF for
Older People and the NSF for Long Term Conditions
Administration of Drugs during Preoperative Fasting
In March 2007, and audit was carried out which aimed to improve the quality
and efficiency of preoperative care by ensuring that nurses and SHOs are
aware of RNOH formulary and RCN guidelines in relation to the administration
of medications to fasting patients.
A questionnaire was sent to five randomly selected nurses on each ward.
Anonymous responses were returned to the project lead for analysis.
The results of this audit suggest that there is a need for increased awareness
of what should and should not be prescribed preoperatively. This will reduce
the number of patients who arrive in theatre not having received their
prescribed analgesia and other medications, thus improving the quality of the
patients care.
The recommendations made were:


3.3
Feedback audit results to staff
Increase awareness of the administration of drugs during preoperative
fasting
Audit of Awareness of NPSA Alert on Placement of NG Tubes
In 2007 and audit was carried out which aimed to ensure that the Trust in
compliant with NPSA guidance on the placement of NG tubes.
The NPSA audit tool was used to collect data from the wards regarding their
use of NG tubes. The findings of the audit demonstrated a lack of awareness
of all areas of NPSA recommendations with relation to NG tube placement,
and have highlighted the need for training in this area.
Sophie Wiggins
Clinical Audit Lead