Portsmouth Hospitals NHS Trust
Clinical Audit Strategy
2015 – 2018
Clinical Audit Department
Portsmouth Hospitals NHS Trust
Clinical Audit Strategy 2015 - 2018
Page 1 of 13
Contents
Contents ...................................................................................................................................... 2
1.
Executive statement ........................................................................................................... 3
2.
Strategic aim....................................................................................................................... 3
3.
Scope .................................................................................................................................. 4
4.
Definition of clinical audit .................................................................................................. 4
5.
Organisational ‘Fit’ ............................................................................................................. 5
6.
Objectives ........................................................................................................................... 7
7.
Operational action plan...................................................................................................... 8
8.
Clinical audit programme ................................................................................................ 11
9.
Acknowledgements .......................................................................................................... 13
Version
1
Name of responsible (ratifying) committee
Clinical Effectiveness Steering Group
Date ratified
24 February 2015
Document Manager (job title)
Clinical Audit and Assurance Manager
Date issued
04 June 2015
Review date
01 December 2018
Electronic location
Corporate Strategies
Related Procedural Documents
Clinical Audit Policy
Key Words (to aid with searching)
Clinical Audit, Quality Improvement, Strategy, NICE,
National Audit, Governance
Version Tracking
Version
Date Ratified
1
24/02/2015
Portsmouth Hospitals NHS Trust
Clinical Audit Strategy 2015 - 2018
Brief Summary of Changes
Previous unpublished strategy reviewed and updated
removing references to the NHS Litigation Authority
standards and re-alignment with the revised HQIP
strategy template
Author
Clinical Audit
and Assurance
Manager
Page 2 of 13
1. Executive statement
Portsmouth Hospitals NHS Trust (the Trust) is committed to delivering effective clinical audit in
all the clinical services it provides. The Trust sees clinical audit as a cornerstone of its
arrangements for developing and maintaining high quality patient-centred services. It is
expected that this strategy will build on previous clinical audit strategies and will support and
complement the Quality Improvement Strategy and Quality Improvement Framework.
When carried out in accordance with best practice standards, clinical audit:
•
•
•
Provides assurance of compliance with clinical standards;
Identifies and minimises risk, waste and inefficiencies;
Improves the quality of care and patient outcomes.
The trust is committed to ensuring that clinical audit delivers these benefits, and has adopted
a policy on the governance and practice of clinical audit which applies to all staff (Clinical
Audit Policy).
Achieving the objectives set out in this strategy will ensure that the Trust policy is
implemented and effective, resulting in sustained improvements to the quality of care provided
to patients.
2. Strategic aim
The aim of this strategy is to ensure there is clarity over the use of clinical audit as a process
to embed clinical quality at all levels within the Trust over the next four years. It will aim to
deliver improvement in patient care and outcomes through the development and
measurement of evidence based practice, creating a culture that is committed to learning and
continuous organisational development.
This strategy will complement the strategic aims of the Trust to:
Deliver Safe, High Quality Patient Centred Care
•
Year on year improvement in national, local and quality account metrics.
•
Year on year reduction in avoidable harm.
•
Maintain compliance against Care Quality Commission outcomes.
•
Deliver good patient experience as measured by Friends and Family Test.
•
Consistently achieve all access standards in line with commissioning and
regulatory requirements.
•
Partner with other organisations to deliver joined up emergency care.
Develop A Reputation For Excellence In Innovation, Research & Development And
Education In The Top 20% Of Our Peers
•
Year on year increase in patient recruitment to clinical trials.
•
Implementation of the academic/innovation centre within PHT.
•
Become a hospital of choice within Wessex for trainees to wish to work in
Become The Hospital Of Choice For General, Specialist And Selected Tertiary Services
•
Maintain and grow referral practice from General Practitioner surgeries in the local
catchment area and beyond.
•
Maintain and grow specialist services with local national and international
reputation.
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Clinical Audit Strategy 2015 - 2018
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•
Maintain and grow Renal and Transplantation service to become centre of
excellence in the UK.
Staff Would Recommend The Trust As A Place To Work And A Place To Receive
Treatment
•
Staff ability to contribute towards improvements at work.
•
Staff recommendation of the Trust as a place to work or receive treatment.
•
Staff motivation at work.
Develop Sufficient Financial Strengths To Adapt To Change And Invest In The Future
•
Achieve a surplus in 2014/15 of at least £2m in 2014/15 and £4m in 2015/16.
•
Develop and update annually a fully Integrated Business Plan underpinned by
robust supporting strategies.
•
Be in a position to make a credible application to Monitor to become a Foundation
Trust in Q3 2014/15.
•
Develop Clinical Service Centres as fully functioning developed business units with
full profit and loss responsibility.
•
Re-align corporate services to support all of the above.
This will be underpinned by the Trusts vision to become the Best hospital, providing the Best
Care by the Best People using our core values:
•
Respect and dignity
•
Quality of Care
•
Working Together
•
Efficiency.
3. Scope
This strategy applies to all members of the Trust with responsibility for undertaking clinical
audit and those who are responsible for overseeing the direction and development of clinical
audit within the Trust. This will typically include members of the board, clinical and specialty
leads, managers, governance leads and members of the clinical audit department (CAD).
This strategy is overseen and directed by the Clinical Effectiveness Steering Group (CESG)
chaired by the Medical Director. The CESG is the corporate committee for monitoring and
encouraging all staff to conduct clinical audit as well as ensuring clinical audit is leading to
improvements and outcomes in the quality of care for patients.
The CAD are responsible for screening audit proposals to ensure sound methodology,
unnecessary repetition is avoided and that groups of patients are not over audited. The CAD
also offers teams and individuals support and guidance on all stages of a clinical audit project.
In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that
it may not be possible to adhere to all aspects of this document. In such circumstances, staff
should take advice from their manager and all possible action must be taken to maintain
ongoing patient and staff safety.
4. Definition of clinical audit
“Clinical audit is a quality improvement process that seeks to improve patient care and
outcomes through systematic review of care against explicit criteria and implementation of
change. Aspects of the structure, process and outcomes of care are selected and
systematically evaluated against explicit criteria. Where indicated, changes are implemented
Portsmouth Hospitals NHS Trust
Clinical Audit Strategy 2015 - 2018
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at an individual, team or service level and further monitoring is used to confirm improvement in
healthcare delivery.”1
“Clinical audit is a clinically-led initiative in which healthcare professionals compare actual
practice against agreed, documented, evidence-based standards with the intention of
modifying their practice where indicated, thereby improving patient care” (National Audit &
Governance Group).
Patient & Public
Involvement
What are we trying to
achieve?
SET STANDARDS
Benchmarking
Monitoring
Guidelines & Care
Pathways
Sharing
Process Redesign
Evidence
Outcomes
Consensus
Data Analysis
Have we made
things better?
Continuous
Quality Monitoring
Sampling
Are we achieving
it?
Questionnaire
Design
Data Collection
Benchmarking
Doing something to
make things better?
Continuous
Quality
Improvement
Process Re-design
Why are we not
achieving it?
Change
Management
Facillitation
Key Features of a Clinical Audit Cycle
1.
2.
3.
4.
5.
Preparing for audit
Selecting criteria
Measuring performance
Making improvements and
Sustaining improvements
Providing evidence of implemented actions and sustaining the changes from clinical audit is a
key fundamental. This can be demonstrated via re-audit or other systems to ensure changes
made have improved the quality of patient care.
5. Organisational ‘Fit’
It is important that clinical audit is not seen as an isolated quality improvement activity but as
one of a set of tools which teams and organisations can use to improve the quality of care that
is delivered to patients and their families. It is also important to consider the links to the wider
quality and governance frameworks that exist.
1
National Institute for Clinical Excellence. Principles for Best Practice in Clinical Audit. Abingdon: Radcliffe Medical
Press; 2002, p. 1.
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Clinical Audit Strategy 2015 - 2018
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Clinical audit (as a body of work) should contribute to the delivery of the Trusts corporate
objectives and its overall vision for:





Clinical governance (the framework through which NHS organisations are accountable
for continually improving the quality of their services and safeguarding high standards
of care by creating an environment in which excellence in clinical care will flourish)2
Corporate assurance (including the Care Quality Commission (CQC) – Essential
Standards3, meeting the statutory and mandatory requirements for clinical audit set out
in the clinical audit policy.
Integrated governance (systems, processes and behaviours by which organisations
lead, direct and control their functions in order to achieve organisational objectives,
safety and quality of service and in which they relate to patients and carers, the wider
community and partner organisations)4
Quality improvement and assurance including quality accounts.
Patient engagement/involvement either indirectly through the use of patient experience
surveys/questionnaires or issues/trends highlighted by patient complaints or directly
through participation of identified individuals on project steering/focus groups or patient
forums.
For the Trust as a provider organisation, clinical audit activity should reflect commissioners’
requirements and aspirations, e.g.:

Evidence for commissioning with regards to contractual requirements on locally agreed
measures to encourage quality improvement such as Commissioning for Quality and
Innovation (CQUIN) targets, which link income to the achievement of local quality
improvement goals.
Other areas which drive clinical audit in the Trust include:


Information Governance (IG), which ensures that clinical audit practice, meets the
requirements of IG best practice.
Research and development (R&D); working arrangements exist between the clinical
audit and R&D department with open communication to clarify details over projects
e.g. where doubt exists about whether a project is audit, research or service
evaluation.
The choice of clinical audit topics supports other key streams of governance and quality
activity, e.g.:



Clinical effectiveness and evidence-based practice.
Clinical risk management/patient safety topics in response to concerns highlighted by
adverse patient safety incidents.
Complaints and other forms of patient feedback.
Clinical audit relates to and supports the following:
2
Scally G, Donaldson LJ. Clinical governance and the drive for quality improvement in the new NHS in England. BMJ
1998;317:61–5.
3
Essential Standards of Quality and Safety, Care Quality Commission, March 2010. (http://www.cqc.org.uk/standards )
4
Deighan M, Bullivant J. Integrated Governance Handbook: A Handbook for Executives and Non-executives in
Healthcare Organisations. London: Department of Health; 2006.
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Clinical Audit Strategy 2015 - 2018
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









Consultant appraisal and revalidation/enabling clinicians to comply with their
professional codes of conduct.
Identified actions/themes arising from complaints and/or Serious Incidents Requiring
Investigation (SIRIs).
Membership councils/council of governors for foundation trusts (as per the duty to
involve patients and public).
Clinical Outcome Review Programmes5 (CORPs); the recommendations produced by
National Confidential Enquiry studies may point to the need for specific clinical audit
projects.
National Clinical Audit Outcomes Programme.
National Patient Safety Agency guidance.
National Service Frameworks, National Strategies.
National Institute for Health and Clinical Excellence (NICE) guidance in all its forms.
Service evaluation; recognising that clinical audit may form a part of service evaluation
projects.
Patient Reported Outcome Measures and Enhanced Recovery Programmes.
6. Objectives
 To maintain an audit programme and forward plan that reflects organisational need
prioritised upon the national clinical audit programme6. Ensuring the timely reporting of
outcomes and a local clinical audit programme based on current best evidence and good
practice guidelines, including concerns/trends from complaints, adverse or serious
incidents. The Trust must participate in national audit programmes to quality benchmark
services. This data is increasingly used by regulatory bodies, commissioners and patients
to benchmark our results/performance with other trusts and other peer groups.
 To ensure NICE guidance in all its forms is prioritised and used to produce audit topics for
the clinical audit programme to ensure evidence of clinical effectiveness and
implementation/ compliance with best practice guidance.
 To ensure organisational compliance with requirements identified within the national
quality agenda i.e. CQC, CORPs, NICE.
5
CORPs formerly known as The National Confidential Enquiry into Patient Outcome and Death (www.ncepod.org.uk );
6
HQIP, National Clinical Audit and Patient Outcomes Programme ( www.hqip.org.uk)
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Clinical Audit Strategy 2015 - 2018
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7. Operational action plan
Objective
To maintain an audit
programme and
forward plan that
reflects
organisational need
based upon the
national clinical audit
programme,
ensuring the timely
reporting of
outcomes and a
local clinical audit
programme based
on current best
evidence and good
practice guidelines,
including concerns/
trends from
complaints, adverse
or serious incidents.
Action
Specialty audit leads (SALs) to
produce /maintain a prioritised forward
annual specialty clinical audit
programme including re-audits (20%)
to ensure implemented actions have
improved patient care.
Annual forward clinical audit
programme approved by the
appropriate CSC governance
committee/leads
Trust wide annual forward clinical
audit programme is approved by the
CESG
SALs to ensure full participation in
National Audits as approved by the
Department of Health (DH) and the
National Clinical Audit and Patient
Outcomes Programme (NCAPOP) as
sponsored by the Healthcare Quality
Improvement Partnership (HQIP) and
required for the Trust Quality Account.
SALs or appointed leads to produce
clinical outcome data to benchmark
their service against national and local
peer groups
Lead
SALs
SALs
CESG
chair
SALs
SALs/
appointed
lead/
CESG
Specialty clinical audit annual report
to be produced
SALs
Trust wide annual clinical audit report
to be produced
CAD
To improve the requirement for
planned audit projects to be registered
and improve the number of completed
projects submitted to the clinical audit
Portsmouth Hospitals NHS Trust
Clinical Audit Strategy 2015 - 2018
SALs
Expected
outcome
Timescale
An audit
programme with
clear time frames
(proposed start and
finish times) and a
lead/ sponsor for
each audit
An approved and
validated forward
clinical audit
programme,
An approved and
validated forward
clinical audit
programme
Full participation in
National Audit
programme (nonparticipation signed
off by the Medical
Director/ CESG
chair).
Trust Quality
Account
compliance.
Specialty portfolio
of clinical outcome
achievements for
CESG and Trust
Board
Specialty clinical
audit annual report
containing
evidence of
implemented
improvements,
learning, benefits to
patient care
Annual report of
audit activity
outcome against
the forward annual
audit plan.
Improved evidence
of audit activity and
evidence of
outcomes/ results
Annually
Jan – Feb.
Annually
Feb March
Annually
March April
Annually
Quarterly
Annually
Jan - Feb
Annually
May June
Monthly
Page 8 of 13
Objective
Action
Lead
Expected
outcome
Timescale
department.
To ensure NICE
guidance in all its
forms is prioritised
and used to produce
audit topics for the
clinical audit
programme to
ensure evidence of
clinical effectiveness
and implementation/
compliance with best
practice guidance.
SALs to ensure a prioritised forward
rolling programme of audit topics
which address NICE guidance in all its
forms.
SALs and CSC governance leads to
be made aware of the appropriate
guidance impacting on their areas.
NICE guidance spreadsheets to be
updated regularly as new guidance is
published each month
Status report to be presented to
CESG
Ensure audit ID no.s are linked to
NICE guidance spreadsheets
Ensure partial/non compliant guidance
is escalated to Risk Registers
To ensure
organisational
compliance with
requirements
identified within the
national quality
agenda i.e CQC,
CORPs, NICE.
Ensure compliance with the Clinical
Audit Policy
Ensure compliance with the NICE
policy
Ensure compliance with the NCEs
policy
Ensure all audit activity fulfils the
‘Engagement in Clinical Audit’ Clinical
Priority Standard (CQC) in line with
the ‘Principles of Best Practice in
Clinical Audit’ (NICE 2002).
1. Evidence of participation in local
and/or national audits of the
treatment and outcomes for
patients in each clinical specialty
covered by the Trust, completing
all the five stages of audit cycle.
2. Have a current clinical audit
strategy and policy, and a
Portsmouth Hospitals NHS Trust
Clinical Audit Strategy 2015 - 2018
SALs
Programme of audit
prioritised against
NICE guidance
Annually
CAD/
SALs
/CSC
governance
leads
Programme of audit
prioritised against
NICE guidance
Monthly
CAD
CAD
CAD
CAD/
SALs
/CSC
governance
leads
CAD/
SALs
CAD/
SALs
Evidence of trust
compliance against
each published
NICE guidance
Summary of trust
compliance against
each published
NICE guidance.
Evidence of audit
activity against
NICE guidance
Monthly
Quarterly
Monthly
Monitoring and
controls in place
Monthly
Policy in date
Annually
Policy in date
Annually
CAD
Policy in date
Annually
CAD
CQC compliance
Annually
CAD/
SALs
Clinical audit
programme.
SALs
Specialty clinical
audit annual report
Annually
Jan-Feb
National and local
clinical audit
database
Complete,
ongoing
Ratified clinical
audit policy
Complete
CAD
CAD
April March
Page 9 of 13
Objective
Action
prioritised programme that relates
to both local and national
priorities with the overall main
aim of improving patient
outcomes.
3. Have in place suitable
governance systems and
arrangements to involve and
support all clinicians to participate
in clinical audit and ensure that
there are clear systems for
undertaking clinical audits and
there is local clinical audit
expertise available.
Lead
Expected
outcome
Timescale
CAD
Ratified clinical
audit strategy
Complete
CAD/
SALs
Clinical audit
programme.
CAD
CAD
CAD
CAD
4. Ensure that all clinicians and
other staff responsible for or
participating in clinical audits are
given appropriate time,
knowledge and skills to facilitate
the successful completion of an
audit.
CAD
HR
workforce
5. Review the results and
recommendations of local and
national audits undertaken in the
trust, as well as other relevant
national findings, to identify
required actions and ensure they
are reflected in the organisation's
aims and objectives as part of the
trust's responsibility to quality
improvement.
6. Ensure management or
governance leads monitor the
progress being made in
implementing the
recommendations of relevant
national clinical audits and other
national findings, including
reviews of the outcomes and any
re-audits being conducted where
necessary.
Portsmouth Hospitals NHS Trust
Clinical Audit Strategy 2015 - 2018
CESG
CESG
SALs/
CSC governance
leads
April March
One to one
advice/training and
consultation service
available
Ratified clinical
audit policy
Ongoing
Complete
Complete,
ongoing
Clinical audit
intranet site
Central clinical
audit database
One to one
advice/training and
consultation service
available from
CAD.
Supporting
Professional
Activities (SPA) for
quality
improvement
projects as part of
clinician job plans
Programme of
outcome review via
CESG and annual
clinical audit report
Complete,
ongoing
Ongoing
Ongoing
Annually
CESG reports to
Governance and
Quality/Trust Board
Quarterly
Specialty reporting
to clinical service
centre governance
meetings, including
submission of
specialty annual
reports.
Annually
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8. Clinical audit programme
The Trust will produce an annual clinical audit programme which will be prioritised and
focussed within the following areas:
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Clinical Audit Strategy 2015 - 2018
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Clinical Audit Strategy 2015 - 2018
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9. Acknowledgements
Healthcare Quality Improvement Partnership template clinical audit strategy.
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Clinical Audit Strategy 2015 - 2018
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