Clinical Audit Policy Clinical Audit Policy Version 2 December 2016 SH NCP 6 Clinical Audit Policy...

1 Clinical Audit Policy Version 2 December 2016

SH NCP 6

Clinical Audit Policy

Version: 2

Summary:

The purpose of this policy is to develop and sustain a culture of best practice in clinical audit within Southern Health NHS Foundation Trust. The policy clarifies the roles and responsibilities of all staff engaged in clinical audit activities.

Keywords (minimum of 5): (To assist policy search engine)

Clinical audit, national audit, audit programme, quality improvement, quality assurance

Target Audience:

All SHFT staff who are required to participate in clinical audits

Next Review Date: December 2020

Approved & Ratified by:

Clinical Effectiveness Group

Date of meeting: 25 October 2016

Date issued:

December 2016

Author:

Helen Alger, Clinical Audit facilitator

Sponsor:

Julie Dawes, Director of Nursing and Quality

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Version Control

Change Record

Date Author Version Page Reason for Change

May 2012 Tracey McKenzie 1.0 All Integration of old HPFT and HCHC policies

April 2015 Tracey McKenzie 1.0 All Extend review date from May to Sept 2015

September 2015 Tracey McKenzie 1.0 All Review date extended to December 2015

December 2015 Tracey McKenzie 1.0 All Review date extended to February 2016

August 2016 Helen Alger 2 All Scheduled policy review

September 2016 Helen Alger 2 6 Changes to Duties and Responsibilities

November 2016 Helen Alger 2 11 Changes to responsibilities for actions

Reviewers/contributors

Name Position Version Reviewed & Date

Helen Alger Clinical Audit facilitator August 2016

Paula Hull Divisional Director of Nursing & AHP August 2016

Sara Courtney Acting Director of Nursing and Allied Health Professionals

August 2016

Debra Moore Deputy Director of Nursing - MH, LD August 2016 Sara Constantine Consultant Psychiatrist, Psychiatry of Older Adults August 2016 Mayura Deshpande Clinical Service Director, Adult MH August 2016 Jennifer Dolman Clinical Director, Community Learning Disability

Team August 2016

Peter Hockey Consultant Respiratory Physician and Clinical Director

August 2016

Mary Kloer Interim Clinical Director Adult Mental Health August 2016 Juanita Pascual Clinical Director North and Mid Hampshire August 2016 Amanda Taylor Consultant Forensic Psychiatrist / Clinical Service

Director, Adult Mental Health August 2016

Theresa Lewis Lead Nurse Infection Prevention and Control August 2016 Julia Lake Deputy Head of Professions, LNFH August 2016 Susanna Preedy Head of Nursing & Allied Health Professionals,

(Mid-West Hampshire) August 2016

Caz Maclean Associate Director of Safeguarding August 2016 Patrick Carrol Integration Project Manager, Business

Development August 2016

Neil Langridge clinical lead physiotherapist August 2016 Gina Winterbates Head of Nursing and AHP's, August 2016 Liz Taylor Associate Director for Nursing & AHP Childrens

Service August 2016

John Stagg Associate Director of Nursing, AHP & Quality (Learning Disabilities)

August 2016

Tracey Mckenzie Head of Compliance, Assurance & Quality August 2016 Sophie Tomkins Clinical Audit facilitator August 2016

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Contents

Page

1. Introduction 4 2. Scope 5 3. Definitions 6 4. Duties/ responsibilities 6 5. Clinical Audit Process 8 5.1 – Distinguishing Between Clinical Audit, Data Collection and

Research 9

5.2 – Agreeing an annual programme of activity 9

5.3 – Working with Commissioners 9

5.4 – Choosing and prioritising local clinical audits 9

5.5 – Systems for registering and approving audits 10

5.6 – Use of databases 10

5.7 – Use of standards (or criteria) in clinical audit 10

5.8 – Reporting 10

5.9 – Dissemination 10

5.10 – Action plans for improvement 11

5.11 – Re-audit 11

5.12 – Clinical audit annual report 11

5.13 – Ethics and consent 12

5.14 – Equality & diversity 12

5.15 – Information Governance: collection, storage and retention of data and confidentiality

13

6. Training requirements 13

6.1 – Overall organisation approach 13

6.2 – Provision of clinical audit training 13

6.3 – Employment and development of clinical audit staff 14

7. Monitoring compliance 14 8. Policy review 14 9. Associated documents 14

10. Supporting references 15

Appendices A1 Training Needs Analysis (TNA) 16 A2 Equality Impact Assessment (EqIA) 17

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Clinical Audit Policy 1. Introduction 1.1 The purpose of this policy is to develop and sustain a culture of best practice in

clinical audit within Southern Health NHS Foundation Trust (hereafter known as ‘The Trust’). The policy clarifies the roles and responsibilities of all staff engaged in clinical audit activities.

1.2 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. 1.3 The importance which the Department of Health and healthcare regulators attach to

effective clinical audit is shown by the extent to which participation in national and local clinical audit is now a statutory and contractual requirement for healthcare providers.

1.4 The NHS standard contracts for acute hospital, mental health, community and

ambulance services 2016/17 cover agreements between commissioners and all providers delivering NHS funded services. It states that Trusts must implement all relevant recommendations of any appropriate clinical audit.

1.5 In addition to this contractual requirement, the regulatory framework operated by the

Care Quality Commission (CQC) assesses organisations on whether the services provided are safe and effective. Clinical audit is a way of monitoring our services against these criteria and to ensure that the standard of care provided comply with national guidelines and local policies.

1.6 The Board is required by NHS Improvement to certify that they have effective

arrangements in place for the purpose of monitoring and continually improving the quality of healthcare provided to patients, and must therefore ensure they have in place systems processes and procedures to monitor, audit and improve quality.

1.7 The National Health Service (Quality Account) Regulations 2010 requires healthcare

providers to produce an annual Quality Account, which must include information on participation in national and local audits, and the actions that have been taken to improve services, as a result of the audit. The Quality Account must identify quality improvement priorities to be achieved in the following financial year. Clinical Audit is used to demonstrate improvements in these areas.

1.8 The NHSLA Risk management Standards 2013/14 requires all scheme members to

have ‘an approved documented process for making sure that all clinical audits are undertaken, completed and reported on in a systematic manner’. As a minimum, the approved documentation must include a description of the:

a) Duties

b) How the organisation sets priorities for audit, including local and national requirements

c) Requirement that audits are conducted in line with the approved process for audit

d) How audit reports are shared

e) Format for all audit reports, including methodology, conclusions, action plans, etc.

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f) How the organisation makes improvements

g) How the organisation monitors action plans and carries out re-audits

h) How the organisation monitors compliance with all of the above. This policy is designed to fulfil these requirements, and all staff are required to ensure that any clinical audits they undertake are conducted in line with this policy.

1.9 The Trust supports the view that whilst Clinical Audit is fundamentally a quality

improvement process, it also plays an important role in providing assurances about the quality of services.

1.10 The Trust considers that the prime responsibility for auditing clinical care lies with the

clinicians who provide that care. The Trust is committed to supporting clinicians who carry out clinical audit by providing advice and assistance from appropriately trained and experienced clinical audit staff, and advice and training in clinical audit processes and practice. Appropriate advice and training will also be made available to non-clinical staff and patients who may be involved in clinical audit projects.

1.11 In addition, the Trust is committed to ensuring that:

It participates in all national clinical audits, national confidential enquiries and inquiries and service reviews which are relevant to the services which it provides

All clinical audit activity within the trust, or conducted in partnership with external bodies, is registered and conforms to nationally agreed best practice standards

The annual programme of clinical audit activity meets the requirements of the Board Assurance Framework, and includes all of the clinical audits necessary to meet regulatory and commissioner requirements.

Where appropriate service users and families are involved in the Clinical audit process.

Adequate records of the clinical audit annual programme, individual clinical audit projects and reviews of the results of national clinical audits, national confidential enquiries and inquiries and service reviews are maintained in order to demonstrate compliance with regulatory and other requirements.

2. Scope 2.1 This policy applies to anyone engaged in the clinical audit process within the Trust. This includes:

all staff, both clinical and non-clinical, including staff on short-term or honorary contracts

students and trainees in any discipline

patients, carers, volunteers and members of the public 2.2 This policy also applies when clinical audit is undertaken jointly across organisational

boundaries. 2.3 The Trust encourages clinical audit undertaken jointly across professions and across

organisational boundaries. Partnership working with other local and regional organisations will be encouraged where improvements to the patient journey may be identified through shared clinical audit activity.

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2.4 The Trust supports collaboration on multi- professional clinical audits of interest to other parts of the local health economy, both within and outside of the NHS e.g. primary/secondary care, local authorities, independent health and social care providers etc.

2.5 The Trust promotes a commitment to the principle of involving patients/carers in the

clinical audit process either indirectly through the use of patient surveys / questionnaires or directly through participation of identified individuals on project steering groups or patient forums.

3. Definitions 3.1 Clinical audit is a quality improvement cycle that involves measurement of the

effectiveness of healthcare against agreed and proven standards for high quality, and taking action to bring practice in line with these standards so as to improve the quality of care and health outcomes. (HQIP ‘New Principles for Best Practice in Clinical Audit’. Radcliffe Publishing, 2011).

3.2 Research is a systematic investigation undertaken to establish facts and reach

conclusions – to add to or confirm what is known – using scientific inquiry 4. Duties / Responsibilities 4.1 Chief Executive

The Chief Executive is ultimately accountable for the quality of care delivered within the Trust and takes overall responsibility for this policy.

4.2 Director of Nursing and Quality

The Director of Nursing and Quality is responsible for ensuring the processes for the quality assurance of care are in place within all Trust services, these include audit and compliance. The Associate Director of Governance is responsible for ensuring effective governance processes are in place.

Their responsibilities in respect of clinical audit are:

To ensure that the Trust clinical audit policy and annual programme of work are aligned to the Boards strategic interests and concerns.

To ensure that clinical audit is used appropriately to support the Board Assurance Framework and strategic objectives

To ensure this policy is implemented across all clinical areas

To ensure that any serious concerns regarding the Trust’s policy and practice in clinical audit, or regarding the results and outcomes of clinical audits, are brought to the attention of the Board

4.3 Clinical Effectiveness Committee

The Clinical Effectiveness Committee is the corporate committee tasked with overseeing the Trust’s clinical audit activities. They will be responsible for approving the annual clinical audit programme.

They will oversee the strategic management of audit across The Trust and will keep the Assurance Committee and Board updated in relation to audit activity, reporting outcomes and risks identified as appropriate.

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4.4 Divisional Governance / Audit Groups / Specialist Clinical Groups

These groups will monitor clinical audit activity against the clinical audit programme; and will report any significant outcomes, action plans, risks etc. to the Clinical Effectiveness Committee as part of the monthly reporting programme.

They will be responsible for monitoring local clinical audit activity and progress

against clinical audit action plans. Any significant risk should be reported up to the Clinical Effectiveness Committee

Members will be responsible for communication between their group and their service

areas. They will ensure audits are being undertaken within their service in accordance with Trust procedure and priorities, and feed their service’s own priorities into the annual audit programme.

4.5 Clinical Audit Team

The Clinical Audit Team is focused on working together with colleagues from across the Trust to develop consistent and common approaches to audit and monitoring of compliance. It is responsible for ensuring that all audits meet the needs of the clinical services, that results are fed back in a meaningful way, and that audit cycles are completed. This will be achieved by working closely with clinical teams during the audit development process.

The Team will maintain databases of clinical audit activity and will centrally hold audit

reports from across the Trust. They will also report participation in National Clinical Audits and their outcomes to the

Clinical Effectiveness Committee. They will produce a Clinical Audit report annually summarising all audit activity for the

year. The Clinical Audit Team will be responsible for training, advice and guidance on

clinical audit projects to all those within the Trust who wish to undertake them. In order to communicate audit requirements, guidance, plans and outcomes etc., the

Team will develop and maintain the Clinical Audit pages on the Trust intranet site. 4.6 Head of Compliance, Assurance and Quality

The Head of Compliance, Assurance and Quality has responsibility for leading the audit and compliance processes across the Trust. They are also responsible for coordinating and reporting on any reviews carried out by external agencies. In addition they are responsible for ensuring lessons learned from clinical audits are included within the organisational learning strategy and data is triangulated with learning from other areas of the trust to inform best practice and quality improvement processes.

4.7 Governance Business partners

Governance Business partners in the divisions are responsible for working with the Commissioners to ensure that the clinical audit programme includes all audit requirements from the Quality Contract.

They are responsible for co-ordinating the submission of contractual data and reports back to the Commissioners.

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They are responsible for gathering data to inform the Quality Report and annual Quality Account which includes outcomes from specific clinical audits.

4.8 Clinical/Area Directors and Clinical Leads for Clinical Audit

All Clinical/Area Directors must ensure that at least one clinician within their division is nominated as the Divisional Lead for Clinical Audit. The responsibilities of the Divisional Leads for Clinical Audit are:

To ensure that this policy is implemented throughout their division.

To ensure that all clinical audit activity within their division is registered and complies with nationally accepted best practice standards

To ensure that their Division participates in all national clinical audits, national confidential enquiries and inquiries and service reviews which are relevant to the services which it provides

To work with clinicians, service managers, divisional governance / quality leads and clinical audit staff to ensure that the clinical audit programme for their division meets all clinical, statutory, regulatory, commissioning and other Trust requirements.

To ensure all actions raised following audits are implemented in a timely manner and that the audit loop is closed.

4.9 Service Managers

Managers are responsible for ensuring that service development and delivery is underpinned by clinical audit and that outcomes from audits are acted upon locally and discussed at team meetings. Clinical staffs’ participation in clinical audit should be discussed at 1:1s and should be form part of Continuing Professional Development as agreed during annual appraisals.

4.10 Individuals

All staff employed by the Trust have a responsibility for the quality of the service which they provide, and all clinically qualified staff are individually accountable for ensuring they audit their own practice in accordance with their professional codes of conduct and in line with the standards set out within this document.

All staff who participate in clinical audits are responsible for ensuring the audit meets

the needs of the service and that they take accountability for actions raised as a result of the audit.

Improving the quality of patient care and outcomes involves non-clinical as well as

clinical staff. Non-clinical ward or department staff may from time to time be required to assist with clinical audit projects.

5. Clinical Audit Process

All audits must be conducted in line with the Trust approved audit process. The principles that the Trust has put in place for what is expected from the clinical audit process are detailed below. Full details of how the clinical audit process is carried out can be found in the Clinical Audit Procedure.

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5.1 Distinguishing Between Clinical Audit, Data Collection and Research Collection of baseline data will not normally be classified as ‘clinical audit’. However

such exercises will be regarded as part of the clinical audit process if the aim is not just to define standards but to follow on with a full clinical audit cycle including re-audit.

Clinical audit and research have complementary roles to play in ensuring clinical

effectiveness. However, there is sometimes some confusion as to the distinction between the two activities.

Most commonly the difference is described in terms of research determining the right

thing to do and that the role of audit is to determine whether the right thing is actually done (Smith, R, 1992, Audit and research – BMJ 305: 905-906). The purpose of research has also been described as ‘to add to a general body of scientific knowledge which has universal application’, and the purpose of clinical audit as ‘to enable practitioners to monitor and improve practice in specific situations’ (Closs SJ, Cheater FM, 1996, Audit or research – what is the difference? Journal of Clinical Nursing 5: 249-256).

If a project is deemed as research then it should be progressed in accordance with

the Research and Development Policy. 5.2 Agreeing an annual programme of activity Prior to the start of every financial year, the Trust will agree an appropriate planned

programme of clinical audit activity. This programme should meet the Trust’s strategic objectives and corporate requirements for assurance, but must be owned by clinical services.

The Head of Compliance, Assurance and Quality will work with Clinical Services and

Corporate Leads to identify the key priorities for the year ensuring that any statutory and contractual requirements are included. The areas considered when setting the priorities for the programme are detailed in the Clinical Audit Procedure.

The clinical audit programme will be approved by the Clinical Effectiveness

Committee and Assurance Committee in February / March each year. It will then be reviewed monthly by the Head of Compliance, Assurance and Quality and will be updated if priorities change. Reason for change will be documented and reported to the Clinical Effectiveness Committee and Assurance Committee on a quarterly basis.

5.3 Working with commissioners The Governance Business partners will work with the Commissioners to ensure that

the annual clinical audit programme meets the requirements of the Quality Contract. 5.4 Choosing and prioritising local clinical audit topics The Trust is committed to supporting other locally determined clinical audit activity as

a significant contributor to the continuous process of service quality improvement. It is acknowledged that individual clinicians may initiate a clinical audit project on the basis of personal interest, personal development or as part of an educational or training programme.

These local audits should however be conducted in line with the Trust’s clinical audit

policy and procedure and also the clinical strategy for the service and registered and

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reported locally within the division through existing clinical governance structures. It is also important that these are registered with the Trust and findings and outcomes reported to the clinical audit team to maximise organisational learning.

5.5 Systems for registering and approving audits

For each local clinical audit project that is undertaken, an audit proposal form must be completed by the project lead and approved by the Clinical Audit Team.

All clinical audit activity must be registered with the Clinical Audit Team irrespective

of the level of facilitation being requested of them. 5.6 Use of databases

Data provided on registration will be used to compile a database of all clinical audit activity undertaken throughout the Trust. This database will be updated regularly by the Clinical Audit Team and will include summary of results, actions taken and key lessons learned. This will be used to report to the Clinical Effectiveness Committee on the progress of the annual clinical audit programme on a quarterly basis.

5.7 Use of standards (or criteria) in clinical audit Audit standards are formal statements about how patients or service users should be

managed or services delivered. They define the aspects of care to be measured in order to find out whether what is being carried out is correct.

Standards may already exist locally or nationally in the form of guidelines or

protocols. National standards are available for certain treatments and conditions in the form of NICE or Royal College / professional body guidelines and are also incorporated into large-scale service delivery documents such as the National Service Frameworks.

If there are no recognised standards available from these sources, audit specific

standards need to be developed working with the Clinical Audit Team. The standards should relate to the audit objectives and should always be based on the best available, most up-to-date evidence of what constitutes best practice. A literature search will need to be undertaken to identify relevant evidence from which to develop the standards.

5.8 Reporting Once an audit is completed an audit report must be written detailing what was done,

the findings, any recommendations and action plans.

Regular summary reports, together with recommendations, should be communicated to all relevant areas of the organisation and Trust committees. A successful audit in one area may be transferable to other parts of the organisation.

5.9 Dissemination Once a round of data collection has been completed and the data has been

analysed, the results should be presented at specialty governance/audit meetings where the findings should be discussed, action plans agreed and a commitment to re-audit made in a designated time.

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Effective dissemination is the key to successful implementation of action plans and to sharing audit lessons across services. Mechanisms for disseminating information on clinical audit activities include:

Registration and reporting of audits using a central database

Publication of Annual Audit Reports

Team briefing, staff updates, briefing newsletters

Clinical audit feed-back sessions / audit leads meetings

Staff appraisals and 1:1s

Clinical audit presentations

Staff intranet site

Use of the Clinical Effectiveness Committee and sub-groups to share good practice and to disseminate information to Services.

5.10 Action plans for improvement The Trust improves its services and clinical care by developing and implementing

action plans in response to the clinical audit results Action plans should be specific, measurable, achievable, realistic and timely

(SMART). They must have clear implementation timescales with identified leads for each action. Action plans should also have been approved by the relevant head of service or lead manager.

Not all clinical audits will require an action plan e.g. where an audit shows that

standards are being met or guidance followed. For such audits there should be an explicit statement saying ‘no further action required’ in the audit summary report and a reason given for no re-audit.

All actions plans must be copied to the Clinical Audit Team for logging. The relevant

divisional governance/audit groups will monitor the implementation of actions, ensuring that any identified changes are incorporated into relevant business plans as appropriate.

5.11 Re-Audit Equal in importance to audit design is to ensure that the audit cycle is completed. It is

the joint responsibility of the individual leading an audit project and the local management team to ensure that audits have action plans, where appropriate, to address the outcomes identified. The Clinical Audit Team will monitor this process and record improvements that have been implemented.

For audits on the Trust clinical audit programme re-audits will be planned in as part of

the development of the programme each year or if required sooner as part of the monthly review.

For local audits the Clinical Audit Team will work with the audit lead to plan a suitable

re-audit date and this will be form part of their action plan. 5.12 Clinical Audit Annual Report The Head Compliance, Assurance and Quality will produce an annual clinical audit

report summarising the audit activity against the audit programme during the year. This will include a summary of:

The audit process and any changes or improvements made to it

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Audits carried out against the programme

National audit participation

Key findings, trends and lessons learned from all audits

Completion of audit cycles

Local audits carried out by services

Future improvements to the audit process 5.13 Ethics and consent

By definition, clinical audit projects should not require formal approval from a Research Ethics Committee. However one of the principles underpinning clinical audit is that the process should do good and not do harm. Therefore clinical audit must always be conducted within an ethical framework.

The ethical framework used by the Trust considers the following four principles:

There is a benefit to existing or future patients or others that outweighs potential burdens or risks.

Each patient’s right to self-determination is respected.

Each patient’s privacy and confidentiality are preserved.

The activity is fairly distributed across patient groups. The Head of Audit and Compliance is responsible for the ethical oversight of clinical

audit across the organisation and any person who has concerns regarding the ethics of clinical audit should refer them to this senior manager.

This ethical oversight will include:

Ensuring that the clinical audit programme is managed efficiently to make best use of resources, and performance management issues associated with poor audit design, poor execution or failure to deliver improvements in patient care are addressed.

Ensuring that any ethical concerns which arise during the design and planning of individual clinical audits are addressed.

Ensuring that any instances of serious shortcomings in patient care which come to light through clinical audit are communicated with the clinical director of the service involved at the earliest opportunity, and that appropriate steps are taken to address them.

Ensuring that risk management issues identified through clinical audit results are addressed in clinical audit action plans, and that those plans are implemented effectively; and where the process of auditing uncovers immediate risks to patient safety or care, ensuring that these raised with the appropriate service lead immediately.

5.14 Equality and diversity The Trust aims to ensure that its healthcare and facilities are not discriminatory and,

wherever possible, attend to the physical, psychological, spiritual, and social and communication needs of any patient or visitor showing no discrimination on the grounds of ethnic origin or nationality, disability, gender, gender reassignment, marital status, age, sexual orientation, race, trade union activity or political or religious beliefs.

The process for determining choice of clinical audit projects, and the manner in which

project patient samples are drawn up, should not inadvertently discriminate against any groups in society based on their race, disability, gender, age, sexual orientation,

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religion and belief. Any person who has concerns regarding the equality & diversity impact of clinical audit activity within the Trust should refer them in the first instance to the Equality & Diversity Lead, who may require equality impact assessments to be undertaken and / or equality data to be collected as part of clinical audits in order to determine whether any particular groups of patients are experiencing variations in practice.

5.15 Information Governance: collection, storage and retention of data and

confidentiality All clinical audits must adhere to NHS Information Governance policies and

standards. Audits should pay special attention to the Data Protection Act (1998) and the Caldicott Principles (1997). This means that data should be:

adequate, relevant and not excessive

accurate

processed for limited purposes

held securely

not kept for longer than is necessary. 6. Training Requirements 6.1 Overall organisational approach Specific aspects of clinical audit require specialist skills to enable successful clinical

audit, for example using the correct clinical audit methodology. This policy sets out how the Trust will ensure that all clinicians and other relevant staff and patients conducting and/or managing clinical audits are given appropriate time, knowledge and skills to facilitate the successful completion of the audit cycle.

Improvements in clinical audit education and training are key to the delivery of this

policy in order to promote clinical audit activities that are led by healthcare professionals.

Training raises the profile of clinical audit and builds up capacity and capability of all

those involved in clinical audit, thus acting as a driver for quality improvement. 6.2 Provision of clinical audit training The Trust will make available suitable training, awareness or support programmes to

all clinicians regarding the trust's systems and arrangements for participating in clinical audit. This can be accessed via the Learning Education & Development (LEaD) on-line training system (see TNA Appendix 1).

Appropriate educational resources on clinical audit processes are available through the Healthcare Quality Improvement Partnership (HQIP) website http://www.hqip.org.uk/

The Trust will provide sufficient and appropriate resources to support and deliver a

robust programme of clinical audit for local, regional and national activities via the Clinical Audit Team and the staff intranet.

Bespoke training will be given to groups and individuals on request by the Clinical Audit Team.

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6.3 Employment and development of clinical audit staff The Trust will employ a team of suitably skilled clinical audit staff to support its

programme of clinical audit activity. The Trust will also ensure that staff have access to further relevant training in order to maintain and develop their knowledge and skills.

Clinical audit staff will be expected to participate in professional training and

development activities including those organised by HQIP and The South Central SHA Clinical Audit Network.

7. Monitoring Compliance 7.1 Monitoring the effectiveness of clinical audit activity

Element to be monitored Lead Tool Frequency Reporting arrangements

Duties (of staff in relation to clinical audit)

Head of Compliance, Assurance and Quality

Random selection of at least 5 re-audits will be selected and reviewed against these criteria

Annually in April

Clinical Effectiveness Committee and Assurance Committee as part of annual report

How the organisation sets priorities for audit, including local and national requirements

How audit reports are shared

Format for all audit reports, including methodology, conclusions, action plans, etc.

Requirement that audits are conducted in line with the approved process for audit

How the organisation makes improvements

how the organisation monitors action plans and carries out re-audits

8. Policy Review 8.1 This policy will be reviewed as a minimum every four years 9. Associated Documents

Clinical Audit Procedure

Annual Clinical Audit Programme

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10. Supporting References

Healthcare Quality Improvement Partnership (HQIP) website http://www.hqip.org.uk/

NHS Litigation Authority (NHSLA) Risk Management Standards 2013 14

HQIP ‘New Principles for Best Practice in Clinical Audit’. Radcliffe Publishing, 2011

SHFT Research and Development Policy

NHS Standard Contract 2016/17

Appendix 1

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LEaD (Leadership, Education & Development) Training Needs Analysis If there are any training implications in your policy, please complete the form below and make an appointment with the LEAD department (Louise Hartland, Strategic Education Lead or Sharon Gomez, Essential Training Lead on 02380 774091) before the policy goes through the Trust policy approval process.

Training Programme

Frequency Course Length Delivery Method Trainer(s) Recording Attendance

Strategic & Operational

Responsibility

Clinical Audit Training

Once as required ½ day Workshop style face-to-face training session

Clinical Audit Team LEaD

Strategic – Julie Dawes Operational - Tracey McKenzie

Directorate Division Target Audience

MH/LD

Adult Mental Health

Any member of staff who would like to gain more knowledge on how to conduct a clinical audit

Learning Disability Services

As above

Older Persons Mental Health

As above

Specialised Services

As above

TQtwentyone

As above

ICS

Adults

As above

Children’s Services

As above

Specialist Services

As above

Corporate Services

All (Workforce & Development, Finance & Estates, Commercial)

As above

Appendix 2

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Southern Health NHS Foundation Trust: Equality Impact Analysis Screening Tool

Equality Impact Assessment (or ‘Equality Analysis’) is a process of systematically analysing a new or existing policy/practice or service to identify what impact or likely impact it will have on protected groups.

It involves using equality information, and the results of engagement with protected groups and others, to understand the actual effect or the potential effect of your functions, policies or decisions. The form is a written record that demonstrates that you have shown due regard to the need to eliminate unlawful discrimination, advance equality of opportunity and foster good relations with respect to the characteristics protected by equality law.

For guidance and support in completing this form please contact a member of the Equality and Diversity team

Name of policy/service/project/plan:

Clinical Audit Policy

Policy Number:

SH NCP6

Department:

Quality & Governance Team

Lead officer for assessment:

Helen Alger – Clinical Audit Facilitator

Date Assessment Carried Out:

August 2016

1. Identify the aims of the policy and how it is implemented. Key questions Answers / Notes

Briefly describe purpose of the policy including

How the policy is delivered and by whom

Intended outcomes

The purpose of this policy is to develop and sustain a culture of best practice in clinical audit within Southern Health NHS Foundation Trust. The policy clarifies the roles and responsibilities of all staff engaged in clinical audit activities.

Appendix 2

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2. Consideration of available data, research and information Monitoring data and other information involves using equality information, and the results of engagement with protected groups and others, to understand the actual effect or the potential effect of your functions, policies or decisions. It can help you to identify practical steps to tackle any negative effects or discrimination, to advance equality and to foster good relations. Please consider the availability of the following as potential sources:

Demographic data and other statistics, including census findings

Recent research findings (local and national)

Results from consultation or engagement you have undertaken

Service user monitoring data

Information from relevant groups or agencies, for example trade unions and voluntary/community organisations

Analysis of records of enquiries about your service, or complaints or compliments about them

Recommendations of external inspections or audit reports

Key questions

Data, research and information that you can refer to

2.1 What is the equalities profile of the team delivering the service/policy?

The Equality and Diversity team will report on Workforce data on an annual basis.

2.2 What equalities training have staff received? All Trust staff have a requirement to undertake Equality and Diversity training as part of Organisational Induction (Respect and Values) and E-Assessment

2.3 What is the equalities profile of service users? The Trust Equality and Diversity team report on Trust patient equality data profiling on an annual basis

2.4 What other data do you have in terms of service users or staff? (e.g results of customer satisfaction surveys, consultation findings). Are there any gaps?

The Trust is preparing to implement the Equality Delivery System which will allow a robust examination of Trust performance on Equality, Diversity and Human Rights. This will be based on 4 key objectives that include: 1. Better health

outcomes for all

Appendix 2

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2. Improved patient access and experience

3. Empowered, engaged and included staff

4. Inclusive leadership

2.5 What internal engagement or consultation has been undertaken as part of this EIA and with whom? What were the results? Service users/carers/Staff

Policy reviewed by clinical audit and governance team and Clinical Effectiveness Committee Policy Approval Group (Virtual Group)

2.6 What external engagement or consultation has been undertaken as part of this EIA and with whom? What were the results? General Public/Commissioners/Local Authority/Voluntary Organisations

n/a

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In the table below, please describe how the proposals will have a positive impact on service users or staff. Please also record any potential negative impact on equality of opportunity for the target: In the case of negative impact, please indicate any measures planned to mitigate against this:

Positive impact (including examples of what the policy/service has done to promote equality)

Negative Impact Action Plan to address negative impact

Yes – this policy includes a section on ensuring that there is no discrimination when audit samples are drawn up

None No negative impacts have been identified at this stage of screening

Actions to overcome problem/barrier

Resources required

Responsibility Target date

Age Clinical Audit undertaken in line with processes detailed in the policy may identify gaps or areas of good practice Consideration is given to Equality & Diversity in the team’s checklist for planning projects. E.g. sample requirements, questions asked & collection of demographic details

None No negative impacts have been identified at this stage of screening

n/a n/a n/a n/a

Disability The Trust responds None No negative n/a n/a n/a n/a

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positively to requests of reasonable adjustments and will provide information in alternative formats upon request. The Equality and diversity Lead can be contacted for information on Interpreting and Translation services

impacts have been identified at this stage of screening

Gender Reassignment

The ethical framework used by the Trust will ensure each patient’s privacy and confidentiality are preserved

None No negative impacts have been identified at this stage of screening

n/a n/a n/a n/a

Marriage and Civil Partnership

None No negative impacts have been identified at this stage of screening

n/a n/a n/a n/a

Pregnancy and Maternity

None No negative impacts have been identified at this stage of screening

n/a n/a n/a n/a

Race The Trust responds positively to requests of information in alternative formats. The Equality and diversity Lead can be

None No negative impacts have been identified at this stage of screening

n/a n/a n/a n/a

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contacted for information on Interpreting and Translation services

Religion or Belief

None No negative impacts have been identified at this stage of screening

n/a n/a n/a n/a

Sex None No negative impacts have been identified at this stage of screening

n/a n/a n/a n/a

Sexual Orientation

The ethical framework used by the Trust will ensure each patient’s privacy and confidentiality are preserved

None No negative impacts have been identified at this stage of screening

n/a n/a n/a n/a