Risk assessing

clinical audit findings

Anne Jones, Head of Clinical Audit and EffectivenessKingston Hospital NHS Foundation Trust

Session objectives

To share our process for introducing a risk assessment approach to clinical audit results, focusing on:

•Why take a risk assessment approach?

•The road to risk assessment

•Undertaking the risk assessment – an example

•Escalation process

•Training the risk assessors

•Benefits to patient care

•Practical example

At a trust-wide or corporate level

Clinical governance describes the structures, processes and culture needed to

ensure quality of the care and continuous improvement

www.gov.uk/government

Quality governance used byMonitor to refer to how a Board should lead on quality and identify and manage risks to

quality.1

Why take a risk assessment approach?

1 Bullivant J, Burgess R. Corbett-Nolan A. and Godfrey K. (2012) Good Governance Handbook. HQIP/Good Governance Institute

At the front line

To support frontline clinicians to assess the significance of

clinical audit results and ensure improvement in patient care

Why take a risk assessment approach?

Relationship between clinical audit and risk

Risk driving clinical audit -High risk is one of the main drivers of clinical audit topic choice 2

-‘Address specific local risks’ 3

-At Kingston, risk registers reviewed for topics for annual clinical audit programme and risks arising throughout the year are added to the clinical audit programme

2 Burgess R. (2011) New Principles of Best Practice in Clinical Audit , HQIP 3 Bullivant J, and Corbett-Nolan A.(2010) Clinical audit: A Simple guide for NHS Boards and partners, HQIP

 To: Anne Jones

 

Relationship between clinical audit and risk

Clinical audit driving risk management ?-Quantify the implications for clinical and organisational practice including potential for harm

Clinical audit can …. Identify major risk, resource and service development implications in an NHS trust ‘3

-At Kingston, process for linking clinical audit to risk and risk registers had not been formally established

3 Bullivant J, and Corbett-Nolan A.(2010) Clinical audit: A Simple guide for NHS Boards and partners, HQIP

Other drivers

HQIP’s Clinical audit: A simple guide for

NHS Boards and partners3

“Ensure that clinical audit results having potential significance, due to the identification of a risk, are brought to the attention of the clinical governance committee …..”

Grant Thornton’s paper ‘Clinical audit: a brave new world’? (2011)4

“Results are not fed into organisational risk assessment. We see many examples of where individuals or groups learn from clinical audit and adjust their practice accordingly. However, we see virtually no examples where the results of clinical audit feed back into the board’s risk assessment and business planning.

3 Bullivant J, and Corbett-Nolan A.(2010) Clinical audit: A Simple guide for NHS Boards and partners, HQIP4 Dossett P. (2011) Clinical audit: a brave new world? Grant Thornton

Francis Report5 - Recommendation 5: The Board should review audit processes and outcomes on a regular basis.

Keogh Report 20136: Ambition 2The boards and leadership of provider and commissioning organisations will …have rapid access to accurate, insightful and easy to use data about quality at service line level. A failing of one of the hospitals was noted as “The governance systems are not providing the expected level of assurance to the Board, and the escalation to the Board of risks and clinical issues is inconsistent”

Berwick Report 20137

The most valuable information of all is information on risks and on things that have gone wrong p10

5 Francis Report http://www.midstaffspublicinquiry.com/report6The Keogh Report (2013) Review into the quality of care and treatment provided by 14 hospital trusts in England7The Berwick report (2013) Improving the Safety of Patients in England

How does this fit with the current national picture?

What were we hoping to achieve?

To provide clinicians, managers and clinical audit staff with a system to categorise and quantify the level of concern/risk

o Escalate appropriate concerns upwards

o Target resources

To ensure a systematic approach where results are below standard

To drive robust action planning and quality improvement

To focus on areas where quality improvement is most required

To feed back into Board’s risk assessment and business planning

System Timeframe Detail

General reporting against standards

Prior to 2011

Clinicians set standard to achieve prior to audit – met/not met

RAG rating of clinical audit results

2011 Clinicians set RAG standards to achieve prior to audit starting, producing RAG audit results.

ReviewClinicians found it difficult to set amber and red objectively.

Unclear whether always flagging up the major issues or right issues.

Risk assessment of clinical audit results

2013 Clinicians set ‘green’ standard to achieve. If not achieved, risk assessment undertaken to more objectively categorise amber/red.

Kingston Hospital’s road to risk assessment

5 steps in risk assessment

http://www.hse.gov.uk/risk/fivesteps.htm

Kingston’s risk assessment form 8

8 Kingston Hospital NHS Foundation Trust (2013) Risk Identification, Assessment and Risk Register Procedure

Grading the consequences for audit of clinical quality

1 Negligible

2 Minor

3 Moderate

4 Major

5 Catastrophic

Peripheral element of treatment/care suboptimal

Overall treatment/care suboptimal

Treatment/care of reduced effectiveness

Unacceptable quality of treatment/care

Totally unacceptable quality of treatment / care

Minimal intervention / treatment

Minor intervention / treatment

Moderate injury requiring intervention

Major injury leading to long term incapacity

Incident leading to death

Increase in length of stay by 1-3 days

Increase in length of stay by 4-15 days

Increase in length of stay by >15 days

Likelihood scoring1

Rare2

Unlikely3

Possible4

Likely5

Almost certain

Probably never happen

Not expected to happen but may

Might happen occasionally

Will probably happen but not persistent

Will undoubtedly happen, possibly frequently

8 Kingston Hospital NHS Foundation Trust (2013) Risk Identification, Assessment and Risk Register Procedure

At start of each clinical audit project, a target for acceptable care or treatment is agreed by the clinical team – ‘green’ RAG rating. Linked to policy, guideline or set standards.

The audit is carried out and the results compared to the target(s) set.

Result > target = Green

Result < target risk assessment to categorise level of risk

Risk Rating < 8 = Amber rated Audit

Risk Rating > 8 = Red rated Audit

The process

Hazards (potential to cause harm):

Antibiotic acquired infection, eg C. difficile, increased resistance to anti-biotics, side effects from treatment, longer recovery period, increased cost

EXAMPLE: Antibiotic prescribing

Audit criteria: Target Result

Indication given

95%

96%

Stop/review date recorded 70%

Duration in accordance with guideline 79%

Antibiotic prescribed according to guideline or Micro 89%

Review/stop dates not put on antibiotic prescription charts and patients left on antibiotics too long. Incorrect antibiotics prescribed.

Risks (effect on the patient/hospital):

Risk ratingConsequence 3 (moderate) x Likelihood 3 (possible) = 9 (RAG rated ‘Red’)

Hazard: Incorrect ABDuration of AB too longRisks: AB acquired infection; Treatment side effects; Longer recovery; AB resistance; Cost

Medicines policyM-F Pharmacist WRMicro/Pharmacist twice weekly WRStop date section on drug chart

Trust-wide

Safe and effective prescribing of antibiotics

Training for junior docsConsultant supervision on ward roundsWeekly publication of dataDaily Micro/Pharm WRs

3 3 9 2 3 6

Clinical Audit report

Summary of results and RAG ratingAudit criterion Result Standard set % Risk rating C x L RAG rating

Indication for AB given 96%

95%Stop date on chart 70%

3 x 3 = 9 RedCorrect duration 79%

Correct antibiotic 89%

Action PlanRecommendation Action Barriers Responsibility Timescale

Train junior doctors Add to induction programme None F1/F2 tutor 30.8.13

Ensure drug charts are fully completed

Supervision on ward rounds None Consultants Weekly

Ensure staff know results

Publication via KPI scorecard None Audit Facilitator 1st of each month

Extend input from Micro/Pharmacy

Increase Antibiotic Pharmacist to FTE

Budget restrictions

Pharmacy Manager

30.9.13

Escalation of ‘red’ audit results

* Sub Committee of the Trust Board

Risk Register

Red

◄ Challenge ►

An iterative process ….

Original Revised

Risk assessment for all criteria that did not meet standard

Risk assessment of findings as a whole

Undertaking a ‘quick’ risk assessment and proceeding to full risk assessment if risk >8

The full risk assessment was not lengthy and this two-step process made it more complicated

Training

• Trust-specific training delivered to Clinical Audit Facilitators by Risk Manager

• Training delivered to our Clinical Audit Leads by Risk Manager and Head of Clinical Audit

• Audit project leads trained by Clinical Audit Facilitators at the time of undertaking a risk assessment

• All managers and senior nursing staff trained in risk assessments

Your turn ……..

Identify the hazards

List all the risks

Existing controls:Falls PolicyAuditsStaff trainingAnalysis of individual falls

Nursing / Trustwide

Describe the topic area

Falls Audit example

? ? ? ? ? ?

Hazard: Failure to provide care plans for all patients at risk of fallsRisks: Physical harm from fall; increase in LOS, increase in falls per1000 bed days

Existing controls:Falls PolicyAuditsStaff trainingAnalysis of individual falls

Nursing / Trustwide

Falls care plans

Falls Audit example

3 4 12 2 4 8

Conclusions

Greater clarity regarding the level of risk to patient care where clinical audit results do not meet standards – good for patients, clinicians and the Trust Board

Greater objectivity than previous system

Provides ‘at a glance’ results and allows clinicians, senior staff and Board members to concentrate on the things that matter

Change and quality improvement to patient care is enhanced by ensuring action plans are robust and staff are held to account for completion, via risk register

Work in progress• Building into overall business planning

Thank you for attending this workshop

Any questions