Clinical Audit Programme Update 5 August 2019

6.2

No:

Item

Agenda Safe & Effective | Kind & Caring | Exceeding Expectation

Trust Board Report Meeting 05/08/19 Date: Title: Annual Audit Report

Executive This report provides an annual update of clinical audit undertaken within Royal Summary: Wolverhampton NHS Trust for the period 01/04/18 – 31/03/19. • Appendix 1a, 1b & 1c: Divisional Audit Completion Rate Report 2018/19 • Appendix 2a , 2b & 2c: Divisional Audit Progress Against Plan Report 2018/19 • Appendix 3: Abandoned Audits and Rationale 2018/19 • Appendix 4: Approved Clinical Audit Plans for 2019/20 • Appendix 5: Outcomes and key actions (40 page report) • Appendix 6: NCAPOP 2018/19 Action Receive and note Requested: For the attention of the Board Assure • 457 audits undertaken in 18/19 • 91% adjusted completion rate (excludes National audits and QIP’s) • 134 re-audits were rated for compliance 70% maintained compliance rate or improved Advise • Increase in the number of audits abandoned since last year (43 in 17/18, 60 in 18/19) – all require a robust rationale and relevant assurances to Division prior to approval to abandon • 79% of SUI actions were completed within target date • Increasing number of QIPs will be undertaken in 19/20 Alert • 40 (30%) of re-audits that were compliance rated showed a decrease in compliance. 23 of these were Trust wide audits OP07 Documentation audit and The Early Warning Signs audit Author + [email protected] - Trust Clinical Audit Lead, Renal Consultant Contact [email protected] – Healthcare Governance Manager Details: [email protected] – Governance Team Leader Links to 1. Create a culture of compassion, safety and quality Trust 2. Proactively seek opportunities to develop our services

Strategic Objectives Resource Revenue: None Implications: Capital: None Workforce: None Funding Source: None CQC Safe: patients, staff and the public are protected from abuse and avoidable harm. Domains Effective: care, treatment and support achieves good outcomes, helping people maintain quality of life and is based on the best available evidence. Responsive: services are organised so that they meet people’s needs. Well-led: the leadership, management and governance of the organisation make sure it's providing high-quality care that's based around individual needs, that it encourages learning and innovation, and that it promotes an open and fair culture. Equality and None Diversity Impact Risks: BAF/ TRR 3644 – Failure to sustain improved compliance with CQC standards TRR Risk: Appetite Public or Public Private: Other formal None bodies involved: References Audit results and audit plans are routinely reviewed at to directorate and divisional level governance meetings. NHS In determining this matter, the Board should have regard to the Core principles Constitution: contained in the Constitution of: • Equality of treatment and access to services • High standards of excellence and professionalism • Service user preferences • Cross community working • Best Value • Accountability through local influence and scrutiny

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CLINICAL AUDIT ANNUAL REPORT 2018-2019

Author: Heather Cooper, Governance Team Leader, Governance

Policy Lead: Dr Shashidhar Cherukuri, Trust Clinical Audit Lead

Date: 07th May 2019

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CONTENTS PAGE

Executive Summary ...... 3 1.0 Introduction ...... 4 2.0 Development of the 2018/19 Clinical Audit Plans ...... 4 3.0 Monitoring of Clinical Audit Plans ...... 4 4.0 Summary of Clinical Audit Activity at Year End (2018/19) ...... 4 4.1 Comparison of total completion rate ...... 4 4.2 Adjusted Completion Rate ...... 5 4.3 Clinical audit activity 2018/19 ...... 5 4.4 Authorised Abandoned Audits ...... 5 4.5 Additional Audits Added in Year ...... 6 4.6 Types of Audits undertaken ...... 6 4.7 Completion of Types of Audits ...... 7 5.0 Clinical Audit Aims and Objectives ...... 7 5.1 Mapping to Trust Strategic Objectives ...... 7 5.2 Mapping to the CQC Domains ...... 8 5.3 Standard Audit Aims ...... 8 5.4 Prioritisation Score ...... 8 5.5 Key Priority Audits ...... 9 5.6 Audits Relating To Risks ...... 9 5.7 Does an audit relate to care planning? ...... 9 6. Audit Outcomes ...... 9 6.1 Outcomes of Completed Audits ...... 9 6.2 Actions following identification of non-compliance ...... 10 6.3 Re-audit required ...... 10 6.4 Re-audit undertaken during 2018/19 ...... 11 6.5 Audits that have made a positive impact ...... 11 6.6 Completion of Audit Actions...... 11 7. NICE Guideline Audits ...... 12 8.0 National Clinical Audit and Patient Outcomes Programme (NCAPOP)...... 12 9.0 Trust Wide Audits ...... 13 10.0 Clinical Audit Quality Review ...... 14 11.0 The Clinical Audit Strategy ...... 14 12.0 Clinician Engagement ...... 14 13.0 The Annual Clinical Audit Awards Event ...... 15 14.0 Future plans for strengthening Clinical Audit during 2019/20 ...... 15 15.0 Quality Improvement Projects………………………………………………………...... 15

16.0 Recommendations ...... 16 17.0 Appendices ...... 17

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Executive Summary This report outlines the clinical audit activity carried out across the Trust from 1st April 2018 to the 31st March 2019. This report describes the management of clinical audit during the year, completion, performance, outcomes of audit and the planned improvements to the delivery of clinical audit during 2019/20.

During 2018/19 there were 457 audits approved for inclusion on the Clinical Audit Plans. The Trusts overall audit completion rate during 2018/19 was 78% demonstrating a 2% reduction in completion against the 2017/18 end of year figure (80%). In total 355 audits were completed. An adjusted figure is also provided which excludes a) National Audits as the Trust has no influence on whether these audits are completed and final reports received within the audit year and b) Quality Improvement Projects, QIPS don't fall within the normal financial year of reporting, and currently there is no robust process to accurately roll over QIPS into the next year without it negatively affecting overall completion figures. The overall adjusted figure is 91%. This is the same adjusted completion rate as at the end of 2017/18.

There has been an increase in the number of audits abandoned since last year (43 audits in 2017/18, increased to 60 in 2018/19). Directorates who propose to abandon an audit are required to provide a robust rationale and relevant assurances to Division prior to approval to abandon.

In 2018/19 there were 152 projects re-audited, of which 134 were able to be compliance rated. The re-audits have been reviewed and rated, 55 (41%) audits demonstrated an improvement in compliance against the standards audited, or have sustained an optimum level of performance (fully compliant). 39 (29%) audits remained at the same level of compliance demonstrated in the original audit and 40 (30%) have seen a decline in compliance. 55% of the audits that showed a decline were Trust wide audits (OP07 Documentation & CP61 Early Warning Signs). All directorates who score less than full compliance have been requested to produce an appropriate action plan to address the areas of low compliance.

489 actions were due for completion between 1st April 2018 and 31st March 2019. Of these, 79% were completed by their proposed completion date.

Recommendations • The Trust must increase and develop the number of Quality Improvement Projects being undertaken. • The Trust’s Clinical Audit Lead should work with the Audit Convenors to address the poor attendance from some areas to the Clinical Audit Group (CAG) meeting. • The Clinical Audit Strategy sets out the medium and long term direction of clinical audit and quality improvement needs to be implemented and monitored for completion.

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1.0 Introduction Clinical audit aims to measure the effectiveness of healthcare and service delivery against agreed standards, in order to implement improvements where necessary. Everyone involved in the provision of healthcare should be encouraged to be involved in clinical audit.

Through the development and delivery of robust clinical audit plans, the Trust has a process for the continuous monitoring and evaluation of the level of care and service provided. The Trust is able to then ensure the care offered is of the highest standard and that any quality improvements made are sustainable.

This report outlines the clinical audit activity carried out across the Trust from 1st April 2018 to 31st March 2019 including the completion rate, overall performance and recommendations for improvements to the management and delivery of clinical audit across the Trust during 2019/20.

2.0 Development of the 2018/19 Clinical Audit Plans The 2018/19 clinical audit plans were developed by Directorate Audit Convenors and their Governance Officers. Directorates were required to prioritise the audit projects for 2018/19 and map them to the Trust strategic objectives and CQC domains. Clinical audit plans included contributions to the National Clinical Audit and Patient Outcomes Programme (NCAPOP), other National Audit and NICE (National Institute for Health and Care Excellence) guidance implementation audits. These plans were agreed locally at the Directorate Governance meetings and then presented to the Divisional Management Team at a Divisional Governance meeting for approval.

3.0 Monitoring of Clinical Audit Plans The clinical audit plans were monitored on a monthly basis by Divisional management teams via audit completion rate and progress reports (Appendices 1 and 2). This information was also presented monthly at local Directorate Governance meetings as part of the Integrated Governance Report (IGR). Progress, in terms of completion of audit projects were reported bi-monthly to the Trusts Clinical Audit Group (CAG). Progress with the National Clinical Audit and Patient Outcomes Programme (NCAPOP) has been monitored on a quarterly basis at the Clinical Quality Review Meeting (CQRM).

4.0 Summary of Clinical Audit Activity at Year End (2018/19) The full clinical audit completion rate reports for 2018/19 split by Division and Directorate are available in the appendices of this report. Comparisons and narrative is given in the tables below.

4.1 Comparison of total completion rate The table below provides a comparison of the Divisional and Trust total audit completion rates (including all audit types) over the last 5 years. A third Division was introduced in 2018/19 and therefore previous year’s results for comparison purposes are not available.

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Total Rate 2014/2015 2015/16 2016/17 2017/18 2018/19 Division 1 86% 83% 84% 84% 80% Division 2 78% 90% 85% 75% 69% Division 3 - - - - 85% Overall Trust 81% 86% 84% 80% 78%

4.2 Adjusted Completion Rate The Trust has participated in 57 national audit projects and 3 national confidential enquires during 2018/19. The reports of 43 completed national clinical audit projects were reviewed within the year. Due to nationally set timescales for the release of reports the majority of the audits participated in wont have the results for 18/19 available yet and therefore the audits will be carried over to the 2019/20 audit plans. National Audits are only classified as completed once the national results have been collated, distributed and Trust actions for improvement have been identified in line with Trust policy. To allow for this discrepancy an adjusted completion rate figure has been provided below, which excludes National Audits. The overall adjusted completion rate for the Trust for 2018/19 was 91%.

Adjusted Rate 2014/15 2015/16 2016/17 2017/18 2018/19 Change % Division 1 93% 89% 88% 91% 93% +2% Division 2 87% 94% 96% 90% 85% -5% Division 3 - - - - 85% - Overall Trust 90% 91% 92% 91% 91% -

4.3 Clinical audit activity 2018/19 The table below provides an overview of the 457 audits authorised for completion during 2018/19. This is 22 more audits than those undertaken in 2017/18.

Divisional Audits on Additional Authorised Total Audits Activity Original Plan Audits Added Abandoned (minus in year Audits abandoned) Division 1 137 70 14 193 Division 2 115 93 29 179 Division 3 71 27 13 85 Overall Trust 323 190 56 457

4.4 Authorised Abandoned Audits Since 2016 directorates who propose to abandon an audit are required to provide a robust rationale and relevant assurances (e.g. audit to be included on plan the following year or alternative risk management process being undertaken). Appendix 3 details the rationale for the abandonment of all audits. Overall in 2018/19 56 audits were abandoned Trust wide. This equates to 11% of the Trust wide audit plan.

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There has been a slight increase (2%) in the number of audits abandoned since last year. There were a number of duplicate entries made which resulted in having to abandon audits and appendix 3 details the full list of rationales.

Authorised Abandoned Abandoned Abandoned Abandoned Abandoned Change Abandoned 2014/15 2015/16 2016/17 2017/18 2018/19 (No) Audits Division 1 16 75 29 25 14 -11 Division 2 24 33 24 18 29 +11 Division 3 - - - - 13 +13 Overall 40 108 53 43 56 +13 Trust

4.5 Additional Audits Added in Year Directorates can add audits to their audit plan through the year. In total 190 audits have been added to the Directorate audit plans in addition to the approved original audit plan within the financial year. The majority of these audits were also completed in year, indicating better management of the audit plan by the Audit Convenors and a focus on prioritising the completion of those audits on the original plan. The number of additional audits equates to 42% of the audit projects.

Divisional Added Added Added Added Added Change Activity 2014/15 2015/16 2016/17 2017/18 2018/19 (No) Division 1 99 81 85 107 70 -37 Division 2 61 54 77 64 93 +29 Division 3 - - - - 27 +27 Overall 160 135 162 171 190 +19 Trust

114 audit projects registered on Clinical Audit Database have been declined by the Audit Convenor (28 in Division 1, 75 in Division 2 and 11 in Division 3). This option is available on the database for Convenors to request further information from the proposer of an audit, or to decline the audit entirely. The audit is then not included on the audit plan or any figures provided in this report.

4.6 Types of Audits undertaken The table below demonstrates the different types of audits which were approved and undertaken during 2018/19. ‘Other’ audit includes Service Evaluations and Trust wide audits.

Planned National Local NICE Other QIP Total Division 1 52 (30%) 59 (31%) 28 (15%) 46 (24%) 8 (4%) 193 Division 2 49 (27%) 54 (30%) 33 (18%) 34 (19%) 9 (5%) 179

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Division 3 14 (16%) 39 (46%) 19 (22%) 10 (12%) 3 (4%) 85 Overall Trust 115 (25%) 152 (33%) 80 (18%) 90 (20%) 20 (4%) 457

4.7 Completion of Types of Audits The table below demonstrates the different types of audits completed during 2018/19 and excellent completion rate of our locally driven audits. 50 (44%) National audit projects have been completed but we are unable to close the audits without a report and action plan and these are generated by the relevant National bodies, of which we have no influence in terms of timescales.

There were 31 audits (9 in Division 1, 18 in Division 2 and 4 in Division 3) carried over for completion in 2019/20 (this figure also excludes National audit projects & Quality Improvement Projects).

Completed National Local NICE Other QIP Total Division 1 26 (50%) 57 (97%) 25 (89%) 42 (91%) 7 (88%) 157 Division 2 18 (37%) 46 (85%) 23 (70%) 34 (100%) 4 (44%) 125 Division 3 6 (43%) 36 (92%) 18 (95%) 10 (100%) 3 (100%) 73 Overall Trust 50 (44%) 139 (91%) 66 (83%) 86 (96%) 14 (70%) 355

5.0 Clinical Audit Aims and Objectives When creating Directorate audit plans, Governance Officers work with the Directorates audit convenors to review and prioritise audits required for the coming financial year. All audits must be mapped to the Trust’s strategic objectives and the CQC domains. All audits have agreed aims and objectives.

5.1 Mapping to Trust Strategic Objectives All the audits can be mapped to one or more of the Trust Strategic Objectives. The following table illustrates the number (and percentage) of audits mapped to each of the six strategic objectives. Audits can be linked to more than one objective; therefore the percentage shown is of the total 457 audits.

Trust Trust Trust Trust Trust Strategic Objectives 2015/16 2016/17 2017/18 2018/19 Attract, retain and develop our staff 23 (4%) 29 (7%) 7 (2%) 14 (3%) and improve employee engagement Be in the top quartile for all 148 (23%) 117 (27%) 111 (26%) 92 (20%) performance indicators Create a culture of compassion, 294 (46%) 292 (67%) 328 (75%) 329 (72%) safety and quality Maintain financial health - appropriate 24 (4%) 38 (9%) 23 (5%) 26 (6%) investment enhancement to patient services Proactively seek opportunities to 99 (15%) 187 (43%) 137 (31%) 145 (32%)

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develop our services To have an effective and well 51 (8%) 155 (65%) 97 (22%) 146 (32%) integrated organisation that operates efficiently

5.2 Mapping to the CQC Domains All audits can be mapped to one or more of the CQC Domains. The following table illustrates the number (and percentage) of audits mapped to each of the 5 CQC domains. Audits can be linked to more than one domain; therefore the percentage shown is of the total 457 audits.

Trust Trust Trust Trust CQC Domains 2015/16 2016/17 2017/18 2018/19 Caring 207 (24%) 159 (36%) 158 (36%) 177 (39%) Effective 385 (44%) 329 (75%) 328 (75%) 312 (68%) Responsive 92 (11%) 106 (24%) 142 (33%) 147 (32%) Safe 154 (18%) 281 (64%) 315 (72%) 292 (64%) Well Led 25 (3%) 82 (19%) 86 (20%) 105 (23%)

5.3 Standard Audit Aims Audit aims fall in to four standard categories; • to improve patient care • to improve compliance • to improve the service and / or • to set local guidelines

The following table details the number (and percentage) of audits mapped to each of the standard aims. Audits can have more than one standard aim; therefore the percentage shown is of the total 457 audits.

Trust Trust Trust Trust Audit Aims 2015/16 2016/17 2017/18 2018/19 Patient Care 185 (42%) 189 (43%) 209 (48%) 174 (38%) Improve Compliance 175 (40%) 161 (37%) 249 (57%) 130 (28%) Improve Service 143 (33%) 151 (34%) 156 (36%) 132 (29%) Set Local Guidelines 43 (10%) 28 (6%) 34 (8%) 30 (7%)

5.4 Prioritisation Score When planning the annual audit plan the Directorate prioritises all proposed audits using the standard scoring tool and agreed as low, medium or high priority from the Trust’s perspective. Of the 176 high priority audits, 124 audits (70%) were completed by the end of the financial year. The 52 incomplete audits have been carried forward on to the 2019/20 audit plans; this figure includes national audit projects.

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Score Trust 2015/16 Trust 2016/17 Trust 2017/18 Trust 2018/19 Low 191 (44%) 108 (25%) 97 (22%) 100 (22%) Medium 180 (41%) 227 (52%) 236 (54%) 181 (40%) High 67 (15%) 103 (24%) 102 (23%) 176 (39%)

5.5 Key Priority Audits Further to prioritisation scoring of the audit, Audit Convenors are asked whether an audit is considered a key priority to undertake from the Directorates perspective.

Key Priority Trust Trust Trust Trust 2015/16 2016/17 2017/18 2018/19 Yes it’s a priority 250 (57%) 229 (52%) 238 (55%) 268 (59%) No it isn’t a priority 180 (41%) 179 (41%) 177 (41%) 189 (41%) Not Indicated 8 (2%) 30 (7%) 20 (4%) -

5.6 Audits Relating To Risks We record on Clinical Audit database whether an audit relates to any issue also captured on the Risk Register.

Relates to a risk 2015/16 2016/17 2017/18 2018/19 Division 1 2 4 6 3 Division 2 9 7 8 7 Overall Trust 11 11 14 10

5.7 Does an audit relate to care planning? The following 60 audits were identified as relating to the care planning requirements of the organisation (28 audits in Division 1, 14 audits in Division 2 and 18 audits in Division 3). This equates to 17% of all audits undertaken by the Trust during 2018/19. This is an 8% increase from 2017/18.

Audits Audits Audits Audits Audits Area of care 2014/15 2015/16 2016/17 2017/18 2018/19 End of Life 7 6 2 1 2 Pressure Injury 0 3 2 2 2 Falls 1 2 4 4 3 Discharge 4 4 9 8 4 Care Plan Evaluation 14 68 72 31 49 Total 26 83 89 46 60

6. Audit Outcomes

6.1 Outcomes of Completed Audits The completed audits have been reviewed and identified how the outcomes are being used to improve services. Directorate Audit Conveners were asked to confirm the

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compliance rating against standards audited. The table below provides a breakdown by level of compliance. Figures demonstrate that the majority of audits, 254 (72%) have been rated as either fully compliant or minor non-compliance against the standard audited.

Level of Total Total Total Total 2018/19 2018/19 2018/19 compliance 2015/16 2016/17 2017/18 2018/19 Div 1 Div 2 Div 3 Fully Compliant 110 (28%) 121 (32%) 87 (25%) 119 34%) 46 (29%) 55 (44%) 18(25%)

Minor non-comp 188 (48%) 155 (41%) 155 (44%) 135 38%) 56 (16%) 38 (30%) 41(56%)

Moderate non- 52 (13%) 46 (12%) 49 (14%) 58 (16%) 29 (8%) 21 (17%) 8 (11%) comp Significant non- 14 (4%) 18 (5%) 8 (2%) 17 (5%) 6 (2%) 6 (5%) 5 (7%) comp Not applicable 16 (4%) 33 (9%) 35 (10%) 26 (7%) 20 (6%) 5 (4%) 1 (1%)

Not yet rated 12 (3%) 3 (1%) 20 (6%) - - - -

Total 398 376 354 355 157 125 73

Audits marked as ‘not applicable’ included service evaluations and Quality Improvement Projects that do not have a specific set of standards to audit compliance against.

6.2 Actions following identification of non-compliance It is vital that where audits have identified moderate or significant non-compliance, that actions are taken to address gaps in compliance and implement changes to improve quality and future compliance. All audits identified as moderate or significant non- compliance were (where appropriate) added to the 2019/20 audit plan for subsequent re- audit. The 2019/20 Divisional audit plans are attached (Appendix 4) for your reference.

Of the 75 audits that identified significant or moderate non-compliance against the standards audited, actions were developed to address these issues. Appendix 5 gives an overview of the outcomes and actions identified for these non-compliant audits.

6.3 Re-audit required All completed audits are reviewed in terms of aims, outcomes and impact. In some cases it is identified that a subsequent re-audit should be undertaken, usually where there are areas of non-compliance, to ensure actions implemented have been effective and there has been an improvement in compliance The table below details the number of audits completed in 2018/19 that need to be re-audited in a subsequent audit year.

Re-Audit 2015/16 2016/17 2017/18 2018/19 Required Division 1 120 107 121 87 Division 2 123 102 114 68 Division 3 - - - 45 Overall Trust 243 209 235 200

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6.4 Re-audit undertaken during 2018/19 In 2018/19 192 projects were to be re-audited. 152 of these re-audits were completed by the end of the financial year, these have been reviewed and rated, of which 94 audits (62%) demonstrated an improvement in compliance against the standards audited, or have sustained the previous level of compliance demonstrated. There were 18 audits (12%) where a compliance rating was not applicable (service evaluations & surveys). 40 audits showed a decline in compliance (26%). 23 of these were Trust wide audits; OP07 Documentation audit and The Early Warning Signs audit. Each directorate is responsible for reviewing their annual results and creating an appropriate action plan to address the areas of low compliance.

The remaining 40 audits that were not completed by the end of the audit year have been carried forward on to the 2019/20 audit plan (this figures includes National audits).

2016/17 2016/17 2017/18 2017/18 2018/19 2018/19 Re-Audits Demonstrated Re-Audits Demonstrated Re-Audits Demonstrated Completed Improvement Completed Improvement Completed Improvement Division 73 56 (77%) 54 44 (81%) 70 37 (53%) 1 Division 71 43 (61%) 71 56 (79%) 55 33 (60%) 2 Division - - - - 27 24 (89%) 3 Overall 144 99 (69%) 125 100 (80%) 152 94 (62%) Trust

6.5 Audits that have made a positive impact The reports of completed clinical audits were reviewed by the Directorate Audit Convenors and Governance Officers to ascertain the impact the audit had on the quality of healthcare provided. Appendix 5 contains the outcome, any areas of non-compliance and actions taken for these audits (40 page report).

6.6 Completion of Audit Actions Action plans are developed to implement recommendations and address any areas of non- compliance. These actions are monitored by Directorates and the Governance Officers through to completion, and reported monthly to Directorate and Divisional Governance meetings.

During 2018/19 there were 548 actions due for completion between 1st April 2018 and 31st March 2019. Of these 363 (66%) were completed by their proposed completion date.

Total Total Total Total Div 1 Div 2 Div 3

2015/16 2016/17 2017/18 2018/19 2018/19 2018/19 2018/19 Actions 503 520 656 503 271 146 87 COG/May 2019 Page 11 of 17

completed (75%) (67%) (94%) (92%) (96%) (88%) (86%) 171 259 41 45 11 19 14 Not completed (25%) (33%) (6%) (8%) (4%) (12%) (14%) Total Actions 674 779 697 548 282 165 101 Due

7. NICE Guideline Audits When NICE guidance is identified as compliant on Health Assure it is automatically registered on the Clinical Audit Database for audit within the required time period; 12 months for Technological Appraisals (TAGs) and applicable Interventional Procedure Guidance (IPG) and 3 years for all other guidance. The re-audit of all NICE guidance is also added to the Database within 5 years on a risk based approach, as per the SOP.

The volume of guidance issued to certain Directorates, for example Oncology and Haematology, who have an extremely high number of applicable TAGs, means a risk based approach must be taken to determine which guidance is audited each year. The Trust’s NICE Lead and Governance Team Leader is presently trying to identify other methods of assurance and developing alternative routes for auditing TAGs, for example via Pharmacy and the Blue Teq system.

The table below provides a breakdown of the number of NICE Guidance audited during 2018/19, split by guidance type and division. In total there were 80 NICE audits proposed to be undertaken during 18/19 and of these, 66 audits were completed by the end of the audit year (83%). Of the completed audits, 85% demonstrated full compliance or minor non-compliance.

Total Total Total Total Total NICE Audits completed 14/15 15/16 16/17 17/18 18/19 Clinical/NICE Guideline 35 (39%) 38 (55%) 36 (47%) 36 (47%) 30 (45%) Technological Appraisal 40 (44%) 13 (19%) 15 (19%) 17 (22%) 22 (33%) Quality Standard 4 (4%) 9 (13%) 12 (16%) 11 (14%) 7 (11%) Interventional Procedure 8 (9%) 6 (9%) 8 (10%) 9 (12%) 5 (8%) Public Health 2 (2%) 1 (1%) 3 (4%) 1 (1%) - Medical Technologies 0 (0%) 1 (1%) 0 (0%) 0 (0%) - Cancer Services 1 (1%) 1 (1%) 1 (1%) 1 (1%) - Diagnostic Guidelines 1 (1%) 0 (0%) 2 (3%) 2 (3%) 2 (3%) Overall Total 89 69 77 77 66

8.0 National Clinical Audit and Patient Outcomes Programme (NCAPOP) The National Clinical Audit and Patient Outcomes Programme (NCAPOP) is a set of centrally-funded national clinical audit projects. All projects within NCAPOP are commissioned and managed by Healthcare Quality Improvement Partnership (HQIP). The NCAPOP audit projects collect data nationally on compliance against evidence based standards. The audit projects analyse data submitted by local Trusts centrally and feedback comparative findings to help participants identify necessary improvements for COG/May 2019 Page 12 of 17

patients. Progress against the National Clinical Audit and Patient Outcomes Programme is monitored locally by the Clinical Quality Review Meeting.

In total 137 audits were included in HQIPs National Directory. This is a list of all known National Clinical Audits and Enquiries. The directory was reviewed and it was confirmed that 44 of these audits were part of the NCAPOP and collected data during the 2018/19 audit year. Of these, 43 audits were identified for inclusion in the NHSE Quality Accounts (Please see Appendix 6 for full details). By the end of the financial year:

• 7 audits were confirmed as not applicable to this Trust • 4 audits were applicable but the Trust did not participate • 33 audits were completed / data submitted, awaiting final report

To date HQIP has identified 87 audits where data collection will take place during the 2019/20 audit year; so far 45 of these have been identified for inclusion in the NHSE Quality Accounts. These projects have been considered by the Directorates for inclusion on their 2019/20 audit plans where applicable.

9.0 Trust Wide Audits The Governance Department presently coordinate 4 trust wide audits. The audit reports are presented at the Clinical Audit Group meeting, at both Divisional Governance meetings and at all Directorate Governance Meetings. Directorates are required to agree and implement appropriate actions to address poor compliance. The end of year (Quarter 4) reports for OP07 Patient Documentation audit and the CP61 Early Warning Score audits have not yet been published, but Directorates receive a quarterly update to ensure areas of non-compliance are addressed promptly.

Trust Wide Audit Frequency Reporting Period CP06 Written Consent Annual 1st Sep - 31st Aug CP11 DNA CPR Annual 1st Jul - 30th Jun OP07 Patient Documentation Quarterly 1st Apr - 31st Mar CP61 Early Warning Score (ViEWS) Quarterly 1st Apr - 31st Mar

There were 9 other trust wide audits undertaken during 2018/19. These audits are captured centrally on Clinical Audit Database but progress is not reported in the same way as the Divisional activity. The results of these audits have been reported to the appropriate monitoring group and / or directly to the respective Directorate to agree actions to address any areas of non-compliance.

Area Audit Title Type Status Trust Wide Annual paediatric cardiac arrest trolley Local Audit Completed Audit (reported June 2018) Infection CPE screening Compliance Local Audit Completed

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Prevention Trust Wide Learning Disability Mortality Review National Audit Completed Programme (LeDeR)

Infection Sharps Audit Local Audit Completed Prevention Infection Trust Audit-Aseptic Non Touch Other Audit Completed Prevention Technique (ANTT) Audit of Clinical Practice Infection Trust IP01 Hand Hygiene Policy Audit Local Audit Completed Prevention Infection Trust IP04 Transportation of clean and Other Audit Completed Prevention contaminated instruments and specimens Infection Trust Wide Commode Audit Local Audit Completed Prevention Infection Trust Wide Isolation Audit Other Audit Completed Prevention

10.0 Clinical Audit Quality Review Regular quality improvement and assurance checks are undertaken on a regular basis by the Governance Officers, to monitor and assess whether clinical audits are compliant with the Clinical Audit and Quality Improvement Standard Operating Procedure (CAQI SOP). This replaces the previous OP45 clinical audit and effectiveness policy compliance audit.

11.0 The Clinical Audit Strategy The 2018/21 Strategy was approved by the Quality Governance Assurance Committee (QGAC) and implemented. The strategy sets the medium and long term direction of clinical audit and quality improvement. The aim is to use clinical audit as a process to embed clinical quality at all levels in the Trust, to deliver demonstrable improvements in patient care, create a culture that is committed to learning and continual development, and a mechanism for providing evidence of assurance about the quality of services.

Key points from the 2018/2021 strategy include: • Establish and implement Quality Improvement Projects (QIPs) across the Trust • Clinical Audit Awards Event takes place annually (since 2015) • Development of a clinical audit training package, guidance and tools • The sharing of best practice from Trust Wide audits and QIP’s should be expanded past shared learning in the Integrated Governance Report (IGR). • Consideration needs to be given to the remit of the Audit Convenor and Audit Lead.

12.0 Clinician Engagement There is still further work to be done around Clinician engagement. During 2018/19 Directorate Audit Convenor attendance at the Clinical Audit Group (CAG) meetings has COG/May 2019 Page 14 of 17

remained poor. There were 7 meetings, of which 70% (5 out of 7) attendance is expected. This year only 5 Directorates have been represented by their Audit Convenor or an appropriate deputy over 70% of the time. 12 (34%) Directorates have not been represented at any of the CAG meetings during this audit year. Directorates who have not attended a 2018/19 CAG meeting are:

• Audiology • Oncology & Haematology • Cardiology • Pharmacy • Cardiothoracic Surgery • Ophthalmology • Diabetes • Pathology • Head & Neck • Trauma & Orthopaedics • Maltings • Urology

13.0 The Annual Clinical Audit Awards Event July 2015 saw the initial launch of the Clinical Audit Awards. This was an opportunity to showcase some of the excellent audit undertaken across the Trust. Due to its success, the Governance Support Team have organised this as an annual event ever since.

The 2017/18 event had a Quality Improvement Masterclass focused on using clinical audit as a QI tool in order to make data count. It was hosted by Carl Walker, UHL Clinical Audit Manager & National Quality Improvement & Clinical Audit Network (NQICAN) chair.

The afternoon’s usual Grand Round presentation slot was hosted by Carl Walker and was a presentation and discussion on the national picture of clinical audit

The Clinical Audit Convenor of the Year Award 2017/18 was won by General Surgery’s Mr Deepak Singh-Ranger and the overall Best Audit was awarded to Oncology & Haematology’s Nicola Robottom for a Neutropenic Sepsis audit.

We are currently organising the 2018/19 event for the 23rd July 2019 which sees the introduction of two new categories and a special recognition award.

14.0 Future plans for strengthening Clinical Audit during 2019/20 Overall 2018/19 has seen continued engagement in Clinical Audit and improvements in the quality of audits conducted across the Trust. The introduction of QIPs will further enhance the level of service improvements seen. The completion rate of audits by the Directorates has also remained high and this level of performance needs to be sustained during 2019/20.

Directorates and Divisions will continue to monitor progress against the audit plans on a monthly basis, which enables any areas of concern to be addressed in a timely manner. Increased scrutiny of quarterly targets avoids slippage of project completion and prevents them being carried forward in to the following audit year.

COG/May 2019 Page 15 of 17

There must be increased engagement from Directorate Audit Convenors and Audit Project Leads. The participation of these key members of staff when planning audit activity at the beginning of the audit year will reduce the need to abandon audits and / or to add audits within the audit year. Their involvement is fundamental to coordinating audit activity and progressing clinical audits through to completion.

The Trust’s Clinical Audit Lead must work with the Audit Convenors to address the lack of engagement from some areas. Areas not represented at the Clinical Audit Group (CAG) meeting should be contacted to understand non-attendance of the Convenor or a representative. The CAG Terms of Reference should be reviewed regularly and meetings dates/times should be revised to ensure all Convenors have an opportunity to attend.

15.0 Quality Improvement Projects (QIPs) 2018/19 saw the introduction of Quality Improvement Projects (QIPs). All junior doctors are expected to carry out clinical audits or QI projects to meet their training requirements. QIPs are rapid cycles of audit, where a deficiency is identified and recommendations to make improvement are implemented quickly. QIPs aim to improve the patient experience and can focus on more holistic issues or where there are no formal standards. A QIP should be a continuous process of learning, development and assessment. In order to fully implement QIPs in the Trust, amendments were made to the existing Clinical audit database in order to capture the registration of QIPs being undertaken. A Continuous Quality Improvement (CQI) team has been formed in order to drive forward Quality Improvement along with support from the Central Governance Officers. Training sessions were set up throughout the year designed to provide staff with information and advice on conducting QIPs.

A prospectus has been created by the CQI team which outlines details on how the Trust will deliver quality improvement; offering practical support and building on the organisations capability. The focus will be on supporting projects to improve patient safety, projects improving on the patient journey, hands on training and education and supporting staff to deliver their own improvement priorities.

Further Changes to the database are required in order to fully capture improvements seen throughout the QIP cycles and to ensure it is user friendly. QIPs must form part of Directorates annual audit plans, be registered on the audit database and be presented at appropriate forums as per the Clinical Audit and Quality Improvement Standard Operating Procedure.

16.0 Recommendations • The Trust’s Clinical Audit Lead must work with the Audit Convenors to address the poor attendance from some areas to the Clinical Audit Group (CAG) meeting. • The Trust must continue to support junior doctors in undertaking Quality Improvement Projects and review the process for ease of registration and completion of the database.

COG/May 2019 Page 16 of 17

17.0 Appendices • Appendix 1a, 1b & 1c: Divisional Audit Completion Rate Report 2018/19 • Appendix 2a , 2b & 2c: Divisional Audit Progress Against Plan Report 2018/19 • Appendix 3: Abandoned Audits and Rationale 2018/19 • Appendix 4: Approved Clinical Audit Plans for 2019/20 • Appendix 5: Outcomes and key actions – DO NOT PRINT (40 page report) • Appendix 6: NCAPOP 2018/19

COG/May 2019 Page 17 of 17 Appendix 1a Division 1 audit completion rate 2018/19 Type of Audits Been Undertaken Types Of Audits Completed

Total Audits Service Adjusted Additional Service Audits on Minus any Evaluatio Total Total Total Completion Audits Abandoned National Local NICE Evaluation Total Audits National Local NICE Directorate original authorised QIP Audit n & Trust QIP Audit Audit in Audit in Completion rate (excl added in Audits Audit Audit Audit & Trust Completed Audit Audit Audit Plan abandoned wide Progress Pending Rate nationals & year wide Audits audits Audits QIPS)

Audiology 7 1 0 8 0 3 0 5 0 7 0 3 0 4 0 1 0 88% 88%

Cardiology 14 1 0 15 6 3 4 2 0 14 5 3 4 2 0 1 0 93% 100% Cardiothoracic 8 7 1 14 5 5 0 2 2 11 3 5 0 2 1 3 0 79% 100% Surgery

Critical Care 9 10 1 18 2 5 1 9 1 17 2 5 1 8 1 1 0 94% 94%

Dental 8 0 1 7 0 4 1 2 0 7 0 4 1 2 0 0 0 100% 100%

General surgery 18 5 4 19 8 4 4 2 1 13 2 4 4 2 1 6 0 65% 100%

Gynaecology 16 3 0 19 1 6 6 3 3 18 1 6 5 3 3 1 0 95% 94%

Head & Neck 6 1 1 6 1 2 1 2 0 4 0 1 1 2 0 2 0 67% 80%

Neonatal 7 2 1 8 2 3 1 1 1 7 1 3 1 1 1 1 0 88% 100%

Obstetrics 15 10 1 24 7 9 4 4 0 19 3 8 4 4 0 5 0 79% 94%

Ophthalmology 6 6 2 10 0 5 1 4 0 8 0 5 0 3 0 2 0 80% 80%

Pathology 6 0 0 6 5 1 0 0 0 3 2 1 0 0 0 3 0 50% 100% Trauma & 7 17 2 22 7 7 2 6 0 17 3 7 2 6 0 5 0 77% 100% Orthopaedics

Urology 10 7 0 17 8 2 3 4 0 12 5 2 2 3 0 6 0 65% 78%

Total 137 70 14 193 52 59 28 46 8 157 27 57 25 42 7 37 1 80% 93% Appendix 1b Division 2 audit completion rate 2018/19 Type of Audits Been Undertaken Types Of Audits Completed

Total Audits Service Adjusted Service Audits on Additional Minus any Evaluation Total Total Total completion Abandoned National Local NICE Evaluation Total Audits National Local NICE Directorate original Audits added authorised QIP Audit & Trust QIP Audit Audit in Audit in Completion rate (excl Audits Audit Audit Audit & Trust Completed Audit Audit Audit Plan in year abandoned Wide Progress Pending Rate QIPs & Wide audits audits audits Nationals)

Accident & Emergency 8 23 3 28 9 14 4 1 0 19 4 12 2 1 0 7 2 68% 79%

Acute medicine 4 5 1 8 1 3 0 1 3 6 0 3 0 1 2 2 0 75% 100%

Care of the elderly 7 6 3 10 3 3 0 2 2 7 2 2 0 2 1 3 0 70% 80%

Diabetes 18 2 3 17 5 3 5 2 2 9 0 2 5 2 0 7 1 53% 90%

Endoscopy 13 2 3 12 2 8 0 2 0 12 2 8 0 2 0 0 0 100% 100%

Gastroenterology 4 12 6 10 1 2 4 2 1 8 0 2 4 2 0 2 0 80% 100%

Maltings 3 0 1 2 1 0 0 1 0 2 1 0 0 1 0 0 0 100% 100%

Neurology 5 7 0 12 6 2 0 4 0 11 5 2 0 4 0 1 0 92% 100%

Oncology & Haematology 26 17 3 40 9 7 16 8 0 24 1 6 9 8 0 16 0 60% 74%

Renal medicine 16 4 2 18 3 7 2 3 3 13 2 7 1 3 0 5 0 72% 92%

Respiratory medicine 7 11 4 14 7 1 1 5 0 7 0 1 1 5 0 7 1 50% 100%

Stroke 4 4 0 8 2 1 1 3 1 7 1 1 1 3 1 1 0 88% 100%

Total 115 93 29 179 49 54 33 34 9 125 18 46 23 34 4 51 4 69% 85% Appendix 1c Division 3 audit completion rate 2018/19 Type of Audits Been Undertaken Types Of Audits Completed Audits on Additional Abandoned Total Audits National Local NICE Service Quality Total Audits National Local NICE Service Quality Total Total Total Adjusted Rate Original Audits Audits Minus Audit Audit Audit Evaluation & Improvement Completed Audit Audit Audit Evaluation Improvemen Audit in Audit Completion (Excl.National Division 3 Plan added in Abandoned Trust Wide Projects & Trust t Projects Progress Pending Rate s & QIPS year audits Wide audits Adult Community 8 1 1 8 0 6 1 1 0 8 0 6 1 1 0 0 0 100% 100% Services

Children's 7 4 0 11 4 5 0 2 0 7 0 5 0 2 0 4 0 64% 100% Services - Acute Children's Services - 5 4 1 8 2 3 1 1 1 8 2 3 1 1 1 0 0 100% 100% Community

7 0 2 5 2 0 2 1 0 5 2 0 2 1 0 1 0 100% 100% Dermatology

3 0 1 2 0 2 0 0 0 2 0 2 0 0 0 0 0 100% 100% Dietetics

3 8 3 8 2 6 0 0 0 4 0 4 0 0 0 4 0 50% 67% Pharmacy

Primary Care 3 1 0 4 0 2 1 1 0 4 0 2 1 1 0 0 0 100% 100% Services (VI)

6 1 1 6 0 3 3 0 0 5 0 3 2 0 0 1 0 83% 83% Radiology

12 5 3 14 3 2 7 1 1 12 1 2 7 1 1 2 0 86% 100% Rheumatology

Sexual 7 2 0 9 1 6 1 1 0 8 1 5 1 1 0 1 0 89% 88% Health/GUM Speech & Language 3 0 1 2 0 1 0 1 0 2 0 1 0 1 0 0 0 100% 100% Therapy

7 1 0 8 0 3 3 1 1 8 0 3 3 1 1 0 0 100% 100% Therapy Services

Total 71 27 13 85 14 39 19 10 3 73 6 36 18 10 3 13 0 85% 94% Appendix 2a Division 1 progress against plan The number The number The number of The number Total Audits of those of those those of those Audits Audits completed Audits due proposed Audits due for proposed Audits due for proposed Audits due for proposed completed in completed in Total Audits including for Directorate Audits , completion In Audits , completion In Audits , completion In Audits , an EARLIER a LATER Audits Completed in audits completion actually Jul-Sept actually Oct-Dec actually Jan-Mar actually quarter than quarter than Due a timeframes completed In Apr-Jun completed in completed in completed in completed in proposed proposed outside Apr-Jun Jul-Sept Oct-Dec Jan-Mar timeframes

Audiology 1 1 1 0 4 1 2 1 0 4 8 3 7

Cardiology 0 0 6 2 6 0 3 3 0 9 15 5 14

Cardiothoracic 2 1 1 0 5 5 6 2 2 1 14 8 11 Surgery

Critical Care 2 0 7 4 3 0 6 6 2 5 18 10 17

Dental 1 0 0 0 0 0 6 6 0 1 7 6 7

General surgery 1 0 3 0 3 0 13 8 1 4 20 8 13

Gynaecology 3 1 0 0 9 1 7 6 3 7 19 8 18

Head & Neck 1 1 2 1 0 0 3 2 0 0 6 4 4

Neonatal 2 0 2 0 1 0 3 1 2 4 8 1 7

Obstetrics 4 0 1 1 5 1 14 9 3 5 24 11 19

Ophthalmology 2 2 2 0 0 0 6 3 2 1 10 5 8

Pathology 0 0 0 0 1 1 5 1 1 0 6 2 3

Trauma & 3 1 2 0 3 0 14 7 4 5 22 8 17 Orthopaedics

Urology 2 1 0 0 1 0 14 8 2 0 17 9 11

Total 24 8 27 8 41 9 102 63 22 46 194 88 156 Appendix 2b Division 2 progress against plan The number The number The number The number Audits Total Audits Audits of those of those of those of those completed completed Audits due Audits due Audits due Audits due completed proposed proposed proposed proposed in an Total Audits including for for for for in a LATER Directorate Audits , Audits , Audits , Audits , EARLIER Audits Completed in audits completion completion completion completion quarter actually actually actually actually quarter Due a timeframes completed In Apr-Jun In Jul-Sept In Oct-Dec In Jan-Mar than completed completed in completed completed than outside proposed in Apr-Jun Jul-Sept in Oct-Dec in Jan-Mar proposed timeframes

Accident & Emergency 0 0 2 0 4 0 11 0 2 0 17 0 2

Acute medicine 0 0 2 0 0 0 2 0 0 0 4 0 0

Care of the elderly 3 0 1 0 2 0 7 0 0 0 13 0 0

Diabetes 4 0 0 0 2 0 6 0 1 0 12 0 1

Endoscopy 0 0 1 0 1 0 2 0 0 0 4 0 0

Gastroenterology 0 0 0 0 0 0 6 0 0 0 6 0 0

Maltings 1 1 0 0 0 0 2 0 0 0 3 1 1

Neurology 1 1 0 0 2 0 6 0 0 0 9 1 1

Oncology & 1 0 3 0 5 0 14 0 0 0 23 0 0 Haematology

Renal medicine 3 0 4 0 6 0 1 0 1 0 14 0 1

Respiratory medicine 5 0 3 0 3 0 6 0 0 0 17 0 0

Stroke 0 0 1 0 1 0 3 0 0 0 5 0 0

Total 18 2 17 0 26 0 66 0 4 0 127 2 6 Appendix 2c Division 3 progress against plan Audits due Number of Audits due Number of Audits due Number of Audits due Number of Audits Audits Total Total Total for proposed for proposed for proposed for proposed completed completed Audits completed completed completion audits completion audits completion audits completion audits EARLIER than LATER than Due within including Division 3 Apr-Jun completed in Jul-Sept completed Oct-Dec completed Jan-Mar completed in proposed proposed agreed outside Q1 in Q2 in Q3 Q4 timeframe timeframes

1 0 1 0 4 0 1 0 0 0 7 0 0 Adult Community 2 0 2 0 5 0 9 0 0 0 18 0 0 Children's Acute 1 0 0 0 6 0 2 0 0 0 9 0 0 Children's Community 0 0 3 0 3 0 4 0 0 0 10 0 0 Dermatology 1 0 1 0 0 0 2 0 0 0 4 0 0 Dietetics 0 0 3 0 1 0 9 0 0 0 13 0 0 Pharmacy 0 0 3 0 1 0 5 0 0 0 9 0 0 Primary Care Services (VI) 6 0 2 0 2 0 5 1 1 0 15 1 2 Radiology 1 0 2 0 4 0 6 0 0 0 13 0 0 Rheumatology 1 1 0 0 2 0 3 0 0 0 6 1 1 Sexual Health 0 0 0 0 0 0 1 0 0 0 1 0 0 Speech & Language 0 0 0 0 5 0 3 0 0 0 8 0 0 Therapy Services Total 13 1 17 0 33 0 50 1 1 0 113 2 3 Appendix 3 Abandoned Audits and Rationale 2018/19 Directorate Audit Audit Type Abandoned Audit Title Abandoned Reason ID Date Accident & 3658 Local audit of admissions of children to PAU with fever 14/09/2018 Bringing in another test at the moment to reduce the admission further is not a priority as Emergency we have changed our set up completely. We have 5 consultants and 4 ACP´s. The admission of children with PUO has decreased as we are better at diagnosing the illnesses.

Accident & 3987 Service A review of current practice around Emergency 20/9/2018 Dr responsible for the audit has left the trust and unable to make contact to retrieve any Emergency Evaluation department investigation of suspected pulmonary data that may have been collected. embolus in the context of underutilised nuclear imaging which has greater sensitivity and a far lower radiation dose. Accident & 4459 National VTE Risk in Lower Limb Immobilisation 18/02/2019 This is a new Directive in Royal College Emergency Medicine and that not many hospitals Emergency in the surrounding areas are doing this audit. New Cross have not started using the VTE Risk Assessment Guidelines It will be discussed within the Directorate going forwards.

Acute medicine 4401 QIP iv fluids prescription on EPMA-Do we prescribe iv 22/01/2019 Audit was set up by two juniors and a consultant who have all subsequently left the Trust fluids correctly? without handing the project over. There is no other alternative, but to abandon.

Adult Community 4161 NICE Audit of Antimicrobial Prescribing by Non Medical 02/07/2018 ASAG Team seem to have registered 2 similar audits in their audit plan. The mix up is due Services Prescribers - ABANDONED to change in audit leads and therefore audit 4161 needs to be abandoned as audit 4351 has been completed. Cardiothoracic 4186 Local Re-audit: A Structured Handover Form for 18/12/2018 Not enough junior medical staff to perform the audit also, the handover problems are very Surgery Cardiothoracic Patients on Transfer from Theatre much reduced. to Critical Care Unit. Care of the elderly 3907 National National Flash Audit of dental hygiene of 14/02/2019 Originally registered in 2017/2018. Following discussions at Governance Meeting Feb hospitalised patients aged 65 and older 2019, this Audit is to be abandoned. A great deal of work is being undertaken around Sepsis and infections and Directorate are developing a SOP around Oral Hygiene and Mouth care to enable Directorate to bench mark Oral Hygiene. Care of the elderly 3909 National National (re)Audit of Dementia Care (Fourth 20/09/2018 This audit was only completed in 2017, to repeat so soon will providee nothing new. Round) Additionally resources are reduced and clinical time would be better spent within department. Care of the elderly 4222 Other Antibiotics (2018/2019) 20/09/2018 This is part of the trust wide Synbiotix audit and does not require adding to the clinical audit database. Children's Services - 3394 NICE A NICE-related Audit: CG089 When to suspect 18/06/2018 NICE guidance CG089 sits with the Safeguarding Dept. The Safeguarding Dept. is currently Community child maltreatment reviewing the guidance and once the review is over, Safeguarding will audit it.

Critical Care 4471 Local Handover of information between recovery and 31/01/2019 Delays in the update and roll-out of Perioperative Care documentation means that we are ward post procedure unable to carry out this audit as planned in Q4 of the 2018/19 fiscal year. We have agreed to abandon this audit and re-register with a view to complete in Q2 - 2019/20. Directorate Audit Audit Type Abandoned Audit Title Abandoned Reason ID Date Dental 4165 NICE IV Sedation 29/03/2019 Dental Services have advised that most appropriate staff member to carry out this audit has left the Trust and the position is vacant. The audit will be undertaken once a new IV Sedation Specialist has been recruited. Dermatology 3993 NICE TA455 Adalimumab, etanercept and ustekinumab 18/02/2019 No patients have met the criteria for TA455 Adalimumab, etanercept and ustekinumab for for treating plaque psoriasis in children and young children. These patients are managed by immunosuppressant's and phototherapy and people cases are rare. If we have a severe case the child would need to be referred to BCH for second opinion before receiving TA455. Diabetes 3766 NICE CG130 Hyperglycaemia in acute coronary 25/01/2019 Discussed at Governance in January 2019 - on review the directorate do not consider this syndromes project to be clinically or cost effective. Diabetes 3761 NICE TA336 Empagliflozin in combination therapy for 18/01/2019 This audit duplicates the national audit of Empagliflozin run by The Association of British treating type 2 diabetes Clinical Diabetologists (ABCD), which the Trust has joined and will be submitting data to.

Diabetes 3763 NICE TA315 Diabetes (type 2) - canagliflozin 30/07/2018 Canagliflozin is part of a class of drugs known as SGLT2 inhibitors, of which two others are on formulary, Dapagliflozin and Empagliflozin. In view of the previously documented high signals for lower limb amputations, seen only with Canagliflozin, we do not initiate this drug. We have had assurance from Pharmacy that it has not been prescribed in this Trust.

Dietetics 4182 Local Nutrition support on the ICCU 15/03/2019 4182 was never started as there are still actions not yet achieved from the original audit 3075. Pending completion of 3075 actions this will add to the audit plan. Endoscopy 3374 Local Local Bowel Preparation audit 17/18 05/09/2018 Ongoing staffing issues and not a priority over existing clinical commitments. Endoscopy 4166 Local Local Bowel Preparation audit 18/19 19/10/2018 This project would have been a re-audit of project 3374, which has previously been abandoned. This project would therefore be of little practical value and with ongoing staffing issues and existing clinical commitments this should not be a priority.

Endoscopy 4177 National National Gastric Ulcer Audit 18/19 19/02/2019 There is no ongoing national audit; hence no plan to continue Gastroenterology 3743 NICE Audit of TA413, TA330, TA363, TA364 and TA365 23/10/2017 These drugs are NHSE funded drugs that require patients to go onto a separate system. As they are funded by NHSE, the NHSE criteria are followed as opposed to the NICE guidance which is slightly different. There is a spread sheet of all patients who are on these drugs and this can be used assurance that the drugs are being used appropriately as the patients must meet the NHSE criteria in order to be put onto the database.

Gastroenterology 3744 NICE Audit of CG165 Hepatitis B (chronic) 23/01/2019 Audit does not measure against old standards as current management of patients is using newer drugs, not mentioned on the old guidance (guidance due to be updated nationally).

Gastroenterology 3897 NICE Audit of CG184 Gastro-oesophageal reflux disease 31/01/2019 Final audit completed in 2016/17 demonstrated full compliance, requirement to re-audit and dyspepsia in adults: investigation and is 5 years later. Will be considered for 21/22 plan. management Gastroenterology 4181 NICE NICE: CG166 Ulcerative Colitis 18/19 12/02/2019 Due to nurse staffing issues audit not completed last year and it's currently being rewritten by NICE and due for publication this year so will be looked at later in the year, rather than audit against outdated guidance and have to repeat in 6 months. Directorate Audit Audit Type Abandoned Audit Title Abandoned Reason ID Date Gastroenterology 4475 NICE 2018 Audit of Ustekinumab use and outcomes in 05/02/2019 This audit has been registered by a junior doctor. This audit is a duplicate of 4476 and Crohns disease; including NICE recommendations 3960.

Gastroenterology 4476 NICE 2018 Audit of Ustekinumab use and outcomes in 31/01/2019 Junior doctor registered and is a duplicate of 4475. Crohns disease; including NICE recommendations

General surgery 3486 National National Endocrine and Thyroid National Audit 11/07/2018 Consultant staff are not members of the BAETS society and therefore cannot submit data (BAETS) to this project. Audit is not a NCAPOP and has not been identified for inclusion in the Quality Accounts. General surgery 3782 NICE IPG480 Endoscopic thoracic sympathectomy for 22/06/2018 Convener advised that the procedure is of limited clinical value and needs to be primary facial blushing abandoned. Thoracoscopic sympathectomises are now a rare procedure and the Directorate do not think they would be supported by POLCV as support has largely been withdrawn for treating hyperhydrosis. General surgery 4282 Local Local: Re-Audit An audit of abscess management in 14/06/2018 Re-audit no longer required. Previous audit (project 3416) demonstrated full compliance a DGH against standards. General surgery 4566 QIP Use of the abscess management pathway 29/03/2019 Duplicate of audit 3416. Head & Neck 3676 NICE Audit of IPG449; Insertion of customised titanium 29/03/2019 Clinical Lead OMFS, advised that they have not had any patient with implants that would implants with soft tissue cover for orofacial fit the need for this audit for the last twelve months. reconstruction Maltings 4137 Local To audit the return of Trust wheelchairs issued to 22/10/2018 Discussed at Malting's Governance Meeting. Ascertained that this audit was not needed our patients and that information needed would be best served by getting a report from the Supplier. .

Neonatal 4263 Local Pneumothorax Audit 2017 DATA 15/03/2019 In line with new NICE guidance, an audit will be completed in 2019/20. The current service will be audited in line with the NICE ventilation strategy and standards for premature babies. The audit will also be known as “Ventilation of premature babies” which encompasses prevention, detection and treatment of Pneumothorax. Obstetrics 3354 NICE A NICE-related Audit on Antenatal Care 16/08/18 This audit has been completed as Audit No. 3678: CG062 (Updated Jan) Antenatal care for uncomplicated pregnancies and missed SGAs. Oncology & 3834 NICE TA360 Paclitaxel as albumin-bound nanoparticles 13/03/2019 Directorate advised this audit is superfluous given the drug is continually monitored Haematology in combination with gemcitabine for previously through the Cancer Drug Fund and Individual Funding Request process. untreated metastatic pancreatic cancer

Oncology & 4118 Local NATSIP Haematology (OP08) Bone Marrow Biopsy 02/04/2019 Duplicate audit of audit already registered - 4312. Haematology Oncology & 4384 NICE TA439 Cetuximab and panitumumab for previously 13/03/2019 Directorate advise this audit is superfluous given the drug is continually monitored Haematology untreated metastatic colorectal cancer through the Cancer Drug Fund and Individual Funding Request process Directorate Audit Audit Type Abandoned Audit Title Abandoned Reason ID Date Ophthalmology 3785 NICE IPG575 Trabecular stent bypass microsurgery for 18/06/18 This audit has been completed as Audit No. 4002: Istent insertion and cataract surgery for open-angle glaucoma (Istent insertion and cataract the management of glaucoma. Also the stent has now been withdrawn from the market. surgery for the management of glaucoma).

Ophthalmology 4205 Local Steroid Induced Osteoporosis in Uvetitis Practice 29/03/19 This is a re-audit of Audit No. 3160 which showed full compliance. Having demonstrated full compliance, it was not the intention of the Audit Lead to re-audit it again. However, he was on long term off sick and has just made this known. The directorate has chosen to use its resource on audits of a higher priority. Pharmacy 4149 NICE An audit assessing the adherence of biologic 31/05/2018 The re-audit was expected to show compliance of the trust deviating from the NICE prescribing within the Rheumatology Day Unit at guidance with their agreed local guidelines. However, the NICE guidance has changed and Cannock Chase Hospital when compared to the is currently no longer valid to current practice. National Institute for Health and Care Excellence The team now use the new regional algorithm and a Blueteq system which complies with guidance on biologic drugs for the treatment of the deviations from NICE. Therefore, a re-audit would not be a useful exercise and the rheumatoid arthritis (May 2013) CG79 team wish to abandon this audit

Pharmacy 4150 NICE NICE Audit QS85 - An audit to assess whether the 13/08/2018 Original audit conducted only showed minor non compliance and the gaps in compliance minimum standards for discharge are provided as will not have changed due to EPMA. Division & NIG have previously accepted the gaps in stipulated by NICE quality standard QS85 when compliance. patients are transferred between hospital and care homes Pharmacy 4151 Local A snapshot audit to ascertain patterns of oral 13/08/2018 Original audit done last year only showed minor non-compliance and an appropriate anticoagulant prescribing practice within the Trust. action plan was put in place. Directorate have since identified more essential audits that are required to be undertaken this year and with limited staff would request this audit is abandoned. Radiology 3558 Local Examining the use of abdominal x-rays as a 06/07/2018 Advised that the junior who was originally allocated has left and Radiology are not able to method of imaging following endovascular re-allocate to another junior due to capacity issues. aneurysm repair. Renal medicine 4075 Local QIP - Home HD Outcomes 22/03/2019 Discussed at Renal Governance 21/03/2019 - is now considered unlikely to be either clinically or cost effective. Clinical Director and Audit Convenor therefore request abandonment. Renal medicine 4004 NICE NICE TA481 - Immunosuppressive therapy for 23/11/2018 The guidance states that “The recommendations apply only to the initial kidney transplant in adults immunosuppressive therapy (induction and maintenance therapy) started around the time of kidney transplant”. Trust sees patients from local transplant centres for follow-up at 3- 12 months post-transplant when they are already established on the maintenance treatment from the guidance. We do not initiate these drugs therefore the guidance does not apply to our practice locally. Respiratory medicine 4190 Local Audit to investigate process of pleural drain 21/03/2109 This audit has been superseded by another "Reducing the length of stay of patients insertion and subsequent pleuradesis in requiring pleural procedures" QIP, which is on the Respiratory 2019/20 Clinical Audit hospitalised patients attending Ward C19 for their Forward Programme. procedure 18/19 Directorate Audit Audit Type Abandoned Audit Title Abandoned Reason ID Date Respiratory medicine 4323 Local HIV Screening in Pneumonia 21/03/2109 This project was part of a proposed 2018/19 West Midlands Regional Respiratory QIP, which has not subsequently progressed beyond the pilot stage. It's unlikely the QIP will ever be completed. Respiratory medicine 3408 NICE NICE: TA278 Asthma 04/06/2018 Since April 2016 it has been compulsory for Omalizumab patients to be discussed at the severe asthma MDT (heartlands) ahead of making a Bluteq application. All cases are then logged on to the national UK database (DENDRITE / UK BTS severe asthma registry). The Trust complies with this and therefore the project lead believes local audit is unnecessary.

Respiratory medicine 4299 Local Assessing factors causing failure of talc pleurodesis 29/11/2018 Clinical Director, Clinical Lead for Lung Cancer and Audit Convener have jointly agreed this in patients with malignant pleural effusion(MPE). project would effectively be research and it is not therefore suitable for clinical audit. Continuing with this audit is therefore inappropriate Rheumatology 3774 NICE TA291 Gout (tophaceous severe debilitating 30/07/2018 Medics reviewed their patient list and the drug has not been used in the rheumatology chronic) - pegloticase department, therefore no patients to audit Rheumatology 3947 NICE TA397, Belimumab for treating active 13/07/2018 Medics reviewed their patient list and the drug has not been used in the rheumatology autoantibody-positive systemic lupus department, therefore no patients to audit erythematosus Rheumatology 4103 Service Re-Audit Exercise and Rheumatoid Arthritis – a 04/03/2019 Discussion at Rheumatology Governance meeting Jan 19 request to postpone until next Evaluation service evaluation year as we hope annual review clinic will be set up by then. Annual review clinic is one of the action and this has not been completed as yet. Proposal for completion on 2019/20 Q3 Speech & Language 4139 NICE NICE CG 162 - Audit of 45 minute Stroke Rehab 19/02/2019 This audit is covered by the SNNAP Stroke Audit and is no longer required to be Therapy standard by SLT undertaken Trauma & 3659 NICE IPG493 Arthroscopic radiofrequency 05/03/18 Radiofrequency chondroplasty is used infrequently and often at operation it is used as an Orthopaedics chondroplasty for discrete chondral defects of the adjunct to some other procedure (which generates the main code) rather than done as a knee. sole procedure. Due to issues with coding unable to audit guidance. Trauma & 4112 NICE Re-audit; Reasons for Delays & average waiting 16/01/19 This was a re-audit following non compliance with NG038 however gaps in compliance Orthopaedics times for ORIF of wrist & Ankle fractures have been previously accepted by Division & NIG therefore re-audit will only show the same results. 19/09/18 Appendix 5 Outcomes for completed audits 2018/19

Directorate Division Audit ID Audit title Type of audit Date completed Compliance rating Key Successes- summarised Key Concerns- Summarised Key actions- summarised

A large proportion of the data showed normal/faecal loading X- Indications for Plain Abdominal Films Include audit findings in teaching sessions in ED and share Accident & Emergency 2 3167 Local 18/10/2018 Fully Compliant The majority of requests meet the i-refer guidelines rays. It also showed that a third required further imagine to reach from the Emergency Department these findings with all colleagues in ED via email the final diagnosis

Absence of: - - Clear documentation specifying which antibiotics are being prescribed in the clerking notes. - indication for antibiotic prescribing. - duration of course of antibiotics. Generally quite good antimicrobial prescribing in ED Documentation that antibiotics are being given/prescribed but no Educate and disseminate information regarding Antibiotic High compliance in: documentation about which antibiotic. Accident & Emergency 2 3224 Antibiotic Prescribing Compliance in ED Local 12/09/2018 Minor non-Compliance Prescription Guidelines cutaneous abscess, ear abscess, pyelonephritis, otitis externa, Re Audit in 3 months Epididymoorchitis, conjunctivitis and tonsillitis Not prescribing gentamicin for diverticulitis = no cover against E.coli which one of the main organisms

Use of gentisone for otitis media only appropriate if there is effusion. If perforated TM but no infection or discharge there is a risk of damage to inner ear via ototoxicity. Should only be used for otitis externa

If one considers only the ketamine sedation, compliance was similar to the previous audit with improvements in the documentation of Demonstration of the emergence of sedation with propofol. At the Develop leaflet Audit of CG112 on sedation in children in Moderate non- observations during the procedure Accident & Emergency 2 3305 NICE 18/10/2018 time of the audit there was no dedicated children’s sedation Guideline in line with RCEM guidance the Emergency Department compliance guideline, consent or leaflet for this type of sedation. Consent form in RWHT formal Following the audit a leaflet, guideline and consent form have all been implemented.

Lack of room safety assessment and mental health risk assessment tool To introduce a mental health risk assessment tool for all Assessment of children with self harm Moderate non- Enabled assessment of processes to identify which need to be Documentation of room safety patients and to develop two stickers for use in patients’ Accident & Emergency 2 3306 presenting to the emergency department NICE 12/03/2019 compliance modified to achieve better compliance medical notes to document room safety and the process to (CG16) Mental health risk assessment for all patients follow if a patient absconds from ED.

Documentation and process if patient absconds from ED

The RWT compliance to RCEM standards is significantly low but not far off from national average.

This is the first time that organisational data were analysed. - 51% of EDs have a nominated lead for hip fracture management. - 87% of EDs have a written protocol but only half of these The RWT compliance to RCEM standards is significantly low but not protocols include guidance on when to perform a CT or MRI scan. far off from national average. Fractured Neck of femur (Royal College Significant non- - 35% of EDs provide information leaflets for patients, carers or Audit was presented to ED teaching. Accident & Emergency 2 3311 National 13/02/2019 of Emergency Medicine) compliance relatives. Audit findings shared with doctors and nurses in department Participation in this audit has enabled the dissemination of - 93% of EDs have the necessary equipment and staff to perform a information in teaching sessions for doctors and nurses nerve block (e.g. facia iliaca block) - 93% of patients with #NOF arrive by ambulance yet only 66% have documented evidence of having received analgesia before arrival. - Re-evaluation of pain is important but not done well (only in 40%) and not done in a timely manner

Either average or above average on all aspects of the TARN reports. TARN (Trauma Audit and Research Accident & Emergency 2 3312 National 02/04/2019 Fully Compliant No major concerns identified No actions identified Network) 2017/18 The action plan done following the TARN review three years ago is complete. Directorate Division Audit ID Audit title Type of audit Date completed Compliance rating Key Successes- summarised Key Concerns- Summarised Key actions- summarised

The main issue is poor documentation of the pain scoring, and re evaluation

Nearly half (45%) of children presenting with limb injuries did not have a pain score recorded at all. Only 1/3 (32%) of pain scores recorded were within 15 minutes of arrival in ED.

Most children (85%) with severe pain were offered analgesia, More children are receiving pre-hospital analgesia than in previous however only 50% received this within 30 minutes and 69% within audits which is a positive change. an hour. Timely administration of analgesia has therefore reduced Pain in Children (Royal College of Significant non- Audit finding to be shared with all clinical staff in department Accident & Emergency 2 3313 National 18/03/2019 since previous audits. Emergency Medicine) compliance via teaching and email Participation in this audit has enabled the dissemination of information in teaching sessions for clinical staff A high proportion of children who are not receiving analgesia despite a documented significant pain score approximately 12% in severe pain and 28% in moderate pain.

Fewer children are receiving analgesia within 60 minutes of arrival in the hospital.

In almost all cases in this audit there is no re-evaluation of the pain score and so it is unclear whether children’s pain is being adequately managed.

74% of patients who triggered sepsis had the Sepsis Screening & For patients who received treatment for sepsis according to the Action tool completed/evidenced in their notes. For patients who pathway; 91% (30/33) had blood culture specimens taken, 93.3% of received treatment for sepsis according to the pathway; 54.6% of Moderate non- Accident & Emergency 2 3315 Sepsis CQUIN audit 2017/18 National 10/04/2019 blood cultures were taken prior to commencement of IV antibiotic IV antibiotics were given in the first hour of attendance, 31.3% of Implementation of EWs 2 across the Trust. compliance therapy and 100% of patients were assessed for oxygen and fluid patients with lactate results ≥2mmol/l had further tests recorded requirements and treated accordingly. and 0% had urine output measured & documented on a fluid balance chart.

Poor documentation Review Documentation process Ensure scoring system used to improve sensitivity and Moderate non- Participation in this audit has enabled the dissemination of Use of scoring system which improves sensitivity and specificity specificity Accident & Emergency 2 3657 Audit of DVT pathway Local 12/03/2019 compliance information in teaching sessions for clinical staff Document the reason why d-dimers not done Keeping patients updated of plan and why it is needed for consent To include audit findings in clinical teaching in ED and also to as patient involvement in decision making relieves anxiety. share these findings with all clinical staff via email

The results show that clinicians do not follow guidelines to the full. ADHERANCE TO GUIDELINES OF Improved understanding of guidelines of managing elderly patients Lack of a proper understanding of guidelines. Update clinicians on the guidelines of managing elderly Accident & Emergency 2 3983 MANAGEMENT OF UTI IN ELDERLY Local 02/07/2018 Minor non-Compliance suspected to have urinary tract infection, thus improving care patients suspected to have urinary tract infection. PATIENTS IN ED Updates needed for local guidelines and National guidelines like NICE and SIGN

Liaise with radiology department to expedite final radiology reports to within 1 hour from time study performed.

The reporting turnaround times for CT heads from ED have not Continual training/ update to EM Consultants in order to During the 2 month period of the audit, there were no significant Audit to see if all CT scans are reviewed Moderate non- met the set standard of 1 hour. Average time to report by maintain high standards - to be provided by Radiology Accident & Emergency 2 4275 Local 18/03/2019 discrepancies between the preliminary ED report and the final in 1 hour compliance Radiology consultant/ registrar 5 hours 33 minutes with 21% of consultants as adhoc sessions/ training days Radiology report CTs reported within chosen standard. Encourage (Contact via email and teaching sessions in ED) EM consultants & registrars to attend stroke MDTs that are currently run weekly.

Either average or above average on all aspects of the TARN reports. TARN (Trauma Audit and Research Accident & Emergency 2 4276 National 02/04/2019 Fully Compliant No major concerns identified No actions identified Network) 2018/19 The action plan done following the TARN review three years ago is complete. Directorate Division Audit ID Audit title Type of audit Date completed Compliance rating Key Successes- summarised Key Concerns- Summarised Key actions- summarised

ECG reports signed by a senior clinician and results documented in notes - 80% compliance against standard. Safeguarding questions considered - Not previously audited. Local documentation audit of ECG/Snr Patients meeting the following criteria must be reviewed by a senior Compliance in children higher than that of adult attendances'. Review/Discharge clinician (ST4 or above); 95% - Senior review previously 100%, To reaudit in Q2 and all aspects of audit to be reiterated at Accident & Emergency 2 4277 checklist/CPE/Safeguarding/Meds Local 16/07/2018 Minor non-Compliance however the documentation as to which consultant has reviewed/ Slight decrease in the use of the discharge check list. The largest next Doctors induction. Rec/MEWS Score - evidence of Track and discussed the patient is clearer and more detailed. area still for none completed is for those patients who are Trigger. admitted. Discharge checklist completed All investigation findings (bloods, ECGs, Radiology ) documented in the patient notes Nurse staffing was inconsistent until the latter part of 2017. Ability to have 2 trained nurses for each long day shift proved difficult and Reviewing and further evaluation of proformas unable to consistently have staff overnight until this point. Redefining and launching the 2nd triage nurse as the UTT 86% feel the Nurse led RAT process is effective as a first assessment Activity through the majors area and adaptations to the RAT (urgent treatment and transfer nurse) in order to improve for the patients in the emergency department model. e.g. RATTING on offload, means some patients may not be compliance with the new sepsis NHS contract requiring 90% Accident & Emergency 2 4278 Nurse Led RAT Audit Local 12/03/2019 Minor non-Compliance captured in the data. compliance from 1st April 2019 82% feel the RAT proforma is appropriate for this assessment One of the key causes of delays within ED involves patient flow Add NLR compliance to the quarterly ED data set within ED and throughput, opening and modification of areas has been introduced to support this. e.g. RAT corridor, AOA, Pre Share with other Trusts admission.

Platelet count documentation not in hospital Address importance on clear documentation Able to address areas of low compliance with documentation and Accident & Emergency 2 4290 DVT/PE Local 12/10/2018 Minor non-Compliance protocol consider changes to protocol to improve this in future. Try to get platelet documentation to be included in protocol Poor Documentation Treated in line with guidance=77% Increase education Audit of Emergency Department Accident & Emergency 2 4348 Management of Acute Asthma in Local 12/10/2018 Minor non-Compliance Proportion admitted (PAU) who met admission criteria=100% Proportion discharged who met criteria for discharge=67% Evaluate + record discharge criteria Children Discharged with wheeze plan=50% Increase guideline availability High false panic alarm rate in a busy ED wastes personnel time, The rate of false attack alarms in the Enabled assessment of panic alarms to occur to identify the desensitizes people to genuine emergencies and is likely to Change alarm type (Flip covered) to protect accidental Accident & Emergency 2 4473 Local 26/02/2019 Not applicable emergency department percentage of true panic alarms increase the risk of mistakes with interrupted tasks, and a solution activation such as a button design change is urgently needed

Documentation of assessment and preparation (including naming the procedure) prior to sedation was suboptimal. A tick box within the contraindication section may help to improve An inadequate number of airway and aspiration risk assessments documentation. Measuring Compliance with the were particularly Moderate non- Enable measurement of safety during conscious sedation of adults Accident & Emergency 2 4479 Emergency Department Adult Procedural Local 01/02/2019 notable. compliance within the Emergency Department Amendment of Sedation Proforma the proforma may be one way to improve documentation Contraindications to sedation were frequently not acknowledged. Explore other methods to improve documentation There was often little or no documentation within the adverse event and discharge sections.

Increased staff awareness of guideline (all ED staff emailed) Some staff were only following guideline - juniors were not Audit of Patients <18 years who did not Enabled assessment of whether patients that 'did not wait' had been discussing these patients with a senior Accident & Emergency 2 4552 Local 12/03/2019 Minor non-Compliance Receptionists have been contacted to check telephone wait to be seen followed up numbers at booking in so that a parent/guardian can be Many patients did not have a contact number documented contacted if needed Doctors on AMU showed better compliance to completing falls assessment forms (60%) following education and introduction of new forms. Weekly audit and reminding junior doctors on daily Acute medicine 2 3941 Falls Audit QIP 17/07/2018 Minor non-Compliance Whilst now within proforma, still not reliably being filled in On average fewer falls on AMU since introduction of new falls form handover compared with previous assessment forms. Although results are not significant.

Recommendation to prescribe oxygen for all patients, not just Education of junior medical staff. There was an improvement in oxygen prescription enabling the those with a need on admission and target saturations. This is not Acute medicine 2 3942 Oxygen audit QIP 17/07/2018 Minor non-Compliance correct dose of oxygen to be given to all patients being done routinely on patients where there is no perceived Prompt on new clerking proforma on PTWR to perform requirement for oxygen review of oxygen needs. Directorate Division Audit ID Audit title Type of audit Date completed Compliance rating Key Successes- summarised Key Concerns- Summarised Key actions- summarised

There was a drop in the number of patients who had their diagnosis documented appropriately Alteration of clerking proforma to improve documentation All clerking documents perused had co-morbidities documented by using correct coding terminology clerking doctors Acute medicine 2 3943 Mortality documentation audit Local 20/02/2019 Minor non-Compliance Delay in interventions and assessment of impact – are the results a reflection of poor sustainability of change post intervention Ongoing education of medical staff in correct terminology, All of March 2018’s post takes were documented by consultants. especially consultants. 'Possible' appeared to be a popular word preceding diagnoses

Proforma for documentation of lumbar puncture introduced - this is now widely used and contains all the necessary details of who, how, Acute medicine 2 3944 Lumbar Puncture QIP Local 12/02/2019 Fully Compliant No major concerns identified No outstanding actions identified when and what was done with respect to the procedure along with any complications All areas of substandard compliance is discussed at the Trust Wide Early Warning Signs Audit Audit has demonstrated levels of compliance with the Track and Clinical Audit Group Meeting and directly with the Some directorates demonstrated poor compliance with the Track 2018/19 Trigger Protocol for Early Warning Signs across the Trust inline with Directorates at their Governance Meeting. Individual action and Trigger protocol in particular with appropriate documentation Acute medicine 2 4461 Trust Wide 01/03/2019 Minor non-Compliance Trust Policy in order to address any areas of substandard plans will be drawn up according to the specific areas of of escalation. Safety Alert NHS/PSA/RE/2018/003 & performance. Areas of excellent compliance can be shared across the concern. Audit is completed annually and previous years

NHS/PSA/RE/2016/005 Trust to encourage learning and improvement. results will be compared to demonstrate any improvements/decline in performance.

There was positive impact as reflected from relatives' feedback. Adult Community 2017/18 Post Bereavement Service 3 3280 NICE 26/06/2018 Fully Compliant The positive feedback gives staff assurance that they display None. None. Services Evaluation NICE QS13 (Re-audit) compassion and their care is of a high standard. The audit is used to monitor performance of local teams. This The staff have maintained high standards when using appropriate Adult Community 2017/18 Re-Audit - Dressing Formulary will ensure staff continue to maintain high standards 3 3323 Local 26/06/2018 Fully Compliant dressings for patient wounds. This efficiency will help to ensure None. Services Compliance required. resources are well managed. Compliance is submitted to CCG for assurance. All areas of substandard compliance is discussed at the Clinical Audit Group Meeting and directly with the Audit has demonstrated levels of compliance with documentation Directorates at their Governance Meeting. Individual action standards across the Trust inline with the Clinical Documentation Some directorates demonstrated poor compliance with the Adult Community Trust Wide OP07 Health Records plans will be drawn up according to the specific areas of 3 4157 Trust wide 04/03/2019 Fully Compliant Guidelines in order to address any areas of substandard performance. standards in particular regarding documentation of clinicians Services Documentation audit (2018/19) concern. Audit is completed annually and previous years Areas of excellent compliance can be shared across the Trust to identification number and full name/signature. results will be compared to demonstrate any encourage learning and improvement. improvements/decline in performance.

The audit has emphasized the importance of complete and timely There is a 7% non-compliance rate where no trigger tool had been Adult Community Specialist Foot Health Services Skin completion of the Trigger Tool. It has refocused the staff and Email sent to each non complaint staff member advising of 3 4158 Local 16/10/2018 Minor non-Compliance completed and a 25% rate of non-compliance with completion Services Integrity Trigger Tool Re-Audit encouraged them to monitor patients’ risk factors and escalate as future monitoring. To re-audit. outside of the set timeframe. appropriate, reducing the risk of patient harm.

The audit provided assurance that the weights of the nursing bags are largely in accordance with local Standard Operating Procedures for To enhance awareness and ensure that the weight of the the clinicians' bags and car boots. nursing bag is in accordance with local Standard Operating procedure for Clinicians Bag and Car Boot. - The audit also gave assurance that the directorate is compliant with To meet infection prevention guidance and ensure that bags Adult Community Local Community Nursing/Health Infection Prevention guidance. The bags and boxes are kept within a 3 4159 Local 17/10/2018 Minor non-Compliance There was minor non-compliance with the weight of the bag. and boxes are kept within a clean environment, wipeable, Services Professional Bag and Car Boot - Re-Audit clean environment, are wipeable and free from tears or scuffs (IP04). free from tears or scuffs (IP04). To meet requirements for carriage of contaminated items, Assurance was also given that the directorate meets requirements for i.e. samples, used equipment, adheres to Transportation of the carriage of contaminated items, i.e. samples and used equipment. clean and contaminated equipment / samples policy (IP04). It adheres to the transportation of clean and contaminated equipment/ samples policy (IP04).

Nurse running PAT to ensure staff undertaking medication At 16.00 staff do not routinely return to base and there is no clear checklist completion are allocated the time. communication of process to be followed for staff to confirm Adult Community Use of Medication Checklist within Identified areas where SOP is not being followed to allow 3 4160 Local 10/01/2019 Minor non-Compliance medications are completed or if any are outstanding. Services District Nursing improvements to be made. Nurse Managers to cascade SOP to all staff. No identified staff member with dedicated time to take responsibility nominated to complete check. Re-audit 2019/20

Audit on the quality of documentation The audit has shown that all patients are consistently provided with Adult Community To continue to consistently give safety netting advice to 3 4162 reflects safety netting in patient Local 16/10/2018 Fully Compliant advice to ensure they are safe and that deterioration in their None. Services patients across the service management plan of medical notes condition is escalated appropriately. This report indicates that the Community Matron Service and Rapid Main area of non-compliance is within the GP home visiting Adult Community Team to highlight the non compliance for GPs actions where 3 4351 Antibiotic Prescribing Audit Local 26/06/2018 Fully Compliant Intervention Team have good compliance compared with the local service where patients are not routinely reviewed when Services possible to some of the GPs audited in this report. and national guidance audited criteria. commenced on antibiotic medications. Directorate Division Audit ID Audit title Type of audit Date completed Compliance rating Key Successes- summarised Key Concerns- Summarised Key actions- summarised

Service User Survey - Children's Service Appointments during school hours are reduced. Parking issues and parents concerned with their child missing Appointments being offered before and after school. Audiology 1 4197 22/10/2018 Minor non-Compliance Audiology Evaluation Parking non-availability minimized. school. Staff off-site parking rota has been created. From the evidence collected the general trend is that patients are Service No concerns as service evaluation demonstrated high levels of Audiology 1 4198 Service User Survey - Adults Audiology 25/03/2019 Not applicable very satisfied with the service that West Park Hearing Services N/A - No areas of concern to address. Evaluation patient satisfaction. provide. Trust Wide OP07 Health Records Audit provides assurance we are fully compliant with audited Audiology 1 4199 Trust Wide 01/03/2019 Fully Compliant No concerns as fully compliant No actions as audit standards were fully compliant. Documentation audit (18/19) standards. Audit of information sent with patient Patients will now be informed regarding the purpose of their Audit revealed appointment information leaflets were only sent The clerical staff are to being reminded to send information Audiology 1 4200 Local 18/10/2018 Minor non-Compliance appointment letters appointment prior to attending via information leaflets. out to 65% of clients. leaflets out to patients Individual staff will be spoken to as identified. Deviation from standards due to clinical need not being Issue added to all Appraisals. Audiology 1 4201 Pure Tone Audiometry (PTA) Audit Local 28/02/2019 Minor non-Compliance Audit will allow for improvements to be made to documentation. documented in the patients notes. All hot keys with patient management system (Auditbase) are being reviewed. Seven Day turn around for patient The audit provided the assurance that the department is meeting the Audiology 1 4202 Local 27/04/2018 Fully Compliant No concerns as fully compliant No actions as audit standards were fully compliant. reports Audit KPI for the 7 day turnaround of reports. (KPI=95%).

The yield of participating GPs was low; however this is an Service Audit has identified areas where improvements are required, e.g. The key action from this project is to work with GPs to Audiology 1 4203 GP Satisfaction Survey 25/03/2019 Not applicable improvement on the previous audit in 2017 whereby only 2 Evaluation communications with GPs re changes to service. communicate to them of the appropriate referral pathway. responded, but lower than the 2018 audit whereby 8 replied. We have already taken steps within the department to expedite DTB times (meetings with ambulance team, ED The door to balloon times (<90 minutes and <60 minutes) are teams from referring centres). Furthermore, we have taken Coronary interventions / Coronary Moderate non- Re-emphasised weaknesses in current practice and areas in which the Cardiology 1 3583 National 03/01/2019 longer than we would expect. One of the limitations of these data steps to more accurately document timings as a previous angioplasty (BCIS) - 2016 data. compliance department can continue to improve. are that they are taken from data collected in 2016. audit highlighted deficiencies in entering data, Therefore we would expect to see improvements in subsequent BCIS audits Low complication rates seen- 3% stroke, 5.6% vascular complications. Trans Catheter Aortic Valve implantation Cardiology 1 3585 National 03/01/2019 Fully Compliant Low 30 day mortality- 1.9% No concerns as fully compliant. No actions as audit standards were fully compliant. (TAVI) - 2017 data Very low rates of moderate/severe paravalvular leak. Cardiac Arrhythmia / Heart Rhythm Cardiology 1 3588 National 24/01/2019 Fully Compliant This audit highlights high volume and high quality EP care. No concerns as fully compliant. No actions as audit standards were fully compliant. Management (HRM) - 2016/17 data. Consultant Cardiologist is reviewing the inpatient care of HF Moderate non- Some of the standards audited revealed very good compliance e.g. Audit demonstrated there could be improvements in cardiology patients, as well as ensuring that the data submitted to the Cardiology 1 3592 Heart failure (HF) - 2016 / 17 data. National 31/03/2019 compliance access to echo (99.6%) and specialist input (97.9%). inpatient care and access to consultant cardiologist input. National Audit is robust. The directorate is exploring the feasibility of expanding capacity for HF patients The uptake of cardiac rehab is in line with national data but it is National Audit of Cardiac Rehabilitation Re-emphasises the high quality cardiac rehabilitation offered to our recognised that female participation could be improved. With Cardiology 1 3595 National 24/01/2019 Minor non-Compliance Continue to educate patients (2015-2016 data) patients continued education, it is hoped that the proportion of attendees will increase. Some patients with single vessel disease were not discussed at There was very high compliance with NICE guidelines with regards to MDT. This has already been highlighted in an earlier audit. ensuring patients were on appropriate medical therapy and still However there is accepted/widespread acceptance (and ESC Cardiology 1 3653 NICE CG126 Stable angina: management NICE 31/03/2019 Minor non-Compliance None required. symptomatic before PCI undertaken. All patients were appropriately recommendations) that patients with single vessel disease (not consented and those requiring MDT input were discussed. LMS/multivessel disease) can be considered for PCI and our practice is in line with this. NICE TA388 Sacubitril valsartan for Cardiology 1 3655 treating symptomatic chronic heart NICE 02/08/2018 Fully Compliant Demonstrates the good work that our heart failure team undertakes. No concerns as fully compliant. No actions as audit standards were fully compliant. failure with reduced ejection fraction NICE IPG481 Optical coherence Demonstrates that we are undertaking procedures safely and in Cardiology 1 3656 tomography to guide percutaneous NICE 21/12/2018 Fully Compliant No concerns as fully compliant. No actions as audit standards were fully compliant. accordance with NICE guidance coronary intervention NICE DG015 Myocardial infarction (acute): Early rule out using high- sensitivity troponin tests (Elecsys Cardiology 1 3664 NICE 21/12/2018 Fully Compliant Demonstrates full compliance with NICE guidance No concerns as fully compliant No actions as audit standards were fully compliant. Troponin T high-sensitive, ARCHITECT STAT High Sensitive Troponin-I and AccuTnI+3 assays). An audit on smoking cessation advice for Demonstrates 100% compliance against NICE guidance with regards Cardiology 1 3913 Local 02/08/2018 Fully Compliant No concerns as fully compliant No actions as audit standards were fully compliant. ACS patients to smoking cessation advice for ACS patients All areas of substandard compliance is discussed at the Audit has demonstrated levels of compliance with documentation Clinical Audit Group Meeting and directly with the standards across the Trust inline with the Clinical Documentation Some directorates demonstrated poor compliance with Directorates at their Governance Meeting. Individual action Trust Wide OP07 Health Records Moderate non- Cardiology 1 3991 Trust Wide 21/03/2019 Guidelines in order to address any areas of substandard performance. the standards in particular regarding documentation of clinicians plans will be drawn up according to the specific areas of Documentation audit 2018/19 compliance Areas of excellent compliance can be shared across the Trust to identification number and full name/signature. concern. Audit is completed annually and previous years encourage learning and improvement. results will be compared to demonstrate any improvements/decline in performance. Directorate Division Audit ID Audit title Type of audit Date completed Compliance rating Key Successes- summarised Key Concerns- Summarised Key actions- summarised

All areas of substandard compliance is discussed at the Trust Wide Early Warning Signs Audit Audit has demonstrated levels of compliance with the Track and Clinical Audit Group Meeting and directly with the 2018/19 Trigger Protocol for Early Warning Signs across the Trust inline with Some directorates demonstrated poor compliance with the Track Directorates at their Governance Meeting. Individual action Cardiology 1 3992 Trust Wide 21/03/2019 Minor non-Compliance Trust Policy in order to address any areas of substandard and Trigger protocol in particular with appropriate documentation plans will be drawn up according to the specific areas of Safety Alert NHS/PSA/RE/2018/003 & performance. Areas of excellent compliance can be shared across the of escalation. concern. Audit is completed annually and previous years NHS/PSA/RE/2016/005 Trust to encourage learning and improvement. results will be compared to demonstrate any improvements/decline in performance. COMPLETION OF COMORBIDITY FORM IN Moderate non- Demonstrated gaps in documentation therefore enabling Cardiology 1 4089 Local 09/01/2019 Comorbidities are not always accurately recorded; 1/3 of cases. Re-education of junior doctors on the ward. CARDIOLOGY WARD. compliance improvements to be made. The departmental SOP has been re-written and all NSTEMI The audit has demonstrated short-falls in appropriate prescribing- Re-audit (2029) - Use of ticagrelor in Significant non- patients (regardless of whether diabetic) will be prescribed Cardiology 1 4100 Local 21/12/2018 Has led to a change in prescribing guidelines in the Trust. only a minority of suitable diabetic NSTEMI patients receive diabetic NSTEMI patients undergoing PCI compliance Ticagrelor when diagnosed with NSTEMI. This new Ticagrelor. prescribing pathway will be launched in early 2019. Patients underwent surgical procedure which is now considered best Audit on Outcome of Pleural Cardiothoracic Surgery 1 3217 Local 17/05/2018 Fully Compliant practice and is currently being evaluated in a formal clinical trial No concerns as fully compliant No actions as audit standards were fully compliant. Mesothelioma at New Cross Hospital. (MARS 2). The unit compares well against local and national targets. Morbidity Cardiothoracic Surgery 1 3596 National Thoracic Surgery Audit 2017/18 National 18/12/2018 Fully Compliant No concerns as fully compliant No actions as audit standards were fully compliant. and mortality data also compares favourably. National Adult Cardiac Surgery Audit Cardiothoracic Surgery 1 3598 National 18/12/2018 Fully Compliant Fully compliant with audited standards. No concerns as fully compliant No actions as audit standards were fully compliant. 2017/18. Incidence and Aetiology of Highlighting the incidence of pneumothorax so that further audits can Cardiothoracic Surgery 1 3626 Local 03/12/2018 Not applicable None None Pneumothorax Post Cardiac Surgery. potentially identify the causes. No need for any change of practice. There were no infection concerns relating to any of the PA sheaths UTILITY OF PULMONARY ARTERIAL audited. Insertion of sheath of ITU can be Out of Hours / time consuming Cardiothoracic Surgery 1 4006 Local 18/12/2018 Minor non-Compliance Sheaths not utilised on ITU should be taken out at the SHEATH IN CARDIAC SURGICAL PATIENTS Cost is not a factor in decision making. earliest opportunity.

Audit Of National Safety Standard for Audit shows that we are compliant with NATSIPPS and the team is Cardiothoracic Surgery 1 4353 Invasive Procedures – Cardiothoracic National 27/06/2018 Fully Compliant No concerns as fully compliant No actions as audit standards were fully compliant. adhering to the inbuilt safety checks and protocols. Surgery Identifying patients with mitral valve prolapse who carry low risk of left ventricular (LV) dysfunction following Cardiothoracic Surgery 1 4354 Local 18/12/2018 Not applicable Further understanding of MV repair patients and their recovery. Not applicable Not applicable mitral valve repair using echocardiographic left ventricle dimensions and function Audit demonstrated good levels of compliance with completion of Post-operative epicardial pacing Cardiothoracic Surgery 1 4371 Local 18/12/2018 Minor non-Compliance documentation; Doctors identification 88%, ICCU chart 100% and No major concerns noted. Discuss audit results at Governance Meeting. documentation in Cardiac Intensive Care. Patients notes 78%. National Audit of Inpatient Falls - Round Care of the elderly 2 2956 National 14/02/2019 Fully Compliant Audit repeated trust wide and compliance improved No major concerns identified No actions identified Two Directorate Division Audit ID Audit title Type of audit Date completed Compliance rating Key Successes- summarised Key Concerns- Summarised Key actions- summarised

Review of and re-launch of ‘About Me’ assessment document.

Dementia Outreach Service led spot compliance audits to be carried out on a quarterly basis. There has been some improvement in compliance and associated care but there is still some room for improvement. Local audit of the utilisation of the About A proportion of patients did not have an 'About Me' document and COE Wards A7, A8 and C22 to nominate two ward based staff Care of the elderly 2 3292 Local 22/06/2018 minor non-Compliance Me document across the Trust. of those a proportion were not completed. members to take lead responsibility for ensuring compliance Increased compliance leading to improvement in person-centred supported by the Dementia Outreach Service. approach to care of patients with dementia Roll out approach in 3 above to all other ward areas.

Use of Dementia Outreach Service Volunteers to support carers in completion of the ‘About Me’ document.

Slight decline from the results of the 2017/18 audit, although audit does not in itself improve Review the About me doc and re-launch with Care bundle Moderate non- Results remain consistent compliance, the decline may in part be due to the spot audits and care plans Care of the elderly 2 4220 About Me (Spot Audit) Local 28/03/2019 compliance with national standards (National Audit of Dementia, 2017) being conducted on a quarterly basis rather than the previous year’s monthly basis thus reducing the practice Recruit more volunteers profile. All areas of substandard compliance is discussed at the Audit has demonstrated levels of compliance with documentation Clinical Audit Group Meeting and directly with the standards across the Trust inline with the Clinical Documentation Some directorates demonstrated poor compliance with the Directorates at their Governance Meeting. Individual action Trust Wide OP07 Health Records Care of the elderly 2 4223 Trust Wide 01/03/2019 Minor non-Compliance Guidelines in order to address any areas of substandard performance. standards in particular regarding documentation of clinicians plans will be drawn up according to the specific areas of Documentation audit (2018/2019) Areas of excellent compliance can be shared across the Trust to identification number and full name/signature. concern. Audit is completed annually and previous years encourage learning and improvement. results will be compared to demonstrate any improvements/decline in performance.

All areas of substandard compliance is discussed at the Trust Wide Early Warning Signs Audit Audit has demonstrated levels of compliance with the Track and Clinical Audit Group Meeting and directly with the Some directorates demonstrated poor compliance with the Track 2018/19 Trigger Protocol for Early Warning Signs across the Trust inline with Directorates at their Governance Meeting. Individual action Significant non- and Trigger protocol in particular with appropriate documentation Care of the elderly 2 4225 Trust Wide 01/03/2019 Trust Policy in order to address any areas of substandard plans will be drawn up according to the specific areas of compliance of escalation. Safety Alert NHS/PSA/RE/2018/003 & performance. Areas of excellent compliance can be shared across the concern. Audit is completed annually and previous years

NHS/PSA/RE/2016/005 Trust to encourage learning and improvement. results will be compared to demonstrate any improvements/decline in performance.

Provides a national picture of the service models, activity, finance, NHS Benchmarking - Managing Frailty workforce and service quality and outcomes has been obtained. The Care of the elderly 2 4356 National 06/02/2019 Fully Compliant No major concerns identified No actions identified and Delays Transfer of Care project explored how the acute care pathway links in with the wider team, inc primary care, community and mental health

All areas of substandard compliance is discussed at the Clinical Audit Group Meeting and directly with the Audit has demonstrated levels of compliance with documentation Directorates at their Governance Meeting. Individual action standards across the Trust inline with the Clinical Documentation Some directorates demonstrated poor compliance with the Children's Services - Trust Wide OP07 Health Records plans will be drawn up according to the specific areas of 3 4268 Trust wide 01/03/2019 Minor non-Compliance Guidelines in order to address any areas of substandard performance. standards in particular regarding documentation of clinicians Acute Documentation audit concern. Audit is completed annually and previous years Areas of excellent compliance can be shared across the Trust to identification number and full name/signature. results will be compared to demonstrate any encourage learning and improvement. improvements/decline in performance.

There was not clear documentation of method of collection of urine, urgent microscopy request, and differentiation of Upper or Lower UTI. Duration of the treatment of lower UTI is Children's Services - recommended to be 3 days as per Trust guidelines which was not Review of current patient leaflet. 3 4269 Urinary Tract Infection (U.T.I.) Audit Local 22/02/2019 Minor non-Compliance Identified where clinical treatments can be improved upon. Acute always seen. Also there should be more clear documentation Review current antibiotic guideline for UTI regarding atypical/recurrent UTI. USS inpatient was not requested as per guidelines for most of the cases, instead they had one as outpatient Current practice and clinical guideline is not in line with Children's Services - Positive outcome as enabled department to update practice and recommendations as per British Association of Paediatric Audit results to be shared with team and Guideline to 3 4270 Nephrotic syndrome Audit Local 26/03/2019 Minor non-Compliance Acute clinical guideline with recommendation from Paediatric Nephrology. Nephrology guidance for recognition, assessment, investigation updated. and treatment for Nephrotic Syndrome. Improvement seen in: Children's Services - Commencing analgesia, Education of staff both face to face and through 3 4271 Sickle Cell Disease Audit Local 05/07/2018 Minor non-Compliance Pain assessments and actions taken not documented. Acute appropriate administration of opiates & development of an E Learning package for all grades of staff. escalation of analgesia. All areas of substandard compliance is discussed at the Audit has demonstrated levels of compliance with the Track and Clinical Audit Group Meeting and directly with the Trustwide EWS Audit (PEWS) Some directorates demonstrated poor compliance with the Track Trigger Protocol for Early Warning Signs across the Trust inline with Directorates at their Governance Meeting. Individual action Children's Services - and Trigger protocol in particular with appropriate documentation 3 4328 Trust wide 01/03/2019 Minor non-Compliance Trust Policy in order to address any areas of substandard plans will be drawn up according to the specific areas of Acute Safety Alert NHS/PSA/RE/2018/003 & of escalation. performance. Areas of excellent compliance can be shared across the concern. Audit is completed annually and previous years NHS/PSA/RE/2016/005 Trust to encourage learning and improvement. results will be compared to demonstrate any improvements/decline in performance. Directorate Division Audit ID Audit title Type of audit Date completed Compliance rating Key Successes- summarised Key Concerns- Summarised Key actions- summarised

Administration of intravenous Children's Services - Product in use can be replaced with a more suitable product. Order placed for longer catheter 3 4404 tobramycin by infusion through a Local 09/08/2018 Minor non-Compliance Audit allowed directorate to identify areas for improvement. Acute An out dated clinical insertion guideline was found. Clinical guideline to be updated. Leaderflex short, mid or long line. High HbA1c CFC; 1.Identifying key worker for each pt. 2.Identifying a consultant for each group of pt. 3.Intensive contact at least 1-2 weeks by the KW. Revisit Identified local cohort of diabetic patients with high HBA1c High HBA1c reported in children with Diabetes which could lead to education and identifying major issues. Children's Services - Moderate non- recordings. Intense actions / interventions planned to reduce HBA1c 3 4589 High Hb A1c Local 26/03/2019 life limiting or disability unless addressed. Comparison to national 4.Review progress 6 weekly by consultant. Acute compliance and reduce risk of further complications as a result of non HBA1c data. 5. If no improvement patient to be discussed in the MDT to management of glucose levels by young people. consider CGM for 2 weeks or other option base on individual needs. 6.Low threshold to admit for stabilization. 7.Address Safeguarding/social issues We have achieved all our aims of the audit; we prepared a proforma Make all effort to provide Paternal PH forms, Maternal and audited our practice against the NICE quality standards. We have Obstetric history forms and GP summaries with IHA for a identified areas of improvement and are addressing this via our action holistic assessment. A NICE-related Audit: QS031 Health and plans. We will continue to capture voice of the child and tried our best Children's Services - Only 11% of GP summary, 29% of maternal obstetric summary and Every child over 5 years of age should be given opportunity 3 3398 wellbeing of Looked After children and NICE 04/10/2018 Fully Compliant to reflect VOC via our questionnaires which we encouraged the CYP to Community 11% of paternal PH forms were available for the IHA. to be seen alone without the carer and it should be young people fill. Lastly through our audit we have encouraged a holistic approach documented in the IHA and RHA. looking at different aspects of the child health and wellbeing (Physical Professionals to read Health Passports, Health action plans health, mental health and emotional wellbeing, wishes and and document it. aspirations and educational attainment).

The audit was able to provide the department with an assessment on Detailed history of service user was not always sought, i.e. history The directorate will consider a prompt to the Child the level of compliance with the RCPCH standards on Child protection. of constipation, faecal or urinary incontinence & UTI. Protection Medical proforma asking: Children's Services - The focus was on signs and symptoms of Child Sexual Abuse and the 3 3719 Child Protection Medical Audit Local 09/04/2018 Minor non-Compliance Clinicians were encouraged to talk to the children alone. If the child has been spoken to alone. Also, the proforma will Community department has put in place steps to enhance compliance to the Also, ask if the possibility of Child Sexual Abuse (CSA) has been standards on Child Protection in order to detect Child Sexual Abuse, Child Sexual Abuse is not being considered routinely. considered. where applicable.

All areas of substandard compliance is discussed at the Clinical Audit Group Meeting and directly with the Audit has demonstrated levels of compliance with documentation Directorates at their Governance Meeting. Individual action standards across the Trust inline with the Clinical Documentation Some directorates demonstrated poor compliance with the Children's Services - Trust Wide OP07 Health Records plans will be drawn up according to the specific areas of 3 4212 Trust wide 01/03/2019 Minor non-Compliance Guidelines in order to address any areas of substandard performance. standards in particular regarding documentation of clinicians Community Documentation audit concern. Audit is completed annually and previous years Areas of excellent compliance can be shared across the Trust to identification number and full name/signature. results will be compared to demonstrate any encourage learning and improvement. improvements/decline in performance.

Raise awareness of the need for accurate record keeping. Improve record keeping within the service. Review current expectations of record keeping and ensure all staff are aware Children's Services - Health Visiting Did Not Attend Improved levels of compliance seen following the results from the last The audit continues to show the need for regular audit of records 3 4214 Local 01/02/2019 Minor non-Compliance of the requirement that records must contain all relevant Community Appointment Documentation Audit audit. by management and the recording of the voice of the child. information to inform risk assessments relating to safeguarding.

The outcome is that we need to have a holistic approach in Reviewed quality of care provided to patients with a cerebral palsy, as assessment and management of the children with clear guidelines examples of a neurodisability condition. and communication with different professionals working along The interfaces between different care providers was assessed as well To audit and look at the clinical facilities in our admitting with these children. Children's Services - Child Health Clinical Outcome Review as transition from child to adult services ward and communication with allied professionals and the 3 4286 National 08/02/2019 Fully Compliant There should be a protocol in place if these children need general Community Programme (Chronic Neurodisability) Children and young people with a cerebral palsy have many complex named consultant if these children who have got complex anaesthesia and any surgery. needs and whilst areas of good practice were seen, much room for health needs get admitted to the ward. These children have got complex healthcare needs and should be improvement was identified. timely transitioned to the adult care services.

Genetic tests were requested in all patients. No uniformity in requesting developmental delay investigations. Children's Services - investigations for developmental delay in Moderate non- 3 4379 Local 08/02/2019 Positive yield in genetic testing , FBC and Ferritin results. No correlation between clinical findings and investigations Review and update clinical guidelines. Community CDC clinics at GEM centre. compliance

Education of medical and nursing staff to the importance of supporting these complex children and the use of the GMFCS score. Audit showed that the directorate was good at ensuring all children There is room for improvement in terms of our meeting the needs Development of a proforma to prompt staff to consider and Service Evaluation of inpatient care, are seen daily on the ward, and that the cause for their of children with chronic neurodisability during admissions on the Children's Services - Moderate non- record their decisions around communication, mobility, 3 4443 communication and facilities for children National 20/03/2019 neurodisability was recorded on admission. The recommended acute inpatient ward. In particular in recording their feeding, Community compliance feeding, MDT involvement and the use of patient held with neuro-disabling conditions equipment was available to meet the physical needs of these communication and mobility status, the use of care plans and records. children. encouraging patient held records. Circulation to nursing staff about the importance of recording up to date weight and height for all admissions & appropriate use of care plans Directorate Division Audit ID Audit title Type of audit Date completed Compliance rating Key Successes- summarised Key Concerns- Summarised Key actions- summarised

Established what the current experiences of girls, young women and More needs to be done by professionals to minimise the impact of Menstruation matters- What parents find their families are, with regards to menstruation, where there are also A parent information leaflet has been developed to help with periods and improve quality of life. This requires a co-ordinated Children's Services - most difficult when their daughters with co-existing profound or severe learning difficulties. discussions around periods. Parents are signposted to school 3 4570 QIP 28/03/2019 Not applicable approach starting with parent education, proactive discussion of Community severe learning difficulties are having Examined whether there are any ways in which we can improve the nurses and school doctors so they can discuss available available medical options and advocacy for better equipment and periods experience of these young women and their families. options. environment to maintain the dignity of the young person.

We were complaint with the recommended AAGBI guidelines. We were complaint with the recommended AAGBI guidelines. The However there were still delays for a small percentage of women need for help with epidurals is already well known and the audit has Anaesthetics out of hours (night time) Service and this appeared to be due to several factors. One was that the Directorate has plans to recruit a HCA/ODP to help deliver a Critical Care 1 3742 27/07/2018 Minor non-Compliance supported that an extra pair of hands to prepare the kit and support activity in maternity Evaluation anaesthetist was already doing an epidural and it has been more efficient epidural service. the anaesthetist would increase efficiency. Hopefully the recruitment identified that help with this procedure, from a HCAS or ODP, of staff will deliver this. would improve this situation. Only 51% of parturients had coagulation studies. Consultant anaesthetist has met with the Obstetric team and

Coagulopathy due to Cholestasis in they are reviewing the guidelines produced which suggest Service Moderate non- Audit has generated MDT discussion between anaesthetics and 9 parturients had coagulation tests within 24hrs prior to Critical Care 1 3901 Obstetric patients undergoing regional 10/12/2018 that coagulation tests to be done on admission to delivery Evaluation compliance Obstetrics to further better patient care. interventions out of 66 parturients. technique suite if bile acids are more than 40umol/L.

Re-audit after implementation of guidelines. None of parturients INR is more than 1.4. 53% patients with BMI>40 attended antenatal anaesthetic clinic. 93% patients had H/W/BMI recorded somewhere in their 66% patients of those who required an anaesthetist were attended Update anaesthetic guideline on obese parturient. Formulate Audit of anaesthetic management of notes/electronic patient record. Critical Care 1 3950 Local 30/09/2018 Minor non-Compliance by a ST6+ or an equivalent grade anaesthetist Referral pathway via Badgernet. morbidly obese women in pregnancy Re-Audit our practice 100% of those patients with BMI >40 were offered an appointment.

1. Re-audit in one years time to ensure continued adherence Some people persist on using old techniques; relying solely on air to the use of pressure cuff monitors. leak test and/or palpation of pilot balloon still shows high or low 2. Present the audit and re audit results at the odp Adherence to recommended cuff cuff pressures when measured by a manometer. This also may governance Critical Care 1 3980 Local 19/06/2018 Not applicable Cuff pressures were greatly improved from previous audit results. pressure guidance - re-audit result in an inadequate seal 3. Consider the potential to audit other variants to do with this project e.g. Frequency of measurement, effect of patient position on cuff readings, effect of gas mixture on cuff readings. Email audit results to all the anaesthetic staff in the Majority of antibiotics are prescribed by anaesthetists (85%), department to follow the trust antibiotic guidelines although 76% of anaesthetists feel it should be the surgeons (emphasising the importance of dosing Gentamicin) to Audit has highlighted the non-compliance with Trust Guidelines which Moderate non- responsibility . improve the compliance . Critical Care 1 3996 Prophylactic antibiotic prescription Local 20/06/2018 can now be addressed with individual departments to improve levels compliance Adherence to trust antibiotic guidelines varies between Email audit results to the specialty leads (Gen surgery, of compliance. specialities; Gynaecology and Urology 100%, General 65% and Max- Gynae, Urology, Max-Fax) to highlight our findings . Fax/ENT 6% . Gentamicin is often under dosed in general surgery. Re-audit in 12 months and present in Governance meeting. 1. Distribute individual audit results to respective anaesthetists for discussion at appraisal. Again the audit found less than 100% compliance with the Moderate non- It is hoped that highlighting areas of non-compliance to individuals 2. Ensure all have an ID stamp and educate that this is a Critical Care 1 4009 Anaesthetic Record-keeping - 2018/19 Local 26/03/2019 documentation of certain parameters, including NM block, post compliance will increase their compliance going forward. requirement. operative instructions and even saturations. 3. Clarify where and why ID info needs to be recorded 4. Re audit annually All areas of substandard compliance is discussed at the Audit has demonstrated levels of compliance with documentation Clinical Audit Group Meeting and directly with the standards across the Trust inline with the Clinical Documentation Some directorates demonstrated poor compliance with Directorates at their Governance Meeting. Individual action Trust Wide OP07 Health Records Moderate non- Critical Care 1 4010 Trust Wide 21/03/2019 Guidelines in order to address any areas of substandard performance. the standards in particular regarding documentation of clinicians plans will be drawn up according to the specific areas of Documentation audit (18/19) compliance Areas of excellent compliance can be shared across the Trust to identification number and full name/signature. concern. Audit is completed annually and previous years encourage learning and improvement. results will be compared to demonstrate any improvements/decline in performance. The audit demonstrated full compliance with the use of US, but 4 forms were inadequately completed/lost, therefore compliance Use of US is associated with reduction in complications. No Use of Ultrasound in CVC insertion (re- with documentation was not 100%. Outcome minor non- Critical Care 1 4015 NICE 30/09/2018 Minor non-Compliance complications were reported during the audit. An improvement on None required. audit) compliance. previous audit outcome which showed moderate non-compliance.

Pre-operative risk scoring needs to be formalised and made The findings have been disseminated to our colleagues in NELA - National Emergency Laparotomy mandatory as part of an emergency laparotomy care pathway. General Surgery and up to Divisional Management level as Moderate non- We have again submitted the required data for this National Audit Critical Care 1 4019 Audit (relates to 2016/17 submission of National 25/03/2019 Having identified a patient as high risk, they should then be there are some areas of concern; Development of a NELA compliance therefore achieving our goal of benchmarking against all NHS Trusts. data). allocated an ICU bed prior to surgery. pathway; discussing ICU admissions with Intensivists to Post-op review by a Geriatrician for all patients >70 years old. improve outcomes.

We again have taken part in this National audit which aims to benchmark our ICU service against similar units nationwide. By National ICNARC Case Mix Audit & successfully collecting and submitting this data within expected Critical Care 1 4020 Research Programme for Critical Care National 14/03/2019 Not applicable There were no causes for concern. Not applicable timescales we are achieving this. (relates to 2017/18 data cycle). The data has shown that we are performing well as an ICU and our data is comparable to other units of the same size. Directorate Division Audit ID Audit title Type of audit Date completed Compliance rating Key Successes- summarised Key Concerns- Summarised Key actions- summarised

Posters are in place in the operating theatres reminding This audit came about as a result of the perception that patients on There are no written guidelines suggesting that teams must teams to consider which patients can drink. elective lists often fast for hours, which can sometimes be avoided consider this however now that fasting times of 2 hours pre This audit and its results have been presented to the Provision of water to patients on elective Service Moderate non- Critical Care 1 4125 13/09/2018 with planning. surgery for water are recommended, we have established that this Anaesthetic department to raise the profile of this lists Evaluation compliance It is hoped that this will improve patient satisfaction if the practice is not always considered by the theatre teams at the beginning of consideration. In the future, we will re-audit to assess if becomes more widespread. the list. there has been any increase in those considering water provision for their patients. Management of Antiplatelet / The aim of the audit was to assess practice, and use this information Critical Care 1 4350 anticoagulant medications in patients Local 18/03/2019 Not applicable None. None. to determine current practice. This has been achieved. undergoing pain interventions Evaluation of adherence to LoSIPPs on Service The evaluation showed that we are following our local guidelines Critical Care 1 4410 21/08/2018 Fully Compliant No concerns as fully compliant No actions as audit standards were fully compliant. the General ICCU. Evaluation appropriately. There needs to be a cultural change that prolonged fasting is Aims have shown 0% compliance with our set standards. unacceptable and detrimental to patients. This requires The objective of showing prolongation of fasting times in emergency education of the nursing and junior medical staff and better Service Significant non- It is clear that there are major problems. A multidisciplinary Critical Care 1 4431 Fasting times in emergency patients 25/03/2019 patients was demonstrated allowing improvements to be made to coordination between the specialities on the timing of Evaluation compliance approach involving the differing surgical specialities who use improve patient care. operations. List orders must be made as far in advance as Trauma and CEPOD theatres as well as Anaesthetists needs to be feasible. These, and any changes to list order should be done taken. on a consultant-to consultant level. 1. Post – op pain scores should be part of patient- pathway and clearly documented Comparison study of GA vs. Spinal Service Audit has shown areas of non compliance so improvements can be 2. Re-audit to ensure that the documentation of post-op pain Critical Care 1 4454 anaesthesia in patients undergoing THR 23/01/2019 Minor non-Compliance Post op pain scores not completed in 100% patients. Evaluation made. scores is happening routinely. and TKR Orthopaedic Consultant to meet with the orthopaedic lead for ER to discuss audit results.

Key audit conclusions to be shared with Directorate via Theatre team meetings and departmental noticeboards, with reminder about the cannulae flush proforma on back of chart.

Handover of responsibility for patients in There is room to improve on all areas of the handover process. In A new recovery document has been produced and has been Aim of audit was met which was to assess compliance with the RCoA theatre recovery Moderate non- most standards 80-90% compliance levels were seen. Compliance ordered. It contains a checklist for handover of patients from Critical Care 1 4465 QIP 07/03/2019 guidelines in regards to handover between recovery and theatre, and compliance with flushing of cannulae was less, at approximately 66%. This is a recovery to the ward, and we will be able to then audit to ask the question about flushing cannulas before leaving theatre. safety alert NHS/PSA/D/2017/006 relatively new additional requirement and some ‘old’ anaesthetic compliance with this additional recommendation. charts without this prompt are still in circulation. Concurrently, we can re-audit ‘cannula flush’ handover to recovery from theatre staff after introducing the new documentation to the staff in theatres and recovery, and allowing a period of time for this to be embedded.

Depth of anaesthesia monitoring (Entropy) not been used in 1. To present this audit in anaesthetic clinical governance Audit on intraoperative use of Service Significant non- Audit has shown areas of non compliance so improvements can be majority of patients who had TIVA with neuromuscular blockade Critical Care 1 4469 28/03/2019 meeting on and explore reasons for non-compliance Entropy/BIS Evaluation compliance made. which constitutes high risk for accidental awareness during GA. 2. To re-audit the practice. [Not used in 70% of patients in this audit]. Senior Dental Nurse to carry out quarterly audit if daily checks on all Emergency Drugs, Defibs and Lifeline Kits are We have assessed that staff have the skills and equipment in place in performed. Dental 1 4037 Medical Emergency Equipment Local 28/02/2019 Minor non-Compliance order to support patients who experience a medical emergency Audit showed 85% compliance at one site. within the department. New equipment ordered and available. Nursing staff have been reminded to check medical emergency equipment and is recorded. 100 % compliance is attained in Hand Hygiene, Waste management; Minor non compliance with decontamination and environment Repair to environment wherever possible. SLA for Mobile Dental 1 4038 HTM01-05 Decontamination Compliance Local 25/03/2019 Minor non-Compliance PPE & Management of Medical Devices. design cleaning in all surgeries and Mobile Dental Unit. Dental Unit.

The majority of x-rays were graded '1' (Excellent- no errors of New x ray log book format is being used . Issues with log sheets; In some cases fault analysis was not RADQA (Radiation Quality Assurance) exposure, positioning or processing) . Installation of new intraoral radiograph unit in surgery 2 at Dental 1 4039 Local 22/03/2019 Minor non-Compliance completed i.e. not rated and one instance of 2 inappropriate codes Audit against IRMER Regulations. Our service is in compliance with national guidelines "FGDP (UK) - one clinic. still being used for fault analysis. Selection Criteria for Dental Radiography: section 9.2 Ideas for audit. Switching to digital dental radiography.

The audit has identified areas for improvement and enabled an action Moderate non- Dental 1 4040 Clinical Record Keeping Local 26/02/2019 plan to be developed to resolve these issues. Practise has changed in Only just over half of the domains (62% or 8 out of 13) were met. Develop standardised record keeping template. compliance line with FGDP guidelines.

• No data collected for Mobile Clinic. Service All questions scored excellent compliance 75 to 100% compliance. The • Data collection by location, therefore not able to analyse to clinic Dental 1 4041 Patient Survey 12/03/2019 Minor non-Compliance Review and redesign evaluation form. Evaluation majority scored 90%+ level. Directorate Division Audit ID Audit title Type of audit Date completed Compliance rating Key Successes- summarised Key Concerns- Summarised Key actions- summarised

All areas of substandard compliance is discussed at the Audit has demonstrated levels of compliance with documentation Clinical Audit Group Meeting and directly with the standards across the Trust inline with the Clinical Documentation Some directorates demonstrated poor compliance with Directorates at their Governance Meeting. Individual action Trust Wide OP07 Health Records Dental 1 4042 Trust Wide 21/03/2019 Minor non-Compliance Guidelines in order to address any areas of substandard performance. the standards in particular regarding documentation of clinicians plans will be drawn up according to the specific areas of Documentation audit (18/19) Areas of excellent compliance can be shared across the Trust to identification number and full name/signature. concern. Audit is completed annually and previous years encourage learning and improvement. results will be compared to demonstrate any improvements/decline in performance. Some of oral health messages based on NG30 require to be added Oral Health Promotion - (NG30 Oral Within the Trust we are compliant in most of areas and we are in OH advice which we give to our patient/parents. Develop a template based on NG30 Oral Health Advice to Dental 1 4193 Health Advice or QS139 Oral Health NICE 01/03/2019 Minor non-Compliance meeting the standard set in this cycle. adopt a standardised approach. Promotion in community)

The vast majority of assessed quality standards have shown 100% compliance with the NICE recommendations. It has been achieved by Patients with mild or moderately severe disease are seen in National Clinical Audit on Psoriasis allocating more time in specially dedicated monitoring clinic run by To arrange for appointments for patients with psoriasis in Dermatology 3 3234 National 26/06/2018 Minor non-Compliance normal FU clinics where we have very limited time for assessing 2017/18 and NICE Compliance CG 153 nurses and junior doctors and by implementing validated tools like nurse led clinic or in clinics run by junior doctors. impact of disease on patients` psychological and social well being. PGS, PEST, DLQI, PASI for assessing disease severity and patients` well being.

Document PASI and DLQI scores before starting treatment TA419 Apremilast for treating moderate and at 16 weeks to assess whether there is 75% reduction in Dermatology 3 3632 NICE 16/08/2018 Minor non-Compliance 54 patients were treated with Apremilast as per guidance. PASI score could not assessed to severe plaque psoriasis PASI or 50% in DLQI to make decision whether to continue treatment.

CNS have not been involved in BBN discussion in some cases due The audit highlighted issues regarding staffing shortages and the NG014 Melanoma: assessment and to the dermatology department being short staffed for a long Clinicians who failed to comply with guideline have been Dermatology 3 3633 NICE 04/12/2018 Minor non-Compliance impact this has on the service. Directorate to discuss at Governance management period of time (long term sickness leaves, , retirement, identified. Emails with outcomes sent to all clinicians. issues regarding MDT cover. discontinuation of employment).

Documentation of patient satisfaction was moderate with no A re-audit is recommended after 5 years (2023). standardised format for this being available other than DLQI. 2. Standardised dataset for patients presenting with clinical Whilst documentation of risk factors for osteoporosis was low, the diagnosis of bullous pemphigoid to be outlined provision of bone protection where relevant was high. 3. Technical aspects of audit standards to be changed to Other measures of care including baseline blood tests (FBC U&E and This is the first audit of its kind and illustrates that documentation National clinical audit on the ensure standards reflect relevant data and care for the Dermatology 3 3968 National 09/04/2019 Not applicable LFT) including TPMT where relevant, demonstrated high compliance. of comorbidities and history of hypertension and diabetes is low management of bullous pemphigoid different points in patient pathway. Follow up blood tests were less frequently with corresponding low measures of blood pressure and HbA1c. 4. Consider inclusion of topical treatment and categorisation undertaken, but it was not possible to determine if this was due to of these in future audits. cessation of systemic treatments or a clinical omission. 5. Offer recommendation of standard measure of patient Future audits should structure the audit question differently to ensure satisfaction to aid compliance with this standard. that this question can be answered.

All areas of substandard compliance is discussed at the Clinical Audit Group Meeting and directly with the Audit has demonstrated levels of compliance with documentation Directorates at their Governance Meeting. Individual action standards across the Trust inline with the Clinical Documentation Some directorates demonstrated poor compliance with the Re-Audit Trustwide OP07 Documentation plans will be drawn up according to the specific areas of Dermatology 3 4241 Trust wide 21/03/2019 minor non-Compliance Guidelines in order to address any areas of substandard performance. standards in particular regarding documentation of clinicians Audit concern. Audit is completed annually and previous years Areas of excellent compliance can be shared across the Trust to identification number and full name/signature. results will be compared to demonstrate any encourage learning and improvement. improvements/decline in performance.

TA393 Alirocumab for treating primary Diabetes 2 3755 hypercholesterolaemia and mixed NICE 12/03/2019 Fully Compliant Compliant with TAG prescribing indications No major concerns identified No actions identified dyslipidaemia TA394 Evolocumab for treating primary Diabetes 2 3756 hypercholesterolaemia and mixed NICE 12/03/2019 Fully Compliant Compliant with TAG prescribing indications No major concerns identified No actions identified dyslipidaemia TA385 Ezetimibe for treating primary Diabetes 2 3758 heterozygous-familial and non-familial NICE 12/03/2019 Fully Compliant Compliant with TAG prescribing indications No major concerns identified No actions identified hypercholesterolaemia To maintain the data-base of patients attending the bariatric CG189 Obesity: identification clinic and continue to monitor the outcomes of those who assessment and management of Identified a cohort of patients who may be able to stop their diabetes There is a need to develop and implement a Tier 3 service to progress to surgery. Diabetes 2 3762 NICE 03/04/2018 Minor non-Compliance overweight and obesity in children medication, anti-hypertensives and statins post-surgery. further streamline the obesity care pathway at New Cross Hospital young people and adults A re-audit in 12 months would be useful to assess more long- term outcomes Whilst improvements have been made to foot assessment this is Development and implementation of foot assessment CG119 Diabetic foot problems - inpatient Highlights improvement in foot assessments for patients with foot still not ideal Diabetes 2 3767 NICE 03/04/2018 Minor non-Compliance management disease and diabetes Use of electronic prescribing will reduced wrong Prescription errors improved but need further improvements prescriptions of insulin type Directorate Division Audit ID Audit title Type of audit Date completed Compliance rating Key Successes- summarised Key Concerns- Summarised Key actions- summarised

All areas of substandard compliance is discussed at the Re-Audit Trustwide Early Warning Signs Audit has demonstrated levels of compliance with the Track and Clinical Audit Group Meeting and directly with the Some directorates demonstrated poor compliance with the Track (EWS) 2018/19 Trigger Protocol for Early Warning Signs across the Trust inline with Directorates at their Governance Meeting. Individual action Moderate non- and Trigger protocol in particular with appropriate documentation Diabetes 2 4080 Trust Wide 22/03/2019 Trust Policy in order to address any areas of substandard plans will be drawn up according to the specific areas of compliance of escalation. Safety Alert NHS/PSA/RE/2018/003 & performance. Areas of excellent compliance can be shared across the concern. Audit is completed annually and previous years

NHS/PSA/RE/2016/005 Trust to encourage learning and improvement. results will be compared to demonstrate any improvements/decline in performance.

Patients are not having repeat cBGS at 30 minutes which could Re-Audit Inpatient Management of Moderate non- DSN team recognize and see patients with hypos and set treatment result in under treatment New MDT meeting within diabetes team to discuss and Diabetes 2 4081 Local 03/07/2018 hypoglycaemia compliance plans accordingly manage patients with hypoglycaemia Need to identify barriers to not checking cBGs in a timely fashion

Improved patient satisfaction and improved patient metrics including Diabetes 2 4083 Re-Audit Insulin Pump Audit Local 17/01/2019 Fully Compliant reduced hypoglycaemia which has short term impacts and reduced No major concerns identified No actions identified levels of HbA1c which have long term impacts

it was identified that 16.6% of HD patients are still not prescribed Re-Audit: Are all RWTH haemodialysis water soluble vitamins. Prescribed medication may not reflect what the GP prescribes or To inform consultant of patients not on renavit, to initiate Dietetics 3 4005 patients prescribed water soluble Local 14/04/2018 Minor non-Compliance It has been agreed that dieticians will identify and request what the patient actually takes. prescription and send standard GP letter. vitamins? prescription of water soluble vitamins to improve patient care. Audit results including areas for improvement have been fed back to dieticians in order for improvements to be made on an individual basis. Specific aims: - All dietetic entries to include SMART aim Improvement in most areas since previous audit in March 2016 in the - Inpatient entries to include summary/ impression/PASS following areas: statement Time Some of the documentation standards audited were not met on all - All dietetic entries to include clear treatment plan Stamped occasions. For inpatient documentation this mainly related to clear - All dietetic entries to state plan for subsequent review or Name and hospital number goals of dietetic intervention and standards around alterations. discharge Dietetics 3 4183 Local: Dietetic Record Keeping Local 19/02/2019 Minor non-Compliance Clear assessment For outpatient documentation, this related to clear goals of - Alterations in written notes to be crossed through with a Clear goals dietetic intervention, clear treatment plans and plans for review or single line, signed and dated. Plans for review/discharge discharge. A group of dieticians are working on a new clinic proforma Alterations template for clinical web portal to help guide dieticians in ensuring their outpatient documentation is clear and complete. Audit tool to be updated in line with most recent version of policy. Re-audit to be completed in 12 months Endoscopy practice has been reviewed and there is no significant Endoscopy 2 3375 National 30 day Mortality audit 17/18 National 28/06/2018 Fully Compliant increase in the mortality attributable to endoscopy, indicating safe No major concerns identified No actions identified practice. Incomplete gastroscopies have been shown to be as a result of For support and quality purposes the failed intubation Endoscopy 2 4167 Gastro Completion audit 18/19 Local 25/10/2018 Minor non-Compliance Able to identify areas of low compliance and review these further. unexpected pathology, risk factors or because the patient did not patients will be looked at separately. tolerate. No significant trends Endoscopy 2 4168 8 Day Readmission audit 18/19 Local 02/04/2019 Fully Compliant No major concerns identified No actions identified Practice remains within accepted standards Endoscopy 2 4169 National EUS audit 18/19 Local 10/07/2018 Fully Compliant The RWT EUS service is clinically safe and effective. No major concerns identified No actions identified All 123 patients had sedation during their procedure. No critical Lack of documentation in the endoscopy report regarding use of incidents were reported. antibiotics

All patients had midazolam, used in varying doses. In one case, increase sedation was needed during procedure due Continue to re-audit to assess trend over years. 63% also had fentanyl to poor tolerance of intubation. Endoscopy 2 4170 National PEG re-audit 18/19 Local 06/09/2018 Minor non-Compliance 5% also had pethidine Importance of documentation of abx in the report Complications noted: No patient had general anaesthetic Intra-abdominal haematoma 4 cases of PEG site infections – 1 requiring hospital admission, and No patients had entonox 1 case MRSA positive at PEG site. The results from this audit demonstrate that RWT provides a safe, effective and quality service. Endoscopy 2 4171 National GRS ERCP National 10/07/2018 Fully Compliant No major concerns identified No actions identified The RWT ERCP service is a tertiary service attracting referrals from across the region and this is on account of its safety, quality and clinical efficacy. Overall performance remains high and is comparable to previous Endoscopy 2 4172 Local Colonoscopy audit 18/19 Local 28/06/2018 Fully Compliant No major concerns identified No actions identified audits Directorate Division Audit ID Audit title Type of audit Date completed Compliance rating Key Successes- summarised Key Concerns- Summarised Key actions- summarised

Service Demonstrated current process to link an Endoscope use to a Patient Endoscopy 2 4173 Local Decontamination audit 18/19 19/10/2018 Fully Compliant No major concerns identified No actions identified Evaluation and that decontamination evidence is available is very good. After discussion, it was felt that the 12 patients receiving Largely compliant with BSG and NICE guidance on therapy for There are some cases of monotherapy, however this is becoming Endoscopy 2 4174 Local Haemostasis audit 18/19 Local 25/10/2018 Minor non-Compliance single therapy should be further scrutinised to identify any gastrointestinal bleeds. less used compared to previous years trends in their treatment plans.

Present findings at Governance and Nurse team meetings.

Ongoing review of patient information leaflets to support consent process.

Ensure patients who have received sedation have their results and discharge advice given with a family member present.

Ensure patients who are examined by trainees understand how courses are run and involvement of The 2018 Patient Satisfaction survey has provided the Endoscopy trainees/trainers/course faculty. Service Endoscopy 2 4175 Local Patient Satisfaction Audit 18/19 13/11/2018 Not applicable team with valuable information on how service users experience the No major concerns identified Evaluation Endoscopy Service. Review Admin processes Recruitment to vacant posts Customer care training Streamlining of information in appointment letters & information booklets. Working with service redesign team to improve the admin processes.

As in previous years: create a ‘You said – We did’ poster detailing the specific changes that have been made as a result of feedback

Review of patient questionnaires.

Implementation of repeat survey by Q3 2019

All referrals were complete

Appropriate completion of diabetes information in all cases Inaccurate information regarding antiplatelets/anticoagulants in 50% of patients on these medications Appropriateness of Procedure Audit Endoscopy 2 4176 Local 01/02/2019 Minor non-Compliance Inaccurate/ incomplete information did not result in cancellation of For discussion at Directorate Governance meeting 18/19 procedure/ adverse events Adherence to BSG antiplatelet/anticoagulation needs to be tightened

Re-assurance that mortality in 30 days following diagnostic and Endoscopy 2 4178 National 30 day Mortality audit 18/19 National 01/02/2019 Fully Compliant No major concerns identified No actions identified therapeutic endoscopy remains low. Compliant with the majority of NG020 Coeliac disease: recognition assessment and management criteria. Average time to endoscopy Average time to endoscopy was not within guidance but this is not NG020 Coeliac disease: recognition Gastroenterology 2 3360 NICE 27/09/2018 Minor non-Compliance was not within guidance but the delay shown was agreed to be clinically significant as average extra delay was only 2 days over None required assessment and management clinically insignificant the NICE standard.

This data will be further analysed to determine whether testing outside of NICE guidelines is cost-effective based on 32% of patient receiving Infliximab received drug level monitoring A large proportion of monitoring in our population was for the routine the drug dosage changes. Audit of DG022 Therapeutic monitoring within NICE guidelines. evaluation in patients on anti-TNFα drugs. These patients are now of TNF-alpha inhibitors in Crohn’s disease Gastroenterology 2 3747 NICE 03/04/2019 Minor non-Compliance considered outside of NICE practice guidelines. Thus, adhering to NICE The audit will be repeated in 3 years to reassess. (LISA-TRACKER ELISA kits IDKmonitor 30% of patients receiving Humira received drug level monitoring guidelines will lead to a substantial reduction in the number of our ELISA kits and Promonitor ELISA kits) within NICE guidelines patients tested The audit will also be reviewed when new guidelines are published later in 2019, which may recommend cost- effectiveness in testing patients more frequently TA456 Ustekinumab for moderately to Gastroenterology 2 3960 severely active Crohn’s disease after NICE 05/02/2019 Fully Compliant Compliant with TAG prescribing indications No major concerns identified No actions identified previous treatment TA430 Sofosbuvir–velpatasvir for treating Gastroenterology 2 4001 NICE 28/03/2019 Fully Compliant Compliant with TAG prescribing indications No major concerns identified No actions identified chronic hepatitis C All areas of substandard compliance is discussed at the Audit has demonstrated levels of compliance with documentation Clinical Audit Group Meeting and directly with the standards across the Trust inline with the Clinical Documentation Some directorates demonstrated poor compliance with the Directorates at their Governance Meeting. Individual action Trust Wide OP07 Health Records Gastroenterology 2 4179 Trust Wide 01/03/2019 Minor non-Compliance Guidelines in order to address any areas of substandard performance. standards in particular regarding documentation of clinicians plans will be drawn up according to the specific areas of Documentation audit (2018/19) Areas of excellent compliance can be shared across the Trust to identification number and full name/signature. concern. Audit is completed annually and previous years encourage learning and improvement. results will be compared to demonstrate any improvements/decline in performance. Directorate Division Audit ID Audit title Type of audit Date completed Compliance rating Key Successes- summarised Key Concerns- Summarised Key actions- summarised

All areas of substandard compliance is discussed at the Trust Wide Early Warning Signs Audit Audit has demonstrated levels of compliance with the Track and Clinical Audit Group Meeting and directly with the Some directorates demonstrated poor compliance with the Track 2018/19 Trigger Protocol for Early Warning Signs across the Trust inline with Directorates at their Governance Meeting. Individual action Significant non- and Trigger protocol in particular with appropriate documentation Gastroenterology 2 4180 Trust Wide 01/03/2019 Trust Policy in order to address any areas of substandard plans will be drawn up according to the specific areas of compliance of escalation. Safety Alert NHS/PSA/RE/2018/003 & performance. Areas of excellent compliance can be shared across the concern. Audit is completed annually and previous years

NHS/PSA/RE/2016/005 Trust to encourage learning and improvement. results will be compared to demonstrate any improvements/decline in performance.

A training programme for all ED nurses and flow charts for tube troubleshooting were introduced to ED. Since an educational and training intervention in ED for tube An emergency enteral toolbox was stored in ED with flow troubleshooting 157 bed days have been saved over 1 year, the Gastroenterology 2 4429 QIP- Enteral Tube Troubleshooting in ED Local 19/10/2018 Minor non-Compliance No major concerns identified charts and all relevant equipment; this is regularly checked percentage of patients admitted is down by over 10% and the patient and resupplied. Six sessions of training, each of 1hr, were journey has improved. delivered between June - November 2017 and encompassed all trained nurses within the ED. This training was incorporated into all future ED nurse induction training.

Mortality remained static across the group, but was significantly skewed by patients receiving a RIG against the advice of the MDT. Had Gastroenterology 2 4450 30 mortality RIG insertion Local 19/10/2018 Fully Compliant those events not occurred then mortality would have fallen to 4%, No major concerns identified No actions identified below the 5% target for national average in keeping with PEG 30 day mortality. Submitted data to national study. Nationally all but one NHS trust National audit of breast cancer in older reported that 75% or more of their patients start treatment within 8 To ensure accurate reporting of local practices and quality of General surgery 1 3426 National 14/02/2019 Not applicable No major concerns noted. people weeks of diagnosis. Breast CNS were involved in the care of 85% of data returns to the national cancer registration services. women, across all ages. Moderate non- The results over the period audited showed a compliance with the The results over the period audited showed a compliance with the Formulate a strategy to implement a hot gallbladder list in General surgery 1 3639 NICE CG188 Gallstone Disease NICE 01/03/2019 compliance guidelines of 100% for diagnosis. guidelines of 55% for management. order to reduce the waiting time for acute cases. 100% of patients were operated on by a competent surgeon. Length NICE TA105 - Colorectal Cancer of stay difference between open and laparoscopic is within the Raised awareness that patients need to be informed about General surgery 1 4127 NICE 29/08/2018 Minor non-Compliance 71% of patients had the discussion regarding the option to have Laparoscopic Surgery (review) standards. option for having open vs. laparoscopic operations. laparoscopic surgeries. Conversions rate, anastomotic leak is within the standard. NATIONAL: Implant Based reconstruction Discussion in the clinical governance regarding outcome and General surgery 1 4135 audit (IBRA) National 01/03/2019 Fully Compliant Fully compliant with audited standards. No concerns as fully compliant all patient engaged in CPD and conferences regarding breast Multicentre National Audit reconstruction. Local: Re-audit Are we compliant with NICE Guidelines on extended prophylaxis Moderate non- Education to operating surgeons about prescribing Extended General surgery 1 4217 Local 01/03/2019 81% had extended VTE prophylaxis 19 % Patients are not receiving extended prophylaxis for patients undergoing lower GI cancer compliance Clexane and to mention it in the operating record resections All areas of substandard compliance is discussed at the Audit has demonstrated levels of compliance with documentation Clinical Audit Group Meeting and directly with the standards across the Trust inline with the Clinical Documentation Some directorates demonstrated poor compliance with Directorates at their Governance Meeting. Individual action Trust Wide OP07 Health Records Moderate non- General surgery 1 4218 Trust Wide 21/03/2019 Guidelines in order to address any areas of substandard performance. the standards in particular regarding documentation of clinicians plans will be drawn up according to the specific areas of Documentation audit (18/19) compliance Areas of excellent compliance can be shared across the Trust to identification number and full name/signature. concern. Audit is completed annually and previous years encourage learning and improvement. results will be compared to demonstrate any improvements/decline in performance. Results have been compared to the previous audit and has Although the scoring has improved from the previous audit (73% Continue with education at induction. The scoring and General surgery 1 4219 Local: Re-audit Acute Pancreatitis Local 05/03/2019 Minor non-Compliance demonstrated improvement in the use of Pancreatitis scoring from 17% on admission and 67% from 11% on 48hrs), it is still pancreatitis Proforma to be discussed at patients handover. proforma. missing the target of 100%. There has not been much change in compliance; 25 % were not Audit has showed that compliance with antibiotic prophylaxis is Re-audit and discuss findings in governance meeting. A compliant in prescription of antibiotic prophylaxis. This could be General surgery 1 4221 QS49 Prophylactic Antibiotics NICE 01/04/2019 Minor non-Compliance unchanged which could impact upon the frequency of surgical site review of the Guidelines is needed to obtain further due to lack of awareness in the prescription of antibiotics to only infection. information on why they were not followed. high risk group as defined by our local guidelines.

Poor compliance in IV Fluid Management in relation to monitoring Education of each bath of incoming junior doctors regarding NICE CG174 IV Fluid Management in Moderate non- Audit has assessed compliance with CG174 and demonstrated areas General surgery 1 4224 NICE 25/03/2019 (50%), fluid balance (50%) and daily fluid maintenance (water = requirements for IV fluids management by including in Acute Surgical Patients compliance of low compliance where the Directorate can make improvements. 20%, glucose = 0% and potassium = 0%) induction. Still not reached 100% of patients receiving the leaflet. Due to Local: Re- audit Are we compliant with using the consent form as evidence of receiving the leaflet unsure Ensure the person consenting the patient will complete the Majority of patients (68%) did receive the leaflet. General surgery 1 4229 Hyperparathyroidism information Local 01/03/2019 Minor non-Compliance if the patient has received the leaflet but it has not been ticked on relevant section on the consent form to indicate a leaflet has leaflets guidance the consent form or if it is that the patient has not received the been given. Already taken place in the Governance meeting leaflet Trust Wide Early Warning Signs Audit To find out the names of the doctors and provide a list of the It was noted that there were issues with COPD patients as they 2018/19 patients included in the samples. Moderate non- always score high due to their medical condition. It was noted General surgery 1 4239 Trust Wide 21/03/2019 Evidence of appropriate escalation process for patients scoring 5+. To liaise with the doctor who collected the EWS audit data compliance that with the new EWS score which came into force in Feb 2019, Safety Alert NHS/PSA/RE/2018/003 & and check whether the nursing notes were reviewed for the these patients will no longer score high. NHS/PSA/RE/2016/005 evidence of escalation and/or review. Posters A quality improvement project looking at Education assessment of venous thromboembolism QIP has, through interventions, improved compliance with VTE Although VTE assessment times have improved to 83%, it is not General surgery 1 4608 QIP 12/03/2019 Minor non-Compliance Survey risk on the Surgical Emergency Unit at assessment times. 100%. Stickers New Cross Hospital. Nurse involvement on post-take ward round Directorate Division Audit ID Audit title Type of audit Date completed Compliance rating Key Successes- summarised Key Concerns- Summarised Key actions- summarised

To confirm the time the patients are being reviewed not the Clexane dose prescribed correctly in all patients apart from one. 2nd time they are admitted at so that can shorten the timing VTE prophylaxis in acute surgical Moderate non- VTE assessment have improved dramatically from 35% to 73%. More 1. Delayed 1st and 2nd VTE assessments. General surgery 1 4612 Local 12/03/2019 measured to the 1st and later the 2nd VTE assessments. patients. compliance important is that the 'not done' category reduced from 51% to 0%. 2. Not compliant fully on patient counselling yet. To increase about the awareness of the importance of the patient counselling. General Practitioners (GPs) should deliver the first line of care to Training is being organised for GPs. women with HMB however, the main practice is that they refer A NICE-related Audit on CG044 and We are currently compliant with NICE guidance on the majority of the women to the Hospital services. 22% patients had received initial Gynaecology 1 3332 NICE 23/08/2018 Minor non-Compliance There are some concerns of consultants about NICE guidance QS047: Heavy Menstrual Bleeding Audit practices identified. treatment in Primary Care. where there is significant pathology, this is to be explored 26% patients were not examined by any health professional before further. treatment was offered. A Local Audit on Intraoperative Service Ensure any incidents are reported on DATIX and ensure Gynaecology 1 3339 23/10/2018 Not applicable All cases were managed appropriately. None noted. Complications in Gynae Evaluation accurate entries on the theatre registry. To ensure that surgeon volume data is included in appraisals. To consider audit to ensure patients are given choice of route

A National Audit: Length of Hospital Stay Assessed days in hospital following elective gynae procedures to be of access, relevant to their condition. Gynaecology 1 3340 National 24/04/2018 minor non-Compliance The hospital stay was 3 days in comparison to 2 days in England, in Gynae (Getting it Right First Time) able to consider where improvements can be made. To consider whether extra training or resources are needed following Gynaecological procedures. to allow increase in laparoscopic procedures if necessary. To review pathways. There are still some surgeries cancelled on the day of operation The audit showed that the numbers of cancellations is slightly The Division have looked at theatre utilisation and a Trust A Local Audit on Procedures Cancelled due to certain circumstances beyond the trust control i.e. winter Gynaecology 1 3641 Local 29/03/2019 Fully Compliant reduced, there is a theatre utilisation group working on the same group has been set up to look into it via the management on the Day of Surgery pressures. However, following audit and theatre utilisation issues. teams. meetings the aim is to reduce this. Audit confirms that actions required are already taking place and that Gynaecology 1 3691 CG171 Urinary incontinence in women NICE 10/12/2018 Fully Compliant No concerns as fully compliant None required. we must maintain already established practices and documentation.

The Management of Ovarian Cyst in The main audit standard showed that the majority of patients (79%) Improve GP awareness of the referral process by presenting Gynaecology 1 4207 NICE 11/03/2019 Minor non-Compliance 69% diagnosis to treatment in 31 days. Premenopausal Women were referred to treatment within 62 days. the results of the audit to the GPs. Referrals and diagnoses were not always done in a timely manner. Laparoscopy in Endometrial Cancer Audit Audit enabled directorate to make improvements to benefit patient Previously, 75% patients met the 62 day target compared to 54% Gynaecology 1 4208 Local 03/04/2019 Minor non-Compliance To feedback the audit results to the relevant clinicians. (re-audit) care. in this audit A NICE related Audit (NG 12, CG 27: Overall survival is good in both groups. Assessing the Quality of Primary Care Moderate non- Fertility preservation surgery done in 18 patients and 6 pregnancies 19% no RMI documented Gynaecology 1 4211 NICE 11/03/2019 To feedback the audit results to the relevant clinicians. Fast Track Referrals for Suspected compliance noted. Gynaecological Cancer A NICE-related audit: IPG 138: Gynaecology 1 4249 Intramural urethral bulking procedures NICE 29/03/2019 Fully Compliant The audit has shown improved service. No concerns as fully compliant No actions as audit standards were fully compliant. for stress urinary incontinence

The colposcopy team unanimously felt that no action plan is Did Not Attend (DNA) in Colposcopy DNA rates in New Cross colposcopy clinics is within the PHE (NHSCSP) Gynaecology 1 4250 Local 21/01/2019 Fully Compliant No concerns as fully compliant needed, as we are meeting our standards. No change is Clinic recommendations. needed in the messaging service as this is a Trust template.

Patient-initiated Follow up in Low Grade The service is patient-friendly as the women are able to choose when Gynaecology 1 4251 Local 29/03/2019 Fully Compliant No concerns as fully compliant No actions as audit standards were fully compliant. Malignancy they come back for follow up and how frequently they make contact. Prospective Audit on Outcomes on the Conventional colposcopies and Dysis had comparable results in low Conventional colposcopies is superior to dysis mapping in high Gynaecology 1 4252 Local 11/03/2019 Minor non-Compliance Re-audit and discuss findings in governance meeting use of Dysis in Colposcopy grade cases. grade cases. The audit showed that most patients are referred correctly.

Need for Coil clinics to avoid workload for OPH Referrals to Hysteroscopy Clinic Audit Increase in uptake of successful pipelle biopsy in GOPD Endometrial sampling should be obtained in hysteroscopy Work load to Diagnostic services increasing Gynaecology 1 4253 (Appropriateness of non fast track Local 11/03/2019 Minor non-Compliance clinics where feasible and the referral pathway to be Resource needs for more clinics. referrals to OP hysteroscopy) Patient can be booked from OPH rather than FU in GOPD to help reviewed. More need for see and Treat Clinics. achieve 18 weeks target

All areas of substandard compliance is discussed at the Audit has demonstrated levels of compliance with the Track and Clinical Audit Group Meeting and directly with the Trustwide EWS Audit Trigger Protocol for Early Warning Signs across the Trust inline with Some directorates demonstrated poor compliance with the Track Directorates at their Governance Meeting. Individual action Gynaecology 1 4329 Trust Wide 13/03/2019 Minor non-Compliance Trust Policy in order to address any areas of substandard and Trigger protocol in particular with appropriate documentation plans will be drawn up according to the specific areas of Safety Alert NHS/PSA/RE/2018/003 & performance. Areas of excellent compliance can be shared across the of escalation. concern. Audit is completed annually and previous years NHS/PSA/RE/2016/005 Trust to encourage learning and improvement. results will be compared to demonstrate any improvements/decline in performance. Directorate Division Audit ID Audit title Type of audit Date completed Compliance rating Key Successes- summarised Key Concerns- Summarised Key actions- summarised

To enhance the service even further a VTE Information More accurate prescribing of VTE Prophylaxis reducing risks of VTE Venous Thromboembolism (VTE) added to the junior doctors induction pack and PE to patients . Gynaecology 1 4405 Prophylaxis in Gynaecology Patients – QIP 09/08/2018 Fully Compliant No concerns as fully compliant & introduction of local VTE checklist on gynae. Increased awareness of medical and midwifery staff on VTE Adherence to Trust Guidelines Teaching sessions 'for all' O7G doctors including info on Trust assessment VTE policy and difference between Obs & Gynae VTE Venous Thromboembolism Prophylaxis in Gynaecology Patients – adherence to Improved compliance. This will result in fewer errors and greater Information packs have been included in the induction packs Gynaecology 1 4460 Trust guidelines QIP 31/10/2018 Fully Compliant awareness at onset of Gynae placement for junior doctors, as No concerns as fully compliant for new doctors in Gynae. Information is also conveyed at Quality Improvement Project: VTE information packs are now available at local inductions. staff briefings and reference is made to online training. Prophylaxis

•9 out of 20 handovers began late (range: 10 minutes early – 20 minutes late)

•The SBAR used at 1/20 handovers (Situation Background Assessment Recommendation) Improving the safety and effectiveness Moderate non- This audit has improved the attendance of medical staff in the clinical Consultant with staff, review of rota and handover time and Gynaecology 1 4529 of gynaecology handover: a Quality QIP 15/03/2019 compliance areas thus improving patient access to medical care. •The Handover sheet was not up to date in 7 out of 20 handovers repeat audit. Improvement Project •Not enough handover sheets available on 7 of 20 handovers

•Not all patients on handover – 11 of 20 sheets

•There were multiple occasions of missing information

Continue to adhere to recommendations, which have been Re-audit Surgical Intervention in Otitis Majority of criteria audited demonstrated improved compliance Marked improvement seen in adherence to NICE guidelines during reiterated during the audit presentation/meeting, in Head & Neck 1 3249 Media with Effusion: Adherence to NICE NICE 12/06/2018 Minor non-Compliance with NICE guidelines. Minor issues noted with documenting this re-audit. particular related to documenting balance assessment and Guidance CG60 balance assessment and upper respiratory health. upper respiratory health.

All areas of substandard compliance is discussed at the Audit has demonstrated levels of compliance with documentation Clinical Audit Group Meeting and directly with the standards across the Trust inline with the Clinical Documentation Some directorates demonstrated poor compliance with Directorates at their Governance Meeting. Individual action Trust Wide OP07 Health Records Moderate non- Head & Neck 1 4101 Trust Wide 21/03/2019 Guidelines in order to address any areas of substandard performance. the standards in particular regarding documentation of clinicians plans will be drawn up according to the specific areas of Documentation audit (18/19) compliance Areas of excellent compliance can be shared across the Trust to identification number and full name/signature. concern. Audit is completed annually and previous years encourage learning and improvement. results will be compared to demonstrate any improvements/decline in performance. Trust Wide Early Warning Signs Audit 2018/19 Documentation of nurses escalating to medical staff. Moderate non- Staff have been reminded at governance meetings to ensure Head & Neck 1 4102 Trust Wide 21/03/2019 Evidence of appropriate escalation process for patients scoring 5+. Documentation of medical staff when actually seeing, changing compliance their escalation and review is appropriately documented. Safety Alert NHS/PSA/RE/2018/003 & triggers and escalating patients. NHS/PSA/RE/2016/005 Audit of compliance to the trust consent Out of 32 consents reviewed only 1 consent was found to have used Head & Neck 1 4422 policy while consenting for dental Local 11/09/2018 Minor non-Compliance No major concerns noted. Development of a pre-printed consent form abbreviations. extractions Respondents indicated that they have already commenced work in the development of patient information where it is lacking.

Information cards to give to patients as inpatients are being Regional Audit - An audit of performance developed There were 5 returns; 2 of which had completed Audit Tool 3 only Develop a single checklist for the patient record that makes it vs the Clinical Guidelines for the pre and clear that information/ opportunities have been provided to Maltings 2 4090 post operative physiotherapy National 04/07/2018 Minor non-Compliance Handover document is being developed patients and carers as appropriate. management of adults with lower limb amputations. BACPAR 2016. Respondents have indicated that they have already considered the development of Physiotherapy assistant competencies – there may be some available regionally or nationally to share (iCSP Amputee Rehabilitation)

All areas of substandard compliance is discussed at the Audit has demonstrated levels of compliance with documentation Clinical Audit Group Meeting and directly with the standards across the Trust inline with the Clinical Documentation Some directorates demonstrated poor compliance with the Directorates at their Governance Meeting. Individual action Trust Wide OP07 Health Records Maltings 2 4136 Trust Wide 22/03/2019 Fully Compliant Guidelines in order to address any areas of substandard performance. standards in particular regarding documentation of clinicians plans will be drawn up according to the specific areas of Documentation audit (2018/19) Areas of excellent compliance can be shared across the Trust to identification number and full name/signature. concern. Audit is completed annually and previous years encourage learning and improvement. results will be compared to demonstrate any improvements/decline in performance. The use of Palivizumab prophylaxis for at The audit has enabled a review of service delivery and Neonatal 1 3223 risk infants based on current government Local 19/07/2018 Fully Compliant Good adherence to NICE recommendations. No concerns as fully compliant ascertain the level of compliance with standards set by the recommendations Government. Unit compares favourably with units in Network cohort however Current performance rating and standard compliance A National Audit on Neonatal Intensive The audit showed local compliance to standards, comparison as to Neonatal 1 3521 National 10/12/2018 Minor non-Compliance local compliance can be improved for all standards of maternal percentages shared with all staff in unit - posters displayed in and Special Care (NNAP) performance within the network and nationally. and baby care. unit as an aid memoir. Directorate Division Audit ID Audit title Type of audit Date completed Compliance rating Key Successes- summarised Key Concerns- Summarised Key actions- summarised

Findings of the audit were presented to the team. Quality Improvement Audit - Antibiotic The audit enabled awareness on where hospital inpatient stay can be Flyers are now displayed raising awareness concerning the Neonatal 1 4262 QIP 20/07/2018 Minor non-Compliance Non checking of blood cultures and CRP at 36 hours. use in early onset Sepsis cut and financial savings made due to reduced use of antibiotics. review of patient status at 36 hours and decisions as to whether antibiotics can be stopped.

Moderate non- Drugs and equipment not available at the point of need. Audit to be presented to midwives with consideration of a re- Neonatal 1 4265 Resuscitation Equipment Audit Local 17/10/2018 Improvements seen in comparison to previous audit. compliance audit. All missing equipment to be stocked/purchased.

Appropriate Safety checks, measures and precautions were taken in Documentation of location of central lines needs to be improved Audit findings shared with medical team and a re-audit Neonatal 1 4347 Positioning of Central Lines Audit Local 18/07/2018 Minor non-Compliance 100% (as per WHO checklist). and x-ray to check position of lines if insitu for more than 1 week. agreed for 19/20.

The audit has enabled the directorate to be aware of the level of non- A local process needs to be put into place which ensures Donor Breast Milk - Tracking and Tracing Significant non- compliance to the NICE guidance. A local process that will be in line There is no process in place for the recording of the use of Donor Neonatal 1 4406 NICE 31/01/2019 compliance with NICE Tracing and Tracking of Donor Breast Process compliance with the NICE guidance will be implemented, in order to enhance Breast Milk to babies. Milk. compliance to the guideline and ensure patient safety and care.

The department triages all referrals on a case by case basis allowing patients to be booked into the most appropriate clinic.

West Midlands Regional audit of Departmental protocol shows that the guidelines are all ready Neurology 2 3189 National 04/07/2018 Fully Compliant No major concerns identified No actions identified Peripheral Neuropathy testing exceeded for the performance of peripheral neuropathy screening.

This in term attracts more staff to apply for vacancies as have extended roles compared to other departments.

EEGs and scans are not done within 2 weeks generally as 6 week All aims have been met, all patients are sent to the first seizure clinic Service waiting list. In EEG terms single seizure patients do not take To reduce waiting lists so that EEG and scans can be Neurology 2 4110 First Fit management and driving audit 15/06/2018 Minor non-Compliance and patients have written information about driving and whether Evaluation priority over referrals that may have many seizures. performed more quickly. further investigations are necessary. Scanning has its own criteria

The audit shows that decompression surgery on patients who show evidence of median nerve compression on Nerve conduction studies At the moment accurate nerve conduction studies are performed have a good clinical outcome after surgery. noting the severity of entrapment syndromes for the orthopaedic consultants but surgical outcomes cannot be predicted from this The audit also demonstrated (corroborating previous studies) that alone. If ultrasound could be used in conjunction this may Audit comparing findings of NCS to there is no relationship between severity and risk of residual Moderate non- improve expected outcomes or help post surgery with patient A research project will be undertaken to look at this in more Neurology 2 4144 carpal tunnel decompression findings Local 03/01/2019 symptoms following surgery. compliance expectations of the outcome of surgery. detail. during operation. Overall the audit demonstrates that nerve conduction studies is a Ultrasound is not performed routinely on patients presenting with valuable tool to investigate Carpal Tunnel Syndrome and that current carpal tunnel symptoms. There is no correlation between post protocols are detecting evidence of compression of the median nerve surgery results and preop findings. at the wrist that is successfully being treated with surgical intervention.

All areas of substandard compliance is discussed at the Trust Wide Early Warning Signs Audit Audit has demonstrated levels of compliance with the Track and Clinical Audit Group Meeting and directly with the Some directorates demonstrated poor compliance with the Track 2018/19 Trigger Protocol for Early Warning Signs across the Trust inline with Directorates at their Governance Meeting. Individual action and Trigger protocol in particular with appropriate documentation Neurology 2 4148 Trust wide 08/03/2019 Not applicable Trust Policy in order to address any areas of substandard plans will be drawn up according to the specific areas of of escalation. Safety Alert NHS/PSA/RE/2018/003 & performance. Areas of excellent compliance can be shared across the concern. Audit is completed annually and previous years

NHS/PSA/RE/2016/005 Trust to encourage learning and improvement. results will be compared to demonstrate any improvements/decline in performance. There were concerns regarding seizure provocation but only a Patients can feel assured that we are offering the best service and are small percentage of patients had an event following sleep A further service evaluation is being performed to look at Neurology 2 4236 Sleep deprived EEG Service evaluation National 22/02/2019 Not applicable offering the least risk for these patients. deprivation with very similar results as to those seen in previous sleep deprivation and sedation EEGs in paediatrics audits of routine EEG and NEAD Directorate Division Audit ID Audit title Type of audit Date completed Compliance rating Key Successes- summarised Key Concerns- Summarised Key actions- summarised

A survey of practice of Neurophysiology Patients can be assured that they are getting the best possible The department already follows the standards and Neurology 2 4237 Departments in the UK for performing National 13/03/2019 Fully Compliant investigation set to national standards and if they had to go to No major concerns identified. recommendations set forward by this audit evoked potentials another department direct comparisons of results could be made. We cannot offer Transcranial magnetic stimulation or ultrasound A future business case for the purchase of these pieces of An exploration of neurodiagnostic Audit shows that we are offering a high standard and timely as these services are not available in the department. These are Neurology 2 4238 National 20/02/2019 Minor non-Compliance equipment and employment of trained staff would be practices for the diagnosis of MND diagnostic procedure for patients with possible MND not essential but would offer a gold standard to diagnosis of necessary. complex cases. All patients currently on Sodium valproate and enzyme - inducer anti-epileptic medications should have their Vitamin Audit has enabled all newly diagnosed patients with epilepsy have Majority of the patients are not tested for Vitamin D and therefore D levels assessed and appropriate treatment and Vitamin D Supplement in Epilepsy Moderate non- Neurology 2 4342 Local 02/07/2018 Vitamin D and Bone profile blood tests which will improve the health not receiving the appropriate supplementation and further investigations performed on the results. Patients compliance of these patients. investigation All new patients due to start anticonvulsants have Vitamin D levels and Bone profile blood tests. West Midlands Region Carpal Tunnel The audit showed that the directorate is fully compliant with all Guidelines are unchanged from those of BSCN which the Neurology 2 4361 National 20/07/2018 Fully Compliant No major concerns identified Audit standards. department follows (see test protocol) All aspects are of the recommendations are already West Midlands Service evaluation of Service All standards are met. Using the devised protocols as standard performed in the department following protocols and on an Neurology 2 4362 Neurophysiology assessment of 20/07/2018 Fully Compliant None noted. Evaluation procedures. individual case by case basis dependant on findings and myopathy patient compliance Staff have been reminded by the Delivery Suite Manager. A copy of the audit and its report has been made available to Obstetrics 1 2862 A Local Audit on Sepsis Local 13/08/2018 Fully Compliant The audit showed increased compliance with Sepsis 6. No concerns as fully compliant the manager of the maternity ward and the Delivery Suite Manager. Management have agreed to implement Vital pac next year. (2019)

Only 8% of women in the NICE audit were ‘Pregnancy ready.’ This equates to just 1:12 women To email Community midwives that all diabetic women A total of 17 out of 30 women were seen in the joint clinic before should be urgently referred to DSM? and advise all women A NICE-related Audit on Diabetes in Moderate non- 10/40. Obstetrics 1 3350 NICE 14/08/2018 Improvement of service/advice provided to diabetic patients. to start folic acid 5mg at booking (if not already taking it). Pregnancy compliance 11 women had commenced folic acid at the recommended level Audit was forwarded to the Diabetes team for comment and prior to ANC review action.

Although some remaining women had commenced Folic Acid it was the incorrect dosage. We have used information shared from neighbouring units in National data provided reassurance National Audit: National Maternity and our own learning and to improve services. We have been Obstetrics 1 3352 National 01/08/2018 Fully Compliant Information provided supports current practice No concerns as fully compliant Perinatal Audit (NMPA) further assured of the veracity of our own data due to the implementation of BadgerNet. CG062 (Updated Jan) Antenatal care for All required equipment for all community midwives and Obstetrics 1 3678 uncomplicated pregnancies and missed NICE 16/08/2018 Minor non-Compliance Audit aims to improve the patient journey. No concerns noted antenatal services across this Trust and Cannock obtained SGAs (Small For Gestational Age) and no further actions required.

The audit has confirmed excellent compliance with management of Obstetrics 1 3685 NG025 Preterm labour and birth NICE 27/03/2019 Fully Compliant No concerns as fully compliant No actions as audit standards were fully compliant. preterm labours in the unit over these 3 months.

A new electronic records system (Badgernet) was in place as the time and it was felt that the sample was too small and there were Re-audit with a higher sample of patients is required before any The audit has been put onto the list for the 2019 - 2020 audit Obstetrics 1 3693 VBAC Audit Local 06/03/2019 Not applicable potential inaccuracies. A plan was made at the meeting that this positive conclusions can be drawn. plan. audit should be repeated with a larger group and at a later date to enable more patient data to have been put onto the system. Review Management of Anaemia guidelines. Teaching session to all medical staff to emphasize the Patient care has been improved because there has been a review of 26% of the patients were not started on treatment following 1st T importance of treating anaemia in pregnancy and the use of The Management of Iron Deficiency the Management of Anaemia guidelines. bloods and remained anaemic at 28 weeks. In addition, oral iron IV iron as an alternative to blood transfusion. Obstetrics 1 3902 National 27/02/2019 Minor non-Compliance Anaemia in Pregnancy Teaching sessions to all medical staff to emphasize the importance of prescription was not standardized and was suboptimal in the Liaising with Pharmacy to use Ferrinject instead of Cosmofer treating anaemia in pregnancy. majority of cases. to reduce hospital stay (2hrs vs. 8 hours) and improve compliance with IV iron treatment Develop posters for all antenatal and postnatal areas. Improvements to documentation; Update theatre board to include: Time in theatre, Starting Anaesthetic, Anaesthetic ready KTS, KTU, Delivery time, Clearer to identify areas of delay. By correctly categorising Caesarean Section, the patient will have Future audit proformas to include timing of specific events to Obstetrics 1 4233 Grade 1 and 2 Caesarean Sections Audit Local 14/08/2018 Minor non-Compliance more time for explanation, choice of anaesthesia and feeling of Cannot change national categorisations capture areas of delay: ? Compulsory boxes on badgernet if control. Compliance with categorisation will improve. category 1. Separate Audit of all category 1 caesarean sections to look at “best” practice.

Audit presented to obstetric team and discussed with the Post-natal readmission rate is acceptable as it is comparable to Obstetrics 1 4234 Postnatal Readmissions audit (Mothers) Local 27/03/2019 Minor non-Compliance Limited documented evidence of input from obstetric consultant aim of improving documentation of consultant contacts and national statistics data. reducing numbers of readmissions. Directorate Division Audit ID Audit title Type of audit Date completed Compliance rating Key Successes- summarised Key Concerns- Summarised Key actions- summarised

All areas of substandard compliance is discussed at the Audit has demonstrated levels of compliance with documentation Clinical Audit Group Meeting and directly with the standards across the Trust inline with the Clinical Documentation Some directorates demonstrated poor compliance with Directorates at their Governance Meeting. Individual action Trust Wide OP07 Health Records Obstetrics 1 4242 Trust Wide 11/03/2019 minor non-Compliance Guidelines in order to address any areas of substandard performance. the standards in particular regarding documentation of clinicians plans will be drawn up according to the specific areas of Documentation audit Areas of excellent compliance can be shared across the Trust to identification number and full name/signature. concern. Audit is completed annually and previous years encourage learning and improvement. results will be compared to demonstrate any improvements/decline in performance. Staff have been reminded by the Delivery Suite Manager. There is also an electronic proforma added to the electronic An improvement in record keeping was seen and by extension, an Documentation and use of Badger net to record loss and details Obstetrics 1 4245 Massive PPH Audit Local 13/08/2018 minor non-Compliance records Badger net. improvement in the quality of care delivered to the patient. can be improved upon. Copies of the presentation and report have been made available to each forum.

Audit will bring about improved and safer care for women in labour Re-audit: CG55: A NICE-related Audit on with oxytocin and improved documentation by midwifery staff. The Obstetrics 1 4246 Intrapartum Care - including the use of NICE 29/03/2019 Minor non-Compliance No concerns as fully compliant No actions as audit standards were fully compliant. documentation improvement is underpinned by the implementation Oxytocin of BadgerNet.

Encourage to explain procedure to patients emphasising importance and help discuss any anxiety at the point of Re-audit: A local Audit on Elective DNA rates in new cross colposcopy clinics is within the PHE Patients referred for follow-up are more likely to default than new referral. Encourage patients to inform the clinic in cases Obstetrics 1 4247 Caesarean Section - including VTE Local 27/02/2019 Minor non-Compliance (NHSCSP)recommendation . patients or those referred for treatment. where its not convenient and emphasise the importance of Prophylaxis of Elective Caesarean Section next appointments at any appointments attended specially in low grade CIN /border line patients.

The risk of birth outside of Delivery Suite cannot be completely The impact of the audit is that it provides the necessary information removed. Staffing in the area needs to be increased via the Shared the information with the Intrapartum team and their Obstetrics 1 4248 Births outside Delivery Suite Audit Local 04/07/2018 Minor non-Compliance relating to births outside of Delivery Suite. recruitment and selection process, provided that the VPs ( vacancy manager to increase awareness and where possible reduce This has created awareness around the importance of history-taking. proforma) are funded by the Trust. This audit may support the the risk. process. Trustwide EWS Audit Obstetrics 1 4330 Trust Wide 13/03/2019 Minor non-Compliance Fully compliant with audited standards. No concerns as fully compliant No actions as audit standards were fully compliant. Safety Alert NHS/PSA/RE/2018/003 & NHS/PSA/RE/2016/005 We have funded and appointed a specialist midwife leading the care Adopted regional standards and practice. We have Regional Audit Project on multiple birth Obstetrics 1 4413 National 25/03/2019 Fully Compliant for women with multiple pregnancy in line with best practice and No concerns as fully compliant appointed a specialist midwife for multiple birth following management following audit. this audit. Audit was done over one month and needs further details Audit of transfer time from Maternity There has been a dramatic improvement in the reduction of delays in regarding women already in labour following induction of labour. A review audit over three months will be undertaken in early Obstetrics 1 4493 Induction Unit to Delivery Suite (Delays Local 18/12/2018 Minor non-Compliance transferring women from the induction ward to delivery suite. Also more data required on those who are favourable but not yet 2019. in transfer following Induction of labour in labour. The team working on this audit have instigated some Handovers are more efficient and effective and more work is in changes to handover already including the use of a 'lollipop' Service Obstetrics 1 4598 Handover Process in the Labour Ward 13/03/2019 Minor non-Compliance progress to further enhance and improve the handover. This is part of No concerns as fully compliant board on delivery suite so that staff know not to interrupt Evaluation on-going reviews. the report . Anaesthetic staff attend the handover as well as other grades of staff. The induction of labour pathway has been updated (HS) the team on Waiting for actions and recommendations to be considered Service the MIU (maternity induction unit) have instigated a more 'managed Obstetrics 1 4603 Induction of Labour Audit 06/03/2019 minor non-Compliance There are no issues - it is a process of change. by the team looking at Delivery Suite guide to practice Evaluation 'approach to induction of labour including removing delays from the documents for 2019. process and improving communication with parents . TA421 Everolimus with exemestane for Oncology & 2 3796 treating advanced breast cancer after NICE 11/06/2018 Fully Compliant NICE guidance is being fully adhered to. No concerns identified. None required. Haematology endocrine therapy TA295 Breast cancer (HER2 negative Oncology & oestrogen receptor positive locally 2 3887 NICE 11/06/2018 Fully Compliant NICE guidance is being fully adhered to. No concerns identified. None required. Haematology advanced or metastatic) - everolimus (with an aromatase inhibitor) Directorate Division Audit ID Audit title Type of audit Date completed Compliance rating Key Successes- summarised Key Concerns- Summarised Key actions- summarised

Patients admitted with vaso-occlusive crisis are not having observations completed at a minimum of every four hours. Chest is not being examined daily for these patients, if it is this is not appropriately documented in the clinical notes. Teaching to be put in place for nurses on the clinical Desaturations are not always escalated for a medical review. haematology unit to emphasise requirement of observations ACS is recognised late and usually labelled “CAP” until reviewed by to be carried out every four hours and oxygen stats <94% Audit of the BSH guideline for the Oncology & Service Moderate non- Areas of low compliance identified and appropriate measures put in a haematologist. should always trigger a medical review. 2 3971 management of acute chest syndrome in 07/11/2018 Haematology Evaluation compliance place to address to improve patient care. G+S or a cross-match is not always sent for in a suspected/actual To be relayed at grand round to all medical staff taking care sickle cell disease chest crisis – this is imperative should the patient deteriorate and of SCD patients that these patients should have their chests require an exchange transfusion. Neither are blood cultures. examined daily and it be noted in the notes. There was no evidence of ABG being done at time of desaturation Management checklist template for ACS will be reviewed. but interestingly this was always written in the plan. Serology for atypical organisms was never carried out, with two of the admissions having their antibiotics changed empirically.

Moldcare cushions increase accuracy of treatment and patient Improving the accuracy of head and neck comfort - now used as standard practice for all radical head and neck Oncology & radiotherapy treatment with the use of Service patients 2 3995 09/04/2018 Fully Compliant No concerns identified. None required. Haematology individualised moldcare head support Evaluation cushions Reduction in the size of the area for treatment therefore reduced toxicity Oncology & 2 4061 Re audit MSCC guidelines NICE 07/11/2018 Fully Compliant Demonstrated full compliance with MSCC guidelines No concerns identified. None required. Haematology Oncology & 2 4084 Re Audit of Neutropenic sepsis (CG151) NICE 07/11/2018 Fully Compliant Showed improvement in practice compared to original audit No concerns identified. re-audit 12 months to ensure continued compliance. Haematology Review the current service for direct GP referrals and Our cohort numbers and quality assurance processes are reliable and produce a 5 year service plan by the end of 2019. effective. Concerns that we currently will not be achieving the 31/62 day Oncology & Re- Audit CUP - Carcinoma of unknown Review what questions we ask of our CUP audit for the 2 4085 NICE 28/02/2019 Fully Compliant Established emergency pathway for CUP patients within the Trust. targets. Haematology primary forthcoming year (July - 2019). Producing the same data is no Our MDT is consistently making appropriate diagnostic and treatment longer providing with meaningful information. Peer review decisions that reflect NICE recommendations. requires an annual report Re Audits for AOS over the next 12 months AO (June 2019). Business Case for AO expansion of the nursing service in in Disease site types, treatment modality, treatment intent and Oncology & Re-Audit of Acute Oncology Service Seven day nursing service. implementation within the next 2 4086 Local 07/11/2018 Fully Compliant presenting symptoms are all comparable to the previous audit None noted. Haematology Activity 12 months. Administrative support No abnormal trends noted Educational drive to support ED over the forthcoming months Sepsis Awareness MSCC. CT planning process, Laterality checks WI7-6-9 Criteria 4 Completed checklists for CT planning and (NATSIPS) Undertake a further quarterly audits to confirm compliance. Oncology & Has provided assurance to trust that there were no significant Pinnacle – 90%. 2 4087 Local 06/06/2018 Minor non-Compliance Present results at Trust Patient Safety Improvement Group & Haematology variation from standards. QP7-5-2-4 Criteria 4.8 Confirmation must be logged on Mosaiq RT Laterality checks QP7-5-2-4,CT planning at RT MDT meeting. notes on day 1 – 80%. process WI7-6-9, Our pragmatic clinic-biochemical imaging algorithm reduced imaging Oncology & requests significantly( 24%) allowing the preferred imaging modalities 2 4117 RE-Audit Myeloma of skeletal surveys Local 14/03/2019 Fully Compliant No concerns identified. None required. Haematology to be performed productively in a cost effective way in face of ever increasing health care cost and demands. Oncology & 2 4122 National RCR RT Bladder Audit National 07/11/2018 Fully Compliant Fully compliant with Nice guidelines No concerns identified. Re-audit after 6-12 months to ensure continued compliance. Haematology All areas of substandard compliance is discussed at the Trust Wide Early Warning Signs (EWS) Audit has demonstrated levels of compliance with the Track and Clinical Audit Group Meeting and directly with the Some directorates demonstrated poor compliance with the Track 2018/19 Trigger Protocol for Early Warning Signs across the Trust inline with Directorates at their Governance Meeting. Individual action Oncology & Moderate non- and Trigger protocol in particular with appropriate documentation 2 4123 Trust wide 22/03/2019 Trust Policy in order to address any areas of substandard plans will be drawn up according to the specific areas of Haematology compliance of escalation. Safety Alert NHS/PSA/RE/2018/003 & performance. Areas of excellent compliance can be shared across the concern. Audit is completed annually and previous years

NHS/PSA/RE/2016/005 Trust to encourage learning and improvement. results will be compared to demonstrate any improvements/decline in performance.

Hickman line removal audit Clinical No never events/ serious incidents/ near misses reported due to Inform all staff of the need to document fully within the Oncology & 2 4280 Oncology Dept. , NXH , Wolverhampton Local 01/05/2018 Minor non-Compliance Hickman line removals in trust during audit period. Procedure need to be documented in pts. medical notes patient notes. Present audit at clinical audit meeting. Haematology ( Oct – Dec 2017 ) Re audit in 6 months to ensure compliance. Specific Hickman line removal WHO safety checklist used in all Oncology & 2 4281 re-audit of Hickman line removal Local 07/11/2018 Fully Compliant patients. None noted. None required. Haematology Procedure recorded in all patients medical records. Directorate Division Audit ID Audit title Type of audit Date completed Compliance rating Key Successes- summarised Key Concerns- Summarised Key actions- summarised

It was found that VIP scores are generally recorded well however Oncology & Service Moderate non- 71% of charts had full name, hospital number and date of birth 29% had not been recorded correctly Education of staff on wards 2 4309 Syringe driver monitoring re-audit 12/06/2018 Haematology Evaluation compliance recorded, this is an increase from 2015 when this was 60% Care professionals names were legible in only 29% of charts in Present at Matron's group 2018, this has almost equal to the 30% in 2015 Oncology & Audit of unscheduled breaks in 2 4310 Local 17/07/2018 Fully Compliant Provides reassurance that effective treatment is given safely. None noted. None required. Haematology radiotherapy TA427 Pomalidomide for multiple Oncology & 2 4313 myeloma previously treated with NICE 07/11/2018 Fully Compliant Audit shows the directorate is compliant with TA427 None noted. None required. Haematology lenalidomide and Bortezomib TA429 Ibrutinib for previously treated Oncology & chronic lymphocytic leukaemia and 2 4314 NICE 07/11/2018 Fully Compliant Directorate compliant with TA429 None noted. None required. Haematology untreated chronic lymphocytic leukaemia with 17p deletion or TP53 mutation Oncology & TA359 Idelalisib for treating chronic 2 4317 NICE 07/11/2018 Fully Compliant Directorate compliant with TA359 None noted. None required. Haematology lymphocytic leukaemia Oncology & TA299 Leukaemia (chronic myeloid) – 2 4318 NICE 07/11/2018 Fully Compliant Directorate compliant with TA299 None noted. None required. Haematology bosutinib Early data suggests significant benefit for stage III disease Oncology & Service Interim data from PORTEC3 for high risk disease shows no significant 2 4319 Endometrial Audit - Real life comparison 17/07/2018 Fully Compliant None noted. local NXH protocols to be updated with full data set; review Haematology Evaluation difference in PFS/OS with CRT and sequential adjuvant chemotherapy. clinical portfolio All complaints were forwarded to persons/areas/managers involved Oncology & 2 4364 Complaints audit Local 19/10/2018 Fully Compliant All complaints were answered with an apology and explanation or None noted. None required. Haematology reassurance.

Recommendations; More rigorous evaluation of the link between G-CSF prophylaxis and severity of neutropenic sepsis, using information such as biomarkers of infection and patient some of the conclusions are based off small patient cohorts. observations (blood pressure, temperature, heart rate etc.). Based on the limited data available, prophylactic G-CSF may be Further research would ideally involve larger patient groups and Oncology & Service Evaluation of the rates of Service Cost-benefit analysis of prescribing G-CSF prophylactically 2 4365 11/12/2018 Fully Compliant effective in not only limiting the frequency of episodes of neutropenic proper statistical analysis. Haematology Neutropenic Sepsis in breast patients Evaluation compared to the cost associated with the increased sepsis but also the severity and the duration. There may be associated costs and side effects with using incidence of neutropenic sepsis. prophylactic G-CSF in chemotherapy Consider an official trial of the management strategy followed by Consultant 1 to investigate whether that results in reduced admission rates followed by re-audit.

The directorate now has information around delays in scanning or Local: Steroid induced osteoporosis in Ophthalmology 1 3160 Local 24/04/2017 Fully Compliant referrals to osteoporosis clinic or seeking advice this is done in a No concerns as fully compliant No actions as audit standards were fully compliant. uveitis practice. timely manner.

The audit provided assurance to the directorate that the local Audit on Laser Retinopexy for Retinal Ophthalmology 1 3381 Local 09/05/2018 Fully Compliant performance was better than that audited. It also encouraged the No concerns as fully compliant No actions as audit standards were fully compliant. Tears clinicians to further improve on current performance.

Moderate non- 22% received clinic dates within 8 weeks of receiving a referral letter 72% of the patients did not receive clinic dates within 8 weeks of Ophthalmology 1 3973 Re-audit of referral vetting outcomes Local 27/02/2019 Increase clinic capacity with business case to be discussed. compliance while 6% were rejected. receiving a referral letter Excellent visual acuity outcomes ; with this new treat and extend Outcome of treat and extend regime of Service regime we have demonstrated far superior visual acuity outcomes in Ophthalmology 1 4000 Lucentis therapy in wet ARMD-2 years 25/03/2019 Not applicable No concerns No actions required Evaluation comparison with national dataset and with our own previous audit of outcome patients treated on a pro re nata regime.

Overall improvement is demonstrated following treatment. 60% of patients responding to the Livechart reported a major benefit. No major side effects, i.e., Ptosis/diplopia reported. Livechart is beneficial at looking at specific response to treatment for Botulinum toxin for Hemifacial spasm Service Ophthalmology 1 4013 13/06/2018 Not applicable individual patients - it encourages patients to consider the actual Not applicable. To continue with current clinical practice and blepharospasm (Botox Audit) Evaluation effects of their treatment. Pretarsal injections show greater efficacy of symptom response but may be associated with more pain and bruising as compared to orbital.

Local audit of post-operative The audit showed that the rates are lower than the standards audited. Ophthalmology 1 4204 endophthalmitis following cataract Local 31/01/2019 Fully Compliant In addition, it showed that the change of procedures has had an No concerns as fully compliant No actions as audit standards were fully compliant. surgery six year results positive effect.

The department will trial a virtual clinic, then review the same questions asked in the current audit - focusing on comparing if the wait time between referral and first test The wait time from referral being made and first appointment issued changes, or number of visits to make final diagnosis changes. have been calculated and looked into. The idea of the virtual clinic is to have patients coming to a We were able to review which tests were done on the day, requested multi disciplinary one stop clinic. The clinic will run on a Ophthalmology 1 4380 Indistinct/ Blurred discs and Papilledema Local 18/10/2018 not applicable No major concerns noted. and reported on. Monday Afternoon. All relevant tests are done, then the The wait from u/s being requested and reported on have been Ophthalmology Consultant will review the notes and decide calculated & the true/false positive rates have been calculated. if/when the patient needs to be seen by a consultant. As seen from the audit, there was a long wait for the initial appointment (as the general paediatric ophthalmology clinics were already full) and for the ultrasound to be reported on.

An alert message will be added to the e-PMA system to 2017 Audit of the management of remind prescribers of the requirement to complete a risk Identified areas where improvements should be made in regards to Patients with identified risk factors for TACO should have a risk Pathology 1 3225 patients at risk of Transfusion Associated National 04/02/2019 Minor non-Compliance assessment where required. risk assessments being completed for TACO. assessment completed - we are non-compliant with this standard. Circulatory Overload (TACO) The Trust consent for transfusion sticker will be amended to included the requirement to consider TACO National Comparative Re-Audit of Red Significant improvement in compliance in the appropriate transfusion Pro-active monitoring of requests from the laboratory and Minor non-compliance is related to issues around comprehensive Pathology 1 3229 Cells and Platelets in Adult Haematology National 08/06/2018 Minor non-Compliance of red cells and platelets - introduction of a clinical guideline and pro- challenge of any requests deemed inappropriate or outside documentation in the clinical notes. Patients active monitoring of transfusion requests. of guidelines. Requirement by the CCG that patients with sickle cell disease are Paediatric team to inform CCG of actions required in relation vaccinated as per guidelines. to vaccination in the community. Requirement to identify patients that need annual virology Audit of Transfusion in Children with Moderate non- Largely compliant with national recommendations. Areas of non Paediatric team to identify patients for virology screening Pathology 1 4453 Local 20/11/2018 screening. Sickle Cell Disease compliance compliance addressed to met national recommendations. and phenotyping and submit samples to the laboratory. Ensure that children with sickle cell disease have extended Consent sticker to be amended to include pre and post phenotyping where possible. transfusion HbS levels. Pre and post transfusion HbS levels required. This audit has highlighted that insulin prescribed by brand reduces the likelihood of prescribing, dispensing and administration errors. Raising prescriber awareness through pharmacy training Pharmacy 3 4109 Safe Insulin prescribing on discharge Local 25/10/2018 Minor non-Compliance Improved communication is required regarding the device required at 13% of patients had the device added to their discharge sessions which are already in place, a section on insulin will discharge however, and it is anticipated that the implementation of 30% of patients had needles on their discharge be added in EMPA which will address this. electronic prescribing will facilitate this. The outcome of the audit will be communicated to consultants and senior nursing staff which will be raised in The wards only managed to hit 100% compliance on one day for governance too. We aim to ensure that junior staff are aware The care-bundle was well embraced as a basis of staff to concentrate the Neonatal Care Bundle. For all other days there were significant of these guidelines and that they are prescribing correctly Safer use of IV gentamicin in neonates on undertaking a small, fixed number of evidence-based interventions low-compliance levels, which raised concern as to whether the Significant non- which will be further emphasised during their teaching Pharmacy 3 4338 through implementation of the NPSA Local 19/10/2018 systematically to effectively optimise patient-safety and therapeutic ward staff recognised the importance of the care-bundle and why compliance sessions throughout their induction. We are currently neonatal gentamicin care bundle outcomes. However the audit has highlighted key areas of co-founding factors hindered achieving the 100% compliance looking at recruitment drive to minimise the issues of staff improvement that we can work on developing. target. Delayed administration of gentamicin due to staff availability during administration process, and we will be availability and distractions on ward level. looking to re-launce the gentamicin care bundles on ward level too.

The aim of the audit was to determine if weight was appropriately considered when prescribing DOAC's. The audit recognised that weight is not categorically considered during the prescribing of An audit reviewing the use of Direct Oral To arrange to present the audit findings at a clinical DOAC's. Prescribing with caution in those underweight was done with Further education and sharing of knowledge was required Pharmacy 3 4375 Anticoagulants (DOAC’s) in patients with Local 19/10/2018 Minor non-Compliance pharmacy meeting. Information has already been shared more precaution however the risks of prescribing in those overweight amongst the pharmacy team and amongst prescribers. an extreme body weight with the doctors on the acute medical unit. were not clearly considered. This highlights that there is a gap in knowledge amongst the trust in regards to the recommendations made by the international society of thrombosis and haemostasis.

The findings of the audit show that the awareness of recording drug allergy is higher on admission than on discharge. Improving A low level of compliance to the trust’s antimicrobial policy about The findings of this audit was presented to the antimicrobial communication between healthcare settings is a multidisciplinary recording the nature of penicillin allergy was observed. Therefore, An audit to assess penicillin allergy Moderate non- stewardship team on 26/09/18. Recommendations were Pharmacy 3 4376 Local 19/10/2018 effort; Pharmacy staff play an important role to ensure that drug several areas of improvement have been identified and the recording compliance discussed. A patient information leaflet is going to be allergy is completed accurately on the drug chart and discharge letter. suggestions will be discussed in the next antimicrobial stewardship created. Hence, the audit will be presented to the pharmacy team in order to meeting. stress the importance of recording drug allergy. Directorate Division Audit ID Audit title Type of audit Date completed Compliance rating Key Successes- summarised Key Concerns- Summarised Key actions- summarised

There was no evidence documented of discussions with the Patient MUST be involved in discussions about DNARCPR if patient, their family or carers on two of the forms. having capacity to do so. Two of the DNARCPR forms had been completed during a Involve family members. telephone consultation and the care home had been requested to All DNARCPR forms had either the patient’s hospital number or NHS Perform Mental Capacity 2 stage Test, if clinicians feel the collect the DNARCPR form from the GP practice. Primary Care Services Moderate non- Unit Number documented. patient may lack capacity. 3 4344 Trust Wide DNA CPR Audit CP 11 Local 14/03/2019 There was no documented evidence that a Mental Capacity Test (VI) compliance All the DNARCPR forms had been signed, the clinician’s position was If lacking capacity, all decisions must be done in the best had been carried out to determine the Best Interests decision documented and the form had been dated. interest and together with the family. documented on one of the forms. Document in the patient notes that DNARCPR has been No evidence that the DNARCPR form completed by acute care had completed and who was involved (list names) within MDT been reviewed by the General Practitioner in Primary care for over discussion. two years.

There is no doubt that documentation of blood monitoring has improved. The audit methodology has changed slightly from the first Suggestion of further changes to the standard procedure to round focussing on every issue of a prescription rather than whether Further improvement required in documentation of normal results Primary Care Services improve the quality of test results held in EMIS and to further 3 4345 Medicines management Local 26/03/2019 minor non-Compliance the patient was having monitoring performed at the correct intervals. which are still less well documented than those results which were (VI) reduce the risk of prescriptions being issued when patients Instead of checking the blood testing interval the audit instead actually abnormal or overdue. do not have planned monitoring testing. checked that sufficiently recent blood tests were available at the time of prescription issue in order to support it being issued safely.

Cervical screening uptake is declining nationally, which is also reflected in Wolverhampton. However the GP practice audited has Audit successfully identified factors influencing non attendance for seen a greater rate of decline as reflected in QOF achievement cervical screening enabling recommendations for the surgery to be Primary Care Services Moderate non- results for 2015 (GP Contract), than the rest of Wolverhampton Recruitment of two Band 6 and 1 Band 3, to support Sexual 3 4346 Cervical cytology Local 25/02/2019 made to help improve attendance rates. It is hoped the additional (VI) compliance and the rest of the UK. This could result in an increase in cervical Health and Primary Care to increase cervical cytology rates. staff will greatly help towards improving the uptake of cervical cancer mortality, as there has already been an increase in cervical screening in the practise audited within Wolverhampton. cancer registrations nationally (Office for National Statistics). This is extremely worrying for our female population.

Primary Care Services NICE CG146 Audit of Bisphosphonates Audit found 1 patient who should have been taking some form of Patients who required change of treatment contacted and 3 4635 NICE 26/03/2019 Minor non-Compliance Only 1 patient did not conform to NICE Standards (VI) and Calcium bone protection as they were on long term steroids. treatment commenced. IPG473 Uterine Artery Embolisation for Moderate non- Compliant for all recommendations of IPG 473 except MDT Radiology 3 3694 NICE 24/09/2018 Not compliant with MDT requirements. Develop a business plan for a gynae MDT treating adenomyosis compliance requirement. The audit highlighted that a small proportion of patients when they No actions required at this time. We are performing well. had the biopsy at the time of the procedure were being treated for Complying with required follow-up regime and outcome NICE IPG353 Percutaneous No major concerns; there have been no major complications, no Radiology 3 4154 NICE 17/01/2019 Fully Compliant oncoytoma (a more benign condition) so now we are more detailed in measures. radiofrequency ablation of renal cancer tumour recurrences or Mets. our discussion about this with the patient and offering them a biopsy before the actual procedure where relevant.

On review, it was apparent that there is a variety of IR(ME)R Audit : Compliance of Employers documentation utilised to evidence that a pregnancy/ breast 1. Share results of audit with all operators in the department Procedure C. Making Enquiries of feeding enquiry has been made i.e. Radiology Request Forms, highlighting areas of poor compliance. Significant non- Audit demonstrated areas of poor compliance with process to allow Radiology 3 4155 Individuals of childbearing potential to Local 05/03/2019 Radiology Information System (Soliton) form, CT/ Nuclear 2. Bi -monthly audited data to be collated and forwarded to compliance monitoring and actions to improve compliance. establish whether an individual is or may questionnaires etc. Some documentation had been partially Modality Team Leaders to liaise with individual operators be pregnant or breast feeding (Reaudit) scanned i.e. one side of two part document or nothing was who consistently fail to comply. scanned providing no evidence that any enquiry had been made. 1. Share results of audit with all operators in the department Overall, the results show significant non-compliance with highlighting areas of poor compliance. evidencing the 6 point identification check had been completed IR(ME)R Audit : Compliance of Employers Significant non- Audit demonstrated areas of poor compliance with process to allow 2. Re- audit 2019-2020 Radiology 3 4156 Local 05/03/2019 and documenting where there has been a variation from method Procedure A. Identification (Reaudit) compliance monitoring and actions to improve compliance. 3. Monthly audited data to be collated and forwarded to of identification as detailed in IR(ME)R Employer’s Procedure A. Modality Team Leaders to liaise with individual operators Identification. who consistently fail to comply. 63% of CT Head requests for head injuries did not follow the NICE Junior doctors in ED must ensure requests fulfil the NICE guidelines guidance. To optimise use of CT scans for Patients Positive findings for both appropriate 34.8% and for inappropriate CT Radiology 3 4447 Local 05/03/2019 Minor non-Compliance Majority of requests were from ED (73%) Ensure requests have good documentation of positive sustaining Head Injuries brain requests 12.5%, (P=0.06) Just over half (58.7%) of CT brain scans had a radiology report findings. made available within an hour of the scan. No ethnicity / survival analysis. Consideration of QIP for various elements of care for AKI; Low mortality, no significant variations in clinical practice across Trust Renal medicine 2 3443 National UK Renal Registry (2017/18) National 07/03/2019 Fully Compliant Co-morbidity binary not cumulative. Consult Service, Education Programme, Guidelines, Alert sites Systems, Hot Clinic, Acute HD & PEX. TA448 - Etelcalcetide for treating Renal medicine 2 3964 NICE 08/02/2019 Fully Compliant Audit shows the directorate is compliant with TA448 None noted. None required. secondary hyperparathyroidism No ethnicity / survival analysis. Consideration of QIP for various elements of care for AKI; Low mortality, no significant variations in clinical practice across Trust Renal medicine 2 4050 National UK Renal Registry National 08/03/2019 Fully Compliant Co-morbidity binary not cumulative. Consult Service, Education Programme, Guidelines, Alert sites Systems, Hot Clinic, Acute HD & PEX. In 2018 there was a spike in December, patients at the time Audit demonstrated year on year reduction in number of falls after Renal medicine 2 4064 Re-Audit Patient Falls on C24 Local 07/03/2019 Fully Compliant tended to be more mobile and tried to be as independent as Continue with the good practise seen. introduction of TAG bay possible. Weaknesses include; Suboptimal documentation, 2 stage consents, RE-Audit (NatSSIP) Renal Biopsy, Strengths include; arranged in a timely manner, good biopsy yield & Post biopsy reviews and advice, Late timing of biopsies, Review-update Documentation for Biopsy Pathway and Renal medicine 2 4065 National Safety Standards for Invasive Local 11/06/2018 Minor non-Compliance current practice appears safe. Completion of protocol observations and Lacking plans re when to consent process Procedures restart anticoagulation. Directorate Division Audit ID Audit title Type of audit Date completed Compliance rating Key Successes- summarised Key Concerns- Summarised Key actions- summarised

All areas of substandard compliance is discussed at the Trust Wide Early Warning Signs (EWS) Audit has demonstrated levels of compliance with the Track and Clinical Audit Group Meeting and directly with the Some directorates demonstrated poor compliance with the Track 2018/19 Trigger Protocol for Early Warning Signs across the Trust inline with Directorates at their Governance Meeting. Individual action Moderate non- and Trigger protocol in particular with appropriate documentation Renal medicine 2 4069 Trust wide 22/03/2019 Trust Policy in order to address any areas of substandard plans will be drawn up according to the specific areas of compliance of escalation. Safety Alert NHS/PSA/RE/2018/003 & performance. Areas of excellent compliance can be shared across the concern. Audit is completed annually and previous years

NHS/PSA/RE/2016/005 Trust to encourage learning and improvement. results will be compared to demonstrate any improvements/decline in performance. Some variation in what Ix are being performed in IMN especially Review of current clinical management by senior medical QIP Membranous GN (use of PLA2R Obtained a valid and reliable picture of current practice and raised regarding screening for secondary causes. Renal medicine 2 4071 Local 11/06/2018 Minor non-Compliance staff. Need to establish and agree the clinical and cost testing) question of the need for further implementation of the testing Imaging not picking up occult malignancies. effectiveness of such testing Minor Issues with checklists, documentation in notes , specimen RRT procedure HD lines PD inserts Only minor issues were found with checklists & documentation labelling and sharps handling. Renal medicine 2 4072 Local 11/06/2018 Minor non-Compliance Review documentation and consent for Line Insertion (medical) providing assurance that the majority are being completed well. Consent for elective procedures Incorporate learning from this audit into the Registrar QIP reviewed transitional care and implemented quality improvement No major concerns identified however extended period of Renal medicine 2 4073 QIP Transitional Care Local 10/09/2018 Not applicable education programme for new rotation and incorporate into package in order to improve patient experience. historical data collection required. their duties/responsibilities. Haemodialysis (in-centre) Vascular Rates are comparable to other local renal units and have remained Renal medicine 2 4074 Local 10/01/2019 Fully Compliant None noted. None required. Access HD related bacteraemia stable despite an increase in the number of line days in the unit. Any consideration of conversion due to deteriorating The data presented at face value would tend to indicate that for those creatinine should only occur after renal biopsy with patients who tolerate conversion from CNI to Sirolimus tend to do consideration of non-DSA / DSA status and biopsy presence OUTCOMES ASSESSMENT OF THE USE OF Up to 30% of patients fail to tolerate the conversion – early well long term however a better analysis would be paired matched of Cd4 staining Renal medicine 2 4094 SIROLIMUS IN RENAL TRANSPLANT Local 03/05/2018 Not applicable phenomenon cohort analysis. PATIENTS @ NXH Current therapeutic drug time-dependent level protocol should probably be reviewed

NXH follow-up data is very good. Review of outcomes for those patients Service Renal medicine 2 4484 07/12/2018 Fully Compliant Causes for graft failure and death have acceptable explanations. None noted. None required. transplanted from 2008 onwards Evaluation

Audit of inpatient referrals to Service Service evaluation conclusion; there is no increase in referrals to Respiratory medicine 2 3393 20/09/2018 Fully Compliant None noted. None required. cardiothoracic team Evaluation thoracics.

There were significant restrictions on the interpretation of this The introduction of a standardised IPF checklist may help direct audit due to the retrospective nature of the audit, and therefore physicians in the identification of key aspects of IPF assessment and reliance on clinic documentation. management. It is acknowledged that in the clinic environment, it is Auditors feel that there is a process of assessing for transplant, very difficult with external time pressures and limitations on The introduction of an checklist with specific sections on however, it may be that the documentation is not clear enough. consultation times, but the checklist may act as a tool or guide to symptoms, lung transplant assessment criteria, pulmonary NICE: CG163 Idiopathic pulmonary To assist with waiting times for follow-up, incorporation of a Respiratory medicine 2 3400 NICE 01/10/2018 Minor non-Compliance ensure all standards of IPF management, treatment and prognosis can rehabilitation, exercise capability and palliative care may fibrosis registrar in the ILD clinic may help reduce waiting times, as well as be discussed appropriately. The introduction of a checklist with help focus the clinician in clinic and prioritise certain provide a good educational opportunity for trainees. specific sections on symptoms, lung transplant assessment criteria, discussions with the patient. There is a need for increased referral to palliative care services pulmonary rehabilitation, exercise capability and palliative care may given the survival statistics for IPF, which may be starting to help focus the clinician in clinic and prioritise certain discussions with improve with the establishment of the combined respiratory/ the patient. palliative care clinic.

Most referrals either contained too much information, or too little Assessing quality and spectrum of information, patient location and consultant name was not Service Audit highlighted issues with current referrals in order to try and Respiratory medicine 2 4007 inpatient respiratory referrals. from non 22/10/2018 Minor non-Compliance mentioned in 40(67%) referrals. Moreover, contact details(i.e. Create new referral form Evaluation make improvements to the service. respiratory wards. bleep number) of the doctor who sent the referral was not mentioned in 45(75%) of the referrals. Trust Wide Early Warning Signs (EWS) Audit has demonstrated levels of compliance with the Track and 2018/19 Trigger Protocol for Early Warning Signs across the Trust inline with Each section with criteria below the 75% pass rate will The team did not meet the required level of evidence documented Respiratory medicine 2 4060 Trust wide 11/05/2018 Minor non-Compliance Trust Policy in order to address any areas of substandard require the team to do an action plan to help staff address for a specific episode of care in the medical/patient records Safety Alert NHS/PSA/RE/2018/003 & performance. Areas of excellent compliance can be shared across the the low compliance NHS/PSA/RE/2016/005 Trust to encourage learning and improvement.

All areas of substandard compliance is discussed at the Trust Wide Early Warning Signs (EWS) Audit has demonstrated levels of compliance with the Track and Clinical Audit Group Meeting and directly with the Some directorates demonstrated poor compliance with the Track 2018/19 Trigger Protocol for Early Warning Signs across the Trust inline with Directorates at their Governance Meeting. Individual action Moderate non- and Trigger protocol in particular with appropriate documentation Respiratory medicine 2 4192 Trust wide 22/03/2019 Trust Policy in order to address any areas of substandard plans will be drawn up according to the specific areas of compliance of escalation. Safety Alert NHS/PSA/RE/2018/003 & performance. Areas of excellent compliance can be shared across the concern. Audit is completed annually and previous years

NHS/PSA/RE/2016/005 Trust to encourage learning and improvement. results will be compared to demonstrate any improvements/decline in performance. These results compare favourably with published data for both lung cancer and sarcoidosis. Respiratory medicine 2 4301 EBUS Audit 2017 Local 04/06/2018 Fully Compliant The Median reported Sensitivity for cancer is 89% with significant None noted. None required. variability (46-97%) which is thought to reflect patient selection and operator experience. NICE TA415 Certolizumab pegol for treating rheumatoid arthritis after No major concerns but the sample size audited was noted to be No action necessary - the new Virtual Clinic dedicated to Rheumatology 3 3635 NICE 02/10/2018 Fully Compliant Biologic treatment was used as per standards in all patients. inadequate response to a TNF-alpha small. biologic drug treatment will ensure continued compliance. inhibitor The data analysis showed that Rheumatology were fully compliant to TA308 Vasculitis (anti-neutrophil NICE guidelines. From the criteria, 9 out of 9 patients were prescribed Rheumatology 3 3773 cytoplasmic antibody-associated) - NICE 20/06/2018 Fully Compliant No concerns. No actions required. the drug as per TA308 Vasculitis (anti-neutrophil cytoplasmic antibody- rituximab (with glucocorticoids) associated) - rituximab (with glucocorticoids) guidelines. 1 patient was seen at 12 weeks however documentation of this appointment could not be found. Clinic letters demonstrate Clear evidence of excellent compliance with the guidelines as 100% of patient still to be on Golimumab 1 year later with good effect, just Rheumatology 3 3779 TA220 Psoriatic arthritis - golimumab NICE 16/01/2019 Fully Compliant patients are being appropriately switched onto golimumab, with 95% No actions required. do not have the documentation to demonstrate effect at 12 having accurate documentation of post-switch review. weeks.

It clear from the results that the Trust is good at assessing patients National Falls and Fragility Fractures Significant non- Capacity issues in the service provision for a fully fledged FLS Business case for fully commissioned FLS service which is Rheumatology 3 3903 National 22/02/2019 with a fracture however the figures are only based on those patients Audit programme (FFFAP) 2017/18 compliance service and poor data submission rates. currently a work in progress. who returned the questionnaire.

Audit of the ICE / DAWN system The audit report has been used as a learning aid to informing staff of Issues with the proportion of patients being identified on DAWN - A feedback session to present audit findings to clinical staff following implementation of the ICE potential problems with electronic monitoring system. This clinical staff issue Rheumatology 3 3919 Local 07/06/2018 Minor non-Compliance will be used to improve registration and updating of the Pathology results system at New Cross awareness should help to improve vigilance of results and patient Rheumatology monitoring tests not being passed through to the database. November 2017 safety within the team. hold monitor/ DAWN system (audit standard 2) – IT issue

Only one patient did not meet part of the guideline, but this may We will stress the importance of eligibility criteria whilst be as we are very strict on the criteria used for auditing. Any TA464 Bisphosphonates for treating prescribing IV bisphosphonates and assessing fracture risk of Rheumatology 3 3959 NICE 16/01/2019 Minor non-Compliance We are consistently adhering to the NICE guidelines. female patient who drinks more than 14 units/week of alcohol osteoporosis the patients in the educational meeting where this audit will qualifies, however this patient was drinking 12-14 units/week. No be presented. other risk factors were noted.

Majority of the patients have been commenced in this treatment TA466 - Baricitinib for moderate to This audit proves that the department was 100% complaint on Rheumatology 3 3965 NICE 15/01/2019 Minor non-Compliance within last 6 months so standard 1.4 could not be audited. There Re-audit 2019/20 severe rheumatoid arthritis standard 1.1 and 1.2. were not enough patient to comment on standard 1.3 at CCH. An audit of management of osteoarthritis No formal recording of BMI in 25% of the patient even though Out patients staff will be informed about the importance of Rheumatology 3 4104 NICE 28/03/2019 Minor non-Compliance Significant improvement in the management of OA patient. in adults (NICE CG177) weight was recorded in all patients. recording BMI in all new patients. Training materials were produced for nursing staff and distributed (paper, email, intranet). • Emailing nurses in key positions • Face to face meetings with nurses in key positions • Day case unit New Cross Hospital 22.3.19 QIP - To stop testing urine dipstick for Results show overall good compliance in using ultrasound for CVC • Day Case Unit CCH 20.3.19 Rheumatology 3 4105 asymptomatic patient with no specific QIP 28/03/2019 Minor non-Compliance insertion, 94% documentation rate in check list, no complications 3 forms were not completed fully and one was not found. • HCA / nurses OPD New Cross 22.3.19 clinical indication. noted i.e. arterial puncture. o HCA OPD CCH 19.3.19 • The production of a poster with key information, references, and supporting documentation (posters x2) • Presentation at clinical governance meeting

Audit of the ICE / DAWN system following implementation of the ICE Audit demonstrated that the electronic system used to process and Rheumatology 3 4106 Local 01/10/2018 Fully Compliant No concerns as fully compliant with the standards audited. None required. Pathology results system at New Cross file blood results worked in all cases. November 2017 All areas of substandard compliance is discussed at the Clinical Audit Group Meeting and directly with the Audit has demonstrated levels of compliance with documentation Directorates at their Governance Meeting. Individual action standards across the Trust inline with the Clinical Documentation Some directorates demonstrated poor compliance with the Trust Wide OP07 Health Records Moderate non- plans will be drawn up according to the specific areas of Rheumatology 3 4107 Trust wide 21/03/2019 Guidelines in order to address any areas of substandard performance. standards in particular regarding documentation of clinicians Documentation audit (2018/19) compliance concern. Audit is completed annually and previous years Areas of excellent compliance can be shared across the Trust to identification number and full name/signature. results will be compared to demonstrate any encourage learning and improvement. improvements/decline in performance.

Directorate Division Audit ID Audit title Type of audit Date completed Compliance rating Key Successes- summarised Key Concerns- Summarised Key actions- summarised

This re-audit shows that the changes made have been successful in improving the Cannock service and has improved patient experience, by integrating previously separate health professionals into one Re-audit – NICE Guidelines NG65 multidisciplinary team. This service has reduced potential three Rheumatology 3 4418 (diagnosis and management of patients NICE 01/10/2018 Fully Compliant separate visits to one for a patient which has been very convenient as No concerns noted. No actions required. with Ankylosing Spondylitis) majority of these patients are in employment . The care provided at CCH now closely mirrors the successful service provided at New Cross hospital, with both having high compliance to the NG65 guidelines

•Reinforce current guidelines in order to maintain improvement in compliance with these, particularly Hepatitis Re- audit of the use of Hepatitis A,B and Hep B PVT done reduced from 20% of samples to just 5% of Re-audit has shown significant improvement since 2014. Re-Audit A. C testing o/n patients in the GU clinic (re- samples. Sexual Health/GUM 3 3507 Local 21/03/2019 Minor non-Compliance provides assurance that patients at risk are receiving their appropriate •Ensure current guidelines are easy to access for all staff audit) ***AUDIT CARRIED OVER TO Hep A testing could not be compared as none were identified in tests to diagnose for Hepatitis A, B and C. working in clinic. 2018/19*** previous audit but compliance was low at 23%. •Current local policy is due to be reviewed in June 2019 and minor changes to Hepatitis A testing need adding.

This audit has revisited the procedure and the quality of service A Five Year Study of Deep/Non Palpable The audit shows the deep/ non palpable rates has not stopped provided to ensure implants are fitted with due care and precision so A training session will be used to highlight issues around Sexual Health/GUM 3 3616 Contraceptive Implants in a CASH Service Local 02/07/2018 Minor non-Compliance deep implants from happening. Key points circulated to clinicians removal is not cumbersome. This in turn should help to reduce the complex procedures and key recommendations circulated. in the West Midlands, UK in house and primary care to ensure rates continue to be low occurrence of deep/ non palpable implants Software programme preventing to save the clinical history Percentage of HIV test uptake rate is higher than the national unless clinician records the coding of HIV Offer/uptake by the standard (60%) patient. NICE Audit QS157 : Quality standards of HIV Uptake rate is 27.0% higher than the National average among our Percentage of our HIV test offered in our Follow up & Rebook Re-education of the clinician through team meeting. Sexual Health/GUM 3 3759 NICE 28/03/2019 Minor non-Compliance HIV testing: encouraging uptake New patients group was lower than the national standard (81%). Provide leaflets targeted at females to educate them about HIV Uptake rate is 19.4% higher than the National average among our risk of HIV and encourage test uptake. Rebook & Follow up patients Poster in every room reminding clinician to record the HIV testing & uptake. Sexual Health Partner notification for Audit demonstrated that we were very close to the national Stress on partner notification methods and patient partner Sexual Health/GUM 3 4210 Local 30/10/2018 Minor non-Compliance The results showed how difficult partner notification was. gonorrhoea recommendations. notification & completion of the forms Peer support. RE-Audit of Cervical Cytology Outcomes Marked improvement in compliance; Reduction of inadequate rates Sexual Health/GUM 3 4213 Local 30/01/2019 Minor non-Compliance No major concerns. To undertake analysis of inadequate rates in cervical in CASH (re-audit) from 10% to 5%. cytology in 2019/2020 quarter 4.

Improved patient access to Community Clinics; avoiding 37 referrals for ultrasound scans into radiology – financial saving; 3700. Evaluation of a 1 stop community The costs of a procedure difficult coil removal/fit if carried out in Directorate to Consider additional clinics to reduce waiting Sexual Health/GUM 3 4216 Local 26/03/2019 Minor non-Compliance Waiting times did not comply with national standard. procedure clinic hospital Gynaecology DSU would be over 300. times. Positive feedback from patients noted they avoided GA, still had their procedures in the community

All areas of substandard compliance is discussed at the Clinical Audit Group Meeting and directly with the Audit has demonstrated levels of compliance with documentation Directorates at their Governance Meeting. Individual action standards across the Trust inline with the Clinical Documentation Some directorates demonstrated poor compliance with the plans will be drawn up according to the specific areas of Sexual Health/GUM 3 4604 OP07 Trustwide Documentation Audit Trust wide 21/03/2019 Fully Compliant Guidelines in order to address any areas of substandard performance. standards in particular regarding documentation of clinicians concern. Audit is completed annually and previous years Areas of excellent compliance can be shared across the Trust to identification number and full name/signature. results will be compared to demonstrate any encourage learning and improvement. improvements/decline in performance.

The audit has highlighted the need to amend the patient treatment Not all patients were given the 1st line treatment due to possibility To amend the proforma to document the reasons for not proforma to include reasons for contraindication of 1st line treatment of poor compliance which could not be documented on the Moderate non- offering 1st line treatment and a tick box that signposting Sexual Health/GUM 3 4616 National (BASHH) SAS AUDIT National 14/03/2019 and document signposting which includes written information from proforma. Also, verbal information / signposting to suitable online compliance which includes written information / suitable online BASHH (British Association of Sexual Health and HIV), suitable online resources was provided verbally but not documented in on patient resources was provided to the patient. resources for patient information, was provided to the patient. record.

All areas of substandard compliance is discussed at the Clinical Audit Group Meeting and directly with the Audit has demonstrated levels of compliance with documentation Directorates at their Governance Meeting. Individual action standards across the Trust inline with the Clinical Documentation Some directorates demonstrated poor compliance with the Speech & Language Trust Wide OP07 Health Records plans will be drawn up according to the specific areas of 3 4140 Trust wide 01/03/2019 Minor non-Compliance Guidelines in order to address any areas of substandard performance. standards in particular regarding documentation of clinicians Therapy Documentation audit (18/19) concern. Audit is completed annually and previous years Areas of excellent compliance can be shared across the Trust to identification number and full name/signature. results will be compared to demonstrate any encourage learning and improvement. improvements/decline in performance.

• Patients having thickened drinks should have “Resource • 33% of patients who required thickened drinks were not Thicken-up Clear” added to their drug charts to ensure it Audit of discharge documentation for prescribed any thickener on discharge goes on to TTOs Speech & Language Significant non- The comparison evaluations of discharges for patient on modified 3 4141 patients discharged from New Cross Local 01/03/2019 • Only 24% patients had their correct swallowing • Medics should record current speech and language therapy Therapy compliance fluids between 2017 and 2018 demonstrate a real improvement. Hospital on modified diet/fluids recommendations described on their eDischarge recommendations on eDischarge • SLTs to prescribe thickener where appropriate on ePMA Directorate Division Audit ID Audit title Type of audit Date completed Compliance rating Key Successes- summarised Key Concerns- Summarised Key actions- summarised

Although the service saw an overall decline in 2017/18 we have implemented new measures that improved our performance. This has been driven by improvements to front door metrics such as direct 1.Ensure direct admissions from A&E to ASU via on-going admissions and scanning, however these scores are also highly audits. dependent on A&E therefore good communication and links with the 2. Develop mechanism for patient/carer involvement in department are vital. Weekly meetings where any non-direct SaLT provision is still lacking in many ways although it has service provision, audit and development Sentinel Stroke National Audit admissions are discussed do take place however any discussions improved, the data can sometimes be inaccurate due to the 3. Ensure Nurse and Dr attendance in A&E- further Stroke 2 3457 National 18/05/2018 Fully Compliant programme (SSNAP) should be passed on the A&E to allow for improvement. amount of therapy patients can tolerate, the therapists own data education. Our rehabilitation performance has improved also, with both OT and also shows large gaps in SaLT across sites. 4. Increase the proportion of patients getting mood screens- Physio achieving high scores, this is helped by both now providing a 7 training for HCAs. day service and a voluntary overtime 7 day service being run at west 5. Work with SaLT to improve service performance and park. staffing to allow for 7 day working. Regionally the SALT service has taken on joint working with other trusts to try and improve patient care and performances.

To ensure accurate data collection, focus on training and Stroke (acute, ischaemic) - alteplase SSNAP data helps to provide benchmarking with other services in the Stroke 2 3700 NICE 01/02/2019 Minor non-Compliance Quality of data collection recruiting data analyst which is overseen by stroke data and TA264 region. information manager All areas of substandard compliance is discussed at the Audit has demonstrated levels of compliance with documentation Clinical Audit Group Meeting and directly with the standards across the Trust inline with the Clinical Documentation Some directorates demonstrated poor compliance with the Directorates at their Governance Meeting. Individual action Trust Wide OP07 Health Records Stroke 2 4228 Trust wide 01/03/2019 Minor non-Compliance Guidelines in order to address any areas of substandard performance. standards in particular regarding documentation of clinicians plans will be drawn up according to the specific areas of Documentation audit (Financial year) Areas of excellent compliance can be shared across the Trust to identification number and full name/signature. concern. Audit is completed annually and previous years encourage learning and improvement. results will be compared to demonstrate any improvements/decline in performance.

All areas of substandard compliance is discussed at the Trust Wide Early Warning Signs (EWS) Audit has demonstrated levels of compliance with the Track and Clinical Audit Group Meeting and directly with the Some directorates demonstrated poor compliance with the Track 2018/19 Trigger Protocol for Early Warning Signs across the Trust inline with Directorates at their Governance Meeting. Individual action Significant non- and Trigger protocol in particular with appropriate documentation Stroke 2 4230 Trust wide 01/03/2019 Trust Policy in order to address any areas of substandard plans will be drawn up according to the specific areas of compliance of escalation. Safety Alert NHS/PSA/RE/2018/003 & performance. Areas of excellent compliance can be shared across the concern. Audit is completed annually and previous years

NHS/PSA/RE/2016/005 Trust to encourage learning and improvement. results will be compared to demonstrate any improvements/decline in performance. The need for appropriate patient indentation for 72-hour tapes remains, so that those who are thought to have had a stroke caused by a cardioembolic event, and would tolerate and benefit Assessing the appropriateness of cardiac There does not appear to be a correlation between severity of stroke from anticoagulation are investigated. investigations in ischaemic strokes in a A screening or vetting process should therefore be Service and number of co-morbidities identified. It could be surmised that the Stroke 2 4419 large stroke unit at a district general 22/01/2019 Minor non-Compliance considered for this investigation according to national/local Evaluation people with more severe strokes may have had undiagnosed co- Echocardiograms: . hospital (New Cross Hospital, guidelines. morbidities which in fact led to them having a more severe stroke. Currently, a significant proportion of echocardiograms have no Wolverhampton) clear investigations, and those that are requested have low yield rates for identifiable causes of heart disease which alter patient management. Teaching sessions for ED juniors and stroke nurses – on-going by Stroke Consultant and registrar Partial compliance with RCP Guidance and Trust Protocol – much room for improvement Posters – Think BP after Haemorrhage! Audit on Management of Hypertension in patients with Acute Primary Raised awareness of gaps in compliance so appropriate actions can be No set guidance for nursing staff in regards to frequency of BP Locally agreed protocol for frequency of BP measurement Stroke 2 4495 Local 22/01/2019 Minor non-Compliance Intracerebral Haemorrhage at Stroke taken. measurement after ICH with education Unit New Cross Hospital Poor awareness of blood pressure targets after a haemorrhagic Teaching on medication - GTN may be a better option due to stroke in the Emergency Department by Doctors and Nurses local experience and prompts for Hourly BP monitoring

Re-audit at 3 months to assess improvement

There was a positive trend in adopting the mood screening exercise Despite the massive improvement in mood screen rates noticed by Highlight the results of mood screens in discharge for stroke patients after the 5th week of the project. This could be the introduction of a volunteer for this role, clinical staff still need summaries. attributable to a mixture of activities including joint educational to be updated regularly on how to conduct these screens. This Think Mood after a Stroke - QIP based on Clinical staff to be updated on a regular basis on how to Stroke 2 4597 QIP 27/02/2019 Minor non-Compliance session, one-to –one meeting and lastly the selection, coaching and would ensure continuity in the event of absence of the volunteers SSNAP (National Audit Data) conduct mood screens. retention of a volunteer mood screen lead. The project team reached or change of role. Clinical staff also need to follow up on the Clinical staff to follow up on the results of these screens and and exceeded the initial aim of ensuring that 80 % of applicable stroke results of these screens and ensure that appropriate action is ensure that appropriate action is taken patients received mood assessment. taken.

All areas of substandard compliance is discussed at the Clinical Audit Group Meeting and directly with the Audit has demonstrated levels of compliance with documentation Directorates at their Governance Meeting. Individual action standards across the Trust inline with the Clinical Documentation Some directorates demonstrated poor compliance with the Trust Wide OP07 Health Records plans will be drawn up according to the specific areas of Therapy Services 3 4255 Trust wide 01/03/2019 Minor non-Compliance Guidelines in order to address any areas of substandard performance. standards in particular regarding documentation of clinicians Documentation Audit 18/19 concern. Audit is completed annually and previous years Areas of excellent compliance can be shared across the Trust to identification number and full name/signature. results will be compared to demonstrate any encourage learning and improvement. improvements/decline in performance.

Therapy Services 3 4256 NICE: CG186 Multiple Sclerosis (QIP) QIP 03/01/2019 Fully Compliant Assurance of excellent compliance with NICE guidance. None. None. Directorate Division Audit ID Audit title Type of audit Date completed Compliance rating Key Successes- summarised Key Concerns- Summarised Key actions- summarised

Achievement of improved compliance has ensured patients get a NICE Clinical Guideline CG162 - Stroke Therapy Services 3 4257 NICE 02/04/2019 Fully Compliant higher intensity of therapy and therefore has positively impacted None. None. Rehabilitation, acute and community patient care and the service as a whole.

Continue therapist awareness, improve notes to show NG59 - Low back pain and sciatica in Therapy Services 3 4258 NICE 03/01/2019 Minor non-Compliance Assurance of compliance with NICE guidance. Reduced compliance of startback usage. evidence of stratification if startback method has not been over 16s: assessment and management used.

Staff have been encouraged to reflect on their individual practice and consider the following: *promoting the ethos of good health as a partnership. These are the 3 lowest scores from the CARE questionnaire: *ensuring patients are informed about all suitable options Helping you to take control (exploring what the patient can do to and supported to choose the right course of treatment for improve their own health; encouraging rather than ‘lecturing’ them. them) NICE guidance QS15 - Patient experience *Being aware of your patient’s expectations/limitations – Therapy Services 3 4259 NICE 02/01/2019 Minor non-Compliance Overall improved positive responses compared to November 2017. Being positive (having a positive approach and a positive attitude; of adult NHS services empathising, providing a different perspective, helping to being honest but not negative about the patient’s problem) promote what is possible rather than reinforcing what isn’t.

Really listening (paying close attention to what the patient is *Body language – eye contact, facing the patient, mirroring saying; not looking at the notes or the computer as the patient is *Asking for clarification/expansion, summarising. talking) *Asking patient’s permission to read notes/look something up on computer if absolutely necessary – telling them why you need to do so.

Order/download smaller quantities, particularly externally produced publications. Still some photocopies being used – very poor quality, which gives Check review dates of externally produced publications on a poor impression of the service. Patient information leaflet audit regular basis, and ensure all out-of-date versions are Therapy Services 3 4260 Local 07/02/2019 Minor non-Compliance Improvement in compliance from previous audit. 1 x internal publication 2 years past its review date – medications (Respiratory Team) removed. mentioned have been superseded, and telephone numbers have Engage users (or potential users) routinely – even if just 1 or changed. 2. Stop photocopying any leaflets. •Process of photocopying of leaflets to cease. •Redraft letters with correct information, and print supplies as and when needed •Access up to date PhysioTools sheets and print as and when •Only 2 leaflets received from CCH (post-op shoulder exercises) needed •Supplementary information being given out (e.g. letters for •Check with Wolverhampton City Council re: current Patient information leaflet audit Identified documents of poor quality and documents that require appointments) is photocopied, out of date, and has incorrect Therapy Services 3 4261 Local 03/04/2019 Minor non-Compliance versions of HARP and Bradley Lodge leaflets (Orthopaedic Team) updating/ quality improvement. Actions are in place to rectify issues. names/logos/trust details etc. •Review all external leaflets for currency/validity at least •PhysioTools print outs are appropriate but not if photocopied annually from very old originals •Ensure that original leaflets are given out with pieces of equipment, not photocopied versions which may have been superseded and could be incorrect for current equipment. forward the results for sharing with the team The following actions have been agreed: Sometimes or often staff feel: Explore the setting up of a ‘Health and Wellbeing’ focus Supportive feedback is not given. group – run by staff, for staff, with clear links to They have to work very intensively. management. Assessing staff experience of work- Renewed focus on health and well-being amongst the workforce, with Some tasks are neglected because they have too much to do. Encourage the use of coaching/mentoring scheme. Therapy Services 3 4421 Local 02/01/2019 Minor non-Compliance related stress a number of staff expressing interest in becoming HWB Champions. Unable to say whether their line manager encourages them at ‘Bend but try not to Break’ course. work. ‘Recognising signs of stress and anxiety in the workplace’ Most staff work unpaid hours, averaging 10 – 20 minutes daily. course. Just over half felt that the stress was unreasonable. ‘Mental Health First Aid’ course. Seek staff input if significant changes are anticipated

Patients undergoing elective orthopaedic procedures are satisfied by Trauma & Patient satisfaction in Pre operative 1 3563 Local 28/06/2018 Fully Compliant the information given to them prior to surgery and are fully aware of No concerns as fully compliant No actions as audit standards were fully compliant. Orthopaedics informed consent the nature and purpose of surgery.

This procedure is not commonly performed, but the cases reviewed had acceptable results. Going forward there is a National database which all surgeons will submit their cases to. This will involve pre & Trauma & NICE IPG558 Biodegradable subacromial 1 3647 NICE 03/01/2019 Fully Compliant post op scoring and results will be available to view in due course. No concerns as fully compliant No actions as audit standards were fully compliant. Orthopaedics spacer insertion for rotator cuff tears This is essentially a research database so would comply with NICE guidance that this procedure only takes place in the context of research.

Lumbar decompression via 'unilateral - bilateral ''over the top'' technique :a Trauma & Service A change of surgical technique has resulted in better outcomes for 1 3956 Service Evaluation - comparison with 03/12/2018 Fully Compliant No concerns as fully compliant No actions as audit standards were fully compliant. Orthopaedics Evaluation patients. traditional 'bilateral ''fenestration'' laminotomies' Directorate Division Audit ID Audit title Type of audit Date completed Compliance rating Key Successes- summarised Key Concerns- Summarised Key actions- summarised

All Consultants and middle grade doctors to consider Audit looked at our current management pathway for buckle MANAGEMENT OF BUCKLE FRACTURES discharging patients' with buckle fractures after first fracture Trauma & Service Moderate non- fractures, highlighted how it differed from NICE guidance. A different 1 4044 OF THE DISTAL RADIUS; A SERVICE 02/07/2018 Not all torus fractures are treated according to NICE guidance. clinic appointment in either a future splint or removable soft Orthopaedics Evaluation compliance pathway has been proposed, that should be closer aligned to NICE EVALUATION AUDIT cast with advice to parents to remove splint in 3-4 weeks. No guidance. follow-up clinic appointments. Trauma & Costly tightrope system no longer used and screws no longer 1 4088 Ankle Syndesmotic Screw Re-audit Local 11/09/2018 Fully Compliant No concerns as fully compliant No actions as audit standards were fully compliant. Orthopaedics removed - financially better. All areas of substandard compliance is discussed at the Audit has demonstrated levels of compliance with documentation Clinical Audit Group Meeting and directly with the standards across the Trust inline with the Clinical Documentation Some directorates demonstrated poor compliance with Directorates at their Governance Meeting. Individual action Trauma & Trust Wide OP07 Health Records 1 4092 Trust Wide 21/03/2019 Minor non-Compliance Guidelines in order to address any areas of substandard performance. the standards in particular regarding documentation of clinicians plans will be drawn up according to the specific areas of Orthopaedics Documentation audit 18/19 Areas of excellent compliance can be shared across the Trust to identification number and full name/signature. concern. Audit is completed annually and previous years encourage learning and improvement. results will be compared to demonstrate any improvements/decline in performance.

Marked improvement in the number of patients being seen by a Re-audit; Cannock and New Cross Trauma & consultant post elective Hip/Knee surgery at Cannock. (Departmental Medical clerking in the ICP handbook needs Continue stressing the importance of Consultant ward round 1 4113 Elective Joint Replacement Integrated Local 01/04/2019 Not applicable Orthopaedics policy – seen by middle grade daily) awareness/improvement across both sites documentation/stamp to junior doctors. Care Pathway

No change in practice for the two consultants who had their data None. The audit did not highlight any change that needed to analysed and no recommendation for any change across the Trauma & Continuation of preoperative Warfarin Service be introduced across the directorate. Both of the current 1 4293 12/12/2018 Fully Compliant department. The audit clearly identified the are different ways of No concerns as fully compliant Orthopaedics for patients undergoing elective THR. Evaluation practises used are appropriate and can be continued. Result addressing joint replacement in patients' who are on warfarin. A discussed at Governance by the whole department. standardised practice does not have to be introduced.

Education phase (awareness of condition and the BSH/trust Incidence Of Heparin Induced guidelines by way of poster/teaching session) Low awareness of the condition and the BSH/trust guidelines. Thrombocytopenia following prolong Trauma & Appropriate use of laboratory investigational assays to confirm HIT. Extremely poor consideration and clinical assessment of HIT 1 4302 DVT prophylaxis with Low Molecular Local 22/03/2019 Not applicable Audit loop to gauge effectiveness of education phase Orthopaedics Alternative anticoagulation commencement. Extremely poor use of pre-test probability calculators in order to weight heparin in Trauma & Orthopaedic consider stopping of heparin. patients. Presentation at governance in 6 months’ time

Areas were we fell short were; All consultants e-mailed to ask them to note the areas were

Management of Paediatric Supracondylar Audit showed where our practice at New Cross did not meet the we were not complaint and recommend a change of Trauma & Moderate non- 1) Use 2mm k-wires (obviously in very small bones 1.6 mm would 1 4337 Humeral Fractures Regional Audit National 22/03/2019 National BOAST 11 standards. A change in practice has been practice. Orthopaedics compliance be OK) – but at NX all wires used were 1.6mm Protocol advocated to all consultants. A local or regional re-audit will be done in a the future, to 2) Follow-up x-rays at 4-10 days. see if a change in practice has occurred. 3) Wire removal at 3-4 weeks. Trauma & The management of donated bone at 1 4343 Local 06/11/2018 Fully Compliant 100% compliance with the three standards assessed. No concerns as fully compliant No actions as audit standards were fully compliant. Orthopaedics Royal Wolverhampton Hospitals Trust National ATILLA (Administration of Trauma & Awaiting formal national guidelines, after which we could re-audit We submitted data to a national audit which may in turn 1 4420 Tranexamic acid In Lower Limb National 22/03/2019 Not applicable Our data at New Cross is comparable to the National data. Orthopaedics the use of Tranexamic acid in lower limb arthroplasty patients. lead to national guidelines being developed. Arthroplasty) Clinicians are now more informed. The audit will be done again, but Trauma & Pattern of presentation of children with Thorough summary of injuries seen and therefore 1 4445 Local 22/03/2019 Not applicable that audit will try and identify if we have missed any NAI's and/or No major concerns noted. Orthopaedics non accidental orthopaedic injury highlighted what injuries clinicians need to look out for. identify processes that make the chance of missing NAI's less likely. T&O Middle Grades on call workload at The audit has confirmed the change in working pattern of the middle Trauma & Service 1 4470 Cannock Chase hospital -An Audit 12/12/2018 Fully Compliant grades has not affected patient care and so we can continue with the No concerns as fully compliant No actions as audit standards were fully compliant. Orthopaedics Evaluation workload new working pattern. Undertaking a re-audit as not all nursing documentation was Trauma & Moderate non- Undertaking a re-audit as not all nursing documentation was 1 4482 NICE CG [124] NICE 01/04/2019 None noted as a further audit is required. reviewed in original audit therefore results are not Orthopaedics compliance reviewed in original audit therefore results are not conclusive. conclusive.

The Trusts rate of non-operative management of hip fractures during some months in 2017 and 2018 was higher than the National average which is approximately 2.2%. Rate of non-operative management of hip fractures was higher Trauma & All cases were looked into and in 21 out of 24 cases a clearly Alterations to NOF pathway documentation will improve 1 4540 Conservatively managed hip fractures Local 22/03/2019 Not applicable than the national average however all cases were looked into and Orthopaedics documented reason for non-operative management was documentation regarding conservatively managed fractures. no concerns were noted. documented. Management appeared appropriate in all the cases. Trust's non-operative level is now back to around the National average, but may rise again if we have very ill patients. Directorate Division Audit ID Audit title Type of audit Date completed Compliance rating Key Successes- summarised Key Concerns- Summarised Key actions- summarised

LOCAL: Hyperthermic mitomycin C (NICE The audit ensures an off-licence treatment is included in the Urology 1 3182 Local 04/05/2018 Fully Compliant No concerns as fully compliant Recurring audit on 3-4 yearly basis. IPG628) governance framework and results are reported in an open fashion. National Audit: Nephrectomy Audit Urology 1 3468 National 26/03/2019 Fully Compliant The audit shows acceptable patient outcomes. No concerns as fully compliant An on-going re-audit is being undertaken. (2017) The audit has highlighted that 57% of patients with low risk NMIBC Discussion in Governance Meeting and emphasise that Surveillance of NMIBC is a risk adapted approach, 57% of patients NG002 Bladder cancer: diagnosis and Moderate non- were discharged at 12 months and 52% of patients had the size of although each case is assessed individually, we should try to Urology 1 3669 NICE 26/03/2019 with low risk NMIBC were discharged at 12 months. management of bladder cancer compliance tumour recorded either in the Haematuria clinic flexi notes or at adhere to the guidelines to minimize the disease burden. turbt The surgeon will plan all cases of surgery carefully and aim National: BAUS Urology Audit - Radical Urology 1 4128 National 18/04/2019 Minor non-Compliance T2 comparable to national average. Higher T3 positive margins. to avoid nerve spanning. A re-audit will be added to the prostatectomy (RALP Audit) Directorates audit plan in 2019/20. To continue with the national audit.

National Audit: BAUS Urology - The audit led to the identification of blood transfusion use in open Urology 1 4129 National 03/12/2018 Fully Compliant No concerns as fully compliant Also, to continue networking with other hospitals to Cystectomy cases. increase surgical volume and provide support to the Cancer Alliance process. BAUS National Complex Surgery Audits/ The audit identified good outcomes and gave room for improvement Urology 1 4132 National 14/03/2019 Not applicable No concerns as fully compliant No actions as audit standards were fully compliant. National Prostate Cancer in treating low risk disease. Group & Save Blood Testing during Pre- Minor room for improvement. Not practical to pursue given Urology 1 4133 Operative Assessment for Elective Local 15/11/2018 Minor non-Compliance The audit has enabled cost saving on unnecessary Group and Save. None resource challenges. Urological surgery: A Retrospective Audit

First 50 TRUS Biopsy results vs. MRI PI- Service The audit has shown that there will be a reduction in waiting times. It Urology 1 4569 22/02/2019 Fully Compliant No concerns as fully compliant No actions as audit standards were fully compliant. RADS Evaluation will also improve continuity of patient care and the patient journey.

Active surveillance for prostate cancer: The audit enabled the directorate to ensure better documentation by None of the newly diagnosed patients had the risk stratification Use of MDT proforma to be reiterated at Governance- accept Urology 1 4573 reaudit to assess progress in compliance NICE 20/02/2019 Minor non-Compliance utilising the MDT proforma. documented on their MDT proforma. that clinical guideline is obsolete with regards to DRE. against national guidelines

The Royal Wolverhampton NHS Trust

Clinical Quality Review Meeting Meeting date: May 2019 Title: National Clinical Audit and Patient Outcomes Programme (NCAPOP) Update Report Executive This report was prepared on 17th April and provides an update on the progress summary: against audits included in the National Clinical Audit and Patient Outcomes Programme (NCAPOP) only. Action requested: That the members note the report Report of: Director of Nursing Author: Heather Cooper, Governance Team Leader, Governance and Legal Services References: N/A

1. Report Details

The National Clinical Audit and Patient Outcomes Programme (NCAPOP) is a closely linked set of centrally-funded national clinical audit projects. All projects within NCAPOP are commissioned and managed by Healthcare Quality Improvement Partnership (HQIP), under the guidance of the National Advisory Group on Clinical Audit & Enquiries (NAGCAE), and funded by NHS England.

The clinical audits collect data on compliance with evidence based standards, and provide local trusts with benchmarked reports on the compliance and performance. They also measure and report patient outcomes. The projects analyse data supplied by local clinicians centrally and feedback comparative findings to help participants identify necessary improvements for patients.

NCAPOP also includes the Clinical Outcome Review Programmes which now encompass Confidential Enquiries and are designed to help assess the quality of healthcare, and drive forward improvement in safety and effectiveness by systematically enabling clinicians, managers and policy makers to learn from adverse events and other relevant data. The programme aims to complement and contribute to the work of other agencies such as NICE, CQC, the Royal Colleges and academic research studies with the aim of supporting changes that can help improve the quality and safety of healthcare delivery.

2018/19 Activity: In total 137 audits were included in the HQIPs National Directory. This is a list of all known National Clinical Audits and Enquiries. 44 of these audits were identified as being part of the NCAPOP and had data collected during 2018/19, of these 43 were identified for inclusion in the NHSE Quality Accounts.

• 4 audits were applicable to the Trust but we did not participate (Table 1) • 7 audits were confirmed as not applicable to this Trust (Table 2) • 33 audits were completed / data submitted, awaiting final report (Table 3)

2019/20 Activity: To date HQIP has confirmed 87 audits where data collection will take place during the 2019/20 audit year. So far 46 of these have been identified as being part of the NCAPOP and 45 for inclusion in the NHSE Quality Accounts. To date 36 projects have been confirmed as applicable and in which the Trust will be actively participating.

• 2 audits are applicable to the Trust but we are not participating (Table 4) • 6 audits are confirmed as not applicable to this Trust (Table 5) • 2 audits are yet to be confirmed if they are applicable and we are participating (Table 6) • 36 audits are in progress (Table 7)

Table 1: Audit projects applicable to the Trust but we are not participating 18/19

NCAPOP Name Lead Rationale for not participating in applicable audits and Work Stream Directorate Child Health Clinical Paediatric The directorate does not have any long term Outcome Review Acute ventilated children and young people. Programme Medical and Surgical General The Directorate did not register for the audit in time. Clinical Outcome Review Surgery Governance will now pull updates from the National Programme –Acute Bowel Directory monthly to ensure all new audits added are Obstruction captured in a timely manner and are sent to the Directorates to review participation. National Audit of Care of the This audit was only completed in 2017 to repeat so soon Dementia (in General Elderly will prove nothing new. Additionally resources are reduced Hospitals) and clinical time would be better spent within department.

National Ophthalmology Ophthalmology Awaiting implementation of Ophthalmology medical Audit - Adult Cataract records system ‘Open Eye’. Once embedded the surgery Directorate will participate in the audit.

Table 2: Audits confirmed as not applicable to The Royal Wolverhampton NHS Trust 18/19

NCAPOP Name and Work Stream Audit not applicable to the Trust Mental Health Clinical Outcome Review Mental Health Trusts Programme Suicide, Homicide & Sudden Unexplained Death National Clinical Audit of Anxiety and Mental Health Trusts Depression - Core audit National Clinical Audit of Anxiety and Mental Health Trusts Depression- Psychological Therapies for Anxiety and Depression National Clinical Audit of Psychosis Mental Health Trusts National Congenital Heart Disease (CHD) Paediatric Heart Surgery not carried out by RWT National Vascular Registry This relates to major vascular interventions which are not undertaken at RWT Paediatric Intensive Care (PICANet) Not applicable as there is no Paeds Intensive Care Unit in the Trust.

Table 3: Audits have been completed / data submitted/ awaiting final report 18/19

NCAPOP Name and Work Stream Lead Data collection Directorate period Adult Cardiac Surgery Cardiothoracic April 18-March 19 Cardiac Rhythm Management (CRM) Cardiology April 18-March 19 Medical and Surgical Outcome Review Programme– Dr Shameer Gopal is April 18-March 19 Pulmonary embolism lead coordinator for Trust. Falls and Fragility Fractures Audit programme (FFFAP) Rheumatology Apr il 18 - March19 Fracture Liaison Service Database Falls and Fragility Fractures Audit programme (FFFAP) T&O April 18-March19 National Hip Fracture Database Learning Disability Mortality Review Programme Trust-wide April 18-March19 (LeDeR) Maternal, Newborn and Infant Clinical Outcome Review Obstetrics April 18-March 19

Page 2 of 7 Programme Perinatal Mortality Surveillance Maternal, Newborn and Infant Clinical Outcome Review Obstetrics April 18-March 19 Programme Perinatal Mortality and Morbidity confidential enquiries Maternal, Newborn and Infant Clinical Outcome Review Obstetrics April 18-March 19 Programme Maternal Mortality surveillance and mortality confidential enquiries Maternal, Newborn and Infant Clinical Outcome Review Obstetrics April 18-March 19 Programme Maternal morbidity confidential enquiries Myocardial Ischaemia National Audit Project (MINAP) Cardiology April 18-March 19 National Audit of Breast Cancer in Older People General Surgery April 18-March 19 (NABCOP) National Audit of Care at the End of Life (NACEL) Oncology (Palliative April 18-October 19 Care Team) National Audit of Percutaneous Coronary Interventions Cardiology April 18-March19 (PCI) (Coronary Angioplasty National Audit of Seizures and Epilepsies in Children Paeds Acute April 18-March19 and Young People (Epilepsy12) National Bowel Cancer (NBOCA) Oncology April 18-March19 Contract until March 2018. National Chronic Obstructive Pulmonary Disease Respiratory Continuous data (COPD) Audit programme collection National Clinical Audit for Rheumatoid and Early Rheumatology April 18-March19 Inflammatory Arthritis (NCAREIA) National Diabetes Audit – Adults - Foot Care Audit Diabetes April 18-March19 National Diabetes Audit – Adults - Inpatient Audit Diabetes May 18- March 19 (NaDia) National Diabetes Audit – Adults - National Core Diabetes May 18- Nov18 Diabetes Audit National Diabetes Audit – Adults- National Diabetes Diabetes April 18-March19 Transition (data linkage audit, no additional data submission required.) National Diabetes Audit – Adults - National Pregnancy in Diabetes April 18-March19 Diabetes Audit National Emergency Laparotomy Audit (NELA) Critical Care April 18-March19 National Heart Failure Audit Cardiology April 18-March19 National Joint Registry (NJR) T&O April 18-March19 National Lung Cancer Audit (NLCA) Respiratory/Oncology April 18-March19 National Maternity and Perinatal Audit (NMPA) Obs & Gynae Continuous National Neonatal Audit Programme - Neonatal Intensive Neonates April 18-March19 and Special Care (NNAP) National Oesophago-gastric Cancer (NOGCA) Oncology April 18-March19 National Paediatric Diabetes Audit (NPDA) Paeds April 18-March19 National Prostate Cancer Audit Oncology April 18-March19 Sentinel Stroke National Audit programme (SSNAP) Stroke April 18-March19

Table 4: Audit projects applicable to the Trust but we are not participating 19/20

Page 3 of 7 National Ophthalmology Ophthalmology Directorate do not use Medisoft cataract Electronic Audit (NOD)- Adult Medical Record (EMR) but will be putting forward a Cataract business case for Open Eyes system however funding for surgery this national audit is only confirmed until 31st August 2019.

Table 5: Audits confirmed as not applicable to The Royal Wolverhampton NHS Trust 19/20

NCAPOP Name and Work Stream Audit not applicable to the Trust Mental Health Clinical Outcome Review Mental Health Trusts Programme Suicide, Homicide & Sudden Unexplained Death National Clinical Audit of Anxiety and Mental Health Trusts Depression - Core audit National Clinical Audit of Psychosis Mental Health Trusts National Congenital Heart Disease (CHD) Paediatric Heart Surgery not carried out by RWT National Vascular Registry This relates to major vascular interventions which are not undertaken at RWT Paediatric Intensive Care (PICANet) Not applicable as there is no Paeds Intensive Care Unit in the Trust.

Table 6: Audits not yet confirmed as participating/applicable to The Royal Wolverhampton NHS Trust 19/20

NCAPOP Name and Work Stream Lead Directorate Medical and Surgical Clinical Outcome Review SALT/General Medicine Programme- Dysphagia in Parkinson’s Disease Medical and Surgical Clinical Outcome Review Cardiology Programme- In-hospital management of out-of-hospital cardiac arrest

Table 7: Audits in which we are actively participating (in progress in 19/20)

NCAPOP Name and Work Stream Lead Directorate Data Collection period

Falls and Fragility Fractures Audit programme Rheumatology April 2019 to March 2020 (FFFAP) (continuous data collection) - Fracture Liaison Service Database Falls and Fragility Fractures Audit programme T&O April 2019 to March 2020 (FFFAP)- National Audit Inpatient Falls (continuous data collection) Falls and Fragility Fractures Audit programme T&O April 2019 to March 2020 (FFFAP)- National Hip Fracture Database (continuous data collection) Learning Disabilities Mortality Review Programme Trust-wide April to May 2019 (LeDeR) Maternal, Newborn and Infant Clinical Outcome Obs and Gynae April 2019 to March 2020 Review Programme- Perinatal Mortality Surveillance Data is collected continuously on all eligible deaths throughout the year. Maternal, Newborn and Infant Clinical Outcome Obs and Gynae April 2019 to March 2020 Review Programme- Perinatal morbidity and mortality confidential enquiries MBRRACE-UK will contact

Page 4 of 7 Trusts if they are required to provide copies of multiple birth case notes for the confidential enquiry. Maternal, Newborn and Infant Clinical Outcome Obs and Gynae April 2019 to March 2020 Review Programme- Maternal Mortality surveillance and mortality confidential enquiries Data are collected continuously on all eligible deaths throughout the year Maternal, Newborn and Infant Clinical Outcome Obs and Gynae April 2019 to March 2020 Review Programme- Maternal morbidity confidential enquiries Trust will be contacted by MBRRACE-UK if they are requested to submit a pulmonary embolism case. National Asthma and Chronic Obstructive Respiratory Launches continuous Pulmonary Disease (COPD) Audit Programme clinical data collection in (NACAP)- Paediatric Asthma Secondary Care June 2019 National Asthma and Chronic Obstructive Respiratory From 1 October 2017 to 31 Pulmonary Disease (COPD) Audit Programme March 2020 - Extraction (NACAP)- Asthma (Adult and paediatric) and date: May 2020 (TBC) COPD Primary care National Asthma and Chronic Obstructive Respiratory On-going continuous Pulmonary Disease (COPD) Audit Programme- clinical data collection Adult Asthma Secondary Care (NACAP) National Asthma and Chronic Obstructive Respiratory On-going continuous Pulmonary Disease (COPD) Audit Programme clinical data collection (NACAP) Chronic Obstructive Pulmonary Disease (COPD) Secondary Care National Asthma and Chronic Obstructive Respiratory On-going continuous Pulmonary Disease (COPD) Audit Programme clinical data collection (NACAP)- Pulmonary rehabilitation National Audit of Breast Cancer in Older People General Surgery Data submitted by (NABCOP) hospitals to National Cancer Registration services: 1 Apr 2019 to 31 Mar 2020; Data supplied to audit in this year will be the most recent available from Registration services National Audit of Care at the End of Life (NACEL) Oncology/Palliative TBC Care Team

National Audit of Dementia (care in general CoE April-May hospitals)- Dementia care in general hospitals National Cardiac Audit Programme (NCAP)- Cardiology April 2019 to March 2020 National Audit of Cardiac Rhythm Management (CRM)

National Cardiac Audit Programme (NCAP)- Cardiology April 2019 to March 2020 Myocardial Ischaemia National Audit Project (MINAP)

Page 5 of 7 National Cardiac Audit Programme (NCAP)- Cardiothoracic April 2019 to March 2020 National Adult Cardiac Surgery Audit

National Cardiac Audit Programme (NCAP)- Cardiology April 2019 to March 2020 National Audit of Percutaneous Coronary Interventions (PCI) (Coronary Angioplasty) National Cardiac Audit Programme (NCAP)- Cardiology April 2019 to March 2020 National Heart Failure Audit

National Diabetes Audit – Adults- National Diabetes April 2019 to March 2020 Diabetes Foot Care Audit

National Diabetes Audit – Adults- National Diabetes September to October Diabetes Inpatient Audit (NaDIA) -reporting data 2019 on services in England and Wales National Diabetes Audit – Adults- NaDIA-Harms - Diabetes April 2019 to March 2020 reporting on diabetic inpatient harms in England

National Diabetes Audit – Adults- National Core Diabetes Primary Care: Diabetes Audit May 2019 August 2019 November 2019 February 2020

Secondary Care: Continuous collection April 2019 to March 2020 National Diabetes Audit - Adults Obstetrics April 2019 to March 2020 - National Pregnancy in Diabetes Audit Continuous data collection National Early Inflammatory Arthritis Audit Rheumatology May 2019 to March 2020 (NEIAA)

National Emergency Laparotomy Audit (NELA) Critical Care April 2019 to March 2019 (continuous data collection)

National Gastrointestinal Cancer Programme Oncology April 2019 to March 2020

From 2018 this project brings together the previously separate NBOCA and NOGCA audits- National Oesophago-gastric Cancer (NOGCA) National Gastrointestinal Cancer Programme Oncology April 2019 to March 2020

From 2018 this project brings together the previously separate NBOCA and NOGCA audits- National Bowel Cancer Audit (NBOCA) National Lung Cancer Audit (NLCA) Oncology April 2019 to March 2019

National Maternity and Perinatal Audit (NMPA) Obs and Gynae TBC

Page 6 of 7 National Neonatal Audit Programme - Neonatal Neonates 1 April 2019 to March 2020 Intensive and Special Care (NNAP)

National Paediatric Diabetes Audit (NPDA) Paeds acute April 2019 to March 2020 National Prostate Cancer Audit Oncology April 2018 to March 2019 Sentinel Stroke National Audit programme Stroke April 2019 to March 2020 (SSNAP) Collection: April to June, July to September, October to December, January to March and April to March (annual).

Page 7 of 7 DIVISION 1 AUDIT PROGRAMME 2019/2020 Audiology Directorate Audit Plan 2019/20 If re-audit, Relates to a Care Planning If re-audit Proposed Quarter Carried over Is this audit a compliance Audit? (Falls/PUs/End of Mapping to the 5 CQC Audit ID Audit Title Audit Lead Audit Type state previous Aim of audit Mapping to Trust Strategic Objectives for Completion from 2018/19? re-audit? rating of Life/Discharge/Evaluation of Domains audit ID previous audit care plans) Re -Evaluation of Tinnitus Postal Review Proactively seek opportunites to develop Safe 3577 Karen Nicklin Quarter 1 Service Evaluation Yes Yes 2778 NA Evaluate service to identify areas for improvement No Service our services Effective Proactively seek opportunites to develop Identify whether REMs are being performed our services Assessment of Real Ear Measurements Safe Saimah Kauser Quarter 1 Local No No N/A N/A appropriately against BSA, BAA, MHAS and MCHAS No (REMs) Effective standards. Create a culture of compassion, safety and quality. Create a culture of compassion, safety and quality. Trustwide Documentation Audit Lesley Peplow Quarter 4 Other No Yes 4199 TBC To assess compliance with OP07 No Safe Proactively seek opportunites to develop our services To improve patient care - To gain confidence that PTAs are undertaken to BSA recommended procedures and the correct results are achieved for each patient. Minor Non Create a culture of compassion, safety Safe Pure Tone Audiometry (PTA) Audit Mark Turner Quarter 4 Local No Yes 4201 No Compliance and quality. Effective To monitor compliance against BSA recommended procedures and UKAS recommendation 207271-01- E00852-001 CL2. Proactively seek opportunites to develop our services Identify satisfaction of adult's audiology and identify Safe Service User Survey - Adults Audiology Rebecca Mainwaring Quarter 4 Service Evaluation No Yes 4198 TBC No any improvements to be made to the service. Effective Create a culture of compassion, safety and quality. Cardiology Audit Plan 2019/20 If re-audit, Relates to a Care Planning If re-audit Proposed Quarter Carried over Is this audit a compliance Audit? (Falls/PUs/End of Mapping to the 5 CQC Audit ID Audit Title Audit Lead Audit Type state previous Aim of audit Mapping to Trust Strategic Objectives for Completion from 2018/19? re-audit? rating of Life/Discharge/Evaluation of Domains audit ID previous audit care plans) Create a culture of compassion, safety & Acute Coronary Syndrome or Acute Minor non Safety, Caring 3590 Dr Ben Wrigley Quarter 1 National Yes Yes 3244 To monitor compliance against National Standards Evaluation of Care Plans quality Proactively seek opportunities to Myocardial infarction (MINAP) - 2016/17 data compliance Effective, Responsive & develop our services Well-Led

Create a culture of compassion, safety & Minor non Safety, Caring 3592 Heart Failure (HF) - 2016/17 data Dr Charles Spencer Quarter 1 National Yes Yes 3245 To monitor compliance against National Standards Evaluation of Care Plans quality Proactively seek opportunities to compliance Effective, Responsive & develop our services Well-Led Safety, Caring Coronary interventions/Coronary angioplasty Create a culture of compassion, safety & 3584 Dr James Cotton Quarter 2 National No Yes 3583 Fully compliant To monitor compliance against National Standards Evaluation of Care Plans Effective, Responsive & (BCIS) - 2017 data quality Well-Led

Create a culture of compassion, safety & Cardiac Arrhythmia/Heart Rhythm Safety, Caring 3589 Dr Petkar Quarter 2 National No Yes 3588 Fully compliant To monitor compliance against National Standards Evaluation of Care Plans quality Proactively seek opportunities to Management (HRM) - 2017/2018 data Effective, Responsive & develop our services Well-Led

Create a culture of compassion, safety & National Audit of Cardiac Rehabilitation Safety, Caring 3594 Maria Glover Quarter 2 National No Yes 3547 Fully compliant To monitor compliance against National Standards Evaluation of Care Plans quality Proactively seek opportunities to (2016/2017 data) Effective, Responsive & develop our services Well-Led

Create a culture of compassion, safety & National Trans Catheter Aortic Valve Safety, Caring 4026 Dr Khogali Quarter 3 National No Yes 3585 Fully compliant To monitor compliance against National Standards Evaluation of Care Plans quality Proactively seek opportunities to Implantation (TAVI) 2018 data Effective, Responsive & develop our services Well-Led

Create a culture of compassion, safety & National Cardiac Arrhythmia/Heart Rhythm Safety, Caring 4027 Dr Petkar Quarter 3 National No Yes 3588 Fully compliant To monitor compliance against National Standards Evaluation of Care Plans quality Proactively seek opportunities to Management (HRM) - 2018/19 Effective, Responsive & develop our services Well-Led NICE IPG603 Subcutaneous implantable Proactively seek opportunities to develop 3978 cardioverter defibrillator insertion for Dr Anita Arya Quarter 3 NICE No No NA NA To monitor compliance against NICE Guidelines Evaluation of Care Plans Effective, Responsive & our services preventing sudden cardiac death Well-Led Create a culture of compassion, safety & Acute Coronary Syndrome or Acute Safety, Caring 3591 Dr Ben Wrigley Quarter 4 National No Yes 3590 TBC To monitor compliance against National Standards Evaluation of Care Plans quality Proactively seek opportunities to Myocardial infarction (MINAP) - 2017/18 data Effective, Responsive & develop our services Well-Led

Create a culture of compassion, safety & Safety, Caring 3593 Heart Failure (HF) - 2017/18 data Dr Charles Spencer Quarter 4 National No Yes 3592 TBC To monitor compliance against National Standards Evaluation of Care Plans quality Proactively seek opportunities to Effective, Responsive & develop our services Well-Led Trust Wide OP07 Health Records Proactively seek opportunities to develop Dr Ben Wrigley Quarter 4 Other No Yes 3991 TBC To monitor compliance re: Documentation No Documentation audit 2019/20 our services Well-Led To have an effective and well integrated To monitor EWS to ensure escalation against the Trust organisation that operates efficiently, Safety, Caring Trust Wide Early Warning Signs Audit 2019/20 Dr Ben Wrigley Quarter 4 Other No Yes 3992 TBC Evaluation of Care Plans Track & Trigger protocol. Create a culture of compassion, safety Effective, Responsive & and quality Well-Led Local Safety Standards for Invasive Proactively seek opportunities to develop Effective,Responsive TBC Quarter 4 Local No No NA NA To monitor appropriateness of lcoal SOP No Procedures (LocSSIPs) our services Well-Led & Safety Cardiothoracic Audit Plan 2019/20 If re-audit, Relates to a Care Planning If re-audit Proposed Quarter Carried over Is this audit a compliance Audit? (Falls/PUs/End of Mapping to the 5 CQC Audit ID Audit Title Audit Lead Audit Type state previous Aim of audit Mapping to Trust Strategic Objectives for Completion from 2018/19? re-audit? rating of Life/Discharge/Evaluation of Domains audit ID previous audit care plans) Proactively seek opportunities to develop 3597 National Thoracic Surgery Audit 2018/19 Mr Patrick Yiu Quarter 2 National No Yes 3596 Fully compliant To monitor compliance with National Standards No Well-Led our services National Adult Cardiac Surgery Audit 2018/ Proactively seek opportunities to develop 3599 Mr Patrick Yiu Quarter 2 National No Yes 3598 Fully compliant To monitor compliance with National Standards No Well-Led 19. our services Safety, Caring To audit the number of falls due to increased number Create a culture of compassion, safety Falls Audit Karen Wooding Quarter 3 Local No No NA NA Falls Effective, Responsive & reported and quality Well-Led Safety, Caring Create a culture of compassion, safety Lip damage caused by intubation Mr Ian Morgan Quarter 3 Local No No N/A NA To evaluate lip damage to patients Evaluation of Care Plans Effective, Responsive & and quality Well-Led Incidence and Aetiology of Pneumothorax To monitor Incidence and Aetiology of Pnemothorax Proactively seek opportunities to develop Mr Ian Morgan Quarter 3 Local No Yes 3626 NA Evaluation of Care Plans Well-Led Post Cardiac Surgery. Post Cardiac Surgery our services Local Safety Standards for Invasive Proactively seek opportunities to develop Safety, Responsive, Steve Robins Quarter 4 Local No No NA NA To audit the SOPs associated with Cardiothoracic No Procedures (LocSSIPs) our services Well-Led & Effective Trust Wide OP07 Health Records To have an effective and well integrated Effective, Responsive & Steve Robins Quarter 4 Other No Yes 4066 TBC To monitor compliance re: Documentation No Documentation audit 2019/20 organisation that operates efficiently Well-Led Caring, Safety, To monitor EWS to ensure escalation against the Trust Create a culture of compassion, safety Trust Wide Early Warning Signs Audit 2019/20 Steve Robins Quarter 4 Other No No 4067 TBC Evaluation of Care Plans Responsive, Well-Led & Track & Trigger protocol. and quality Effective Mr Patrick Yiu/Mr Ahmed Proactively seek opportunities to develop Robotic Assisted Thoricoscopic Surgery Quarter 4 NICE No No NA NA To monitor compliance with NICE Guidance No Well-Led Habib our services Critical Care Audit Plan 2019/20 If re-audit, Relates to a Care Planning If re-audit Proposed Quarter Carried over Is this audit a compliance Audit? (Falls/PUs/End of Mapping to the 5 CQC Audit ID Audit Title Audit Lead Audit Type state previous Aim of audit Mapping to Trust Strategic Objectives for Completion from 2018/19? re-audit? rating of Life/Discharge/Evaluation of Domains audit ID previous audit care plans) Proactively seek opportunities to Perioperative anaesthetic management of Ensure patients who present with 3rd & 4th develop our services, To have Safety, Responsive, 4428 patients with 3rd and 4th degree Dr Jessica Goude Quarter 1 Local Yes No NA NA degree perineal tears are managed appropriately No an effective and well integrated Effective & Well-Led perineal tears as per guidelines organisation that operates efficiently

To have an effective and well integrated Evaluation of failure of epidural top ups for Dr Rangaswamy To evaluate the failure of epidural top ups for organisation that operates efficiently, Safety, Responsive & 4456 Quarter 2 Local No No NA NA No caesarean section Chandrashekar caesarean section Proactively seek opportunities to develop Effective our services

To have an effective and well Handover of information between recovery To evaluate and monitor the sharing of documentation integrated organisation that operates Safety, Responsive & Well- 4471 Dr Jacquelyn Lewin Quarter 2 Local No No NA NA Yes and ward post procedure between recovery and ward post procedure efficiently, Create a culture of Led compassion, safety and quality Compliance with LocSSIP 4 - Surgical gowning Proactively seek opportunities to Safety, Responsive, Matron Emma Lengyel Quarter 3 Local No No NA NA To monitor compliance with LocSSIP 4 No and gloving develop our services Effective & Well-Led Compliance with LocSSIP 10 - Handling and Caring, Safety, Proactively seek opportunities to checking of prostheses and Matron Emma Lengyel Quarter 3 Local No No NA NA To monitor compliance with LocSSIP 10 No Responsive, Well-Led & develop our services implants Effective Compliance with LocSIPP 15 - Handling of Caring, Safety, Proactively seek opportunities to controlled drugs in operating Matron Emma Lengyel Quarter 3 Local No No NA NA To monitor compliance with LocSSIP 15 No Responsive, Well-Led & develop our services theatres Effective NELA - National Emergency Laparotomy To monitor compliance against National Proactively seek opportunities to develop Safety, Responsive & Well- Audit Dr Andy Claxton Quarter 4 National No Yes 4019 TBC No Standards our services Led (relates to 2017/18 submission of data) National ICNARC Case Mix Audit & Research Maintain financial health - appropriate Programme for Critical Care Dr Jagtar Pooni Quarter 4 National No Yes 4020 TBC To monitor and record all interventions No investment enhancement to patient Responsive & Well-Led (relates to 2018 data cycle) services To have an effective and well To ensure appropriate monitoring of anaesthetic Anaesthetic record-keeping audit Dr Simon Fenner Quarter 4 Local No Yes 4009 TBC No integrated organisation that operates Well-Led records against Trustwide standards efficiently Trustwide OP07 - Health Records Proactively seek opportunities to David Collins Quarter 4 Local No Yes 4010 TBC To monitor compliance re: Documentation No Well-Led Documentation audit (2019) develop our services General Surgery Directorate Audit Plan 2019/20 If re-audit, Relates to a Care Planning If re-audit Proposed Quarter Carried over Is this audit a compliance Audit? (Falls/PUs/End of Mapping to the 5 CQC Audit ID Audit Title Audit Lead Audit Type state previous Aim of audit Mapping to Trust Strategic Objectives for Completion from 2018/19? re-audit? rating of Life/Discharge/Evaluation of Domains audit ID previous audit care plans) Create a culture of compassion, safety and quality. Effective Trustwide Documentation Audit 2019/20 Mr Singh-Ranger Quarter 4 Other No Yes 4218 TBC Audit compliance with OP07 policy No Proactively seek opportunites to develop Safe our services Create a culture of compassion, safety and quality. Effective Trust Wide Early Warning Signs Audit 2019/20 Mr Singh-Ranger Quarter 4 Other No Yes 4239 TBC Audit compliance with CP61 and OP88 No Proactively seek opportunites to develop Safe our services Create a culture of compassion, safety NICE IPG417 Breast Reconstruction using and quality. Effective 3666 Mr Sircar Quarter 4 NICE No Yes 2218 Fully compliant Audit practice agaisnt IPG417 No lipomodelling after breast cancer treatment Proactively seek opportunites to develop Safe our services Create a culture of compassion, safety and quality. Effective 4283 Nats sip Mrs Elgaddal Quarter 4 Other Yes No N/A N/A Audit SIP(s) No Proactively seek opportunites to develop Safe our services To record the details of any individual, who has a breast implant operation for any reason, so that they Create a culture of compassion, safety National: Breast and Cosmetic Implant can be traced in the event of a product recall or other and quality. Effective 3531 Miss R Vidya Quarter 4 National Yes No N/A N/A No Registry (BCIR) safety concern relating to a specific type of implant. Proactively seek opportunites to develop Safe The registry will also allow the identification of possible our services trends and complications relating to specific implants. Create a culture of compassion, safety National audit - Use of Negative pressure and quality. Effective 3545 Raghavan Vidya Quarter 4 National Yes No N/A N/A To assess compliance to national standards No dressing in breast surgery Proactively seek opportunites to develop Safe our services NATIONAL IBRA-2 Study - A national The aim of iBRA-2 is to work with the Breast Create a culture of compassion, safety prospective multicentre audit of the impact of Reconstruction Research Collaborative network to and quality. Effective 4134 Senthurun Mylvaganam Quarter 4 National Yes Yes 3076 TBC No immediate breast reconstruction on the evaluate the impact of IBR on the time to delivery of Proactively seek opportunites to develop Safe delivery of adjuvant therapy adjuvant therapy. our services

NeST is a national multicentre audit which aims to explore current practice in relation to the use of Create a culture of compassion, safety Neoadjuvant Systemic Therapy in Breast neoadjuvant systemic therapies in U.K. practice. The and quality. Effective 4305 Cancer: a prospective multicentre audit.- RAGHAVAN VIDYA Quarter 4 National Yes No N/A N/A No aim is to generate high-quality data that will inform Proactively seek opportunites to develop Safe NATIONAL AUDIT decision-making in relation to utilisation of our services neoadjuvant therapies in the future. Create a culture of compassion, safety To audit compliance to pre-, intra-, and postoperative REspiratory COmplications after abdominal and quality. Effective 4488 Mr B Liu Quarter 4 National Yes No N/A N/A RCOA and ERAS guidelines for reducing risk of post- No Surgery (RECON) Proactively seek opportunites to develop Safe operative pulmonary complications. our services Effective Create a culture of compassion, safety Safe and quality. 4588 The fate of rectum Nuha Yassin Quarter 4 National No No N/A N/A Follow up in patients with UC post bowel surgery No Caring Proactively seek opportunites to develop Well Led our services Responsive Gynaecology Audit Plan 2019/20 If re-audit, Relates to a Care Planning If re-audit Proposed Quarter Carried over Is this audit a compliance Audit? (Falls/PUs/End of Mapping to the 5 CQC Audit ID Audit Title Audit Lead Audit Type state previous Aim of audit Mapping to Trust Strategic Objectives for Completion from 2018/19? re-audit? rating of Life/Discharge/Evaluation of Domains audit ID previous audit care plans) Detection in primary care. Establishing the diagnosis in Create a culture of compassion, safety & secondary care Management of suspected early (stage quality. To have an effective and well 3520 Management of Ovarian Cancer Mr A. Elghobashy Quarter 1 NICE Yes No N/A N/A 1) ovarian cancer. Management of advanced stafe Evaluation of Care Plans Safe, effective & caring integrated organsiation that operates (stage 11 - 1V) ovarian cancer. Support needs of efficiently women with newly diagnosed ovarian cancer

To ascertain the level of current shortfall. To determine Create a culture of compassion, safety & Minor non the most common omissions from the operation notes. quality. To have an effective and well Gynaecology Operation Notes Audit/Review Mr K. Afifi Quarter 2 Local No Yes 3898 No Safe, effective compliance To effect improvement in the operation notes and integrated organsiation that operates reduce the number of omissions efficiently Trust Wide OP07 Health Records Be in the top quartile for all performance Lorraine Smith Quarter 3 Other No Yes 4254 TBC To assess compliance to Trust standards No Safe, effective & caring Documentation Audit indicators Create a culture of compassion, safety & To assess compliance to NICE standards: service quality. To have an effective and well CG156 Fertility Mr J. Samra Quarter 3 NICE No No N/A N/A No Effective & caring requirement, service provision and patient outcome. integrated organisation that operates efficiently To assess the success rate and complications of Create a culture of compassion, safety & A NICE-related Audit on CG154 and QS 47: outpatient medical management of miscarriage at NX quality. To have an effective and well Outpatient Medical Management of Mr M. Saeed Quarter 3 NICE No Yes 3334/2144 Fully compliant No Safe, effective & caring Hospital and to enhance compliance to the Trust and integrated organisation that operates Miscarriage - Early Pregnancy Complications NICE guidelines efficiently Create a culture of compassion, safety & Dr A. Douglas/Sister O To assess current service provisions and effectiveness quality. To have an effective and well Nurse Led Ring Clinic Quarter 3 Local No No N/A N/A No Effective & caring Ncube of service offered. integrated organsiation that operates efficiently To assess the management and care and to make Total Laparoscopic Hysterectomy (Benign Be in the top quartile for all performance Dr S. Tirumuru? Quarter 3 Local No No N/A N/A recommendations for improvements in care if Evaluation of Care Plans Safe, effective & caring Gynaecology) indicators applicable To assess the management and care and to make Out-come of Women referred with Create a culture of compassion, safety & Dr S. Tirumuru? Quarter 3 Local No No N/A N/A recommendations for improvements in care if Evaluation of Care Plans Safe, effective & caring asymptomatic endometrial thickness quality. applicable Be in the top quartile for all performance Trustwide EWS Lorraine Smith Quarter 4 Other No Yes 4329 TBC To assess compliance to Trust standards Evaluation of Care Plans Safe, effective & caring indicators To assess patient outcome/success rates and identify Create a culture of compassion, safety & Autologus Fascial Sling Procedure Mr K. Afifi Quarter 4 Local No No N/A N/A any ongoing issues. Asesss compliance with British No Safe, effective & caring quality. Society of Urogynaecology recommendations Local and National Safety Standards for Invasive Procedures (LOCSSIPs) To check the efficiency of local invasive procedures and Create a culture of compassion, safety & Julie Davies Quarter 4 Local No No N/A N/A Evaluation of Care Plans Safe, effective & caring - Colposcopy compliance with best practice quality. - Hysteroscopy Quality To have an effective and well integrated QIP Hand over - Gynaecology Mr Riad Quarter 4 Improvement No No N/A N/A QIP series No Safe, effective & caring organisation that operates efficiently Project Quality To have an effective and well integrated QIP Coding Gynaecology theatre Mr K. Afifi Quarter 4 Improvement No No N/A N/A QIP series No Well-led organisation that operates efficiently Project Head & Neck Audit Plan 2019/20 If re-audit, Relates to a Care Planning If re-audit Proposed Quarter Carried over Is this audit a compliance Audit? (Falls/PUs/End of Mapping to the 5 CQC Audit ID Audit Title Audit Lead Audit Type state previous Aim of audit Mapping to Trust Strategic Objectives for Completion from 2018/19? re-audit? rating of Life/Discharge/Evaluation of Domains audit ID previous audit care plans) Create a culture of compassion, safety and quality. Effective EWS Mr Rehman Quarter 4 Other No Yes 4102 TBC Audit compliance with CP61 and OP88 No Proactively seek opportunites to develop Safe our services Create a culture of compassion, safety and quality. Effective Documentation Mr Rehman Quarter 4 Other No Yes 4101 TBC Assess compliance with OP07 No Proactively seek opportunites to develop Safe our services to assess the process of care and its outcomes in Create a culture of compassion, safety patients diagnosed with new primary or recurrent head and quality. Effective HANA (National Head and Neck Cancer Audit) TBC Quarter 4 National No No NA NA and neck cancer in England and Wales and to improve No Proactively seek opportunites to develop Caring the quality of services and the outcomes achieved for our services patients Create a culture of compassion, safety West Midlands Regional Audit on Orthodontic and quality. Outcomes in secondary care using the PAR Mr Prabu Quarter 4 Local No No 4567 TBC To assess the orthodontic outcome of patient No Effective,caring Proactively seek opportunites to develop index our services Create a culture of compassion, safety Antibiotic prophylaxis in daycase Significant non The use of antibiotic prophylaxis in dentoalveolar and quality. Effective Mr Shetty Quarter 4 Local No Yes 3535 No dentoalveolar compliance surgery Proactively seek opportunites to develop Caring our services Create a culture of compassion, safety Post-tonsillectomy bleed morbidity audit. To look at re-admission and return to theatre rates for and quality. Effective (What are our re-admission and return to Miss Jackson Quarter 4 Local No No NA NA No post tonsillectomy bleed Proactively seek opportunites to develop Caring theatre rates?) our services Create a culture of compassion, safety Emergency clinic attendance audit. (Are we To look at the follow up arrangements for patient seen and quality. Effective Mr Murphy Quarter 4 Service Evaluation No No NA NA No arranging FU appropriately?) in emergency ENT clinic Proactively seek opportunites to develop Caring our services Create a culture of compassion, safety Adherence to NICE guidelines for treatment Minor non To look at adherence to NICE guidelines for the and quality. Effective of OME. (Are we following guidelines and Mr Murphy Quarter 4 NICE No Yes 3249 No compliance management of OME Proactively seek opportunites to develop Caring meeting criteria?) our services Neonates Audit Plan 2019/20 If re-audit, Relates to a Care Planning If re-audit Proposed Quarter Carried over Is this audit a compliance Audit? (Falls/PUs/End of Mapping to the 5 CQC Audit ID Audit Title Audit Lead Audit Type state previous Aim of audit Mapping to Trust Strategic Objectives for Completion from 2018/19? re-audit? rating of Life/Discharge/Evaluation of Domains audit ID previous audit care plans) Palizumab Audit Dr Kumararatne Quarter 2 Service Evaluation No Yes 3223 fully compliant Improve patient safety and care No Improve patient care and safety safety effectiveness/caring Create a culture of compassion, safety and Neonatal Audit Programme - Neonatal Minor non Improved patient care / Improve Dr Sutcliffe Quarter 4 National No Yes 4264 quality/Proactively seek opportunities to develop our Evaluation of Care Plans safety/effectiveness/ caring Intensive and Special Care compliance compliance/ improve service services Create a culture of compassion, safety and quality/ Create a culture of compassion, safety Safety/effectiveness and Trustwide Documentation Auditt S. Judge Quarter 4 Local No Yes 4266 TBC Evaluation of Care Plans Proactively seek opportunities to develop our services and quality caring Neonatal Sepsis - Antibiotics for the early onset of neonatal infections/for the Minor non Create a culture of compassion, safety Dr Heaver Quarter 4 NICE No Yes 4262 Improve compliance to policy Evaluation of Care Plans Safety and effectiveness prevention and treatment of early onset compliance and quality neonat infections Minor non Ensure patient safety through reducing of risk from Safe service/ effective service Location of Central Lines /Long Lines Audit Dr Belfitt Quarter 4 Local No Yes 4347 Evaluation of Care Plans Safety compliance central line migration leading to infilteration and caring Obstetrics Audit Plan 2019/20 If re-audit, Relates to a Care Planning If re-audit Proposed Quarter Carried over Is this audit a compliance Audit? (Falls/PUs/End of Mapping to the 5 CQC Audit ID Audit Title Audit Lead Audit Type state previous Aim of audit Mapping to Trust Strategic Objectives for Completion from 2018/19? re-audit? rating of Life/Discharge/Evaluation of Domains audit ID previous audit care plans) Minor non To create a culture of compassion, safety Safe, effective, caring, Second stage CS Dr L Morse Quarter 1 Local No Yes 3055 To assess compliance with local policy Evaluation of Care Plans compliance and quality. responsive To create a culture of compassion, safety Safe, effective, caring, Term NNU admission Dr L Morse Quarter 1 Local No No N/A N/A To assess compliance with local policy Evaluation of Care Plans and quality. responsive Local and National Safety Standards for Invasive Procedures (LOCSSIPs) - Fetal Blood Sampling Water birth Be in the top quartile for all performance - Normal Vaginal Births Lorraine Smith Quarter 2 Local No Yes N/A N/A Compliance with Trust and professional standards No indicators - comparison to other Safe, effective, caring -Forceps delivery divisions) - Ventouse - Caearean Sections

Improving the timeframes of transfers f women who QIP are in labour and those with Induction of labour being To create a culture of compassion safety - Audit the IOL care pathway, including transferred from the Maternity Induction Unit to the and quality, proactively seek Minor non transfer time from the Maternity Induction Sister J Ridley Quarter 2 Local No No 4493 Delivery Suite and women who are suitable for IOL and Evaluation of Care Plans opportunities to develp our services, to Safe, effective, caring compliance Unit (MIU) to Delivery Suite. are ARM'able should be transferred to delivery Suite have and effective and well integrated within 8 hours and those who are in labour should be organisation that operates efficiently transferred within one hour A Local Audit on Antibiotic Prophylaxis in Minor non To create a culture of compassion safety Mr K Afifi Quarter 3 Local No Yes 2864 To assess compliance with Trust Guidelines Evaluation of Care Plans Safe, effective, caring Obstetrics compliance and quality RCOG Report Audits - - Audit of selected case notes of SGA babies To create a culture of compassion safety Dr T Vanner Quarter 3 Other No Yes 3678 Fully compliant Saving Babies Lives Bundle Evaluation of Care Plans Safe, effective, caring not detected antenatal to identify care issues, and quality make recommendations and action plans.

RCOG Report Audits - To create a culture of compassion safety - Audit the use of FMAT after 6 months of use, and quality, proactively seek to identify that the tool was being given, used Mr D Churchill Quarter 3 Other No No N/A N/A Saving Babies Lives Bundle No opportunities to develp our services, to Safe, effective, caring appropriately and action taken by staff as have and effective and well integrated indicated by the presence of risk factors for organisation that operates efficiently FGR or stillbirth.

To create a culture of compassion, safety QS098 Nutrition: improving maternal and Specialist MW & PMA Minor non To assess Trust compliance with Baby Lifeline, WHO Safe, effective, caring, Quarter 3 NICE No Yes 3344 No and quality. Be in the top quartile for all child nutrition Mrs A Costello compliance standards and Trust Guidelines responsive performance indicators To look at means of improving maternal and newborn Be in the top quartile for all performance Safe, effective, caring, MBRACCE Audit Mr O Orakwue Quarter 4 National No Yes 4243 TBC Evaluation of Care Plans outcomes indicators responsive and well-led To look at means of improving maternal and newborn Be in the top quartile for all performance Safe, effective, caring, MBRACCE Perinatal Audit Mr O Orakwue Quarter 4 National No Yes 4243 TBC Evaluation of Care Plans outcomes indicators responsive and well-led National Audit: National Maternity and To assess whether the local trends are in line with Be in the top quartile for all performance Safe, effective, caring, IT Specialist: B Williams Quarter 4 National No Yes 4244 TBC No Perinatal Audit national maternity and perinatal trends. indicators responsive and well-led To create a culture of compassion, safety Trust Wide OP07 Health Records and quality. To have an effective and Lorraine Smith Quarter 4 Local No Yes N/A TBC To assess audit compliance to Trust standards No Safe and effective Documentation Audit well integrated organisation that operates efficiently

To create a culture of compassion, safety and quality. To have an effective and Trustwide EWS Lorraine Smith Quarter 4 Local No Yes 4242 TBC To assess audit compliance to Trust standards No Safe, caring and effective well integrated organisation that operates efficiently

Saving Babies Lives Bundle - a care bundle fore To create a culture of compassion, safety reducing stillbirth. CG062 (Updated Mar) Antenatal care for and quality. To have an effective and Safe, effective, caring, Dr T Vanner Quarter 4 NICE No Yes 3678 Fully compliant Antenatal care for uncomplicatied pregnancies - CG62. No uncomplicated pregnancies (SBL Element 1-3) well integrated organisation that responsive and well-led Antenatal care Quality standard QS 22. operates efficiently Look at areas for improvement within current practice

To create a culture of compassion, safety NG003 Diabetes in pregnancy: management Moderate non and quality. To have an effective and Safe, effective, caring, of diabetes and its complications from Mr D Churchill Quarter 4 NICE No Yes 3350 To asess compliance with Trust guidelines and NICE Evaluation of Care Plans compliance well integrated organisation that responsive preconception to the postnatal period operates efficiently

To assess management and outcomes of women who had planned VBAC but either elected for repeat To create a culture of compassion, safety Safe, effective, caring, Management of women with previous CS Mr Afifi Quarter 4 Local No No N/A N/A Evaluation of Care Plans Caesarean section or who had emeregency or request and quality. responsive Caesarean when in labour Ophthalmology Audit Plan 2019/20 If re-audit, Relates to a Care Planning If re-audit Proposed Quarter Carried over Is this audit a compliance Audit? (Falls/PUs/End of Mapping to the 5 CQC Audit ID Audit Title Audit Lead Audit Type state previous Aim of audit Mapping to Trust Strategic Objectives for Completion from 2018/19? re-audit? rating of Life/Discharge/Evaluation of Domains audit ID previous audit care plans) Create a culture of compassion, safety and quality. 4380 Indistinct/ Blurred discs and Papilledema Shelagh Baynham TBC Service Evaluation No Yes 4380 N/A To improve patient care and service No Safety, effective, responsive Proactively seek opportunities to develop our services. Trust Wide OP07 Health Records Create a culture of compassion, safety Mr Caruana Quarter 4 Other No Yes 4206 TBC To assess compliance with the Health Records policy No Safety, effective, responsive Documentation Audit and quality. Visual outcomes and complications following To ass ess the management of patients presenting for Create a culture of compassion, safety scleral sutured intraocular lenses and iris scleral sutured intraocular lenses and iris clipped and quality. 4331 Mr Ilango Quarter 4 Service Evaluation No No N/A N/A No Safety, effective, responsive clipped intraocular lenses in aphakic eyes intraocular lenses in aphakic eyes without capsular Proactively seek opportunities to develop without capsular support support our services. Create a culture of compassion, safety Outcomes following automated anterior To evaluate the management of patients presenting for and quality. 4332 Mr Ilango Quarter 4 Service Evaluation No No N/A N/A No Safety, effective, responsive lamellar keratoplasty automated anterior lamellar keratoplasty Proactively seek opportunities to develop our services. Pathology Audit Plan 2019/20 If re-audit, Relates to a Care Planning If re-audit Proposed Quarter Carried over Is this audit a compliance Audit? (Falls/PUs/End of Mapping to the 5 CQC Audit ID Audit Title Audit Lead Audit Type state previous Aim of audit Mapping to Trust Strategic Objectives for Completion from 2018/19? re-audit? rating of Life/Discharge/Evaluation of Domains audit ID previous audit care plans) National Comparative Audit of Blood Safe Transfusion Programme - Fresh Frozen Create a culture of compassion, safety 4194 Maxine Boyd Quarter 4 National Yes No N/A N/A TBC No Responsive Plasma and Cryoprecipitate in Children and and quality. Well Led Neonates Safe National Comparative Audit of Blood Create a culture of compassion, safety 4195 Maxine Boyd Quarter 4 National Yes No N/A N/A TBC No Responsive Transfusion Programme - O Neg use and quality. Well Led National Comparative Audit of Blood Safe Create a culture of compassion, safety 4196 Transfusion programme - massive Maxine Boyd Quarter 4 National Yes No N/A N/A TBC No Responsive and quality. haemorrhage Well Led Special Care Dental Audit Plan 2019/20 If re-audit, Relates to a Care Planning If re-audit Proposed Quarter Carried over Is this audit a compliance Audit? (Falls/PUs/End of Mapping to the 5 CQC Audit ID Audit Title Audit Lead Audit Type state previous Aim of audit Mapping to Trust Strategic Objectives for Completion from 2018/19? re-audit? rating of Life/Discharge/Evaluation of Domains audit ID previous audit care plans) Create a culture of compassion, safety Minor non- and quality. HTM01-05 - Infection Prevention Avril Rudge Quarter 4 Local No Yes 4038 Audit compliance with HTM01-05 No Safe, Well Led compliance Proactively seek opportunites to develop our services Create a culture of compassion, safety To assess compliance against RADQA standards, Minor non- and quality. Radiography Quality Assurance Ishfaq Khan Quarter 4 Local No Yes 4039 whether radiographs are taken and recorded in the log No Safe, Well Led compliance Proactively seek opportunites to develop books correctly. our services Create a culture of compassion, safety Gather feedback from 80 service users in order to and quality. Patient Survey Vanessa Wright Quarter 4 Service Evaluation No Yes 4041 TBC assess the service and make improvements where No Caring, Responsive Proactively seek opportunites to develop necessary our services Create a culture of compassion, safety Audit compliance against OP07 Health Records Policy and quality. Trustwide Documentation Audit Vanessa Wright Quarter 4 Other No Yes 4042 TBC and the 14 generic record keeping standards as No Effective Proactively seek opportunites to develop approved by the Royal College of Physicians our services Create a culture of compassion, safety To audit compliance on IV Sedation against NICE and quality. 4165 IV Sedation TBC Quarter 4 NICE Yes No N/A N/A Evaluation of Care Plans Safe, Effective Guidance CG112 Proactively seek opportunites to develop our services Effectiveness of pain relief following Create a culture of compassion, safety To evaluate the effectiveness pain relief following treatment on comprehensive care and and quality. Tahir Butt Quarter 4 Local No No N/A N/A treatment on comprehensive care and paediatric GA Evaluation of Care Plans Effective paediatric GA list Proactively seek opportunites to develop list our services Create a culture of compassion, safety and quality. Dental LoCSSIP Tahir Butt Quarter 4 Local No No N/A N/A To audit compliance with Dental extractions No Safe Proactively seek opportunites to develop our services Trauma & Orthopaedics Audit Plan 2019/20 If re-audit, Relates to a Care Planning If re-audit Proposed Quarter Carried over Is this audit a compliance Audit? (Falls/PUs/End of Mapping to the 5 CQC Audit ID Audit Title Audit Lead Audit Type state previous Aim of audit Mapping to Trust Strategic Objectives for Completion from 2018/19? re-audit? rating of Life/Discharge/Evaluation of Domains audit ID previous audit care plans) NICE NG37 Fractures (complex): assessment To have an effective and well integrated Responsive, well-Led & 3662 ? Mr Adrian Simons Quarter 3 NICE No No NA NA To monitor compliance with Nice Guidance No and management organisation that operates efficiently Safety

IPG607 Mosaicplasty for symptomatic To have an effective and well integrated 4307 Mr Chugh Quarter 3 NICE No Yes 2830 Fully compliant To monitor compliance with NICE Guidance No Effectiveness articular cartilage defects of the knee organisation that operates efficiently

NICE IPG619 Superior capsular augmentation Proactively seek opportunities to develop 4412 Mr Adrian Simons Quarter 3 NICE No No NA NA To monitor compliance with NICE Guidance No Well-Led for massive rotator cuff tears - our services

Create a culture of compassion, safety PROMS (Patient Reported Outcome 3603 Mr David Simpson Quarter 4 National No Yes 3602 TBC To monitor compliance with National Standards No and quality Proactively seek Effectiveness & Caring Measures) Audit 2017-18 data opportunities to develop our services Create a culture of compassion, safety and quality Proactively seek 4058 National Joint Registry 2018/19 data Mr David Simpson Quarter 4 National No Yes 3601 TBC To monitor compliance with National Standards No opportunities to develop our services Be Effectiveness & Caring in the top quartile for all performance indicators NICE IPG621 (NICE does not recommend) NICE IPG622 (should only be used in the Mr Adrian Simons (NICE Proactively seek opportunities to develop 4464 Quarter 4 NICE No No NA NA To monitor compliance with NICE Guidance No Effectiveness & Well-Led context of research.) lead) our services NICE IPG623 Create a culture of compassion, safety Caring , Safety, 4491 Patient Falls Documentation Audit Divine Cooper Quarter 4 Local No No NA NA To document patient falls Falls and quality Responsive & Well-Led Trust Wide OP07 Health Records To have an effective and well integrated Mr David Simpson Quarter 4 Other No Yes 4092 TBC To monitor compliance re: Documentation No Effective, Responsive & Documentation audit 19/20 organisation that operates efficiently Well-Led Safety, Caring To monitor EWS to ensure escalation against the Trust Create a culture of compassion, safety Trust Wide Early Warning Signs Audit 2019/20 Mr David Simpson Quarter 4 Other No Yes 4093 TBC Evaluation of Care Plans Effective, Responsive & Track & Trigger protocol. and quality Well-Led

Proactively seek opportunities to develop MANAGEMENT OF BUCKLE FRACTURES OF Moderate Non- To audit and evaluate the management of Fractures of our services To have an effective and well THE DISTAL RADIUS; A SERVICE EVALUATION Mr S Deshpande Quarter 4 Service Evaluation No Yes 4044 No Effectiveness & Well-Led compliance the Distal Radius integrated organisation that operates AUDIT efficiently Local Safety Standards for Invasive All LocSSIPs must be registered on audit plan, will be Proactively seek opportunities to develop Responsive, Well-Led & Procedures (LocSSIPs) SOP - Trauma & Mr David Simpson Quarter 4 Local No No NA NA presented to QSIG. Please use link to access T&O No our services Effective Orthopaedics Ptotocol for all invasive procedures Proactively seek opportunities to develop National Hip Fracture Data Annual Report Mr David Simpson Quarter 4 National No Yes 3600 TBC To monitor compliance with National Standards No Well-Led & Responsive our services Falls and Fragility Fractures Audit programme Create a culture of compassion, safety Mr O Thomas Quarter 4 National No Yes 4051 TBC To monitor complaince with National Standards Falls Effectiveness & Caring (FFFAP) and quality Urology Audit Plan 2019/20 If re-audit, Relates to a Care Planning If re-audit Proposed Quarter Carried over Is this audit a compliance Audit? (Falls/PUs/End of Mapping to the 5 CQC Audit ID Audit Title Audit Lead Audit Type state previous Aim of audit Mapping to Trust Strategic Objectives for Completion from 2018/19? re-audit? rating of Life/Discharge/Evaluation of Domains audit ID previous audit care plans) Create a culture of compassion, safety and quality. To improve the care provided to patients presenting for Proactively seek opportunities to develop National Audit: BAUS Urology - Cystectomy Mr David Mak Quarter 4 National No Yes 4129 Fully compliant No Safety, effective, responsive cystectomy. our services. Be in the top quartile for all performance indicators. Create a culture of compassion, safety and quality. To improve the care provided to patients presenting for Proactively seek opportunities to develop National Audit: Nephrectomy Mr Chakravarti Quarter 4 National No Yes 4130 TBC No Safety, effective, responsive nephrectomy. our services. Be in the top quartile for all performance indicators. Create a culture of compassion, safety IDENTIFY STUDY - The Investigation and and quality. Detection of Urological Neoplasia in Patients To evaluate the management of neoplasis in patients Proactively seek opportunities to develop Mr David Mak Quarter 4 National No Yes 3957 TBC No Safety, effective, responsive Referred with Suspected Urinary Tract referred with suspected urinary tract cancer our services. Cancer. Be in the top quartile for all performance indicators. Create a culture of compassion, safety and quality. National: BAUS Urology Audit - Radical To improve the care provided to patients presenting for Proactively seek opportunities to develop Miss Boody Quarter 4 National No Yes 4128 TBC No Safety, effective, responsive prostatectomy prostatectomy. our services. Be in the top quartile for all performance indicators. Create a culture of compassion, safety and quality. A National Audit: percutaneous To improve the care provided to patients presenting for Proactively seek opportunities to develop Mr Inglis Quarter 4 National No Yes 4131 TBC No Safety, effective, responsive nephrolithotomy (PCNL) PCNL our services. Be in the top quartile for all performance indicators. Create a culture of compassion, safety and quality. BAUS National Complex Surgery Audits/ To improve the care provided to patients with prostate Proactively seek opportunities to develop Mr Cooke Quarter 4 National No Yes 4132 TBC No Safety, effective, responsive National Prostate Cancer cancer our services. Be in the top quartile for all performance indicators. Create a culture of compassion, safety and quality. Trust Wide OP07 Health Records Proactively seek opportunities to develop Mr Cooke Quarter 4 Other No Yes 4402 TBC To improve the quality of health records No Safety, effective, responsive Documentation Audit our services. Be in the top quartile for all performance indicators. Create a culture of compassion, safety and quality. Proactively seek opportunities to develop Trustwide EWS Audit Mr Cooke Quarter 4 Other No Yes 4240 TBC To enhance compliance with Trust policy. No Safety, effective, responsive our services. Be in the top quartile for all performance indicators. DIVISION 2 AUDIT PROGRAMME 2019/2020 AMU Directorate Audit Plan 2019/20 If re-audit Relates to a Care Planning Proposed Carried Is this If re-audit, state Audit? (Falls/PUs/End of Mapping to Trust Mapping to the 5 Audit ID Audit Title Audit Lead Quarter for Audit Type over from audit a re- compliance rating Aim of audit previous Life/Discharge/Evaluation of Strategic Objectives CQC Domains Completion 2018/19? audit? of previous audit audit ID care plans) Create a culture of Trustwide Documentation Safety & Governance Quarter 4 Other No Yes 4609 TBC Measure compliance No compassion safety and audit Effectiveness quality Create a culture of Safety & Trustwide EWS audit Governance Quarter 4 Other No Yes 4461 TBC Measure compliance Evaluation of Care Plans compassion safety and Effectiveness quality Society for Acute Create a culture of Medicine's Benchmarking Safety & 4563 Dr K Willmer Quarter 4 National No No NA NA Measure compliance No compassion safety and Audit (SAMBA)Annual since Effectiveness quality 2012 (19/20) Care of the Elderly Directorate Audit Plan 2019/20 If re-audit Relates to a Care Planning Proposed Carried Is this If re-audit, state Audit? (Falls/PUs/End of Mapping to Trust Mapping to the 5 Audit ID Audit Title Audit Lead Quarter for Audit Type over from audit a re- compliance rating Aim of audit previous Life/Discharge/Evaluation of Strategic Objectives CQC Domains Completion 2018/19? audit? of previous audit audit ID care plans) Create a culture of Whether developing a an A4 double compassion, safety and sided proforma will help to quality To have an Safety, Effective, Consultant Ward Round standardize important features of 4510 Philip Thomas Quarter 1 Local No No NA NA No effective and well caring, responsive, Proforma ward rounds and improve integrated organisation well led documentation (of e.g. DNACPR that operates efficiently status) for continuity of care.

1. Establishing the extent of the problems by collecting data for risk factors (which includes extremes of ages,use of medications that Quality Improvement Be in the top quartile for promote candida growth Project on Reducing all performance indicators (antibiotics & steroids),Diabetes Safety, Effective, incidence of oral thrush in Dr Friday To have an effective and 4517 Quarter 2 QIP No No NA NA mellitus, denture wearers, poor oral Evaluation of Care Plans caring, responsive, the elderly patient at WPH Nehikhare well integrated hygiene, smoking, poor diet, well led (ward 2) by 20% through organisation that operates nutritional efficiency and Impaired preventative measures. efficiently salivary function). 2. Instituting preventative measures 3. Re-auditing to monitor improvement

Improve compliance against OP07 Trust Wide OP07 Health Health Records Policy and the 14 create a culture of 4503 Records Documentation Tony Oke Quarter 4 Other No Yes 4223 TBC generic record keeping standards as No compassion, safety & Safety audit (2019/2020) approved by the Royal College of Quality Physicians

Assess if the equipment & environment on each ward may be create a culture of Minor Non contributing to the high falls 4509 Fall in Hospital Philip Thomas Quarter 4 other No Yes 3439 Falls compassion, safety & safety Compliance prevalence. (Examples of this would Quality include - glasses and walking aids etc not being within easy reach)

This guideline covers diagnosing and treating delirium in people aged 18 and over in hospital and in long- Be in the top quartile for Audit of Clinical Protocol term residential care or a nursing all performance indicators for the Prevention, home. It also covers identifying Effective, To have an effective and 4571 Diagnosis and Management Julie Willoughby Quarter 4 national No Yes 4226 TBC people at risk of developing Evaluation of Care Plans responsive, well integrated of Delirium in Adult delirium in these settings and effective, caring organisation that operates Inpatients preventing onset. It aims to efficiently improve diagnosis of delirium and reduce hospital stays and complications.

The aim of this audit is to assess compliance with policy CP61 create a culture of Safety, Effective, Trust Wide Early Warning 4504 Tony Oke Quarter 4 Other No Yes 4225 TBC regarding the Track & Trigger Evaluation of Care Plans compassion, safety & caring, responsive, Signs Audit 2019/20 protocol of Early Warning Score Quality well led (EWS) used within the Trust. Assess compliance against Local Create a culture of Local Safety Standards for Safety Standards for Invasive Safety, Effective, Tony Oke TBC Local No No NA NA No compassion, safety & Elective Lumbar puncture Procedures (LocSSIPs) as per Well Led quality. National standards Diabetes Directorate Audit Plan 2019/20 If re-audit Relates to a Care Planning Proposed Carried Is this If re-audit, state Audit? (Falls/PUs/End of Mapping to Trust Mapping to the 5 Audit ID Audit Title Audit Lead Quarter for Audit Type over from audit a re- compliance rating Aim of audit previous Life/Discharge/Evaluation of Strategic Objectives CQC Domains Completion 2018/19? audit? of previous audit audit ID care plans) QIP: Investigating the use To determine the frequency of and frequency of Blood monitoring of blood glucose in Glucose Monitoring in Quality stable diabetic inpatients. To have an effective & well Responsive, 4427 stable non-insulin Dr Young Quarter 1 Improvement Yes No NA NA To assess whether there is scope for Evaluation of Care Plans integrated organisation Effectiveness and dependent hospital Project reducing frequency of that operates efficiently Well Led inpatients and its logistical measurements in cases where the and cost implications patient’s glycaemic control is stable. To reduce the rates of Re-Audit Inpatient To have an effective & well Responsive, Moderate non hypoglycaemia in the trust and Management of Dr Young Quarter 1 Local No Yes 4081 Evaluation of Care Plans integrated organisation Effectiveness and compliance improve management of hypoglycaemia that operates efficiently Well Led hypoglycaemia when it occurs.

Improve patient care and experience - The National Diabetes Footcare Audit (NDFA) enables all National Diabetes Audit - diabetes footcare services to To have an effective & well Responsive, 4046 Adults 18/19 (National Dr Hariman Quarter 2 National Yes Yes 3436 TBC measure their performance against No integrated organisation Effectiveness and Diabetes Foot Care Audit) NICE clinical guidelines and peer that operates efficiently Well Led units, and to monitor adverse outcomes for people with diabetes who develop diabetic foot disease.

Improve patient care and experience - The National Diabetes Footcare Audit (NDFA) enables all National Diabetes Audit - diabetes footcare services to To have an effective & well Responsive, 3436 Adults 17/18 (National Dr Hariman Quarter 2 National Yes Yes 3084 Fully compliant measure their performance against No integrated organisation Effectiveness and Diabetes Foot Care Audit) NICE clinical guidelines and peer that operates efficiently Well Led units, and to monitor adverse outcomes for people with diabetes who develop diabetic foot disease.

National Diabetes Audit - To have an effective & well Responsive, Minor non Measure practice against national 4047 Adults (National Diabetes Jenny Dudley Quarter 2 National Yes Yes 3438 No integrated organisation Effectiveness and compliance clinical standards Inpatient Audit (NaDia) that operates efficiently Well Led

National Diabetes Audit - To have an effective & well Responsive, Minor non Measure practice against national 4048 Adults (National Core Dr Young Quarter 2 National Yes Yes 3440 No integrated organisation Effectiveness and compliance clinical standards Diabetes Audit) that operates efficiently Well Led

National Diabetes Audit - To have an effective & well Responsive, Measure practice against national 4049 Adults (National Diabetes Dr Raghavan Quarter 2 National Yes No NA NA No integrated organisation Effectiveness and clinical standards Transition) that operates efficiently Well Led

Improve compliance against OP07 Health Records Policy and the 14 To have an effective & well Caring, Safety and OP07 Documentation Audit Dr Young Quarter 4 Other No Yes 4079 TBC generic record keeping standards as No integrated organisation Responsive approved by the Royal College of that operates efficiently Physicians

The purpose of this report is to review compliance with The Royal Wolverhampton NHS Trust Policy for the Prevention and To have an effective & well Trust Wide Early Warning Caring, Safety and Dr Young Quarter 4 Other No Yes 4080 TBC Management of the Deteriorating Evaluation of Care Plans integrated organisation Signs Audit Responsive Patient (CP61) and the VitalPAC that operates efficiently Policy & Procedure (OP88) at New Cross Hospital, West Park Hospital and Cannock Chase Hospital Association of British Assessing outcomes and in terms of To have an effective & well Responsive, Clinical Diabetologists Dr Young Quarter 4 National No No NA NA safety and efficacy for patients No integrated organisation Effectiveness and (ABCD) - National using Empagliflozin that operates efficiently Well Led Empagliflozin audit ED Directorate Audit Plan 2019/20 If re-audit Relates to a Care Planning Proposed Carried Is this If re-audit, state Audit? (Falls/PUs/End of Mapping to Trust Mapping to the 5 Audit ID Audit Title Audit Lead Quarter for Audit Type over from audit a re- compliance rating Aim of audit previous Life/Discharge/Evaluation of Strategic Objectives CQC Domains Completion 2018/19? audit? of previous audit audit ID care plans) This audit was Audit of admissions of Create a culture of abandoned in Safety and children to PAU with lisa kehler Quarter 3 Local No No NA Measuring Compliance Evaluation of Care Plans compassion, safety and 18/19 (previous Effectiveness fever quality ID 3658) Do rapid antigen throat swabs reduce antibiotic Create a culture of Dr Kehler/ Dr Safety and 4549 therapy in children Quarter 3 Service Evaluatio No No NA NA Measuring Compliance No compassion, safety and Joshary Effectiveness <15years with tonsillitis in quality ED Create a culture of Trustwide Documentation Safety and Governance Dept Quarter 4 Other No Yes 4274 TBC Measuring Compliance No compassion, safety and audit Effectiveness quality Create a culture of Safety and CG134 Anaphylaxis Mr A Morgan Quarter 4 NICE No No NA NA Measuring Compliance Evaluation of Care Plans compassion, safety and Effectiveness quality Assessing Cognitive Create a culture of Impairment in Older Safety and TBC Quarter 4 National No No NA NA Measuring Compliance No compassion, safety and People (Care in Effectiveness quality Emergency Departments) Create a culture of Care of Children (Care in Safety and TBC Quarter 4 National No No NA NA Measuring Compliance No compassion, safety and Emergency Departments) Effectiveness quality Major Trauma Audit 19/20 Create a culture of Mr Asif/Mr Safety and (Audit operates a Quarter 4 National No No 4276 Continous audit Measuring Compliance No compassion, safety and Simons (T&O) Effectiveness continuous data cycle quality TARN) Mental Health (Care in Create a culture of Emergency Departments) Moderate non Safety and TBC Quarter 4 National No Yes 1779 Measuring Compliance No compassion, safety and compliance Effectiveness quality

Improving Asthma risk stratification and Create a culture of Dr K Willmer/Dr Safety and followup in Quarter 4 QIP No No NA NA Measuring Compliance No compassion, safety and A Szuszman Effectiveness exacerbations presenting quality to ED Gastroenterology Directorate Audit Plan 2019/20 If re-audit Relates to a Care Planning Proposed Carried Is this If re-audit, state Audit? (Falls/PUs/End of Mapping to Trust Mapping to the 5 Audit ID Audit Title Audit Lead Quarter for Audit Type over from audit a re- compliance rating Aim of audit previous Life/Discharge/Evaluation of Strategic Objectives CQC Domains Completion 2018/19? audit? of previous audit audit ID care plans) Improving management of Create a culture of decompensated Chronic Safety and Dr H Steed Quarter 1 Local No No NA NA Measuring Compliance No compassion, safety & liver Effectiveness quality disease with ascites Create a culture of Safety and Trustwide EWS audit Governance Dept Quarter 2 Other No Yes 4180 TBC Measuring Compliance Evaluation of Care Plans compassion, safety & Effectiveness quality Create a culture of Safety and National GRS ERCP Dr Menon Quarter 2 National No Yes 4171 Fully compliant Measuring Compliance No compassion, safety & Effectiveness quality Create a culture of Trustwide Documentation Safety and Governance Dept Quarter 3 Other No Yes 4179 TBC Measuring Compliance No compassion, safety & audit Effectiveness quality Create a culture of Safety and National EUS audit 18/19 Dr Menon Quarter 3 National No Yes 4169 Fully compliant Measuring Compliance No compassion, safety & Effectiveness quality Create a culture of National 30 day Mortality Safety and Sam Mason Quarter 4 National No Yes 4178 Fully compliant Measuring Compliance No compassion, safety & audit 19/20 Effectiveness quality Create a culture of Local Patient Satisfaction Service Safety and Sharon Powell Quarter 4 No Yes 4175 Fully compliant Measuring Compliance No compassion, safety & Audit 18/19 Evaluation Effectiveness quality Maltings Directorate Audit Plan 2019/20 If re-audit Relates to a Care Planning Proposed Carried Is this If re-audit, state Audit? (Falls/PUs/End of Mapping to Trust Mapping to the 5 Audit ID Audit Title Audit Lead Quarter for Audit Type over from audit a re- compliance rating Aim of audit previous Life/Discharge/Evaluation of Strategic Objectives CQC Domains Completion 2018/19? audit? of previous audit audit ID care plans) Improve compliance against OP07 Create a culture of Safety, Health Records Policy and the 14 compassion, safety & Effectiveness, OP07 Documentation Audit Louise Tisdale Quarter 4 Local No Yes 4136 TBC generic record keeping standards as No quality Caring, Responsive, approved by the Royal College of Well-Led Physicians Create a culture of Safety, compassion, safety & Clopidogrel prescribing for Dr Alexander/Dr Effectiveness, Quarter 1 Local No No NA NA Measuring Compliance Evaluation of Care Plans quality diabetic amputees Grubb Caring, Responsive, Well-Led Create a culture of Safety, compassion, safety & Neuropathic Pain Louise Tisdale/Dr Effectiveness, Quarter 3 Local No No NA NA Measuring Compliance No quality Medication Alexander Caring, Responsive, Well-Led Create a culture of Safety, compassion, safety & Wheelchair Voucher Effectiveness, Sally Horton Quarter 4 Local No No NA NA TBC No quality System Caring, Responsive, Well-Led Neurology Directorate Audit Plan 2019/20 If re-audit Relates to a Care Planning Proposed Carried Is this If re-audit, state Audit? (Falls/PUs/End of Mapping to Trust Mapping to the 5 Audit ID Audit Title Audit Lead Quarter for Audit Type over from audit a re- compliance rating Aim of audit previous Life/Discharge/Evaluation of Strategic Objectives CQC Domains Completion 2018/19? audit? of previous audit audit ID care plans) Create a culture of Vitamin D Supplement in Dr Gabir/Phil Moderate non Safety and Quarter 3 Local No Yes 4342 To measure compliance No compassion safety & Epilepsy Patients Tittensor compliance Effectiveness quality Audit into treatment Create a culture of Safety and 4145 pathways for patients with Phil Tittensor Quarter 3 Local No No NA NA To measure compliance Evaluation of Care Plans compassion safety & Effectiveness NEADs quality This audit was Create a culture of abandoned in Safety and 3668 CG150 Headaches Nikki Edwards Quarter 4 NICE No No NA To measure compliance Evaluation of Care Plans compassion safety & 18/19 (previous ID Effectiveness quality 2296) NICE Audit - A NICE audit of Create a culture of newly Diagnosed MS Gail Shore, Dan Minor non Safety and 4143 Quarter 4 NICE No Yes 3487 To measure compliance Evaluation of Care Plans compassion safety & Patients (QS 108: Standard Kuch compliance Effectiveness quality 2) Create a culture of Trustwide Documentation Safety and Governance Quarter 4 Other No No 4147 TBC To measure compliance No compassion safety & audit Effectiveness quality Create a culture of Safety and Trustwide EWS audit Governance Quarter 4 Other No No 4148 TBC To measure compliance Evaluation of Care Plans compassion safety & Effectiveness quality Create a culture of Safety and Parkinson's audit 2019 Dr Al-Moyeed Quarter 4 National No No NA NA To measure compliance No compassion safety & Effectiveness quality Create a culture of National Audit of Safety and Phil Tittensor Quarter 4 National No No NA NA To measure compliance No compassion safety & Seizures in Hospital – PT Effectiveness quality Create a culture of Motor Neuron Disease Safety and Nij Mistry Quarter 4 National No No NA NA To measure compliance No compassion safety & Care Audit – NM Effectiveness quality Oncology & Haematology Directorate Audit Plan 2019/20 If re-audit Relates to a Care Planning Proposed Carried Is this If re-audit, state Audit? (Falls/PUs/End of Mapping to Trust Mapping to the 5 Audit ID Audit Title Audit Lead Quarter for Audit Type over from audit a re- compliance rating Aim of audit previous Life/Discharge/Evaluation of Strategic Objectives CQC Domains Completion 2018/19? audit? of previous audit audit ID care plans) Compliance with all documentation relating to the treatment planning Create a culture of Radiotherapy Lateralality Stephen West / Minor non Safety, Caring, 1 National No Yes 4087 and administration to ensure safe Evaluation of Care Plans compassion, safety & (NATSIPS) Ian Sayers compliance responsive delivery and compliance with quality Quality Procedures

The overarching aim of this audit is to improve the quality of care and Create a culture of Safety, Caring, 4119 National End of Life Audit Dr C Marlow 2 National Yes No NA TBC services for patients who have End of Life compassion, safety & responsive reached the end of their life, in quality hospitals in England. Create a culture of Measure practice against national Safety, Caring, 4054 Bowel Cancer (NBOCAP) Mr Williams 2 National Yes Yes 3461 TBC Evaluation of Care Plans compassion, safety & clinical standards responsive quality Create a culture of Head and Neck Cancer Measurement of practice against Safety, Caring, 4052 Miss Spinou 2 National Yes Yes 3462 TBC Evaluation of Care Plans compassion, safety & Audit national clinical standards responsive quality Create a culture of Oesophago-gastric Cancer Measurement of practice against Safety, Caring, 4055 Mr Curran 2 National Yes Yes 3463 TBC Evaluation of Care Plans compassion, safety & (NAOGC) national clinical standards responsive quality The purpose of the audit is to review the quality of lung cancer Create a culture of National Lung Cancer Audit Safety, Caring, 4120 Kerry Davies 2 National Yes Yes 3467 TBC care, to highlight areas for Evaluation of Care Plans compassion, safety & (NLCA) responsive improvement and to reduce quality variation in practice. Determine whether the care that men with prostate cancer receive is Create a culture of National Prostate Cancer Safety, Caring, 4056 Kerry Davies 2 National Yes Yes 3470 TBC in keeping with recommended Evaluation of Care Plans compassion, safety & Audit responsive practice and to identify areas where quality improvements are needed Create a culture of National Audit RCR - Audit to describe practice: CHART, Safety, Caring, 4121 Dr Pek Koh 2 National Yes Yes 3475 TBC Evaluation of Care Plans compassion, safety & Radical Lung SABR, CCRT responsive quality

The multi-modality nature of radical bladder cancer treatment requires Create a culture of interdisciplinary expertise and Safety, Caring, RCR RT Bladder Audit Dr Dandamudi 2 National No Yes 4122 Fully compliant Evaluation of Care Plans compassion, safety & effective multi-disciplinary responsive quality pathways for successful care delivery. These can be audited.

The purpose of this report is to review compliance with The Royal Wolverhampton NHS Trust Policy for the Prevention and Create a culture of Responsive, Trust Early Warning Signs Dr Joseph 4 Other No No 4123 N/A Management of the Deteriorating Evaluation of Care Plans compassion, safety & Effectiveness and Patient (CP61) and the VitalPAC quality Well Led Policy & Procedure (OP88) at New Cross Hospital, West Park Hospital and Cannock Chase Hospital

Improve compliance against OP07 Health Records Policy and the 14 Create a culture of Responsive, OP07 - Trust Dr Joseph 4 Other No No 4124 N/A generic record keeping standards as No compassion, safety & Effectiveness and Documentation Audit approved by the Royal College of quality Well Led Physicians Create a culture of Service Moderate non Improve compliance in completion Safety, Caring, Syringe Driver re- audit Dr Marlow 3 No Yes 4309 End of Life compassion, safety & Evaluation compliance of syringe driver charts responsive quality Reducing Delays between To reduce the delays between Create a culture of cycles of radioactive iodine cycles of radioactive iodine Safety, Caring, Dr Sayers 3 QIP No No NA NA No compassion, safety & treatment in thyroid cancer treatment in thyroid cancer responsive quality patients patients.

TA416 Osimertinib for treating locally advanced or Create a culture of Responsive, Assess compliance with NICE 3803 metastatic EGFR T790M Dr Sayers 3 NICE Yes No NA NA Evaluation of Care Plans compassion, safety & Effectiveness and guidelines mutation-positive non- quality Well Led small-cell lung cancer TA360 Paclitaxel as albumin- bound nanoparticles in Create a culture of Responsive, combination with Assess compliance with NICE 3834 Dr Sayers 3 NICE Yes No NA NA Evaluation of Care Plans compassion, safety & Effectiveness and gemcitabine for previously guidelines quality Well Led untreated metastatic pancreatic cancer

DG009 & TA374 Epidermal growth factor receptor tyrosine kinase (EGFR-TK) Create a culture of Responsive, Assess compliance with NICE 3857 mutation testing in adults Dr Sayers 3 NICE Yes No NA NA Evaluation of Care Plans compassion, safety & Effectiveness and guidelines with locally advanced or quality Well Led metastatic non-small-cell lung cancer

TA439 Cetuximab and panitumumab for Create a culture of Responsive, Assess compliance with NICE 4384 previously untreated Dr Sayers 3 NICE Yes No NA NA Evaluation of Care Plans compassion, safety & Effectiveness and guidelines metastatic colorectal quality Well Led cancer Create a culture of Re- Audit CUP - Carcinoma Re-audit to measure improvement Safety, Caring, Dr Sayers 1 Local No Yes 4085 Fully compliant Evaluation of Care Plans compassion, safety & of unknown primary in practice responsive quality Renal Directorate Audit Plan 2019/20 If re-audit Relates to a Care Planning Proposed Carried Is this If re-audit, state Audit? (Falls/PUs/End of Mapping to Trust Mapping to the 5 Audit ID Audit Title Audit Lead Quarter for Audit Type over from audit a re- compliance rating Aim of audit previous Life/Discharge/Evaluation of Strategic Objectives CQC Domains Completion 2018/19? audit? of previous audit audit ID care plans) Create a culture of Responsive, Compliance with national UK Renal Registry Dr Acton Quarter 3 National Yes Yes 3443 Fully compliant Evaluation of Care Plans compassion, safety & Effectiveness and standards. quality Well Led Quality Improve patient care & service via Create a culture of Responsive, QIP eDischarge - 4063 Dr Acton Quarter 2 Improvement Yes Yes 3281 NA communication / documentation Evaluation of Care Plans compassion, safety & Effectiveness and completeness Project between secondary / primary. quality Well Led

Renal Biopsy, National Are we following the protocol? Create a culture of Responsive, Safety Standards for Minor non Rates of complications N Sarwen Quarter 3 National No Yes 4065 Evaluation of Care Plans compassion, safety & Effectiveness and Invasive Procedures compliance Adequacy of biopsies quality Well Led (NatSSIP) Identify areas for improvement?

Improve compliance against OP07 Health Records Policy and the 14 Create a culture of Safety, Caring, OP07 Documentation Audit Dr Acton Quarter 4 Local No Yes 4068 TBC generic record keeping standards as No compassion, safety & responsive approved by the Royal College of quality Physicians

The purpose of this report is to review compliance with The Royal Wolverhampton NHS Trust Policy for the Prevention and Create a culture of Safety, Caring, Early Warning Signs Dr Acton Quarter 4 Local No No 4069 TBC Management of the Deteriorating Evaluation of Care Plans compassion, safety & responsive Patient (CP61) and the VitalPAC quality Policy & Procedure (OP88) at New Cross Hospital, West Park Hospital and Cannock Chase Hospital What are the current trends for investigation including screening for Quality malignancy and PLAR2R testing in Create a culture of Responsive, QIP Membranous GN (use N Sarwen Quarter 1 Improvement No Yes 4071 NA idiopathic membranous Evaluation of Care Plans compassion, safety & Effectiveness and of PLA2R testing) Project nephropathy? quality Well Led Also look at management. Is there variation in practice? Quality Create a culture of Responsive, Measure practice against local QIP Transitional Care J Peracha Quarter 2 Improvement No Yes 4073 NA Evaluation of Care Plans compassion, safety & Effectiveness and clinical standards Project quality Well Led Quality Improvement Project- Improving Improving compliance of renal Quality Create a culture of Responsive, compliance of renal department with EWS, 4489 Dr Acton Quarter 1 Improvement Yes No NA NA No compassion, safety & Effectiveness and department with EWS, Documentation and Antimicrobial Project quality Well Led Documentation and Audit Antimicrobial Audit. National Audit - To improve CVC patency, To Prospective Audit to study Create a culture of Responsive, establish more effective use of 3579 Syner-kinase use to restore Helen Spooner Quarter 1 National Yes No NA NA Evaluation of Care Plans compassion, safety & Effectiveness and costly medication & Inform current patency in occluded central quality Well Led clinical practice guidelines venous catheters Assess rate of peritonitis in our renal unit Assess rate of PD tube Quality Create a culture of Responsive, RRT procedure HD lines PD Moderate non exit site infection M Janomohamed Quarter 2 Improvement Yes Yes 4072 Evaluation of Care Plans compassion, safety & Effectiveness and inserts (medical) compliance Assess adequacy of PD tube Project quality Well Led insertion in our unit through revising checklist protocols Create a culture of Responsive, QS005 - Chronic Kidney Assess compliance against NICE Dr Acton Quarter 2 NICE No No NA NA Evaluation of Care Plans compassion, safety & Effectiveness and Disease/NCKDA guidelines. quality Well Led Create a culture of Responsive, Assess compliance against NICE CG174 - IV Fluid in Adults Dr Acton Quarter 3 NICE No No NA NA Evaluation of Care Plans compassion, safety & Effectiveness and guidelines. quality Well Led Respiratory Directorate Audit Plan 2019/20 If re-audit Relates to a Care Planning Proposed Carried Is this If re-audit, state Audit? (Falls/PUs/End of Mapping to Trust Mapping to the 5 Audit ID Audit Title Audit Lead Quarter for Audit Type over from audit a re- compliance rating Aim of audit previous Life/Discharge/Evaluation of Strategic Objectives CQC Domains Completion 2018/19? audit? of previous audit audit ID care plans) Audit against the updated British National Adult CAP Audit Create a culture of Responsive, Thoracic Society (BTS) Guidelines 4184 (included in the Quality Dr Gulati 4 National Yes No NA TBC Evaluation of Care Plans compassion, safety & Effectiveness and for the management of Community Accounts List 2019/20) quality Well Led Acquired Pneumonia (CAP)

The audit captures the process and clinical outcomes of treatment in Create a culture of Responsive, National Non-Invasive 4187 Dr Gulati 4 National Yes No NA TBC patients admitted to hospital in Evaluation of Care Plans compassion, safety & Effectiveness and Ventilation Audit England and Wales with COPD quality Well Led exacerbations,

Non-identifiable registry data is UK Cystic Fibrosis used to improve the health of Registry/NICE Quality Nicola Create a culture of Responsive, people with cystic fibrosis through 4189 Standard QS168 (included Macduff/Dr 4 National Yes Yes 3608 NA Evaluation of Care Plans compassion, safety & Effectiveness and research, to guide quality in the Quality Accounts List Thickett quality Well Led improvement at care centres and to 2019/20) monitor the safety of new drugs.

Improve compliance against OP07 Health Records Policy and the 14 Create a culture of Trustwide OP07 Dr Thickett 4 Local No Yes 4191 TBC generic record keeping standards as No compassion, safety & Caring, Safety Documentation Audit approved by the Royal College of quality Physicians

The purpose of this report is to review compliance with The Royal Wolverhampton NHS Trust Policy for the Prevention and Create a culture of Trustwide Early Warning Dr Gulati 4 Local No Yes 4060 TBC Management of the Deteriorating Evaluation of Care Plans compassion, safety & Caring, Safety Signs (EWS) Audit Patient (CP61) and the VitalPAC quality Policy & Procedure (OP88) at New Cross Hospital, West Park Hospital and Cannock Chase Hospital

TA431 - Mepolizumab for Create a culture of Responsive, Assess compliance with NICE treating severe refractory Dr Szuzman 3 NICE No No NA NA Evaluation of Care Plans compassion, safety & Effectiveness and guidelines eosinophilic asthma quality Well Led

QS025 - Asthma and/or Create a culture of Responsive, Assess compliance with NICE NG080 - Asthma , diagnosis Dr Szuzman 2 NICE No No NA NA Evaluation of Care Plans compassion, safety & Effectiveness and guidelines and management quality Well Led

Improving the OP follow-up engagement and reducing To improve the OP follow-up Create a culture of Responsive, 28-day re-attendance of engagement and reduce 28 day re Dr Huntley 1 QIP No No NA NA Evaluation of Care Plans compassion, safety & Effectiveness and patients after attending ED attendance of patients attending ED quality Well Led with an exacerbation of with an exacerbation of asthma. asthma

Reducing the length of stay To reduce the length of stay of Create a culture of Responsive, of patients requiring pleural Dr Huntley 1 QIP No No NA NA patients requiring plueral Evaluation of Care Plans compassion, safety & Effectiveness and procedures procedures quality Well Led Create a culture of Responsive, NatSSips Dr Matthew 2 National No No NA NA Assess compliance with NatSSips No compassion, safety & Effectiveness and Bronchoscopy/EBUS quality Well Led Create a culture of Responsive, Cancelled EBUS Dr Gulati 2 QIP No No NA NA TBC Evaluation of Care Plans compassion, safety & Effectiveness and quality Well Led Create a culture of Responsive, Improving Ward Dr Thickett 3 QIP No No NA NA To improve the ward round No compassion, safety & Effectiveness and Round/Huddle quality Well Led Create a culture of Responsive, NIV Mortality Dr Gulati 3 QIP No No NA NA TBC TBC compassion, safety & Effectiveness and quality Well Led

An evaluation of the impact of changing from the To evaluate the the impact of European Community for changing from the European Coal and Steel (ECCS) Community for Coal and Steel Create a culture of Responsive, reference equations to the (ECCS) reference equations to the Dr Chowdhury 1 QIP No No NA NA Evaluation of Care Plans compassion, safety & Effectiveness and Global Lung Function Global Lung Function Initiative (GLI) quality Well Led Initiative (GLI) reference reference equations on the equations on the predicted predicted normal parameters for normal parameters for diffusion capacity (TLco) diffusion capacity (TLco) Stroke Directorate Audit Plan 2019/20 If re-audit Relates to a Care Planning Proposed Carried Is this If re-audit, state Audit? (Falls/PUs/End of Mapping to Trust Mapping to the 5 Audit ID Audit Title Audit Lead Quarter for Audit Type over from audit a re- compliance rating Aim of audit previous Life/Discharge/Evaluation of Strategic Objectives CQC Domains Completion 2018/19? audit? of previous audit audit ID care plans) QIP, IDENTIFICATION OF DIABETES AS A RISK Be in the top quartile for FACTOR IN ISCHAEMIC to identify Diabetes as a risk all performance indicators. STROKE AND ASSESSMENT factorassessment of Glycaemic Responsive, 4596 Saugata Das Quarter 3 QIP No No NA NA no Proactively seek OF GLYCAEMIC CONTROL control in patients admitted to effective opportunities to develop IN PATIENTS ADMITTED TO stroke unit with Ischeamic stroke our services STROKE UNIT WITH ISCHAEMIC STROKE-

Be in the top quartile for all performance indicators Proactively seek Ensure antibiotic guidance is opportunities to develop Safety, effective, 4539 Antibiotics Simon McBride Quarter 4 Other No Yes 4227 TBC Evaluation of Care Plans followed our services To have an responsive effective and well integrated organisation that operates efficiently

Create a culture of Improve compliance against OP07 compassion, safety and Trust Wide OP07 Health Health Records Policy and the 14 quality. To have an safety, effective, 4505 Records Documentation Saugata Das Quarter 4 Other No Yes 4228 TBC generic record keeping standards as No effective and well caring audit (Financial year) approved by the Royal College of integrated organisation Physicians. that operates efficiently

The purpose of this report is to review compliance with The Royal Wolverhampton NHS Trust Policy for the Prevention and Create a culture of Effective, caring, Trust Wide Early Warning 4506 Saugata Das Quarter 4 Other No Yes 4230 TBC Management of the Deteriorating Evaluation of Care Plans compassion, safety and safety , responsive, Signs Audit 2018/19 Patient (CP61) and the VitalPAC quality well led Policy & Procedure (OP88) at New Cross Hospital, West Park Hospital and Cannock Chase Hospital

To measure the rate of changes in stroke service organisation and quality of care for stroke patients Be in the top quartile for since the National Audit Office Sentinel Stroke National all performance indicators Report of 2010. To measure 4535 Audit programme (SSNAP) Saugata Das Quarter 4 national No Yes 4231 TBC No Create a culture of Effective, caring progress in providing hyperacute 2019/2020 compassion, safety and services to a greater proportion of quality the stroke population To measure provision of community specialist services for stroke. DIVISION 3 AUDIT PROGRAMME 2019/2020

Adult Community Directorate Audit Plan 2019/20

Relates to a Care Planning If re-audit If re-audit, Proposed Quarter Carried over Is this audit a Audit? (Falls/PUs/End of Mapping to Trust Strategic Mapping to the 5 CQC Audit ID Audit Title Audit Lead Audit Type state previous compliance rating Aim of audit for Completion from 2018/19? re-audit? Life/Discharge/Evaluation of Objectives Domains audit ID of previous audit care plans)

Insulin administration therapuetic window To assess compliance with therapeutic window for 1. Create a culture of compassion, Tracey Slater Quarter 1 Local No No N/A N/A No Safety, effectivenss, responsive compliance administration of insulin safety & quality

1. Create a culture of compassion, safety & quality Audit of Antimicrobial Prescribing by Non Tracey Slater Quarter 2 Local No Yes 4351 Fully compliant To determine the appropriateness of prescribing Discharge 5. To have an effective & well Safety, effectivenss, responsive Medical Prescribers integrated organisation that operates efficiently

1. Create a culture of compassion, Local Community Nursing/Health Professional Minor non To assess compliance with local content and weight safety & quality Nicola Dimmock Quarter 3 Local No Yes 4159 No Safety, effectivenss, responsive Bag and Car Boot - Re-Audit compliance recomendations 2. Attract, retain & develop our staff & improve employee engagement

Use of Medication Checklist within District Moderate non 1. Create a culture of compassion, Tracey Slater Quarter 3 Local No Yes 4160 To improved patient safety No Safety, effectivenss, responsive Nursing compliance safety & quality

Specialist Foot Health Services Skin Integrity Minor non To ensure the appropriate skin/pressure management of 1. Create a culture of compassion, Russ Hanks Quarter 3 Local No Yes 4158 Evaluation of Care Plans Safety, effectivenss, responsive Trigger Tool compliance podiatry patients safety & quality

1. Create a culture of compassion, safety & quality Trust Wide OP07 Health Records Kate Jenks Quarter 4 Other No Yes 3218 Fully compliant To assess compliance with record keeping No 5. To have an effective & well Safety, effective, responsive Documentation Audit integrated organisation that operates efficiently

appropriate investment and enhancement to patient services 5. To have an effective & well Local Audit - Dressings formulary Compliance Kate Jenks Quarter 4 Local No Yes 3323 Fully compliant To assess compliance with Formulary Product use No Effectiveness, Responsive integrated organisation that operates efficiently

1. Create a culture of compassion, safety & quality Effectiveness, caring, Post Bereavement Monitoring (NICE QS 13) Nicola Dimmock Quarter 4 NICE No Yes 3280 Fully compliant To evaluate family satisfacation following bereavement End of Life 6. Proactively seek opportunities to responsiveness develop our services Children's Services Acute Directorate Audit Plan 2019/20

Dr Davies/A. Nephrotic syndrome Audit Quarter 2 Local No Yes 4270 TBC Patel Audit our practice of management of nephrotic syndrome against the standards set by the RCPCH and Create a culture of compassion, Safety, Responsive, Well Led, improve patient care No safety & quality effective

Maintain financial health - auditing rational for paediatric patients who have been appropriate investment Patient Admitted Over 2 weeks Dr Jayaraman Quarter 2 QIP No No NA NA Yes safety, responsive an inpatient longer than 14 days enhancement to patient services

All patients in and out of PAU over an agreed period of Opportunities to help develop PAU Flow Audit Dr Pargass Quarter 2 Local No No NA NA No responsive, well led time. service

Proactively seek opportunities Review whether standards relating to speed of referral to develop our services Newly Diagnosed Juvenile idiopathic Arthritis Dr Copeman/Dr and review of JIA are being met by measuring patient Safety, responsive, effective, 4601 Quarter 3 Local No No NA NA No (JIA) Davies experience against standards 3,12, 22 and 27 of the well led, caring BSPAR standards for JIA

Safety, Responsive, Well Led, Febrile Neutropenia Dr Brent Quarter 3 Local No No NA NA Compliance with target one hour door to needle time No create culture of compassion effective

1. Create a culture of compassion, safety & quality Local Safety Standards for Invasive Procedures Dr Dhanarass Quarter 3 Local No No NA NA To assess compliance with locssips No 2. To have an effective & well Safety, Effectiveness (LocSSIPs) integrated organisation that operates efficiently

Assessment of the management of pain in those create culture of compassion Be in Minor Non- Safety, Responsive, Well Led, Sickle Cell Disease Audit Dr Brent Quarter 3 Local NO Yes 4271 presenting to New Cross Hospital Paediatric Assessment No the top quartile for all performance compliance effective Unit (PAU) with a painful sickle cell crisis indicator

1. Create a culture of compassion, 2019 - 2020: National Paediatric Diabetes safety & quality Dr Pargass Quarter 4 National No Yes 3527 TBC To improve patient care. No safety, effectiveness, caring Audit (NPDA) 2. Be in the top quartile for all performance indicators

Improve compliance against OP07 Health Records Policy Trust Wide OP07 Health Records Create a culture of compassion, 4499 Surinder Judge Quarter 4 Other No Yes 4268 TBC and the 14 generic record keeping standards as approved No Quality, Safety Documentation audit safety & quality by the Royal College of Physicians

The purpose of this report is to review compliance with The Royal Wolverhampton NHS Trust Policy for the Create a culture of compassion, Effective, caring, safety , 4500 Trustwide EWS Audit (PEWS) Abbey Wood Quarter 4 Other No Yes 4328 TBC Prevention and Management of the Deteriorating No safety and quality responsive, well led Patient (CP61) and the VitalPAC Policy & Procedure (OP88) at New Cross Hospital,

To determine compliance to Trust strategic objectives - National Audit- National Epilepsy 12 Audit (DR Minor Non- Safe environment and National NHS quartile of Be in the top quartile for all 4533 Dr Sastry Quarter 4 National No Yes 4532 No Effectiveness DISON)- Re audit compliance benchmarks. CQC standards - Effectiveness and Caring performance indicators CQC standards - 4

All children who undergo a procedure under sedation should have had a consent form signed by their parent or Create a culture of compassion, Neuro Imaging Audit Dr Sastry Quarter 4 Local No No NA NA guardian and consent should hve been taken either by a No Safety, Effective Responsive safety & quality consultant or by a middle grade doctor who has been specifically assessed to take consent for sedation

Opportunities to help develop Asthma Dr Gupta Quarter 4 Local No No NA NA To ensure compliance with the guidance No responsive, well led service

1. Create a culture of compassion, safety & quality Bronchiotis Dr Gupta Quarter 4 Local No No NA NA ensure appropriate bronchillitus treatment in children Yes 2. To have an effective & well Safety, responsive, well led integrated organisation that operates efficiently Children's Services Community Directorate Audit Plan 2019/20

CYPic Dip audit following action plan from Create a culture of compassion, 4560 Audit QS031 A nice related audit for health and Dr S. Khan Quarter 2 Local no No NA NA Compliance with NICE guidance No Safety, Effectiveness, Caring, safety & quality wellbeing of looked after children

Information for patientsand their families to help Proactively seek opportunities 4555 Child protection parent information leaflet Dr Ravi Kumar Quarter 3 QIP No No NA NA no Quality, Safety develop our service and improve patient care to develop our services

Dr Indu To improve patient care and create a culture of Proactively seek opportunities 4556 Menstruation matters Quarter 3 QIP no No NA NA no Caring, responsive, quality lakshminarayana compassion, safety and quality. to develop our services

To have an effective & well integrated safety, organisation that operates efficiently Proactively Proactively seek opportunities to 4557 Obesity Dr Sarah Steadmen Quarter 3 QIP no No NA NA no Effectiveness,caring,responsive seek opportunities to develop our services and develop our services , well lead improve our service.

1. Create a culture of compassion, safety & quality2. seek oppertunities Radiological Guidance on non accidental Dr Indu To improve patient care and improve our services 4559 Quarter 3 local no No NA NA no to develop our service .3. To have an Quality, safety injuries lakshminarayana by working together for safeguarding children. effective and well integrated organisation that operates effiiciently.

Improve compliance against OP07 Health Records Policy Trust Wide OP07 Health Records Create a culture of compassion, 4498 Dr S Khan Quarter 4 Other No Yes 4212 TBC and the 14 generic record keeping standards as approved No Safety Documentation audit safety & quality by the Royal College of Physicians

1. Create a culture of compassion, safety & quality 2. Attract, retain & develop our staff & improve Child Health Clinical Outcome Review Safety, Effectiveness, Caring, 4558 Dr S. Khan Quarter 4 National NO Yes 4286 Fully compliant To improve patient care. No employee engagement Programme (Chronic Neurodisability) Responsive, Well-Led 3. Be in the top quartile for all performance indicators 4. Maintain financial health appropriate Dermatology Directorate Audit Plan 2019/20

TA442 Ixekizumab for treating moderate to To assess compliance against NICE TA442 Ixekizumab for Create a culture of compassion, Safety, Effective, responsive 3994 Dr J Frankiewicz Quarter 1 NICE Yes No N/A N/A No severe plaque psoriasis treating moderate to severe plaque psoriasis safety & quality and Well Led

To review patient care pathway from referral to CP50 Review of Diagnostic Test Results from Create a culture of compassion, Safety, Caring, responsive, Dr Frankiewicz Quarter 2 Local No No N/A N/A treatment for timely review of test results correct Evaluation of Care Plans referral to diagnosis & Treatment safety & quality Well Led pathway

compliance against British Association of Dermatologist Create a culture of compassion, Guidelines (BAD) for pre assessment of general well safety & quality. To have an Biologics - NX and CCH Jason Vistenia Quarter 2 Local No No N/A N/A Evaluation of Care Plans Caring, Responsive, Well Led being of patients co morbidities, monitoring progress of effective & well integrated improvement organisation that operates efficiently

Moderate Non- Compliance with trust policy/patients safety questions as Create a culture of compassion, Safety, Effective, responsive Re-Audit WHO Checklist Lynne Moreland Quarter 2 Local No Yes 3447 No compliance featured on WHO check list safety & quality and Well Led

Local Safety Standards for Invasive Procedures Create a culture of compassion, Safety, Effective, responsive Dr Hamad Quarter 3 Local No No N/A N/A Audit local SOP for Biopsies excisions Evaluation of Care Plans (LocSSIPs) safety & quality and Well Led

Debbie Graham / The aim of this audit report is to assess compliance to Create a culture of compassion, Written Consent Quarter 3 Local No No N/A N/A No Effective, Responsive, Well Led Chrissie Owen the Trust’s Consent Policy CP06. safety & quality

To have an effective & well Waiting times (Diagnostic Biopsy) concerns To assess patients waiting times for initial biopsy and Safety, Caring, responsive, Dr Ibrahim Quarter 3 Local No No N/A N/A No integrated organisation that regarding back log diagnosis diagnosis due to capacity issues. Well Led operates efficiently

To review compliance against British Association of Local Reaudit of Compliance to guidelines for Minor Non- Dermatologist Guidelines (BAD) for Consent pre tests Create a culture of compassion, Safety, Caring, responsive, 4472 Isotretinoin includinding documentation of Dr Abadie Quarter 4 Local No Yes 2040 Evaluation of Care Plans compliance and treatment monitoring for patients taking safety & quality Well Led pregnancy testing on the prescription. Isotretonoin.

To have an effective & well To assess patients from referral to MDT discussion and Safety, Caring, responsive, Cancer Local referral Pathway Andrea Smith Quarter 4 Local No No N/A N/A Evaluation of Care Plans integrated organisation that breaking bad news to commencing treatment Well Led operates efficiently

To assess compliance against 15 generic standards set by Create a culture of compassion, OP07 Trustwide Documentation Audit Dheensa Tarsem Quarter 4 Other No Yes 4241 TBC Royal College of Physicians for Trustwide OP07 No Effective, Responsive, Well Led safety & quality Documentation Audit

Assess compliance against NICE TA475 Dimethyl TA475 Dimethyl fumarate for treating Create a culture of compassion, Safety, Effective, responsive 4373 TBC Quarter 4 NICE No No N/A N/A fumarate for treating moderate to severe plaque No moderate to severe plaque psoriasis safety & quality and Well Led psoriasis Dietetics Directorate Audit Plan 2019/20

Accuracy of MUST Completion & referal of High To assess the accuracy of MUST Completion & referal of Proactively seek opportunities to 4582 Kathryn Robinson Quarter 1 Local No No NA NA No effectiveness Risk Patients for Dietetic Intervention High Risk Patients for Dietetic Intervention develop our services

To assess current nutrition practices on the ICCU 1.1 Moderate Non- Nutritional screening using MUST on Vitalpac 1.2 Create a culture of compassion, 4595 Nutrition support on the ICCU Jaci Chapman Quarter 2 Local No Yes 3075 No safety, effective compliance Referral to the dietitian using the ICCU referral criteria safety & quality 1.3 Meeting nutritional requirements

To identify strengths and weaknesses of dietetic 1. Create a culture of compassion, inpatient and outpatient documentation in order to safety & quality 3. Be in the top facilitate improvement in communication between the quartile for all performance Minor Non- 4575 Local: Dietetic Record Keeping Kathryn Robinson Quarter 4 QIP Yes Yes 4183 healthcare team, continuity of care and effectiveness of No indicators 5. To have an effective & effectiveness compliance dietetic intervention To develop action plan to facilitate well integrated organisation that improvement in dietetic documentation operates efficiently 6. Proactively To identify appropriate date for re-audit To identify seek opportunities to develop our Pharmacy Directorate Audit Plan 2019/20

To assess baseline competency of nurses and theatre 1. Create a culture of compassion, practitioners who are responsible for patients with safety & quality Nurse, Midwife and Theatre Practitioner epidurals, paravertebrals and local anaesthetic infusions. 2. Proactively seek opportunities to safety, effectiveness, caring, 4521 Competency for Epidural and Paravertebral Ravinder Bratch Quarter 2 Local no Yes 3955 TBC To assess efficacy of a pilot teaching programme for No develop our services well led Analgesia staff involved in the management of these patients. 3. To have an effective & well Nurse training with clearly defined competencies will integrated organisation that lead to improved management of patients with 1. Createoperates a culture efficiently of compassion, The NPSA Alert on neonatal gentamicin provides a safety & quality 2.Attract, retain & Safer use of IV gentamicin in neonates through national care bundle approach to the prescription, develop our staff & improve Significant non Well-Led, Responsive, Caring, implementation of the NPSA neonatal Tayebah Abbasi Quarter 4 Local No Yes 4338 administration and monitoring of gentamicin and aims to Evaluation of care plans employee engagement compliance Effectiveness, Safety gentamicin care bundle reduce error and improve the safety associated with its 3. Be in the top quartile for all use performance indicators To determine the prevalence rate of penicillin allergy at 4 Maintain financial health this hospital To determine the compliance to the medicine policy MP01 and the antimicrobial policy MP05 Moderate non Proactively seek opportunities to An audit to assess penicillin allergy recording Pam Kang Quarter 4 Local No Yes 4376 by assessing the completeness of the allergy status on No Safety compliance develop our services drug charts and the nature of penicillin allergy on drug charts To improve communication between primary and secondary care by assessing if allergy status is recorded 1. Create a culture of compassion, The NPSA Alert on neonatal gentamicin provides a safety & quality 2. Attract, retain & Safer use of IV gentamicin in neonates through national care bundle approach to the prescription, develop our staff & improve Significant non safety, effectiveness, caring, 4552 implementation of the NPSA neonatal Tayebah Abbasi Quarter 4 Local no Yes 4338 administration and monitoring of gentamicin and aims to Evaluation of Care Plans employee engagement compliance well led gentamicin care bundle reduce error and improve the safety associated with its 3. Be in the top quartile for all use. performance indicators 4 Maintain financial health -

Moderate non To determine the prevalence rate of penicillin allergy at 1. Proactively seek opportunities 4524 An audit to assess penicillin allergy recording Pam Kang Quarter 4 Local no Yes 4376 No safety compliance this hospital to develop our services

1. Create a culture of compassion, safety & quality 2019-20CQUIN Indicator 2d: Reducing the Reduction in antibiotic consumption (DDDs per 1,000 2. Be in the top quartile for all impact of serious infections (Antimicrobial admissions) and increase the proportion of antibiotic Well-Led, Responsive, 4525 Christine Dunphy Quarter 4 Other No Yes 4432 TBC No performance indicators Resistance and Sepsis) - Antibiotic usage (for both in-patients and out-patients) within the Effectiveness, Safety 3. Maintain financial health - Consumption Access group of the AWaRe* category appropriate investment and 1.enhancement Create a culture to patient of compassion, services Number of antibiotic prescriptions reviewed between 24 safety & quality 3. Be in the top CQUIN 2c: Percentage of antibiotic to 72 hours of initiation in patients diagnosed with sepsis quartile for all performance prescriptions documented and reviewed by a 4526 Christine Dunphy Quarter 4 National no Yes 4433 TBC that meet the criteria above (i.e. by an appropriate No indicators Led, Responsive, Effectiveness, S competent clinician within 72 hours meeting clinician PLUS one of the seven documented outcomes 4. Maintain financial health - the following three criteria: PLUS an IV to oral switch assessment). appropriate investment and enhancement to patient services An audit to establish current practice in 1. Proactively seek opportunities relation to the correct and timely An audit to establish current practice in relation to the to develop our services. 2. Create a culture of administration of anti-parkinsonian correct and timely administration of anti-parkinsonian Caring, well led, responsive, 4355 Misba Janjua Quarter 4 Local Yes Yes 4355 TBC No compassion, safety and quality medications to patients with Parkinson’s medications to patients with Parkinson’s disease at The effective, safety, responsive 3. Attract, retain and develop our disease at The Royal Wolverhampton NHS Royal Wolverhampton NHS Trust. staff and improve employee Trust. engagement Primary Care Directorate Audit Plan 2019/20

Audit compliance against Local SOP . Review pathways Create a culture of compassion, CP50 Review of Test Results Julian Parkes Quarter 2 Local No No N/A N/A for 30 patients from point of referral to timely review of Evaluation of Care Plans Safety, Effective, Well Led safety & quality. test results and treatment

LocSSIP's Audit of Safety Standards for Invasive Assess compliance against Local Safety Standards for Create a culture of compassion, Julian Parkes Quarter 2 Local No No N/A N/A No Safety, Effective, Well Led Procedures. Invasive Procedures (LocSSIPs) as per National standards safety & quality.

High Risk Drugs Audit - Blood checks prior to Review of patients on shared care agreements and Create a culture of compassion, Safety Caring Responsive Well Dave Birch Quarter 3 Local No No N/A N/A Evaluation of Care Plans prescribing high risk drugs monitoring of patients condition. safety & quality. Led

To audit compliance against CP11 Attachment 6 - Do not Create a culture of compassion, Safety Caring Responsive Well Re-Audit Trustwide DNA CPR Audit Katie Welborn Quarter 4 Other No Yes 4344 TBC End of Life attempt resuscitation across the Trust. safety & quality. Led

Create a culture of compassion, Trustwide Consent Audit Julian Parkes Quarter 4 Local No No N/A N/A Adherence to the trust consent policy CP06 No Safety Effective Well Led safety & quality.

Identifying frailty usind the eFI score. GP Create a culture of compassion, Katie Welborn Quarter 4 Local No No NA NA Adhere to GP enhanced contract No Safety Effective Well Led enhanced specification 2017/2018 safety & quality.

Identify any similarities in the demographic of cervical screening non-attenders, Recognise any characteristics Be in the top quartile for all Safety Caring Responsive Well Re-Audit Cervical Cytology Katie Welborn Quarter 4 Local No Yes 4346 TBC of this section of the patient demographic and No performance indicators Led Distinguish if there are any features of the non-attenders which render cervical screening inappropriate

Create a culture of compassion, Safety Caring Responsive Well Re-Audit Medicines Management David Birch Quarter 4 Local No Yes 4345 TBC Review of Medicines Management within Primary Care Evaluation of Care Plans safety & quality. Led

Radiology Directorate Audit Plan 2019/20

Re-Audit IPG473 Uterine Artery Embolisation Moderate non Create a culture of compassion, Dr Dyer Quarter 1 NICE No Yes 3694 To assess compliance with national standards (NICE) No Safety, Effective, Well Led for treating adenomyosis compliance safety & quality.

Audit of new procedure to prevent exessive blood loss by Patients with renal cell cancer metastases in blocking the blood supply in Interventional Radiology just Proactively seek opportunities to their skeleton have orthopaedic procedures to Harminder Sensi Quarter 1 Local No No N/A N/A Evaluation of Care Plans Safety, Effective Responsive before the operation for patients with tumours, hip or develop our services prevent fractures femur fractures which would be catastrophic.

Local Safety Standards for Invasive Procedures Assess compliance against Local Safety Standards for Create a culture of compassion, Dr Dyer Quarter 3 Local No No N/A N/A No Safety, Effective, Well Led (LocSSIPs) for Intervention / CT Invasive Procedures (LocSSIPs) as per National standards safety & quality.

NICE Guidance IPG611 Prostate artery An audit will be undertaken by Dr Rangarajan/Dr Collins Create a culture of compassion, embolisation for lower urinary tract symptoms Rangarajan/Dr Coll Quarter 3 NICE No No N/A N/A No Safety, Effective Responsive after the first 6 cases have been performed safety & quality. caused by benign prostatic hyperplasia

Create a culture of compassion, IR(ME)R procedure J clinical evaluation S Thomas Quarter 4 Local No No N/A N/A Compliance of Employers Procedure J, Clinical Evaluation No Safety, Effective, Well Led safety & quality. Rheumatology Directorate Audit Plan 2019/20

Ensure that all adults with RA have rapid access to Sr Barbara specialist care for flares within 24 hours as per NICE Create a culture of compassion, 4516 NICE NG100 Telephone Advice Line Quarter 1 NICE No No N/A N/A Evaluation of Care Plans Effective Douglas NG100 safety & quality. Risk Register 5137

TA445 Certolizumab pegol and secukinumab Create a culture of compassion, for treating active psoriatic arthritis after Dr Barkham Quarter 2 NICE No No N/A N/A Assess RWT compliance against TA445 No Effective safety & quality. inadequate response to DMARDs

TA497 Golimumab for treating non- Create a culture of compassion, Dr Barkham Quarter 2 NICE No No N/A N/A Assess RWT compliance against NICE TA437 No Effective radiographic axial spondyloarthritis safety & quality.

Re-Audit of the ICE / DAWN system following Minor Non- To help reduce the chance of problems occurring with Create a culture of compassion, implementation of the ICE Pathology results Dr Bateman Quarter 3 Local No Yes 3919 No Effective, Responsive, Well Led compliance the Rheumatology monitoring tests safety and quality system at New Cross November 2017

Local Safety Standards for Invasive Procedures Assess compliance against Local Safety Standards for Create a culture of compassion, Dr Bateman Quarter 3 Local No No N/A N/A No Safety, Effective, Well Led (LocSSIPs) Invasive Procedures (LocSSIPs) as per National standards safety & quality.

TA485 Sarilumab for moderate to severe Create a culture of compassion, Dr Sheeran Quarter 3 NICE No No N/A N/A Assess RWT compliance against TA485 No Effective rheumatoid arthritis safety & quality.

TA518 Tocilizumab for treating giant cell Create a culture of compassion, Dr George Hirsch Quarter 3 NICE No No N/A N/A Assess RWT compliance against NICE TA518 No Effective arteritis safety & quality.

National Falls and Fragility Fractures Audit Audit RWT compliance against National standard Falls Be in the top quartile for all Dr Sapkota Quarter 4 National No Yes 4051 TBC Falls Caring, Effective programme (FFFAP) 2019/20 and Fragility Fractures Audit programme permormance indicators

CG146 (updated Feb) Osteoporosis: assessing Create a culture of compassion, 3636 Dr Sapkota Quarter 4 NICE No No N/A N/A Assess RWT compliance against NICE CG146 Evaluation of Care Plans Safety, Effective, Well Led the risk of fragility fracture safety & quality.

Audit compliance against 15 standards set by Royal To have an effective & well Trust Wide OP07 Health Records Dr Tochukwu Quarter 4 Other No Yes 4107 TBC College of Phyicians regarding documentation of No integrated organisation that Safety, Responsive, Well Led Documentation audit (2018/19) Adizie outpatient records operates efficiently

Audit compliance against Local SOP . Review pathways Create a culture of compassion, CP50 Review of Test Results Dr BateMan Quarter 4 Local No No N/A N/A for 30 patients from point of referral to timely review of Evaluation of Care Plans Safety, Effective, Well Led safety & quality. test results and treatment

NEIAA - National Early Inflammatory Arthritis Audit RWT compliance against National standard for Be in the top quartile for all 4308 Dr Sabrina Raizada Quarter 4 National Yes No N/A N/A Evaluation of Care Plans Caring, Effective Audit (2018 -2020) Early Inflammatory Arthritis Audit (2018 -2020) permormance indicators Speech & Language Directorate Audit Plan 2019/20

To have an effective and well Improve compliance against OP07 Health Records Policy integrated organisation that Trust Wide OP07 Health Records 4502 Charlotte Colesby Quarter 4 Other No Yes 4140 TBC and the 14 generic record keeping standards as approved No operates efficiently Create a safety, effective, caring Documentation audit (18/19) by the Royal College of Physicians. culture of compassion, safety and quality

Minor Non- Create a culture of compassion, 4583 Managers Case-note audit (2019/2020) Charlotte Colesby Quarter 4 Local No Yes 3379 To assess compliance to Case-note audit 2019/2020 No Safety Effective compliance safety and quality

Sexual Health Directorate Audit Plan 2019/20

RE-Audit of Cervical Cytology Outcomes in Minor Non- Re-audit to demonstrate further improved compliance Create a culture of compassion, Safety, Caring, Effective and Dr Gupta Quarter 3 Local No Yes 4213 No CASH (re-audit) compliance against regional and national cervical cytology outcomes safety & quality. Well Led

Audit compliance against Local SOP . Review pathways Create a culture of compassion, CP50 Review of Diagnostic Test Results Dr McCathie Quarter 3 Local No No N/A N/A for 30 patients from point of referral to timely review of Evaluation of Care Plans Safety, Effective, Well Led safety & quality. test results and treatment

National Audit Management of syphilis as per Assess RWT compliance against National BASHH Be in the top quartile for all Dr Alpana Verma Quarter 3 National No No N/A N/A No Safety, Responsive, Well Led BASHH Guidelines Standards performance indicators

Local Safety Standards for Invasive Procedures Assess compliance against Local Safety Standards for Create a culture of compassion, Dr Gupta Quarter 4 Local No No N/A N/A No Safety, Effective, Well Led (LocSSIPs) Invasive Procedures (LocSSIPs) as per National standards safety & quality.

Audit compliance against 15 standards set by Royal To have an effective & well Re-Audit OP07 Documentation Audit Dr Alpana Verma Quarter 4 Other No Yes 3506 TBC College of Phyicians regarding documentation of No integrated organisation that Safety, Responsive, Well Led outpatient records operates efficiently

To ensure national best practice guidelines are adhered Re-Audit of Partner Notification for chlamydia Dr McCathie / Minor Non- Create a culture of compassion, Quarter 4 Local No Yes 3509 by reducing the risk of undiagnosed Chlamydia in the No Safety, Responsive, Well Led Trachomatis in Sexual Health serv Nurse Stephanie compliance safety & quality. community Therapies Directorate Audit Plan 2019/20

Using risk stratification as per the NG59 guideline can To have an effective & well NG59 - Low back pain and sciatica in over 16s: Minor Non- help prevent overtreatment and aide decision making 4576 P Smallman Quarter 3 NICE No Yes 4258 No integrated organisation that safety, effectoive, well led assessment and management compliance with regards to therapists treatment options. Reaudit operates efficiently against 2 points only - see extract from minutes.

To confirm that all patients receiving printed information Judy Phazey & Minor Non- Create a culture of compassion, 4577 Patient information leaflet audit (Hands Team) Quarter 3 Local No Yes 4260 from the Hands Team are being given good quality, up-to- No safety Jayne Seymour compliance safety & quality. date and approved copies.

4584 Neuro Splinting Audit Jane Bisiker Quarter 3 Local No No NA NA Audit against national guidelines NO create culture of compassion caring responsive

By identifying the key stressors to our staff we can Assessing staff experience of work-related Minor Non- Attract, retain & develop our staff & 4579 Ros Leslie Quarter 3 Local No Yes 4421 address these and this in turn will improve staff No respponsive, well led stress compliance improve employee engagement performance , which will improve the patient experience.

To understand our patients' perceptions of our services Nice Guidance QS15 - patient Experience of Minor Non- as measured by the CARE questionnaire and the Friends Create a culture of compassion, 4463 Judy Phazey Quarter 3 NICE No Yes 4259 No caring, responsive Adult NHS Services compliance & Family test, and to map this against the standards in safety & quality. QS15

We will develop our own tool appropriate for children Minor Non- Create a culture of compassion, 4581 patient Experience Childrens Services Jane Sellar Quarter 4 NICE No Yes 4259 and with reference to any relevant national No caring, responsive compliance safety & quality. standards/guidance

To confirm that all patients receiving printed information Patient information leaflet audit (Women's Judy Phazey & Create a culture of compassion, 4578 Quarter 4 Local No Yes 4261 NA from the Women's Health Team are being given good No Safety Health) Lisa Hastie safety & quality. quality, up-to-date and approved copies.

The purpose of this report is to review compliance with The Royal Wolverhampton NHS Trust Policy for the Trust Wide OP07 Health Records Prevention and Management of the Deteriorating Create a culture of compassion, safety, effective, well led, 4501 Rosalind Leslie Quarter 4 Other No Yes 4255 NA No Documentation Audit 19/20 Patient (CP61) and the VitalPAC Policy & Procedure safety & quality. caring, responsive (OP88) at New Cross Hospital, West Park Hospital and Cannock Chase Hospital