UKMi Audit standards and toolkit Protocol for measuring the quality of NHS medicines information services
Centre:
Medicines Informatio n manager:
Auditor:
Date of audit:
This document is a guide to the audit process can be used as a recording tool for use by the auditor Contentscan be used as the final audit report.
Headings below are hyperlinked to individual sections. In addition, page numbers highlighted in blue in the rest of the report are also hyperlinked to relevant pages.
UKMi Clinical Governance Working Group May 2010 1 Executive summary...... 3 Principles...... 4 Procedures and checklist...... 5 Background to the audited MI service...... 7 Resources...... 11 Enquiry answering...... 13 Publications and proactive work...... 17 Training...... 19 Research and service development...... 21 Risk management...... 23 Specialist advisory services...... 24 Summary of recommendations and priorities for action...... 25 Appendices...... 26 Appendix 1: Visit letter template – MI Manager...... 26 Appendix 2: Visit letter template – SPM/Principal Pharmacist responsible for MI...... 27 Appendix 3: Access to the service...... 28 Appendix 4. Enquiry answer assessment form...... 30 Appendix 5. Definitions for ranking enquiries...... 31 Appendix 6. Criteria for grading answers to enquiries...... 32 Appendix 7. Score calculator...... 33 Appendix 8. Guide to auditor – Report writing...... 34 Appendix 9. Workload survey results...... 35 Appendix 10. User survey of the medicines Information Centre – Score calculator...... 36 Appendix 11. Report cover...... 37 Appendix 12: Report letter template – MI Manager...... 38 Appendix 13. Report letter template – SPM/Principal Pharmacist responsible for MI...... 39
UKMi Clinical Governance Working Group May 2010 2 Executive summary This should contain a summary of the relevant points from each section of the audit. Highlight areas of excellence and areas for improvement together with recommendations for action.
Background to the service Recommendations:
Resources Recommendations:
Enquiry answering Recommendations:
Publications and proactive work Recommendations:
Training Recommendations:
Research and service development Recommendations:
Risk management Recommendations:
Specialist advisory services Recommendations:
Any other comments Recommendations:
Progress since last audit Recommendations:
Signatures (electronic acceptable): MI manager……………………………………………………………………………….Date……………………………….. Auditor……………………………………………………………………………………..Date………………………………. Senior pharmacy manager………………………………………………………………Date…………………………......
UKMi Clinical Governance Working Group May 2010 3 Principles
The UKMi strategy ‘Effective information for managing medicines’ (1) highlights key issues underpinning organisational change within the NHS, namely: Patient safety Patient access to good quality care Cost-effective prescribing A competent work force Value for money Medicines information (MI) pharmacists individually and the MI network as a whole must accept responsibility for provision of a high quality service which meets the needs of its users. An early attempt to address quality issues in provision of health care was made by the World Health Organisation in 1983.(2) The report identified four aspects of quality - professional performance, resource use (efficiency), risk management and user satisfaction. These concepts were further developed in the White Paper on quality. “A First Class Service: Quality in the new NHS”. (3) Four principal components are identified for achieving excellence in practice (4) Clear lines of responsibility and accountability for overall quality of clinical care A comprehensive programme of quality improvement activities (e.g audit, continuing professional development, research and development) Clear policies aimed at managing risks Procedures for identification of poor performance. The first national standards for MI services were introduced in 1990 and have undergone several revisions and expansions. Most regions have introduced audit programmes with external audit undertaken by the regional centre. These are often supplemented with internal audits. Peer review sessions for enquiry answering are also undertaken by some centres. The aim is for all MI services to be externally audited against UKMi audit standards at least every three years. This document outlines UKMi standards and provides a pathway for achieving excellence. Account will be taken of previous audit results. This document can be used to audit both local and regional centres although not all sections will apply. The standards cover the following areas: Resources Enquiry answering Publications and proactive work Training Research and service development Risk management Specialist advisory services These standards not only ensure a minimum level of working but also highlight best practice which centres can work towards. Examples of good practice may be highlighted by an audit but not listed in this document. If anyone feels that they are exceeding the minimum standard in any area please highlight this in the report and feed this back to the UKMi Clinical Governance group ([email protected]) for incorporation into future versions. It should be remembered that the aim of an audit is to identify areas of good practice as well as deficiencies in service provision. Recommendations arising from the audit can only serve to ensure standards are maintained across the UKMi network and they should not be viewed as negative or critical – it is not like a driving test, there is no pass or fail. Positive outcomes from an audit can be achieved by helping to improve working conditions.
1. Effective Information for Managing Medicines. A strategy for the UK Medicines Information Network in the NHS. September 2007. www.ukmi.nhs.uk/filestore/misc/Strategy2007[2].pdf 2. World Health Organisation. The principles of quality assurance. Pub. Copenhagen: WHO, 1983 (Report on a WHO meeting) 3. Department of Health. A First Class Service: Quality in the new NHS, 1998 4. NHS Executive. Clinical governance - quality in the new NHS HSC1999/065
UKMi Clinical Governance Working Group May 2010 4 Procedures and checklist
Responsibilities of the auditor 1. Arrange a mutually convenient date for the audit visit which will usually take one full day. It is useful to arrange to meet with the SPM/Principal Pharmacist responsible for MI during the day to discuss the MI service or relevant MI initiatives identified by either party. 2. Confirm the visit with both the MI Manager and the SPM. Template letters are on pages 27 and 28. 3. Prior to the visit audit access via telephone, email and web (if applicable). See page 29. 4. Liaise with the MI manager and agree a suitable sampling period for enquiries. In addition, request the annual percentage of level 1, 2 and 3 enquiries. *Obtain the list of enquiry numbers covering the sampling period from the MI manager. Select 30 enquiries ensuring a suitable mix of level 1, 2 and 3 enquiries to reflect the usual workload of the centre. It is preferable to audit the enquiries prior to the visit so that appropriate feedback can be given on the day. Allow sufficient time before the visit to complete this. 5. If possible, prior to the visit, audit the e-mailed enquiries. See pages 31, 32, 33. Take the report with you to discuss with the MI manager on the day of the audit. 6. Obtain a copy of the previous audit report if available. 7. On the day of the visit: Agree a timetable for the day to ensure that the remaining aspects of the audit report are covered. Discuss results of enquiry audit Agree recommendations/actions with the MI manager. Ideally meet with the SPM to discuss findings and any other relevant information. 8. Aim to complete the first draft of the audit report within two weeks if possible. Use the checklist on page 35 to convert this toolkit into a report. Send the first draft to the MI Manager for comment. This is to ensure that the report reflects the discussions and actions agreed. It is usually best to set a deadline of 2-3 weeks. 9. Finalise the audit report and send a copy to the MI Manager and SPM within 6 to 8 weeks of the audit date. Template covering letters can be found on page 39 and 40. 10. Ensure any documentation with patient identifiers is deleted/shredded. Responsibilities of the centre being audited 1. Before the visit annotate the ‘Resources for Purchase by NHS MI centres’ to indicate holding. Latest edition is available at www.ukmi.nhs.uk/activities/clinicalGovernance/default.asp?pageRef=4 2. Liaise with the auditor to assess what an appropriate sampling period for enquiries should be and how these will be audited. See point 4 above. The aim is to do as much of the audit electronically, which means that much can be done before the day. Send the list of enquiries to the auditor at least two weeks before. *See below for how to obtain a report of enquiry numbers with complexity level from MiDatabank. The auditor will select 30 enquiries ensuring an appropriate mix of level 1, level 2 and level 3. If possible, these will be audited prior to the visit. To facilitate this, e-mail anonymised copies of the relevant queries to the auditor at least one week before the visit. Annotate to indicate all patient relevant details have been removed. If this is not possible and electronic access is only available by one computer, print the relevant enquiries for auditing on the day. All material should be shredded and/or deleted at the end of the process. 3. Undertake user satisfaction survey if not previously done. Questionnaire and calculator available at www.ukmi.nhs.uk/activities/clinicalGovernance/default.asp?pageRef=4 4. Complete the ‘Background to the audited MI service’ prior to the visit. 5. Consider completing the Time activity matrix available at www.ukmi.nhs.uk/activities/clinicalGovernance/default.asp?pageRef=9. This is optional. Discuss with your SPM whether they would find the results of this useful. It is a way of converting what you do into WTE. However, it is based on 2001 data. If you wish you could consider adapting it. An updated version will be available in the near future. Insert results into appendices for final report. 6. Collate relevant reports including previous audit, local (internal) audits, peer review reports etc for review on the day. Ensure interruptions are minimal on the day and liaise with the auditor to ensure all UKMi Clinical Governance Working Group May 2010 5 relevant sections are completed.
7. Comment on the first draft of the audit report. Ensure that it reflects the discussions and actions agreed. 8. The auditor will send you the final report. You and your SPM should sign it and return a copy. Responsibilities of the senior pharmacy manager 1. Ideally ensure you are available on the day of the visit to meet with the auditor at a mutually convenient time. 2. Sign the final report and retain a copy for your records. 3. Agree an action plan with the MI manager for addressing recommendations in the report.
*Selecting enquiries for audit from MiDatabank
1. Go into ‘reporter’ function in MiDatabank. 2. To obtain the percentage of level 1, 2 and 3 enquiries handled by the centre select a time frame of 1 year (or since MiDatabank installation if less than 1 year). Click on ‘Show report’. Note percentage of level 1, 2 and 3 enquiries listed in ‘Workload’ page. 3. Run a second report covering the time frame chosen for the audit. Click on ‘Show report’ then click on ‘Enquiries’ tab at the top of the page. NB. It may take some time to build this report if there are lots of enquiries. If this is the case then it may be worth producing three separate reports by filtering for complexity level. 4. Once the ‘Enquiries’ report has been built click on ‘Save’ tab and save as a Word document. The report will be saved as a table in this format. 5. Delete all columns except enquiry number and complexity level. The table can be highlighted and sorted by complexity level using the ‘sort’ function in Word. 6. This document, together with details of the yearly percentages of enquiry complexity level, should be sent to the auditor to select 30 enquiries that are representative of the enquiries received e.g. if 50% of enquiries are level 1 then 15 level 1 enquiries should be selected for audit.
UKMi Clinical Governance Working Group May 2010 6 7. Background to the audited MI service
This section outlines the current MI service activities. The sections can be expanded as needed. Environment and staffing Location of MI centre: Core opening hours:
Specialist advisory service:
Out-of-hours enquiry arrangements
Management and reporting arrangements. Line manager for MI manager (If available attach organisational chart).
List all staff members with Grade WTE JD & PS (date) KSF (date) Last IPR/PDP (date) MI in their JD – include current vacant posts MI Pharmacists (including director)
MI Technicians MI Admin staff MI Other staff Details of rotational/temporary staff i.e availability on a day-to-day basis and rotation period.
List competencies of MI technician where appropriate.
Ward/ clinical/ dispensary commitments of MI staff
Describe arrangements for short or long term absence of MI manager
Service user profile Local service: base Trust (indicate specialities/tertiary services) and number of beds
Regional service: no. local MI centres supported, no. PCTs and population size
External organisations e.g. PCT support, private sector, palliative care services, NHS Direct, mental health trust. List details of SLAs if applicable.
Is there a service specification outlining service provision and its limitations?
UKMi Clinical Governance Working Group May 2010 7 Service provision - Enquiries Current year Previous year Year before Date range: Date range: Date range:
n % n % n change change Total number of enquiries Number of enquiries/hospital bed Mean monthly number of enquiries Mean time taken per enquiry (mins) Enquirer type n (%) % n (%) % change change
Level 1 Level 2 Level 3 Specialist advisory service Patient helpline Patient Helpline include date established and outline MI involvement:
Any liaison with PALS? Service provision – medicines management Development work: e.g. develop/write prescribing guidelines by involvement with formulary work/ D & T /Medicines Management/ Area Prescribing Committees etc, patient group directions
Implementation work: e.g. NICE guidance, IV guide etc.
Active information e.g. publications, Trust Intranet, journal club
UKMi Clinical Governance Working Group May 2010 8 Contribution to national UKMI network e.g Q&As, NeLM news, IV guide, New Medicines Profiles (NMPs), Pharmline abstracts etc – list titles/no. in last year
Service provision - safety/clinical governance Local activities e.g. local ADR reporting, NPSA alerts, contribution to IRMIS scheme and utilisation of report, complaints received and how managed
Service provision - Training No./yr Training time /yr Pharmacists - induction Pharmacists - rotation Pre-registration pharmacists (hospital) Community pre-regs Technicians - MI Technicians - student Others
Teaching or training of non pharmacy staff or staff external to the organisation e.g. pharmacy undergrads, diploma students, nurses, NHS Direct, non-medical prescribers etc.
Networking and communication MI team meetings, describe format, frequency
Interactions/ liaison with main service users e.g. Clinical pharmacist meetings, Primary care meetings
MI promotional activity within organisation and to core customers e.g. Intranet, BNFs etc
Access and relationship with Trust based library e.g. facility for loan/photocopies, training, shared holdings
Contributions to mi-uk?
Involvement in regional MI network e.g. attendance/organisation regional meetings, peer review, active contribution to conference organisation, circulation of regional meeting minutes (regional centre) etc.
UKMi Clinical Governance Working Group May 2010 9 Contribution to national UKMI network e.g. meetings, membership of working groups
Service development Service developments undertaken since last audit/ in last 3 years e.g. increased input to medicines management programmes, development of training materials, helpline etc.
Research (include details of any external publications that have had MI input or authorship e.g. journal papers, posters)
Miscellaneous Annual report from MI centre: Yes/No Attach if available.
Business plan: Does the MI centre have one or is it specifically mentioned in the departmental business plan? List details if applicable.
Participation in UKMI national workload survey. Attach most recent copy.
UKMi Clinical Governance Working Group May 2010 10 Notes and Recommendations:
UKMi Clinical Governance Working Group May 2010 11 Resources
Standard: The MI Centre has appropriate space, facilities and resources to ensure the provision of a safe and efficient service. Risks of non-implementation Potential outcomes if not implemented Breech of Health & Safety legislation. Legal case under Health & Safety legislation. Inefficient working environment and practices. Adverse effect on patient care. Low staff morale. Inadequate or wrong advice/ information supplied. Difficulties in recruiting and retaining staff.
Satisfactory √ Commended √ 1. Books, journals and databases 100% of resources listed in ‘Resources for Supplementary resources appropriate to Purchase’ held. workload of Centre held. 100% of resources listed in ‘Resources with MiDatabank or Centre’s website Favorites list free access’ included on MiDatabank or includes appropriate additional sites to those Centre’s website Favorites list. on the UKMi lists. Each member of staff is registered with NeLM Appropriate electronic resources available to and mi-uk other pharmacy staff/on call staff etc. 2. IT Each member of staff has unrestricted access to a PC. Sufficient facilities are available for trainees Appropriate staff have access to server from PCs have functionality that supports home. MiDatabank and Internet access. Read-only access to MiDatabank available to All computers are networked. other pharmacy staff. MiDatabank is implemented in the MI centre. Clinical pharmacists are using MiDatabank 3. Telephones There is at least one dedicated advertised Headsets are used by all staff when using phone line available for enquiry answering. MiDatabank. The number of extensions is adequate for incoming and outgoing calls given the number of staff working in the centre. There is a facility (e.g. voicemail or diverted extension) to receive incoming calls to avoid caller receiving engaged tone. 4. Facilities Centre has easy access to printer/ photocopier/ fax/ scanner.
UKMi Clinical Governance Working Group May 2010 12 5. Environment. “Workplace health, safety and welfare: A short guide for managers” available at www.hse.gov.uk/pubns/indg244.pdf Workstation risk assessment has been undertaken and is compliant with Trust policy. Space per staff member has been risk assessed and is compliant with Trust policy. Centre has appropriate lighting and temperature control and arrangements are in Part of the MI Centre is designated as a quiet place for emergency light and power (Estates working area. dept can advise). Flexible working arrangements are General noise and interruption factors are at considered as an option for quiet working an acceptable level. where appropriate and such arrangements Staff can move to another area for quiet work. comply with Trust guidance 6. Storage Each permanent member of staff has adequate storage for personal papers etc. – including confidential material. Centre has appropriate and safe linear shelf space for resources storage. 7. Workforce There is adequate staff to fulfil service provision requirements to include cover for annual leave. Notes and Recommendations:
Calculation from Time activity matrix if appropriate:
MI managers comments on environment:
UKMi Clinical Governance Working Group May 2010 13 Enquiry answering
Standard: The service is organised to permit prompt and efficient handling of enquiries Risks of non-implementation Potential outcomes if not implemented Enquirers unable to contact MI service Adverse effect on patient care Unacceptable delay between contacting the service and Healthcare professionals proceed with action obtaining response without advice Unavailability of MI staff Inadequate or wrong advice/ information given Inexperienced staff answer enquiry Enquiries unanswered or answered too late to be useful Enquirers are discouraged from contacting the MI service in future Satisfactory √ Commended √ 1. Dedicated access by telephone for internal and external callers, during the advertised opening hours of the service, including answerphone & bleep if no MI staff available to answer the phone 2. Answerphone message details opening hours 3. Answerphone message gives suitable direction for urgent and out-of-hours enquiries including poisons enquiries, or direction for alternative services. 4. MI phone answered within 6 rings (or 20 seconds) (see page 29). 5. Answerphone messages acknowledged within 1 30 minutes working hour or within timeframe specified on message (see page 29). 6. Email address for receiving enquiries and local Acknowledgment and deadline procedure for ensuring that the mailbox is checked negotiation arrangements are in place. at least twice daily on working days (see page 29). Appropriate arrangements cover absences. 7. Web based facilities (if applicable) for receiving enquiries and local procedure for ensuring that the mailbox is checked at least twice daily on working days (see page 29). 8. Procedures in place for handling postal enquiries. 9. MI pharmacist or accredited MI technician MI pharmacist or accredited MI available to take call within 5 minutes (see page 29) technician always available to take call 10. Procedure for managing enquiry workload is documented i.e. all staff aware of how enquiries received from all routes are received, processed, answered etc. See Enquiries to document 11. Written procedure for handling enquiries in the short-term and long-term absence of MI pharmacist or accredited MI technician. 12. Pending enquiries in MiDatabank at audit: <15% of mean monthly number of enquiries not <10% of mean monthly number of completed AND closed in MiDatabank on day of enquiries not completed AND closed audit in MiDatabank on day of audit No unclosed enquiry in MiDatabank is > No unclosed enquiry in MiDatabank is 2months old > 1 month old UKMi Clinical Governance Working Group May 2010 14 Notes and Recommendations:
Results of audit of access to the MI service: Auditor’s note: Insert here boxes from ‘Appendix 3: Access to the service’ containing results of audit for telephone, e-mail and web access where relevant.
Standard: Professional expertise and judgement are used in enquiry answering Risks of non-implementation Potential outcomes if not implemented MI enquiries are poorly documented Inability to retrieve information for future reference or for follow-up Analyses and searches are Potential for misinterpretation of information if previous enquiry used inadequate to answer subsequent enquiries Answers are misleading or incorrect Harm to patients as a result of wrong/ misleading information or advice Damage to reputation of MI service and subsequent fall in use of the service √ √ Sample of enquiries audited = 30 Ensure that proportions of Level 1, 2 and 3 enquiries* are representative of the mix of level 1, 2 and 3 enquiries answered *See Quality in enquiry answering guidelines, Definitions for ranking enquiries (page 32) and Criteria for grading answers (page 33). Circle/highlight below relevant results from score calculator (page 34) for each stage. 1. Enquiries audited Unsatisfactory Satisfactory Commended Documentation <80% 80-90% >90% Analysis of enquiry <80% 80-95% >95% Search coverage <80% 80-95% >95% Answer <80% 80-90% >90% Satisfactory √ Commended √ 2. All enquiries audited have a minimum score of All enquiries audited have a minimum 15. score of 18. 3. From audited enquiries deadline was met at least From audited enquiries deadline was met 95% of the time. > 95% of the time. 4. Deadlines were met at least 95% of the time in Deadlines were met at > 95% of the time all enquiries received over last year (state date in all enquiries received over last year range). (state date range). 5. All answers involving calculations are checked Where there is interpretation of evidence by another pharmacist, technician or pre- and/or advice given based on that registration pharmacist. interpretation all written answers are checked for clarity by another pharmacist. 6. Where an MI technician has answered an enquiry that is outside their competence, there is documentary evidence that it has been checked by a pharmacist. 7. Peer review of enquiries by MI staff undertaken. Involved in peer review with another See Peer Review Good Practice Guidance centre or undertaken at regional level. Peer review undertaken for training purposes. Notes and Recommendations:
UKMi Clinical Governance Working Group May 2010 15 Standard: MI service meets the requirements of its users Risks of non-implementation Potential outcomes if not implemented Not known if users satisfied with answers provided Risk to patients Not known if users satisfied with general helpfulness/ Provision of inappropriate information and advice timeliness Waste of resources Not known if there are problems with access to the Decline of MI service a result of providing a service service that does not meet users’ needs Improvements to service not introduced Satisfactory √ Commended √ 1. User satisfaction survey conducted at least User survey conducted more frequently or on once per annum. The number of questionnaires an ongoing basis. The number of should reflect the number of enquiries questionnaires should reflect the number of answered/month (see below). NB. Exclude NHSD enquiries answered/month (see below) enquiries; other exclusion criteria determined locally. 2. Concerns raised in survey responses are Stakeholder group address requirements of investigated (see also Research and service users. development). 3. Changes implemented to avoid repetition of problems identified. 4. Satisfaction survey sample size. See Number of relevant % of No. of questionnaires No. of questionnaires Number of questionnaires enquiries enquiries sent out every month sent out once per year returned/year (assuming 50% answered/month surveyed (over 1 month) return) 0-100 ≥5% 5 60 30 100-200 4% 4 - 8 48-96 24-48 200-400 3% 6 - 12 72-144 36-72 400+ 2% 12 144 72 Survey results (maximum scores in each section =5). This scoring system is only applicable if the UKMi satisfaction survey is used. Other user satisfaction surveys that collect more qualitative data are acceptable. Auditors note: Insert copy of score calculator into appendices (see page 37) Poor √ Satisfactory √ Good √ Excellent √ Score < 3.5 Users satisfied with Score 4-4.5 Score >4.5 answer provided (minimum score 3.5-4) Score < 3.5 Users satisfied with Score 4-4.5 Score >4.5 general helpfulness/timeliness (minimum score 3.5-4) Problems with No problems with Score 4-4.5 Score >4.5 access identified access identified Notes and Recommendations:
UKMi Clinical Governance Working Group May 2010 16 Standard: Adequate procedures are in place for records management. See Records Management: A good practice guide for medicines information services. Risks of non-implementation Potential outcomes if not implemented Inability to retrieve past enquiries Loss of enquiry to follow-up e.g. if enquirer needs Inability to identify individual record more information Enquiries stored for insufficient length of time Duplication of work Inability to deal with complaint/legal case Inability to understand workflow Satisfactory √ Commended √ 1. MiDatabank enquiry recording system in use 2. Previous enquiries archived and accessible to MI Previous enquiries archived and accessible to pharmacists MI pharmacists and other staff e.g. clinical pharmacists 3. Suitable back-up facilities are in place for electronic records 4. Enquiries held for 8 years (general), 25 years (obstetrics/paediatrics/mental health) or as per Trust procedure. 5. Trust Clinical Governance leads are aware of nature of records held in MiDatabank. 6. Evidence that storage time meets Trust requirements. Notes and Recommendations:
UKMi Clinical Governance Working Group May 2010 17 Publications and proactive work
Standard: Adequate procedures are in place to ensure that publications produced are accurate, current, of good quality and achieve stated aims. NB. This does not apply to reports of business meetings. Risks of non-implementation Potential outcomes if not implemented Incomplete, incorrect or misleading information Does not fulfil the needs of its users circulated Incomplete or incorrect information could lead to Publications produced do not meet needs of audience patient harm No understanding locally of user opinion or expectations Damage to the reputation of the MI service or of the publications produced. UKMi Satisfactory √ Commended √
For publications produced by an MI centre for dissemination locally
1. Documented evidence of the aims and target Mechanism to invite stakeholder / user audience prior to preparing the publication, against suggested topics for future publications. which the final document is checked. 2. All publications should have written procedures Mechanism to track the progress of which are adhered to 100% of time, detailing publications currently in preparation e.g. processes to be followed. regular meetings Search strategy Adequate checking procedures at various stages of document preparation, to ensure appropriate literature search undertaken, references included, and interpretation of the literature. Mechanism to facilitate external, industry or expert review of document Adequate checking of final printed document 3. Checklist for each publication completed at all stages. 4. Author of material and checkers are identifiable. Mentorship for MI staff new to writing publications
5. Documentation retained for an appropriate period (minimum of two years and at least while the publication is in the public domain). Documentary evidence of the information search Checklists retained for all publications Source material and comments retained with master 6. Survey of target audience conducted since last More frequent survey of users. audit confirms that publications achieve aim(s). Formal analysis of survey results presented to users and stakeholders, with clear action plan to address any issues raised. Stakeholder/user group to discuss publications
For publications produced by an MI centre on behalf of UKMi
7. All UKMi publications written by the MI centre adhere to the UKMI SOPs for the document type e.g. Q+A, New Medicine Profiles 8. Regional MI centres meet agreed commitment to Regional MI centres exceed agreed write Q+As commitment to write Q+As
UKMi Clinical Governance Working Group May 2010 18 9. Regional MI centres meet agreed commitment to Regional MI centres exceed agreed write New Medicines Profiles commitment to write New Medicines Profiles 10. Local and regional MI centres meet agreed Local and regional MI centres exceed agreed commitment to write IV monographs commitment to write IV monographs 11. Regional MI centres meet agreed commitment to Regional MI centres exceed agreed QA IV guide monographs commitment to QA IV guide monographs Notes and Recommendations:
UKMi Clinical Governance Working Group May 2010 19 Training
Standard: The MI Service offers or commissions training for permanent MI staff, relevant pharmacy staff and pharmacy trainees (e.g. diploma pharmacists, pre- registration pharmacists and NVQ3 trainees). Standard: The training is offered in line with standard practice, meets the individual needs of the trainees, is documented and where appropriate assessed. Trainees should be properly supervised whilst working in MI. Standard: Regional MI centres support local MI managers by offering orientation/induction, identification of learning needs and access to national MI training courses. Risks of non-implementation Potential outcomes if not implemented MI staff do not have the minimum knowledge, skills Patient care is harmed as a result of poor or and competencies and/or maintain continuing unreliable information and advice. professional development/continuing education Trainees will not achieve the skills and required to provide a safe and effective service. competencies required for their qualifications and/or Rotational and other pharmacy workforce have registrations. inadequate MI skills leading to unreliable information The organisation may be susceptible to legal action and advice being used in patient care. if patients suffer harm as a result of the use of poor Pre-registration trainees do not meet the and unreliable information. requirements of their respective syllabus/curriculum. Time is wasted through inefficient working. Satisfactory √ Commended √ 1. The MI centre offering training must meet the minimum operational requirements (see Resources standards), demonstrated by three yearly audits. 2. MI staff have undertaken formal training in training, e.g. generic ‘train the trainer’ course or equivalent. This can often be accessed within the Trust. 3. Newly appointed MI pharmacists should have attended the National MI training course within 6 months of appointment unless documented reason for not attending. Certificate of Attendance available. 4. MI technicians should have completed the UKMi Accredited MI training scheme within 2 years of appointment or when the next cohort is available. 5. The supervising MI pharmacy technician holds current accreditation. 6. All MI staff have regular appraisals that inform their personal development plans. Competency based frameworks appropriate to MI are used as part of this process e.g. Knowledge and Skills Framework, General Level Framework, Advanced Consultant level Framework. 7. All MI staff undertake mandatory training, e.g. information governance, fire safety. 8. A programme of in-house training should be in place for permanent MI staff tailored to their needs.
UKMi Clinical Governance Working Group May 2010 20 9. Regional centre standard: Newly appointed MI managers are contacted within 2 months of appointment to arrange orientation/induction to the regional and national services. 10. Regional centre standard: Training and support needs assessed the for newly appointed MI managers within 3 months of starting. 11. MI manager has attended a UKMi Practice MI manager or other member of MI team Development seminar since the last audit. routinely attends UKMi Practice Development Seminar 12. A dated record is kept of all trainees who All staff who receive any training in MI have: receive MI training. This record (training record A range of assessment methods used to template) details the training provided including: assess their MI knowledge and Learning objectives. competencies. Period of training. Documentation of on-going reviews Arrangements for the supervision of their throughout training. training. Arrangements for the supervision of their work. Review of their learning objectives at the end of their training period. A training template is available from UKMi for student technicians and pre-registration pharmacists working in MI. 13. Delivery of effective, organised and appropriately supervised MI rotation(s) structured according to the preregistration trainees learning needs and demands of the GPhC syllabus. In practice, this may take 4 weeks to complete and a suggested training programme [hyperlink - http://www.ukmi.nhs.uk/activities/manpowerTraining/d efault.asp?pageRef=5] is available. The training programme template is designed to be a starting point in planning training for pre-registration pharmacists and is flexible in both duration and structure. 14. All Non-MI pharmacists have MI training as Non-MI pharmacists receive MI training as an part of their induction. annual refresher/update. 15. MI is promoted at induction to relevant MI staff contribute to the training of prescribers. healthcare professionals. Notes and Recommendations:
UKMi Clinical Governance Working Group May 2010 21 Research and service development
Standard: The MI service manager develops the service and demonstrates its value through participation in audit, practice research and other similar activities. Risks of non-implementation Potential outcomes if not implemented No understanding locally of user opinion or user Service does not fulfil the needs of its users because expectations of the MI service. methods of improving the service are not identified or Lack of data relating to the impact of MI on the host implemented. organisation (e.g. patient benefits) and its value to MI is not valued by the host organisation resulting in those who pay for the service. service shrinkage or stagnation. Lack of clear objectives for the MI centre and its Duplication of effort, and wasted time and resources. staff, and no opportunity to promote MI through Uncoordinated approach to MI service development innovation or publication. nationally. No sharing of good practice, research findings or No positive publicity for the MI centre/pharmacy service developments with other MI centres in the locally or nationally. UK or further afield. MI pharmacists have inadequate skills for advanced Inadequate knowledge and skill set for advanced practice, do not meet KSF criteria, cannot achieve practice. higher bands under AfC. Satisfactory √ Commended √ 1. Documented evidence that the user Formal analysis of survey results presented in satisfaction survey (for enquiry answering) is writing or verbally to pharmacy or managerial conducted at least annually and the results are colleagues. used to improve the quality of the service. Examples of how helpful suggestions for improvement were implemented, or unsatisfactory feedback addressed to prevent recurrence. 2. Documentary evidence (either through the Annual report on MI’s contribution to manager’s performance review or as a separate organisational/funders’ objectives produced. exercise) that the objectives of the MI centre are Evidence of how the MI service has evolved or aligned regularly with the business plan of the adapted to meet host organisation’s/funder’s organisation within which it is based and/or its objectives. major funders. 3. Documentary evidence of at least one Three or more examples can be provided. attempted or successful service development Service development has resulted in sustained since the last audit (e.g. made a request for new increased investment in the MI service since last resources, completed a project, introduced a new audit. service, supported new service users, or supervised a piece of research). 4. MI should actively promote and engage in Suggestions for MI audit or research projects research: are submitted as options for pharmacy staff As part of personal development review, all within the organisation (e.g. pre-registration permanent MI pharmacists should identify a pharmacists, diploma/MSc pharmacists). research project they plan to undertake or Suggestions for MI audit or research are support, even if this is not a short-term submitted to establishments outside the objective. organisation in which MI is based (e.g. Documentary evidence that MI actively Universities). supports research other than above within the A bid has been submitted for local, regional or host organisation (e.g. provision of advice to national research sponsorship (whether pharmacists or trainees regarding database successful or not). search strategies or literature evaluation; MI has its own research programme. protocol review for pharmacy research The MI pharmacist sits on a local or multicentre projects; statements in MI promotional research ethics committee. materials that MI will support local research) The MI pharmacist sits on a pharmacy or host organisation research committee. The MI pharmacist has conducted/ supported research involving non-pharmacy staff.
UKMi Clinical Governance Working Group May 2010 22 5. All MI pharmacists that have been in MI All MI pharmacists that have been in MI practice practice for 6 years or more have completed at for 6 years or more have published at least one least one piece of research or audit in the past 6 piece of research or audit. This may be as a years. conference poster or presentation, or for a local or national publication (e.g. intranet, internal report, journal). The MI pharmacist need not be the lead author. The MI pharmacist has a portfolio of publications that is kept up-to-date. The MI pharmacist has contributed research towards the UKMi National Research Strategy priority subjects. Notes and Recommendations:
UKMi Clinical Governance Working Group May 2010 23 Risk management
Standard: The MI Centre has an ongoing risk assessment process. Risks of non-implementation Potential outcomes if not implemented Breech of Health & Safety legislation. Risk of harm to patients, users of the MI Complaints about service. service and MI staff. Adverse publicity/media attention. Satisfactory √ Commended √ 1. Local Risk Management Policy (RMP) available (UKMi RMP may be used as template for local adaptation). 2. Risk assessment undertaken annually against Local RMP. 3. Action plan to ensure compliance with Local RMP available. 4. Action plan reviewed annually. 5. Centre has up-to-date SOPs from UKMi Centre has up-to-date recommended list which have not expired. additional/appropriate SOPs. 6. MI centre complies with Trust risk management requirements where applicable. Notes and Recommendations:
UKMi Clinical Governance Working Group May 2010 24 Specialist advisory services
These standards apply to all designated specialist advisory services listed in the UKMi directory. MICs wishing to provide a new specialist advisory service should demonstrate a need for the specialist advisory service by presenting a 'business case' to the UKMi Executive. Services should be introduced based on need, rather than an individual’s interest in a subject. Specialist service (e.g. renal, dental): Risks of non-implementation Potential outcomes if not implemented Lack of high quality service delivery. Service does not fulfil the needs of its users Inadequate knowledge and skill set for advanced MI is not valued nationally by Mi colleagues or the practice wider service community. No sharing of good practice, research findings or No positive publicity for the MI centre/pharmacy service developments with other MI centres in the locally or nationally. UK or further afield.
Satisfactory √ Commended √ 1. Service should always be available during the Service is extended to out-of-hours availability opening hours of the MI centre, (but not necessarily out of hours). 2. Specialist advisory service should have a Annual report on MI’s contribution to written statement outlining the services they are organisational/funders’ objectives produced. able to offer (e.g. enquiry answering support, Evidence of how the MI service has evolved or access to specialist clinician, references from adapted. specialist journals etc.) and the range of users the service is available to. 3. Service should produce guidance on where they would expect another MI centre to search before referring to specialist advisory service, and the background information the service requires from users in order to advise fully. 4. Point 2 and 3 above: Details are published on UKMi site 5. Service contributes to or shares their expertise Service contributes their expertise to non-MI for relevant UKMi activities e.g. Q&As, training activities e.g. publications, advisor at national materials. level outwith pharmacy, training other healthcare professionals. 6. Service has access to specialist healthcare professional in that field e.g. doctors, specialist pharmacist, nurses 7. Service has sufficient trained staff to provide the service. 8. Service has a training programme in place to train new MI staff (i.e. new to that centre) to handle the specialist calls. 9. Service has up-to-date resources, relevant to the area of specialty to facilitate enquiry answering. 10. Service has suitably trained staff available to answer urgent enquiries 11. Any funding is declared. Notes and Recommendations:
UKMi Clinical Governance Working Group May 2010 25 Summary of recommendations Previous audits Dates of previous audits: Action points from previous audit: Comments:
Recommendations and priorities from this audit
Comments by MI manager:
Comments by auditor:
Comments by senior pharmacy manager:
UKMi Clinical Governance Working Group May 2010 26 Appendices
Appendix 1: Visit letter template – MI Manager
The wording included here is a suggestion only and should be adapted according to local need/circumstances/personal preference etc.
Dear
Medicines Information Quality Assurance audit
I am writing to confirm that I will be visiting you to undertake a Quality Assurance audit of your MI service on
The standards that we will be assessing and a copy of the report that will be completed as a record of the visit can be found on the UKMi website/ Clinical Governance/ Service standards.
Prior to the visit (refer to ‘Procedures and checklist’ in the Audit standards and toolkit document) I will liaise with you regarding the most appropriate method for auditing your enquiries. This may be done on the day or electronically before the visit. Please refer to Procedures and checklist on page 5.
If not already undertaken a user satisfaction survey will need to be completed. A questionnaire is available on the UKMi website but a suitably adapted version is also acceptable. Please see page 14 for suggested sampling sizes which will vary according to the number of enquiries you do.
Complete as much as possible of the section ‘Background to the audited MI service’. This will be discussed and reviewed on the day.
Annotate the ‘Resources for Purchase by NHS MI centres’ with your current holding.
Consider completing the Time activity matrix available on the UKMi website/Clinical governance/service developments. Discuss with your line manager whether this would be useful bearing in mind that it is based on data collected in 2001.
Please also ensure you are familiar with the UKMi Audit standards and toolkit and gather together relevant documents for review.
The visit Time needed to complete the audit will depend on how much has been completed before the visit. Please ensure there is sufficient time to discuss the results of the enquiry audit and the content of the report. I have also written to your Senior Pharmacy Manager to ask them to arrange a convenient time for me to meet them during the visit.
This visit is also an opportunity for you to discuss any other relevant issues you wish. Please give this some thought before the visit.
A full report and any recommendations will be sent to yourself and your Senior Pharmacy Manager shortly after the visit.
I look forward to seeing you.
UKMi Clinical Governance Working Group May 2010 27 Appendix 2: Visit letter template – SPM/Principal Pharmacist responsible for MI
The wording included here is a suggestion only and should be adapted according to local need/circumstances/personal preference etc.
Dear
Medicines Information Quality Assurance visit
I will be visiting
I would like to meet with you briefly during my visit to discuss aspects of the QA programme and relevant MI issues. Please liaise with
A full report including any recommendations will be sent to yourself and your MI Manager shortly after the visit.
In the meantime, please feel free to contact me on the above number if I can be of any further assistance.
Yours sincerely
UKMi Clinical Governance Working Group May 2010 28 Appendix 3: Access to the service
Procedure The wording here is a suggestion and can be adapted.
Telephone
1. Telephone the relevant MIC using either the direct line or via the hospital switchboard.
2. Record the time taken (in seconds) or number of rings for the telephone to be answered (either by a person or answer machine).
3. If the telephone is answered use the following phrase: a. “This is name of caller from RMIC name. I am ringing as part of the QA programme. Is there an MI pharmacist or MI technician available to take this call?”
4. Record whether or not a MI pharmacist or MI technician is available.
5. If they are not available, ask: a. “when they will be available?”
6. Record when they will be available.
7. If the time exceeds 5 minutes ask: a. “is there another pharmacist available to answer urgent enquiries?” b. Note. If someone else is available, you do not need to speak to them.
8. Record whether or not there is another pharmacist available for urgent enquiries.
9. If the telephone switches to an answer machine leave the following message: a. “This is name of caller from RMIC name. I am ringing as part of the QA programme. Please could the MI pharmacist ring me back on xxxx as soon as they are available. Thank you”
10. Record whether or not a bleep number was provided in the message for urgent enquiries. a. Note. If a bleep number is provided you do not need to bleep it.
11. Record the time taken for the pharmacist to reply to your message.
Auditor’s note: Copy results into enquiry answering standard (see page 15) Telephone number: Date Time to Is an MI IF YES, If No, or time Answer machine. Time answer Pharmacist or WHEN ARE >5mins is another Is a bleep number taken for (seconds) MI technician THEY pharmacist available? reply to or number available? AVAILABLE available? answer of rings ? machine Yes No Yes No Yes No message
UKMi Clinical Governance Working Group May 2010 29 E-mail
1. Send an email to the relevant MIC, using the following standard message: This message is being sent as part of the UKMi Quality Assurance programme to assess access to the service. Please could the person responsible for MI reply to this message upon receipt. Please send the following response: "Message received and read". Thank you
2. Record the relevant details. Auditor’s note: Copy results into enquiry answering standard (see page 15) E-mail address: Date sent Time sent Date acknowledged Response time
Web
1. Submit a message via the web based enquiry form, using the following standard message: This message is being sent as part of the UKMi Quality Assurance programme to assess access to the service. Please could the person responsible for MI reply to this message upon receipt. Please send the following response: "Message received and read". Thank you
2. Record the relevant details. Auditor’s note: Copy results into enquiry answering standard (see page 15) Web address: Date sent Time sent Date acknowledged Response time
UKMi Clinical Governance Working Group May 2010 30 Appendix 4. Enquiry answer assessment form Copy according to number of enquiries to be assessed
Enquiry No. Documentation Analysis Coverage Answer Total (Max =20) Level:
Enquiry title: Comments: D: General comments:
A:
C:
Ans: Deadline met? Y/N
Enquiry No. Documentation Analysis Coverage Answer Total (Max =20) Level:
Enquiry title: Comments: D: General comments:
A:
C:
Ans: Deadline met? Y/N
Enquiry No. Documentation Analysis Coverage Answer Total (Max =20) Level:
Enquiry title: Comments: D: General comments:
A:
C:
Ans: Deadline met? Y/N
Enquiry No. Documentation Analysis Coverage Answer Total (Max =20) Level:
Enquiry title: Comments: D: General comments:
A:
C:
Ans: Deadline met? Y/N
UKMi Clinical Governance Working Group May 2010 31 Appendix 5. Definitions for ranking enquiries Level 1. Simple enquiries = Data - Information only, from one or two sources. Level 1 enquiries are mostly straightforward requests for information which any qualified pharmacist would be expected to be able to deal with using personal knowledge and/or readily available sources. In addition, simple enquiries that require use of medicines information resources, but do not require specialist professional expertise would be included in level 1, e.g. reference finding, tablet identification.
These enquiries can be answered using authoritative general reference texts. The BNF, the Data Sheet/SPC Compendium, and Martindale are the most obvious examples of these; although others such as local formularies and guidelines, paediatric formularies, and electronic databases such as Micromedex; might be considered level 1 sources, as they are often the first choice of resource for straightforward enquiries in medicines information centres.
For level 1 enquiries, the information found in the above sources can be passed on to the enquirer with relatively little need for further evaluation and interpretation, other than setting the information in context – particularly if the enquirer is not a health professional. Level 1 may also include contacting the pharmaceutical industry on behalf of the enquirer.
Many types of enquiry could fit into this category. Common examples might be as follows: requests for standard dosing information and/or administration instructions for licensed, or commonly accepted unlicensed indications; basic information about well known adverse effects; patient counselling over the telephone; identification of foreign drugs, tablet identification using TICTAC (either directly or by contact with the RDIC); ‘librarian services’ such as finding a particular reference for which some details are known; requests to contact the pharmaceutical industry for basic information about the availability, ‘out-of-fridge’ stability, or excipient content of their products.
Level 2. Enquiries of intermediate complexity = Searches - Multiple database and/or textbook searches. Little or no interpretation. Minimal advice given. Level 2 enquiries are requests for advice or information, which requires the use of more specialist resources and the application of clinical pharmacy expertise.
This is also a broad category of enquiries comprising those that either require use of information sources in addition to those outlined under level 1 or require evaluation and interpretation to allow them to be applied to a specific situation. Possible examples are as follows: dosing information for unlicensed indications; intravenous compatibilities not likely to be found in the SPC/data sheet e.g. admixtures or Y-site compatibilities; dosing adjustments for commonly-used drugs in renal failure (not requiring individualised pharmacokinetic calculations); checking for previous case reports of an adverse drug reaction; advice on drugs in pregnancy/lactation (but see below).
Level 3. Complex enquiries = Interpretation - Primary literature retrieval required. Interpretation & advice given. Specialist personal knowledge. Analysis/ evaluation of data. Most written answers. Level 3 enquiries are those that require specialist skills in literature retrieval and evaluation combined with clinical expertise in order to provide an adequate answer. Enquiries regarding comparative effectiveness of treatments, which require evaluation of clinical trials, would fall into this category. Also, enquires regarding safety and incidence of adverse effects – which require evaluation of pharmacoepidemiological data (this would include some drugs in pregnancy enquiries). Individual clinical problems which are unusual or complicated and not likely to be well documented in the literature would also come into this category, for example unusual co-morbidities, or drug interactions, as well as enquiries which require use of patient-specific data, such as pharmacokinetic calculations.
NB. The examples are for guidance only, some of the categories of enquiry listed above under one level may sometimes fit better into another, e.g. enquiries about drugs in pregnancy and lactation (listed as levels 2 and 3 above) may sometimes fit into level 1, if the drug concerned is widely used in pregnancy and its safety is well known.
UKMi Clinical Governance Working Group May 2010 32 Appendix 6. Criteria for grading answers to enquiries. This guidance is under review (May 2010)
CORRECT – score 5 INCOMPLETE – score 1-4 INCORRECT – Score 0 Document- Form is complete i.e. Form is complete to the extent that There are key omissions ation legible; with correct spelling and no the form is legible, i.e. (Standards are unfamiliar abbreviations; enquirer details are sufficient to permit the form is illegible the same for all enquirer details complete (full name, the enquirer to be traced, or a statement contact name and or levels of address/contact). If the enquirer that enquirer wished to remain means of contact are complexity) wished to remain anonymous, this is anonymous is present. missing. stated; a summary of the answer is present, the question and/or patient’s details are present if but there are one or more deficiencies, answer cannot be relevant, e.g. as follows: understood. the question is documented to allow a enquirer details are incomplete, e.g. first third party to tackle it without further name and department only, contact with the enquirer; patient details (if appropriate) are details of resources are complete missing or incomplete, including edition numbers; documentation of resources used is names of others contacted with regard incomplete. to the enquiry are recorded; a concise summary of the answer given is present (if the reply was in writing, the letter is attached). Analysis The form shows evidence that the Some relevant information (useful but not Question does not appear (As above) question has been fully understood, and essential) is missing which may have to have been understood, that sufficient, relevant background assisted in providing a more no background information has been obtained. comprehensive answer. Implications of information. Omissions in enquiry not fully understood enquiry. Coverage Level 1 – Simple enquiries = Data - Information only, from one or two sources. (Standards Shows evidence of use of relevant Accurate but not comprehensive personal Inaccurate personal depend on authoritative reference texts or knowledge used. Answer might have been knowledge used. Answer level of (if appropriate) accurate and up-to-date improved by use of additional/alternative not supported by relevant complexity) personal knowledge. references. texts. Level 2 – Enquiries of intermediate complexity = Searches - Multiple database and/or textbook searches. Little or no interpretation. Relevant authoritative general reference There is evidence appropriate texts have Key texts appear to have texts have been used. In addition, been used but omissions are apparent, been omitted. It is likely databases, in-house files and more and/or the resources have not been used in than important information specialised texts used where a systematic fashion (i.e. authoritative has been missed. appropriate. It appears unlikely that references first, then more specialised further useful information would be resources if needed). Some useful gained by further resource use. information may have been missed. Level 3 – Complex enquiries = Interpretation - Primary literature retrieval required. Interpretation & advice given. Specialist personal knowledge. Analysis/ evaluation of data. Most written answers. As for level 2. In addition, where As for level 2, and/or incomplete use of Key resources omitted. It necessary, a thorough search of the bibliographic databases where use of these is likely that important literature has been conducted. was necessary. information was missed. Answer Level 1 - Simple enquiries = Data - Information only, from one or two sources. (Standards Evidence that the answer is accurate The answer appears to be accurate and The answer is inaccurate, depend on and based on comprehensive supported, but there may have been some or the enquiry has not level of knowledge supported by appropriate problems, e.g. as follows: been answered at all, complexity) texts where necessary. The answer level of detail inadequate; and/or there has been a appears to have been communicated at serious failure in a suitable level (use of language) and by inappropriate level of communication; or communication. an appropriate method. communication method. Levels 2 and 3– Intermediate and complex enquiries. Evidence that comprehensive Accurate information has been supplied but The answer is inaccurate, knowledge and thorough consideration there are deficiencies e.g. in one or more of or the enquiry has not of the issues have been used in the following areas: been answered at all, formulating the answer. The information some issues relevant to the answer have and/or there has been a has been evaluated in a logical fashion. been overlooked; serious failure in Skill in interpreting the information and communication. application to individual circumstances the information has been passed on demonstrated. Calculations are correct. without evaluation, or insufficient The answer appears to have been evaluation; communicated at a suitable level (use of level of detail inadequate; language). The method of inappropriate level of communication or communication was appropriate. communication method
UKMi Clinical Governance Working Group May 2010 33 Appendix 7. Score calculator
Procedure Examine each enquiry record and assign level of complexity (1,2 or 3), according to the criteria above. Judge each enquiry record against the columns ‘Correct’, Incomplete’ and ‘Incorrect’ and assign a score. Enter the scores in the Enquiry Answer Assessment Form and calculator below. Also document any comments in the spaces provided in the recording sheets. The calculator will automatically calculate total scores, percentages and the number of enquiries for each level.
Score and level calculator NB. Double click to use as an Excel spreadsheet. Click outside of the table once finished.
MI Centre Date Enquiry No Level Document Analysis Coverage Answer Total % Max 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0% Totals 0 0 0 0 0 % max 0% 0% 0% 0% 0%
No % Level 1 0 0% Level 2 0 0% Level 3 0 0% Total 0
UKMi Clinical Governance Working Group May 2010 34 Appendix 8. Guide to auditor – Report writing
This toolkit can be used as the basis of the final report. However, to convert it to a readable report much of the process directions should be deleted. The following checklist contains suggestions for amendments before returning the preliminary report for comment and signing.
1. Change the footer to ‘Medicines Information Audit report – X hospital, date’. 2. Move the report cover from page 38 to the front, complete the relevant boxes and delete the existing front cover ‘UKMI audit standards and toolkit’. 3. Delete sections from the report not relevant to the audit e.g. specialist services. 4. Use the ‘Executive summary’ to highlight the commended points and recommendations for action under the relevant sections. 5. Use the ‘Summary of recommendations’ (page 26) to list the action points and priorities for action. 6. Replace ‘Appendix 4: Enquiry answer assessment form’ with form containing details of the 30 audited enquiries. This enables the MI manager to review these at a later date and implement any recommendations. 7. Insert details of Workload survey into appendices as appropriate. 8. Insert details of User survey score calculator as appropriate. 9. Insert details of Time activity matix as appropriate. 10. Insert any additional appendices as appropriate e.g. annual report, organisational chart. Remember to cross reference to these in the final report. 11. Delete ‘process’ appendices from the final report retaining only those containing data relevant to the audit. You may want to keep ‘Definitions for ranking enquiries’ and ‘Criteria for grading answers to enquiries’ as explanatory notes. 12. Renumber remaining appendices. These will be automatically updated in the contents table when you finally update that section. 13. Read report carefully to remove any further ‘process’ instructions and ensure references/hyperlinks within the document are appropriate. Remember if cross referencing with hyperlinked page numbers they will update automatically as document page numbers change. 14. Update contents table by right clicking then choosing update field option. Choose update entire table option. Format to desired font and size as normal. 15. Update any hyperlinked pages numbers in the document i.e. those highlighted blue are hyperlinked and can be updated by right clicking over them and choosing ‘update field’. 16. Send report to MI manager for comment with covering letter (page 39) appropriate. 17. Make any amendments suggested by MI manager and send final copy to MI manager and SPM (covering letter page 40) for signing.
UKMi Clinical Governance Working Group May 2010 35 Appendix 9. Workload survey results
Auditor’s note: Insert a copy of the latest workload survey results submitted to the regional centre for collation of national statistics.
UKMi Clinical Governance Working Group May 2010 36 Appendix 10. User survey of the medicines Information Centre – Score calculator.
Auditors note: Insert copy of completed calculator here. Questionnaire and calculator available at www.ukmi.nhs.uk/activities/clinicalGovernance/default.asp?pageRef=4.
UKMi Clinical Governance Working Group May 2010 37 Appendix 11. Report cover.
Auditor’s note: Use this as a replacement cover for producing the final report.
UKMi Audit Report measuring the quality of NHS medicines information services
Centre:
Medicines Informatio n manager:
Auditor:
Date of audit:
Pharmacy manager:
UKMi Clinical Governance Working Group May 2010 38 Appendix 12: Report letter template – MI Manager
The wording included here is a suggestion only and should be adapted according to local need/circumstances/personal preference etc.
Dear
Quality Assurance audit of Medicines Information Service
Please find enclosed the final audit report for your service for
Please arrange to review the report with your SPM. The report should be signed by yourself and your SPM and returned to me as soon as possible. Please keep a copy for your own records.
Please contact me if you would like to discuss any aspect of the report.
With best wishes
Yours sincerely
UKMi Clinical Governance Working Group May 2010 39 Appendix 13. Report letter template – SPM/Principal Pharmacist responsible for MI
The wording included here is a suggestion only and should be adapted according to local need/circumstances/personal preference etc.
Dear
Quality Assurance audit of Medicines Information Service
The final report for the
Please arrange to review the report with
Please contact me if you would like to discuss any aspect of the report.
With best wishes
Yours sincerely
UKMi Clinical Governance Working Group May 2010 40