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Clinical Audit: a Simple Guide for NHS Boards & Partners

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Clinical Audit: a Simple Guide for NHS Boards & Partners Clinical audit: A simple guide for NHS Boards & partners Authors: Dr. John Bullivant, Director, Good Governance Institute (GGI) Good Governance Andrew Corbett-Nolan, Institute Chair, Institute of Healthcare Management (IHM) Contents Executive summary Executive summary 3 Whilst this guide is specifically about clinical audit, much of what • Delivers a return on investment. is described here is relevant to the way in which NHS Boards can • Improvements are implemented and sustained. 1. Clinical audit: Ten simple rules for NHS Boards 5 monitor clinical quality as a whole within the context of clinical or integrated governance. A PCT has specific responsibilities in relation to clinical audit that 2. Foreword 7 should be managed through the Professional Executive Clinical audit has been endorsed by the Department of Health in Committee (PEC) or an equivalent committee. 3. Clinical audit as part of the modern healthcare system 9 successive strategic documents as a significant way in which the quality of clinical care can be measured and improved. Originally, Boards should use clinical audit to confirm that current practice 4. Definitions and types of clinical quality review 11 clinical audit was developed as a process by which clinicians compares favourably with evidence of good practice and to reviewed their own practice. However, clinical audit is now 5. The importance and relationship of clinical audit to clinical ensure that where this is not the case that changes are made recognised as an effective mechanism for improving the quality that improve the delivery of care. governance, NHS Boards and their partner organisations 15 of care patients receive as a whole. It offers a crucial component of the drive to improve quality. Boards have not always done Clinical audit can: 6. The content and oversight of a clinical audit strategy 19 enough in the past to measure quality; now they must do so, and clinical audit provides a mechanism for this. • Provide evidence of current practice against national 7. The clinical audit cycle/spiral 23 guidelines or NHS standards. There are a variety of related processes which also have a role in 8. Roles and responsibilities 27 measuring and improving quality, such as confidential or • Provide information about the structures and processes of a significant event enquiries, patient surveys, research, peer healthcare service and patient outcomes. 9. References 30 review, internal audit and so on. None of these replace clinical audit and systematic clinical audit is the main way of assessing • Assess how closely local practice resembles recommended 10. Further reading, references and access to glossary 31 compliance of ongoing clinical care against evidence-based practice. standards. • Check “Are we actually doing what we think we are doing?” Clinical audit needs to be a strategic priority for boards as part of The purpose of clinical audit is to improve patient care. • Provide evidence about the quality of care in a service to their clinical governance function. Clinical audit is effectively the establish confidence amongst all of its stakeholders – staff, The focus of this guide is to provide an explanation of the review of clinical performance against agreed standards, and the patients, carers, managers and the public. importance and relevance of clinical audit in improving patient refining of clinical practice as a result. It is one of the key care to NHS Boards and their partner organisations. compliance tools at a board’s disposal and has an important role within the assurance framework. Clinical audit needs to be Boards will want to be assured that clinical audits are: It will also be useful to clinicians, managers, service users and carefully compared with, and is complementary to, internal • Material – i.e.that they are prioritised to focus on key issues partner agencies regarding the role of NHS Boards, their audit; however they are different processes. members and committees in gaining assurance that clinical and that the value outweighs the cost. Boards have a role in driving quality assurance, compliance, audit is relevant, focused and complete by ensuring results • Professionally undertaken and completed – i.e. clinical internal audit and ‘closing the loop.’ They need to ensure that are shared, acted on, reviewed and sustained. audits are undertaken and completed to professional the recommendations of reviews and clinical audits are actioned standards including the quality of data being analysed. This resource will be of value to Primary Care Trusts. by seeking assurance that improvements in care have been made. Ideally this should be part of an overall quality framework ISBN: 978-1-907561-01-6 • Producing results that are shared and acted upon. and should be reported in the trust’s publicly reported ‘Quality January 2010 Accounts.’ • Followed by improvements that are made and sustained. Trusts will be regulated and performance managed against their This document has been produced by the Good Governance Boards have clear questions they should ask about any clinical participation in clinical audit and the findings. Institute (GGI) audit programme in their trust. To advance clinical audit, roles www.good-governance.org.uk Boards will want assurance that there is a clinical audit strategy and responsibilities need to be clearly established. The board’s and the Healthcare Quality Improvement Partnership (HQIP) in place that meets their strategic priorities: role is to ensure that clinical audit is strategic; it happens with thanks to those who commented on earlier drafts. regularly; is clinically and cost effective; and is linked to the • Meets national commitments and expectations. Quality, Innovation, Productivity and Prevention (QIPP) agenda. Holland House • Prioritises local concerns. 4 Bury Street London • Integrates financial and clinical audit. EC3A 5AW 020 7469 2500 www.hqip.org.uk 3 1. Clinical audit: Ten simple rules for NHS Boards 1. Use clinical audit as a tool in strategic management; ensure the clinical audit strategy is allied to broader interests and targets that the board needs to address. 2. Develop a programme of work which gives direction and focus on how and which clinical audit activity will be supported in the organisation. 3. Develop appropriate processes for instigating clinical audit as a direct result of adverse clinical events, critical incidents and breaches in patient safety. 4. Check the clinical audit programme for relevance to board strategic interests and concerns. Ensure that results are turned into action plans, followed through and re-audit completed. 5. Ensure there is a lead clinician who manages clinical audit within the trust, with partners/suppliers outside, and who is clearly accountable at board level. 6. Ensure patient involvement is considered in all elements of clinical audit, including priority setting, means of engagement, sharing of results and plans for sustainable improvement. 7. Build clinical audit into planning, performance management and reporting. 8. Ensure with others that clinical audit crosses care boundaries and encompasses the whole patient pathway. 9. Agree the criteria of prioritisation of clinical audits, balancing national and local interests, and the need to address specific local risks, strategic interests and concerns. 10. Check if clinical audit results evidence complaints and if so, develop a system whereby complaints act as a stimulus to review and improvement. 4 5 2. Foreword What is clinical audit? The rationale behind this is clear, but boards have been slow to The universally accepted definition for both national and local recognise this opportunity and clinical focus at board level can still clinical audit as defined by the National Institute for Health and be described as modest. Clinical Excellence (NICE) in their ‘Principles for Best Practice in The Burdett Report (2006) found that only 14% of items in meetings Clinical Audit’ is: were rated as clinical. Trusts with higher levels of clinical issues discussed generally had a chief executive officer with a clinical “a quality improvement process that seeks to improve background who ensured that clinical issues were closely linked to patient care and outcomes through systematic review of care all trust developments including finance and information technology. against explicit criteria and the implementation of change. Aspects of the structure, processes, and outcomes of care are The Audit Commission report ‘Taking it on Trust’ (2009) found that selected and systematically evaluated against explicit “few trusts could set out how clinical audit was being used in a criteria. Where indicated, changes are implemented at an systematic way to address risks” and the failure to use clinical individual, team, or service level and further monitoring is audit to support the Board Assurance Framework (BAF) was used to confirm improvement in healthcare delivery.” identified as a significant weakness. NICE, 2002 The Audit Commission also criticised NHS organisations’ checks of the accuracy of clinical and activity data, finding “very little Clinical audit is a key element of clinical governance. This guide evidence of board level discussion or challenge of data quality”. sets out a range of actions and roles an NHS board should adopt to Where high-level involvement did exist, “this was the exception ensure that clinical governance supports the strategic direction of rather than the rule” (Figures You Can Trust, AC 2009). their organisation and enables them to promote and measure their commitment to quality. Much of what is described here, although There is also some concern that, in spite of the exhortations of the specifically written about clinical audit, can be translated to apply Integrated Governance Handbook (2006) and the Audit Committee to the way quality in clinical care is monitored and addressed. Handbook (2005), that boards continue to assess and review performance of cost and quality separately. Clinical audit should be seen as a continuous cycle of: NHS Boards need to be aware of the value and usefulness of • Deciding which topics to audit. clinical audit to their role in effective governance and delivering • Measuring care delivered against standards.
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