1. Meeting National Standards for Clinical Audit: NHS Litigation Authority Level 3
Helen Clarke
Clinical Audit / NHSLA Lead
Mid Essex Hospital Services Trust

2. NHS Litigation Authority & Risk Management Standards
MEHT approach to assessment
Criterion for Clinical Audit
Performance issues

3. NHS Litigation Authority (NHSLA)
Clinical Negligence Scheme for Trusts;
Liabilities to Third Parties Scheme; and
Property Expenses Scheme1.
Risk Management Standards
5 standards, each with 10 criteria
Designed to focus attention on key safety & quality areas.
1 NHSLA (2012) NHSLA Risk Management Standards for NHS Trusts providing Acute, Community, or Mental Health & Learning Disability Services and Non-NHS Providers of NHS Care

4. Assessment levels Level 1 2 yearly 10% Level 2 3 yearly 20%
Requirement at assessment
Frequency
Discount
Level 1
Policy
The process for managing risks has been described and documented in a formally approved document
2 yearly
10%
Level 2
Practice
The process for managing risks is in use
3 yearly
20%
Level 3 Performance
The process for managing risk is working across the entire organisation - where deficiencies have been identified through monitoring, action plans have been drawn up and changes made to reduce the risks.
30%

5. Mid Essex Hospitals Services Trust
Acute Trust with supra-regional St Andrews Plastics & Burns Unit
Just under 600 beds
3500 plus WTE staff
NHSLA Level 2 achieved November 2008
NHSLA Level 3 assessment November 2011
Assessment preparation co-ordinated within Clinical Audit Department

6. Acute Services: our approach1
Identify Executive and Operational Lead(s) 2
Review policy against requirements including monitoring process 3
Develop audit plan for each criterion

7. Acute Services - our approach to level 34
Audit findings reported to identified committee 5
Action plan developed to address any deficiencies 6
Progress monitored at subsequent meetings until closed

8. NHSLA Risk Management Standards 2012–13
Std  1 2 3 4 5
Criterion 
Governance
Learning from Experience
Competent & Capable Workforce
Safe Environment
Acute, Community and Non-NHS Providers
Risk Management Strategy
Clinical Audit
Corporate Induction
Secure Environment
Supervision of Medical Staff in Training
Policy on Procedural Documents
Incident Reporting
Local Induction of Permanent Staff
Violence & Aggression
Patient Information & Consent
High Level Risk Committee(s)
Concerns & Complaints
Local Induction of Temporary Staff
Slips, Trips & Falls (Staff & Others)
Consent Training
Risk Management Process
Claims Management
Risk Management Training
Slips, Trips & Falls (Patients)
Maintenance of Medical Devices & Equipment
Risk Register
Investigations
Training Needs Analysis
Moving & Handling
Medical Devices Training 6
Dealing with External Recommendations
Analysis & Improvement
Risk Awareness Training for Senior Management
Hand Hygiene Training
Screening Procedures 7
Health Records Management
Learning Lessons from Claims
Moving & Handling Training
Inoculation Incidents
Diagnostic Testing Procedures 8
Health Record- Keeping Standards
Best Practice - NICE
Harassment & Bullying
The Deteriorating Patient
Transfusion 9
Professional Clinical Registration
National Confidential Enquiries & Inquiries
Supporting Staff
Clinical Handover of Care
Venous Thromboembolism 10
Employment Checks
Being Open
Stress
Discharge
Medicines Management
2.1 Clinical Audit

9. Criterion on Clinical Audit (1of 2)
Level 1 - Policy a) duties b) how the organisation sets priorities for audit, including local and national requirements c) requirement that audits are conducted in line with the approved process for audit

10. Criterion on Clinical Audit (2 of 2)
d) how audit reports are shared e) report format including methodology, conclusions, action plans etc. f) how the organisation makes improvements g) how the organisation monitors action plans and carries out re-audits h) how the organisation monitors compliance with the above

11. Monitoring compliance with the Trust’s Clinical Audit Policy
Sample of clinical audit projects reviewed against specific measures;
Report submitted to Clinical Audit Group (CAG) for approval & development of action plan;
Progress monitored at subsequent CAG meetings; and
Key findings & learning disseminated.

12. Audit Measures / Performance
Compliance threshold
Standard met
2011
2012 1
Priority level identified
95% 2
Factors influencing proposal identified 3
Proposal form completed with identified Project & Clinical Leads 4
a. Project standards based
90%
b. Standards identified 5
Directorate Audit Lead approval

13. Audit Measures / Performance
Compliance threshold
Standard met
2011
2012 6
Audit completed / CA informed
95% 7
Report submitted to CA 8
Appropriate report template
75 % 9
Audit findings disseminated
90% 10
Evidence action plan developed 11
Evidence of implementation 12
Plan for re-audit
50%

14. Actions to address deficiencies
Robust gatekeeping by Clinical Audit Department;
Directorate Audit Lead role;
Increased clarity for about role;
Training commissioned;
Software purchased;
Annual review, performance data to Clinical Audit Group & Directorates.

15. The future ….. Cultural shift
Impact of regulatory, safety & quality improvement agendas:
Quality Accounts & HQIP / National Clinical Audit Programme
Care Quality Commission
Monitor
CQUINs
Medical Revalidation
NHSLA consultation

16. Any questions?