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Risk assessing clinical audit findings Anne Jones, Head of Clinical Audit and Effectiveness Kingston Hospital NHS Foundation Trust.

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Presentation on theme: "Risk assessing clinical audit findings Anne Jones, Head of Clinical Audit and Effectiveness Kingston Hospital NHS Foundation Trust."— Presentation transcript:

1 Risk assessing clinical audit findings Anne Jones, Head of Clinical Audit and Effectiveness Kingston Hospital NHS Foundation Trust

2 Session objectives To share our process for introducing a risk assessment approach to clinical audit results, focusing on: Why take a risk assessment approach? The road to risk assessment Undertaking the risk assessment – an example Escalation process Training the risk assessors Benefits to patient care Practical example

3 At a trust-wide or corporate level Clinical governance describes the structures, processes and culture needed to ensure quality of the care and continuous improvement Quality governance used by Monitor to refer to how a Board should lead on quality and identify and manage risks to quality. 1 Why take a risk assessment approach? 1 Bullivant J, Burgess R. Corbett-Nolan A. and Godfrey K. (2012) Good Governance Handbook. HQIP/Good Governance Institute

4 At the front line To support frontline clinicians to assess the significance of clinical audit results and ensure improvement in patient care Why take a risk assessment approach?

5 Relationship between clinical audit and risk Risk driving clinical audit -High risk is one of the main drivers of clinical audit topic choice 2 -‘Address specific local risks’ 3 -At Kingston, risk registers reviewed for topics for annual clinical audit programme and risks arising throughout the year are added to the clinical audit programme 2 Burgess R. (2011) New Principles of Best Practice in Clinical Audit, HQIP 3 Bullivant J, and Corbett-Nolan A.(2010) Clinical audit: A Simple guide for NHS Boards and partners, HQIP To: Anne Jones

6 Relationship between clinical audit and risk Clinical audit driving risk management ? -Quantify the implications for clinical and organisational practice including potential for harm Clinical audit can …. Identify major risk, resource and service development implications in an NHS trust ‘ 3 -At Kingston, process for linking clinical audit to risk and risk registers had not been formally established 3 Bullivant J, and Corbett-Nolan A.(2010) Clinical audit: A Simple guide for NHS Boards and partners, HQIP

7 Other drivers HQIP’s Clinical audit: A simple guide for NHS Boards and partners 3 “Ensure that clinical audit results having potential significance, due to the identification of a risk, are brought to the attention of the clinical governance committee …..” Grant Thornton’s paper ‘Clinical audit: a brave new world’? (2011) 4 “Results are not fed into organisational risk assessment. We see many examples of where individuals or groups learn from clinical audit and adjust their practice accordingly. However, we see virtually no examples where the results of clinical audit feed back into the board’s risk assessment and business planning. 3 Bullivant J, and Corbett-Nolan A.(2010) Clinical audit: A Simple guide for NHS Boards and partners, HQIP 4 Dossett P. (2011) Clinical audit: a brave new world? Grant Thornton

8 Francis Report 5 - Recommendation 5: The Board should review audit processes and outcomes on a regular basis. Keogh Report : Ambition 2 The boards and leadership of provider and commissioning organisations will …have rapid access to accurate, insightful and easy to use data about quality at service line level. A failing of one of the hospitals was noted as “The governance systems are not providing the expected level of assurance to the Board, and the escalation to the Board of risks and clinical issues is inconsistent” Berwick Report The most valuable information of all is information on risks and on things that have gone wrong p10 5 Francis Report 6 The Keogh Report (2013) Review into the quality of care and treatment provided by 14 hospital trusts in England 7 The Berwick report (2013) Improving the Safety of Patients in Englandhttp://www.midstaffspublicinquiry.com/report How does this fit with the current national picture?

9 What were we hoping to achieve? To provide clinicians, managers and clinical audit staff with a system to categorise and quantify the level of concern/risk o Escalate appropriate concerns upwards o Target resources To ensure a systematic approach where results are below standard To drive robust action planning and quality improvement To focus on areas where quality improvement is most required To feed back into Board’s risk assessment and business planning

10 SystemTimeframeDetail General reporting against standards Prior to 2011 Clinicians set standard to achieve prior to audit – met/not met RAG rating of clinical audit results 2011Clinicians set RAG standards to achieve prior to audit starting, producing RAG audit results. Review Clinicians found it difficult to set amber and red objectively. Unclear whether always flagging up the major issues or right issues. Risk assessment of clinical audit results 2013Clinicians set ‘green’ standard to achieve. If not achieved, risk assessment undertaken to more objectively categorise amber/red. Kingston Hospital’s road to risk assessment

11 5 steps in risk assessment 1. List the hazard – something with potential to cause harm 2. Decide who or what is affected by the hazard Evaluate risks arising from the hazard and decide whether existing controls are adequate - risk is effect of the hazard if it occurs 4. Record the risk assessment 5. Review the risk assessment as necessary

12 Kingston’s risk assessment form 8 8 Kingston Hospital NHS Foundation Trust (2013) Risk Identification, Assessment and Risk Register Procedure

13 Grading the consequences for audit of clinical quality 1 Negligible 2 Minor 3 Moderate 4 Major 5 Catastrophic Peripheral element of treatment/care suboptimal Overall treatment/care suboptimal Treatment/care of reduced effectiveness Unacceptable quality of treatment/ care Totally unacceptable quality of treatment / care Minimal intervention / treatment Minor intervention / treatment Moderate injury requiring intervention Major injury leading to long term incapacity Incident leading to death Increase in length of stay by 1-3 days Increase in length of stay by 4-15 days Increase in length of stay by >15 days Likelihood scoring 1 Rare 2 Unlikely 3 Possible 4 Likely 5 Almost certain Probably never happen Not expected to happen but may Might happen occasionally Will probably happen but not persistent Will undoubtedly happen, possibly frequently 8 Kingston Hospital NHS Foundation Trust (2013) Risk Identification, Assessment and Risk Register Procedure

14 At start of each clinical audit project, a target for acceptable care or treatment is agreed by the clinical team – ‘green’ RAG rating. Linked to policy, guideline or set standards. The audit is carried out and the results compared to the target(s) set. Result > target = Green Result 8 = Red rated Audit The process

15 Hazards (potential to cause harm): Antibiotic acquired infection, eg C. difficile, increased resistance to anti- biotics, side effects from treatment, longer recovery period, increased cost EXAMPLE: Antibiotic prescribing Audit criteria:TargetResult Indication given 95% 96% Stop/review date recorded70% Duration in accordance with guideline79% Antibiotic prescribed according to guideline or Micro89% Review/stop dates not put on antibiotic prescription charts and patients left on antibiotics too long. Incorrect antibiotics prescribed. Risks (effect on the patient/hospital): Risk rating Consequence 3 (moderate) x Likelihood 3 (possible) = 9 (RAG rated ‘Red’)

16 Hazard: Incorrect AB Duration of AB too long Risks: AB acquired infection; Treatment side effects; Longer recovery; AB resistance; Cost Medicines policy M-F Pharmacist WR Micro/Pharmacist twice weekly WR Stop date section on drug chart Trust-wide Safe and effective prescribing of antibiotics Training for junior docs Consultant supervision on ward rounds Weekly publication of data Daily Micro/Pharm WRs

17 Clinical Audit report Summary of results and RAG rating Audit criterionResultStandard set %Risk rating C x L RAG rating Indication for AB given96% 95% Stop date on chart70% 3 x 3 = 9Red Correct duration79% Correct antibiotic89% Action Plan RecommendationActionBarriersResponsibilityTimescale Train junior doctorsAdd to induction programmeNoneF1/F2 tutor Ensure drug charts are fully completed Supervision on ward roundsNoneConsultantsWeekly Ensure staff know results Publication via KPI scorecardNoneAudit Facilitator1 st of each month Extend input from Micro/Pharmacy Increase Antibiotic Pharmacist to FTE Budget restrictions Pharmacy Manager

18 Escalation of ‘red’ audit results Clinical audit results Reported to Clinical Audit Group and Clinical Division Risk Management Committee Reported to Quality Assurance Committee* * Sub Committee of the Trust Board Risk Register Red ◄ Challenge ►

19 An iterative process …. OriginalRevised Risk assessment for all criteria that did not meet standard Risk assessment of findings as a whole Undertaking a ‘quick’ risk assessment and proceeding to full risk assessment if risk >8 The full risk assessment was not lengthy and this two-step process made it more complicated

20 Training Trust-specific training delivered to Clinical Audit Facilitators by Risk Manager Training delivered to our Clinical Audit Leads by Risk Manager and Head of Clinical Audit Audit project leads trained by Clinical Audit Facilitators at the time of undertaking a risk assessment All managers and senior nursing staff trained in risk assessments

21 Your turn ……..

22 Identify the hazards List all the risks Existing controls: Falls Policy Audits Staff training Analysis of individual falls Nursing / Trustwide Describe the topic area Falls Audit example ? ? ?

23 Hazard: Failure to provide care plans for all patients at risk of falls Risks: Physical harm from fall; increase in LOS, increase in falls per1000 bed days Existing controls: Falls Policy Audits Staff training Analysis of individual falls Nursing / Trustwide Falls care plans Falls Audit example

24 Conclusions Greater clarity regarding the level of risk to patient care where clinical audit results do not meet standards – good for patients, clinicians and the Trust Board Greater objectivity than previous system Provides ‘at a glance’ results and allows clinicians, senior staff and Board members to concentrate on the things that matter Change and quality improvement to patient care is enhanced by ensuring action plans are robust and staff are held to account for completion, via risk register Work in progress Building into overall business planning

25 Thank you for attending this workshop Any questions


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