1 Meeting National Standards for Clinical Audit: NHS Litigation Authority Level 3 Helen ClarkeClinical Audit / NHSLA LeadMid Essex Hospital Services Trust
2 NHS Litigation Authority & Risk Management Standards MEHT approach to assessmentCriterion for Clinical AuditPerformance issues
3 NHS Litigation Authority (NHSLA) Clinical Negligence Scheme for Trusts;Liabilities to Third Parties Scheme; andProperty Expenses Scheme1.Risk Management Standards5 standards, each with 10 criteriaDesigned 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 assessmentFrequencyDiscountLevel 1PolicyThe process for managing risks has been described and documented in a formally approved document2 yearly10%Level 2PracticeThe process for managing risks is in use3 yearly20%Level 3 PerformanceThe 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 UnitJust under 600 beds3500 plus WTE staffNHSLA Level 2 achieved November 2008NHSLA Level 3 assessment November 2011Assessment preparation co-ordinated within Clinical Audit Department
6 Acute Services: our approach 1Identify Executive and Operational Lead(s)2Review policy against requirements including monitoring process3Develop audit plan for each criterion
7 Acute Services - our approach to level 3 4Audit findings reported to identified committee5Action plan developed to address any deficiencies6Progress monitored at subsequent meetings until closed
8 NHSLA Risk Management Standards 2012–13 Std 12345Criterion GovernanceLearning from ExperienceCompetent & Capable WorkforceSafe EnvironmentAcute, Community and Non-NHS ProvidersRisk Management StrategyClinical AuditCorporate InductionSecure EnvironmentSupervision of Medical Staff in TrainingPolicy on Procedural DocumentsIncident ReportingLocal Induction of Permanent StaffViolence & AggressionPatient Information & ConsentHigh Level Risk Committee(s)Concerns & ComplaintsLocal Induction of Temporary StaffSlips, Trips & Falls (Staff & Others)Consent TrainingRisk Management ProcessClaims ManagementRisk Management TrainingSlips, Trips & Falls (Patients)Maintenance of Medical Devices & EquipmentRisk RegisterInvestigationsTraining Needs AnalysisMoving & HandlingMedical Devices Training6Dealing with External RecommendationsAnalysis & ImprovementRisk Awareness Training for Senior ManagementHand Hygiene TrainingScreening Procedures7Health Records ManagementLearning Lessons from ClaimsMoving & Handling TrainingInoculation IncidentsDiagnostic Testing Procedures8Health Record- Keeping StandardsBest Practice - NICEHarassment & BullyingThe Deteriorating PatientTransfusion9Professional Clinical RegistrationNational Confidential Enquiries & InquiriesSupporting StaffClinical Handover of CareVenous Thromboembolism10Employment ChecksBeing OpenStressDischargeMedicines Management2.1 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; andKey findings & learning disseminated.
12 Audit Measures / Performance Compliance thresholdStandard met201120121Priority level identified95%2Factors influencing proposal identified3Proposal form completed with identified Project & Clinical Leads4a. Project standards based90%b. Standards identified5Directorate Audit Lead approval
13 Audit Measures / Performance Compliance thresholdStandard met201120126Audit completed / CA informed95%7Report submitted to CA8Appropriate report template75 %9Audit findings disseminated90%10Evidence action plan developed11Evidence of implementation12Plan for re-audit50%
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 ProgrammeCare Quality CommissionMonitorCQUINsMedical RevalidationNHSLA consultation