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Helen Clarke Clinical Audit / NHSLA Lead Mid Essex Hospital Services Trust 1.

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Presentation on theme: "Helen Clarke Clinical Audit / NHSLA Lead Mid Essex Hospital Services Trust 1."— Presentation transcript:

1 Helen Clarke Clinical Audit / NHSLA Lead Mid Essex Hospital Services Trust 1

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

3 3 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 Clinical Negligence Scheme for Trusts; Liabilities to Third Parties Scheme; and Property Expenses Scheme 1. 5 standards, each with 10 criteria Designed to focus attention on key safety & quality areas.

4 4 LevelRequirement at assessmentFrequencyDiscount Level 1 Policy The process for managing risks has been described and documented in a formally approved document 2 yearly10% Level 2 Practice The process for managing risks is in use 3 yearly20% 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. 3 yearly30%

5 5 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 1 Identify Executive and Operational Lead(s) 2 Review policy against requirements including monitoring process 3 Develop audit plan for each criterion 6

7 4 Audit findings reported to identified committee 5 Action plan developed to address any deficiencies 6 Progress monitored at subsequent meetings until closed 7

8 8 Std  Criterion  Governance Learning from Experience Competent & Capable Workforce Safe Environment Acute, Community and Non-NHS Providers 1 Risk Management Strategy Clinical Audit Corporate InductionSecure Environment Supervision of Medical Staff in Training 2 Policy on Procedural Documents Incident Reporting Local Induction of Permanent Staff Violence & Aggression Patient Information & Consent 3 High Level Risk Committee(s) Concerns & Complaints Local Induction of Temporary Staff Slips, Trips & Falls (Staff & Others) Consent Training 4 Risk Management Process Claims Management Risk Management Training Slips, Trips & Falls (Patients) Maintenance of Medical Devices & Equipment 5 Risk RegisterInvestigations 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 ChecksBeing OpenStressDischarge Medicines Management 2.1 Clinical Audit

9 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 9

10 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 10

11  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. 11

12 12 Audit Measures Compliance threshold Standard met 2011 Standard met Priority level identified95% 2 Factors influencing proposal identified 95% 3 Proposal form completed with identified Project & Clinical Leads 95% 4 a. Project standards based 90% b. Standards identified 5Directorate Audit Lead approval95%

13 13 Audit Measures Compliance threshold Standard met 2011 Standard met Audit completed / CA informed95% 7Report submitted to CA95% 8Appropriate report template75 % 9Audit findings disseminated90% 10Evidence action plan developed90% 11Evidence of implementation90% 12Plan for re-audit50%

14  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. 14

15  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 15

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