1 NCEPOD Audit Tools Marisa Mason Chief Executive

2 NCEPOD What we do How we do it Use of study outputs – Reports – Checklists – Toolkits

3 Development of the toolkit To provide health care professionals with a tool to carry out local audits based on the findings of each of the NCEPOD reports Developed through pilot studies Aimed to be as simple to use as possible

4 Audit pack Data collection tool Data comparison tool Format

5 Audit pack Introduction and method Overall quality of care Key findings and recommendations Audit pack

6 Paper questionnaire Electronic questionnaire Questions relate to key findings and recommendations Data collection & comparison

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9 Paper questionnaire Electronic questionnaire Questions relate to key findings and recommendations Data collection & comparison

10 Data collection & comparison

11 Audit tools

12 Audit tool Available on our website Rolled out for each new study and being back dated for previous studies Examples of use – Reporting back to Trust boards – Junior doctors who needed to do an audit – Evidence of CPD activity – Compliance with NHSLA CNST standard 2.9 Audit tools

13 Audit tool Thank you Audit tools

14 Audit tool CNST Level 1 Your documented process must include: … d) how a gap analysis is conducted to identify shortfalls e) how action plans are developed to address any shortfalls, including recording decisions not to implement National Confidential Enquiry/Inquiry recommendations f) how the organisation monitors compliance with all of the above. Level 2 You must evidence implementation of your documented process in relation to: ― how a gap analysis is conducted to identify shortfalls ― how action plans are developed to address any shortfalls, including recording decisions not to implement National Confidential Enquiry/Inquiry recommendations. Level 3 You must evidence monitoring of your documented process in relation to: ― how a gap analysis is conducted to identify shortfalls ― how action plans are developed to address any shortfalls, including recording decisions not to implement National Confidential Enquiry/Inquiry recommendations. Where your monitoring has identified shortfalls, you must evidence that changes have been made to address them.