1. Title of Clinical Audit Project Name of presenter Date of presentation Presentation template via www.clinicalaudittools.comwww.clinicalaudittools.com

2. Background to the audit Why was the topic selected? - high risk, high volume, high cost - patient safety incident or compliant - mandatory (e.g. NCA) or commissioner-led - other Who acted as the audit lead? Did the audit have to gain approval? - e.g. clinical audit registration process/committee approval Presentation template via www.clinicalaudittools.comwww.clinicalaudittools.com

3. Aim of the audit The aim should be expressed as a singular statement (not a number of separate aims) The aim clearly states what the audit hopes to achieve For example, the aim for a clinical audit might be to: - improve the quality of clinical record keeping within the organisation Useful verbs to use when writing an audit aim, include: - to improve, to enhance, to ensure, to change, etc. Presentation template via www.clinicalaudittools.comwww.clinicalaudittools.com

4. Objectives of the audit Whereas the aim of the audit is a broad and over-arching statement, objectives add further clarity Objectives describe the steps needed in order to measure if the aim has been achieved For example, the objectives for a clinical audit might be to: - assess current records to see if they meet best practice - identify examples of good record keeping to cascade - identify examples of poor record keeping to highlight problems and aid training for staff members (e.g. legal requirements) Presentation template via www.clinicalaudittools.comwww.clinicalaudittools.com

5. Identifying Best Practice Describe how best practice was identified, e.g. searching the evidence/literature, professional consensus, asking patients and other stakeholders, etc. Explicitly state best practice source used for the audit, e.g. Nursing and Midwifery Council’s ‘Record keeping: Guidance for nurses and midwives’ (July 2009), or Royal College of Physicians approved ‘Generic Medical Record Keeping Standards’ (2007) Presentation template via www.clinicalaudittools.comwww.clinicalaudittools.com

6. Criteria and standards Criteria and standards inform the audience specifically what aspects of care are being measured Criteria and standards highlight best practice Include exceptions (i.e. justified reasons which may result in care not meeting the agreed standard) List criteria and standards in a table CriterionStandardException Clinical records must be written in black ink 100%Annotations by pharmacists will be in purple ink Presentation template via www.clinicalaudittools.comwww.clinicalaudittools.com

7. Population and sample Describe how the population for the audit was identified, e.g. ‘all patient records in the hospice’ were included in the audit Provide details of any sampling techniques that were employed as part of the audit, for example: - confidence level of sample = x% +/-x% - sample method = random, systematic, etc. Presentation template via www.clinicalaudittools.comwww.clinicalaudittools.com

8. Data collection How was the clinical audit data collected? e.g. electronically, via a data collection form, using an online tool, etc. What data items were collected, e.g. demographic, clinical, etc. When was the data collected (times/dates/years) and approximately how long did it take to collect the data? Who collected the clinical audit data? How was patient confidentiality maintained? Provide details if a pilot data collection was conducted If possible, show the audience the data collection tool used (this may be a via a computer screenshot or handout) Presentation template via www.clinicalaudittools.comwww.clinicalaudittools.com

9. Data analysis How was the clinical audit data analysed? e.g. computer query, electronic package (excel/snap/formic/survey monkey), by hand (tally chart) When was the data analysed (times/dates/years) and approximately how long did it take to analyse the data? Who analysed the clinical audit data? Presentation template via www.clinicalaudittools.comwww.clinicalaudittools.com

10. Audit results Show audit results in a user-friendly way that the audience will understand Ensure audit results compare care to standard/s Display data consistently, e.g. either numeric or graphic Ensure patient and individual clinician confidentiality is maintained (unless clinicians have agreed otherwise) CriterionStandardResult Clinical records must be written in black ink 100%133/156 =85.3% (n=158, 2 exceptions) Presentation template via www.clinicalaudittools.comwww.clinicalaudittools.com

11. Observations Follow Pendleton’s Rules and outline where care meets best practice or is close to it Identify any areas for improvement, i.e. where care is less than agreed best practice Identify limitations of the audit, e.g. patient records that could not be accessed, problems analysing, suggestions on how the audit may have been conducted differently, factors that impacted on the audit results NB All observations must be backed by factual evidence Presentation template via www.clinicalaudittools.comwww.clinicalaudittools.com

12. Discussion This will depend on whether the audit findings have been discussed and recommendations made or if the intention is to use the presentation to generate discussion… Presentation template via www.clinicalaudittools.comwww.clinicalaudittools.com

13. Recommendations and actions List the main recommendations from the audit Specify what actions need to be carried out: areas for improvement, what action will be implemented, who will lead on the implementation, when will the action be implemented, etc. Area for improvement Action to implement Who will take lead Date for action Black ink not routinely used in clinical notes NHS supplies to only buy black pens Office Manager1 st December 2012 Presentation template via www.clinicalaudittools.comwww.clinicalaudittools.com

14. Next steps Audit report will be written and disseminated to relevant staff by [given date] Audit actions will be implemented by [given date] Re-audit will commence on [given date] Presentation template via www.clinicalaudittools.comwww.clinicalaudittools.com

15. Acknowledgements A list should be provided of all those who helped to conduct the clinical audit project, for example: - Research librarian (for identifying best practice) - IT department (for identifying patients) - Nursing staff (for collecting clinical audit data) - Clinical audit facilitator (general support) - Local hospital Trust (for sharing their audit report) Presentation template via www.clinicalaudittools.comwww.clinicalaudittools.com

16. References List all references relevant to the clinical audit Use a recognised referencing system, e.g. Vancouver Presentation template via www.clinicalaudittools.comwww.clinicalaudittools.com