Clinical Audit Annual Report 2011

Julie Evans 13th April 2012 Clinical Audit Annual Report 2011

Author: Julie Evans

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Contributions: Claire Gorzanski

Clinical Audit Annual Report 2011 Contents

Introduction

Page 3

Background

Page 3

Clinical Audit Activity

Page 4

Staffing

Page 5

National Audit Participation

Page 5-7

NICE guidance and Compliance

Page 7-8

Highlights in 2011

Page 8

Areas for development 2012-13

Page 8

Recommendations 2012

Page 9

Clinical Audit Program 2012-13

Clinical Audit Annual Report 2011

Appendix 1

Author: Julie Evans

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Contributions: Claire Gorzanski

1.0

Introduction

1.1 Clinical audit provides a means of measuring how well care is being provided compared to expectations of good practice. It is a cyclical process that demonstrates that improvement has been achieved and sustained. Its purpose is to benefit patients through systematic review of care against explicit criteria and the implementation of change. 1.2 According to the publication by the Healthcare Quality Improvement Partnership (HQIP) ‘Clinical Audit: a simple guide for NHS Boards and Partners’, clinical audit needs to be a strategic priority for Boards as part of their quality governance function. The Clinical Governance Committee and Board will want to be assured that clinical audits are: • • • •

Prioritised to focus on key areas Professionally undertaken and completed Produce results Followed by improvements

Salisbury NHS Foundation Trust has sound clinical audit structures and processes and this annual report should offer the Board the assurance that clinical audit is embedded in the practices of the Trust. As always, there is room for improvement and these are outlined under recommendations, later in the report. 2.0

Requirements

2.2 The Care Quality Commission outcome 16 – Assessing and monitoring the quality of service provision states that organisations should ‘gather information about safety and quality of their service from all relevant sources, including: audits’ and ‘submit, where appropriate, information to be collected as part of national mandatory data collection systems’ and finally ‘use the findings from clinical and other audits, including those undertaken at a national level, and national service reviews to ensure action is taken to protect people who use services from risks associated with unsafe care, treatment and support’, 2.3 In the Trust this is demonstrated in a number of ways: Completion of the Trust’s annual audit programme which includes audits supporting risk management, patient experience and clinical effectiveness (through audit of all NICE guidance), monitoring of all audit activity through the Online System for Clinical Audit (OSCA); good participation in national audits and national datasets / registries; and a review of published national audit reports and action plans through the Clinical Management Board (CMB) 2.4 Improving arrangements for audit in all clinical departments and making participation in audit processes in accordance with contemporary standards of practice as recommended in the Francis Enquiry, remains a challenge. Reporting of clinical audit activity in the Directorate 3:3 meetings is improving but further work with the Directorates to assist them to develop an annual audit programme that offers assurance will continue in 12/13 3.0 Clinical Audit Activity 3.1

The high volume of national and NICE audits that SFT participates in has taken priority, with most departments and clinical teams being involved in this activity. As a consequence there has been a slight decrease in local clinical

Clinical Audit Annual Report 2011

Author: Julie Evans

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Contributions: Claire Gorzanski

audit activity which may be due to a decrease in the Nursing Audit Toolkit audits that have been undertaken. There has also been a slight decrease in the number of Clinical Guidelines produced and an increase in the number of these that have been non-applicable to the Trust. 3.2

The total reports received has stayed quite consistent but low, however the number of action plans received has fallen over the last three years. These are two areas of work that the audit department will be seeking to improve over the next financial year. 2009 -2010

2010 - 2011

2011 - 2012

367

326

272

52 (14%) 172 (47%)

45 (14%) 162 (50%)

33 (12%) 124 (46%)

Number of audits resulting in an action plan (or where no action necessary)

168 (46%)

138 (42%)

98 (36%)

Change implemented/All actions completed

27 (7%)

26 (8%)

31 (11%)

Total number of audits for the period 1 April – 31 March Number of re-audits Number of audit reports received

3.3 The online system for clinical audit (OSCA) has been used to record all clinical audits started in 2011/12. This includes all national, regional, contract, local and NICE audits carried out within the Trust. 3.4 Clinical audit results that have potential significance, due to identification of risk, deterioration of clinical quality or show good results compared to benchmark data are bought to the attention of the clinical risk group or CMB for agreed action. The Head of Clinical Effectiveness reviews all audit reports on OSCA and ensures feedback to the clinical audit leads and DMT’s as appropriate. 3.5 The annual ‘striving for excellence’ awards include a number of clinical audit projects that have shown improvement in practice following changes and re-audit activity. Clinical audit leads are also encouraged to publish their audit results / reports in the bimonthly clinical governance newsletter or to present at one of the monthly ‘hospital rounds’. The trainee doctor health improvement projects also encompass clinical audit as a tool for service improvement 4.0

Staffing

4.1 Clinical audit activity in the Trust is supported by a centralised clinical audit department which is currently part of the Quality Directorate. Each Facilitator supports one designated Clinical Directorate and assists them with national, regional, local and NICE audits. The clinical audit team co-ordinates the Trust annual audit programme, ensuring timely completion.

Clinical Audit Annual Report 2011

Author: Julie Evans

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Contributions: Claire Gorzanski

The clinical audit team comprises the following Acting Senior Clinical Audit Facilitator (0.3 wte)

Clinical Audit / OSCA Administrator (0.76 wte)

Clinical Audit Facilitator (1.0 wte)

Clinical Audit Facilitator (1.0 wte)

Clinical Audit Facilitator (0.4 wte )

Clinical Audit Facilitator 0.5wte

Clinical Audit Facilitator (0.6 wte )

Clinical Audit Data Collector (0.2 wte)

4.2 The online system for clinical audit (OSCA) has enabled the monitoring of all clinical audit activity and all phases of the audit cycle and routine clinical audit reports are made available to DMT’s and individual clinicians as required. 4.3 The Clinical Audit Facilitators have been trained in clinical audit methodology and processes and as such they are technically competent to undertake clinical audit. Some of the staff also hold a recognised teaching certificate and nursing qualifications. Some of the clinical audit staff have also been trained in the use of FORMIC and Excelicare data forms. 4.4 The facilitators undertake clinical audit training for all disciplines of staff. The training programme now encapsulates how to get the most out of OSCA, service improvement methodologies and what library services are available. 4.5 Further links are needed with the safety project and the information department database developments. 5.0

National Audit Participation

5.1 The Trust remains active in the national audit programme with full participation in nearly all relevant audits – 88% this year (see table). Audits

Eligible Participation

% of cases submitted to each audit

Peri and Neo-natal Perinatal Mortality (MBRRACE-UK) Neonatal Intensive and Special Care (NNAP)

Yes Yes

Yes Yes

100% 100%

Yes

No

N/A

Children Paediatric Pneumonia (BTS) Clinical Audit Annual Report 2011

Author: Julie Evans

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Contributions: Claire Gorzanski

Paediatric Asthma (BTS) Pain Management (CEM) Childhood Epilepsy (RCPH) Paediatric Intensive Care (PICANet) Paediatric Cardiac Surgery (NICOR) Diabetes (RCPH)

Yes Yes Yes No No Yes

No Yes Yes N/A N/A Yes

N/A 100% 100% N/A N/A 100%

Emergency Use of Oxygen (BTS) Adult Community Acquired Pneumonia (BTS) Non Invasive Ventilation – Adults (BTS) Pleural Procedures (BTS) Cardiac Arrest (National Cardiac Arrest Audit)

Yes Yes Yes Yes Yes

Yes Yes Yes No No

Severe Sepsis and Septic Shock (CEM) Adult Critical Care (ICNARC) Seizure management

Yes Yes Yes

Yes Yes Yes

100% 100% 100% N/A Ongoing local audit as part of safety work stream 100% 100% 100%

Yes Yes Yes Yes Yes Yes Yes

Yes Yes Yes Yes Yes No No

100% 100% 100% 100% 100% N/A N/A

Hip, knee and Ankle Replacements (National Joint Registry) Elective Surgery (PROMs)

Yes

Yes

100%

Yes

Yes

Variable across 4 procedures

Intra-thoracic Transplantation (NHSBT UK) Liver Transplantation (NHSBT UK) Coronary Angioplasty (NICOR Adult Cardiac Interventions Audit) Peripheral Angioplasty (VSGBI Vascular Surgery Database) Carotid interventions CABG and Valvular Surgery (Adult Cardiac Surgery Audit)

Yes Yes Yes

N/A N/A N/A

N/A N/A N/A

Yes

Yes

100%

Yes No

Yes N/A

100% N/A

Yes Yes Yes Yes

Yes Yes Yes Yes

100% 100% 100% 100%

No No

N/A N/A

N/A N/A

Yes Yes Yes Yes

Yes Yes Yes Yes

100% 100% 100% 100%

Yes Yes

Yes Yes

100% 100%

No

N/A

-

Acute Care

Long Term Conditions Diabetes – Adults Heavy Menstrual Bleeding (RCOG) Chronic Pain Ulcerative Colitis and Crohn’s Disease (UK IBD Audit) Parkinson’s Disease Adult Asthma (BTS) Bronchiectasis (BTS)

Elective Procedures

Cardiovascular Disease Acute Myocardial Infarction and Other ACS (MINAP) Heart Failure Acute Stroke (SINAP) Cardiac Arrhythmia (Cardiac Rhythm management Audit)

Renal Disease Renal Replacement Therapy (Renal Registry) Renal Transplantation (NHSBT UK)

Cancer Lung Cancer (NLCA) Bowel Cancer (NBCAP) Head and neck Cancer (DAHNO) Oesophago-Gastric Cancer

Trauma Hip Fracture Severe Trauma (TARN)

Psychological Conditions Prescribing in Mental Health Services (POMH)

Clinical Audit Annual Report 2011

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Contributions: Claire Gorzanski

Schizophrenia

No

N/A

-

Yes Yes

Yes Yes

100% 100%

Yes

Yes

100%

Yes

Yes

100%

Blood Transfusion Bedside Transfusion Medical Use of Blood

Health promotion Risk Factors (National Health promotion in Hospitals Audit)

End of Life Care of the Dying in Hospital (NCDAH)

5.2 The process of reporting on the findings and proposed action to the Trust has improved through the year. The Clinical Leads are requested to present the results and proposed action to the CMB within three months of publication of the national report – 85% of all reports published this year were presented at the CMB. 5.3 For NCEPOD reports that cover more than one team or Directorate are presented to the relevant group / committee e.g. The CMB received the NCEPOD reports ‘Are We There Yet’ and ‘Knowing the Risk’ along with departmental action plans which will be monitored through to completion. 5.4 The national datasets and registries are more difficult to report on in the Trust as the reports are published annually (but with data from previous year) and the results are not always participant identifiable e.g. Head and Neck. The data is also collected and sent externally with no internal reporting currently undertaken outside of the clinical team themselves. 6.0

NICE guidance and Compliance NICE Clinical Guidelines Published Between 1st April 2011 and 31st March 2012 3 6 2

2

6 Compliant (CGs 121, 122, 126) In Progress (CGs 132, 137) Not Started - Baseline (CGs 128, 130, 131, 133, 134, 135) Non-Compliant Low Risk (CGs 129, 124) N/A to SFT (CGs 123, 125, 127, 133, 136, 139)

Clinical Audit Annual Report 2011

Author: Julie Evans

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Contributions: Claire Gorzanski

6.1

The clinical audit department has set a standard that all clinical guidelines published by NICE will have a baseline audit undertaken within 5 months and a report and action plan by 8 months after publication.

6.2

Any standards that the Trust is not compliant with are risk assessed by the clinical teams. Any risk rating over 12 is considered a high risk and must be re-audited within 6 months. Risk ratings under 12 are classed as low risk and must be re-audited within a year. The last NHSLA assessment showed the Trust was compliant with this standard.

6.3

During 2012 the CMB ratified the process for baseline assessments of NICE Quality Standards. The process is similar to that of the Clinical Guidelines and all assessments must be completed within 8 months of publication. So far 3 Quality Standards have been assessed and found to be non-compliant low risk.

7.0

Highlights in 2011 •

The annual health care records audit was again undertaken through the intranet using FORMIC web forms – all departments loaded the data electronically and the clinical audit department analysed the data and wrote the report. The report was presented to the Health Care Records Committee and the CMB. This year had the most clinicians participating and the highest number of records audited.



The department hosted a further placement of Interprofessional Learning Students for module 2 relating to Clinical Audit. This year the group were asked to audit the smoking status of patients pre-op and how good the trust was at offering advice to stop smoking.



The team is now fully staffed which has enabled Facilitators to better support teams and directorates throughout the trust. This has helped to improve the standard of audit that is being undertaken.



The Trust achieved Level 2 of the NHSLA risk management standards for NICE, NCEPOD processes and Clinical Audit policy.



The Clinical Audit Team are cleaning up any old or unfinished audits that have been submitted through OSCA. So far all audits from 2008 have been cleared and further work is being done to clear outstanding audits from 2009.



The department now has 4 Key Performance Indicators to monitor activity and efficiency of the team. A KPI report is reviewed by the Head of Clinical Effectiveness on a monthly basis.

8.0

Areas for Development 2012-13 •

There continue to be too many local audits undertaken with too few re-audits to ensure improvement in practice has been made and sustained. The DMT’s need to review the audit activity in their Directorates and set an annual programme that will support Quality Improvements.

Clinical Audit Annual Report 2011

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Contributions: Claire Gorzanski



Facilitators have not been able to reach the Junior Doctors to educate them about good clinical audit which may help to decrease the amount of unfinished audits within the Trust.

9.0

Clinical Audit programme 2012

9.1

The Trust’s clinical audit programme is a prioritised list of audits that we plan to complete in the coming year. It consists of the National Clinical Audit and Patient Outcomes Programme (NCAPOP) which is a set of centrally-funded national projects that provide local Trusts with a common format by which to collect audit data. Data is analysed centrally and comparative findings are reported back to participating Trusts so that they can identify necessary improvements for patients. Participation in this programme is a mandatory report within the Quality Account. From 2012 the Trust must contribute a maximum of £23,500 to take part in 9 national audits.

9.2

In addition, the programme includes national audits set by independent providers such as the Royal Colleges, National Confidential Enquires, national continuous datasets, NICE clinical guidelines and technology appraisals, NHS Litigation Authority (NHSLA) requirements, PCT contractual requirements and local clinical governance / Quality Account priorities.

10.0 •

Recommendations for 2012 Assist Directorate management teams to develop Directorate and department audit programmes are that are linked to the Trust priorities and Directorate needs. Improve assurance that clinical audits have led to improvement in service delivery (both clinical and cost effectiveness) through completion of action plans. This needs to be a focus for all teams this year. Work closely with clinical information to make best use of the emerging technology of Excelicare forms to collect data (instead of FORMIC) and link to the ‘clinicians view’ to make clinical audit ‘real time’ Ensure that all completed reports are added to OSCA and work with teams to increase re-audit percentage and completion of action plans. Further refine OSCA and develop its reporting function including reports for DMT’s to use for quality assurance purposes and for clinicians to use for appraisals and revalidation To ensure that all Quality Standards that have been published to date are baseline assessed following the process agreed at CMB and in a timely manner.





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Clinical Audit Annual Report 2011

Author: Julie Evans

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Contributions: Claire Gorzanski

Appendix 1

Trust Wide Audit Programme 2012 – 2013 Audit Title

Type

Priority

Directorate

NCAPOP PROGRAMME Food and Nutrition (1yr development project) IBD Pain Database Dementia Continence Care Falls and Bone Health Sentinel Stroke Stroke Improvement Audit Project Stroke National Audit Project Epilepsy 12 (Paeds)

National

High

Quality

National National National National National National National National National

High High High High High High High High High

Diabetes (Paeds)

National

High

Heavy Menstrual Bleeding

National

High

Medicine Musculo-Skeletal Medicine Medicine Medicine Medicine Medicine Medicine Clinical Support and Family Services Clinical Support and Family Services Clinical Support and Family Services

College of Emergency Medicine Fever in Children #NOF Renal Colic British Thoracic Society Emergency Oxygen Adult Asthma Bronchiectasis Paediatric Asthma Paediatric Pneumonia

National National National

High High High

Medicine Medicine Medicine

National National National National National

High High High High High

Adult Community Acquired Pneumonia

National

High

Adult NIV National Blood Service 2011 Audit of the medical use of red cells 2012 Audit of blood sampling and labeling 2012 Audit of the use of Anti-D 2013 Audit of patient information and consent NCEPOD Elective & emergency surgery

National

High

Medicine Medicine Medicine Medicine Clinical Support and Family Services Clinical Support and Family Services Medicine

National National National National

High High High High

Medicine Medicine Medicine Medicine

National

High

National National National National

High High High High

Surgery / MusculoSkeletal Surgery / Paediatrics Medicine Surgery Medicine

Paediatric surgery Cardiac arrest Procedures Peri-operative care Alcoholic Liver Disease

Clinical Audit Annual Report 2011

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Contributions: Claire Gorzanski

Subarachnoid Hemorrhage National High Contract/CQUIN Patient Moves Contract High Unplanned Return to Theatre Contract High Access to contraception advice during Contract High delivery of abortion services Evidence based steps to promote normal Contract High birth Discharge Summaries Contract High NICE QS 6 monthly Report Contract High Annual Audit Report Contract High Learning Disabilities Contract High Dementia Contract High End of Life Care Contract High Communication (OP Clinic Letters) Contract High Essential Standards: Dementia, Learning Contract High Disabilities, mental Health, Older People Elective Care Contract High Discharge Plan within 24 hours of elective Contract High admissions Discharge plan within 48 hours of nonContract High elective admissions NHSLA Consent 2012 Local High Health Care Records 2012 Local High Prescription 2012 Local High NICE Non-Compliant Quality Standards (Low Risk Re-Audits) Specialist Neonatal Care Local High Stroke Local VTE Local NICE Quality Standards (Baseline Assessments) Alcohol dependence and harmful alcohol Local use Breast cancer Local Chronic heart failure Local Chronic kidney disease Local Chronic Obstructive Pulmonary Disease Local (COPD) Dementia Local Depression in adults Local Diabetes in adults Local End of life care in adults Local Hip fracture for adults Local Lung cancer for adults Local Patient experience in adult NHS services Local Glaucoma Local NICE Quality Standards (Awaiting publication) Ovarian Cancer Local Bacterial Meningitis and Meningococcal Local Septicaemia in Children Autism in Adults Local Antenatal Care Local Stable Angina Clinical Audit Annual Report 2011

Local Author: Julie Evans

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Medicine Quality Quality Quality Quality Quality Quality Quality Quality Quality Quality Quality Quality Quality Quality Quality

Quality Quality Quality

High High

Clinical Support and Family Services Medicine Quality/Medicine

High

Medicine

High High High High

Medicine Medicine Medicine Medicine

High High High High High High High High

Medicine Medicine Medicine Medicine Musculo-Skeletal Medicine Quality Surgery

High High

Medicine Clinical Support and Family Services Medicine Clinical Support and Family Services Medicine

High High High

Contributions: Claire Gorzanski

Colorectal Cancer Nutrition Support in Adults Drug Use Disorders

Local Local Local

High High High

Patient Experience in Genetic Terms

Local

High

NICE Non-Compliant Clinical Guidelines (Low Risk Re-Audits) CG015 – Type 1 Diabetes Local Low CG016 - Self-harm CG054 - Urinary tract infection in children: diagnosis, treatment and long-term management CG059 - The care and management of osteoarthritis in adults CG067 - Lipid Modification CG068 – Stroke CG083 - Critical illness rehabilitation CG084 - Diarrhoea and vomiting in children under 5 CG084 - Diarrhoea and vomiting in children under 5 CG095 - Chest pain of recent onset CG098 - Neonatal Jaundice

Surgery Medicine Clinical Support and Family Services Clinical Support and Family Services Clinical Support and Family Services Medicine Clinical Support and Family Services

Local Local

Low Low

Local

Low

Musculo-Skeletal

Local Local Local Local

Low Low Low Low

Medicine Medicine Musculo-Skeletal Medicine

Local

Low

Local Local

Low Low

CG099 – Constipation in Children

Local

Low

CG100 - Alcohol Use Disorders - Clinical Management CG102 - Bacterial Meningitis and Meningococcal Septicemia in Children CG104 - Metastatic Malignant Disease of Unknown Primary Origin CG108 - Chronic Heart Failure (Partial Update) CG109 - Transient Loss of Consciousness in Adults CG109 - Transient Loss of Consciousness in Adults CG112 - Sedation in Children and Young People CG119 - Diabetic foot problems - inpatient management NICE Clinical Guidelines (Baseline Audits) CG111 - Nocturnal Enuresis in Children (Bedwetting) (October 10) CG128 - Autism in children and young people (September 2011) CG130 - Hyperglycaemia in acute coronary syndromes (October 2011) CG131 - Colorectal Cancer (November 2011) CG133 - Self-harm: Longer-term Management (November 2011) CG134 – Anaphylaxis (December 2011)

Local

Low

Clinical Support and Family Services Medicine Clinical Support and Family Services Clinical Support and Family Services Medicine

Local

Low

Local

Low

Clinical Support and Family Services Medicine

Local

Low

Medicine

Local

Low

Medicine (ED)

Local

Low

Local

Low

Medicine (Cardiology) Surgery

Local

Low

Medicine

Local

Low

Local

Low

Local

Low

Clinical Support and Family Services Clinical Support and Family Services Medicine

Local

Low

Medicine

Local

Low

Local

Low

Clinical Support and Family Services Medicine

Clinical Audit Annual Report 2011

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Contributions: Claire Gorzanski

CG134 – Anaphylaxis (December 2011)

Local

Low

CG135 - Organ donation for transplantation Local (December 2011) NICE Clinical Guidelines (Awaiting Publication) Infection Control (Update) Local Opiods in Palliative Care Local Acute Upper GI Bleeding Local Spasticity in Children and Young People Local

Low

Low Low Low Low

Venous Thromboembolic Diseases Autism in Adults Sickle Cell Acute Painful Episode Osteoporosis: Assessing the Risk of Fragility Fracture Fertility (Update)

Local Local Local Local

Low Low Low Low

Local

Low

Neutropenic Sepsis Incontinence in Neaurological Disease Lower Limb Peripheral Arterial Disease Headaches Pain and Bleeding in Early Pregnancy

Local Local Local Local Local

Low Low Low Low Low

Bipolar Disorder (Update)

Local

Low

Diabetes in Children (Update)

Local

Low

Social Anxiety Disorder

Local

Low

Stroke Rehabilitation Antibiotics for Neonatal Infection

Local Local

Low Low

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Clinical Support and Family Services Medicine

Quality Medicine Medicine Clinical Support and Family Services Medicine Medicine Medicine Musculo-Skeletal Clinical Support and Family Services Medicine Medicine Medicine Medicine Clinical Support and Family Services Clinical Support and Family Services Clinical Support and Family Services Clinical Support and Family Services Medicine Clinical Support and Family Services

Contributions: Claire Gorzanski