Operational action plan Objective Action Lead Expected outcome Timescale To maintain an audit programme and forward plan that reflects organisational need based upon the national clinical audit programme, ensuring the timely reporting of outcomes and a local clinical audit programme based on current best evidence and good practice guidelines, including concerns/ trends from complaints, adverse or serious incidents. Specialty audit leads (SALs) to produce /maintain a prioritised forward annual specialty clinical audit programme including re-audits (20%) to ensure implemented actions have improved patient care. SALs An audit programme with clear time frames (proposed start and finish times) and a lead/ sponsor for each audit Annually Jan – Feb. Annual forward clinical audit programme approved by the appropriate CSC governance committee/leads SALs An approved and validated forward clinical audit programme, Annually Feb - March Trust wide annual forward clinical audit programme is approved by the CESG CESG chair An approved and validated forward clinical audit programme Annually March - April SALs to ensure full participation in National Audits as approved by the Department of Health (DH) and the National Clinical and Patient Outcomes Programme (NCAPOP) as sponsored by the Healthcare Quality Improvement Partnership (HQIP) and required for the Trust Quality Account. SALs Full participation in National Audit programme signed off by the Medical Director/ CESG chair). Trust Quality Account compliance. Annually SALs or appointed leads to produce clinical outcome data to benchmark their service against national and local peer groups SALs/ appointed lead/ CESG Specialty portfolio of clinical outcome achievements for CESG and Trust Board Quarterly
Specialty clinical annual report to be produced SALs Specialty clinical audit annual report containing evidence of implemented improvements, learning, benefits to patient care Annually Jan - Feb Trust wide annual clinical audit report to be produced CAD Annual report of audit activity outcome against the forward annual audit plan. Annually May - June To improve the requirement for planned audit projects to be registered and improve the number of completed projects submitted to the clinical audit department. SALs Improved evidence of audit activity and evidence of outcomes/ results Monthly To ensure NICE guidance in all its forms is prioritised and used to produce audit topics for the clinical audit programme to ensure evidence of clinical effectiveness and implementation/ compliance with best practice guidance. SALs to ensure a prioritised forward rolling programme of audit topics which address NICE guidance in all its forms. SALs Programme of audit prioritised against NICE guidance Annually SALs and CSC governance leads to be made aware of the appropriate guidance impacting on their areas. CAD/ SALs /CSC leads Programme of audit prioritised against NICE guidance Monthly NICE guidance spreadsheets to be updated regularly as new guidance is published each month CAD Evidence of trust compliance against each published NICE guidance Monthly Status report to be presented to CESG CAD Summary of trust compliance against each published NICE guidance. Quarterly Ensure audit ID no.s are linked to NICE guidance spreadsheets CAD Evidence of audit activity against NICE guidance Monthly Ensure partial/non compliant guidance is escalated to Risk Registers CAD/ SALs /CSC leads Monitoring and controls in place Monthly To ensure organisational compliance with requirements identified within the national quality agenda i.e CQC, CORPs, NICE. Ensure compliance with the Clinical Audit Policy CAD/ SALs Policy in date Annually Ensure compliance with the NICE policy CAD/ SALs Policy in date Annually Ensure compliance with the NCEs policy CAD Policy in date Annually CAD CQC compliance Annually
Ensure all audit activity fulfils the ‘Engagement in Clinical Audit’ Clinical Priority Standard (CQC) in line with the ‘Principles of Best Practice in Clinical Audit’ (NICE 2002). Evidence of participation in local and/or national audits of the treatment and outcomes for patients in each clinical specialty covered by the Trust, completing all the five stages of audit cycle. CAD/ SALs Clinical audit programme. April - March SALs Specialty clinical audit annual report Annually Jan-Feb CAD National and local clinical audit database Complete, ongoing Have a current clinical audit strategy and policy, and a prioritised programme that relates to both local and national priorities with the overall main aim of improving patient outcomes. CAD Ratified clinical audit policy Complete CAD Ratified clinical audit strategy Complete CAD/ SALs Clinical audit programme. April - March Have in place suitable governance systems and arrangements to involve and support all clinicians to participate in clinical audit and ensure that there are clear systems for undertaking clinical audits and there is local clinical audit expertise available. CAD One to one advice/training and consultation service available Ongoing CAD Ratified clinical audit policy Complete CAD Clinical audit intranet site Complete, ongoing CAD Central clinical audit database Complete, ongoing Ensure that all clinicians and other staff responsible for or participating in clinical audits are given appropriate time, knowledge and skills to facilitate the successful completion of an audit. CAD One to one advice/training and consultation service available from CAD. Ongoing HR workforce Supporting Professional Activities (SPA) for quality improvement projects as part of clinician job Ongoing