Healthcare Quality Team Annual Conference Realising the Potential of Clinical Audit

1. Healthcare Quality Team Annual Conference Realising the Potential of Clinical Audit

2. Releasing the potential of Clinical Audit – the challenge post election Robin Burgess Chief Executive, HQIP

3. What I will do in this presentation • Overview Clinical Audit in the UK in the light of the new government • Give a brief introduction to HQIP. • Overview, priorities and difficulties from now onwards

4. HQIP’s aims • To re-invigorate clinical audit • To be a leading agency in quality improvement

5. What audit is • There are not two things, ‘clinical audit’ and ‘improvement’ • Audit IS a quality improvement strategy • Audit IS NOT just about measurement • Audit IS a cycle that includes improvement activity • Anything less is bad audit

6. The clinical audit cycle

7. The new climate – opportunities and threats Threats Opportunities • Political interest in audit as a means of measuring outcomes • Ability for audit to show patients how good services are • Requirements to report on participation in audit and the changes that result • Revalidation • Use of audit in QIPP • Lack of funding for local audit/service changes • Burden of national audit • Continuance of poor quality audit practice undermining its image

8. Possible new policy directions • Commissioning some national audits through subscription, achieved by mandation? • Requirement that audit measures ‘outcomes’, not just ‘process’ • Extending the number of national audits, linking these more directly to other policy activity in the Department – eg quality standards? • A change in the landscape of national organisations – in what direction is QI going with the demise of the NPSA/HPA/NHSIII etc?

9. Changes and challenges at the local level • New commissioning arrangements will need management: • GPs will have to be encouraged to require and use audit as commissioners (and as providers) • Provider trusts will have to be encouraged not to cut audit capacity/opportunities for training and networking --------------------------------------------------------------------------------- • Greater linkage between clinical and internal audit • Getting boards engaged, and using audit data • Continuing challenges in encouraging/developing audit beyond secondary care – in community care, and beyond, to social care • Patient engagement an even greater need

10. An update on the UK programme National audit • Commissioning of 27 national audits covering many major health issues and procedures • We help these audits to be effective and encourage change in local practice • More coming - and integration of confidential enquiries into HQIP is proposed • Publication of participation data, by Trust

11. Other HQIP work • We continue to implement our strategy through a mix of encouragement and requirement: • Continuing development work with clinicians, via: • Education, pre and post grad, and CPD; focus on addressing the limitations of junior doctor audit • Support and networking is facilitated, in person and on-line • Printed and web based resources and learning aids • Encouraging Clinical championing and leadership of audit, by individuals and through their professional bodies • Continuing work to support audit within revalidation • Ongoing help for local audit practitioners

12. QIPP and audit • See our website: we believe audit should be marketed as a means of helping QIPP/efficiency activity • Audit can show money is saved, practice improved, outcomes achieved, patients benefit • Local audit needs to start making some cost assessments of the effect of clinical practice changes

13. CAKE • CAKE is an online software programme which will enable the collection and reporting of audit activity by individual organisations; and • Comparison between local organisations where they are conducting similar audits, eg on NICE guidelines, or regional or speciality audits • Development work is slower than hoped but we currently hope to have to ready by Christmas

14. Contact us Healthcare Quality Improvement Partnership Holland House, 4 Bury Street, London EC3A 5AW 0207 4692500 www.hqip.org.uk communications@hqip.org.uk Promoting quality improvement for better healthcare

15. Supporting Clinical Audit

16. THE BOARD: ROLES, RESPONSIBILTIES AND REALITIES Dr John BullivantGood Governance Institute

17. The purpose of clinical audit is to improve patient care Purpose

18. All change…….. • Changing landscape with ‘Equity and Excellence: Liberating the NHS’ • Changing Governance • Board Assurance prompts: how much medicine does a board need to know? • Assurance and anticipating risk • Annual Review and Board Development

19. Good Governance Institute • Origins in NHS CGST Board Development Team • Integrated Governance • Governance between Organisations (GBO) • Board Assurance prompts • Standards • Clinical: Pneumonia & Diabetes • Themes eg Flexible Workers

20. Changing landscape From ‘Governing the new NHS 2010’

21. Changing landscape

22. Changing landscape • “the most striking feature was in the disconnection between what was happening on the wards at night and what the board knew. The board had no idea”. Aintree Hospital Review • ‘the main lesson I take from the problems experienced at mid-Staffs – that in future, we must never separate quality and financial data. They are always two sides of the same coin’. ’Andy Burnham, then SoS

23. Burdett Trust Report 2006 • Overall 14% of items in meetings were rated as clinical but this varied from 7% to 22% over the year for different trusts. • In trusts with higher levels of clinical content, non-executive directors seemed to question and interrogate trust board executives in a more open and transparent manner. • indicators of a greater clinical focus. • more clinical staff present at board meetings, • less use of acronyms in reporting the minutes, • more evidence of liaison with social services • questions from the public being sometimes accepted, and • infection control issues being presented

24. ‘Taking it on Trust’ 2009 • Use of clinical audit as part of the BAF was poorly developed. This is a significant weakness. • Few trusts could set out how clinical audit was being used in a systematic way to address risks with the results reported to the board through the BAF; • Boards need to ‘better align clinical audit programmes to key strategic and operational risks to maximise the assurance provided by the clinical audit function’ The Audit Commission

25. ‘Taking it on Trust’ 2009 • To what extent do we use the clinical audit function appropriately? • Is it systematic and focused on our own risks as well as on nationally identified issues? • Are the results regularly reported to the board through the assurance framework? • Does it give us a comprehensive view of the quality of clinical services across the trust’s portfolio? Audit Commission

26. Mid Staffs • The Healthcare Commission found that the audits in Mid Staffordshire were inadequate. • The mid Staffordshire Board was found to have inadequate information relating to patient safety. • They were therefore unaware that mortality was both rising within the trust and out of step with national averages.

27. How much medicine…..Board Assurance Prompts-Diabetes

28. Board questions

29. Board Challenges

30. GGI/HQIP Maturity Matrix

31. 10 simple principles • Use clinical audit as a tool in strategic management; ensure the clinical audit strategy is allied to broader interests and targets that the board needs to address. • Develop a programme of work which gives direction and focus on how and which clinical audit activity will be supported in the organisation. • Develop appropriate processes for instigating clinical audit as a direct result of adverse clinical events, critical incidents and breaches in patient safety. • Check the clinical audit programme for relevance to board strategic interests and concerns. Ensure that results are turned into action plans, followed through and re-audit completed. • Ensure there is a lead clinician who manages clinical audit within the trust, with partners/suppliers outside, and who is clearly accountable at board level.

32. 10 simple principles • Ensure patient involvement is considered in all elements of clinical audit, including priority setting, means of engagement, sharing of results and plans for sustainable improvement. • Build clinical audit into planning, performance management and reporting. • Ensure with others that clinical audit crosses care boundaries and encompasses the whole patient pathway. • Agree the criteria of prioritisation of clinical audits, balancing national and local interests, and the need to address specific local risks, strategic interests and concerns. • Check if clinical audit results evidence complaints and if so, develop a system whereby complaints act as a stimulus to review and improvement.

33. Assurance & anticipating risk • Aligning service transformation, quality, audit and VFM • Integrating all audit • Risk Committee looking forward From CHI, David Bawden

34. Annual Review & Board Development • Annual Review Matrix • Board Assurance Framework • Clinical Audit • Board Development

35. More information: Governing the New NHS: Issues and Tensions in Health Service Management By John Storey, John Bullivant, Andrew Corbett-Nolan http://www.routledge.com/books/details/9780415492768 John.bullivant@good-governance.org.uk

36. Supporting Clinical Audit

37. Clinical Audit: A Commissioner’s Perspective Martin Ferris Head of Clinical Audit and Effectiveness NHS Sheffield

38. Is this you…….

39. Clinical Audit: A Commissioner’s Perspective Three main strands:- • Working with Providers • Clinical Audit in Service Development • Clinical Audit within a Commissioning Organisation

40. Working with Providers • Why • How • Contract • Priorities • Agreement • Monitoring • Assurance • Reporting to Board • Shared responsibilities / agenda

41. Justification • World Class Commissioning competencies • Lead the NHS locally • Money for clinical audit is included within PbR tariff • For example: 0.5% of £100m budget for an acute trust equates to £500,000 • Need to be assured that clinical audit is being done systematically and robustly • Need to be assured that clinical audit is integral to provider culture and not an add-on to tick boxes

42. Contract • Specific entry in contract for all providers that: • Conduct audits as per commissioner priority programme • Act on recommendations • Provide quarterly updates against priorities • Support clinical audit in all areas • Provide annual report

43. Awareness • Commissioner needs to be aware of national / regional / local priorities • Monitoring of key national drivers e.g. • HQIP • DH / NCAAG • Confidential Enquiries • NSFs and similar • NICE • Royal Colleges • GMC • NHSLA

44. Priorities • Annual priority programme in Sheffield since 2001 • Draft produced in November / December each year • Shared with colleagues in commissioning organisation • Commissioning leads • Public health • Medicines management • Contract managers • Performance monitoring

45. ”Programme content – National “must-do’s” • All audits within quality accounts • All NSF audits e.g. CHD, Cardiac rehab • NHSLA • Confidential Enquiries • DH (suicide) • National CQUINs

46. Programme content – Regional / Local Priorities • CQUINs • Commissioning intentions • GP DES / LES monitoring • Other local priorities e.g. dental recall

47. Agreement • Final commissioner draft sent to providers in January • Meetings held as necessary to resolve issues • Programme changed if necessary • Programme “signed off” by relevant bodies by end of March. • In NHS Sheffield done by Clinical Executive (PEC) • In providers by Governance Committee or similar

48. Effect of Programme • Contractual requirement • Gives direction to providers • Gives leverage to provider audit departments • Focuses resource usage • Consistency across health community Providers like it!

49. Its not NICE!Clinical Audit v Clinical Effectiveness • Clinical Effectiveness = NICE • Not always necessary to do audit(s) to show compliance with NICE guidance • Often one audit is not enough to show compliance • Many other sources of information can be used to show compliance :- • Prescribing data • New / updated policies / protocols / pathways • Departmental / organisational restructure • Training packages • Events / workshops • Completed baseline assessment • Patient feedback / PROMs and PREMs • Service Evaluations SO – LET’S PARK EFFECTIVENESS AND LOOK AT AUDIT

50. Clinical Audit Monitoring • Quarterly progress reports from all providers • Progress colour coded:- • Blue – complete (with evidence list) • Green – progressing OK (with evidence list) • Amber – delayed (with action plan) • Red– cause for concern (with action plan) • Detailed evidence asked for specific projects • Quarterly board report • Quarterly contract meetings with providers • General monthly meeting with all providers together