Risk assessing clinical audit findings

1. Risk assessing clinical audit findings Anne Jones, Head of Clinical Audit and Effectiveness Kingston Hospital NHS Foundation Trust

2. Session objectives To share our process for introducing a risk assessment approach to clinical audit results, focusing on: Why take a risk assessment approach? The road to risk assessment Undertaking the risk assessment – an example Escalation process Training the risk assessors Benefits to patient care Practical example

3. Why take a risk assessment approach? At a trust-wide or corporate levelClinical governance describes the structures, processes and culture needed to ensure quality of the care and continuous improvementwww.gov.uk/governmentQuality governance used byMonitor to refer to how a Board should lead on quality and identify and manage risks to quality.1 1 Bullivant J, Burgess R. Corbett-Nolan A. and Godfrey K. (2012) Good Governance Handbook. HQIP/Good Governance Institute

4. Why take a risk assessment approach? At the front lineTo support frontline clinicians to assess the significance of clinical audit results and ensure improvement in patient care

5. Relationship between clinical audit and risk Risk driving clinical audit  High risk is one of the main drivers of clinical audit topic choice 2 ‘Address specific local risks’ 3 At Kingston, risk registers reviewed for topics for annual clinical audit programme and risks arising throughout the year are added to the clinical audit programme 2 Burgess R. (2011) New Principles of Best Practice in Clinical Audit , HQIP 3 Bullivant J, and Corbett-Nolan A.(2010) Clinical audit: A Simple guide for NHS Boards and partners, HQIP To: Anne Jones

6. Relationship between clinical audit and risk Clinical audit driving risk management ? Quantify the implications for clinical and organisational practice including potential for harm Clinical audit can …. Identify major risk, resource and service development implications in an NHS trust ‘3 At Kingston, process for linking clinical audit to risk and risk registers had not been formally established 3 Bullivant J, and Corbett-Nolan A.(2010) Clinical audit: A Simple guide for NHS Boards and partners, HQIP

7. Other drivers Grant Thornton’s paper ‘Clinical audit: a brave new world’? (2011)4 “Results are not fed into organisational risk assessment. We see many examples of where individuals or groups learn from clinical audit and adjust their practice accordingly. However, we see virtually no examples where the results of clinical audit feed back into the board’s risk assessment and business planning. 3 Bullivant J, and Corbett-Nolan A.(2010) Clinical audit: A Simple guide for NHS Boards and partners, HQIP 4 Dossett P. (2011) Clinical audit: a brave new world? Grant Thornton HQIP’s Clinical audit: A simple guide for NHS Boards and partners3 “Ensure that clinical audit results having potential significance, due to the identification of a risk, are brought to the attention of the clinical governance committee …..”

8. How does this fit with the current national picture? Francis Report5- Recommendation 5: The Board should review audit processes and outcomes on a regular basis. Keogh Report 20136: Ambition 2The boards and leadership of provider and commissioning organisations will …have rapid access to accurate, insightful and easy to use data about quality at service line level. A failing of one of the hospitals was noted as “The governance systems are not providing the expected level of assurance to the Board, and the escalation to the Board of risks and clinical issues is inconsistent”Berwick Report 20137The most valuable information of all is information on risks and on things that have gone wrong p105Francis Report http://www.midstaffspublicinquiry.com/report6The Keogh Report (2013) Review into the quality of care and treatment provided by 14 hospital trusts in England7The Berwick report (2013) Improving the Safety of Patients in England

9. What were we hoping to achieve? To provide clinicians, managers and clinical audit staff with a system to categorise and quantify the level of concern/risk Escalate appropriate concerns upwards Target resources To ensure a systematic approach where results are below standard To drive robust action planning and quality improvement To focus on areas where quality improvement is most required To feed back into Board’s risk assessment and business planning

10. Kingston Hospital’s road to risk assessment

11. 5 steps in risk assessment http://www.hse.gov.uk/risk/fivesteps.htm

12. Kingston’s risk assessment form 8 8 Kingston Hospital NHS Foundation Trust (2013) Risk Identification, Assessment and Risk Register Procedure

13. Grading the consequences for audit of clinical quality Likelihood scoring 8 Kingston Hospital NHS Foundation Trust (2013) Risk Identification, Assessment and Risk Register Procedure

14. The process At start of each clinical audit project, a target for acceptable care or treatment is agreed by the clinical team – ‘green’ RAG rating. Linked to policy, guideline or set standards.The audit is carried out and the results compared to the target(s) set.Result > target = GreenResult < target risk assessment to categorise level of riskRisk Rating < 8 = Amber rated AuditRisk Rating > 8 = Redrated Audit

15. EXAMPLE: Antibiotic prescribing Hazards (potential to cause harm): Review/stop dates not put on antibiotic prescription charts and patients left on antibiotics too long. Incorrect antibiotics prescribed. Risks (effect on the patient/hospital): Antibiotic acquired infection, eg C. difficile, increased resistance to anti-biotics, side effects from treatment, longer recovery period, increased cost Risk rating Consequence 3 (moderate) x Likelihood 3 (possible) = 9(RAG rated ‘Red’)

16. Trust-wide   Safe and effective prescribing of antibiotics  Medicines policy M-F Pharmacist WR Micro/Pharmacist twice weekly WR Stop date section on drug chart Training for junior docs Consultant supervision on ward rounds Weekly publication of data Daily Micro/Pharm WRs Hazard: Incorrect AB Duration of AB too long 2 3 6 3 3 9 Risks: AB acquired infection; Treatment side effects; Longer recovery; AB resistance; Cost

17. Clinical Audit report Action Plan Summary of results and RAG rating

18. Escalation of ‘red’ audit results Red ◄ Challenge ► Risk Register * Sub Committee of the Trust Board

19. An iterative process ….

20. Training Trust-specific training delivered to Clinical Audit Facilitators by Risk Manager Training delivered to our Clinical Audit Leads by Risk Manager and Head of Clinical Audit Audit project leads trained by Clinical Audit Facilitators at the time of undertaking a risk assessment All managers and senior nursing staff trained in risk assessments

21. Your turn ……..

22. Falls Audit example Nursing / Trustwide   Describe the topic area  Existing controls: Falls Policy Audits Staff training Analysis of individual falls ? ? ? ? ? ? Identify the hazards List all the risks

23. Falls Audit example Nursing / Trustwide   Falls care plans  Hazard: Failure to provide care plans for all patients at risk of falls Existing controls: Falls Policy Audits Staff training Analysis of individual falls 2 4 8 3 4 12 Risks: Physical harm from fall; increase in LOS, increase in falls per1000 bed days

24. Conclusions Greater clarity regarding the level of risk to patient care where clinical audit results do not meet standards – good for patients, clinicians and the Trust Board Greater objectivity than previous system Provides ‘at a glance’ results and allows clinicians, senior staff and Board members to concentrate on the things that matter Change and quality improvement to patient care is enhanced by ensuring action plans are robust and staff are held to account for completion, via risk register Work in progress Building into overall business planning

25. Thank you for attending this workshopAny questions