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Clinical Audit for Board Assurance

Clinical Audit for Board Assurance. Anne H Lawson Director of Governance – HDFT Visiting Fellow – Loughborough University. NHSFT Code of Governance . Directors are ultimately and collectively responsible for all aspects of the performance of the Trust How can they know?. The Balance.

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Clinical Audit for Board Assurance

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  1. Clinical Audit for Board Assurance Anne H Lawson Director of Governance – HDFT Visiting Fellow – Loughborough University

  2. NHSFT Code of Governance Directors are ultimately and collectively responsible for all aspects of the performance of the Trust How can they know?

  3. The Balance Assurance or detailed knowledge Too much or too little Strategic or operational TRUST CHALLENGE

  4. Role of Internal Audit • Advising the Board of the adequacy and effectiveness of overall arrangements • Provide a coordinating role on assurance issues • Work closely with other reviewers

  5. INTERNAL AUDIT • Provides the Audit Committee with an • “opinion on the overall adequacy and effectiveness of the organisation’s risk management, control and governance processes”

  6. WHY FOCUS ON CLINICAL AUDIT? • The Audit Committee should consider • “…how best to engage with clinical audit to meet its own needs for assurance…” • “..expect to see regular reports of the outcomes of Clinical Audit work” • Audit Committee Handbook • January 2010

  7. SHOULD THE AUDIT COMMITTEE CONSIDER CLINICAL GOVERNANCE ISSUES? • “consider clinical objectives and risks in the Assurance Framework” • Audit Committee Handbook • January 2010

  8. Changes to the Audit committee focus • Challenging for non-execs who may have no health background • Challenging for trust clinical effectiveness and audit staff.

  9. Why do we carry out Audit?

  10. Local Audit

  11. National audit

  12. Assurance

  13. Boardof Directors Sub groups of Board

  14. Outcomes of audits • For assurance • Measure performance against a known standard and facilitate improvement • Benchmark performance against other organisations • To teach the practice/art of auditing (junior doctors)

  15. There is real gain to be realised from Internal audit and clinical audit working together although each will always have their particular remit.

  16. Challenges • We use different languages • We have different purposes for doing an audit • We report differently • We need to recognise diversity • We have different expected outcomes

  17. Challenges • Self assessment • Clinical Outcomes • Compliance • Evidence base standards • Independent view • Systems and Controls

  18. Challenges

  19. Levels of assurance • Description of compliance • Full • Significant • Limited • None

  20. Perceptions • Board are nervous of limited assurance • If worry area should expect gaps – make clear expectation at start • Re-audit WILL be for assurance purposes • Do not drive the issues underground

  21. If we have no limited assurances we have not prioritised the correct areas False Assurance We can only ‘measure’ what we can measure.

  22. Internal Internal Audit Clinical Audit Assurance Framework Governance Annual report Robust reporting and accountability structures Performance Indicators Self assessments- research/information governance, child protection Complaints/incidents/claims External NHSLA National Audits Audit Commission Regulator – CQC/Monitor Audit Office College Visits Deanery Visits Cancer Peer Review Performance Indicators Benchmarking Patient and Staff surveys Sources Of Assuranceexamples

  23. CQC CQC reviews and reports Independent reviews Monitor NICE Guidelines etc. NHSLA Risk Management Standards Patient Safety Alerts Health Service Circulars Managers Code of Conduct Other DH Standards e.g. Internal Audit, IWL, etc. Other ‘arms length’ bodies e.g. National Patient Safety Agency, MHRA, NHS Estates, etc. National Confidential Enquiries Independent reviews Parliament - laws and regulations Royal Colleges Other professional organisations e.g. IHM Other UK health department related e.g. Scottish Inter-Collegiate Network (SIGN) Regulatory bodies e.g. HSE British & International Standards (BSI & ISO) Accreditation e.g. HQS, Trent, Laboratories, etc. Other independent healthcare organisations e.g. ECRI Investors in People (IIP) Trade associations Local policies etc. Standards to enable comparisons DH & related Standards Other

  24. Effectiveness and Outcomes • CQUINS • Mortality rates– now on Choose and Book • CQC measurables • Safety measurables • Specialty audits • National audits • Nice • Other recommendations • Trust objectives

  25. Assurance framework • Used to let the Board know status of organisation • Informs the annual governance statement • Identifies gaps in assurance • Is a dynamic document used to update the Board as to actions.

  26. Assurance Framework • Highest level for Board Assurance • Identify resource for gaps • Revisit it at Board after 6 months • Action Plan for leads • Should drive the working of the Board • Cross Check against progress • Evidence for Audit, CQC and Commissioners

  27. Consultation • Int audit set programme • Directors • Directorates • Clinicians • Regulation • Worry areas • Local interest

  28. Planning the audit programme • Must dos for external and internal audit – systems and processes – for assurance • Assurance framework and risk registers • Gap analyses from national audits etc – audit to determine progress • Quality improvement work streams • Regulators – CQC, Monitor • NHSLA/CNST • Worry areas where we do not exactly know the problem • Local – very clinical audit – for learning

  29. Structuring the programme • Pure Internal audit • Joint Audits • Pure clinical audits • Trust wide • Local

  30. Prioritisation of audit • Not • When you know exactly what is wrong • To gain investment • To highlight an area

  31. Joint audits • Different starting points • Different language • Assurance versus other • Measures of success different • Challenges for reporting and scoring Set the brief very carefully

  32. Structure in HDFT

  33. Board of Directors Audit Committee Quality and Governance Group Standards Group Clinical Effectiveness and Audit Group

  34. Chief Executive Complaints and Risk Management (CORM) Corporate Risk Review Group Standards Group Director team Clinical Effectiveness and Audit Group

  35. Clinical Effectiveness and Audit Group • Input from Specialty Leads for clinical team and to support junior doctors • Prioritisation of audit support • Data-base of Audits • Teaching of Audit methods • Ensuring Change • Sharing Good practice

  36. Standards group • Minutes from CEAG • Clinical Audit report • Gap analyses from National audits and national recommendations/HLEs/ Confidential Enquiries • Action Plan monitoring including CAS alerts and SUIs • External visits and accreditations • National data submissions • Prioritisation of audit support to standards audits • Audit Plan with CEAG

  37. Audit Committee • Minutes for standards • Internal audits and action plans • Standards report • Clinical audit report • Joint Audit plan – who and when • Corporate Risk register • Assurance framework and updates

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