Re-audit = Evidence

1. Re-audit = Evidence Ann Burnett Julie Hancocks Clinical Effectiveness ManagerClinical Effectiveness Information Analyst

2. South Devon Healthcare Foundation Trust

3. Introduction • The trigger • Strategy and Accountability • Structure of department • Process • How re-audit rate is calculated

4. The trigger The nagging questions

5. The trigger The nagging questions Is Clinical Audit improving practice?

6. The trigger The nagging questions Is Clinical Audit improving practice? Is Clinical Audit living up to expectations?

7. Trust Strategy • Embedded into the culture • Incorporated into all clinical job descriptions • Informs Trust Board via Patient Safety Committee • Annual Audit Programme

8. Accountability • Audit Co-ordinator for each Specialty • Clinical Directors and Divisional Managers sign Audit Proposals • Clinical Directors/Clinical Governance Leads sign Action Plans • Clinical Effectiveness Group (CEG) • Patient Safety Committee

9. Department Strategy • Responsive and timely service • Audit Facilitators • Clear framework of operation • Education • Support of Team Leader • Database • Terminology

10. Department Structure AF – Clinical Audit Facilitator WCD – Women’s, Children’s, Diagnostics and Therapies

11. Role of Audit Facilitator • Facilitate audit projects • Service audit meetings • Point of contact for the specialty for audit • Maintain information on the database • Maintain record of time spent on each audit • Participate in teaching on the Clinical Audit Workshop

12. Process Target Times

13. Process • CA Proposal Form • Approved by Clinical Effectiveness Group • Registered on database • Stage 1 completion results reported to: • Specialty, Action Plan raised • CEG • Published on the intranet • Re-audit

14. Summary Reports & Action Plans 5708 Traceability and documentation of blood transfusions 5787 Urinary Catheter Standards of Care

15. Database • The database is key and acts as the main driver • Developed in house over a number of years making it responsive to change • Provides extensive reports • Generates standard documentation • Project evaluation forms and service evaluation forms

16. Key fields required on database None date fields: Key date fields: Project Registration date* Stage 1 completion date* Stage 1 Implementation check date Re-audit commencement date* Re-audit completion date* • Unique project number • Title • Directorate information • Audit Co-ordinator information • Audit Facilitiator information • Results / Outcome Information * Key fields to calculate re-audit rate

17. Incentives • Audit Certificate • Team Leader monitors re-audit rate for KSF • Re-audit rate reported monthly to Dept. Meeting. • Service evaluations per project • Bottle of Wine

18. Reduction of projects without standards

19. Average turn round time Staff shortages

20. Re-audit rate

21. Calculating the Re-Audit Rate • Establish the number audits that have completed Stage 1 • Establish the number of completed Re-Audits c. Establish the number of audits, which demonstrated compliance at Stage 1 etc,

22. Calculating the re-audit rate – doing the sum 150 / 200 = 75%

23. Benefits of strategy • Clinical engagement • High profile because of CEG • Feeds into organisational philosophy of SPI and PDSA • Widely disseminated results • Robust action plans

24. Benefits of strategy • Reduce the turn-round time • Increase re-audit rate • Reduce the number of audits without standards • EVIDENCE - Quality Improvement - Quality Assurance

25. Questions

26. Workshop What do you think are the key things you need to do to improve your re-audit rate?

27. Workshop • Clinical and Board level buy-in • Database and Recording • Monitoring (Team Leader) - Links to KSF • Good communication skills • Clinical Staff Training • Culture of Stage 1 – not audit