Clinical audit in Trusts: a new vision

1. Clinical audit in Trusts:a new vision Nick Black Chair National Advisory Group for Clinical Audit & Enquiries Healthcare Conferences UK London 13 February 2013

2. Outline • NAGCAE’s enquiry: why and how? • Concerns of audit staff in Trusts • Underlying problems • A new vision for audit staff in Trusts • Proposal apropos Francis Inquiry report

3. NAGCAE’s enquiry: why and how? • Surveys by CASC and HQIP • Identified as NAGCAE priority (May 2011) • Roundtable discussion (April 2012) • Local audit staff, national audit staff, medical directors, clinical audit support organisations • Consultation on draft report (July-Sept 2012) • 66 responses (54 from audit staff in Trusts) • considered by NAGCAE (Dec 2012) • Recommendations to NHS CB (March 2013)

4. NAGCAE’s concern and interest • Focus is the role and function of audit staff in Trusts and not the ability and achievements of existing staff. • We share the positive views of many Trust CEOs as to the calibre and contribution of staff. • Our aim is to help facilitate and support that contribution in the future.

5. Consultation response • Widespread support (70-80% of respondents) for most views and recommendations • Others reported that nothing new being suggested...already organised and operating in ways suggested. • Some thought NAGCAE aiming to establish ‘rules’ • we are purely advisory; aim is to stimulate innovation • we recognise that Trusts vary and specific arrangements will vary; aim to provide a ‘vision’ which we think will strengthen clinical audit and audit staff roles in Trusts

6. Concerns of audit staff in Trusts- don’t all apply in every Trust • Too many demands from numerous sources with a lack of clarity as to which are mandatory and how to determine priorities • External requirements over-ride local priorities • Priorities focus on financial needs of Trusts (CQUIN, QUIP) • Insufficient resources and skills (reduction on consultants’ PAs) • Insufficient support from management, senior executives and Trust Boards • Insufficient support on how to use national audit output • Value of some (many) audits questioned (both national and local) • Insufficient ownership and engagement by clinicians • Diverted to undertake other activities Conclusion: Unsatisfactory and unsustainable (74% agreed)

7. Features of vision for audit staff in Trusts • Explicit definition and recognition of the two key components of achieving quality (78%) • quality assessment; quality improvement • Greater recognition of multiple approaches to quality improvement (70%) • service redesign; education; incentives; regulation • Greater integration (80%) • data collection; clinicians, managers and audit staff; organisational structure; funding • Support to enhance roles and responsibilities of audit staff (92%) • will require support, training and guidance • Sharing experiences: learning from the best (86%) • new opportunities with regional organisations (eg AHSNs)

8. Proposal: five components • Recognition and acceptance of some fundamental issues (86%) • advantage of distinguishing the two key aspects of achieving high quality services: quality assessment and quality improvement • complementary benefits of and need for both local and national clinical audits • quality is the collective responsibility of clinicians, managers and audit staff • clinicians and managers are responsible for assessing and improving the quality of the clinical service they run

9. Development of Quality Departments (or Facilities) in Trusts (70%) • audit staff , clinicians and managers (full-time or part-time; permanent or temporary) • good leadership (based on ability not occupation) • direct access to the Trust Board via an executive director • provide specialist advice, facilitate activities and guide quality assessment and improvement

10. Training opportunities for audit staff (AND clinicians and managers) (98%) • Technical skills in quality assessment and improvement (improvement science) • Understanding of national and local policies affecting quality agenda • Behavioural skills in quality improvement (including leadership, change management, facilitation)

11. Establishment of multi-Trust initiatives (91%) • create and contribute to ‘regional’ and national activities • active in emerging regional organisations • Improvement in service from NCA suppliers (100%) • improve feedback to Trusts on quality (based on rigorous data) • stimulate quality improvement (eg regional events, websites, webinars etc)

12. Francis Inquiry Report (February 2013) Health & Safety Executive Deanery/University Local community Clinical audit? Trust Board GMC/NMC HCC/CQC DH GPs PCTs/CCGs RCN Health Protection Agency NPSA Monitor SHAs

13. Many issues identified but key one... • Need to bring together assessment of different dimensions of quality • Safety • Patient incident reporting (NRLS) • Health care associated infections • Experience (humanity) • Patient experience surveys • Waiting times • Effectiveness • Outcomes (morbidity, disability QoL) • Processes (adherence to guidelines)

14. Many issues identified but key one... • Need to bring together assessment of different dimensions of quality • Safety • Patient incident reporting (NRLS) • Health care associated infections • Experience (humanity) • Patient experience surveys • Waiting times • Effectiveness • Outcomes (morbidity, disability QoL) • Processes (adherence to guidelines) Clinical audit

15. Key recommendations • Information on performance and outcomes • must be made available to patients for treatment choice, understanding of outcomes (1.219), & to compare relative performance (1.220) • All providers should publish performance on consultants & specialist teams • Mortality, morbidity, outcome, satisfaction (1.222) • Professional duty to collaborate (1.223) • Designated Board member as Chief Information Officer (1.225) • Quality Accounts • to show compliance with standards (1.226) & comparisons between organisations of outcomes (1.227) • signed by all Board directors • Wilful or reckless falsehood a criminal offence (1.228)

16. The vision Wonderful opportunities for audit staff in Trusts to contribute to the transformations in clinical services and pathways Clinical audit staff are an essential part of wider quality management Quality management cannot be achieved without audit staff