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South Devon Healthcare NHS Foundation Trust
Ann Burnett, Head of Clinical Effectiveness
Introduction
Clinical audit is embedded into the culture of the South Devon Healthcare NHS Foundation Trust through a clear system of process, and organisational structure and accountability. Conducting audits is incorporated into all clinical job descriptions, and clinical audit provides vital information to the Trust Board and informs strategic decisions and objectives.
The Trust employs some 3,900 staff and runs Torbay Hospital, a medium-sized district general hospital serving the South Devon area, as well as providing clinics at community hospitals.
Staff actively participate in clinical audit but historically the number of re-audits was low, with a re-audit rate of 6% in 2001-2002. However, following some changes and the successful introduction of new procedures, the rate of re-audits occurring rose to 77% this year. This figure does exclude clinical audit projects where results have demonstrated compliance with criteria of 90% and above, as this was considered to be good evidence of compliance, making re-audit unnecessary. The Clinical Effectiveness Group in the trust (consisting of Medical Director, Director of Nursing and Quality, Governance & Patient Safety Lead and Clinical Effectiveness Manager) review all results of audits together with action plans, and ensure that these are robust and implemented. The priority is to focus on those audits below 90% achievement level.
Organisational Structure
The organisational lead, (Clinical Effectiveness Manager, line managed by the Director of Nursing and Governance) has been in post since 1990 and firmly believes that clinical audit is only value for money when it can demonstrate a subsequent change in practice, or provide evidence of compliance to best practice. It is therefore essential to have a mechanism to identify when re-audits are due to take place and the re-audit rate. Continuity of senior staff within the department has contributed to embedding and developing the systems in place. The Effectiveness Manager has two deputies, one is responsible for audits being carried out and completing the audit cycle, the other deputy is responsible for effectiveness through protocols, guidelines such as NICE, clinical audit training and is highly skilled in the use of databases. The department also employs four clinical audit facilitators. Three facilitators are assigned to particular divisions in the trust (i) women, children, diagnostics and therapies, (ii) medical services (nine specialities), (iii) surgical services (eight specialties). The fourth facilitator is responsible for trust wide projects including patient safety alerts. The facilitators' divisional responsibilities rotate every two years.
Within each clinical speciality, either a consultant or senior nurse takes on the responsibility of Clinical Audit Co-ordinator (clinical lead), usually for a period of 3 years. The Clinical Audit Co-ordinator nominates a project lead for each audit and the clinical audit facilitator works with this clinician to ensure that the project is robust and complies with audit methodology. In some specialties rotational clinicians are required to undertake a clinical audit during their period in that specialty; they may be required to initiate an audit or undertake the re-audit. On completion the project lead is issued with a "Certificate of Completion" detailing the extent of their involvement. The annual audit programme stipulates two audits from each specialty/department but in practice more are carried out.
Clinical audit workshops are carried out by the departmental deputies with support from the Clinical Effectiveness Manager and facilitators. The workshop is open to all clinicians and relevant administrative staff. The material used is based on a package purchased from Healthcare Quality Quest which has been adapted to the needs of the trust and is periodically updated to account for changes in legislation and new initiatives. A certificate is given to delegates completing the workshop.
System
A robust Access database is used to monitor clinical audit registration, progress, action plans and implementation, and ensures re-audits are carried out when changes are implemented. Information on clinical audits is published on the local intranet with permission of clinicians and the Clinical Effectiveness Group a small group including key members of the Trust Board. Clinical audit information is also discussed at the Patient Safety & Quality Committee which reports directly to the Trust Board. The clinical audit Access database generates standard letters, and reports including the stage, audit completion status and action plans. The system produces report templates for the Clinical Effectiveness Group which facilitates feedback on action plans. This feedback is signed by the Chair of the Clinical Effectiveness Group and sent to the clinician accountable.
The database is completed by the audit facilitator responsible for the specific divisional area as progress occurs. Ad hoc reports are generated and a large proportion of the annual audit report is produced automatically.
Clinical audit meetings are set up by the clinical audit facilitator and occur on a regular basis for each specialty within their designated divisional areas. It is viewed as being vital for clinical audit staff to have contact with clinicians, providing audit facilitators with an opportunity to pursue audit information and sustaining the audit profile. The facilitators take responsibility for the agenda and note taking, providing them with an insight into clinical practice. For example anaesthetics department meetings always have a clinical audit presentation and a set agenda with protected audit time where the status of each audit is discussed and required actions are decided. The facilitators take the responsibility of noting down the actions that are required. The actions are entered in the database, generating an action plan and covering letter which is forwarded to the clinical lead, and identifies a clinician for each action with a target date for implementation. This action plan is signed off by the clinical lead and returned to the Clinical Effectiveness Department where it is logged on the database to track implementation progress and subsequent re-audit start.
Processes
A clinical audit proposal form is completed by the project lead, giving details of the objectives and standards for the project, including signed agreement from the Clinical Governance Lead and Clinical Audit Co-ordinator for the project to be undertaken. The Clinical Director signs the form to agree to fund any changes identified as a result of the audit. The form is then submitted to the Clinical Effectiveness Group for approval.
All clinical audits are registered on the system by the audit facilitators once approval has been obtained. No audits are commenced prior to approval. The system is populated by the audit facilitators, who enter a unique audit reference number and full details of the project.
Additional information is captured by the clinical audit facilitators as the project progresses, enabling progress reports to be presented at clinical audit meetings and the Clinical Audit Team Leader to monitor progress and re-audit rate. Once the presentation date and the action plan are entered, a report is submitted to the Clinical Effectiveness Group. This is an essential requirement ensuring that high level members of the organisation are fully aware of all audit activity.
A template is used and completed by the facilitator which is attached to the manual audit file to capture recording of hours spent on the audit.
The system can capture cross boundary information, for example where the clinical audit is led by A&E and links with surgical and anaesthetics. All departments involved are kept informed of progress and invited to be part of the meeting when the final presentation is made.
The initial audit is referred to as stage 1, the re-audit is stage 2. At the end of each stage an evaluation form is sent to the Clinical Director, Clinical Governance Lead and Clinical Audit Co-ordinator to feedback on the value of the audit.
An additional evaluation form is sent to the project lead to assess the performance of the facilitator/service evaluation. This forms part of the 1:1 between the audit facilitator and the Clinical Audit Team Leader and contributes to appraisal and KSF.
Data collection forms and presentations are placed on the intranet.
Benefits/Key Features
- easy-to-see benchmark improvement comparisons
- close clinician involvement and a lot of support from the audit team makes it easier/less work for the clinicians
- feeds into organisational philosophy of PDSA (plan-do-study-act)
- because results are presented to speciality audit meetings, they are widely disseminated and understood
- clinical sign-off and decision making helps maintain engagement
- close links with Board
- valued contribution to a learning organisation/improved practice.
Conclusion
The organisational structure, process and comprehensive database ensures a complete record of all audit activity is maintained and the monitoring of action plan implementation takes place, enabling the re-audit to be commenced at the earliest opportunity. Priority is given to re-audits which in the past 7 years has enabled the Clinical Effectiveness Department to increase the re-audit rate from 6% to the current rate of 77%. There is still room for improvement as 23% of audits are currently not re-audited in a timely manner; however, we still manage to carry out a minimum of 2 new audits per year per department.
The above also ensures that the results of audit are widely disseminated to relevant clinical staff and key board members are aware of issues arising from audit.
