Transcript Macmillan Quality Environment Mark

NHSLA Risk Management Standards
Criterion 5.1 - Clinical Audit
HQIP National Conference
Gaynor Pickavance and Gill Feerick, DNV Risk Management Assessors, DNV Healthcare UK
28th April 2010
Session structure
 Provide an overview of the NHSLA schemes and assessment process
 Highlight the requirements of the new criterion 5.1 - Clinical Audit
 Breakout sessions 1 and 2 and feedback
 Consider how you can assist your organisations
28th April 2010
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The NHSLA - What is it?
 Special Health Authority - part of NHS
 Geographical limits - England
 Not an insurance company (mutual pool)
ROLE OF THE NHSLA
Handle clinical and non-clinical claims
Encourage good risk management practices
Provide a Human Rights Act information service
Support the activities of the Family Health Services
Appeals Authority
Coordinate equal pay claims
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The NHSLA and assessment process
 The NHSLA is a Special Health Authority which provides the means for NHS
organisations to fund the cost of legal liabilities for clinical negligence, third party
and property losses
 It provides a fair and cost-effective means of handling claims, supported by risk
management activities to enable learning from claims experience
 Membership of the schemes is voluntary and open to all NHS trusts, foundation
trusts and PCTs in England
 Organisations are entitled to a discount on their scheme contributions if they can
demonstrate compliance with the standards
 The standards have been designed to encourage and support organisations in
taking a proactive approach to risk management
 Organisations have a formal assessment on a periodic basis dependant upon their
level of compliance
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Aims of the NHSLA schemes
Contribute to improvements in patient safety and well-being of staff
Increase risk management awareness
Improve systems and processes
Reduce the number and severity of incidents
Lower the number and cost of claims
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The Risk Management Standards
 Moved from separate clinical and non-clinical standards
 Self-assessment to determine level of assessment
 Informal visit(s)
 Formal assessment
NHSLA Risk Management Standards for Acute Trusts, Primary
Care Trusts and Independent Sector Providers of NHS Care
NHSLA Risk Management Standards for Mental Health &
Learning Disability Trusts
NHSLA Risk Management Standards for Ambulance Trusts
CNST Maternity Clinical Risk Management Standards
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NHSLA Risk Management Standards - Levels
 Organisations have a financial and quality incentive to contribute
 Discounts are awarded at three levels when compliance with the standards is
demonstrated
 An organisation’s contributions decrease in accordance with the level achieved
Level 1 Risk management systems and processes have been documented (Policy)
Level 2 The systems described at Level 1 have been implemented (Practice)
The organisation is monitoring its compliance with the systems and
Level 3 acting on the findings (Performance)
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NHSLA Acute Standards 2010-11
Standard

1
2
3
4
5
Criterion

Governance
Competent &
Capable Workforce
Safe
Environment
Clinical
Care
Learning from
Experience
1
Risk Management Strategy
Corporate Induction
Secure Environment
Patient Identification
Clinical Audit
2
Policy on Procedural
Documents
Local Induction of
Permanent Staff
Sickness Absence
Patient Information
Incident Reporting
3
Risk Management
Committee(s)
Local Induction of
Temporary Staff
Safeguarding Adults
Consent
Concerns/Complaints
4
Risk Awareness Training
for Senior Management
Supervision of Medical Staff
in Training *
Moving & Handling
Health Record-Keeping
Standards
Claims
5
Risk Management Process
Risk Management Training
Slips, Trips & Falls
Transfer of Patients
Investigations
6
Risk Register
Training Needs Analysis
Inoculation Incidents
Medicines Management
Analysis
7
Responding to External
Recommendations Specific
to the Organisation
Medical Devices Training
Maintenance of Medical
Devices & Equipment
Blood Transfusion
Improvement
8
Health Records
Management
Hand Hygiene Training
Harassment & Bullying
Resuscitation
Best Practice - NICE
9
Professional Clinical
Registration
Moving & Handling Training
Violence & Aggression
Infection Control
Best Practice - National
Confidential
Enquiries/Inquiries
10
Employment Checks
Supporting Staff involved in
an Incident, Complaint or
Claim
Stress
Discharge of Patients
Being Open
Pilot criteria are denoted with grey shading.
* Not applicable to independent sector providers of NHS care.
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Venous Thromboembolism
New criterion 5.1 - Clinical Audit
Why did we bring clinical audit into the NHSLA
Risk Management Standards?
What do you think we have seen during our
assessments that has concerned us?
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Areas of concern observed at assessment
One page audit results/reports
Standards of performance not stated or not tested properly - e.g. wristband
audits
Audits with no proforma attached so we couldn’t see the audit questions
Results which gave overall compliance opinions when there were several
parts to the documented process
Poor results with no formal actions
Subsidiary risk issues that had not been picked up - e.g. six health records
could not be found - the missing health records then ignored in the actions
Actions that merely stated “re-audit in six months”
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© Det Norske Veritas AS. All rights reserved.
New criterion 5.1 - Clinical Audit
Why did we bring clinical audit into the NHSLA
Risk Management Standards?
28th April 2010
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Reasons for including clinical audit
Alignment of concerns and complaints regulations left a gap in Standard 5
Quality of audit and approaches taken to audit were of concern both in the
acute and maternity settings
Uncertainty in the value that those audits were bringing
Poorly written audit reports with very little learning contained within them
Claims histories showing that despite clinical audit lessons were not being
learned rigorously enough
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5.1 - Clinical Audit: Level 1
Standard 5 - Criterion 1: Clinical Audit (Pilot)
The organisation has an approved documented process for ensuring that all clinical audits
are undertaken, completed and reported on in a systematic manner that is implemented
and monitored.
Level 1
Minimum Requirements
1.5.1
As a minimum, the approved documentation must include a description of the:
a. duties
b. process for setting priorities for a clinical audit programme including
participation in local and national clinical audits
c. process for ensuring appropriate standards of performance are
audited
d. process for disseminating audit results/reports
e. format for all audit reports, i.e. methodology, conclusions, action plans, etc.
f. process for making improvements
g. process for monitoring action plans and carrying out re-audits
h. process for monitoring compliance with all of the above.
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5.1 - Clinical Audit: Level 2
Standard 5 - Criterion 1: Clinical Audit (Pilot)
The organisation has an approved documented process for ensuring that all clinical audits
are undertaken, completed and reported on in a systematic manner that is implemented
and monitored.
Level 2
2.5.1
Minimum Requirements
The organisation can demonstrate compliance with the objectives set out
within the approved documentation described at Level 1, in relation to the:
 process for ensuring appropriate standards of performance are audited
 process for making improvements.
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5.1 - Clinical Audit: Level 3
Standard 5 - Criterion 1: Clinical Audit (Pilot)
The organisation has an approved documented process for ensuring that all clinical audits
are undertaken, completed and reported on in a systematic manner that is implemented
and monitored.
Level 3
3.5.1
Minimum Requirements
The organisation can demonstrate that it is monitoring compliance with the
minimum requirements contained within the approved documentation
described at Level 1, in relation to the:
 process for ensuring appropriate standards of performance are audited
 process for making improvements.
Where the monitoring has identified deficiencies, there must be evidence that
recommendations and action plans have been developed and changes
implemented.
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5.1 - Clinical Audit: Assessment in 2010-11
 Pilot criterion for the year 2010-11 - a positive score will be awarded
 Developed in conjunction with HQIP
 New template document and Audit Report Proforma in line with the HQIP
documents Link
 Adapted Audit Report Proforma for maternity services Link
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Ensuring appropriate standards of performance
are audited
Standard 5 - Criterion 1: Clinical Audit (Pilot)
The organisation has an approved documented process for ensuring that all clinical audits
are undertaken, completed and reported on in a systematic manner that is implemented
and monitored.
Level 1
Minimum Requirements
1.5.1
As a minimum, the approved documentation must include a description of the:
c. process for ensuring appropriate standards of performance are
audited
Q
28th April 2010
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So what does this mean?
Ensuring appropriate standards of performance
are audited
The 'appropriate standards of performance' relates to the documented
standards that staff are expected to achieve
 To make sure that staff know what the standards of performance are, and that they
are tested in an audit and not something else
 So you are required to document the process you have in place for making sure that
audits are carried out properly and actually test the 'standards' that have been set
within approved documents
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Ensuring appropriate standards of performance
are audited
Ensuring the audit process tests the documented ‘standards’ may require…
 Training those who undertake audit
 Making staff use approved audit proformas that are checked prior to the audit being
undertaken
 Documenting examples of how to/how not to set the questions that the audit should
ask
You can decide on the best process for yourselves but you must document
your process at Level 1 and be able to demonstrate it at Level 2 and monitor it
at Level 3
28th April 2010
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Misinterpretations
“Ensuring appropriate standards of performance are audited” is NOT…
 Performance management of clinical areas and the selection of the most important
to audit and monitor
 Reference to the standards of an individual audit
 The process by which the department knows that standards are being used for audit
purpose
 Auditing standards of service (although that could be how you may monitor at Level
3)
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Breakout group 1
TASK:
Breakout group
To look at examples of maternity documents:
 Guideline on the management of severe or
fulminating pre-eclampsia (high blood pressure)
 Audit proforma
 Audit report and action plan
 Power point presentation of the audit results
1. Determine whether this was a good audit that clearly tested the
appropriate standards of performance
2. Are there any suggestions or changes that you would make?
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Breakout group 2
TASK:
Breakout group
To look at two policies for patient identification in the
primary care setting:
 One policy for in-patient areas
 One policy for community settings
1. To devise an audit that clearly shows that the appropriate
standards of performance will be audited?
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TOP TIP
It cannot be stressed enough…
READ THE MANUAL
And stay in contact with your assessor
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Any questions?
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Safeguarding life, property
and the environment
www.dnv.com
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