Transcript Document
Helen Clarke Clinical Audit / NHSLA Lead Mid Essex Hospital Services Trust 1 NHS Litigation Authority & Risk Management Standards MEHT approach to assessment Criterion for Clinical Audit Performance issues 2 • Clinical Negligence Scheme for Trusts; • Liabilities to Third Parties Scheme; and • Property Expenses Scheme1. • 5 standards, each with 10 criteria • Designed to focus attention on key safety & quality areas. 1 NHSLA (2012) NHSLA Risk Management Standards for NHS Trusts providing Acute, Community, or Mental Health & Learning Disability Services and Non-NHS Providers of NHS Care 2012-13 3 Level Requirement at assessment Frequency Discount Level 1 Policy The process for managing risks has been described and documented in a formally approved document 2 yearly 10% Level 2 The process for managing risks is in use 3 yearly 20% Level 3 The process for managing risk is working across the entire organisation - where deficiencies have been identified through monitoring, action plans have been drawn up and changes made to reduce the risks. 3 yearly 30% Practice Performance 4 • Acute Trust with supra-regional St Andrews Plastics & Burns Unit • Just under 600 beds • 3500 plus WTE staff • NHSLA Level 2 achieved November 2008 • NHSLA Level 3 assessment November 2011 • Assessment preparation co-ordinated within Clinical Audit Department 5 1 • Identify Executive and Operational Lead(s) 2 • Review policy against requirements including monitoring process 3 • Develop audit plan for each criterion 6 4 •Audit findings reported to identified committee 5 • Action plan developed to address any deficiencies 6 • Progress monitored at subsequent meetings until closed 7 Std 1 2 3 4 5 Criterion Governance Learning from Experience Competent & Capable Workforce Safe Environment Acute, Community and Non-NHS Providers 1 Risk Management Strategy Clinical Audit Corporate Induction 2.1 Clinical Audit 3 Policy on Procedural Documents High Level Risk Committee(s) 4 Risk Management Process Claims Management 5 Risk Register Investigations 6 Dealing with External Recommendations Analysis & Improvement Learning Lessons from Claims 9 Health Records Management Health RecordKeeping Standards Professional Clinical Registration National Confidential Enquiries & Inquiries Supporting Staff 10 Employment Checks Being Open Stress 2 7 8 Secure Environment Incident Reporting Concerns & Complaints Best Practice - NICE Local Induction of Permanent Staff Local Induction of Temporary Staff Violence & Aggression Slips, Trips & Falls (Staff & Others) Risk Management Training Slips, Trips & Falls (Patients) Training Needs Analysis Risk Awareness Training for Senior Management Moving & Handling Training Harassment & Bullying Moving & Handling Supervision of Medical Staff in Training Patient Information & Consent Consent Training Maintenance of Medical Devices & Equipment Medical Devices Training Hand Hygiene Training Screening Procedures Inoculation Incidents Diagnostic Testing Procedures The Deteriorating Patient Clinical Handover of Care Discharge Transfusion Venous Thromboembolism Medicines Management 8 Level 1 - Policy a) duties b) how the organisation sets priorities for audit, including local and national requirements c) requirement that audits are conducted in line with the approved process for audit 9 d) how audit reports are shared e) report format including methodology, conclusions, action plans etc. f) how the organisation makes improvements g) how the organisation monitors action plans and carries out re-audits h) how the organisation monitors compliance with the above 10 Sample of clinical audit projects reviewed against specific measures; Report submitted to Clinical Audit Group (CAG) for approval & development of action plan; Progress monitored at subsequent CAG meetings; and Key findings & learning disseminated. 11 Audit Measures Compliance Standard Standard threshold met met 2011 1 Priority level identified Factors influencing proposal 2 identified Proposal form completed with 3 identified Project & Clinical Leads 4 a. Project standards based 2012 95% 95% 95% 90% b. Standards identified 5 Directorate Audit Lead approval 95% 12 Audit Measures Compliance Standard Standard threshold met met 2011 2012 6 Audit completed / CA informed 95% 7 Report submitted to CA 95% 8 75 % Appropriate report template 9 Audit findings disseminated 90% 10 Evidence action plan developed 90% 11 90% Evidence of implementation 12 Plan for re-audit 50% 13 Robust gatekeeping by Clinical Audit Department; Directorate Audit Lead role; ◦ Increased clarity for about role; ◦ Training commissioned; ◦ Software purchased; Annual review, performance data to Clinical Audit Group & Directorates. 14 Cultural shift Impact of regulatory, safety & quality improvement agendas: ◦ Quality Accounts & HQIP / National Clinical Audit Programme ◦ Care Quality Commission ◦ Monitor ◦ CQUINs ◦ Medical Revalidation NHSLA consultation 15