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Meeting National S tandards for Clinical Audit: NHS Litigation Authority Level 3

Meeting National S tandards for Clinical Audit: NHS Litigation Authority Level 3. Helen Clarke Clinical Audit / NHSLA Lead Mid Essex Hospital Services Trust. NHS Litigation Authority & Risk Management Standards MEHT approach to assessment Criterion for Clinical Audit Performance issues.

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Meeting National S tandards for Clinical Audit: NHS Litigation Authority Level 3

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  1. Meeting National Standards for Clinical Audit:NHS Litigation Authority Level 3 Helen Clarke Clinical Audit / NHSLA Lead Mid Essex Hospital Services Trust

  2. NHS Litigation Authority & Risk Management Standards • MEHT approach to assessment • Criterion for Clinical Audit • Performance issues

  3. NHS Litigation Authority (NHSLA) • Clinical Negligence Scheme for Trusts; • Liabilities to Third Parties Scheme; and • Property Expenses Scheme1. Risk Management Standards • 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

  4. Assessment levels

  5. Mid Essex Hospitals Services Trust • 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

  6. Acute Services: our approach

  7. Acute Services - our approach to level 3

  8. NHSLA Risk Management Standards 2012–13 2.1 Clinical Audit

  9. Criterion on Clinical Audit (1of 2) 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

  10. Criterion on Clinical Audit (2 of 2) 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

  11. Monitoring compliance with the Trust’s Clinical Audit Policy • 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.

  12. Audit Measures / Performance

  13. Audit Measures / Performance

  14. Actions to address deficiencies • 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.

  15. The future ….. • 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

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