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Clinical Audit departments are now facing the challenge of changing
their role to incorporate the remit of Clinical Effectiveness. This
letter describes some of how we undertook that change in the background of
a busy district general hospital.
Following our CHI review the key area that we had to consider was to
link clinical audit with other clinical governance activity, especially
risk management and clinical effectiveness. It was decided at the CHI
action-planning day to extend the remit of the department to tie in
effectiveness with audit. Therefore The Clinical Audit Department was
renamed the Clinical Audit & Effectiveness Department. This change
allows us to undertake a wider range of ‘top down’ audits relating to
issues that have a direct bearing on the service delivery of the Trust,
such as documentation, monitoring of the implementation and use of NICE
guidelines and National Service Frameworks. A register of NICE guidelines
has been produced to show which are in use in the Trust, when they were
implemented and a date for review. All Clinical Audit Leads have been
asked to consider national or local guidelines, policies or protocols in
their directorates as subjects for audit, to produce evidence of best
practice. At the audit committee meeting audit leads are asked to
provide evidence that they are complying to these guidelines.
One of our main issues was that we needed to ensure that at the end
of every audit, appropriate recommendations and an action plan are
produced in order to implement changes and enable re-audit. The most
important step is the presentation of the audit and the directorate
monthly educational half day. Here the recommendations made as a result
of the audit are recorded. The Clinical Audit Contract outlines the
requirements for completed projects – that they be in BMJ abstract format,
with discussion points and recommendations added at the time of
presentation. Once abstracts are submitted the Clinical Audit &
Effectiveness Department allocate an Implementation of Clinical
Effectiveness (ICE) score which identifies the risks of danger and damage
to the Trust, ranging from 1 – 3, 1 = High Risk, 3 = Low Risk.
Once audits are scored we then make an action plan and forward to all
relevant parties where we expect the appropriate actions to be taken by
the individuals involved. This helps us monitor the ongoing progress of
each audit and ensure that the audit cycle is completed.
It is fair to say that over the last four years the department has
moved on from a non descript, poorly supported and vaguely orientated
institution to one with definite purpose and more importantly respect from
the peer review establishment. By coordinating audit activity with
Clinical Effectiveness a pathway can be developed which undoubtedly must
lead to an improvement in patient care.
Clinical Audit and Effectiveness
Clinical Audit departments are now facing the challenge of changing
their role to incorporate the remit of Clinical Effectiveness. This
letter describes some of how we undertook that change in the background of
a busy district general hospital.
Following our CHI review the key area that we had to consider was to
link clinical audit with other clinical governance activity, especially
risk management and clinical effectiveness. It was decided at the CHI
action-planning day to extend the remit of the department to tie in
effectiveness with audit. Therefore The Clinical Audit Department was
renamed the Clinical Audit & Effectiveness Department. This change
allows us to undertake a wider range of ‘top down’ audits relating to
issues that have a direct bearing on the service delivery of the Trust,
such as documentation, monitoring of the implementation and use of NICE
guidelines and National Service Frameworks. A register of NICE guidelines
has been produced to show which are in use in the Trust, when they were
implemented and a date for review. All Clinical Audit Leads have been
asked to consider national or local guidelines, policies or protocols in
their directorates as subjects for audit, to produce evidence of best
practice. At the audit committee meeting audit leads are asked to
provide evidence that they are complying to these guidelines.
One of our main issues was that we needed to ensure that at the end
of every audit, appropriate recommendations and an action plan are
produced in order to implement changes and enable re-audit. The most
important step is the presentation of the audit and the directorate
monthly educational half day. Here the recommendations made as a result
of the audit are recorded. The Clinical Audit Contract outlines the
requirements for completed projects – that they be in BMJ abstract format,
with discussion points and recommendations added at the time of
presentation. Once abstracts are submitted the Clinical Audit &
Effectiveness Department allocate an Implementation of Clinical
Effectiveness (ICE) score which identifies the risks of danger and damage
to the Trust, ranging from 1 – 3, 1 = High Risk, 3 = Low Risk.
Once audits are scored we then make an action plan and forward to all
relevant parties where we expect the appropriate actions to be taken by
the individuals involved. This helps us monitor the ongoing progress of
each audit and ensure that the audit cycle is completed.
It is fair to say that over the last four years the department has
moved on from a non descript, poorly supported and vaguely orientated
institution to one with definite purpose and more importantly respect from
the peer review establishment. By coordinating audit activity with
Clinical Effectiveness a pathway can be developed which undoubtedly must
lead to an improvement in patient care.
With regards
Liz Summers
Clinical Audit and Effectiveness Manager
Competing interests:
None declared
Competing interests: No competing interests