Helen ClarkeClinical Audit / NHSLA Lead

Mid Essex Hospital Services Trust

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NHS Litigation Authority & Risk

Management Standards

MEHT approach to assessment

Criterion for Clinical Audit

Performance issues

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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

• 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.

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Level Requirement at assessment Frequency

Discount

Level 1Policy

The process for managing risks has been described and documented in a formally approved document

2 yearly 10%

Level 2Practice

The process for managing risks is in use

3 yearly 20%

Level 3 Performance

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%

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• 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

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Std 1 2 3 4 5

Criterion

Governance Learning fromExperience

Competent & Capable Workforce

SafeEnvironment

Acute, Community and Non-NHS

Providers

1 Risk Management Strategy

Clinical AuditCorporate Induction Secure Environment

Supervision of Medical Staff in

Training

2 Policy on Procedural Documents Incident Reporting Local Induction of

Permanent StaffViolence &

Aggression Patient Information

& Consent

3 High Level Risk Committee(s)

Concerns & Complaints

Local Induction of Temporary Staff

Slips, Trips & Falls (Staff & Others) Consent Training

4 Risk Management Process Claims Management Risk Management

TrainingSlips, Trips & Falls

(Patients)

Maintenance of Medical Devices &

Equipment

5 Risk Register Investigations Training Needs Analysis Moving & Handling Medical Devices

Training

6 Dealing with External Recommendations

Analysis & Improvement

Risk Awareness Training for Senior

Management

Hand Hygiene Training

Screening Procedures

7 Health Records Management

Learning Lessons from Claims

Moving & Handling Training Inoculation Incidents Diagnostic Testing

Procedures

8 Health Record-Keeping Standards Best Practice - NICE Harassment &

Bullying The Deteriorating

Patient Transfusion

9 Professional Clinical Registration

National Confidential Enquiries & Inquiries Supporting Staff Clinical Handover of

CareVenous

Thromboembolism

10 Employment Checks Being Open Stress Discharge Medicines Management

2.1 Clinical Audit

Level 1 - Policya) 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

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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

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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.

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Audit Measures Compliance

threshold

Standard met2011

Standard met2012

1 Priority level identified 95%

2Factors influencing proposal identified

95%

3Proposal form completed with identified Project & Clinical Leads

95%

4a. Project standards based

90%b. Standards identified

5 Directorate Audit Lead approval 95%

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Audit Measures Compliance

threshold

Standard met2011

Standard met2012

6 Audit completed / CA informed 95%

7 Report submitted to CA 95%

8 Appropriate report template 75 %

9 Audit findings disseminated 90%

10 Evidence action plan developed 90%

11 Evidence of implementation 90%

12 Plan for re-audit 50%

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.

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Cultural shift Impact of regulatory, safety & quality improvement agendas:

◦ Quality Accounts & HQIP / National Clinical Audit Programme

◦ Care Quality Commission◦ Monitor◦ CQUINs◦ Medical Revalidation

NHSLA consultation15