Irish National ICU Audit Governance...

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Irish National ICU Audit Governance Committee

Title Irish National ICU Audit Governance Committee - Terms of Reference

Authors Dr Rory Dwyer / Collette Tully / Mary Baggot

Approved by NOCA Governance Board

Issue Date April 2017, updated December 2017

Revision Due on or before April 2019

Version

Purpose The following Terms of Reference set out the responsibilities of the Irish National ICU Audit Governance Committee, under the governance structures established by the National Office of Clinical Audit. Administration The Clinical Lead and the ICU Audit Manager shall be responsible for the administration of the ICU Audit Governance Committee. Quorum The Irish National ICU Audit Governance Committee requires the presence of six of its members in

attendance to establish a quorum for any meeting convened. The Clinical Lead and ICU Audit Manager

will report to and attend all Governance Committee meetings.

Procedures for the appointment of members

It has been agreed through the NOCA Governance Board, that in order to establish the Irish National

ICU Audit Committee, the Clinical Lead for Audit will Chair the Committee for the first 6 months.

Subsequent Chairpersons will be elected from the overall membership of the Governance Committee.

In consultation with NOCA Management, the National Clinical Lead for ICU Audit invited nominations

from the following to join the Governance Committee:

mailto:[email protected]



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Lead Clinician for ICU Audit Dr Rory Dwyer

ICU Audit Manager Mary Baggot

ICU Assistant Audit Manager Fionnuala Treanor

NOCA Executive Director Collette Tully

Joint Faculty of Intensive Care Medicine of Ireland Dr Brian Marsh

Intensive Care Society of Ireland Dr Catherine Motherway

College of Anaesthesiologists of Ireland Dr Gerry Fitzpatrick

Office of the Nursing and Midwifery Services Director Mr Derek Cribbin

Irish Association of Directors of Nursing and Midwifery Eileen Whelan

Critical Care Programme Lead Dr Michael Power

Paediatric Intensive Care Audit Network (PICANet)

Dr Martina Healy

Royal College of Physicians in Ireland Professor Tim McDonnell

Royal College of Surgeons in Ireland

Professor David Healy

Public / Patient Interest Representative Barbara Egan

Public / Patient Interest Representative Damien Nee

ICU Audit Nurse Magdalena Pecak

Tenure

Membership of the ICU Audit Governance Committee will be for a staggered period of two years.

Members will be selected to reflect the interests of the ICU clinical community as a whole and to

achieve an appropriate mix of relevant skills to support ICU audit under the Governance of NOCA.

The number of other positions held by candidates will be considered so that candidates are not

overburdened and will have appropriate time to commit to ICU Audit. If the Committee decides that

further nominations are required for the ICU Governance Committee, these will be invited to join by

the Chair in consultation with the Committee.

Resignation of Governance Committee Members

Membership of the ICU Governance Committee will be for a period of two years. Resignation before

completion of tenure will be tendered and accepted only in writing to the Chair and will allow for no

less than two months’ notice. In the case of resignation of an individual, who may have been involved,

or offering specific advice or guidance in respect of the completion on any particular audit output or

report, the Committee Member will first ensure all obligations are fully discharged before tendering

resignation. The Chair shall invite additional members to fill casual vacancies from relevant cohort or

as the need arises in order to ensure adequate expertise is represented.

Attendance It is intended the ICU Governance Committee will meet quarterly. Prior notice will be issued by email. In the event a member is not in a position to attend, apologies should be sent to the ICU Audit Clinical Lead / ICU Audit Coordinator in advance. If a member of the Committee cannot attend it is not appropriate to send an alternate.




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Expenses The NOCA Governance Board and its respective Audit Committees are convened as voluntary board/committees and as such no member will be paid for their time. Travel expenses are available to any member attending the Governance Committee. These would normally be at public transport rates and normally only for those coming from outside Dublin. Confidentiality The operation of the Audit must be totally confidential. Members of the Governance Committee are nominated by various bodies and part of their role is to keep these bodies informed about developments in ICU Audit. However it would be a major breach of professional confidentiality to divulge any information about specific quality of care issues which may be discussed at the Governance Committee. Management of Conflicts of Interest In order to ensure the ICU Audit Governance Committee operates in a transparent and unbiased way, all Governance Committee Members will be asked to declare any conflict of interest to the Chair. Indemnity The Clinical Indemnity Scheme has been engaged by the HSE to provide indemnity cover to NOCA clinical staff and its officers, the convened members of the NOCA Governance Board and the respective Audit Governance Committees of NOCA, in respect of all clinical audit conducted by NOCA, in the unlikely event that such personnel may be sued in a personal injury action alleging clinical negligence arising from the proper discharge of the duties and obligations of the Committee.

Responsibilities of the Governance Committee The primary role of the Governance Committee is to monitor the ICNARC reports of the quality of care provided in each Critical Care Unit. In addition the Committee will advise the Lead Clinician on the operation of the Audit and will provide the link to the overall NOCA Governance Board to report on the operation and findings of the Audit Programme. The Lead Clinician supported by the NOCA executive team has operational responsibility for structuring and running the Audit Responsibilities;

i. Ensure that appropriate national protocols are in place for control of data, in compliance with ethical and statutory requirements.

ii. Advise re appropriate local hospital structures to provide local governance structures and data protection.

iii. Monitor the quarterly ICNARC reports to confirm that the quality of care in each Unit is achieving acceptable standards.

iv. Ensure that the NOCA Monitoring and Escalation policy is implemented if statistical outliers are noted for Quality Indicators in the quarterly ICNARC reports (see below).

v. Consider other issues relating to quality of care in ICU as appropriate. This will occur only if agreed by the Committee on a case-by-case basis.

vi. Ensure appropriate communication of the results of the Audit by a regular report to the overall NOCA Governance Board and by the publication of an Annual Report.

vii. Provide guidance on the strategic direction of the ICU Audit Programme and on any practical issues which arise in the operation of the Audit.

Confidentiality and Data Protection recommendations for ICU Audit Data




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1. Aim of ICU Audit is to provide maximum benefit for as many relevant stakeholders in the hospital as possible while (i) protecting confidentiality of data (ii) ensuring that data and reports are accompanied by information to allow appropriate interpretation.

2. Data must be handled sensitively and confidentially, in accordance with the Freedom of Information Act 1997 & 2003, Data Protection Acts 1998 and 2003, Professional Codes of Practice and all other relevant legislation. Users should also comply with their local hospital’s Data Protection policy.

3. The NOCA National ICU Audit Data is governed by NOCA. There is a NOCA National ICU Audit Data Protection Policy in place detailing the measures NOCA takes to protect the data. Patient identifiable information is stored on a HSE server but is only accessible by the relevant hospital. IT Security safeguards have been put in place to protect the data. No patient identifiable information is shared externally to ICNARC or anyone else from the National ICU Audit database.

4. One individual must take responsibility for ICU Audit data management. This should be the local Clinical Lead. The local Clinical Lead will be asked annually to confirm in writing that appropriate Data Protection and local Governance procedures are being followed in their institution.

5. To ensure compliance with this access to the infoFlex data base should be restricted to Audit Nurse and the local Clinical Lead with access for all others via the Data Access Request Form recommended by NOCA (Appendix 1).

Local Governance structures

1. Local Clinical Lead who is responsible for

(i) maintenance of data collection quality,

(ii) procedures for data protection,

(iii) ensuring deadlines for data submission are met and

(iv) receives and reviews the reports returned by ICNARC.

The local Clinical Lead for Audit is normally the ICU Director or their nominee

To fulfil these responsibilities, it is essential the Audit Nurse reports to the local Clinical Lead.

2. A mechanism for review of ICNARC reports by clinicians involved in the Unit; nursing and medical.

Normally this will be via regular ICU multidisciplinary team (MDT) meetings

3. Mechanism for submission of ICNARC reports and conclusions of local ICU MDT meeting to local hospital governance structures; i.e. Quality Assurance Committees, hospital Clinical Lead clinician, CEO etc.

See Appendix 2 for NOCA Guidelines on structures for local Hospital Clinical Audit Committees.

NOCA response to statistical outliers for the quality indicators reported by ICNARC quarterly

The Clinical Lead and National Audit Manager will review the Quarterly Quality Reports from ICNARC for each participating Unit and classify each Quality Indicator as ‘Acceptable’ or ‘For review’. The




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criterion for classifying a Quality Indicator ‘For review’ will be a value > 2 Standard Deviations (SD) outside the Mean for two Quarters or a value > 3 SDs for one Quarter. In addition if an indicator is > 2 SDs for the calendar year as a whole, this would trigger a review. Reports ‘For review’ will be dealt with as per the NOCA Monitoring and Escalation Policy (see below) Quality Indicators (also known as Key Performance Indicators (KPIs) are specific and measurable elements of practice that can be used to assess quality of care.

An outlier is a result that is statistically significantly further from the expected value of an agreed quality indicator than would occur by chance alone.

For ICU Audit we have defined a statistical outlier as outcomes that fall:

2 SDs outside the expected value across 2 consecutive quarters;

OR

3 SDs outside the expected value for 1 quarter.

A finding of a statistical outlier does not in the first instance indicate a problem with the quality of care, but rather a result that is unlikely to have arisen from random variation. This should trigger further analysis and review in the hospital, firstly to ensure the quality of the data. The ICU Audit Manager and the National Clinical Lead can provide assistance in this process.

The ICU Audit Governance Committee acknowledges that new audit sites will require a period for “bedding down” their data quality. Data quality should always be the first point of analysis and review of a statistical outlier.

NOCA response to a statistical outlier for a Quality Indicator.

If a statistical outlier for a Quality Indicator is noted, the NOCA Audit Manager/NOCA Audit Clinical Lead will email the Hospital Audit Clinical Lead and ICU Audit Nurse regarding data quality, within 15 working days.

The Hospital Audit Clinical Lead and Hospital Audit Coordinator investigate and inform the NOCA Audit Manager in writing of the outcome within 20 working days (unless otherwise agreed with NOCA).

If it is agreed there is a data quality issue, the local Hospital Audit Clinical Lead and Hospital ICU Audit Nurse correct the data and notifies NOCA in writing. The NOCA Audit Manager will arrange for further statistical analysis to verify correction of the data quality issue.

If it is agreed there is no data quality issue, NOCA will commence a process of escalation in relation to the statistical outlier.

The NOCA Audit Clinical Lead will notify Hospital CEO/ Manager of the statistical outlier and also inform the Group CEO, the National Director for Acute Hospitals and the local Hospital Audit Clinical Lead.

The NOCA notification letter will outline the details of the statistical outlier and required next steps (as below).




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i. The Hospital CEO/ Manager should nominate a Senior Accountable Person to undertake the review and analysis of the statistical outlier.

ii. Within 15 working days of receipt of the NOCA notification letter, the Hospital CEO/ Manager will in writing acknowledge receipt of the NOCA notification letter and provide details of: Name and contact details of Senior Accountable Person. Indicative timelines for completion of review.

iii. Senior Accountable Person will complete a review and analysis of the statistical outlier and prepare a report outlining the key findings and required corrective actions.

iv. Hospital CEO/ Manager is accountable for ensuring that the required corrective actions are added to the Hospital QI Plan and implemented within agreed timeframes. (v) Hospital CEO/ Manager or a nominee sends the statistical outlier report with associated corrective actions to the Hospital Group CEO, the HSE National Director and the NOCA ICU Audit Governance Committee (via the NOCA ICU Audit Manager).

v. The ICU Audit Annual Report will include details on statistical outliers on named hospitals, along with an update on the findings/ progress of the statistical outlier review carried out by the hospital.

vi. The ICU Audit Annual Report will include a summary on key lessons and recommendations arising from ICU Audit.

vii. The NOCA ICU Audit Manager will maintain a log of all statistical outliers and will update the ICU Audit Governance Committee quarterly.

Greater detail on the NOCA Monitoring and Escalation Policy can be found on the NOCA website noca.ie

NOCA process for Review of Paediatric Reports

A combined annual report for the two units participating in PICANet (Temple Street & Crumlin) is received each year around March. The same review process applied to ICNARC reports will also apply to PICANet reports and to reports on ‘Children in Adult ICUs’. ICU Clinical Lead, National Manager and National Lead for Paediatric Audit will meet annually to discuss these reports. Freedom of Information Acts 1997 & 2003 NOCA and its Governance Board, Officers and ICU Audit Governance Committee are working to Section 21(1) (a), Freedom of Information Acts 1997 & 2003 which provides that ..a public body may refuse access to a record if it considers that access could reasonably be expected to prejudice the effectiveness of tests, examinations, investigations, inquiries or audits conducted by or on behalf of a public body or the procedures or methods employed for the conduct thereof. Section 21(1) (b), also provides that a request for access to a record may be refused where ‘..access could reasonably be expected to have a significant, adverse effect on the performance by a public body of any of its functions relating to management’. In addition, Section 32 of the Freedom of Information Act 1997 and 2003 provides for the refusal of access to certain records whose disclosure is prohibited, or non-disclosure authorised, by other enactments. This is a very important provision when taken into consideration specifically with the Medical Practitioners Act 2007, Part 11. ICU Audit relies on voluntary participation and support for the Audit. This promotes quality improvement for the individual, the institution and the wider health system. Participation is consistent




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with the Professional Competence Schemes managed by the Training Bodies. In order to create a culture of reflective practice and to ensure clinicians are encouraged and supported to contribute to ICU Audit, NOCA will ensure an environment of full confidentiality.




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Appendix 1.




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Appendix 2. Guidelines for Hospital Clinical Audit Committee

This can be applied to any Hospital Clinical Audit Committee to oversee the local operation of a National Audit under the auspices of NOCA In some hospitals, it may be appropriate that a single Clinical Audit Committee provides oversight to a number of Clinical Audits.

Role and Remit of the Clinical Audit Committee The Clinical Audit Committee should provide governance for the Clinical Audit. It will provide both clinical and professional expertise when required, and work closely with the Hospital Clinical Lead for each Audit. This Committee is responsible for

Monitoring and support of hospital participation in clinical audit,

Identifying clinical expertise for case review,

Reviewing Reports from clinical audit and making recommendations regarding unexpected outcomes,

Reporting to Hospital Quality and Safety Executive Committee on results from Clinical Audit.

Provide assurance to the relevant NOCA Governance Committee regarding local governance of the Clinical Audit

Membership of Clinical Audit Committee Membership should reflect the stakeholders in Patient Safety in each Hospital and provide an appropriate mix of relevant expertise to support Clinical Audit governance. Suggested membership may be as follows;

Relevant Medical Specialties for the area of the relevant Clnical Audit

Clinical Lead for the hospital NOCA ICU Audit

Nursing representatives for the area of the relevant Clnical Audit

Clinical Director and Directorate Nurse Manager

Quality / Risk Manager

Allied Health Professional representatives

Patient Representative

Audit Coordinator

Hospital CEO or nominee

Consideration may be given to identifying ‘Core’ and ‘Standing’ members of the Committee.

Core members should attend every meeting.

Standing members are welcome to attend all meetings, however they are only expected to attend if there are relevant agenda items and/or if requested to attend by the chair.

Chair to be appointed at the establishment of the Committee. Terms of reference for the Committee should be formalised, to include duration of membership and of Chairmanship, number required for a quorum, frequency of meetings, etc.




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Attendance Normally a Clinical Audit Committee would meet quarterly. Inability to attend and contribute to 3 consecutive meetings per year will require review of membership and possible re-nomination from relevant stakeholder group. Administration The Chairman should ensure that Minutes of Meetings are kept to record;

names of the attendees

summary of proceedings.

decisions taken or the conclusions reached by the Committee.

actions to be followed by the Committee.

Accountability and Reporting Relationships The Clinical Audit Committee is accountable to the Hospital Quality and Safety Executive Committee Chair. Consideration should be given to development of an annual Audit Report to the Hospital Quality and Safety Committee.


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