Reference: DCM102 Version: 4.0 This version issued: 21/11/19 Result of last review: Major changes Date approved by owner (if applicable):

N/A

Date approved: 11/09/19 Approving body: Quality Governance Group Date for review: December, 2024 Owner: Jeremy Daws, Head of Quality Governance Document type: Miscellaneous Number of pages: 15 (including front sheet) Author / Contact:

Hayli Garrod & Jason Baker, Audit Specialists & Department Managers

Northern Lincolnshire and Goole NHS Foundation Trust actively seeks to promote equality of opportunity. The Trust seeks to ensure that no employee, service user, or member of the public is unlawfully discriminated against for any reason, including the “protected characteristics” as defined in the Equality Act 2010. These principles will be expected to be upheld by all who act on behalf of the Trust, with respect to all aspects of Equality.

Medical Director’s Office

QUALITY AND AUDIT STRATEGY 2019 – 2024

Reference DCM102 Date of issue 21/11/19 Version 4.0

Printed copies valid only if separately controlled Page 2 of 15

Contents

Section ............................................................................................................. Page

1.0 Introduction and Purpose ............................................................................. 3

2.0 Area ............................................................................................................. 3

3.0 Responsibilities ............................................................................................ 3

4.0 Philosophy ................................................................................................... 4

5.0 Definition of Clinical Audit ............................................................................ 4

6.0 Organisational Context ................................................................................ 5

7.0 Objectives .................................................................................................... 6

8.0 Key Performance Indicators ......................................................................... 8

9.0 Monitoring Compliance and Effectiveness ................................................... 8

10.0 Associated Documents ................................................................................ 9

11.0 References ................................................................................................... 9

12.0 Consultation ................................................................................................. 9

13.0 Dissemination .............................................................................................. 9

14.0 Implementation ............................................................................................ 9

15.0 Document History ........................................................................................ 9

16.0 Equality Act (2010) ..................................................................................... 10

17.0 Freedom to Speak Up ................................................................................ 10

Appendix A - Operational Action Plan ................................................................... 11

Reference DCM102 Date of issue 21/11/19 Version 4.0

Printed copies valid only if separately controlled Page 3 of 15

1.0 Introduction and Purpose

1.1 The use of clinical audit within organisations continues to evolve. External governing bodies place more emphasis on clinical audit and are increasing utilising national benchmarking data and local intelligence to measure performance and quality within Trusts.

1.2 Northern Lincolnshire and Goole Foundation Trust (NLAG) considers clinical audit to be a key component in of achieving its vision to deliver safe and high quality patient-centred services. The Trust’s strategic framework principles detailed in the strategic plan (2019-24) state that the Trust should “deliver the right patient centred care at the right time and right place”. By using clinical audit, performance can be measured against evidence based standards of best practice to provide robust quality assurance, identify areas of non-compliance and drive improvement in the quality of care provided.

1.3 This document describes the strategic approach within the Trust will take to develop quality and audit over the next five years, identifies the key quality and audit objectives required to meet national and local priorities and determines how the Trust will work collaboratively to learn from quality and audit and other areas of clinical governance, ultimately improving patient care.

1.4 This strategy links to the Quality Strategy (2019-2024).

2.0 Area

This strategy is intended to inform and support all staff working at Northern Lincolnshire and Goole NHS Foundation Trust and external parties who have an interest and responsibility for contributing to and overseeing the development, direction and delivery of clinical audit and effectiveness activity within the organisation.

3.0 Responsibilities

3.1 The overall responsibility for this strategy is the Medical Director who is ultimately accountable for the quality assurance and audit arrangements throughout the Trust, delegating the direction and leadership of Clinical Audit to the Associate Director of Quality Governance.

3.2 The Head of Assurance has lead responsibility for the oversight of the Quality Development Plan and the clinical audits which support this plan.

3.3 The Trust’s delivery of the quality and audit programme is achieved by multi professional working with divisional management teams. Therefore, led by the Divisional Clinical Director, the divisional triumvirates will focus on the delivery of this strategy.

3.4 Governance Group which outlines the projects to be undertaken each financial year.

Reference DCM102 Date of issue 21/11/19 Version 4.0

Printed copies valid only if separately controlled Page 4 of 15

3.5 To monitor progress in fulfilling the programme, quarterly reports will be produced to the Quality Governance Group and divisional governance groups outlining progress and highlighting key delays where necessary. In addition, an annual report will be produced to summarise key activity and delivery throughout the year.

4.0 Philosophy

4.1 In 2008, The Healthcare Quality Improvement Partnership (HQIP) was established to promote quality in healthcare and in particular to increase the impact that clinical audit has on healthcare quality. The Trust’s approach to quality and audit is adopted from these principles and based on what they consider to be “best practice in clinical audit”.

4.2 The importance which HQIP (2017) and healthcare regulators attach to effective clinical audit is shown by the extent to which participation in national and local clinical audit is now a statutory and contractual requirement for healthcare providers. Northern Lincolnshire and Goole NHS Foundation Trust echo this importance and recognise the positive relationship between clinical audit and improvement.

4.3 One of the Trust’s strategic objectives is “to give good care” where safe, high quality services are offered. To support this objective the Trust aim to further strengthen and develop the build on a strong foundation by which clinical audit not only provides robust quality assurance to patients, but drives the quality of their care through evidence based practice with the philosophy to:

Support the delivery of the Quality and Audit Forward Programme to meet the national and contractual requirements set out in the NHS Standard Contract.

Ensure local quality and audit projects undertaken by the Trust are relevant, timely and utilised to drive and monitor change.

Encourage multidisciplinary working and commitment throughout the Trust to deliver the Quality and Audit Forward Programme.

Ensure poor results are acted on and escalated in accordance with the Trust’s Quality and Audit Policy.

Ensure staff have access to support and training in quality and audit methodologies

Promote patient focused quality and audit activity, in line with the HQIPs Criteria for Best Practice in Clinical Audit

5.0 Definition of Clinical Audit

5.1 HQIP (2017) describe clinical audit as “a quality improvement cycle that involves measurement of the effectiveness of healthcare against agreed and proven standards for high quality, and taking action to bring practice in line with these standards so as to improve the quality of care and health outcomes.”

Reference DCM102 Date of issue 21/11/19 Version 4.0

Printed copies valid only if separately controlled Page 5 of 15

5.2 By following the clinical audit cycle (Figure 1), any health professional or team should be able to see where their practice can be improved against given benchmarks, to take action, and then to re-measure and make further improvements.

Figure 1:

6.0 Organisational Context

6.1 It is important that clinical audit is not seen as an isolated quality improvement activity but as one of a set of tools which teams and services can use to improve the quality of care that is delivered to service users and their carers. Consideration must be given to links with the wider quality and governance frameworks that exist.

6.2 Corporate Assurance

The clinical audit strategy outlines the process by which the Trust Board will be assured that effective clinical audits are conducted to drive and measure quality of clinical care. Information on the provision and quality of services derived from clinical audit will inform the Board Assurance Framework and provide evidence for registration requirements of the Care Quality Commission and other external assessors. Assurances can be gained by the Board from the Trust’s Clinical Audit process in support of self-certification. The clinical audit framework will also contribute to meeting commissioners' requirements, including NICE clinical guidelines and Quality Accounts, in terms of assessment of the quality of services they commission. Achievement of a number of Commissioning for Quality and Innovation (CQUIN) goals will be evidenced by clinical audit.

Reference DCM102 Date of issue 21/11/19 Version 4.0

Printed copies valid only if separately controlled Page 6 of 15

6.3 Quality Governance Framework

Quality governance is the combination of structures and processes at and below board level to lead on trust-wide quality performance including: ensuring required standards are achieved; investigating and taking action on sub-standard performance; planning and driving continuous improvement; identifying, sharing and ensuring delivery of best- practice; and identifying and managing risks to quality of care. Clinical audit provides quality assurance to the Trust. In particular, the clinical audit programme is driven by national audits, with processes for initiating additional audits as a result of identification of local risks (e g incidents), ensuring robust action plans are in place to address quality performance issues and that the quality of information is robust.

6.4 Complaints and Other Forms of Patient and Public Involvement

Themes from this intelligence can be used to propose topics for clinical audit. For example, if local complaints or Patient Reported Outcome Measures illustrate specific, persistent and/or local concerns, then the clinical audit programme can be designed to include the monitoring of standards related to those concerns.

7.0 Objectives

7.1 To support the Trust’s philosophy and achieve the strategic approach aim outlined above, developing the following areas of clinical audit during 2019-2024. The key aims and objectives detailed below are supported by the operational plan shown in Appendix A.

7.2 Key Aim: Ensure a co-ordinated consistent approach to all quality & audit activity undertaken within NLAG and ensure robust systems are in place

7.2.1 Objectives:

Develop clear and precise systems and processes to support the delivery of clinical audit activity

Coordinate all clinical audit activity in the Trust to ensure there is a central point of information and duplication of activity is avoided

Ensure a consistent approach to reviewing data/national data to determine potential outlier status prior to submission to national Quality Account/National Clinical Audit Patient outcome Programme (NCAPOP) audits

Ensure relevant NICE Guidance and Patient Safety Alerts are considered in clinical audit activity

Reference DCM102 Date of issue 21/11/19 Version 4.0

Printed copies valid only if separately controlled Page 7 of 15

7.3 Key Aim: Increased oversight of intelligence data to allow early detection of the Trust’s poor performing areas aiming to reduce ‘outlier’ alerts

7.3.1 Objectives:

Review external insight reports to identify areas of concern within the Trust to inform the Quality and Audit Forward Programme

Review Trust audit data against national published clinical audit benchmarking to identify Trust outliers and support divisions to act on this intelligence

Strengthen the links with clinical governance and risk management to identify key risk areas and learn lessons

7.4 Key Aim: Increased oversight of intelligence data to allow early detection of the Trust’s poor performing areas aiming to reduce ‘outlier’ alerts

7.4.1 Objectives:

Introduce a simplified approach to reporting and action planning to improve timeliness, ease of understanding and robustness

Specialty quality and audit/quality and safety meetings to be clinically led with support from the Quality and Audit team to ensure concerns and ideas of all staff are listened to

Utilise the procedural information to aid increased communication and promote joint working

Further develop and maintain the Quality and Audit page on the intranet to better inform staff within the Trust of current audit activity

Promote ownership of developing and approving action plans through the Clinical Governance Process

Develop closer links with the clinical audit leads/divisional management teams; providing support and encourage ownership of the rolling programme and resulting action plans to ensure learning and improvements is at the centre of the audit

7.5 Key Aim: Ensure staff have access to support and training in quality and audit

7.5.1 Objectives:

Develop an induction package to aid the process of initiation into the Quality and Audit Department

Review the support, guidance and resources available to clinical staff to ensure it is fit for purpose, relevant and provides the necessary information to enable them to undertake clinical audit activity

Reference DCM102 Date of issue 21/11/19 Version 4.0

Printed copies valid only if separately controlled Page 8 of 15

Develop the Quality and Audit Workshop training package to detail the relationship between quality improvement projects (QIP’s) and clinical audit activity

Further develop and maintain the Quality and Audit intranet page with up to date training resources, and ‘how to’ guides and key information on current audit activity

7.6 Key Aim: Promote patient focused quality and audit activity, in line with the Trust Quality & Audit Policy and HQIP’s Criteria for Best Practice in Clinical Audit

7.6.1 Objectives:

Ensure clinical audit supported by the Quality and Audit Team is compliant with the Trust’s Quality and Audit Policy and HQIP’s Criteria for Best Practice in Clinical Audit

Promote a culture of quality and audit that is patient and carer focused

8.0 Key Performance Indicators

Key Performance Indicators (KPIs) have been developed to provide measurements around the delivery of key stages of clinical audit activities. To ensure the KPI’s are measured equally across the specialties further work will be undertaken to determine timeframes for escalation where progress is not on target. Reporting will occur on a monthly basis.

Performance Metric Threshold

(X number) out of the (X number) Quality Accounts (QA) and National Clinical Audit & Patient Outcomes Programme (NCAPOP) National Audit Reports published are shared with leads/stakeholders within 7 days of receipt.

95%

(X number) out of the (X number) Quality Accounts (QA) and National Clinical Audit & Patient Outcomes Programme (NCAPOP) National Audits are on target for completion (This covers from project initiation up to and including results being shared/presented).

95%

XX out of XX relevant QA and NCAPOP National Audits are on target to have an action plan developed and agreed at Governance.

95%

Following approval at Governance XX out of the XX QA and NCAPOP action plans are on target for completion

95%

9.0 Monitoring Compliance and Effectiveness

The implementation and delivery of the objectives detailed in section 7.0 will be monitored by the Quality and Audit Department with the oversight from the Head of Quality Assurance.

Reference DCM102 Date of issue 21/11/19 Version 4.0

Printed copies valid only if separately controlled Page 9 of 15

10.0 Associated Documents

10.1 Trust Quality and Audit Policy (DCP157).

10.2 Trust Quality Strategy (DCM108).

11.0 References

11.1 Healthcare Quality Improvement Partnership (HQIP), Criteria and indicators of best practice in clinical audit (2016).

11.2 Healthcare Quality Improvement Partnership (HQIP), Clinical Audit – Statutory and Mandatory Requirements (2017).

12.0 Consultation

12.1 The Quality Governance Group is responsible for overseeing the ongoing development and implementation of the Quality and Audit Strategy.

12.2 The Quality Governance Group will be responsible for the approval of the annual Quality and Audit Forward Programme and the Annual Report, with the involvement of the Quality & Safety Committee.

13.0 Dissemination

The following groups/committees will receive a copy of the published the strategy in electronic format:

Quality Governance Group

Audit, Risk and Governance Committee

Quality and Safety Committee

Divisional Clinical Governance Groups

14.0 Implementation

The implementation and delivery of the objectives detailed in section 7.0 will be monitored by the Quality and Audit Department.

15.0 Document History

Major changes.

Reference DCM102 Date of issue 21/11/19 Version 4.0

Printed copies valid only if separately controlled Page 10 of 15

16.0 Equality Act (2010)

16.1 Northern Lincolnshire and Goole NHS Foundation Trust is committed to promoting a pro-active and inclusive approach to equality which supports and encourages an inclusive culture which values diversity.

16.2 The Trust is committed to building a workforce which is valued and whose diversity reflects the community it serves, allowing the Trust to deliver the best possible healthcare service to the community. In doing so, the Trust will enable all staff to achieve their full potential in an environment characterised by dignity and mutual respect.

16.3 The Trust aims to design and provide services, implement policies and make decisions that meet the diverse needs of our patients and their carers the general population we serve and our workforce, ensuring that none are placed at a disadvantage.

16.4 We therefore strive to ensure that in both employment and service provision no individual is discriminated against or treated less favourably by reason of age, disability, gender, pregnancy or maternity, marital status or civil partnership, race, religion or belief, sexual orientation or transgender (Equality Act 2010).

17.0 Freedom to Speak Up

Where a member of staff has a safety or other concern about any arrangements or practices undertaken in accordance with this strategy, please speak in the first instance to your line manager. Guidance on raising concerns is also available by referring to the Trust’s Freedom to Speak Up Policy and Procedure (DCP126). Staff can raise concerns verbally, by letter, email or by completing an incident form. Staff can also contact the Trust’s Freedom to Speak Up Guardian in confidence by email to nlg.tr.ftsuguardian@nhs.net. More details about how to raise concerns with the Trust’s Freedom to Speak Up Guardian or with one of the Associate Guardians can be found on the Trust’s intranet site.

_________________________________________________________________________

The electronic master copy of this document is held by Document Control, Trust Secretary, NL&G NHS Foundation Trust.

Reference DCM102 Date of issue 21/11/19 Version 4.0

Printed copies valid only if separately controlled Page 11 of 15

Appendix A

The table below describes the actions the Trust will be taking in order to deliver the agreed objectives

Operational Action Plan

Key Aim Objective How will we implement

Ensure a co- ordinated consistent approach to all quality & audit activity undertaken within NLAG and ensure robust systems are in place

Develop clear and precise systems and processes to support the delivery of clinical audit activity

Develop a Quality and Audit Standard Operating Procedure (SOP) to include the following flowcharts that defines the process with clear times frames and lines of escalation:

Steps to undertake a national priority audit (Quality Account / NCAPOP

Steps to undertake a local trust priority audit

Action to take when identified as an ‘outlier’ / potential ‘outlier’

Steps to take when undertaking a priority 3 audit (clinical staff and Quality and Audit staff).

Share completed SOP with Clinical Governance Groups and Specialty Audit Groups.

Ensure robust action plans are developed using SMART principles and that implementation of actions is evidenced / tested (i.e. rapid cycle audits) for all priority projects.

Ensure assurance levels are applied and appropriate escalation occurs to help drive improvements in patient care through clinical audit.

Ensure audits that have two consecutive limited assurance ratings are highlighted to the Clinical Governance Group and follow the risk assessment process.

Ensure re-audit dates and how results/learning will be shared are explicitly documented in all priority project action plans and monitored.

Reference DCM102 Date of issue 21/11/19 Version 4.0

Printed copies valid only if separately controlled Page 12 of 15

Key Aim Objective Action required to implement objective

Coordinate all clinical audit activity in the Trust to ensure there is a central point of information and duplication of activity is avoided

When agreeing the divisional forward programmes, encourage divisional management teams include projects that are being led by the division

Further develop the quality and audit systems for recoding projects on the priority 3 database (refer to SOP)

Inform new clinical staff at junior doctor’s induction (rolling basis)

Communication to be sent out utilising the Trust’s computer screensavers, highlighting the need for all clinical audit activity to be registered with the Quality and Audit Department

Ensure a consistent approach to reviewing national data (where available) to determine potential outlier status prior to submission to national Quality Account / National Clinical Audit Patient outcome Programme (NCAPOP) audits

Process to be agreed and included as part of the SOP for undertaking a national audit

Where potential outlier status is identified the appropriate escalation process should be triggered and discussed with divisional leads and stakeholders via standardised communication methods

Ensure relevant NICE Guidance and Patient Safety Alerts are considered in clinical audit activity

When developing the Quality and Audit Forward Programme, triangulate most recent published NICE guidance and patient safety alerts (PSA) relevant to the project and record on the Quality and Audit Reporting Spreadsheet

Project plan to make reference to relating NICE and PSA, include in measurement of standards (where possible)

Encourage clinical staff looking to undertake a priority 3 project to base audit standards on most recent NICE guidance

Reference DCM102 Date of issue 21/11/19 Version 4.0

Printed copies valid only if separately controlled Page 13 of 15

Increased oversight of intelligence data to allow early detection of the Trust’s poor performing areas aiming to reduce ‘outlier’ alerts

Review external insight reports to identify areas of concern within the Trust to inform the Quality and Audit Forward Programme

Ensure CQC insight reports are reviewed on a monthly basis and any concerns highlighted to the relevant divisional teams.

Review Trust audit data against national published clinical audit benchmarking to identify Trust outliers and support divisions to act on this intelligence.

Ensure HQIPs clinical audit benchmarking website is reviewed on a monthly basis to action where

Ensure the appropriate response and escalation takes place if the Trust is notified of an ‘outlier’ alert (managed in line with SOP)

Strengthen the links with clinical governance and risk management to identify key risk areas and learn lessons

Ensure all clinical audits resulting from Serious Incidents are included in the annual Quality and Audit Forward Programme on an annual basis.

Increased partnership working / engagement / ownership with clinicians and divisional management

Introduce a simplified approach to reporting and action planning to improve timeliness, ease of understanding and robustness

Appropriate reporting templates to be utilised by the Quality and Audit Team.

One page highlight reports to be developed (where appropriate)

National report to be distributed along with blank action plan template if local Trust data is easily understood

Specialty quality and audit / quality and safety meetings to be clinically led with support from the Quality and Audit team

Ensure terms of reference are developed for each local speciality clinical audit / quality and safety meetings.

Ensure clinical audit leads are supported in agenda setting and have the relevant information to lead the meeting.

Utilise the procedural information (SOP) to aid increased communication and promote joint working

Ensure quarterly reports are circulated to clinical leads / divisional management in addition to Quality Governance Groups.

Standard communication templates to be developed and introduced for use to provide regular updates and highlight risk of non-delivery of audit activity.

Reference DCM102 Date of issue 21/11/19 Version 4.0

Printed copies valid only if separately controlled Page 14 of 15

Key Aim Objective Action required to implement objective

Further develop and maintain the Quality and Audit page on the intranet to better inform staff within the Trust of current audit activity

Update the information stored on the Quality and Audit intranet site to reflect current processes, procedures and staffing information.

Promote ownership of developing and approving action plans through the Clinical Governance Process

Encourage Clinical Audit Leads to discuss the completed audit project and proposed action plan for sign off at the Clinical Governance Meetings.

Develop closer links with the clinical audit leads / divisional management teams; providing support and encourage ownership of the rolling programme and resulting action plans

Face to face meetings to take place with Clinical Audit Leads and Quality and Audit Facilitators (at least quarterly) or more often if required

Where requested ensure information is made available for divisional PRIM.

Ensure staff have access to support and training in quality and audit

Develop an induction package to aid the process of initiation into the Quality and Audit Department.

Quality and Audit Workbook to be reviewed, updated and available for new members of staff starting in the Quality and Audit Department.

Review the support, guidance and resources available to clinical staff to ensure it is fit for purpose, relevant and provides the necessary information to enable them to undertake clinical audit activity

Ensure the SOP relating to priority 3 audits sets out the support, training and resources available to assist clinical staff in undertaking audit activity.

Update current guidance / how to guides with up to date, relevant and more detailed information to be made available via various methods such as; the intranet, junior doctor inductions, speciality audit meetings.

Review the most recent virtual clinical audit training packages available and ensure this is made available to clinical staff.

Reference DCM102 Date of issue 21/11/19 Version 4.0

Printed copies valid only if separately controlled Page 15 of 15

Key Aim Objective Action required to implement objective

Develop the Quality and Audit Workshop training package to detail the relationship between quality improvement projects (QIP’s) and clinical audit activity

Review the content of the current training package in place.

Ensure training workshop dates are advertised on the Quality and Audit intranet page with easy access booking system for clinical staff available.

Further develop and maintain the Quality and Audit intranet page with up to date information

Ensure all information is up to date and relevant to current processes and resources within the Quality and Audit Department.

Publish the annual forward programme on the Quality and Audit intranet page to allow clinical staff to view planned audit activity.

Promote a culture of quality and audit that is patient and carer focused

Utilise patient / carer feedback from national clinical audit activity

Where Patient Reported Outcome Measures are available through national clinical audit projects, ensure the feedback is shared with the clinical teams and include in action plans where necessary.

Continue to report on national Patient Reported Outcome measures (PROMS) on a bi annual basis and share results with the appropriate clinical teams.

Ensure patient involvement in clinical audit through the patient panel/group representatives and provide appropriate training to any patient participant.

At the time of developing the Quality and Audit Forward Programme liaise with the patient panel lead to share the details of the forward programme and ask for the details of those who would like to be involved in the clinical audit process.

Where patient participation occurs in the audit process, ensure the relevant process is followed to support their involvement.

Where training requests are received, ensure bespoke or group packages are made available.