Clinical Audit for Board Assurance Anne H Lawson Director of Governance – HDFT Visiting Fellow – Loughborough University
Dec 26, 2015
Clinical Audit for Board AssuranceAnne H Lawson
Director of Governance – HDFTVisiting Fellow – Loughborough University
NHSFT Code of Governance
Directors are ultimately and collectively responsible for all
aspects of the performance of the Trust
How can they know?
The Balance• Assurance or detailed knowledge
• Too much or too little
• Strategic or operational
• TRUST
• CHALLENGE
Role of Internal Audit
• Advising the Board of the adequacy and effectiveness of overall arrangements
• Provide a coordinating role on assurance issues
• Work closely with other reviewers
INTERNAL AUDIT
• Provides the Audit Committee with an
• “opinion on the overall adequacy and effectiveness of the organisation’s risk management, control and governance processes”
WHY FOCUS ON CLINICAL AUDIT?
• The Audit Committee should consider
• “…how best to engage with clinical audit to meet its own needs for assurance…”
• “..expect to see regular reports of the outcomes of Clinical Audit work”
• Audit Committee Handbook• January 2010
SHOULD THE AUDIT COMMITTEE CONSIDER CLINICAL GOVERNANCE ISSUES?
• “consider clinical objectives and risks in the Assurance Framework”
• Audit Committee Handbook• January 2010
Changes to the Audit committee focus
• Challenging for non-execs who may have no health background
• Challenging for trust clinical effectiveness and audit staff.
Local Audit
Clinical audit local
Outcomes against
standards
Comparison with peers
Process against policy
Patient experience
surveys
Other surveys
Learning for staff
National audit
Clinical audit
national
Benchmarking of organisational attributes
Benchmarking of process
Benchmarking of outcomesGap
analysis
Audit of action planning
regulation
CQC
NHSLA
HSE
CPA
HTAMonitor
Others
Internal Audit
External Audit
Clinical audit local
Outcomes against
standards
Comparison with peers
Process against policy
Patient experience
surveys
Other surveys
Learning for staff
Clinical audit
national
Benchmarking of
organisational attributes
Benchmarking of process
Benchmarking of outcomes
Gap analysis
Audit of action
planning
audit
Change and re-audit
Assurance
Board of Directors
Sub groups of Board
Outcomes of audits
• For assurance• Measure performance against a known
standard and facilitate improvement• Benchmark performance against other
organisations• To teach the practice/art of auditing (junior
doctors)
There is real gain to be realised from Internal audit and clinical
audit working together although each will always have their
particular remit.
Challenges
• We use different languages• We have different purposes for doing an audit• We report differently• We need to recognise diversity• We have different expected outcomes
Challenges
• Self assessment • Clinical Outcomes• Compliance• Evidence base
standards
• Independent view• Systems and Controls
Perceptions
• Board are nervous of limited assurance• If worry area should expect gaps – make clear
expectation at start• Re-audit WILL be for assurance purposes• Do not drive the issues underground
False Assurance
We can only ‘measure’ what we can measure.
If we have no limited assurances we have not prioritised the correct areas
Sources Of Assuranceexamples
Internal• Internal Audit• Clinical Audit• Assurance Framework• Governance Annual report• Robust reporting and accountability structures• Performance Indicators• Self assessments- research/information governance, child protection• Complaints/incidents/claims
External• NHSLA• National Audits• Audit Commission• Regulator – CQC/Monitor• Audit Office• College Visits• Deanery Visits• Cancer Peer Review• Performance Indicators• Benchmarking• Patient and Staff surveys
Standards to enable comparisons
• CQC• CQC reviews and reports• Independent reviews• Monitor• NICE Guidelines etc.• NHSLA Risk Management
Standards• Patient Safety Alerts• Health Service Circulars• Managers Code of Conduct• Other DH Standards e.g. Internal
Audit, IWL, etc.• Other ‘arms length’ bodies e.g.
National Patient Safety Agency, MHRA, NHS Estates, etc.
• National Confidential Enquiries
• Independent reviews• Parliament - laws and regulations• Royal Colleges• Other professional organisations e.g.
IHM• Other UK health department related
e.g. Scottish Inter-Collegiate Network (SIGN)
• Regulatory bodies e.g. HSE• British & International Standards (BSI
& ISO)• Accreditation e.g. HQS, Trent,
Laboratories, etc.• Other independent healthcare
organisations e.g. ECRI• Investors in People (IIP)• Trade associations• Local policies etc.
DH & related Standards Other
Effectiveness and Outcomes• CQUINS• Mortality rates– now on Choose and Book• CQC measurables• Safety measurables• Specialty audits• National audits• Nice• Other recommendations• Trust objectives
Assurance framework
• Used to let the Board know status of organisation
• Informs the annual governance statement• Identifies gaps in assurance• Is a dynamic document used to update the
Board as to actions.
Assurance Framework
• Highest level for Board Assurance• Identify resource for gaps• Revisit it at Board after 6 months• Action Plan for leads• Should drive the working of the Board• Cross Check against progress• Evidence for Audit, CQC and Commissioners
Consultation
• Int audit set programme• Directors• Directorates• Clinicians• Regulation• Worry areas• Local interest
Planning the audit programme• Must dos for external and internal audit – systems
and processes – for assurance• Assurance framework and risk registers• Gap analyses from national audits etc – audit to
determine progress• Quality improvement work streams• Regulators – CQC, Monitor• NHSLA/CNST• Worry areas where we do not exactly know the
problem• Local – very clinical audit – for learning
Structuring the programme
• Pure Internal audit
• Joint Audits
• Pure clinical audits
– Trust wide– Local
Prioritisation of audit
• Not– When you know exactly what is wrong– To gain investment– To highlight an area
Joint audits
• Different starting points• Different language• Assurance versus other• Measures of success different• Challenges for reporting and scoring
Set the brief very carefully
Board of DirectorsAudit Committee
Standards Group
Clinical Effectiveness and Audit Group
Quality and Governance
Group
Director team
Standards Group
Corporate Risk Review Group
Clinical Effectiveness and Audit Group
Chief ExecutiveComplaints and Risk Management (CORM)
Clinical Effectiveness and Audit Group
• Input from Specialty Leads for clinical team and to support junior doctors
• Prioritisation of audit support• Data-base of Audits• Teaching of Audit methods• Ensuring Change• Sharing Good practice
Standards group• Minutes from CEAG• Clinical Audit report• Gap analyses from National audits and national
recommendations/HLEs/ Confidential Enquiries • Action Plan monitoring including CAS alerts and SUIs• External visits and accreditations• National data submissions• Prioritisation of audit support to standards audits• Audit Plan with CEAG
Audit Committee
• Minutes for standards• Internal audits and action plans• Standards report• Clinical audit report• Joint Audit plan – who and when• Corporate Risk register• Assurance framework and updates