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CLINICAL AUDIT Powered By Docstoc
					   Wirral University Teaching Hospital
                        NHS Foundation Trust


                              Bev Hawkes
          Clinical Governance Co-ordinator
         Pharmacy and Corporate Services
                                June 2008



Executive Summary

Divisional Audit Forward Plans
    AHP and Rehabilitation Directorate         5

    Corporate Services and CPRU Involvement    9

    Diagnostic Division                       11

    Division of Medicine

              A&E                            13
              DME                            14
              General Medicine               16

    Pharmacy Directorate                      21

    Division of Surgery

              General Surgery                22
              Special Surgery                24
              Theatres & Anaesthetics        25
              Trauma & Orthopaedics          27

    Division of Women and Children

              Paediatrics                    28
              Women’s Services               29

Acknowledgements                              31


Executive Summary
The 2008/2009 Forward Plan for Clinical Audit highlights the extent of audit
planned for the coming year.
The National Institute for Clinical Excellence (NICE) Guidelines are monitored
by CPRU through the Clinical Governance Co-ordinators and clinicians
identify those where audit is required. Some of the audit work this year around
NICE Guidance will be base line data collection and setting up systems to
support audit once the guidance changes have been introduced.
This year’s Forward Plan includes national priorities as determined by NICE,
NCEPOD and the National Service Frameworks as well as a diversity of
national and regional projects together with those that are proposed by Trust
NICE Guidance Audits
Not all NICE guidance issued is relevant to our Trust, but where relevant
guidance is identified, clinical leads are asked to comment on the evidence
and identify any audit requirements. General Medicine have planned to
undertake (or are undertaking) 28 audits assessing their compliance with
NICE Guidance. Some of the other audits planned to measure the Trust’s
compliance with NICE Guidance are:
      Cheshire & Merseyside Regional Audit on NICE Guidance relating to
       TB services
      NICE Acutely Ill Patients in Hospital
      Head Injury Management
NCEPOD/National Confidential Enquiries
We will respond to any such requirements throughout the year.

Mandatory Audits
The Healthcare Commission arrange a large number of clinical audit projects, that
trust is required to participate in. These cover subjects such as cancer, heart disease
children and maternity services, long-term conditions, mental health and older people
services. For example
      National bowel cancer audit project (NBOCAP)
      Myocardial Infarction National Audit Programme (MINAP)
      Heart failure audit
      National neonatal audit programme
      National diabetes audit
      Carotid endarterectomy

     National Audits

     In 2008/9 the Trust will involved in 43 National Audits . These include

           National audit projects that are co-ordinated by Intensive Care National
            Audit & Research Centre (ICNARC).

           General Surgery are involved in 8 national audits this year and some of
            the other national audits that the Trust have planned to participate in
            during 2008/09 are:
                       National COPD audit 2008
                       British Thoracic Society Lung Biopsy Audit
                       UK Comparative audit of upper Gastrointestinal Bleeding and
                        the use of blood

     Regional Audits
     There have been 7 regional audits identified so far for 2008/9. These are
       Critical Care are participating in 6 audits planned to run in 2008/09 by the
        Cheshire and Mersey Critical Care Network
       Trauma & Orthopaedics together with DME and A&E are again involved
        with the Greater Manchester & Wirral Falls Risk Assessment re-audit

     Trust Priorities
       CPRU are leading 7 policy audits as part of the NHSLA assessment
       The Trust continues to support the NPSA “cleanyourhands” campaign
        with regular audits undertaken at ward level by the Nursing and Midwifery
        Audit Team.
       Audits remain to be identified through Complaints and Clinical Incidents
        highlighted through the Risk Management Department.
       Nursing & Midwifery Audit
       Learning with Patients

During 2008/9, the trust will be auditing quality indicators for services in medicine and
orthopaedics, as a first wave trust in the Strategic Health Authority’s Advancing Quality
Initiative. This project aims to improve outcomes for patients by delivering consistent high
quality care.

As part of the quality framework, there is to be a review of current systems for approving
audit, including the audit structure and process. The audit strategy will be re-developed by
the Clinical Governance Leads Network (CGLN).

AHP and Rehabilitation Directorate Audit Plan 2008/09

      Type                       Details                         Due             Key people in                          Progress
                                                                             (…) = Trust Leads in other
                   1. National COPD audit 2008           tbc               1. (Dr Corless; Medicine)       1. Identify AHP and rehab
                                                                              Respiratory, PR, Medical        involvement + contribute to
National audits                                                               teams                           COPD modernisation group.
                   2. National Audit of Falls and bone   Org data Nov      2. (Dr Pritchard Howarth;       2. Identify AHP and rehab
                      health in older people 2008        2008, Clinical       DME)                            involvement + contribute
                                                         data 2009            Jane Marriott, Nicky
                   3. DAFNE programme                    Yearly            3. Julia Rosie, dietetics;      3. Submit data to national audit
                                                                              Chrissie Bigg-Wither,           database.
                                                                              Diebetis specialist nurse.
                   4. National Calcaneum Fracture        tbc               4. (Mr Hennessy:                4. On-going, contribute
                      audit                                                   Orthopaedic)
                                                                              Guy Kusabbi, Kerry
                   1. Greater Manchester & Wirral        Feb 2009          1. (Dr Pritchard Howarth)       1. Identify AHP and rehab
Regional audits       Falls Risk Assessment re-audit                          Jane Marriott, Nicky            involvement + contribute
                   1. Nutritional screening tool         early             1. Pamela Richardson            1. Submitted to the Nutritional
Corporate audits                                                                                              steering group and the Care
                                                                                                              Standards Committee

       Type                    Details                       Due       Key people in Directorate                  Progress
                                                                       (…) = Trust leads in other
                1. Integrated pathway for People       Sept 2008       1. Mandy Whalley              1. Cross organisational meeting
                   with Learning Difficulties                                                           established
                   attending hospital.
                2. Regional pathway for discharge      tbc             2. Mark Dillon: WNRU          2. Audit planned
Care Pathways      of people with ABI
                3. Care pathway within a shared        Nov 2008        3. Anne McGInnity, Joan       3.
                   model in podiatry for patients                         Taylor, Podiatry, Mike
                   with diebetis. (Audit relating to                      Milton
                   NICE guidelines)
                4. WUTH Falls pathway                  tbc             4. (Martin Pritchard-         4. Review of pathway
                                                                          Jane Marriott, Nicky
                5. National Stroke strategy:           On-going        5. Marilyn Wallace, Lindsay   5. Contribute to the pathway
                   developing a pathway to meet                           Clayton                    development
                   quality markers

Infection       1. Bare below the elbow audit          On-going        1. Service heads              1. Monthly audit;, quarterly in
                                                                                                        OPD areas

     Type                      Details                           Due         Key people in Directorate               Progress
                                                                                 (…) = Trust leads
               1. 6 day working unplanned Care             June 08         1. Nicky Norriss, Melanie     1. Audit complete, awaiting joint
                                                                              Jones                         OT/ PT report
               2. Exploration of band 3 post in            April 09        2. Nicky Norriss              2. Audit planned
                  physiotherapy and implications for the
Other audits
               3. Vitamin and mineral intake of            Nov 09          3. Adele Whiteway, Lucy       3. Data is being collected
                  haemodialysis patients audit                                Evans (Renal dietitians)
                  against ESPEN (European soc of
                  parenteral and enteral nutrition)

               4. Wound healing rates                      Dec 2008        4. Nicola Burn, Wirral Limb   4. Audit planned

               5. Falls in amputees                        tbc             5. Dr Suresh Keetarut         5. Audit planned

               6. Perceptions of signs over beds           Oct 2008        6. Anne McGinnity             6. Audit planned

               7. Management of total knee                 tbc             7. Simon Derriscott           7. Audit planned

               8. Evaluation of group work with            Nov 2008        8. Clare Wiggins              8. Audit planned
                  children with developmental co-
                  ordination disorder

               9. Outcome measures for amputees            Oct 2008        9. Gillian West, Veronica     9. Audit planned
                                                                              Hoyle, Limb Centre.

     Type                     Details                       Due         Key people in Directorate                 Progress
                                                                             (…) = Trust leads
               10. Priority patients MAU              November 08     10. Elaine Humphreys            10. Audit planned
                   Follow up visits MAU                                   Christopher Wynne
Other audits
continued      11. Documentation Audit                various         11. Many areas                  11. Audit planned

               12. Booking OPD appointments on        September 08    12. Anne Shepherd               12. In progress
                   the day

               13. Telephone answering audit          July 08         13. CGSG                        13. Audit planned

               14. Survey of patient information at   April 09        14. Jane Marriot, Nicky Burns   14. Audit planned
                   Wirral Limb Centre

               15. Lack of SALT; impact on patients   tbc             15. Rebecca Smith, Mark         15. Audit planned
                                                                          Dillon. WNRU

Corporate Services and CPRU Annual Audit Plan 2008/09

     Type                    Audit Title                  Date                  Lead                        Progress
                 Advancing Quality Initiaitive      April 2008       Dr M Maxwell, CPRU       In progress
Trust Priority   Nursing & Midwifery Audit          Ongoing          Mr L Porter, Nursing &   In progress
                                                                     Midwifery Team
                 Learning with Patients             Ongoing          Mrs P Birt, PPI          In progress
                 Policy No 01 Name: Producing       tbc              Mrs B Parker, CPRU       Planned
                 Patient Information for Patients
                 and Carers
                 Policy 06 Name: Producing          Sep 08           Ms B Hawkes, CPRU        Audit tool devised; Database to
                 Clinical Guidance                                                            be established.
Trust Priority
               Policy No 54 Name:                   Sep 08           Ms B Hawkes, CPRU        Planned
               Dissemination and
               implementation of NICE
                 Policy No 114 Name: Reviewing      Dec 08           Ms B Hawkes, CPRU        Database available on S Drive
                 National Confidential Enquiry                                                which is regularly updated.
                 Policy No 116 Name: Health         tbc              Dr M Maxwell, CPRU       Planned
                 Care Commission Reports Policy
                 Policy No 117 Name                 tbc              Dr M Maxwell, CPRU       Planned
                 Management of External Agency
                 Visits, Inspections and
                 Policy No 118 Name NSFs &          tbc              Dr M Maxwell, CPRU       Planned
                 other National Guidance -
                 implementing Best Practice

       Type                 Audit Title         Date                  Lead                     Progress
NICE             Assist with NICE Guidance    2008/9        Dr M Maxwell, CPRU      We will respond to any such
                 baseline compliance audits                                         requirements throughout the
Mandatory        NCEPOD Audits                2008/9        Topic dependent lead.   We will respond to any such
Audits                                                                              requirements throughout the
National Audits Assist with National Audits   2008/9        Dr M Maxwell, CPRU      We will respond to any such
                                                                                    requirements throughout the

Diagnostic Division Audit Forward Plan 2008/09

Type                    Directorate                Details             Date            Lead        Status
National          Radiology             Breast Screening re-call    October        Debbie          In progress
Audits/External                         rate, interval Ca rate      2008           Meacock
                  Laboratory Medicine   National Pathology          Jan/Feb        Alistair        Planned
                                        Benchmarking Service        2009           Bardsley
                                        (NPBS) 2007/2008
                  Laboratory Medicine   C Diff / Cause of Death     April 2008     Dr J Cunniffe   In progress
                  Laboratory Medicine   National Comparative        Starts April   Mike Goldberg   In progress
                                        Audit of the use of fresh   08
                                        frozen plasma
                  Laboratory Medicine   National Comparative        Starts         Mike Goldberg   Planned
                                        Audit of bedside            September
                                        transfusion practice        08
                  Laboratory            National Audit of           Data           Elaine          In progress
                  Medicine/Maternity    Antenatal Sickle Cell and   collection–    Lupton/John
                                        Thalassaemia Screening      Mar 08.        Wellbourn
                                        Programme – Low             Data to be
                                        Prevalence Laboratories     submitted
                                                                    2nd week of
                                                                    May 08
                  Laboratory Medicine   CPA audits                  Jan 2008       G Christian     In progress

Type                  Directorate              Details                 Date            Lead      Status
                Radiology             Ultrasound Fetal              October      Diane           In progress
                                      Abnormality                   2008         Williams/Lana
                Laboratory Medicine   Anti-D Prophylaxis            June 2008    David           Planned

                Laboratory            Audit in collaboration with   June 2008    David           Planned
NICE Guidance   Medicine/Obstetrics   Obstetrics as the                          Goodridge
                                      prophylaxis has just been
                                      changed from a two-dose
                                      to a single-dose regime

                Laboratory Medicine   Cheshire & Merseyside         To present   Dr J Cunniffe   In progress
                                      Regional Audit on NICE        at the
                                      Guidance relating to TB       Merseyside
                                      services                      audit
                                                                    Meeting 8
                Radiology             British Thoracic Society      01/09/08     Dr V            In progress
                                      Lung Biopsy Audit                          Williamson
Trust Policy                                                                     Donna
                                                                                 Cancer MDT
                Laboratory Medicine   An Audit on the Standard      June 2008    Craig           In progress
                                      for Labelling Laboratory                   Mackintosh
                                      Specimens                                  Helen Nelson

                                      Division of Medicine
Accident & Emergency Department Audit Plan 2008/ 2009

                              Audit Title               Date   Consultant Lead           Progress

                     Re-audit of Asthma Pathway   tbc          Dr. Good                  planned

NICE Guidance        Audit of Fever in children   tbc          Dr. McGuigan              planned

                     Audit of NICE Head Injury    tbc          Mr Pennycook              planned

                     BAEM Audits as requested     tbc          To be agreed nearer the   planned
                     by HCC                                    time
National Audits

                     Participation in UKTARN      tbc          To be agreed              planned

DME Directorate Annual Audit Plan 2008/09
         Type                    Details                     Date               Lead      Progress
                                                       Org. data
                   National Sentinel Audit of Stroke   2/05/08          Dr G Sangster     Org data submitted
                   2008                                Clinical data
National Audits                                        30/11/08

                                                       Org. data Nov.
                   National Audit of Falls & Bone      2008             Dr M Pritchard-   Planned
                   Health in Older People 2008         Clinical data    Howarth
Regional Audits    Greater Manchester & Wirral Falls   February 2009    Dr M Pritchard-   Planned
                   Risk Assessment Re-Audit                             Howarth
                   Dementia (Baseline Audit)                            Dr J Russell/Dr
NICE Guidance                                                           Spencer
                   Faecal Incontinence (Baseline                                          In progress
                   Audit)                                               Prof. J Barrett

                   Behind Closed Doors                  31/03/09    Dr D King             Planned
                   Withdrawing and Withholding          31/03/09    Dr C Turnbull         Planned
                   Stroke Care pathway                              Prof. J Barrett       Planned
                   (Audit revised Pathway)
Trust Priorities
                   Falls Care Pathway                               Dr M Pritchard-       Planned
                   (Audit revised Pathway)                          Howarth

                   Clostridium Difficile on DME Wards   31/08/08    Debbie Mirrlees       In progress
                   at APH

Local Priorities   Fluid Balance Charts                 Oct 2008    Jenny Fewtrell        In progress
                   Use of MRSA Pathways                 Oct 2008    Kate Braithwaite      In progress
                   Pain Management                      Oct 2008    Kate Braithwaite &    In progress
                                                                    Yvonne Whiston
                   Medical Equipment Re-audit           Oct. 2008   Maureen Fitzmaurice   Planned

                   Slipper Audit                        Jun 2008    Dr C Hallam           Audit tool designed

Medicine Directorate Audit Forward Plan 2008/09
        Type                        Details                    Date           Lead           Progress
                                                                                             Re-audit 2008 when
                       NICE (2004) No 12 - COPD          tbc                                 re-issued guidelines
                       NICE (2004) No 15 - Type 1        tbc          Diabetes Team          Continuous audit of
                       Diabetes                                                              2 education
                                                                                             Audit -
                       NICE (2005) No 24 - Lung Cancer   February/    Respiratory Team       Bronchoscopy
                                                         March 2009                          numbers in relation
NICE Guidance Audits                                                                         to higher use of CT
                                                                                             Pressure ulcer
                       NICE (2005) No 19                 2007/8       Mr B Haughton          Documentation is
                       Pressure Ulcer Management                                             now incorporated
                                                                                             into the Nursing
                                                                                             documentation for
                                                                                             Trust roll out 08
                                                                                             Education for ward
                                                                                             nurses Autumn 08.
                       NICE (2006) - Coronary Heart      tbc          Cardiology Team        Audit – Statin Use
                                                         tbc          Hepatitis C Specialist Audit completed
                       NICE (2006) No TAG 96 HEP B                    Nurse                  following Guidelines
                       NICE (2006) No 33 - TB            tbc          Respiratory Team       Re-audit 2008/9

        Type                        Details                       Date         Lead            Progress
                      NICE TAG 37                          tbc           Haematology Team      2008 re-audit to
                      Rituximab for Non Hodgkins                                               commence,
                      lymphoma                                                                 proforma design
                     NICE (2006) CG 39                     Ongoing*      Renal Team            Continues to be
                     Anaemia in Chronic Kidney             (Reviewed                           audited
                     Disease                               quarterly.)
                     NICE (2006) TAG 114 Drug                            Substance     Misuse Methadone Pathway
NICE Guidance Audits Misuse                                tbc           Nurse & Pharmacy     developed following
(con/d)                                                                                       Audit
                                                                                              Re-Audit 07/08 after
                      NICE (2007) TAG 119                  tbc           Haematology Team     Re-Audit if following
                      Fludatabine Leukaemia                                                   Guidelines 2008/9
                      NICE (2007) CG 46                    September     VTE Steering Group   Audit complete
                      VTE                                  2008                               feedback April 08
                                                                                              PCIS assessment
                                                                                              screens live June 08
                      NICE (2007) CG 48                    2007          Cardiology Teams     Audit in progress,
                      MI 2nd Prevention                                                       not compliant at
                      NICE (2007) TAG 120                  tbc           Cardiology team
                      Heart Failure Biventricular pacing
                      NICE (2007) CG 50 Acutely ill        tbc           Dr Gavin Frances      Audit of mews
                      patients in Hospital                               lead for Medicine     completed review of
                                                                                               MEWS forms to
                                                                                               ensure NICE
        Type                        Details                       Date           Lead          Progress

                       NICE (2007) CG 52 Drug Misuse   tbc                       Audit planned

                       NICE (2007) CG 51 Drug Misuse   tbc   Substance misuse    Continue to engage
                       psychological interventions           nurse/ pharmacy     with drug services to
                                                                                 ensure patients
                                                                                 Methadone are
                     NICE (2007) CG 53 Chronic fatigue tbc   Rhuematology Team   Audit Planned
NICE Guidance Audits syndrome/ myalgic
(con/d)              encephalomyelitis
                     NICE (2007) TAG 126 Rituximab     tbc   Rhuematology Team   Audit in progress
                     Rheumatoid Arthritis
                     NICE (2007) TAG 133               tbc   Respiratory team    Currently used for
                     Omalizumab for severe persistent                            very few pts
                     allergic asthma                                             Team discussion re
                                                                                 future audit as
                                                                                 numbers increase

                       NICE (2006) CG 43               tbc   Diabetes Team       Audit Planned

         Type                       Details                            Date         Lead          Progress
                     NICE (2008) CG 59                           tbc          Rheumatology Team   Audit Planned
                     Osteoarthritis- The care and
                     management of osteoarthritis in
                     NICE (2008) CG 138 Inhaled                  tbc          Respiratory Team    Audit Planned
                     steroids for the treatment of chronic
                     asthma in adults and children over
                     NICE (2008) CG 64 Prophylaxis               June 2008    Cardiology Teams    Audit to commence
NICE Guidance Audits against infective endocarditis                                               June 08
(con/d)              NICE (2008) CG 63 Diabetes in               June 2008    Diabetes Teams      Audit of
                     Pregnancy                                                                    preconception OPD
                                                                                                  clinic and
                                                                                                  gestational clinics
                         NICE (2008) TAG 139                     May 2008     Respiratory Team    Compliant with
                         Continuous positive airway                                               guidance. Audit
                         pressure for the treatment of                                            completed
                         Obstructive sleep apnoea/
                         hypopnoea syndrome
                         NICE (2008) TAG 143                     June 2008    Rheumatology Team   Audit agreed,
                         Adalimumab, etanercept and                                               proforma
                         infliximab for Ankylosing spondylitis                                    completed, patients
                         NICE (2008) Lipid Modification CG       June 2008    Cardiology Team     Audit Planned

         Type                 Details                       Date           Lead        Progress
                  National COPD audit                 tbc          Respiratory Team    Registration Nov 07
                                                                                       Audit 2008
                  UK Comparative audit of upper       June 2008    Gastroenterology    Action plan
                  Gastrointestinal Bleeding and the                Team, Transfusion   developed, new
National Audits   use of blood                                     department          upper GI bleed
                                                                                       pathway to include
                                                                                       risk assessment in
                                                                                       pilot phase
                  National COPD audit 2008            May 2008     Respiratory Team    In progress
                  National Comparative audit of       June 2008    Dr Galvani / Mike   In progress
                  platelet transfusion                             Goldberg
                  Clinical effectiveness and          June 2008    Mike Goldberg       In progress
                  Evaluation unit. National Blood
                  Transfusion service audit

                Corporate Directorate
                 Pharmacy Division
                  2008/9 Audit Plan
Type                      Details                                                   Due          Lead                 Progress
NICE Guidance             Audit of cinacalcet use against TA117                     September    Beth Ebrall          On-going
CG Standards              Allergy Status of Patients                                December     TBA                  Planned
                          Audit of antimicrobial prescribing                        May 2008     Katherine Stirling   Data collection
NPSA Alerts               NPSA 18 – Audit of warfarin initiation                    May 2008     Simon Purcell        On-going
                          Re-audit of NPSA Safer Practice Notice – High dose        December     TBA                  Planned
                          ampoules of morphine and diamorphine                      2008
                          Re-audit of NPSA PSA02 – Potassium chloride               December     TBA                  Planned
                          concentrate solutions                                     2008
Other                     Audit of number of pharmacy interventions made to         September    Julie Orton          Planned
                          medication regimens prescribed                            2008
Root Cause Analysis       Identified through incident reporting                     On-going     Julie Orton          On-going
Pharmacy Services Audit   Re-audit of dispensing incident survey following          July 2008    Sue Smith            Planned
                          automation (CGH)
                          Re-audit of goods receipt process following automation    July 2008    Rachael Fallon       Planned
                          Re-audit of ward box filling following automation (CGH)  July 2008     Rachael Fallon       Planned
                          Nursing Survey                                           August 2008   Rachael Fallon       Planned
                          Audit of oral step-down of intravenous antibiotics       September     Anna Poole           Planned
                          Review of prescribing of broad spectrum antibiotics once September     Fiona Watson         Planned
                          sensitivities available                                  2008
                          Audit of Medicines Management Policy-general             September     Julie Orton          Planned

                                           Surgical Division
General Surgery and Urology Directorate Audit Plan 2008/09
         Type                    Details                     Date          Lead         Progress
                   Head Injury (update)                April 2008   Mr J Anderson       Audit to commence
                                                                                        April 2008
                   Bioprosthetic Anal Fistula Plugs    June 2007    Mr C Walsh          Ongoing
NICE Guidance      Laparoscopic insertion of PD        tbc          Mr R Chandrasekar   Planned
                   Other NICE guidance audits as
                   Bowel Cancer (NBOCAP)               Ongoing      Mr J Anderson       Ongoing

                   Oesophago-Gastric Cancer            Ongoing      Mr J Anderson       Ongoing
National Audits
                   Mastectomy and Breast               Ongoing      Mr F Swe            Ongoing
                   Reconstruction Audit
                   Patient Outcomes in Surgery         September    Mr J Anderson       Planned
                   British Association of Urological   Ongoing      Mr N Parr           Ongoing
                   Surgeons Cancer Registry
                   BASO – Association of Breast        Ongoing      Mr D Berstock       Ongoing

         Type                          Details                       Date             Lead     Progress
                         UK Inflammatory Bowel Disease          September      Mr C Walsh      Planned
                         Audit 2nd round                        2008
                         Vascular Governance North West         Ongoing        Mr S Blair      Ongoing
National Audits (cont/d) National Vascular Database
                             Carotid endarterectomy
                             Abdominal aortic aneurysm
                                (AAA) repair
                             Major limb amputation
                             Infra Inguinal Bypass
                         NCEPOD                                 As published                   As published
                         Complaints identified through          Ongoing                        Ongoing

Local Priorities        Clinical Incidents identified through   Ongoing                        Ongoing
                        Clinical Governance Standards           Ongoing                        Ongoing

                        Head Injury Audit                       April 2008     Mr J Anderson   Audit to commence
Re-audits                                                                                      April 2008

                        Site Marking Audit                      January 2008   Mr J Anderson   Further Audit to
                                                                                               commence following
                                                                                               finalisation of policy

Special Surgery Directorate Audit Plan 2008/09
           Type                    Details                     Date              Lead       Progress
                                                      Guidance expected   Dr S White        Planned
                      Psoriasis – adalimumab          April 08
NICE Guidance
                      Surgical site infection         Guidance expected   tba               Planned
                                                      Sep 08
                      The National Anonymous Tonsil   Ongoing             Mr V Srinivasan   In progress
                      Archive (ENT)
National Audits
                      The National Comparative        Ongoing             Mr V Srinivasan   In progress
                      Myringoplasty Audit (ENT)
                      Data for Head and Neck          April 08            Mr V Srinivasan   Ongoing
                      Oncology (DAHNO) (ENT/MAX
                      National Audit of Basal Cell    Tba                 Dr S White        Planned
                      European Cataract Outcome       Sep 08              Dr G Rudduck      Ongoing
                      Study - European Audit
                      Surgical Site Marking (NPSA)    June 2007           Mr J Anderson     In progress
National Guidance                                                         Mr J Stamer
                                                                          Mr V Srinivasan
                       NCEPOD “Functioning as a       tbc                                   Planned
Trust Priorities      Hand Hygiene                    Quarterly report    Carmel Edwards    Ongoing

Theatre & Anaesthetics Directorate Audit Plan 2008/09
          Type                    Details                       Date                 Lead    Progress
NICE Audits           NICE Acutely Ill Patients in
                      Hospital                           August 2008         Anaesthetists   Audit Planned
                      National audit projects that are   As and when         Critical Care   Audit Planned
                      co-ordinated by Intensive Care     determined by
National Audits       National Audit & Research          ICNARC
                      Centre (ICNARC)
                      NCEPOD 2005 An Acute
                      Problem.                           August 2008         Anaesthetists   Audit Planned

                      Cheshire and Mersey Critical       May 2008            Alison Barnes   In progress
                      Care Network – Renal Care
                      Cheshire & Mersey Critical Care    October 2008        Alison Barnes   Audit Planned
                      Network - ‘Levels of Care’
Regional Audits       Cheshire and Mersey Critical       July 2008           Alison Barnes   Audit Planned
                      Care Network - Critical Care
                      Patient Flow Analysis
                      Cheshire and Mersey Critical       As and when         Alison Barnes   Audit Planned
                      Care Network - Nutrition Care      notified by CMCCN
                      Cheshire and Mersey Critical       As and when         Alison Barnes   Audit Planned
                      Care Network - Sepsis Care         notified by CMCCN
                      Cheshire and Mersey Critical       As and when         Alison Barnes   Audit Planned
                      Care Network - Delayed             notified by CMCCN

           Type                 Details                    Date           Lead        Progress
                   Clinical Governance Standard     Quarterly      Carmel Edwards     In progress
Trust Priorities   no.13 NPSA “cleanyourhands”
                   Audit of Perioperative Deaths    May 2008       Dr Atherton        In Progress

Local Priorities   'Surviving Sepsis Campaign       October 2008   Sepsis Awareness   Audit Planned
                   Proforma (2003).                                Group
                   Quality of Anaesthetic Records   March 2009     Anaesthetists      Audit Planned

Trauma and Orthopaedics Directorate Audit Forward Plan 2008/09

           Type                   Details                    Date             Lead          Progress
                     Arthroscopic femoro acetabular    Ongoing         Mr Thomas            Ongoing
NICE Audits          surgery for hip impingement
                     Advancing Quality - Pilot.        April 2008      Mr Parkinson         In progress
                     Mandatory Annual Surveillance                     Orthopaedic
National Audits      of Surgical Sites of Infection    October 2008    directorate          Audit planned
                     Orthopaedic Audit
                     National Hip Fracture Database    tbc             Orthopaedic
                                                                       directorate          Audit planned
                     National Joint Register           Ongoing         Orthopaedic          Ongoing
                     National Comparative Audit of
                     the Use of Blood in Primary,      November 2008   Dr Galvani           Audit planned
                     Elective, Unilateral Total Hip
                     POIS Patient outcomes in          tbc             Mr Stamer            Audit planned
                     surgery Audit
Regional Audits      Greater Manchester and Wirral     April 2008      DME/Surgery/Orthop   In progress
                     Falls Risk Assessment Audit                       aedics
                     Clinical Governance Standard      Quarterly       Carmel Edwards       In progress
                     no.13 NPSA “cleanyourhands”
Trust Priorities     campaign
                     Trustwide survey ‘Learning from   Ongoing         Trust Wide           Ongoing
Local Priorities     Correct Site Surgery              April 2008      Mr Stamer            In progress

                            Division of Women and Children
Paediatrics Directorate Audit Plan 2008/09
          Type                      Details                    Date          Lead        Progress
NICE Audits            Atopic Eczema in Children: Are    tbc          Dr Donal Manning   Audit planned
                       we compliant with NICE
                       Guidance 57?
                       UTI in Children: Are we           tbc          Dr A Hughes        Audit planned
                       compliant with NICE Guidance
Local Priorities       Monitoring Pain in Children and   tbc          Dr David Lacy      Audit planned
                       the Effectiveness of the Pain
                       Assessment Tool

Obstetrics & Gynaecology Directorate 2008/9 Audit Plan
Type                Details                                                 Date         Lead             Progress
NICE Audits         Acutely ill patients in hospital                        July 08      Dr John Barker   Analysis
                    Complaints identified through Clinical Risk             Continuous   J Higginson      Ongoing
Trust Priorities    Management Group
                    Clinical Incidents identified through ACE meetings      Continuous   M Ellard         Ongoing
                    Clinical Governance Standards - identify those not      Ongoing      TBA              Ongoing
                    done corporately
                    Root Cause Analysis identified through Clinical Risk    Ongoing      M Ellard         Ongoing
                    Management Group
                    Continuous monthly audit of maternity record keeping    Continuous   S Edwards        Ongoing
Local Priorities    Continuous monthly audit of screening tests             Continuous   J Higginson      Ongoing
                    Audit of women transferred from Midwifery Led Unit to   July 08      P Brown          In progress
                    Labour Ward
                    Annual audit of supervision                             May 08       L Birch          In progress
                    Continuous audit of mandatory training attendance       May 08       D Williams       In progress
                    Audit of VTE protocol                                   June 08      J Higginson      Planned
                    Re-audit of multiple pregnancy                          Jul 08       J Higginson      Planned
                    Audit of bookings before 12 weeks                       June 08      L Gorman         Planned
                    Audit of mental health screening                        June 08      TBA              Planned
                    Audit of obesity guideline within Maternity             June 08      TBA              Planned
                    Re-audit of PPH protocol                                July 08      A Verma          Planned
                    Re-audit of APH protocol                                July 08      TBA              Planned
                    Audit of counselling for assisted conception patients   July 08      TBA              Planned
                    Audit of presence of consultant at caesarean section    Aug 08       M Ellard         Planned
                    Audit of referral to Anaesthetist                       Aug 08       TBA              Planned
                    Re-audit of antibiotic prophylaxis for caesarean        Sept 08      TBA              Planned

Type                        Details                                       Due        Lead          Progress
                            Audit of Maternal Deaths                      Dec 08     L Birch       Planned
                            Re-audit of Thromboprophylaxis Protocol       April 09   TBA           Planned
Local Priorities (cont/d)   Audit of compliance with issuing VBAC and CS April 09    TBA           Planned
                            Leaflet to patients
                            Audit of Ovarian Hyperstimulation Protocol    July 09    TBA           Planned
                            Re-Audit of Proteinuric Hypertension Protocol July 09    TBA           Planned
                            Re-audit of shoulder dystocia                 Dec 08     J Higginson   Planned

We gratefully acknowledge the help of the Clinical Governance Co-ordinators in
the production of this report.


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